Femoral Head Avascular Necrosis Treatment & Management
- Author: John D Kelly, IV, MD; Chief Editor: Craig C Young, MD more...
Essentially, nonoperative treatment for symptomatic AVN of the hip yields unfavorable results. Restricted patient weight bearing with the use of a cane or crutches has not been shown to affect the natural history of the disease and is useful only in controlling symptoms. Physical therapy provides only symptomatic control and also does little to alter disease progression.
If the AVN is associated with a patient's alcohol use, the clinician is urged to assist the patient in alcohol abstinence. Patient referral to social services, psychologic or psychiatric counseling, or community outreach is recommended. For patients with prolonged steroid use, osteoporosis screening is indicated. (See also the Medscape Reference article Anabolic Steroid Use and Abuse, as well as Alcohol Disorders Common, Largely Untreated Among American Adults and Predictors of Future Anabolic Androgenic Steroid Use on Medscape News.)
Surgical treatment of AVN can be broadly categorized as either prophylactic measures (to retard progression) or reconstruction procedures (after femoral head collapse). Small asymptomatic lesions do not warrant surgical intervention and are closely monitored with serial examination. If symptoms ensue, repeat imaging and surgical treatment are indicated.
- The most commonly performed prophylactic surgical intervention is core decompression, whereby one or more cores of necrotic femoral head bone is removed in order to stimulate repair. Core decompression is often supplemented with bone grafting (cancellous autograft or structural allograft) to enhance mechanical support and augment healing. Biologic augmentation of core decompression includes the addition of demineralized bone matrix, bone morphogenic proteins, or electric/electromagnetic stimulation. These agents are purported to either enhance bone formation or decrease bone resorption in the hope of maintaining the structural integrity of the femoral head. Biologic augmentation of core decompression alone offers therapeutic benefit—if it is instituted before subchondral collapse (Steinberg stage III). A study analyzed the clinical, functional and radiological outcome of core decompression and bone grafting in 20 patients with 28 cases of osteonecrosis of the femoral head (ONFH) up to stage IIB (Ficat & Arlet). The study concluded that core decompression and bone grafting provide satisfactory outcome when patients are carefully selected in early stages of the disease (stage I), before the stage of collapse. However patients with stage II disease had poorer outcomes approximately 50% with improvement.
- The addition of a vascularized fibular graft to core decompression offers promise in cases with more advanced lesions, but this procedure involves considerable morbidity. One study indicated that vascularized fibular grafts were more effective in preventing femoral head collapse than nonvascularized fibular autografts.[12, 13]
- The results of prophylactic measures for femoral head AVN have considerable variation, but certain generalizations can safely be stated. Namely, the clinical results of core decompression alone deteriorate with more advanced lesions. The addition of cancellous bone grafting appears to slightly enhance clinical outcomes if subchondral fracture is present. The addition of demineralized bone matrix to core decompression confers little (if any) clinical response, and the effects of bone morphogenic protein remain uncertain.
- The supplemental implementation of electrical stimulation with core decompression has provided disappointing results. Low-frequency pulsed electric and magnetic fields may offer more promise, but clinical results thus far are inconclusive. The placement of a structural graft through a core tract into the femoral head generally yields disappointing results. However, grafts placed into the femoral neck or directly into the femoral head are more promising. Free vascularized fibular grafting significantly alters disease progression in precollapse lesions and is even useful in modifying disease in mildly collapsed and early arthritic hips.
- Osteotomies are performed in attempt to move necrotic bone away from primary weight-bearing areas in the hip joint. Osteotomies can be angular or rotational, with the latter proving to be much more technically difficult. These techniques may delay arthroplasty, but they are best suited for small precollapse or early postcollapse of the femoral head in patients who don't have an ongoing cause of AVN. However, osteotomies make subsequent arthroplasty more challenging and, unfortunately, these procedures are associated with an appreciable risk of nonunion.
- The role of arthroscopy to better stage the extent of disease has emerged. Arthroscopic evaluation of the joint can help better define the extent of chondral flaps, joint degeneration and even joint collapse and may help with the temporary relief of synovitis. Arthroscopic-assisted reduction of the head collapse is experimental at this time.
- Despite aggressive management, most hips that undergo collapse ultimately require reconstruction (ie, replacement). Prosthetic replacement offers the most predictable means of pain relief in advanced AVN; however, many arthroplasty options are available to meet the challenge of painful arthropathy in younger patients.
- Femoral resurfacing arthroplasty is gaining acceptance for younger patients. Both the femoral head and acetablum are "resurfaced" with metal, indicating minimal bone resection. This procedure circumvents the problem of polyethylene wear. However, technical and design problems with surface replacements may explain the relatively high failure rate in some clinical series. Nonetheless, refinements in both technique and design predict improved outcomes.
- Resurfacing arthroplasty remains a controversial procedure that likely will not last a patient’s lifetime. Current recommendations are that resurfacing is contraindicated if the avascular area exceeds one third of the femoral head. Furthermore, there is a 1% incidence of femoral neck fracture with this procedure. Lastly, the issue of metal ion release has spurred much debate, although there are no good data available to suggest injurious effects. Fortunately, resurfacing arthroplasty likely confers no significant compromise for subsequent arthroplasty.
