Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with aseptic necrosis of the femoral
head

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
MI, 33 year old man with recent history of left
total hip arthroplasty

1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Personal data

Patient Complaints
Moderate pain and stiffness in left hip, moderate disability in gait.
Post surgical (left hip arthroplasty with implantation of a total denture) rehabilitation status.

ANAMNESIS (history)
Our 33 year old man accused pain in the left hip irradiated in the knee area with functional impotence of the left
lower limb with onset of about 3 months.
Patient MI is from an urban environment, he is a construction worker, smoker (40 cigarettes per day from age 11),
chronic alcohol consumption (beer, wine / daily), without significant pathological personal and collateral history.
He was advised by his family doctor to have an x-ray for both hips, that showed the presence of aseptic necrosis of
the left femoral head. He then went to the Orthopedics-Traumatology Clinic were imaging investigations continued
with a CT scan that confirmed the diagnosis.
The patient underwent surgery for hip arthroplasty with implantation of a left total hip arthroplasty. Upon discharge
the following the recommendations were made: physical therapy to recover walking and change of lifestyle: quit
smoking and severely limit alcohol consumption.

MI is coming in our department to perform and to learn the rehabilitation measures for regain his gait and his
independence daily life.
 Personal data
Questions (for assessment detailed answers see next page)

1. Age and sex of the patient could be a contributing factor in the onset of the disease?
a. Yes
b. No
c. This are indifferent
R=a

2. Which of the following represent risk factors for the development of aseptic necrosis of the femoral head in our
patient?
a. Urban environment
b. Working in construction
c. Alcohol intake
R=c

3. Can smoking be considered a risk factor in our patient case?

a. It is indifferent
b. Yes
c. No
R=b
 Personal data
Questions` answers

1. Age and sex of the patient could be contributing factor in the onset of the disease?
Aseptic necrosis of the femoral head mainly affects young adults between the 3rd and 5th decade of life. It is considered
that aseptic necrosis of the femoral head affects men, four times more frequently than women. Some authors recorded a
male to female sex ratio of 8:1.

2. Which of the followings represent risk factors for the development of aseptic necrosis of the femoral head in our
patient case?
The relative frequency of the most common causes of avascular necrosis of the femoral head at a global level is:
alcoholism (20-40%), corticosteroid therapy (35-40%) and idiopathic causes (20-40%). Several studies have shown
that alcohol plays an important role in proliferation and adipocyte hypertrophy, fatty degeneration osteocytes and
bone bays modification issues by reducing the number and appearance of narrowed trabecular areas. A significant
proportion of patients with aseptic necrosis of the femoral head primary risk factor in the development of the disease
is the alcohol consumption. Alcohol consumption and the incidence of aseptic necrosis of the femoral head have a
significant doseeffect relationship.

3. Can smoking be considered a risk factor in our patient case?

A significantly increased risk of developing aseptic necrosis of the femoral head was found in smokers. As regards
the causal link between smoking and the onset of the disease, several studies have confirmed the association between
the effects of smoking as the only risk factor or associated to excessive alcohol consumption.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

MI has normal weight (BMI= 23,8 Kg/m2)., discrete erythrose of the cheekbone.
Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine scoliotic attitude- lumbar spine.

Upper limb joints ROM and muscle strength with normal values in accordance with his age.
Lower limb ROM of right hip, both knee and ankle joints in normal limits, muscle strength of right lower limb with
normal values in accordance with his age.
Left hip joint - minimal pain with any movement of the left leg. The skin is normal, with scar after surgical
intervention in the lateral side of the groin. MI had limited ROM to 0-75 degrees of flexion, 15-20 degrees of
abduction, internal rotation less than five degrees, and external rotation less than 10 degrees. Weakness of the hip
muscles was noted (the dynamic stabilizers of the pelvis, including hip flexors, extensors, and abductors had -4, -4
and -4 at MMT, respectively) and the ability to stand and balance on left lower limb is diminished. A passive
straight-leg raise was possible but with pain, like rectus femoralis stretch test.
Gait is possible with one crutch, on the right side (partial weight bearing gait on the left lower extremity).
Neurovascular status of lower limbs are intact. His peripheral pulses are palpable, and he has normal distal sensation
in both of the lower extremities.
Vital Signs: temperature 36.7C, blood pressure 130/70 mmHg, rhythmic pulse 72 b/min, 18 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. Manual muscle testing is necessary in physical examination in our patient?

