eMedicine Specialties > Sports Medicine > Hip

Femoral Head Avascular Necrosis: Follow-up

Author: John D Kelly IV, MD, Associate Professor of Orthopedic Surgery, Vice Chairman, Department of Orthopedic Surgery, Temple University; Consulting Surgeon, Temple Children's Hospital and Shriner's Hospital for Surgery
Coauthor(s): David Wald, DO, FACOEP, Assistant Program Director, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Temple University School of Medicine
Contributor Information and Disclosures

Updated: Nov 6, 2007

Follow-up

Return to Play

AVN of the hip is generally a contraindication to sports participation. Even when this condition is successfully treated, impact sports should be discouraged. The athlete can maintain fitness with pursuits that are easy on the joints, such as swimming, biking, and using elliptical training devices.

Complications

In most cases, progression from femoral head AVN to femoral head collapse requires arthroplasty.

Prevention

Abstinence from excessive alcohol intake and taking the lowest possible dose of a corticosteroid (when indicated) are the 2 chief means of AVN prevention.

There are some data regarding cholesterol-lowering statin therapy as a means of decreasing the risk of AVN for those receiving corticosteroids.4 Given the relatively favorable safety profile of these agents, such therapy should be considered.

Cutaneous electrical stimulation, in the form of capacitive coupling, is purported by some to have a disease-modifying effect, although long-term studies are lacking.

Anticoagulation therapy in the form of enoxaparin was shown in one investigation to retard progression of early AVN.14 This lends support to the "thrombophilia theory" of AVN disease etiology.

Lastly, the antiresorptive, alendronate, was demonstrated to prevent collapse of early AVN.15 This finding adds credence to the argument that the bone's repair response (resorption), rather than the actual infarction, leads to femoral head collapse and the subsequent morbidity.

Prognosis

If AVN of the femoral head is untreated, progression to subchondral collapse occurs in approximately 67% of individuals with asymptomatic hips and in more than 85% of those who have symptomatic hips.

Education

Information regarding the deleterious effects of alcohol and corticosteroids on femoral head circulation should be disseminated to those who are at risk for AVN.

Miscellaneous

Medicolegal Pitfalls

  • The clinical appearance of AVN of the hip may be mistaken for less worrisome conditions, such as synovitis or a labral tear. A missed diagnosis invites potential legal action because the earlier AVN is diagnosed, the more predictable the treatment. Obtaining a thorough patient history and physical examination, as well as an MRI in the face of negative radiographs, helps to circumvent missed diagnoses and legal action.
 


More on Femoral Head Avascular Necrosis

Overview: Femoral Head Avascular Necrosis
Differential Diagnoses & Workup: Femoral Head Avascular Necrosis
Treatment & Medication: Femoral Head Avascular Necrosis
Follow-up: Femoral Head Avascular Necrosis
References
[ CLOSE WINDOW ]

References

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

  2. Vail TP, Covington DB. The incidence of osteonecrosis. In: Urbaniak JR, Jones JR, eds. Osteonecrosis: Etiology, Diagnosis, Treatment. Rosemont, Ill: American Academy of Orthopedic Surgeons; 1997:43-9.

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

  4. Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop Relat Res. May 2001;386:173-8. [Medline].

  5. Arlet J, Ficat P. [Non-traumatic avascular femur head necrosis. New methods of examination and new concepts] [Polish]. Chir Narzadow Ruchu Ortop Pol. 1977;42(3):269-76. [Medline].

  6. Steinberg ME. Avascular necrosis: diagnosis, staging, and management. J Musculoskel Med. 1997;14(11):13-25.

  7. Steinberg ME. Diagnostic imaging and the role of stage and lesion size in determining outcome in osteonecrosis of the femoral head. Techniques in Orthopaedics. Mar 2001;16(1):6-15. [Full Text].

  8. McGrory BJ, York SC, Iorio R, et al. Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head. J Bone Joint Surg Am. Jun 2007;89(6):1194-204. [Medline].

  9. Ciombor DM, Aaron RK. Biologically augmented core decompression for the treatment of osteonecrosis of the femoral head. Techniques in Orthopaedics. Mar 2001;16(1):32-8. [Full Text].

  10. Katz MA, Urbaniak JR. Free vascularized fibular grafting of the femoral head for the treatment of osteonecrosis. Techniques in Orthopaedics. Mar 2001;16(1):44-60. [Full Text].

  11. McCarthy J, Puri L, Barsoum W, et al. Articular cartilage changes in avascular necrosis: an arthroscopic evaluation. Clin Orthop Relat Res. Jan 2003;406:64-70. [Medline].

  12. Ivankovich DA, Rosenberg AG, Malamis A. Reconstructive options for osteonecrosis of the femoral head. Techniques in Orthopaedics. Mar 2001;16(1):66-79. [Full Text].

  13. Squire M, Fehring TK, Odum S, Griffin WL, Bohannon Mason J. Failure of femoral surface replacement for femoral head avascular necrosis. J Arthroplasty. Oct 2005;20(7 suppl 3):108-14. [Medline].

  14. Glueck CJ, Freiberg RA, Sieve L, Wang P. Enoxaparin prevents progression of stages I and II osteonecrosis of the hip. Clin Orthop Relat Res. Jun 2005;435:164-70. [Medline].

  15. [Best Evidence] Lai KA, Shen WJ, Yang CY, 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. Oct 2005;87(10):2155-9. [Medline].

  16. DeLee JC. Fractures and dislocations of the hip. In: Rockwood CA, Green DP, Bucholz RW, eds. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996:1661-9.

  17. Etienne G, Mont MA, Khanuja HS, Hungerford DS. Nonvascularized bone grafts for osteonecrosis of the femoral head: current concepts and techniques. Techniques in Orthopaedics. Mar 2001;16(1):39-43. [Full Text].

  18. Kim SY, Kim YG, Kim PT, et al. Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head. J Bone Joint Surg Am. Sep 2005;87(9):2012-8. [Medline].

  19. Urbaniak JR, Barnes CJ. Meeting the challenge of osteonecrosis in adults. J Musculoskel Med. 2001;18:395-403.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

aseptic necrosis, ischemic necrosis, AVN of the femoral head, osteonecrosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

John D Kelly IV, MD, Associate Professor of Orthopedic Surgery, Vice Chairman, Department of Orthopedic Surgery, Temple University; Consulting Surgeon, Temple Children's Hospital and Shriner's Hospital for Surgery
John D Kelly IV, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

David Wald, DO, FACOEP, Assistant Program Director, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Temple University School of Medicine
David Wald, DO, FACOEP is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Gerard A Malanga, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, New Jersey Medical School; Director of Pain Management, University of Medicine and Dentistry at New Jersey, Overlook Hospital; Director of Sports Medicine, Mountainside Hospital
Gerard A Malanga, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

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

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.