Patient with hip pain and normal x-ray but MRI shows early avascular necrosis of femural head.
Yes. There are reports that suggest that bisphosphonate in early avascular necrosis of femoral head in the pre collapse stages of the disease may be beneficial and showed improvement in the clinical function, a reduction in the rate of
collapse and a decrease in the requirement for total hip replacement. But Longer-term data are required before this recommendation can be made Check article in file attachment.
In my opinion this could be only a therapy of hope. Biphosphonates have nothing to do with the recovery of blood circulation of the femoral head. They do not reach the avascular zones and consquently cannot interfere with bone metabolism at all. My experience of 40+ years with different medications (incl. biphosphonates) for early stages of avascular necrosis of the femoral head is disappointing.
Limitation of weight bearing and use of crutches are helpful. Use of bisphosphonate is supported by number of of papers and showed an improvement in early AN. Also, statin may prevent steroid induced AVN.
Dear Dr. Isho and Dr. Elwakd,
Would you, please, share your personal experience with biphosphonates ? This is very important because many reports in the literature are not evidence-based, and some of them are encouraged by commercial goals.
dear dr Panayot Tanchev ,drMohamed Elwakd ,and dr Faiq Isho , thanks alot for your valuable openion, i think the patient with early avascular necrosis may benefit from biphosphonate trial although the success rate may be low
The problem in literature is that many cases started biphos in a to late stage, if your are able tot start within the first week that necrosis occur, the result is amazing.
The problem is as soon revascularisation starts and that is direct after the incident, osteoclast work harder to get space for vessels and thereafter osteblast starts to work
biphos slow down this turnover from the osteoclast work and that how it will work.
greetz
Dear Dr. Pruijs,
As far as I could understand your explanation the osteoclasts in acute AN work intensively to get space for vessels (i.e. for revascularisation ?). How should this activity be stimulated by biphos ? It is generally accepted and proven that biphos block the osteoclast activity, don't they ?
Dear Tanchev
Good day
We have many patients who were diagnosed ealy by MRI as stage 1 and 2 avascular necrosis of femur head and were treated by Alendronate 70 mg /wk and followed up, patients showed significant clinical improvement in pain and clinical function.We are still following them, some of them about 2 years and patient did not progressed to late stages of femur head collapse.
Which opinion is reliable ? To start biphos the first week (stage O) or to start at stage 2 ? Sorry, I do not understand.
Theoretical slowing down the process of osteoclast , osteoclast find more time to induce bone formation. What you get after fracture is that the first 6 months you don't see anything changing and after a year you see the callus comming.
So the total process is slowing down, but with a good outcome without collaps of the femural head. In avasculair necrosis, weiggth bearing is allowed, as dedbone is as stron as living bone. The overreaction after necrosis of the osteoclasts make room for the collaps.
Sorry, osteoclasts may conduct but they do not induce bone formation. They are responsible for the catabolism of bone.
Furthermore, I am really upset by the idea to allow weight bearing in cases with AVN. It is generally accepted that weight bearing leads to dead fragment collapse. The idea of long-time avoiding of weight bearing is to preserve the form of the head untill the revascularization (if ever !) occurs. Here, I would make a link to the treatment of Perthes disease.
In my opinion the association of the process of AVN with the fracture healing is not appropriate. These things are different. In my opinion the fracture healing (some changes !) beginns immediately after the injury with the formation of hematoma with its pluripotent cells.
sorry I mis typed in the first sintenc the twice osteoclst were i should type osteoblast.
I do not see difference in fracture heling or necrosis, except the missing bloodcloth.
The problem in all necrosis is that resorbition of dedbone goes much vaster tha formation of new bone. That why biphos, slowing down osteoclast are functional in treatment.
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