a. No
b. It can be ignored in rehabilitation program
c. Yes
R=c

2. Why is important to perform ROM in our patient?

a. To establish the extension and flexion mechanisms of lower limb
b. To complete the physical examination
c. To monitor the pain of lower limb
R=b

3. Why is it important to perform MMT (manual muscle testing) for all muscles of the lower limb?
a. For gait are important both extension and flexion kinetic chains of lower limb
b. For controling the hip pain
c. For choosing the AINS medication
R=a
 Clinical data
Questions` answers

1. Manual muscle testing is necessary in physical examination in our patient?

The physical examination of lower limb muscles starts with palpation. Through this physical examination we feel
the soft tissues around the sore area and check skin temperature and swelling, pinpoint sore areas, and look for
tender points or spasm in the muscles around the hip. Muscles that may be checked include the quadriceps
(thighs), buttocks, hamstrings, and calves. The results are compared to the other side. Weakness in key muscles
will be addressed with a strengthening program.

2. Why is important to perform ROM in our patient?

Checking the range of motion (ROM) in the operated hip is a measurement of how far our patient can move his
affected hip in different directions. Measurements might include all motions, in all three planes (flexion /
extension, internal rotation / external rotation, abduction / adduction). These aspects are essential for gait
rehabilitation. The ROM values during each visit are important to chart the functional progress for our patient.

3. Why is it important to perform MMT (manual muscle testing) for all muscles of the lower limb?
All rehabilitation programs for gait in patients with aseptic necrosis of the femoral head take into consideration
the global kinetic exercises, after analytic kinetic program. The kinetic muscle chains of the lower limb for
extension and for flexion are very important for independence ambulation, so previous kinetic program must
do the MMT.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Imagistic data

Between the occurrence of hip injury and detection on X-ray suggestive images a
5 year interval usually passes. The sensitivity of the method in the diagnosis of
early stages is only 41%.

In the early stages, the sensitivity of CT is quite low, being only 55%, but can
detect certain alterations in bone density when X-ray images are normal. CT is
useful in assessing the later stages for lesion extension, such as sclerosis and other
events occurring in the state of repair.

IRM is a non-invasive imaging

technique with the highest degree
of specificity and sensitivity used
in the diagnosis of aseptic
necrosis of the femoral head. In
the early stages it is more
effective than simple
computerized tomography (CT)
or the single-photon emission
(SPECT), with a degree of
increased specificity in the
detection of the condition of up to
90%.
Imagistic data
Questions (for assessment detailed answers see next page)

1. Which of the followings aspects found on the X-ray performed before surgery suggests the diagnosis?
a. Loss of sphericity of the left femoral head
b. Collapse of the right femoral head
c. Left joint space narrowing
R = a, c

2. Are the imagistic findings on X-ray of the acetabulum important in choosing the type of implant used?
a. No
b. Yes
c. It is indifferent
R=b

3. A normal image obtained by X-ray does translate into the absence of aseptic necrosis of the femoral head?
a. Yes
b. No, the X-ray should be repeated after a year
c. No, other imaging technique should be performed (IRM, CT)
R=c
 Imagistic data
Questions` answers

1. Which of the followings aspects found on the X-ray performed before surgery suggest the diagnosis?
Anteroposterior x-ray of the hip performed before surgery noted loss of sphericity and collapse of the left femoral
head, left joint space narrowing and acetabular changes. No changes were found in the right femoral head.

2. Are the imagistic findings on X-ray of the acetabulum important in choosing the type of implant used?
The pelvic radiography of our patient performed before surgery noted acetabular changes. Therefore a total denture
was used instead of a partial denture. This has a direct impact on the rehabilitation program and the later evolution of
the patient. The young age of the patient makes it very likely that they will need additional hip surgery.

