Skip to main content
SpringerLink
Log in

Osteonecrosis

  • Chapter
Diagnosis and Management of Hip Disease

  • 1156 Accesses

Abstract

Osteonecrosis or avascular necrosis is a condition in which a localized area of bone becomes necrotic due to an impairment of its blood supply. It affects primarily young adults and has been associated with several etiologic factors. The pathophysiology will be discussed as it provides a basic understanding of ON, as well as a biologic basis for diagnosis and management. Early diagnosis and treatment are essential to retard or prevent progression and preserve the femoral head. A number of treatment options are available, although none is completely successful. Once collapse has occurred, total hip replacement is currently the treatment of choice when clinically indicated. Results have improved considerably with modern techniques and components, and survivorship of 25 or more years might be anticipated.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 59.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 79.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Abbreviations

ARCO:

Association Research Circulation Osseous

BMES:

Bone marrow edema syndrome

BMP:

Bone morphogenetic protein

CT:

Computerized tomography

DBM:

Demineralized bone matrix

DJD:

Degenerative joint disease

eNOS:

Endothelial nitric oxide synthase

FVFG:

Free vascularized fibular grafts

MFCA:

Medial femoral circumflex artery

ON:

Osteonecrosis

PET:

Positron emission tomography

SLE:

Systemic lupus erythematosus

SRA:

Surface replacement arthroplasty

THR:

Total hip replacement

TOH:

Transient osteoporosis of the hip

VEGF:

Vascular endothelial growth factor

References

  1. Luck JV. Bone and joint diseases. Springfield: Charles C. Thomas; 1950.

    Google Scholar 

  2. Hungerford DS, Jones LC. Asymptomatic osteonecrosis: should it be treated? Clin Orthop Relat Res. 2004;(429):124–30.

    Google Scholar 

  3. Jones JP. Intravascular coagulation and osteonecrosis. Clin Orthop. 1992;277:41–53.

    PubMed  Google Scholar 

  4. Glueck CJ, Freiberg RA, Fontaine RC, et al. Hypofibrinolysis, thrombophilia, osteopenia. Clin Orthop Relat Res. 2001;386:19–33.

    Article  PubMed  Google Scholar 

  5. Kim T-H, Hong J-M, Lee J-Y, et al. Promoter polymorphisms of the vascular endothelial growth factor gene is associated with osteonecrosis of the femoral head in the Korean population. Osteoarthritis Cartilage. 2008;16(3):287–91.

    Article  Google Scholar 

  6. Koo K-H, Lee J-A, Lee Y-S, et al. Endothelial nitric oxide synthase gene polymorphisms in patients with non-traumatic femoral head osteonecrosis. J Orthop Res. 2006;24(8):1722–8.

    Article  CAS  PubMed  Google Scholar 

  7. He W, Li K. Incidence of genetic polymorphisms involved in lipid metabolism among Chinese patients with osteonecrosis of the femoral head. Acta Orthop. 2009;80(3):325–9.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Kenzora JE, Glimcher MJ. Accumulative cell stress: the multifactorial etiology of idiopathic osteonecrosis. Orthop Clin North Am. 1985;16:669.

    CAS  PubMed  Google Scholar 

  9. Atsumi T, Kuroki Y, Yamano K. A microangiographic study of idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res. 1989;246:186–94.

    PubMed  Google Scholar 

  10. Atsumi T, Kuroki Y. Role of impairment of blood supply of the femoral head in the pathogenesis of idiopathic osteonecrosis. Clin Orthop Relat Res. 1992;277:22–30.

    PubMed  Google Scholar 

  11. Gautier E, Ganz K, Krügel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg. 2000;82-B:679–83.

    Article  Google Scholar 

  12. Iwata H, Torii S, Hasegawa Y, et al. Indications and results of vascularized pedicle iliac bone graft in avascular necrosis of the femoral head. Clin Orthop Relat Res. 1993;295:281–8.

