Raiyyan Tahsan

Raiyyan Tahsan
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TC(994).(05).Orthopedics Case No 72.Avascular Necrosis / AVN

Avascular Necrosis / AVN — বাংলায় ক্লিনিক্যাল নোট

AVN / Osteonecrosis হলো কোনো হাড়ের অংশে রক্ত সরবরাহ কমে বা বন্ধ হয়ে যাওয়ার কারণে bone marrow ও osteocyte মারা যাওয়া। সবচেয়ে বেশি দেখা যায় femoral head / hip joint-এ। শুরুতে X-ray normal থাকতে পারে, কিন্তু untreated থাকলে femoral head collapse হয়ে secondary osteoarthritis হতে পারে।

1. Definition

Avascular necrosis = ischemic death of bone.
অর্থাৎ bone-এর vascular supply ক্ষতিগ্রস্ত হলে subchondral bone দুর্বল হয়ে যায়, microfracture হয়, পরে femoral head-এর গোলাকার shape নষ্ট হয়ে collapse করে।

Common sites:
Hip/femoral head > knee > shoulder/humeral head > talus.

2. Causes / Etiology — কারণগুলো

A. Traumatic cause

  1. Femoral neck fracture
    Femoral head-এর retinacular vessels ছিঁড়ে যায়, তাই blood supply কমে AVN হতে পারে।
  2. Hip dislocation
    Dislocation দীর্ঘ সময় unreduced থাকলে femoral head ischemia হয়।
  3. Previous hip surgery / trauma
    Vascular injury বা intraosseous pressure বাড়ার মাধ্যমে AVN হতে পারে।

B. Non-traumatic cause

  1. Long-term or high-dose corticosteroid
    যেমন prednisolone, dexamethasone, methylprednisolone। Steroid marrow fat hypertrophy, fat emboli, endothelial dysfunction ও intraosseous pressure বাড়িয়ে ischemia করে। Steroid ও alcohol non-traumatic AVN-এর বড় অংশের জন্য দায়ী।
  2. Alcohol excess
    Alcohol marrow fat cell enlargement ও lipid deposition করে small vessel block করতে পারে।
  3. Sickle cell disease / hemoglobinopathy
    Sickled RBC small vessels block করে bony infarction ঘটায়।
  4. SLE / autoimmune disease
    SLE নিজে এবং steroid therapy—দুই কারণেই AVN risk বাড়ে।
  5. Antiphospholipid syndrome / thrombophilia
    Microthrombi তৈরি হয়ে femoral head perfusion কমে যায়।
  6. Hyperlipidemia
    Fat embolism ও vessel narrowing-এর মাধ্যমে risk বাড়ায়।
  7. Radiotherapy / chemotherapy / malignancy
    Vascular injury ও bone weakening হতে পারে।
  8. HIV, pancreatitis, Gaucher disease, renal transplant, decompression sickness
    এগুলোও AVN-associated condition হিসেবে পরিচিত।
  9. Idiopathic AVN
    কোনো clear cause না পাওয়া গেলে idiopathic বলা হয়।

3. Pathophysiology — সহজ ভাষায়

Blood supply কমে গেলে femoral head-এর subchondral bone মারা যায় → dead bone mechanical load নিতে পারে না → microfracture হয় → X-ray-এ crescent sign আসতে পারে → femoral head flatten/collapse করে → cartilage damage ও secondary osteoarthritis হয়।

4. Symptoms — উপসর্গ

  1. Early stage: asymptomatic
    শুরুতে কোনো ব্যথা নাও থাকতে পারে; X-ray normal থাকতে পারে।
  2. Groin pain
    Hip AVN-এর সবচেয়ে typical pain groin-এ হয়; thigh বা buttock-এ radiate করতে পারে।
  3. Weight-bearing pain
    হাঁটা, সিঁড়ি ওঠা, দাঁড়িয়ে থাকা—এসব করলে ব্যথা বাড়ে।
  4. Rest pain / night pain
    Disease advance হলে বিশ্রামেও ব্যথা থাকে।
  5. Limping / antalgic gait
    ব্যথার কারণে রোগী খুঁড়িয়ে হাঁটে।
  6. Restricted hip movement
    বিশেষ করে internal rotation ও abduction painful/restricted হয়।
  7. Bilateral symptoms
    Steroid/alcohol/SLE/sickle cell-related AVN-এ দুই hip-ই involve হতে পারে।