3. A normal image obtained by X-ray does translate into the absence of aseptic necrosis of the femoral head?
Changes in the early stages of aseptic necrosis of the femoral head are hard to detect on plane X-ray. A normal image
obtained by X-ray does not necessarily translate into the absence of the disease. Patients at high suspicion should
undergo an IRM or a CT examination, even if the plane X-ray have not detected significant changes, because the
diagnosis of aseptic necrosis of the femoral head in the early stages is a necessity in order to obtain an optimal result
when performing conservative treatment. A thorough investigation is particularly important for patients whose disease
is already present at one of coxofemoral joint as in 50-60% of cases bilateral aseptic necrosis occurs.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assess, in accordance with ICF:

impairments of body functions - pain, stiffness, muscle weakness, diminish in maxim hip ROM (b28015 pain in lower
limb; b2804 radiating pain in a segment or region);
changes in body structures aseptic necrosis femoral head (s7408 structure of pelvic region, s7508 structure of lower
extremity);
activity limitation - limited walking ability and problems with ADLs (d4153 maintaining a sitting position - Staying in a
seated position, on a seat or the floor, for some time as required, such as when sitting at a desk or table)
participation restrictions - reduced participation in leisure activities and in household chores.
The primary ICF activities and participation codes associated with ankle stability and movement coordination impairments
are d450 walking, d4552 running, d4558 moving around, specified as direction changes while walking or running.

We used:
easily reproducible physical performance measures for activity limitation and participation restriction
VAS = 8 before, 4 after rehabilitation program;
6 Minute Walk, with crutches = 170 meters before; 260 meters after rehabilitation program;
Timed Up and Go, with crutches = 39 seconds before; 21 seconds after rehabilitation program;
scales for condition-specific health status measures
The Harris Hip Score (HHS) - is a clinician tool used for the assessment of the hip status. HHS includes four
subscales - there are 10 items. Score ranges from 0-100 with higher score representing less dysfunction and better
outcomes (a maximum of 100 points - best possible outcome) covering pain (1 item, 044 points), function (7 items,
047 points), absence of deformity (1 item, 4 points), and range of motion (2 items, 5 points) = 34 before
rehabilitation; 48 after rehabilitation program.
SF-36 (the lower the score the more disability - a score of zero is equivalent to maximum disability; the higher the
score the less disability a score of 100 is equivalent to no disability) = 36 before rehabilitation; 50 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. It is important to assess the functional status in our patient ?

a. Yes
b. No
c. It is not important to mention
R=a

2. The final score of the two scales used for our patient The HHS and SF-36 are in concordance with the
disability status ?
a. No
b. There is no possibility to compare the two score scales
c. Yes
R=c

3. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
a. There are no explanations
b. The functional status is not improved after intervention
c. The rehabilitation program for muscular joint status takes a few weeks after intervention
R=c
 Functional data
Questions` answers

1. It is important to assess the functional status in our patient ?

Yes. In accordance with the International Classification of Functioning, Disability and Health (ICF), the degree of
impairments, disabilities, participation problems and health related quality of life should be described from the
patients perspective.

2. The final score of the two scales used for our patient The HHS and SF-36 are in concordance with the
disability status ?
Yes. The both scales contain the items for quality of life and various daily activities in which the lower limb, hip
especially, is responsible for balance and gait. The gait scheme is disturbed in aseptic necrosis of the femoral head.

3. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Complete recovering from the surgery reclaim 2 3 months for plateau in strength and functional gains. The outcome
measures chosen for our patient study are common clinical measurements and their associated impairments are
theoretically addressable by targeted rehabilitation techniques, in accordance with medical literature data.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Aseptic necrosis of the left femoral head stage IV (Ficat and Arlet classification)(operated 7
weeks ago, hip arthroplasty with implantation of left total hip denture).
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. Which of the followings brings the most important data for the complete diagnosis in our patient ?
a. The functional data
b. Heredo-collateral antecedents
c. The imagistic findings
R=c

2. Do the clinical aspects bring enough data for our patients complete diagnosis?
a. Yes
b. No
c. It is indifferent
R= b

3. The following complications may occur in our patient?

a. Aseptic necrosis of the right femoral head
b. Left hip arthrosis
c. Additional left hip surgery
R = a, c
 Complete diagnosis
Questions` answers

1. Which of the followings brings the most important data for the complete diagnosis in our patient ?
The X-ray and CT scan findings such as loss of sphericity and collapse of the left femoral head, left hip joint space
narrowing, degeneration of the left hip joint, acetabular changes, sclerosis, presence of cysts, were suggestive for the
diagnosis.

