Skip to main content

Advertisement

Log in

Osteonecrosis of the Hip in Adults

  • Original Paper
  • Published:
Clinical Reviews in Bone and Mineral Metabolism Aims and scope Submit manuscript

Abstract

Atraumatic osteonecrosis in adults most commonly presents in the hip. The specific etiology and pathogenesis is often uncertain, and we will review some of the specific theories regarding the development of this disease. The utility of radiographs and magnetic resonance imaging in the diagnosis and staging of osteonecrosis will also be presented. We include a summary of the different non-surgical and surgical treatment options. Early, pre-collapse, disease often has a better prognosis with head-sparing treatment options available such as core decompression and bone grafting. More advanced disease may require total hip or resurfacing arthroplasty.

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

Access this article

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

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis). N Engl J Med. 1992;326(22):1473–9.

    Article  PubMed  CAS  Google Scholar 

  2. Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. 1999;7(4):250–61.

    PubMed  CAS  Google Scholar 

  3. Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am. 2006;88(5):1117–32.

    Article  PubMed  Google Scholar 

  4. Malizos KN, et al. Osteonecrosis of the femoral head: etiology, imaging and treatment. Eur J Radiol. 2007;63(1):16–28.

    Article  PubMed  Google Scholar 

  5. Bluemke DA, Zerhouni EA. MRI of avascular necrosis of bone. Top Magn Reson Imaging. 1996;8(4):231–46.

    Article  PubMed  CAS  Google Scholar 

  6. Mont MA, et al. Bone scanning of limited value for diagnosis of symptomatic oligofocal and multifocal osteonecrosis. J Rheumatol. 2008;35(8):1629–34.

    PubMed  Google Scholar 

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

    PubMed  CAS  Google Scholar 

  8. Ohzono K, et al. The fate of nontraumatic avascular necrosis of the femoral head. A radiologic classification to formulate prognosis. Clin Orthop Relat Res. 1992;277:73–8.

    PubMed  Google Scholar 

  9. Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br. 1995;77(1):34–41.

    PubMed  CAS  Google Scholar 

  10. Jones JP Jr. Fat embolism and osteonecrosis. Orthop Clin North Am. 1985;16(4):595–633.

    PubMed  Google Scholar 

  11. Jones JP Jr. Coagulopathies and osteonecrosis. Acta Orthop Belg. 1999;65(Suppl 1):5–8.

    PubMed  Google Scholar 

  12. Jones JP Jr, Ramirez S, Doty SB. The pathophysiologic role of fat in dysbaric osteonecrosis. Clin Orthop Relat Res. 1993;296:256–64.

    PubMed  Google Scholar 

  13. Chryssanthou CP. Dysbaric osteonecrosis. Etiological and pathogenetic concepts. Clin Orthop Relat Res. 1978;130:94–106.

    PubMed  Google Scholar 

  14. Kenzora JE, Glimcher MJ. Accumulative cell stress: the multifactorial etiology of idiopathic osteonecrosis. Orthop Clin North Am. 1985;16(4):669–79.

    PubMed  CAS  Google Scholar 

  15. Jones JP Jr. Fat embolism, intravascular coagulation, and osteonecrosis. Clin Orthop Relat Res. 1993;292:294–308.

    PubMed  Google Scholar 

  16. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77(3):459–74.

    PubMed  CAS  Google Scholar 

  17. Jones JP Jr. Alcoholism, hypercortisonism, fat embolism and osseous avascular necrosis. 1971. Clin Orthop Relat Res. 2001;393:4–12.

    Article  PubMed  Google Scholar 

  18. Saito S, Ohzono K, Ono K. Early arteriopathy and postulated pathogenesis of osteonecrosis of the femoral head. The intracapital arterioles. Clin Orthop Relat Res. 1992;277:98–110.

    PubMed  Google Scholar 

  19. Hungerford DS, Lennox DW. The importance of increased intraosseous pressure in the development of osteonecrosis of the femoral head: implications for treatment. Orthop Clin North Am. 1985;16(4):635–54.

    PubMed  CAS  Google Scholar 

  20. Kerachian MA, Seguin C, Harvey EJ. Glucocorticoids in osteonecrosis of the femoral head: a new understanding of the mechanisms of action. J Steroid Biochem Mol Biol. 2009;114(3–5):121–8.

    Article  PubMed  CAS  Google Scholar 

  21. Jacobs B. Epidemiology of traumatic and nontraumatic osteonecrosis. Clin Orthop Relat Res. 1978;130:51–67.

    PubMed  Google Scholar 

  22. Boettcher WG, et al. Non-traumatic necrosis of the femoral head. I. Relation of altered hemostasis to etiology. J Bone Joint Surg Am. 1970;52(2):312–21.

    PubMed  CAS  Google Scholar 

  23. Catto M. Ischaemia of bone. J Clin Pathol Suppl (R Coll Pathol). 1977;11:78–93.

    CAS  Google Scholar 

  24. Frost HM. In vivo osteocyte death. J Bone Joint Surg Am. 1960;42-A:138–43.

    PubMed  CAS  Google Scholar 

  25. Chernetsky SG, et al. Pathologic features in steroid and nonsteroid associated osteonecrosis. Clin Orthop Relat Res. 1999;368:149–61.