    PubMed  Google Scholar 

  13. Ohzono K, Takaoka K, Saito S, Saito M, Matsui M, Ono K. Intraosseous arterial architecture in nontraumatic avascular necrosis of the femoral head. Clin Orthop Relat Res. 1992;277:79–88.

    PubMed  Google Scholar 

  14. Trueta J, Harrison MH. The normal vascular anatomy of the femoral head in adult man. J Bone Joint Surg Br. 1953;35-B(39):442.

    CAS  PubMed  Google Scholar 

  15. Ono K. Diagnostic criteria, staging system and roentgenographic classification of avascular necrosis of the femoral head (steroid induced, alcohol associated or idiopathic nature (in Japanese)). In: Ono K, editor. Annual report of Japanese Investigation Committee for Intractable Disease, avascular necrosis of the femoral head. Tokyo: Ministry of Health and Welfare; 1987. p. 331–6.

    Google Scholar 

  16. Sugano N, Takoaka K, Ohzono K, Matsui M, Masuhara K, Ono K. Prognostication of nontraumatic avascular necrosis of the femoral head: significance of location and size of the necrotic lesion. Clin Orthop Relat Res. 1994;303:155–64.

    PubMed  Google Scholar 

  17. Bozic KJ, Zurakowski D, Thornhill TS. Survivorship analysis of hips treated with core decompression for nontraumatic necrosis of the femoral head. J Bone Joint Surg. 1999;81-A:200–9.

    Google Scholar 

  18. Steinberg ME, Corces A, Fallon M. Acetabular involvement in osteonecrosis of the femoral head. J Bone Joint Surg. 1999;81-A:60–5.

    Google Scholar 

  19. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br. 1995;77:34–41.

    CAS  PubMed  Google Scholar 

  20. Arlet J, Ficat RP. Forage-biopsie de la tete femorale dans l’osteonecrose primitive. Observations histopathologiques portant sur huit foranes. Rev Rheum. 1964;31:257–64.

    Google Scholar 

  21. Ficat RP, Arlet J. Necrosis of the femoral head. In: Hungerford DS, editor. Ischemia and necrosis of bone. Baltimore: Williams & Wilkins; 1980. p. 53–74.

    Google Scholar 

  22. Ficat RP. Idiopathic bone necrosis of the femoral head: early diagnosis and treatment. J Bone Joint Surg Br. 1985;67:3–9.

    CAS  PubMed  Google Scholar 

  23. Marcus ND, Enneking WF, Massam RA. The silent hip in idiopathic aseptic necrosis: treatment by bone grafting. J Bone Joint Surg Am. 1973;55:1351–66.

    CAS  PubMed  Google Scholar 

  24. Sugioka Y. Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip. Clin Orthop Relat Res. 1978;130:191–201.

    PubMed  Google Scholar 

  25. Steinberg ME, Hayken GD, Steinberg DR. A new method for evaluation and staging of avascular necrosis of the femoral head. In: Arlet J, Ficat RP, Hungerford DS, editors. Bone circulation. Baltimore: Williams & Wilkins; 1984. p. 398–403.

    Google Scholar 

  26. Steinberg ME, Steinberg DR. Evaluation and staging of avascular necrosis. Semin Arthroplasty. 1991;2(3):175–81.

    Google Scholar 

  27. Gardeniers J. ARCO Committee on Terminology and Staging. A new proposition of terminology and an international classification of osteonecrosis. ARCO Newsl. 1991;3:153–9.

    Google Scholar 

  28. Gardeniers JWM. A new international classification of osteonecrosis of the ARCO Committee on Terminology and Classification. ARCO Newsl. 1992;4:41–6.

    Google Scholar 

  29. Gardeniers JWM. ARCO Committee on Terminology and Staging. Report on the committee meeting at Santiago de Compostella. ARCO Newsl. 1993;5:79–82.

