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Hip Osteonecrosis Treatment & Management

  • Author: Michael Levine, MD; Chief Editor: William L Jaffe, MD  more...
 
Updated: Dec 29, 2015
 

Medical Therapy

Nonsurgical treatment of osteonecrosis is limited. Observation and protected weight bearing are options. Certain cases of early-stage disease (eg, Ficat stage 1) can be treated successfully with this option. However, most studies indicate that the risk of disease progression is greater with nonsurgical treatment than with surgical intervention.

Nonsteroidal anti-inflammatory drugs can be used to reduce pain and inflammation in patients who cannot have surgery for medical or other reasons or for patients who are undergoing surgical treatment.

Physical therapy can be helpful to restore motion and improve gait.

Electrical stimulation has been used in several centers. In some studies, it has been helpful in treatment prior to femoral head collapse. The benefit of surgical treatment options versus observation is controversial in certain cases. Further study is required.

Pharmacotherapy that addresses the pathophysiology of the disease has had mixed results. Examples include gemfibrozil (Lopid) for hyperlipidemias and nifedipine for vascular disorders. Alendronate has been suggested as an option to avoid or delay progression of the disease clinically and radiographically. However, one randomized study showed no significant difference in radiographic and MRI data between the alendronate and control groups.[10] Short-term follow-up (about 24 months) of patients in alendronate studies have demonstrated delayed femoral head collapse.[11]

Extracorporeal shockwave treatment has shown some promise in treating early disease by promoting angiogenesis and bone remodeling.[12, 13]

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Surgical Therapy

The mainstay of treatment for osteonecrosis is surgical. Numerous procedures are available, indicating that no single procedure is distinctly advantageous. Preoperative staging, particularly with collapse of the femoral head, and acetabular involvement are the determining factors for choosing a particular operation.

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Preoperative Details

The choice of procedure is based on preoperative staging. Core decompression and cancellous and cortical bone grafting procedures usually are indicated in Ficat stage IIa or earlier stages. The trapdoor procedure and allograft procedures are indicated for stage IIb or stage III lesions. Osteotomies are used for stage II and stage III disease. Arthrodesis and arthroplasty are utilized primarily for stages III and IV but occasionally are used for stages I and II.

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Intraoperative Details

The objective in core decompression is to stimulate revascularization and decrease pressure within the femoral head. The patient is placed supine on a fracture table. Using image intensification through a lateral incision above the trochanteric ridge, a 10-mm core of bone is removed from the femoral necrotic lesion.

Bone grafting has several techniques:

  • Cancellous bone grafting: A core decompression is performed. The defect is filled with cancellous bone graft material, usually iliac crest or allograft.
  • Cortical bone grafting: A core decompression is performed, and a strut graft is placed in the defect under the weightbearing surface of the femoral head. Iliac crest or fibula has been used. Recently, use of a vascularized free fibular graft harvested from the ipsilateral leg with a vascular pedicle inserted into the proximal femoral defect and anastomosed with the lateral circumflex artery has become popular.
  • Osteochondral allograft procedure: The necrotic area is replaced with a nonvascularized free allograft.
  • Muscle pedicle bone grafting: This procedure was adapted primarily for traumatic osteonecrosis. Cancellous iliac crest graft is placed in a channel in the infracted region and covered by a graft with the quadratus femoris muscle attached.
  • The growth factors Op-1 (osteogenic protein-1) and rhBMP-2 (recombinant human bone morphogenetic protein-2) may be useful bone grafting adjuncts. [14]
  • Implantation of mesenchymal stromal cells is currently under investigation. [15, 16, 17]
  • Strut grafting with a tantalum implant, a highly porous metallic cylinder placed in a channel to support subchondral bone [18, 19]
  • Platelet-rich plasma therapy [20, 21]

The concept in osteotomy is to rotate the diseased area of the femoral head away from the weightbearing surface. Several different techniques are available:

  • Angular osteotomy: Varus or valgus flexion usually is performed intertrochanterically and fixed with a plate.
  • Rotational osteotomy: The head is rotated transtrochanterically, moving the weightbearing surface away from the necrotic lesion.

