eMedicine Specialties > Orthopedic Surgery > Hip

Osteonecrosis, Hip: Workup

Author: Michael Levine, MD, Chairman, Department of Orthopedic Surgery, Western Pennsylvania Hospital
Coauthor(s): Amar Rajadhyaksha, MD, Resident, Department of Orthopedic Surgery, New York Medical College; Michael Mont, MD, Associate Professor, Department of Orthopaedic Surgery, Johns Hopkins Medical Institution
Contributor Information and Disclosures

Updated: Mar 26, 2009

Workup

Laboratory Studies

  • Lab tests have limited utility in the diagnosis of osteonecrosis, with exceptions as follows:
    • Sickle cell testing in African Americans
    • Lipid profile
    • Screening for coagulopathies -Protein S and protein C deficiencies, factor V Leiden disease

Imaging Studies

  • Anteroposterior (AP) radiographs (see Image 1) and frog lateral radiographs of both hips are the primary diagnostic modalities.
Osteonecrosis, hip. Anteroposterior radiograph sh...

Osteonecrosis, hip. Anteroposterior radiograph showing Ficat stage III disease.

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Osteonecrosis, hip. Anteroposterior radiograph sh...

Osteonecrosis, hip. Anteroposterior radiograph showing Ficat stage III disease.

  • AP and frog lateral tomograms
    • Indicated if patients have evidence of disease on radiographs but have no collapse
    • Often helpful in staging
  • MRI
    • Sensitivity and specificity is greater than 98%, which is higher than all other modalities.
    • This study is ideal if x-ray findings are normal and clinical suspicion is high. MRI should be performed in all patients with osteonecrosis to assess the extent of the disease. Three-dimensional MRI scanning with image registration may be used to assess changes in lesion size.
    • MRI is recommended to identify bilateral disease when 1 hip has radiographic signs of disease and the other is normal (see Image 2).
MRI showing osteonecrosis of right hip, normal le...

MRI showing osteonecrosis of right hip, normal left hip.

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MRI showing osteonecrosis of right hip, normal le...

MRI showing osteonecrosis of right hip, normal left hip.


Bone scan showing osteonecrosis of right hip.

Bone scan showing osteonecrosis of right hip.

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Bone scan showing osteonecrosis of right hip.

Bone scan showing osteonecrosis of right hip.

  • Bone scanning (see Image 3)
    • Helpful when x-ray findings are normal if MRI cannot be obtained
    • Low-cost alternative when index of suspicion is low

Diagnostic Procedures

  • Core biopsy (see Image 4) and interosseous pressure measurement
    • An open biopsy of 10-mm core of bone from the femoral head can be used for diagnosis.
    • Measurement of interosseous pressure can be obtained before and after biopsy to confirm decompression of intraosseous space.
Osteonecrosis, hip. Anteroposterior radiograph co...

Osteonecrosis, hip. Anteroposterior radiograph core biopsy.

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Osteonecrosis, hip. Anteroposterior radiograph co...

Osteonecrosis, hip. Anteroposterior radiograph core biopsy.

  • Venography
    • Injection of contrast under image intensification has been used as part of the functional evaluation of bone when measuring intraosseous pressure.
    • This can be used to confirm presence of the needle within the head and venous congestion.

Histologic Findings

The first histologic findings are marrow and adipocyte necrosis. Next, liquefaction necrosis and interstitial edema occur. Pyknotic nuclei with empty lacunae are identified as osteocyte necrosis occurs. Eventually, the zone of necrosis is surrounded by repair tissue as revascularization proceeds. During this phase, the subchondral plate is weakened as resorption occurs faster than reformation, leading to subchondral collapse and eventual cartilage damage.

Staging

Several radiographic staging systems are currently used.