- A report on preliminary clinical results of 5 subjects who underwent a total of 7 focal anatomic-resurfacing implantation procedures for the treatment of osteonecrosis of the femoral head, found that the alternative technique of focal anatomic hip resurfacing yielded preliminary successful results at 2+ year follow-up.
- Bipolar arthroplasty theoretically decreases shear stress and impact load on acetabular cartilage, although this concept has not been born out clinically. Persistent groin pain, high rates of polyethylene wear, and early loosening have mitigated the appeal of this option. Resection arthroplasty should only be considered in very young patients and in debilitated patients who are at high risk for infection (eg, patients on dialysis).
- Total hip arthroplasty is perhaps the most commonly performed and successful surgery for advanced AVN of the hip. However, clinical outcomes are inferior to those of total hip arthroplasty that is performed for osteoarthritis. Cementless prostheses with an improved design may afford increased longevity relative to cemented counterparts. Despite recent improvements in prosthetic replacement, replacement arthroplasty precludes further participation in impact activities (eg, running, jogging) because these activities greatly decrease implant longevity.
Because AVN of the hip is often associated with pronounced medical comorbidities (eg, sickle cell disease, systemic lupus erythematosus), medical consultation is prudent, particularly during the perioperative period. Furthermore, if no obvious cause of AVN is seen, medical consultation would be a reasonable measure in order to help discern less common etiologies. (See Clinical, Causes, above.)
Injections of cortisone into the hip joint may temporarily alleviate the symptoms of AVN; however, these injections are not generally recommended because of their invasiveness and short-lasting effects.
Missed diagnoses, especially of the contralateral hip, are not uncommon. Review radiographs of patients with a characteristic history, examination findings, and risk factors. If radiographs are negative, order an MRI.
A feared complication of core decompression is subtrochanteric fracture. This adverse event can be somewhat prevented by fastening the core tract as proximally as possible.
Consider administering low molecular weight heparin (LMWH) for thrombophilic patients; LMWH may aid in preventing the progression of idiopathic osteonecrosis of the hip.
Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. 1999 Jul-Aug. 7(4):250-61. [Medline].
Vail TP, Covington DB. The incidence of osteonecrosis. Urbaniak JR, Jones JR, eds. Osteonecrosis: Etiology, Diagnosis, Treatment. Rosemont, Ill: American Academy of Orthopedic Surgeons; 1997. 43-9.
Ai ZS, Gao YS, Sun Y, Liu Y, Zhang CQ, Jiang CH. Logistic regression analysis of factors associated with avascular necrosis of the femoral head following femoral neck fractures in middle-aged and elderly patients. J Orthop Sci. 2012 Nov 1. [Medline].
Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995 Mar. 77(3):459-74. [Medline].
Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop Relat Res. May 2001. 386:173-8. [Medline].
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].
Steinberg ME. Avascular necrosis: diagnosis, staging, and management. J Musculoskel Med. 1997. 14(11):13-25.
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].
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. 2007 Jun. 89(6):1194-204. [Medline].
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].
Shah SN, Kapoor CS, Jhaveri MR, Golwala PP, Patel S. Analysis of outcome of avascular necrosis of femoral head treated by core decompression and bone grafting. J Clin Orthop Trauma. 2015 Sep. 6 (3):160-6. [Medline].
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].
Fang T, Zhang EW, Sailes FC, McGuire RA, Lineaweaver WC, Zhang F. Vascularized fibular grafts in patients with avascular necrosis of femoral head: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2012 Oct 18. [Medline].
McCarthy J, Puri L, Barsoum W, et al. Articular cartilage changes in avascular necrosis: an arthroscopic evaluation. Clin Orthop Relat Res. 2003 Jan. 406:64-70. [Medline].
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].
Squire M, Fehring TK, Odum S, Griffin WL, Bohannon Mason J. Failure of femoral surface replacement for femoral head avascular necrosis. J Arthroplasty. 2005 Oct. 20(7 suppl 3):108-14. [Medline].
Bilge O, Doral MN, Yel M, Karalezli N, Miniaci A. Treatment of osteonecrosis of the femoral head with focal anatomic-resurfacing implantation (HemiCAP): preliminary results of an alternative option. J Orthop Surg Res. 2015 Apr 28. 10:56. [Medline].
Chotanaphuti T, Thongprasert S, Laoruengthana A. Low molecular weight heparin prevents the progression of precollapse osteonecrosis of the hip. J Med Assoc Thai. 2013 Oct. 96(10):1326-30. [Medline].
Glueck CJ, Freiberg RA, Sieve L, Wang P. Enoxaparin prevents progression of stages I and II osteonecrosis of the hip. Clin Orthop Relat Res. 2005 Jun. 435:164-70. [Medline].
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. 2005 Oct. 87(10):2155-9. [Medline].
Takahashi S, Fukushima W, Kubo T, Iwamoto Y, Hirota Y, Nakamura H. Pronounced risk of nontraumatic osteonecrosis of the femoral head among cigarette smokers who have never used oral corticosteroids: a multicenter case-control study in Japan. J Orthop Sci. 2012 Nov. 17(6):730-6. [Medline].
DeLee JC. Fractures and dislocations of the hip. Rockwood CA, Green DP, Bucholz RW, eds. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996. 1661-9.
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].
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. 2005 Sep. 87(9):2012-8. [Medline].
Urbaniak JR, Barnes CJ. Meeting the challenge of osteonecrosis in adults. J Musculoskel Med. 2001. 18:395-403.