Arthrodesis is fusion of the hip joint. The joint is denuded of articular cartilage, and the femoral head and acetabulum are fixed to create a solid interface.

In arthroplasty, conventional techniques are used with either cemented or cementless implants:

  • Resection arthroplasty involves excision of the femoral head.
  • Mold or cup arthroplasty involves resurfacing of the articular surface of the femoral head with a prosthetic device.
  • Resurfacing arthroplasty involves a cup-type arthroplasty on the femoral side with a metal-on-metal acetabular component.
  • Unipolar prosthetic arthroplasty involves replacement of the femoral head with a nonmobile bearing head.
  • Bipolar arthroplasty involves replacing the femoral head with a mobile bearing component.
  • Total hip replacement primarily with cementless devices, with metal-on-polyethylene, ceramic-on-polyethylene, or ceramic-on-ceramic bearings

The trapdoor procedure involves open excision of the necrotic bone by elevation of the cartilage and cancellous grafting.

Limited femoral resurfacing for young patients with intact acetabular cartilage and a collapsed femoral head is a valuable alternative to total hip replacement.

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Postoperative Details

See the list below:

  • Core decompression - Non-weightbearing ambulation for 6-12 weeks, then gradual resumption of normal activities as tolerated
  • Cancellous bone grafting - Similar to core decompression
  • Cortical bone grafting - No weight bearing for 6 weeks, with progressive weight bearing to 6 months
  • Trapdoor - Twenty percent weight bearing for 6 weeks, 50% weight bearing to 10 weeks, then progress to full weight bearing
  • Arthrodesis - No weight bearing, with full weight bearing initiated at 3 months
  • Osteotomy - Protected weight bearing for 6 weeks with gradual progression
  • Limited femoral resurfacing - Fifty percent weight bearing for 6 weeks, then weight bearing as tolerated
  • Resurfacing arthroplasty - Rehabilitation similar to total hip arthroplasty
  • Arthroplasty - Weight bearing as tolerated immediately following surgery, depending on surgeon preference
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Follow-up

See the list below:

  • Core decompression: Success rates are better than those with conservative treatment, with approximately 70% success in stages before radiographic collapse and limited morbidity. [22] Core decompression has been shown to be a highly cost-effective alternative when a total hip replacement is delayed by 5 years or more.
  • Cancellous grafting: No statistical evidence exists of superiority over core decompression alone.
  • Cortical grafting (avascular): No evidence exists of superiority over core decompression.
  • Vascularized fibular grafting: The procedure is technically difficult with increased morbidity and has questionable benefit compared with core decompression.
  • Tantalum implants: Recent retrieval studies have shown little bone ingrowth, insufficient mechanical support of subchondral bone, and a significant rate of femoral head collapse. [23]
  • Trapdoor: Indicated more in stage III disease, in which above procedures are unsuccessful; 83% good or excellent results were demonstrated in 1 study. [24]
  • Osteotomy: This procedure is technically very difficult; use in cases in which total hip replacement is not advisable, understanding that future total hip replacement is technically more difficult.
  • Cup arthroplasty, unipolar arthroplasty, and bipolar arthroplasty: Success rates are poor; disease appears to affect both sides of the hip joint.
  • Limited femoral resurfacing: Newer designs have increased the longevity of the procedure to greater than 10 years. Therefore, limited femoral resurfacing is a valuable alternative to total hip replacement in young patients with osteonecrosis; however, some studies suggest poor results when compared with age-matched patients with osteoarthritis.
  • Total resurfacing arthroplasty: Greater than 90% survivorship at greater than 3 years
  • Arthrodesis: Results are poor in terms of achieving fusion and patient satisfaction.
  • Total hip replacement: Early results were poor with early cement techniques, with failures up to 25% or higher. Recent studies have shown success rates at over 90% with current techniques, making it the treatment of choice following collapse or failure of less-invasive procedures.
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Complications

See the list below:

  • Core decompression: Complications are minimal in the hands of experienced surgeons. The most severe complication is fracture, which can occur if core is drilled below the trochanteric ridge.
  • Bone grafting procedures: The same complications as with core decompression, along with donor-site morbidity; peroneal sensory neuropathy, contractures of the flexor hallucis longus, deep venous thrombosis, and ankle pain with ambulation have been noted in vascularized fibular graft procedures.
  • Trapdoor: Limited complications are reported aside from deep venous thrombosis.
  • Osteotomies: Complications include nonunion and malunion, along with those stated above.
  • Limited femoral resurfacing: Cases of loosening and acetabular wear have been reported but complications are minimal.
  • Total resurfacing arthroplasty: Femoral neck fracture is the most common and critical complication; patient selection is key.
  • Total hip replacement: Infection, peroneal nerve palsy, deep venous thrombosis, intraoperative fracture, and postoperative dislocation are noted; risk-benefit ratio strongly reflects success of procedure.
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Outcome and Prognosis

The success rate in patients not treated by arthroplasty in stage 0 or I approaches 90% in some series. Once femoral head collapse occurs, these treatments offer limited benefit. Procedures such as the trapdoor procedure potentially may improve results in stage II and III, but presently, total hip replacement remains the treatment of choice once collapse has occurred. If not treated, 80% of femoral heads collapse within 4 years of diagnosis. Location and extent of the necrotic lesion appear to be good indicators of collapse of the femoral head.

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Future and Controversies

The natural history of atraumatic osteonecrosis is still not well understood. Different etiologies of the disease often have different clinical courses. Steroid-induced disease has the worst prognosis, and most cases progress to collapse of the femoral head. Future studies hopefully will focus on the natural history of the disease; surgical procedures of limited morbidity to prevent collapse in the early stages; and procedures for use following collapse but before development of arthritis, short of total hip replacement.

Prostheses with novel bearing surfaces (ie, metal-on-metal, ceramic-on-ceramic) are being investigated, to increase the success rate for total hip replacements in patients with osteonecrosis.

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Contributor Information and Disclosures
Author

Michael Levine, MD Vice Chairman, Department of Orthopedic Surgery, Forbes Regional Hospital; Associate Clinical Professor of Orthopedic Surgery, Temple University School of Medicine

Michael Levine, MD is a member of the following medical societies: Pennsylvania Medical Society, Phi Beta Kappa, Orthopaedic Research Society, Pennsylvania Orthopaedic Society, American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, American Medical Association

Disclosure: Consultant and receive royalties from DJO surgical.

Coauthor(s)

Amar Rajadhyaksha, MD Director, Miami Spine Institute, Miami Institute for Joint Reconstruction

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

James J McCarthy, MD, FAAOS, FAAP Director, Division of Orthopedic Surgery, Cincinnati Children's Hospital; Professor, Department of Orthopedic Surgery, University of Cincinnati College of Medicine

James J McCarthy, MD, FAAOS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Orthopaedic Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Pennsylvania Orthopaedic Society, Pediatric Orthopaedic Society of North America, Orthopaedics Overseas, Limb Lengthening and Reconstruction Society, Alpha Omega Alpha, American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Orthopediatrics, Phillips Healthcare, POSNA<br/>Serve(d) as a speaker or a member of a speakers bureau for: Synthes<br/>Received research grant from: University of Cincinnati<br/>Received royalty from Lippincott Williams and WIcins for editing textbook; Received none from POSNA for board membership; Received none from LLRS for board membership; Received consulting fee from Synthes for none.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

B Sonny Bal, MD, JD, MBA Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

B Sonny Bal, MD, JD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Received none from Bonesmart.org for online orthopaedic marketing and information portal; Received none from OrthoMind for social networking for orthopaedic surgeons; Received stock options and compensation from Amedica Corporation for manufacturer of orthopaedic implants; Received ownership interest from BalBrenner LLC for employment; Received none from ConforMIS for consulting; Received none from Microport for consulting.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Michael Mont, MD,to the development and writing of this article.

References
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Osteonecrosis, hip. Anteroposterior radiograph showing Ficat stage III disease.
MRI showing osteonecrosis of right hip, normal left hip.
Bone scan showing osteonecrosis of right hip.
Osteonecrosis, hip. Anteroposterior radiograph core biopsy.
Osteonecrosis, hip. A radiograph of a limited femoral resurfacing performed for a collapsed femoral head with damaged femoral head cartilage and intact acetabular cartilage.
 
 
 
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