5. Clinical Diagnosis — clinically কীভাবে সন্দেহ করবেন

History

  • Hip/groin pain আছে কি না
  • Steroid use: dose, duration, repeated pulse therapy
  • Alcohol history
  • Trauma/dislocation/fracture history
  • SLE, sickle cell, renal transplant, HIV, thrombophilia history
  • Previous radiotherapy/chemotherapy
  • Pain duration, weight-bearing relation, night pain
  • Bilateral hip symptoms

Physical examination

  • Antalgic gait
  • Trendelenburg gait/sign
  • Hip ROM: internal rotation, flexion, abduction painful
  • FABER / FADIR test pain may be positive
  • Limb length discrepancy late stage collapse হলে
  • Neurologic exam usually normal; radiculopathy exclude করতে হবে

6. Investigations — specific

1. X-ray pelvis with both hip AP view + frog-lateral view

  • Early AVN-এ normal হতে পারে
  • Late finding: sclerosis, cystic change, crescent sign, femoral head flattening, joint-space narrowing

2. MRI hip — investigation of choice

MRI is best for early AVN, especially when X-ray normal but clinical suspicion high. MRI staging ও lesion size/location দেখায়; bilateral hip screening-এ useful।

Typical MRI findings:

  • T1 low-signal serpiginous band
  • T2 double-line sign
  • Bone marrow edema
  • Subchondral fracture/collapse

3. CT scan

  • Subchondral fracture, crescent sign, collapse define করতে useful
  • Surgical planning-এ helpful
  • Early diagnosisে MRI-এর চেয়ে কম sensitive

4. Bone scan

  • MRI unavailable/contraindicated হলে করা যায়
  • Early AVN detect করতে পারে, but specificity কম

5. Laboratory tests — cause খোঁজার জন্য

AVN diagnose imaging দিয়ে হয়; lab tests cause/risk factor identify করতে করা হয়।

  • CBC, ESR, CRP
  • Fasting lipid profile
  • RBS/HbA1c
  • LFT, RFT
  • Serum calcium, phosphate, ALP, vitamin D
  • ANA, anti-dsDNA — SLE suspicion
  • Antiphospholipid antibody: lupus anticoagulant, anticardiolipin, anti-β2 glycoprotein I
  • Hb electrophoresis / sickling test
  • Coagulation profile if thrombophilia suspected
  • Steroid exposure documentation

6. Staging

Common systems: Ficat-Arlet, ARCO, Steinberg.
Treatment decision depends on stage, lesion size/location, age, pain, collapse আছে কি না। Guidelines treatment selection individualize করতে বলে।

7. Differential Diagnosis

  • Osteoarthritis hip
  • Transient osteoporosis / bone marrow edema syndrome
  • Subchondral insufficiency fracture
  • Septic arthritis
  • Tubercular arthritis of hip
  • Femoroacetabular impingement
  • Lumbar radiculopathy
  • Ankylosing spondylitis hip arthritis
  • Rheumatoid arthritis hip involvement
  • Pigmented villonodular synovitis / synovial chondromatosis
    Guideline sources specifically OA, AS, RA ও synovial disorders-এর differentiation mention করে।

8. Complications — বাংলায় বুঝে বলি

  1. Femoral head collapse
    Dead bone body weight নিতে পারে না, তাই femoral head বসে যায়/চ্যাপ্টা হয়।
  2. Secondary osteoarthritis
    Femoral head smooth shape হারালে cartilage damage হয়, joint-space কমে যায়, severe arthritis হয়।
  3. Chronic severe pain
    হাঁটা, বসা, সিঁড়ি ওঠা—সবকিছুতে ব্যথা বাড়ে।
  4. Restricted mobility
    Hip stiff হয়ে যায়; internal rotation ও abduction কমে যায়।
  5. Limping and disability
    রোগী কাজকর্ম/হাঁটা কমিয়ে দেয়, quality of life কমে।
  6. Bilateral AVN
    এক hip AVN হলে অন্য hip-ও screen করা উচিত, especially steroid/alcohol/SLE/sickle cell patient.
  7. Need for total hip replacement
    Collapse/arthritis হলে joint-preserving surgery late হয়ে যায়; THR লাগতে পারে।