    Google Scholar 

  30. Koo K-H, Kim R. Quantifying the extent of osteonecrosis of the femoral head: a new method using MRI. J Bone Joint Surg Br. 1995;77:875–80.

    CAS  PubMed  Google Scholar 

  31. Cherian SF, Laorr A, Saleh KJ, et al. Quantifying the extent of femoral head involvement in osteonecrosis. J Bone Joint Surg. 2003;85-A:309–15.

    PubMed  Google Scholar 

  32. Ha Y-C, Jung WH, Kim J-R, et al. Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg. 2006;88-A(Supplement 3):35–40.

    Article  Google Scholar 

  33. Mitchell MD, Kundel HL, Steinberg ME, et al. Avascular necrosis of the hip: comparison of MRI, CT, and scintigraphy. Am J Radiol. 1986;147:67.

    CAS  Google Scholar 

  34. Lang P, Genant HK, Jergesen HF, et al. Imaging of the hip joint: computed tomography versus magnetic resonance imaging. Clin Orthop Relat Res. 1992;157:751–6.

    Google Scholar 

  35. Gardeniers JWM. The ARCO perspective for reaching one uniform staging system of osteonecrosis. In: Schoutens A, Arlet J, Gardiniers JWM, Hughs SPF, editors. Bone circulation and vascularization in normal and pathological conditions. New York: Plenum Press; 1993. p. 375–80.

    Chapter  Google Scholar 

  36. Lee G-C, Steinberg ME. Are we evaluating osteonecrosis adequately? Int Orthop (SICOT). 2012;36:2433–9.

    Article  Google Scholar 

  37. Mont MA, Marulanda GA, Jones LC, et al. Systematic analysis of classification systems for osteonecrosis of the femoral head. J Bone Joint Surg. 2006;88-A(Supplement 3):16–26.

    Article  Google Scholar 

  38. Lee G-C, Khoury V, Steinberg D, Kim W, Dalinka M, Steinberg M. How do radiologists evaluate osteonecrosis? Skeletal Radiol. 2014;43:607–14.

    Article  PubMed  Google Scholar 

  39. Massari L, Fini M, Cadossi R, et al. Biophysical stimulation with pulsed electromagnetic fields in osteonecrosis of the femoral head. J Bone Joint Surg. 2006;88-A(Supplement 3):56–60.

    Article  Google Scholar 

  40. Ciombor DMK, Aaron RK. Electric, electromagnetic and acoustic treatment for avascular necrosis of the femoral head. Tech Orthop. 2008;23(1):11–7.

    Article  Google Scholar 

  41. Reis ND, Schwartz O, Militianu D, et al. Hyperbaric oxygen therapy as a treatment for stage-I avascular necrosis of the femoral head. J Bone Joint Surg Br. 2003;85:371–5.

    Article  CAS  PubMed  Google Scholar 

  42. Nishi T, Sugano N, Mike H, et al. Does Alendronate prevent collapse in osteonecrosis of the femoral head? Clin Orthop Relat Res. 2006;443:273–9.

    Article  Google Scholar 

  43. Davidson JL, Coogan PG, Gunneson EE, Urbaniak JR. The asymptomatic contralateral hip in osteonecrosis of the femoral head. In: Urbaniak JR, Jones JP, editors. Osteonecrosis: etiology, diagnosis and treatment. Rosemont: American Academy of Orthopaedic Surgeons; 1997. p. 231–40.

    Google Scholar 

  44. Hernigou P, Poignard A, Nogier A, Manicom D. Fate of very small asymptomatic stage-I osteonecrotic lesions of the hip. J Bone Joint Surg. 2004;86-A:2589–95.

    CAS  PubMed  Google Scholar 

  45. Belmar CJ, Steinberg ME, Hartman KM. Does pain predict outcome in hips with osteonecrosis? Clin Orthop Relat Res. 2004;(425):158–62.

