History

Patients with osteonecrosis usually are men in the sixth decade of life who experience pain primarily in the groin but occasionally the buttocks. Pain usually is deep and throbbing and is worse with ambulation, but it also is significant at night. Onset often can be described as acute. Patients frequently describe a catching or popping sensation with motion. A history of trauma, steroid use, alcohol abuse, and other risk factors should be sought.

Physical Examination

Physical examination reveals pain with range of motion and ambulation. Limitation of internal rotation in both flexion and extension are prevalent, with passive internal rotation in extension being particularly painful. A Trendelenburg gait often is present.

Workup

Barney J, Piuzzi NS, Akhondi H. Femoral Head Avascular Necrosis. 2021 Jan. [QxMD MEDLINE Link]. [Full Text].
Kang JS, Moon KH, Kwon DG, Shin BK, Woo MS. The natural history of asymptomatic osteonecrosis of the femoral head. Int Orthop. 2013 Mar. 37(3):379-84. [QxMD MEDLINE Link]. [Full Text].
Cohen-Rosenblum A, Cui Q. Osteonecrosis of the Femoral Head. Orthop Clin North Am. 2019 Apr. 50 (2):139-149. [QxMD MEDLINE Link].
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.
Cenni E, Fotia C, Rustemi E, Yuasa K, Caltavuturo G, Giunti A, et al. Idiopathic and secondary osteonecrosis of the femoral head show different thrombophilic changes and normal or higher levels of platelet growth factors. Acta Orthop. 2011 Feb. 82(1):42-9. [QxMD MEDLINE Link].
Soyfoo MS, Watik A, Stordeur P, Gangji V. Cryofibrinogen levels are increased in non-traumatic osteonecrosis: a new pathogenic clue to osteonecrosis?. Rheumatology (Oxford). 2013 Sep. 52(9):1694-700. [QxMD MEDLINE Link].
Sonoda K, Yamamoto T, Motomura G, Hamai S, Karasuyama K, Kubo Y, et al. Bilateral corticosteroid-induced osteonecrosis of the femoral head detected at a 6-week interval. Springerplus. 2015 Nov 2. 4:662. [QxMD MEDLINE Link].
Flouzat-Lachaniette CH, Roubineau F, Heyberger C, Bouthors C, Hernigou P. Multifocal osteonecrosis related to corticosteroid: ten years later, risk of progression and observation of subsequent new osteonecroses. Int Orthop. 2016 Apr. 40 (4):669-72. [QxMD MEDLINE Link].
Yoon BH, Jones LC, Chen CH, et al. Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 1: Glucocorticoid-Associated Osteonecrosis. J Arthroplasty. 2019 Jan. 34 (1):163-168.e1. [QxMD MEDLINE Link]. [Full Text].
Yoon BH, Jones LC, Chen CH, et al. Etiologic Classification Criteria of ARCO on Femoral Head Osteonecrosis Part 2: Alcohol-Associated Osteonecrosis. J Arthroplasty. 2019 Jan. 34 (1):169-174.e1. [QxMD MEDLINE Link]. [Full Text].
Kubo T, Ueshima K, Saito M, Ishida M, Arai Y, Fujiwara H. Clinical and basic research on steroid-induced osteonecrosis of the femoral head in Japan. J Orthop Sci. 2016 Jul. 21 (4):407-413. [QxMD MEDLINE Link]. [Full Text].
Steinberg ME, Oh SC, Khoury V, Udupa JK, Steinberg DR. Lesion size measurement in femoral head necrosis. Int Orthop. 2018 Jul. 42 (7):1585-1591. [QxMD MEDLINE Link].
Stulberg BN, Davis AW, Bauer TW. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop. 1991 Jul. (268):140-51. [QxMD MEDLINE Link].
Andronic O, Weiss O, Shoman H, Kriechling P, Khanduja V. What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?. Int Orthop. 2021 Mar. 45 (3):605-613. [QxMD MEDLINE Link]. [Full Text].
Tanzer M, Bobyn JD, Krygier JJ, Karabasz D. Histopathologic retrieval analysis of clinically failed porous tantalum osteonecrosis implants. J Bone Joint Surg Am. 2008 Jun. 90(6):1282-9. [QxMD MEDLINE Link].
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. 1998 Jan. 80(1):56-62. [QxMD MEDLINE Link].
Berkowitz JL, Potter HG. Advanced MRI Techniques for the Hip Joint: Focus on the Postoperative Hip. AJR Am J Roentgenol. 2017 Sep. 209 (3):534-543. [QxMD MEDLINE Link]. [Full Text].
Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg [Br]. 1985 Jan. 67(1):3-9. [QxMD MEDLINE Link].
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.
Steinberg DR, Steinberg ME. The University of Pennsylvania classification of osteonecrosis. Koo KH, Mont MA, Jones LC, editors. Osteonecrosis. Heidelberg: Springer; 2014. 201-206.
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.
Papakostidis C, Tosounidis TH, Jones E, Giannoudis PV. The role of "cell therapy" in osteonecrosis of the femoral head. A systematic review of the literature and meta-analysis of 7 studies. Acta Orthop. 2016 Feb. 87 (1):72-8. [QxMD MEDLINE Link].
Hernigou P, Trousselier M, Roubineau F, Bouthors C, Chevallier N, Rouard H, et al. Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress. Clin Orthop Surg. 2016 Mar. 8 (1):1-8. [QxMD MEDLINE Link]. [Full Text].
Houdek MT, Wyles CC, Collins MS, Howe BM, Terzic A, Behfar A, et al. Stem Cells Combined With Platelet-rich Plasma Effectively Treat Corticosteroid-induced Osteonecrosis of the Hip: A Prospective Study. Clin Orthop Relat Res. 2018 Feb. 476 (2):388-397. [QxMD MEDLINE Link]. [Full Text].
Jones KB, Seshadri T, Krantz R, Keating A, Ferguson PC. Cell-based therapies for osteonecrosis of the femoral head. Biol Blood Marrow Transplant. 2008 Oct. 14(10):1081-7. [QxMD MEDLINE Link].
Lim YW, Kim YS, Lee JW, Kwon SY. Stem cell implantation for osteonecrosis of the femoral head. Exp Mol Med. 2013 Nov 15. 45:e61. [QxMD MEDLINE Link].
Rastogi S, Sankineani SR, Nag HL, Mohanty S, Shivanand G, Marimuthu K, et al. Intralesional autologous mesenchymal stem cells in management of osteonecrosis of femur: a preliminary study. Musculoskelet Surg. 2013 Dec. 97(3):223-8. [QxMD MEDLINE Link].
Migliorini F, Maffulli N, Eschweiler J, Tingart M, Baroncini A. Core decompression isolated or combined with bone marrow-derived cell therapies for femoral head osteonecrosis. Expert Opin Biol Ther. 2021 Mar. 21 (3):423-430. [QxMD MEDLINE Link].
Piuzzi NS, Chahla J, Schrock JB, LaPrade RF, Pascual-Garrido C, Mont MA, et al. Evidence for the Use of Cell-Based Therapy for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature. J Arthroplasty. 2017 May. 32 (5):1698-1708. [QxMD MEDLINE Link].
Chen CH, Chang JK, Lai KA, Hou SM, Chang CH, Wang GJ. Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis: A two-year multicenter, prospective, randomized, double-blind, placebo-controlled study. Arthritis Rheum. 2012 May. 64(5):1572-8. [QxMD MEDLINE Link].
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. 2005 Oct. 87(10):2155-9. [QxMD MEDLINE Link].
Wang CJ, Wang FS, Ko JY, Huang HY, Chen CJ, Sun YC, et al. Extracorporeal shockwave therapy shows regeneration in hip necrosis. Rheumatology (Oxford). 2008 Apr. 47(4):542-6. [QxMD MEDLINE Link].
Gao F, Sun W, Li Z, Guo W, Wang W, Cheng L, et al. High-Energy Extracorporeal Shock Wave for Early Stage Osteonecrosis of the Femoral Head: A Single-Center Case Series. Evid Based Complement Alternat Med. 2015. 2015:468090. [QxMD MEDLINE Link].
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. 2008 Mar. 5(2):231-8. [QxMD MEDLINE Link].
Ibrahim V, Dowling H. Platelet-rich plasma as a nonsurgical treatment option for osteonecrosis. PM R. 2012 Dec. 4(12):1015-9. [QxMD MEDLINE Link].
Martin JR, Houdek MT, Sierra RJ. Use of concentrated bone marrow aspirate and platelet rich plasma during minimally invasive decompression of the femoral head in the treatment of osteonecrosis. Croat Med J. 2013 Jun. 54(3):219-24. [QxMD MEDLINE Link]. [Full Text].
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. 2007 Jan. 10(1):4-10. [QxMD MEDLINE Link].
Zhao D, Zhang Y, Wang W, Liu Y, Li Z, Wang B, et al. Tantalum rod implantation and vascularized iliac grafting for osteonecrosis of the femoral head. Orthopedics. 2013 Jun. 36(6):789-95. [QxMD MEDLINE Link].
[Guideline] Ando W, Sakai T, Fukushima W, Kaneuji A, Ueshima K, Yamasaki T, et al. Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head. J Orthop Sci. 2021 Jan. 26 (1):46-68. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

