3

© 2017 CHINESE ORTHOPAEDIC ASSOCIATION AND JOHN WILEY & SONS AUSTRALIA, LTD

GUIDELINE

Chinese Guideline for the Diagnosis and Treatment

of Osteonecrosis of the Femoral Head in Adults
Microsurgery Department of the Orthopedics Branch of the Chinese Medical Doctor Association, Group from the
Osteonecrosis and Bone Defect Branch of the Chinese Association of Reparative and Reconstructive Surgery, Microsurgery
and Reconstructive Surgery Group of the Orthopedics Branch of the Chinese Medical Association

The treatment of adult osteonecrosis of the femoral head (ONFH), with 8.12 million patients in China, remains a chal-
lenge to surgeons. To standardize and improve the efficacy of the treatment of ONFH, Chinese specialists updated the
experts’ suggestions in March 2015, and an experts’ consensus was given to provide a current basis for the diagno-
sis, treatment and evaluation of ONFH. The current guideline provides recommendations for ONFH with respect to epi-
demiology, etiology, diagnostic criteria, differential diagnosis, staging, treatment, as well as rehabilitation. Risk
factors of non-traumatic ONFH include corticosteroid use, alcohol abuse, dysbarism, sickle cell disease and autoim-
mune disease and others, but the etiology remains unclear. The Association Research Circulation Osseous (ARCO)
staging system, including plain radiograph, magnetic resonance imaging, radionuclide examination, and histological
findings, is frequently used in staging ONFH. A staging and classification system was proposed by Chinese scholars in
recent years. The major differential diagnoses include mid−late term osteoarthritis, transient osteoporosis, and sub-
chondral insufficiency fracture. Management alternatives for ONFH consist of non-operative treatment and operative
treatment. Core decompression is currently the most common procedure used in the early stages of ONFH. Vascular-
ized bone grafting is the recommended treatment for ARCO early stage III ONFH. This guideline gives a brief account
of principles for selection of treatment for ONFH, and stage, classification, volume of necrosis, joint function, age of
the patient, patient occupation, and other factors should be taken into consideration.
Key words: Diagnosis; Guideline; Osteonecrosis of the femoral head (ONFH); Treatment

Introduction Microsurgery Department of the Orthopedics branch of the

O steonecrosis of the femoral head (ONFH), also known

as avascular necrosis of the femoral head (AVNFH) or
aseptic necrosis of the femoral head (ANFH), continues to
be a challenging disease to treat. The normative and effective
choice of treatment is determined according to age and path-
ological staging. The etiology remains unclear, and it often
affects young patients who want to maintain an active life-
style. In 2007, Chinese experts reached a consensus on the
main aspects of diagnosis and treatment and issued recom-
mendations (2007). Guidelines were published in the follow-
ing document: Chinese Experts’ Consensus on the Diagnosis
and Treatment of Osteonecrosis of the Femoral Head in
Adults (2012), which now plays an important role in the
standardization of the diagnosis and treatment of ONFH.
Some shortcomings are still present in the clinical applica-
tion of these guidelines. To standardize and improve the effi-
cacy of the treatment of ONFH, the group from the
Chinese Medical Doctor Association and the group from the
Bone Defect and Osteonecrosis branch of the Chinese Asso-
ciation of Reparative and Reconstructive Surgery sponsored
a senior experts’ seminar on ONFH and updated the experts’
suggestions in March 2015. All members of the microsurgery
groups and the senior experts were invited to discuss the lat-
est concepts and debate on the diagnosis and treatment of
ONFH. Finally, an experts’ consensus was given to provide a
current basis for the diagnosis, treatment and evaluation
of ONFH.
Definition
O steonecrosis of the femoral head is not a specific diag-
nostic entity, but is considered to be a very complicated
pathophysiological process that involves venous congestion
and the impairment or interruption of the blood supply to
the femoral head, causing cell death within the femoral head.