    Google Scholar 

  46. Johnson AJ, Mont MA, Tsao AK, Jones LC. Treatment of femoral head osteonecrosis in the United States: 16+ year analysis of nationwide inpatient sample. Clin Orthop Relat Res. 2014;472:617–23.

    Article  PubMed Central  PubMed  Google Scholar 

  47. McGrory BJ, York SC, Iorio R, Macaulay W, Pelker RR, Parley BS, Teeny SM. Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head. J Bone Joint Surg. 2007;89-A:1194–204.

    Google Scholar 

  48. Steinberg ME, Brighton CT, Corces A, et al. Osteonecrosis of the femoral head: results of core decompression and grafting with and without electrical stimulation. Clin Orthop Relat Res. 1989;(249):199–208.

    Google Scholar 

  49. Hungerford DS, Jones LC. Core decompression. Tech Orthop. 2008;23(1):26–34.

    Article  Google Scholar 

  50. Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res. 1996;324:169.

    Article  PubMed  Google Scholar 

  51. Fairbank AC, Bhatia D, Jinnah RH, Hungerford DS. Long-term results of core decompression for ischemic necrosis of the femoral head. J Bone Joint Surg Br. 1995;77:42.

    CAS  PubMed  Google Scholar 

  52. Kerboul M, Thomine J, Postel M, Merle d’Aubigne R. The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. J Bone Joint Surg Br. 1974;56:291–6.

    CAS  PubMed  Google Scholar 

  53. Atsumi T, Kajiwara T, Hiranuma Y, et al. Posterior rotation osteotomy for nontraumatic osteonecrosis with extensive collapse in young patients. J Bone Joint Surg. 2006;88-A(Supplement 3):42–7.

    Article  Google Scholar 

  54. Meyers MH. The treatment of osteonecrosis of the hip with fresh osteochondral allografts and with the muscle pedicle graft technique. Clin Orthop Relat Res. 1978;130:202–9.

    PubMed  Google Scholar 

  55. Meyers MH, Convery FR. Grafting procedures in osteonecrosis of the hip. Semin Arthroplasty. 1991;3:189–97.

    Google Scholar 

  56. Mont MA, Einhorn TA, Sponseller PD, Hungerford DS. The trapdoor procedure using autogenous cortical and cancellous bone grafts in the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Br. 1998;80:56–62.

    Article  CAS  PubMed  Google Scholar 

  57. Phemister DB. Fracture of neck of femur, dislocation of hip, and obscure vascular disturbances producing aseptic necrosis of head of femur. Surg Gynecol Obstet. 1934;59:415.

    Google Scholar 

  58. Bonfiglio M, Bardenstein MD. Treatment by bone grafting of aseptic necrosis of the femoral head and non-union of the femoral neck (Phemister Technique). J Bone Joint Surg Am. 1958;40:1329–46.

    PubMed  Google Scholar 

  59. Rosenwasser MP, Garino JP, Kiernan HA, Michelson CB. Long-term follow up of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis. Clin Orthop Relat Res. 1994;306:17–27.

    PubMed  Google Scholar 

  60. Gilbert A, Judet H, Judet J, Agatti A. Microvascular transfer of the fibula for necrosis of the femoral head. Orthopedics. 1986;9:885.

    CAS  PubMed  Google Scholar 

  61. Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. J Bone Joint Surg Am. 1995;77:681–94.

    CAS  PubMed  Google Scholar 

  62. Aldridge III JM, Urbaniak JR. Free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. Tech Orthop. 2008;23(1):44–53.

    Article  Google Scholar 

  63. Judet H, Gilbert A. Long term results of free vascularized fibular grafting for femoral head osteonecrosis. Clin Orthop Relat Res. 2001;386:114–9.

    Article  PubMed  Google Scholar 

  64. Coogan PG, Urbaniak JR. Multicenter experience with free vascularized fibular grafts for osteonecrosis of the femoral head. In: Urbaniak JR, Jones JP, editors. Osteonecrosis: etiology, diagnosis and treatment. American Academy of Orthopaedic Surgeons. Developed by the American Orthopaedic Association; 1997. Ch. 45, p. 327–46.