9. Treatment Management — stage-based

A. General / non-pharmacological

  • Early stage: activity modification, cane/crutch, partial weight-bearing
  • Avoid running/jumping/heavy load
  • Physiotherapy: ROM exercise, hip abductor strengthening, gait training
  • Stop alcohol, stop smoking
  • Steroid dose reduce/avoid if clinically possible
  • Treat hyperlipidemia, thrombophilia, SLE, sickle cell crisis prevention
  • Orthopedic referral early, especially MRI-confirmed AVN

B. Surgical / definitive treatment

  1. Pre-collapse stage: core decompression
    Intraosseous pressure কমিয়ে revascularization help করতে পারে।
  2. Core decompression + bone marrow aspirate concentrate / stem-cell augmentation
    Early AVN-এ selected cases; evidence evolving।
  3. Bone grafting / vascularized fibular graft / osteotomy
    Young patient, pre-collapse or selected early collapse cases।
  4. Total hip arthroplasty / THR
    Femoral head collapse, severe pain, secondary OA, joint dysfunction হলে best definitive option। Guidelines stage IV/V বা severe dysfunction-এ arthroplasty recommend করে।

10. Pharmacological Management — Bangladesh prescription-focused

Important: AVN-এর কোনো oral medicine femoral head collapse reverse করে না। ওষুধ মূলত pain control, bone protection, underlying cause control, peri-operative thrombosis prevention অথবা selected early-stage off-label therapy হিসেবে ব্যবহৃত হয়। Pharmacologic agents নিয়ে strong consensus নেই।

নিচের brand names MedEx Bangladesh-এ পাওয়া verified examples; availability/price সময়ের সাথে বদলাতে পারে, prescription দেওয়ার আগে latest availability verify করা উচিত।

1. Paracetamol

  • Generic name: Paracetamol
  • Therapeutic category: Analgesic, antipyretic
  • Pharmacological class: Non-opioid analgesic
  • Purpose in AVN: mild–moderate pain relief; NSAID contraindicated হলে safer first-line
  • Adult dose: 500–1000 mg PO 6–8 hourly PRN; maximum 3–4 g/day, liver disease/alcohol use হলে lower dose
  • Duration: 3–7 days PRN; chronic daily high-dose avoid
  • Side effects: nausea, rash, hepatotoxicity in overdose
  • Interaction: alcohol, warfarin effect may increase with prolonged high-dose use
  • Bangladesh available brand examples: Napa 500 mg, Ace 500 mg, Reset 500 mg, Fast 500 mg; MedEx paracetamol list includes many 500 mg brands.

2. Etoricoxib

  • Generic name: Etoricoxib
  • Therapeutic category: Analgesic / anti-inflammatory
  • Pharmacological class: Selective COX-2 NSAID
  • Purpose in AVN: inflammatory hip pain, OA-like pain; GI risk তুলনামূলক কম হলেও CV risk assess করতে হবে
  • Adult dose: 60 mg once daily; severe painে 90 mg once daily short course
  • Duration: 5–10 days; lowest effective dose, shortest duration
  • Side effects: dyspepsia, edema, hypertension, renal impairment, ↑CV thrombotic risk
  • Interaction: warfarin/anticoagulants bleeding risk, ACEi/ARB/diuretics renal risk, lithium/methotrexate toxicity risk
  • Bangladesh available brand examples: Oricox 60/90/120 mg, Recox 60/90/120 mg, Ribox 60/90/120 mg, Etorix 60/90/120 mg, Fabetor 60/90/120 mg.

3. Naproxen / Naproxen sodium

  • Generic name: Naproxen sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-selective NSAID
  • Purpose in AVN: moderate pain with inflammatory component
  • Adult dose: 250–500 mg PO twice daily after food
  • Duration: 5–10 days; chronic use avoid unless monitored
  • Side effects: gastritis, peptic ulcer, GI bleeding, renal injury, BP rise
  • Interaction: aspirin/anticoagulants bleeding risk, ACEi/ARB/diuretics renal risk, SSRI bleeding risk
  • Bangladesh available brand examples: Naprox 250/500 mg, Naprosyn 250/500 mg, Naxin 250/500 mg, Napryn 250/500 mg, Nuprafen 250/500 mg.