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.

of 5

Table 1. University of Pennsylvania classification of osteonecrosis

Stage	Criteria
0	Normal radiograph, bone scan, and magnetic resonance images
I	Normal radiograph. Abnormal bone scan and/or magnetic resonance images A: Mild (< 15 % of femoral head affected) B: Moderate (15–30 % of femoral head affected) C: Severe (>30 % of femoral head affected)
II	Cystic and sclerotic changes in femoral head A: Mild (< 15 % of femoral head affected) B: Moderate (15–30 % of femoral head affected) C: Severe (> 30 % of femoral head affected)
III	Subchondral collapse without flattening (crescent sign) A: Mild (< 15 % of femoral head affected) B: Moderate (15–30 % of femoral head affected) C: Severe (>30 % of femoral head affected)
IV	Flattening of femoral head A: Mild (< 15 % of surface and < 2 mm of depression) B: Moderate (15–30 % of surface and 2–4 mm of depression) C: Severe (>30 % of surface and > 4 mm of depression)
V	Joint narrowing or acetabular changes A: Mild B: Moderate C: Severe
VI	Advanced degenerative changes

Table 2. Association Research Circulation Osseous (ARCO) system

Stage	Criteria
0	Bone biopsy results consistent with osteonecrosis; other test results normal
I	Positive findings on bone scan, MRI, or both A: < 15% involvement of the femoral head (MRI) B: 15-30% involvement C: > 30% involvement
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
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
IV	Articular surface flattened; joint space shows narrowing; changes in acetabulum with evidence of osteosclerosis, cyst formation, and marginal osteophytes

Back to List

Author

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

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, Phi Beta Kappa

Disclosure: Received research grant from: DJO surgical<br/>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 Grossman 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 College of Surgeons, American Orthopaedic Association, 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, PhD, MBA CEO and President, SINTX Technologies, Salt Lake City, UT

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SINTX Technologies.

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.

Hip Osteonecrosis Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?