    Google Scholar 

  65. Hernigou P, Zilber S, Filippini P, Rouard H, Mathieu G, Poignard A. Bone marrow injection in hip osteonecrosis. Tech Orthop. 2008;23(1):18–25.

    Article  Google Scholar 

  66. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res. 2002;405:14–23.

    Article  PubMed  Google Scholar 

  67. Gangji V, Hauzeur JP. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. J Bone Joint Surg. 2005; 87-A:106–12.

    Google Scholar 

  68. Steinberg ME, Larcom PG, Strafford B, Hosick B, Corces A, Bands RE, Hartman KM. Core decompression with bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2001;366:71–8.

    Article  Google Scholar 

  69. Salvati EA, Cornell CN. Long-term follow up of total hip replacements in patients with avascular necrosis. Instr Course Lect. 1988;37:67. American Academy of Orthopaedic Surgeons.

    Google Scholar 

  70. Ortiguera CJ, Pulliam IT, Cabanela ME. Total hip arthroplasty for osteonecrosis. Matched-pair analysis of 188 hips with long term follow up. J Arthroplasty. 1999;14:21–8.

    Article  CAS  PubMed  Google Scholar 

  71. Mont MA, Seyler TM, Plate JF. Uncemented total hip arthroplasty in young adults with osteonecrosis of the femoral head: a comparative study. J Bone Joint Surg. 2006;88-A(Supplement 3):104–9.

    Article  Google Scholar 

  72. Seyler TM, Bonutti PM, Shen J, et al. Use of alumina-on-alumina bearing system in total hip arthroplasty for osteonecrosis of the hip. J Bone Joint Surg. 2006;88-A(Supplement 3):116–25.

    Article  Google Scholar 

  73. Hannouche D, Zaoui A, Sedel L, Nizard R. Thirty years experience with alumina-on-alumina bearing in total arthroplasty. Int Orthop. 2011;35(2):207–13.

    Article  PubMed Central  PubMed  Google Scholar 

  74. Steinberg ME. Summary and conclusions: surface replacement arthroplasty of the hip. Orthop Clin N Am. 1982;13(4):895–902.

    CAS  Google Scholar 

  75. Revell MP, McBryde CW, Bhatnagar S, et al. Metal-on-metal resurfacing in osteonecrosis of the femoral head. J Bone Joint Surg. 2006;88-A(Supplement 3):98–103.

    Article  Google Scholar 

  76. Mont MA, Delanois RE, Quesada MJ, Childress L. Femoral and acetabular surface replacement and hemi-surface replacement for osteonecrosis of the hip. Tech Orthop. 2008;23(1):65–73.

    Article  Google Scholar 

  77. Huo MH, Stockton KO, Mont MA, Bucholz RW. What’s new in total hip arthroplasty. J Bone Joint Surg. 2012;94-A:1721–7.

    Article  Google Scholar 

  78. Glyn-Jones S, Roques A, Taylor A, et al. The in vivo linear and volumetric wear of hip resurfacing implants revised for pseudotumor. J Bone Joint Surg. 2011;93-A:2180–8.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Penn Musculoskeletal Center, Penn Medicine University City, 3737 Market Street, Sixth Floor, Philadelphia, PA, 19104, USA

    David R. Steinberg MD & Marvin E. Steinberg MD

Authors
  1. David R. Steinberg MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marvin E. Steinberg MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David R. Steinberg MD .

Editor information

Editors and Affiliations

  1. Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA

    Roy K. Aaron

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Steinberg, D.R., Steinberg, M.E. (2015). Osteonecrosis. In: Aaron, R. (eds) Diagnosis and Management of Hip Disease. Springer, Cham. https://doi.org/10.1007/978-3-319-19905-4_7

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-19905-4_7

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-19904-7

  • Online ISBN: 978-3-319-19905-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation