Skip to main content
SpringerLink
Log in

Classification systems of hip osteonecrosis: an updated review

  • Review Article
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

Osteonecrosis of the femoral head (ONFH) typically impacts middle-aged patients who are typically more active and in whom many surgeons would try to delay performing a total hip arthroplasty (THA). This poses a clinical decision-making challenge. Therefore, several options for joint preservation have been advocated, but varying indications and success rates have led to debate on when to use the various procedures. This is due in part to the lack of a generalized system for assessing ONFH, as well as the absence of a standardized method of data collection for patient stratification. Due to the paucity of studies, in this review, we aimed to provide an up-to-date review of the most widely utilized classification systems and discuss the characteristics of each system.

Methods

A comprehensive literature review was conducted. Studies published between January 1st, 1975 and March 1st, 2018 were reviewed. The following key words were used in combination with Boolean operators AND or OR for the literature search: “osteonecrosis,” “avascular necrosis,” “hip,” “femoral head,” “classification,” “reliability,” and “validity.” We defined the inclusion criteria for qualifying studies for this review as follows: (1) studies that reported on the classification systems for hip osteonecrosis, (2) studies that reported on the inter-observer reliability of the classification systems, and (3) studies that reported on the intra-observer reliability of any ONFH classification systems. In addition, we employed the following exclusion criteria: (1) studies that assessed classification systems for traumatic osteonecrosis, (2) Legg-Calvé-Perthes disease, or (3) Developmental Dysplasia of the Hip. Additionally, we excluded case reports and duplicate studies among searched databases.

Results

The following classification systems were the most commonly utilized: The Ficat and Arlet, Steinberg, the Association Research Circulation Osseous (ARCO), and the Japanese Investigation Committee (JIC) classification systems. The details of each system have been discussed and their inter- and intra-observer reliability has been compared.

Conclusion

To this date, there is a lack of consensus on a universal and comprehensive system, and the use of any of the previous classification systems is a matter of dealer’s choice. The Ficat and Arlet system was the earliest yet remains the most widely utilized system. Newer classification systems have been developed and some such as the JIC shows promising prognostic value while maintaining simplicity. However, larger validating studies are needed. While all of these systems have their strengths, the lack of a unified classification and staging system is still a problem in the diagnosis and prognosis ONFH. Further multi-center collaborative efforts among osteonecrosis experts are needed to adopt a universal classification system that may positively reflect on patient’s outcomes.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Ficat RP (1985) Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg (Br) 67:3–9

    Article  CAS  Google Scholar 

  2. Seamon J, Keller T, Saleh J, Cui Q (2012) The pathogenesis of nontraumatic osteonecrosis. Arthritis 2012:601763. https://doi.org/10.1155/2012/601763

    Article  PubMed  PubMed Central  Google Scholar 

  3. Mont MA, Seyler TM, Plate JF et al (2006) Uncemented total hip arthroplasty in young adults with osteonecrosis of the femoral head: a comparative study. J Bone Joint Surg Am 88(Suppl 3):104–109. https://doi.org/10.2106/JBJS.F.00451

    Article  PubMed  Google Scholar 

  4. Mont MA, Seyler TM, Marker DR et al (2006) Use of metal-on-metal total hip resurfacing for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am 88(Suppl 3):90–97. https://doi.org/10.2106/JBJS.F.00543

    Article  PubMed  Google Scholar 

  5. Marker DR, Seyler TM, McGrath MS et al (2008) Treatment of early stage osteonecrosis of the femoral head. J Bone Joint Surg Am 90(Suppl 4):175–187. https://doi.org/10.2106/JBJS.H.00671

    Article  PubMed  Google Scholar 

  6. Jacobs B (1978) Epidemiology of traumatic and nontraumatic osteonecrosis. Clin Orthop Relat Res 130:51–67. http://www.ncbi.nlm.nih.gov/pubmed/639407. Accessed 11 June 2018

  7. Chughtai M, Piuzzi NS, Khlopas A et al (2017) An evidence-based guide to the treatment of osteonecrosis of the femoral head. Bone Joint J 99–B:1267–1279. https://doi.org/10.1302/0301-620X.99B10.BJJ-2017-0233.R2

    Article  PubMed  Google Scholar 

  8. Mont MA, Ragland PS, Etienne G (2004) Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res 429:131–8. http://www.ncbi.nlm.nih.gov/pubmed/15577477. Accessed 11 June 2018

  9. Kim S-Y, Kim Y-G, Kim P-T et al (2005) Vascularized compared with nonvascularized fibular grafts for large Osteonecrotic lesions of the femoral head. J Bone Joint Surg 87:2012–2018. https://doi.org/10.2106/JBJS.D.02593

    Article  PubMed  Google Scholar 

  10. Dean MT, Cabanela ME (1993) Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. J Bone Joint Surg (Br) 75:597–601

    Article  CAS  Google Scholar 

  11. Lee G-C, Steinberg ME (2012) Are we evaluating osteonecrosis adequately? Int Orthop 36:2433–2439. https://doi.org/10.1007/s00264-012-1658-7

    Article  PubMed  PubMed Central  Google Scholar 

  12. Mont MA, Marulanda GA, Jones LC et al (2006) Systematic analysis of classification systems for osteonecrosis of the femoral head. J Bone Joint Surg Am 88(Suppl 3):16–26. https://doi.org/10.2106/JBJS.F.00457

    Article  Google Scholar 

  13. Zibis AH, Karantanas AH, Roidis NT et al (2007) The role of MR imaging in staging femoral head osteonecrosis. Eur J Radiol 63:3–9. https://doi.org/10.1016/j.ejrad.2007.03.029

    Article  PubMed  Google Scholar 

  14. Steinberg ME, Steinberg DR (2004) Classification systems for osteonecrosis: an overview. Orthop Clin N Am 35:273–283, vii–viii. https://doi.org/10.1016/j.ocl.2004.02.005

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

  16. ARCO-Abstracts

  17. Sugano N, Atsumi T, Ohzono K et al (2002) The 2001 revised criteria for diagnosis, classification, and staging of idiopathic osteonecrosis of the femoral head. J Orthop Sci 7:601–605. https://doi.org/10.1007/s007760200108

    Article  Google Scholar 

  18. Kerboul M, Thomine J, Postel M, Merle d’Aubigné R (1974) The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. J Bone Joint Surg (Br) 56:291–296

    Article  CAS  Google Scholar 

  19. Plakseychuk AY, Shah M, Varitimidis SE, et al. (2001) Classification of osteonecrosis of the femoral head. Reliability, reproducibility, and prognostic value. Clin Orthop Relat Res 386:34–41. http://www.ncbi.nlm.nih.gov/pubmed/11347846. Accessed 11 June 2018

  20. Kay RM, Lieberman JR, Dorey FJ, Seeger LL (1994) Inter- and intraobserver variation in staging patients with proven avascular necrosis of the hip. Clin Orthop Relat Res 307:124–9. http://www.ncbi.nlm.nih.gov/pubmed/7924024. Accessed 11 June 2018

  21. Schmitt-Sody M, Kirchhoff C, Mayer W et al (2008) Avascular necrosis of the femoral head: inter- and intraobserver variations of Ficat and ARCO classifications. Int Orthop 32:283–287. https://doi.org/10.1007/s00264-007-0320-2

    Article  PubMed  Google Scholar 

  22. Smith SW, Meyer RA, Connor PM et al (1996) Interobserver reliability and intraobserver reproducibility of the modified Ficat classification system of osteonecrosis of the femoral head. J Bone Joint Surg Am 78:1702–1706

    Article  CAS  PubMed  Google Scholar 

  23. Takashima K, Sakai T, Hamada H et al (2018) Which classification system is most useful for classifying osteonecrosis of the femoral head? Clin Orthop Relat Res. https://doi.org/10.1007/s11999.0000000000000245

  24. Stöve J, Riederle F, Kessler S et al (2001) Reproducibility of radiological classification criteria of femur head necrosis. Z Orthop Ihre Grenzgeb 139:163–167. https://doi.org/10.1055/s-2001-15050