4. Diclofenac sodium

  • Generic name: Diclofenac sodium
  • Therapeutic category: Analgesic, anti-inflammatory
  • Pharmacological class: Non-selective NSAID
  • Purpose in AVN: acute flare pain; IM form occasionally severe acute painে used
  • Adult dose: 50 mg PO 2–3 times daily after food; SR 100 mg once daily; IM 75 mg deep IM only short term
  • Duration: 3–5 days preferred; prolonged use avoid
  • Side effects: gastritis, GI bleeding, renal injury, fluid retention, ↑CV risk, liver enzyme rise
  • Interaction: anticoagulants/antiplatelets, ACEi/ARB/diuretics, lithium, methotrexate
  • Bangladesh available brand examples: Diclofen 50 mg/100 mg SR/75 mg injection, Clofenac 50 mg, Diclorex 50 mg/75 mg injection/100 mg retard, Fengel 50 mg/100 mg SR/gel.

5. NSAID + PPI gastroprotection

Esomeprazole

  • Generic name: Esomeprazole
  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: Proton pump inhibitor / PPI
  • Purpose in AVN: NSAID-induced dyspepsia/ulcer prevention in high-risk patient
  • Adult dose: 20–40 mg PO once daily before breakfast
  • Duration: during NSAID course; usually 5–14 days, high GI-risk হলে longer by indication
  • Side effects: headache, diarrhea/constipation, hypomagnesemia/B12 deficiency with long-term use
  • Interaction: may reduce clopidogrel activation; affects drugs needing acidic pH
  • Bangladesh available brand examples: Esotid 20/40 mg, Exor 40 mg, Esoral 20 mg sachet/40 mg IV, Onepro 20/40 mg.

Pantoprazole

  • Generic name: Pantoprazole sodium
  • Therapeutic category: Anti-ulcerant
  • Pharmacological class: PPI
  • Purpose: NSAID gastritis/ulcer prophylaxis
  • Adult dose: 40 mg PO once daily before breakfast
  • Bangladesh brand examples: Pantex 20/40 mg, Pantid 20/40 mg, Pantogut 20/40 mg, Pantolok 20/40 mg, Pantopra 20/40 mg.

6. Tramadol — severe pain only

  • Generic name: Tramadol hydrochloride
  • Therapeutic category: Analgesic
  • Pharmacological class: Centrally acting opioid analgesic; μ-opioid agonist + serotonin/noradrenaline reuptake inhibition
  • Purpose in AVN: severe pain where paracetamol/NSAID insufficient; short course only
  • Adult dose: 50 mg PO 6–8 hourly PRN; maximum usually 400 mg/day; elderly/renal impairment lower
  • Duration: 2–5 days; dependence risk থাকায় chronic avoid
  • Side effects: nausea, vomiting, dizziness, constipation, sedation, respiratory depression, seizure risk, dependence
  • Interaction: SSRI/SNRI/TCA/MAOI → serotonin syndrome risk; alcohol/benzodiazepine → sedation/respiratory depression; seizure-threshold lowering drugs
  • Bangladesh available brand examples: Anadol 50 mg capsule/100 mg SR, Dolonil 50 mg, Utramal IR 50 mg, Doloran 50/100 mg.

7. Alendronic acid — selected early AVN / steroid-induced osteoporosis context

  • Generic name: Alendronic acid / Alendronate
  • Therapeutic category: Bone formation & bone disorder drug
  • Pharmacological class: Bisphosphonate preparation
  • Purpose in AVN: early pre-collapse non-traumatic AVN-এ off-label use করা হয় femoral head collapse delay করার উদ্দেশ্যে; evidence mixed, routine universal therapy নয়। Also steroid-induced osteoporosis prevention/treatment.
  • Adult dose often used: 70 mg once weekly; take in morning empty stomach with full glass water, 30 min upright
  • Duration: often 3–6 months or longer depending osteoporosis/orthopedic plan; AVN indicationে specialist decision
  • Side effects: esophagitis, dyspepsia, musculoskeletal pain, hypocalcemia, rare osteonecrosis jaw, atypical femur fracture
  • Interaction: calcium/antacid/iron reduce absorption; NSAID/aspirin increase upper GI irritation
  • Contraindication: esophageal stricture/achalasia, inability to sit/stand 30 min, hypocalcemia, CrCl <35 mL/min
  • Bangladesh available brand examples: Alendon 10 mg, Alendon 70 mg.