2. Does the clinical aspect bring enough data for our patients complete diagnosis?
Aseptic necrosis of the femoral head has no clinically relevant characteristic. For the complete diagnosis of aseptic
necrosis of the femoral head the physician should have a high index of suspicion, especially in patients with risk
factors. The main risk factors of the disease are represented by trauma, chronic alcohol consumption, smoking,
corticosteroid treatment. The complete diagnosis is based on imaging techniques (IRM, CT scan, X-ray).

3. The following complications may occur to our patient?

Our patient should be constantly investigated because for patients whose disease was already present at one hip
joint in 50-60% of cases, bilateral aseptic necrosis occurs. Taking into account the age of our patient, it is unlikely
that the prosthesis used during hip arthroplasty to retain functionality for 40-45 years, as is his life expectancy.
Unfortunately long-term results on the use of full dentures (cemented or uncemented) in the treatment of aseptic
necrosis of the femoral head is generally unsatisfactory.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Rehabilitation program (RP)

1. Objectives of RP in our patient:

painful status control;
to restore function of the involved limb
correcting abnormal walking scheme, with recovery of normal walking;
keeping the hip in the economy of the limb biomechanics;
maintenance of normal daily activities and improving of quality of life; to return our patient to the same level of
independence and activity that existed before his injury.

2. Methods of RP used in our patient:

pharmacological modalities analgesics.
non-pharmacological modalities:
- educational- quit smoking and severely limit alcohol consumption., dietary and hygienic,
- posture (activity modification), elastic compression stockings in the first 4 weeks after surgical procedure,
- physical (thermotherapy ice-pack to control pain and edema; electrotherapy - TENS, laser, NMES) - decreased joint
pain will reduce chances of developing complications during the rehabilitation process;
- massage classic for trunk, special venous drainage massage for lower limbs and special massage (Cyriax),
- kinetic and occupational therapy for ADL rehabilitation
- early rehabilitation includes gait training with assistive devices, walker and crutches, cane after; ankle pumps,
range of motion exercises (passive and active, from foot to hip), isometric contraction of all muscles of lower
limbs;
- non-weight-bearing exercises, treadmill exercises, weight-bearing exercises, respiratory exercises
- intensive physical training active ROM, strength training, progressive resistive exercises - can improve
quality of life and reduce disability, balance and proprioception exercises, global exercise to improve functional
mobility and walking ability.
 Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why was hip arthroplasty indicated in our patient?

a. Conservative methods (non-surgical) were to expensive
b. The patient requested the intervention
c. His left hip joint was compromised
R=c

2. Why should we respect the kinetic algorithm program in our patient rehabilitation ?
a. Because it is the patient option
b. Because ROM exercises must preceded the strength exercise
c. Because the patient has a total hip denture
R=b

3. What were the goals of RP in our patient, when he came in our department ?
a. Initiate functional weight bearing exercises, open kinetic chain AROM and isotonic strengthening exercises
b. Restoration of strength, power, and endurance
c. Initiate proprioception and gradual gait exercises
R = a, c
 Rehabilitation program
Questions` answers

1. Why was hip arthroplasty indicated in our patient?

The therapeutic modalities used to treat necrosis of the femoral head include: non-surgical and surgical. Nonsurgical
means are used especially before the femoral head collapse, involve behavioral changes in patients and have not proven
effective, even in the early stages. Surgical treatment means are divided into two categories: rescue procedures and
reconstructive procedures. Rescue procedures are used in early stages, attempting to stop or delay the progress. These are
represented by drilling biopsy, bone grafts and osteotomies. Reconstructive methods are used after the femoral head
collapse, as in our patient case, and are represented by bipolar arthroplasty or total arthroplasty (cemented or un-
cemented). The total hip arthroplasty reduces pain, corrects deformities and helps restore the ability to move the affected
joint.

2. Why should we respect the kinetic algorithm program in our patient rehabilitation ?
The range of motion, strengthening, and proprioceptive exercises of the involved joint should be initiated and
progressed as indicated and tolerated by the individual. The rehabilitation program is adapted to the surgical
intervention performed for our patient.

3. What were the goals of RP in our patient, when he came in our department ?
The patient is coming in our department 7 weeks after the hip intervention. The goals of the rehabilitation program
are: normalizing AROM and impaired proprioception, initiate gradual return to functional activities and light work
activities. All rehabilitation has to respect the progression for optimal control of patients impairments and functional
limitation.