  • Ficat classification2
    • Stage 0 - No pain, normal radiographic findings, abnormal bone scan or MRI findings
    • Stage I - Pain, normal x-ray findings, abnormal bone scan or MRI findings
    • Stage IIa - Pain, cysts and/or sclerosis visible on x-ray, abnormal bone scan or MRI findings, without subchondral fracture
    • Stage III - Pain, femoral head collapse visible on x-ray, abnormal bone scan or MRI findings, crescent sign (subchondral collapse) and/or step-off in contour of subchondral bone
    • Stage IV - Pain, acetabular disease with joint space narrowing and arthritis (osteoarthrosis) visible on x-ray, abnormal MRI or bone scan findings
  • Steinberg staging system3
    • Stage 0 - Normal or nondiagnostic radiographic, bone scan, and MRI findings
    • Stage I - Normal radiographic findings, abnormal bone scan and/or MRI findings
      • A - Mild: <15% of head affected
      • B - Moderate: 15-30%
      • C - Severe: >30%
    • Stage II - Lucent and sclerotic changes in femoral head
      • A - Mild: <15%
      • B - Moderate: 15-30%
      • C - Severe: >30%
    • Stage III - Subchondral collapse (crescent sign) without flattening
      • A - Mild: <15% of articular surface
      • B - Moderate: 15-30%
      • C - Severe: >30%
    • Stage IV - Flattening of femoral head
      • A - Mild: <15% of surface or <2-mm depression
      • B - Moderate: 15-30% of surface or 2- to 4-mm depression
      • C - Severe: >30% of surface or >4-mm depression
    • Stage V - Joint narrowing and/or acetabular changes
      • A - Mild: Average of femoral head involvement as in stage IV and estimated acetabular
      • B - Moderate involvement
      • C - Severe
    • Stage VI - Advanced degenerative changes
  • International classification of osteonecrosis of the femoral head (Association Research Circulation Osseus [ARCO])4
    • Stage 0 - Bone biopsy results consistent with osteonecrosis; other test results normal
    • Stage I - Positive findings on bone scan, MRI, or both
      • A - <15% involvement of the femoral head (MRI)
      • B - 15-30% involvement
      • C - >30% involvement
    • Stage II - Mottled appearance of femoral head, osteosclerosis, cyst formation, and osteopenia on radiographs; no signs of collapse of femoral head on radiographic or CT study; positive findings on bone scan and MRI; no changes in acetabulum
      • A - <15% involvement of the femoral head (MRI)
      • B - 15-30% involvement
      • C - >30% involvement
    • Stage III - Presence of crescent sign lesions classified on basis of appearance on AP and lateral radiographs
      • A - <15% crescent sign or <2-mm depression of femoral head
      • B - 15-30% crescent sign or 2- to 4-mm depression
      • C - >30% crescent sign or >4-mm depression
    • Stage IV - Articular surface flattened; joint space shows narrowing; changes in acetabulum with evidence of osteosclerosis, cyst formation, and marginal osteophytes

More on Osteonecrosis, Hip

Overview: Osteonecrosis, Hip
Workup: Osteonecrosis, Hip
Treatment: Osteonecrosis, Hip
Follow-up: Osteonecrosis, Hip
Multimedia: Osteonecrosis, Hip
References
Further Reading
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References

  1. Aaron RK. Osteonecrosis: etiology, pathophysiology, and diagnosis. In: Callahan JJ, Rosenberg AG, and Rubash HE. The Adult Hip. Philadelphia, Pa:. Lippincott-Raven Publishers;1998:451-66.

  2. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg [Br]. Jan 1985;67(1):3-9. [Medline].

  3. Steinberg ME, Hayken GD, Steinberg DR. A new method for evaluation and staging of avascular necrosis of the femoral head. In: Arlet J, Ficat,P, Hungerford. Bone Circulation. Baltimore, Md: Williams and Wilkins;1984:398-403.

  4. ARCO Committee on Terminology and Staging. The ARCO perspective for reaching one uniform staging system for osteonecrosis. In: Schoutens pathologic conditions. New York, NY: Plenum Press;1993:375-80.

  5. [Best Evidence] Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM. 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. Oct 2005;87(10):2155-9. [Medline].

  6. Wang CJ, Wang FS, Ko JY, Huang HY, Chen CJ, Sun YC, et al. Extracorporeal shockwave therapy shows regeneration in hip necrosis. Rheumatology (Oxford). Apr 2008;47(4):542-6. [Medline].