8. Alendronate + Vitamin D3

  • Generic name: Alendronic acid + Cholecalciferol
  • Therapeutic category: Combined preparation inhibiting bone resorption
  • Pharmacological class: Bisphosphonate + vitamin D
  • Purpose: osteoporosis/low vitamin D risk থাকলে bone protection; AVN cure নয়
  • Adult dose: Alendronate 70 mg + Vitamin D3 2800 IU once weekly
  • Duration: osteoporosis risk অনুযায়ী; specialist follow-up
  • Side effects/interactions: alendronate-এর মতো; calcium/antacid same timeে নিলে absorption কমে
  • Bangladesh available brand examples: Bonemass D 70 mg + 2800 IU, Ostel-D 70 mg + 2800 IU.

9. Risedronate sodium

  • Generic name: Risedronate sodium
  • Therapeutic category: Bone disorder drug
  • Pharmacological class: Bisphosphonate
  • Purpose: osteoporosis management; early AVN-এ alendronate alternative হিসেবে sometimes considered, but not universal AVN cure
  • Adult dose: 35 mg once weekly or 150 mg once monthly for osteoporosis
  • Duration: osteoporosis indication অনুযায়ী
  • Side effects: dyspepsia, esophagitis, hypocalcemia, musculoskeletal pain, rare ONJ/atypical fracture
  • Interaction: calcium, iron, antacid reduce absorption; NSAID increases GI irritation
  • Bangladesh available brand examples: Risonet 35/150 mg, Risedon 150 mg, Salost 5/150 mg, Salost DR 35 mg, Sedron 5/35 mg.

10. Calcium + Vitamin D3

  • Generic name: Calcium carbonate + Vitamin D3
  • Therapeutic category: Mineral + vitamin supplement
  • Pharmacological class: Calcium preparation + cholecalciferol
  • Purpose in AVN: low calcium/vitamin D, steroid-induced osteoporosis prevention; AVN reverse করে না
  • Adult dose: elemental calcium 500–600 mg + vitamin D3 200–400 IU once/twice daily depending diet/lab
  • Duration: 8–12 weeks then reassess; long-term if deficiency/osteoporosis
  • Side effects: constipation, bloating, hypercalcemia, renal stone risk
  • Interaction: reduces absorption of levothyroxine, tetracycline, quinolone, bisphosphonate—separate 4 hours
  • Bangladesh available brand examples: A-Cal D, Calci-D Plus 500 mg + 200 IU, Calcibo D 500 mg + 200 IU, Oscal-D Forte 600 mg + 400 IU, Ostoplus-DX 600 mg + 400 IU.

11. Cholecalciferol / Vitamin D3

  • Generic name: Cholecalciferol
  • Therapeutic category: Vitamin supplement
  • Pharmacological class: Vitamin D preparation
  • Purpose: vitamin D deficiency correction; steroid users/low BMD patientে supportive
  • Adult dose: 20,000 IU weekly for 6–8 weeks or 2,000 IU daily; severe deficiencyে protocol অনুযায়ী
  • Duration: 6–8 weeks then maintenance/lab reassessment
  • Side effects: hypercalcemia, nausea, polyuria, kidney stone risk in overdose
  • Interaction: thiazide diuretic hypercalcemia risk; anticonvulsants may lower vitamin D
  • Bangladesh available brand examples: D-Rise 20,000 IU/40,000 IU/50,000 IU, Aristo D3 20,000 IU/40,000 IU/200,000 IU/ml, D-20000 20,000 IU, D-Balance 50,000 IU.

12. Aspirin — not routine AVN drug

  • Generic name: Aspirin
  • Therapeutic category: Antiplatelet / analgesic
  • Pharmacological class: COX inhibitor, antiplatelet at low dose
  • Purpose in AVN: routine AVN treatment নয়; antiphospholipid syndrome, vascular risk, post-op thromboprophylaxis—indication থাকলে physician uses
  • Adult dose: 75–100 mg once daily for antiplatelet indication; analgesic dose আলাদা
  • Duration: indication-based
  • Side effects: gastritis, GI bleeding, bronchospasm, renal injury
  • Interaction: NSAID/anticoagulant/SSRI increase bleeding risk
  • Bangladesh available brand examples: Ecosprin 75/81 mg, Disprin CV 100 mg, Solrin 75 mg, Erasprin 75/81 mg, Disprin 300 mg.