Address for correspondence De-wei Zhao, MD, Department of Orthopaedics, Zhongshan Hospital of Dalian University, No.6 Jiefang Street,
Zhongshan District, Dalian, China 116001 Tel: 0086-411-62893509; Fax: 0086-411-62893555; Email: zhaodewei2016@163.com; Yong-cheng Hu,
MD, Department of Orthopaedics, Tianjin Hospital, 406 Jiefangnan Road, Tianjin, China 300211 Tel: 0086-013920006965; Fax: 0086-22-
28241184; Email: yongchenghu@126.com
Disclosure: This work was supported by grants from the NHFPC special fund for health scientific research in the public welfare (No. 201402016).
Received 13 August 2016; accepted 4 September 2016

Orthopaedic Surgery 2017;9:3–12 • DOI: 10.1111/os.12302


4
ORTHOPAEDIC SURGERY
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017
Histologically, ONFH is characterized by dead osteocytes,
necrotic marrow elements, and a lack of vasculature in a
defined region in the femoral head. In most cases, these
changes ultimately lead to collapse of the subchondral bone
and the destruction of the hip joint in patients1–10.
Epidemiology
T here are an estimated 8.12 million ONFH cases among
Chinese people aged 15 years and older. The prevalence
of ONFH per 10,000 people for each demographic subgroup
was as follows: 11.76 per 100,000 in plain farmers, 9.57 per
100,000 in city residents, 7.92 per 100,000 in workers, 6.29
per 100,000 in hill farmers, and 5.53 per 100,000 in coastal
fishermen. The prevalence of ONFH was significantly higher
in males than females. Among ONFH patients, residents of
northern China had a higher prevalence of ONFH than resi-
dents of southern China11,12.
Etiology
T
he etiology of ONFH includes traumatic and non-
traumatic causes. ONFH commonly occurs after direct
trauma, such as femoral neck or head fracture, acetabular
fracture, hip dislocation, or severe sprain or contusion of the
hip13–18. The pathogenesis of non-traumatic ONFH is not
well understood, and the main risk factors in China include
corticosteroid use, alcohol abuse, dysbarism, sickle cell dis-
ease, and autoimmune disease (systemic lupus erythematosus
and antiphospholipid syndrome), as well as chemotherapy,
radiation, Caisson disease, pancreatitis, Gaucher disease, and
smoking6,12,19–24 (Table 1).
Diagnostic Criteria
T he diagnostic criteria were determined using the Chinese
Experts’ Consensus on the Diagnosis and Treatment of
Osteonecrosis of the Femoral Head in Adults and the interna-
tional diagnostic criteria for osteonecrosis of the femoral
head1,6–8.
Clinical Symptoms, Signs and Medical Histories
Although early in the disease process the condition is pain-
less, the chief complaint of a patient with osteonecrosis is
pain with limitation of movement. The pain is usually loca-
lized to the groin area, but occasionally it can involve the
ipsilateral buttock and knee or the greater trochanteric area.
The pain has been described as a deep, intermittent, throb-
bing pain, with an insidious onset that can be sudden. The
pain is exacerbated with weight-bearing and is relieved
by rest.
Physical examination reveals pain with both active and
passive range of motion, especially with forced internal rota-
tion. A limitation of passive abduction is usually elicited, and
passive internal and external rotation of the extended leg can
cause pain.
The medical history usually includes excessive cortico-
steroid use, alcohol abuse, smoking, coagulopathies, hemo-
globinopathy, gout, systemic lupus erythematosus, and
17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GUIDELINE FOR ONFH
chemotherapy or exposure to radiotherapy. Patients with
traumatic ONFH should provide a history of hip injury that
includes dislocations and fractures6,11,12,20.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) achieves excellent sensi-
tivity for early ONFH detection25–28. Diagnoses can be made
on the T1-weighted axial localizer and T1-weighted or T2-
weighted spin-echo coronal images. The necrotic margin is
evident as a single line on T1-weighted images and a double
line on T2-weighted images. The double-line sign is also a
specific and pathognomonic sign in non-traumatic osteone-
crosis and is observed in concentric low and high signal-
intensity bands on the T2-weighted image26,29,30.
Radiography
Standard anteroposterior and frog-leg (Lowenstein) lateral
radiographs should be obtained in both legs as part of a
patient’s work-up because bilateral disease is common. The
delineation of small areas of ONFH on plain radiographs
may be difficult, but the most common early findings are
mottled radiodense and radiolucent areas on the subchondral
portion of the anterosuperior part of the femoral head. The
presence of the crescent sign corresponds with the progres-
sion of ONFH, reflecting the discrepancy in densities of the
femoral head because of subchondral bone collapse. In addi-
tion, the final stages of joint space narrowing, acetabular
changes, or both, and advanced degenerative changes can be
observed31.
Computed Tomography
Computed tomography scans (CT) show diagnostic findings
in advanced stages and are less sensitive in the early stages of
osteonecrosis. CT scans of the femoral head show that the
necrotic and repairing bone is in the surrounding sclerotic
bone; a subchondral bone fracture may also be observed, but
CT scans are less sensitive than MRI32–34.
Radionuclide Examinations
Radionuclide bone scintigraphy using technetium-labeled
phosphate analogs such as methylene diphosphonate (99mTc-
MDP) and dicarboxypropane diphosphonate (99mTc-DPD)
may be used for the early diagnosis of ONFH. In the acute
phase of osteonecrosis, a decreased or absent uptake of bone
tracer (“cold” lesion) can be observed. After weeks or
months, an increased accumulation of bone tracer occurs
(“hot” lesion) with chronic vascular stasis in repair and in
revascularization35. Single-photon emission computed
tomography (SPECT) may improve radionclide sensitivity
for the diagnosis of osteonecrosis36,37. Positron emission
tomography (PET) scans provide a real-time image of physi-
ology based on the type of radiolabeled marker used. It may
be possible that PET scans detect osteonecrosis earlier than
MRI and SPECT scans and predict the progression as well as
the outcome of osteonecrosis38.
 17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5
ORTHOPAEDIC SURGERY GUIDELINE FOR ONFH
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017

joint, joint space narrowing of the hip, and features of sec-

TABLE 1 Etiologic factors associated with osteonecrosis
ondary osteoarthritis.
Causes Diseases
Ankylosing Spondylitis Involving the Hip
Trauma Hip dislocation
Femoral neck fracture
Ankylosing spondylitis (AS) is a common inflammatory
Femoral head fracture rheumatic disease that affects the axial skeleton, causing
Corticosteroid use Solid organ transplantation characteristic inflammatory back pain, which can lead to
Bone marrow transplantation
structural and functional impairments and a decrease in the
Acute lymphoblastic leukemia
Systemic lupus erythematosus quality of life. The pathogenesis of AS is poorly understood.
Alcohol consumption Immune-mediated mechanisms involving human leucocyte
Coagulation disorders Antithrombin III deficiency antigen (HLA)-B27 are associated with the pathogenesis of
Protein C deficiency
Protein S deficiency
AS. Involvement of the hip is common among patients with
Thrombocytosis AS and is understood to be a result of inflammation of the
Disseminated intravascular coagulation subchondral bone marrow. Hip involvement often affects
Human immunodeficiency bilateral femoral heads, and radiography shows sacroiliac
virus (HIV) infection
Hemoglobinopathy Sickle cell disease joint erosions and iliac-side subchondral sclerosis.
Thalassemia
Polycythemia Idiopathic Transient Osteoporosis of the Hip
Metabolic disease Gaucher’s disease
Gout
Idiopathic transient osteoporosis of the hip (ITOH) occurs
Other rare disorders Hyperlipidemia mostly in middle-aged men but can sometimes occur in
Liver disease women, usually in late pregnancy. An increase in pain and a
Dysbaric phenomenon limp is observed, accompanied by some local muscle wasting.
Miscellaneous factors Smoking
Pregnancy
An abnormal bone scan may precede radiographic osteopo-
Chemotherapy rosis of the femoral head and neck. Symptoms reach a pla-
Radiation teau and then resolve, and bone density returns to normal.
MRI shows low signal intensity on T1WI and high signal
intensity on T2WI, extending from the femoral head to the
Pathologic Diagnosis of Core Biopsy
intertrochanteric region39–41.
A core biopsy of the diseased femoral head shows that empty
lacunae were observed in more than 50% of the bone trabe-
Chondroblastoma in the Femoral Head
culae, and damage of many adjacent bone trabeculae and
Chondroblastoma is a benign bone tumor arising most often
bone marrow necrosis was also present.
in the epiphyses of long bones, but can also affect the proxi-
mal femur. Nearly 90% of these tumors occur in patients
Digital Subtraction Angiography between the ages of 5 and 25 years. MRI shows high signal
This procedure can be used to assess venous congestion and intensity on T2WI. CT scans show irregular dissolved bone.
impaired or interrupted blood supply to the femoral head,
which can cause cell death within the femoral head. This Subchondral Insufficiency Fracture
invasive procedure is not recommended as a routine Subchondral insufficiency fractures (SIF) occur mostly in
investigation. women over 60 years of age with osteoporosis. The initial
Ascertaining the history and clinical symptoms combined symptom is acute onset of hip pain. Radiologically, a sub-
with any of the other signs is primary to making a diagnosis. chondral collapse mainly in the superolateral segment of the
femoral head is noted. One of the characteristic MRI findings
Differential Diagnosis is the shape of a low-intensity band on T1WI and high-
intensity T2WI (bone marrow edema pattern) that is gener-
Mid–late Term Osteoarthritis ally irregular, serpiginous, convex to the articular surface,
Osteoarthritis is the most common cause of chronic joint and often discontinuous42,43.
pain among middle-aged and older people. Osteoarthritis
involves the entire joint, including the nearby muscles, Pigmented Villonodular Synovitis
underlying bone, ligaments, joint lining (synovium), the joint Pigmented villonodular synovitis (PVNS) is a rare disorder
cover (capsule), and the joint space narrowing of the hip. CT affecting joints and a benign proliferative disorder of the
scans show sclerotic bone and cystic changes; the crescent synovium with uncertain cause. PVNS occurs mostly in the
sign can be observed on MRI. second and the fourth decade of life. No significant sex pre-
ponderance has been reported. This condition may involve
Acetabular Dysplasia Secondary Osteoarthritis tendon sheaths, bursae, or joints, the latter occurring as dif-
This condition most commonly affects female children and fuse involvement or a localized nodule. X-rays and CT scans
young adults bilaterally. X-rays show dislocation of the hip show narrowing of the hip joint space. MRI shows extensive
 17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6
ORTHOPAEDIC SURGERY GUIDELINE FOR ONFH
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017