  7. Stiehl JB, Ulrich SD, Seyler TM, Bonutti PM, Marker DR, Mont MA. Bone morphogenetic proteins in total hip arthroplasty, osteonecrosis and trauma surgery. Expert Rev Med Devices. Mar 2008;5(2):231-8. [Medline].

  8. Jones KB, Seshadri T, Krantz R, Keating A, Ferguson PC. Cell-based therapies for osteonecrosis of the femoral head. Biol Blood Marrow Transplant. Oct 2008;14(10):1081-7. [Medline].

  9. Nadeau M, Séguin C, Theodoropoulos JS, Harvey EJ. Short term clinical outcome of a porous tantalum implant for the treatment of advanced osteonecrosis of the femoral head. Mcgill J Med. Jan 2007;10(1):4-10. [Medline].

  10. Stulberg BN, Davis AW, Bauer TW. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop. Jul 1991;(268):140-51. [Medline].

  11. Tanzer M, Bobyn JD, Krygier JJ, Karabasz D. Histopathologic retrieval analysis of clinically failed porous tantalum osteonecrosis implants. J Bone Joint Surg Am. Jun 2008;90(6):1282-9. [Medline].

  12. Mont MA, Einhorn TA, Sponseller PD. The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head. J Bone Joint Surg Br. Jan 1998;80(1):56-62. [Medline].

  13. Beaty JH. Osteonecrosis. In: Orthopedic Knowledge. Update 6. Rosemont, Ill:. American Academy of Orthopedic Surgery;1999:460-5.

  14. Bradway JK, Morrey BF. The natural history of the silent hip in bilateral atraumatic osteonecrosis. J Arthroplasty. Aug 1993;8(4):383-7. [Medline].

  15. Kerboul M, Thomine J, Postel M. The conservative surgical treatment of idiopathic aseptic necrosis of the femoral head. J Bone and Joint Surg. 1974;56-B(2):291-96. [Medline].

  16. Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. Jul-Aug 1999;7(4):250-61. [Medline].

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

  18. Petty W. Osteonecrosis: Strategies for treatment. In: Callahan, Rosenberg AG, and Rubashed HE. The Adult Hip. Philadelphia, Pa:. Lippincott-Raven Publishers;1998:467-84.

  19. Steinberg ME, Corces A, Fallon M. Acetabular involvement in osteonecrosis of the femoral head. J Bone Joint Surg Am. Jan 1999;81(1):60-5. [Medline].

  20. Stulberg BN, Bauer TW, Belhobek GH. A diagnostic algorithm for osteonecrosis of the femoral head. Clin Orthop. Dec 1989;(249):176-82. [Medline].

  21. Urbaniak JR, Harvey EJ. Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg. Jan-Feb 1998;6(1):44-54. [Medline].

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Keywords

hip osteonecrosis, aseptic necrosis, avascular necrosis, osteonecrosis of the femoral head, ischemic necrosis, protein C deficiency, protein S deficiency, sickle cell anemia

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Contributor Information and Disclosures

Author

Michael Levine, MD, Chairman, Department of Orthopedic Surgery, Western Pennsylvania Hospital
Michael Levine, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, American Medical Association, Orthopaedic Research Society, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Phi Beta Kappa
Disclosure: encore medical Consulting fee Consulting; glaxo smith kline Honoraria Speaking and teaching

Coauthor(s)

Amar Rajadhyaksha, MD, Resident, Department of Orthopedic Surgery, New York Medical College
Disclosure: Nothing to disclose.

Michael Mont, MD, Associate Professor, Department of Orthopaedic Surgery, Johns Hopkins Medical Institution
Michael Mont, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Stryker Orthopaedics Consulting fee Consulting; Wright Medical Technology, Inc. Consulting fee Consulting

Medical Editor

B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine
B Sonny Bal, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;
James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Orthopaedic Association, Limb Lengthening and Reconstruction Society ASAMI-North America, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
Disclosure: Zimmer Stock Implant Designer

 
 
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