13. Enoxaparin — thrombophilia / peri-operative use

  • Generic name: Enoxaparin sodium
  • Therapeutic category: Anticoagulant
  • Pharmacological class: Low molecular weight heparin / parenteral anticoagulant
  • Purpose in AVN: hypercoagulable early AVN selected cases or post-operative DVT prophylaxis; routine AVN pain drug নয়
  • Adult prophylactic orthopedic dose: 4000 Anti-Xa IU / 0.4 ml SC once daily for 7–10 days; extended prophylaxis may be needed after orthopedic surgery
  • Therapeutic dose: weight-based; specialist decision
  • Side effects: bleeding, thrombocytopenia, injection-site hematoma, ↑LFT; neuraxial hematoma risk with spinal/epidural anesthesia
  • Interaction: aspirin, NSAID, anticoagulants, antiplatelets increase bleeding risk
  • Bangladesh available brand examples: Cleven 2000/4000/6000/8000 IU, Clotinex 4000/6000 IU, Enorin 4000/6000/8000 IU, Noxarin 2000/4000/6000/8000 IU, Parinox 2000/4000/6000/8000 IU.

14. Rivaroxaban — post-op / VTE indication, not routine AVN

  • Generic name: Rivaroxaban
  • Therapeutic category: Oral anticoagulant
  • Pharmacological class: Direct factor Xa inhibitor
  • Purpose in AVN: THR/core decompression post-op VTE prophylaxis or separate VTE indication; routine AVN treatment নয়
  • Adult dose example for orthopedic prophylaxis: 10 mg once daily, timing/duration surgery protocol অনুযায়ী
  • Side effects: bleeding, anemia, GI upset
  • Interaction: NSAID/aspirin/antiplatelet bleeding risk; strong CYP3A4/P-gp inhibitors/inducers
  • Bangladesh available brand examples: Rivarox 2.5/10/15/20 mg, RivaXa 2.5/10 mg, Roxarel 2.5/10/15 mg, Rixoban 2.5/10 mg, Kinexa 10 mg.

15. Statin — only if dyslipidemia/risk present

  • Generic name: Atorvastatin / Rosuvastatin
  • Therapeutic category: Lipid-lowering drug
  • Pharmacological class: HMG-CoA reductase inhibitor / statin
  • Purpose in AVN: dyslipidemia control; steroid-associated lipid abnormality থাকলে risk modification. Routine AVN treatment হিসেবে নয়।
  • Adult dose: Atorvastatin 10–20 mg nightly; Rosuvastatin 5–10 mg nightly, lipid profile অনুযায়ী
  • Duration: dyslipidemia/CV risk অনুযায়ী long-term
  • Side effects: myalgia, ↑LFT, rare rhabdomyolysis, new-onset diabetes risk
  • Interaction: macrolides/azole antifungals, cyclosporine, grapefruit; fibrate with statin increases myopathy risk
  • Bangladesh available brand examples: Atorvastatin—Atova 10 mg, Atomax 10/20 mg, Atostin 10/20 mg, Liplo 10/20 mg; Rosuvastatin—Rosuva 10 mg, Rostab 5/20 mg, Rosubest 10 mg, Rosucard 10 mg.

11. বাংলাদেশে doctors সাধারণত AVN prescription-এ কী দেন — practical list

  1. Pain mild: Paracetamol 500 mg PRN
  2. Pain moderate/inflammatory: Etoricoxib 60/90 mg or Naproxen 500 mg BD or Diclofenac 50 mg BD/TDS short course
  3. Gastric protection: Esomeprazole 20/40 mg or Pantoprazole 40 mg OD, especially NSAID use করলে
  4. Severe pain short course: Tramadol 50 mg PRN
  5. Early pre-collapse AVN / steroid-induced osteoporosis: Alendronate 70 mg weekly ± Vitamin D3, but specialist decision
  6. Vitamin D deficiency / low BMD: Cholecalciferol + Calcium/Vitamin D3
  7. Thrombophilia/post-op/VTE risk: Enoxaparin or Rivaroxaban; routine AVN caseে নয়
  8. Dyslipidemia/steroid risk: Atorvastatin/Rosuvastatin if lipid abnormality present
  9. Definitive plan: Orthopedic staging → core decompression or THR depending collapse/stage