    Article  PubMed  Google Scholar 

  26. Mukisi-Mukaza M, et al. Histopathology of aseptic necrosis of the femoral head in sickle cell disease. Int Orthop. 2010.

  27. Hauzeur JP, et al. Diagnosis of aseptic osteonecrosis of the femoral head by percutaneous transtrochanterian needle biopsy. Clin Rheumatol. 1986;5(3):346–58.

    Article  PubMed  CAS  Google Scholar 

  28. Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res. 1996;324:169–78.

    Article  PubMed  Google Scholar 

  29. Hungerford DS, Mont MA. The natural history of untreated asymptomatic hips in patients who have non-traumatic osteonecrosis. J Bone Joint Surg Am. 1998;80(5):765–6.

    PubMed  CAS  Google Scholar 

  30. Alves EM, Angrisani AT, Santiago MB. The use of extracorporeal shock waves in the treatment of osteonecrosis of the femoral head: a systematic review. Clin Rheumatol. 2009;28(11):1247–51.

    Article  PubMed  Google Scholar 

  31. Yan SG, Huang LY, Cai XZ. Low-intensity pulsed ultrasound: a potential non-invasive therapy for femoral head osteonecrosis. Med Hypotheses 2010.

  32. Glueck CJ, et al. Idiopathic osteonecrosis, hypofibrinolysis, high plasminogen activator inhibitor, high lipoprotein(a), and therapy with Stanozolol. Am J Hematol. 1995;48(4):213–20.

    Article  PubMed  CAS  Google Scholar 

  33. Agarwala S, Shah S, Joshi VR. The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years. J Bone Joint Surg Br. 2009;91(8):1013–8.

    Article  PubMed  CAS  Google Scholar 

  34. Lai KA, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am. 2005;87(10):2155–9.

    Article  PubMed  Google Scholar 

  35. Nishii T, et al. Does alendronate prevent collapse in osteonecrosis of the femoral head? Clin Orthop Relat Res. 2006;443:273–9.

    Article  PubMed  Google Scholar 

  36. Cardozo JB, Andrade DM, Santiago MB. The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clin Rheumatol. 2008;27(6):685–8.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  38. Hernigou P, et al. Cell therapy of hip osteonecrosis with autologous bone marrow grafting. Indian J Orthop. 2009;43(1):40–5.

    Article  PubMed  Google Scholar 

  39. Gangji V, Hauzeur JP. Cellular-based therapy for osteonecrosis. Orthop Clin North Am. 2009;40(2):213–21.

    Article  PubMed  Google Scholar 

  40. Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res. 2004;429:131–8.

    Article  PubMed  Google Scholar 

  41. Song WS, et al. Results of multiple drilling compared with those of conventional methods of core decompression. Clin Orthop Relat Res. 2007;454:139–46.

    Article  PubMed  Google Scholar 

  42. Lavernia CJ, Sierra RJ. Core decompression in atraumatic osteonecrosis of the hip. J Arthroplasty. 2000;15(2):171–8.

    Article  PubMed  CAS  Google Scholar 

  43. Stulberg BN, et al. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop Relat Res. 1991;268:140–51.

    PubMed  Google Scholar 

  44. Sugioka Y, Hotokebuchi T, Tsutsui H. Transtrochanteric anterior rotational osteotomy for idiopathic and steroid-induced necrosis of the femoral head. Indications and long-term results. Clin Orthop Relat Res. 1992;277:111–20.

    PubMed  Google Scholar 

  45. Sugioka Y, Yamamoto T. Transtrochanteric posterior rotational osteotomy for osteonecrosis. Clin Orthop Relat Res. 2008;466(5):1104–9.

    Article  PubMed  Google Scholar 

  46. Yamamoto T, et al. The repair process of osteonecrosis after a transtrochanteric rotational osteotomy. Clin Orthop Relat Res. 2010.

  47. Miyanishi K, et al. Prediction of the outcome of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head. J Bone Joint Surg Br. 2000;82(4):512–6.

    Article  PubMed  CAS  Google Scholar 

  48. Dean MT, Cabanela ME. Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. J Bone Joint Surg Br. 1993;75(4):597–601.

    PubMed  CAS  Google Scholar 

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

    PubMed  Google Scholar 

  50. Scher MA, Jakim I. Intertrochanteric osteotomy and autogenous bone-grafting for avascular necrosis of the femoral head. J Bone Joint Surg Am. 1993;75(8):1119–33.

    PubMed  CAS  Google Scholar 

  51. Jacobs MA, Hungerford DS, Krackow KA. Intertrochanteric osteotomy for avascular necrosis of the femoral head. J Bone Joint Surg Br. 1989;71(2):200–4.

    PubMed  CAS  Google Scholar 

  52. Scher MA, Jakim I. Late follow-up of femoral head avascular necrosis managed by intertrochanteric osteotomy and bone grafting. Acta Orthop Belg. 1999;65(1):73–7.

    PubMed  Google Scholar 

  53. Mont MA, et al. Corrective osteotomy for osteonecrosis of the femoral head. J Bone Joint Surg Am. 1996;78(7):1032–8.

    PubMed  CAS  Google Scholar 

  54. Phemister DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg Am. 1949;31A(1):55–66.

    PubMed  CAS  Google Scholar 

  55. Merledaubigne R. Idiopathic necrosis of the femoral head in adults. Ann R Coll Surg Engl. 1964;34:143–60.

    PubMed  CAS  Google Scholar 

  56. Rosenwasser MP, et al. Long term followup 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 

  57. Buckley PD, Gearen PF, Petty RW. Structural bone-grafting for early atraumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1991;73(9):1357–64.

    PubMed  CAS  Google Scholar 

  58. Israelite C, et al. Bilateral core decompression for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2005;441:285–90.

    Article  PubMed  Google Scholar 

  59. Keizer SB, et al. Treatment of avascular necrosis of the hip by a non-vascularised cortical graft. J Bone Joint Surg Br. 2006;88(4):460–6.

    Article  PubMed  CAS  Google Scholar 

  60. Lieberman JR, Conduah A, Urist MR. Treatment of osteonecrosis of the femoral head with core decompression and human bone morphogenetic protein. Clin Orthop Relat Res. 2004;429:139–45.

    Article  PubMed  Google Scholar 

  61. Plakseychuk AY, et al. Vascularized compared with nonvascularized fibular grafting for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003;85-A(4):589–96.

    PubMed  Google Scholar 

  62. Rijnen WH, et al. Treatment of femoral head osteonecrosis using bone impaction grafting. Clin Orthop Relat Res. 2003;417:74–83.

    PubMed  Google Scholar 

  63. Steinberg ME, et al. Core decompression with bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2001;386:71–8.

    Article  PubMed  Google Scholar 

  64. Wang CJ, et al. Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting. J Bone Joint Surg Am. 2005;87(11):2380–7.

    Article  PubMed  Google Scholar 

  65. Meyers MH, et al. Fresh autogenous grafts and osteochondral allografts for the treatment of segmental collapse in osteonecrosis of the hip. Clin Orthop Relat Res. 1983;174:107–12.

    PubMed  Google Scholar 

  66. Ko JY, Meyers MH, Wenger DR. “Trapdoor” procedure for osteonecrosis with segmental collapse of the femoral head in teenagers. J Pediatr Orthop. 1995;15(1):7–15.

    PubMed  Google Scholar 

  67. Mont MA, et al. The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head. J Bone Joint Surg Br. 1998;80(1):56–62.

    Article  PubMed  CAS  Google Scholar 

  68. Mont MA, Etienne G, Ragland PS. Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res. 2003;417:84–92.

    PubMed  Google Scholar 

  69. Seyler TM, et al. Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis. Clin Orthop Relat Res. 2008;466(5):1125–32.

    Article  PubMed  Google Scholar 

  70. Wang BL, et al. Treatment of nontraumatic osteonecrosis of the femoral head using bone impaction grafting through a femoral neck window. Int Orthop. 2010;34(5):635–9.

    Article  PubMed  Google Scholar 

  71. Yuhan C, et al. Local cancellous bone grafting for osteonecrosis of the femoral head. Surg Innov. 2009;16(1):63–7.

    Article  Google Scholar 

  72. Urbaniak JR, et al. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am. 1995;77(5):681–94.

    PubMed  CAS  Google Scholar 

  73. Yoo MC, et al. Long-term followup of vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res. 2008;466(5):1133–40.

    Article  PubMed  Google Scholar 

  74. Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. J Bone Joint Surg Am. 2003;85-A(6):987–93.

    PubMed  Google Scholar 

  75. Aldridge JM III, Urbaniak JR. Avascular necrosis of the femoral head: role of vascularized bone grafts. Orthop Clin North Am. 2007;38(1):13–22.

    Article  PubMed  Google Scholar 

  76. Beaule PE, et al. Duration of symptoms and outcome of hemiresurfacing for hip osteonecrosis. Clin Orthop Relat Res. 2001;385:104–17.

    Article  PubMed  Google Scholar 

  77. Garino JP, Steinberg ME. Total hip arthroplasty in patients with avascular necrosis of the femoral head: a 2- to 10-year follow-up. Clin Orthop Relat Res. 1997;334:108–15.

    Article  PubMed  Google Scholar 

  78. Johannson HR, et al. Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop. 2010.

  79. Mont MA, et al. Use of metal-on-metal total hip resurfacing for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am. 2006;88(3):90–7.

    Article  PubMed  Google Scholar 

  80. Kim YH, Choi Y, Kim JS. Cementless total hip arthroplasty with alumina-on-highly cross-linked polyethylene bearing in young patients with femoral head osteonecrosis. J Arthroplast. 2010.

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Lynne C. Jones.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Jones, L.C., Johnson, A.J., Mont, M.A. et al. Osteonecrosis of the Hip in Adults. Clinic Rev Bone Miner Metab 9, 13–22 (2011). https://doi.org/10.1007/s12018-011-9091-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12018-011-9091-9

Keywords

Navigation