    Article  PubMed  Google Scholar 

  25. Steinberg DR, Steinberg ME, Garino JP et al (2006) Determining lesion size in osteonecrosis of the femoral head. J Bone Joint Surg Am 88(Suppl 3):27–34. https://doi.org/10.2106/JBJS.F.00896

    Article  PubMed  Google Scholar 

  26. Nishii T, Sugano N, Ohzono K et al (2002) Significance of lesion size and location in the prediction of collapse of osteonecrosis of the femoral head: a new three-dimensional quantification using magnetic resonance imaging. J Orthop Res 20:130–136. https://doi.org/10.1016/S0736-0266(01)00063-8

    Article  PubMed  Google Scholar 

  27. Hernigou P, Poignard A, Nogier A, Manicom O (2004) Fate of very small asymptomatic stage-I osteonecrotic lesions of the hip. J Bone Joint Surg Am 86–A:2589–2593

    Article  Google Scholar 

  28. Takatori Y, Kokubo T, Ninomiya S et al (1993) Avascular necrosis of the femoral head. Natural history and magnetic resonance imaging. J Bone Joint Surg (Br) 75:217–221

    Article  CAS  Google Scholar 

  29. Shimizu K, Moriya H, Akita T et al (1994) Prediction of collapse with magnetic resonance imaging of avascular necrosis of the femoral head. J Bone Joint Surg Am 76:215–223

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cleveland Clinic, Department of Orthopaedic Surgery, Cleveland, OH, USA

    Assem A. Sultan, Nequesha Mohamed, Linsen T. Samuel, Morad Chughtai, Viktor E. Krebs, Kim L. Stearns, Robert M. Molloy & Michael A. Mont

  2. Lenox Hill Hospital, New York City, NY, USA

    Nipun Sodhi & Michael A. Mont

Authors
  1. Assem A. Sultan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nequesha Mohamed
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Linsen T. Samuel
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Morad Chughtai
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nipun Sodhi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Viktor E. Krebs
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Kim L. Stearns
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Robert M. Molloy
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Michael A. Mont
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael A. Mont.

Ethics declarations

Conflict of interest

Assem A. Sultan, MD: nothing to disclose.

Nequesha Mohamed, MD: nothing to disclose.

Linsen T. Samuel, MD, MBA: nothing to disclose.

Morad Chughtai, MD.

Cymedica: Paid consultant.

DJ Orthopedics: Paid consultant.

Peerwell: Paid consultant.

Refelection: Paid consultant.

Sage Products: Paid consultant.

Stryker: Paid consultant.

Nipun Sodhi, BA: nothing to disclose.

Viktor Erik Krebs, MD.

Journal of Arthroplasty: Editorial or governing board.

Stryker: IP royalties; Paid presenter or speaker.

Stryker Orthopedics: Paid consultant.

Kim L Stearns, MD.

Fidiapharma: Paid presenter or speaker.

Robert M. Molloy, MD.

Stryker: Paid consultant; Paid presenter or speaker; Research support.

Zimmer: Research support.

Michael A Mont, MD.

AAOS: Board or committee member.

Abbott: Paid consultant.

Cymedica: Paid consultant.

DJ Orthopedics: Paid consultant; Research support.

Johnson & Johnson: Paid consultant; Research support.

Journal of Arthroplasty: Editorial or governing board.

Journal of Knee Surgery: Editorial or governing board.

Mallinckrodt Pharmaceuticals: Paid consultant.

Microport: IP royalties.

National Institutes of Health (NIAMS & NICHD): Research support.

Ongoing Care Solutions: Paid consultant; Research support.

Orthopedics: Editorial or governing board.

Orthosensor: Paid consultant; Research support.

Pacira: Paid consultant.

Peerwell: Stock or stock Options.

Performance Dynamics Inc.: Paid consultant.

Sage: Paid consultant.

Stryker: IP royalties; Paid consultant; Research support.

Surgical Techniques International: Editorial or governing board.

TissueGene: Paid consultant; Research support.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sultan, A.A., Mohamed, N., Samuel, L.T. et al. Classification systems of hip osteonecrosis: an updated review. International Orthopaedics (SICOT) 43, 1089–1095 (2019). https://doi.org/10.1007/s00264-018-4018-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-018-4018-4

Keywords

Search

Navigation