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Hip Osteonecrosis Workup

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

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
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Imaging Studies

Anteroposterior (AP) radiographs (see image below) and frog lateral radiographs of both hips are the primary diagnostic modalities.

Osteonecrosis, hip. Anteroposterior radiograph shoOsteonecrosis, 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 below).
    MRI showing osteonecrosis of right hip, normal lefMRI showing osteonecrosis of right hip, normal left hip.

Bone scanning (see image below)

Bone scan showing osteonecrosis of right hip. Bone scan showing osteonecrosis of right hip.

See the list below:

  • Helpful when x-ray findings are normal if MRI cannot be obtained
  • Low-cost alternative when index of suspicion is low
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Diagnostic Procedures

Core biopsy (see image below) and interosseous pressure measurement

Osteonecrosis, hip. Anteroposterior radiograph corOsteonecrosis, hip. Anteroposterior radiograph core biopsy.

See the list below:

  • 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.

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.
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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.

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Staging

Several radiographic staging systems are currently used.

  • Ficat classification[7]
    • 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 system[8]
    • 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])[9]
    • 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
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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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