RICE & MICE: Avascular Necrosis and Ray Emery’s comeback

Ray Emery’s hockey career was hanging in the balance when diagnosed with avascular necrosis of the hip last March. An MRI done to evaluate some nagging groin and hip pain revealed the condition. His season was definitely over, and had this occurred 10-15 years ago, his career could very well have been over.

He made the decision to have surgery that promised everyday function of his hip, “The success is kind of considered being mobile, not playing professional sports,” he said at the time.

Avascular necrosis (AVN), also called osteonecrosis, can affect any bone in the body and can be a complication of bone fractures. AVN of the hip occurs when normal blood flow is interrupted and the blood that gets to the head of the femur (ball of the hip joint) is not sufficient enough to sustain bone health. The decrease or loss of blood flow can cause the bone to die and become brittle and eventually collapse. AVN can cause nagging pain in the earliest stages and in more severe stages, severe pain, and decreased range of motion of the hip as well as severe arthritis and loss of cartilage.

AVN of the hip has been linked to traumatic hip injuries, such as fractures and dislocations, as well as stress fractures; narrowed blood vessels caused by fat deposition or clogged vessels (this can occur in sickle cell disease).

Two of the more common risk factors that have been linked to AVN are excessive alcohol consumption (3 or more beers on a daily basis) or prolonged high doses of corticosteroids (think prednisone; not Arnold Schwarzenegger) that are sometimes used to treat medical conditions, such as lupus and rheumatoid arthritis.

AVN ended Bo Jackson’s career in the early 1990’s. Bo’s AVN was cause by a fracture and dislocation of his hip that damaged blood vessels around the hip joint during an otherwise routine play in a Los Angeles Raiders game against the Cincinnati Bengals. Treatment options for AVN were limited at the time and Bo ended up having a total hip replacement. Bo knows how difficult it is to face this injury and to attempt a comeback from it. One almost wonders if Bo’s career would have ended so early if we knew then what we know now.

Emery’s hip condition was discovered after an MRI. Early on in AVN, plain x-rays will be normal so in younger patients that complain of persistent pain in the groin or hip combined with any of the risk factors will usually get an MRI.

MRI can distinguish changes in the bone marrow caused by loss of blood flow well before changes the changes will show on an x-ray. Additionally, since both hips are routinely imaged in the same sitting, MRI is useful in because it evaluates both hips, and since 50% of people with AVN of one hip can develop it in the other hip, an MRI may even pick up changes before the patient has symptoms.

Present-day treatment options still include total hip replacement, in which the dead or damaged section of bone is removed and a prosthetic ball and socket are put into place. There is a limited life on artificial joints and they aren’t a great option for anyone in the mid 20’s on up, since most patients will need revisions every 10 years or so.

Hip replacements can last up to 20 years in patients over the age of 50. If the hip joint is severely damaged by AVN, total joint replacement may be the only option. There are also hip resurfacing procedures, a form of partial hip replacement with metal, available, but this is a relatively newer procedure. If AVN is diagnosed early and the affected area of the femoral head is very small, a procedure called core decompression and bone grafting. This procedure involves removing a limited amount of dead bone from the “ball” of the hip in hopes of relieving pressure within the femoral head and allowing the body to restore its own blood supply over time.

The surgery that Emery had is called free vascularized fibular grafting and has been shown to be successful in restoring the hip bone and preventing the need for hip replacement.

Free vascularized fibular grafting for the hip is performed at only a few medical centers throughout the country (Ray’s surgery was done at Duke Medical Center) and the surgeons who perform the surgery have extensive training.  Basically the surgery involves removal of the dead areas of bone from the hip. A section of the fibula, the smaller, non-weight bearing bone of the lower leg (the one on the lateral or outside of your lower leg) is harvested along with the corresponding blood vessels. This section of bone is then fitted into the hip and the blood vessels of the fibula are attached to the blood vessels that surround the hip.

The blood vessels and “live” bone taken from the fibula provide immediate circulation of blood to the hip where the “dead” bone was removed. The section of fibula helps to reinforce the ball, so a larger portion of the dead bone can be removed.

The rehabilitation for free vascularized fibular grafting is extensive and slow. The patient is usually hospitalized for a period of time before going home using crutches or a walker. The patient is not allowed to bear any weight on the hip in the first 6 weeks. After that, crutches provide protected and limited weight bearing for a period of about 6 months. After 6 months, full weight bearing is allowed and rehabilitation consists of muscle strengthening and flexibility.

Emery’s rehabilitation consisted of a regimen that included yoga, Pilates, swimming, and acupuncture. The training was extensive and tedious. Emery worked out twice a day, every day. Running and other impact activities are usually not allowed for the first year after surgery. This procedure promises the average Joe an active and pain free life. Emery is no average Joe and he has made it clear that he is willing to fight for his career.

“Usually when you have this type of thing done, they just want you to walk again,” Emery told ESPN.com in an October interview. “The doctor was understanding of what I wanted. I told him that I could care less if I can’t walk in five years, but I want just want to play hockey for five years.” The longer term success has yet to be seen. He was 6-0-0 in his first 6 starts for Anaheim since making his return to the NHL and has since been nominated for the 2010-2011 Bill Masterton Memorial Trophy.

I don’t know if Ray Emery will be playing in the next five years; there’s been no precedent for a recovery to professional sports from such a condition. There’s always a risk of developing avascular necrosis in his other hip and subsequent arthritis will also be cause for concern, however his perseverance and drive to return to the NHL are definitely admirable. I wish him the best for as long as his career lasts.

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