12. Prevention — কীভাবে prevent করবেন

  1. Steroid stewardship
    High-dose/repeated corticosteroid avoid; lowest effective dose, shortest duration; steroid card/history document।
  2. Alcohol stop/limit
    Heavy alcohol AVN-এর major risk factor।
  3. Smoking cessation
    Smoking blood vessel narrow করে perfusion কমায়।
  4. Lipid control
    Hyperlipidemia থাকলে diet, exercise, statin indication অনুযায়ী।
  5. High-risk patient screening
    Steroid therapy, SLE, sickle cell, renal transplant, hip trauma—persistent groin pain হলে early MRI।
  6. Hip dislocation urgent reduction
    Delay হলে femoral head AVN risk বাড়ে।
  7. Sickle cell care
    Hydration, crisis prevention, hematology follow-up।
  8. Post-operative DVT prophylaxis
    THR/core decompression after surgery protocol অনুযায়ী anticoagulation।

Overview / Summary

AVN হলো femoral head-এ blood supply কমে bone death হওয়া। Common causes হলো trauma, chronic/high-dose steroid, alcohol, sickle cell disease, SLE, thrombophilia, hyperlipidemia। Early stage-এ X-ray normal থাকতে পারে, তাই MRI is the key test। Medicine mainly pain control ও risk-factor management করে; pre-collapse stageে core decompression helpful হতে পারে, আর collapse/arthritis হলে THR definitive treatment।

Actionable Plan / Steps

  1. Suspected AVN: Groin pain + steroid/alcohol/trauma/SLE/sickle cell history → X-ray AP pelvis + frog lateral।
  2. X-ray normal but suspicion high: MRI both hips।
  3. Stage disease: Ficat/ARCO/Steinberg staging + lesion size/location।
  4. Early pre-collapse: Orthopedic referral; protected weight-bearing, analgesic, risk factor control; consider core decompression ± selected bisphosphonate।
  5. Collapse/arthritis: THR planning।
  6. Drug safety: NSAID দিলে BP/RFT/GI risk দেখুন; PPI add করুন if GI risk; anticoagulant only clear indicationে।
  7. Follow-up: pain, gait, ROM, imaging progression, contralateral hip screening।

Reference List — Textbook + Guideline + DOI

Textbooks

  1. Harrison’s Principles of Internal Medicine, 21st ed. McGraw-Hill; musculoskeletal/rheumatology sections discussing osteonecrosis risk in systemic disease and glucocorticoid exposure.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Elsevier; rheumatology/metabolic bone disease sections.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Elsevier; bone ischemic necrosis/osteonecrosis pathology.
  4. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; osteonecrosis of femoral head, core decompression, osteotomy, arthroplasty.

Guideline / consensus

  1. Joint Surgery Group, Orthopaedic Branch of Chinese Medical Association. Guideline for Diagnostic and Treatment of Osteonecrosis of the Femoral Head. Orthopaedic Surgery. 2015/2019 consensus; treatment selection by stage, lesion location, age, and collapse.
  2. Zhao D, et al. Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults: 2019 version. Journal of Orthopaedic Translation. 2020.

Peer-reviewed journals with DOI

  1. Petek D, Hannouche D, Suva D. Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. EFORT Open Reviews. 2019;4(3):85–97. DOI: 10.1302/2058-5241.4.180036.
  2. Chughtai M, Piuzzi NS, Khlopas A, et al. An evidence-based guide to the treatment of osteonecrosis of the femoral head. Bone & Joint Journal. 2017;99-B(10):1267–1279. DOI: 10.1302/0301-620X.99B10.BJJ-2017-0233.R2.
  3. Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. J Bone Joint Surg Am. 2005;87(10):2155–2159. DOI: 10.2106/JBJS.D.02959.
  4. Chen CH, Chang JK, Lai KA, et al. Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis. Arthritis & Rheumatism. 2012;64(5):1572–1578. DOI: 10.1002/art.33498.

Md.Rafiqul Islam Lipu,Date:-13-06-2026 Saturday Time:-03-03-29 Pm

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