IMAGING OF

OSTEONECROSIS OF THE
FEMORAL HEAD
Narasumber : Dr. dr. Hermina
Sukmaningtyas, Sp.Rad (K). M.Kes

AULIA FITRIANI
INTRODUCTION

Osteonecrosis (ON) is a common disease caused by an ischemic injury toward the

epiphyseal and sub-articular bone with sparing of the adjacent hyaline cartilage
1. a reduction in blood supply leads to a progressive bone loss and subsequently to a
impaired structure→ fractures and end-stage secondary osteoarthritis.
ETIOLOGY

• Idiopathic (37% all cases)

• Systemic disease
• Trauma
• Therapy eith corticosteroid
• Alcohol abuse

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• The skeletal regions most frequently affected are femoral
head, humeral head, knee (distal femur and proximal tibia)
and talus of patients aging between 30 and 50 years.

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 ETIOLOGY AND PATHOGENESIS OF OSTEONECROSIS OF THE
FEMORAL HEAD
Osteonecrosis of the femoral
head is a common disease.
➢usually idiopathic and often
bilateral
➢affecting both children (Legg –
Calvè – Perthes disease) and
adults (Chandler disease); it is
newly diagnosed in up to
30.000 Patients yearly in the
United State
AFTER CELLULAR NECROSIS, REPARATIVE
MECHANISMS
UNDERGO THREE SUBSEQUENT STEPS

Revascularization

Cellular migration

Complication

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Main symptoms are acute hip
pain and functional
impairment; apyrexia and
negative inflammatory
markers differentiate ON from
acute arthritis (e.g.
rheumatoid and septic
arthritis)

Clinical Features

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• X-RAY • Computed tomography

Plain radiographies are usually the

initial approach for Patients suffering Often more sensitive than plain
from hip pain because of their high film in showing subchondral
availability and low cost. fractures.

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• Magnetic • Bone Scan
resonance
• Magnetic resonance (MR) presents
the highest sensitivity and specificity • As well as MR, bone
in both diagnosis and follow-up scintigraphy may detect the
compared to x-rays, CT and bone early stages of osteonecrosis of
scintigraphy the femoral head, especially in
patients with unilateral
diagnosis and negative opposite
radiographs.
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FICAT AND ARLET CLASSIFICATION

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 A B
A. Antero-Posterior view of the B. Axial view of the left hip x-ray showing a
right hip x-ray showing alternating subchondral fracture line and a cortical
regions of sclerosis and lucency on discontinuity (arrowhead) expression of the
superior aspect of femoral head collapse of the subchondral bone in a 28
(stage 2 ficat arlet) years old woman, in dialysis for lupus
nephritis, suffering from hip pain (stage 3
ficat arlet)
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Antero-posterior view of
the right hip x-ray show
collapse with flattening
and sclerosis of the
femoral head in a young
male. (stage 4 ficat arlet)

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 Magnetic resonance

• MR Classification sec. Mitchell

The first adipose phase - characterized by arterial ischaemia causing cellular necrosis
The haematic phase is characterized by the presence of micro
The fluid phase is caused by the venous congestion that determines a persistent cellular
damage leading to the death of all cellular lineage; inflammation, hyperaemia and fibrosis
are irregularly distributed
The fibrous phase shows the predominance of sclerotic and fibrotic alterations

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axial and coronal CT Images shows sclerotic
interface between necrotic and viable bone
(A,B) and analogous line of low signal
surrounding the necrotic bone seen on TSE T2
MRI axial and coronal images.

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 C

Table. Mitchell’s MRI staging shows the different T1-w and T2-w characteristics signal,
according to the tissue present in osteonecrosis area

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Coronal FSE T1-w (A) and coronal FSE
T2-w (B) image of a male patient
suffering of bilateral osteonecrosis of
the femoral head in different stages of
evolution, namely the fibrosis-(on the
left) and the fatty-phase (on the right)
where shows high signal intensity line
in the inner zone (arrow head) and a
low-signal-intensity line (arrow) in the
parallel outer zone

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 Once various conditions such as osteoarthritis,
osteomyelitis, trauma and septic arthritis are
excluded in accord with anamnestic and clinical
information, the differential diagnosis of
osteonecrosis comprises “sympathetic dystrophy
syndrome” (RSDS or algodystrophy), given their
clinical and radiological overlaps

Differential Diagnosis

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 Bone marrow oedema syndrome (BMES)

Transient clinical conditions of unknown aetiology,

Include conditions – transient osteoporosis of the hip
(TOH), – regional migratory osteoporosis (RMO), –
reflex sympathetic dystrophy (RSD). BMES is
characterized by bone marrow oedema (BME) pattern.
Affects the hip, the knee, and the ankle of middle -aged
males. Third trimester of pregnancy.

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Coronal view of hip-MR in a young
male. Patient suffering from
algodystrophy demonstrates the
typical segmental distribution of bone
marrow oedema of femoral head, neck
and intertrocanteric region (arrow). (A)
DP-SPAIR sequence highlights bone
marrow oedema as hyperdense; DP-
SPAIR is also useful to detect intra-
articular effusion (arrowhead). (B) FSE
T1-w image shows the same
distribution of bone marrow oedema
(arrow), nevertheless intra-articular
effusion is not easily identified

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 TRANSIENT OSTEOPOROSIS

• (TOH) was first described by Curtiss and Kincaid in 19591 as a syndrome of transient
demineralization of the hip in the third trimester of pregnancy.
• Distinct self limiting condition → present spontaneously
• Sudden onset pain in the hip
• Gradually resolving within 6-8 motnhs

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A THE L ATERAL RADIOGRAPH OF THE RIGHT HIP JOINT IS UNREMARK ABLE.
B THE L ATERAL RADIOGRAPH OF THE LEFT HIP JOINT SHOWS MARKED
OSTEOPENIA OF BOTH THE FEMORAL HEAD AND NECK AND THE ACETABULUM
( ARROWS
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THE L ATERAL RADIOGRAPHS SHOW LYSIS AND SCLEROSIS IN BOTH
FEMORAL HEADS ( ARROWS IN A AND B), SUGGESTING BIL ATERAL
OSTEONECROSIS. THE “CRESCENT” SIGN IN THE LEFT FEMORAL HEAD
(OPEN ARROW) IS DIAGNOSTIC OF ADVANCED OSTEONECROSIS WITH
SUBARTICUL AR FRACTURE BUT NOT ARTICUL AR COLL APSE 22
 SCINTIGRAPHY TC
99

a. Transient osteoporosis:-
b. Avascular necrosis of the
left hip

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 CT SCAN

transient osteoporosis of the left hip. A The plain AP

radiograph shows osteopenia of the outer part of the left
femoral head (arrow). b The corresponding CT scan
obtained on the same day shows to better advantage the
marked osteopenia of the left femoral head with mottled
or moth-eaten pattern of the trabecular bone (arrows)

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 MRI

(a )The coronal T1-w TSE

MR image shows low signal
intensity in the right femoral
head. (b) &(c) The transverse
fat-suppressed T2-w TSE and
the coronal STIR MR images
demonstrate the same area
with high signal intensity in
keeping with bone marrow
edema. A moderate joint
effusion is also eviden 25
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CONCLUSIONS

Magnetic resonance imaging plays a crucial role in the

early detection and staging of osteonecrosis; it allows
clear quantification and evaluation of lesions that are
undetectable on plain radiographs.

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 TERIMA KASIH

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