thickening of the joint lining or an extensive mass, possibly
with destructive bone changes.
Bone Infarction
A bone infarct occurs with ischemic death of the cellular ele-
ments of the bone and marrow. This condition affects bilat-
eral hip joints. MRI shows high signal intensity on T2-W
images and the appearance of the characteristic double-line
sign, which consists of a hyperintense inner ring and a
hypointense outer ring (Table 2).
Staging
1991. This modification was discussed and approved at the
General Assembly of ARCO in 1994 (Table 3)44. The Chi-
nese staging system was designed by Chinese scholars in
recent years (Table 4)45.
Treatment of Osteonecrosis of the Femoral Head
M anagement alternatives for ONFH include non-
operative treatment and operative treatment. Factors
affecting the outcome of these procedures include patients’
age, etiology and stage of osteonecrosis, and the size and
location of the osteonecrotic lesion.

V
arious classification systems have been proposed and
used to distinguish the different stages and necrotic
extent of femoral head osteonecrosis, including the systems
described by Marcus and co-authors Ficat and Arlet, Stein-
berg and associates, and the classification system of Ohzono
and associates. The extent of necrosis has been evaluated
using the Steinberg system or the Japanese Investigation
Committee (JIC) classification. The Association Research
Circulation Osseous (ARCO) staging system was considered
more systematic and more comprehensive than any other
type of staging system developed by scholars. The first
ARCO staging system was designed in Nijmegen, Nether-
lands at a meeting by the members of the ARCO in May
Non-operative Treatment
Non-surgical management can only be selected for early
stages and very small lesions or among patients in whom
surgical management is contraindicated.
Weight Bearing
Recommendations include avoiding collision and combat
sports. The use of two crutches can reduce pain, but wheel-
chair use must not be encouraged.
Treatment with Drugs
Recommendations include anticoagulants, fibrinolytic agents,
vasodilators, and lipid-lowering drugs46,47. These agents

TABLE 2 Differential diagnosis of diseases analogous to osteonecrosis of the femoral head (ONFH)

Unilateral or Acetabulum
Diseases Age predilection Sex predilection Etiology Bilateral involved or not Diagnosis elements

Osteoarthritis Middle-age and older No gender Degeneration Bilateral Yes CT: sclerotic bone and cystic change
differences MRI: crescent sign
Acetabular dysplasia Children and youth Female Genetic factors Bilateral Yes X-rays: hip joint dislocation, hip joint
secondary space narrowing and features of
osteoarthritis secondary osteoarthritis
Ankylosing spondylitis Teenagers Male Genetic factors and Bilateral Yes HLA-B27(+), sacroiliac joint erosions
involving the hip environment and iliac side subchondral sclerosis
Idiopathic transient Middle-aged and No gender None Unilateral No MRI: low signal intensity on T1WI, high
osteoporosis of the youth differences signal intensity on T2WI, extending
hip (ITOH) from the femoral head to the
intertrochanteric region
Chondroblastoma in Children and Male Unclear Unilateral No MRI: high signal intensity on T2WI; CT:
femoral head teenager irregular dissolved bone
Subchondral Elderly Female Osteoporosis Unilateral No X-rays: femoral head becomes flat; MRI:
insufficiency subchondral low signal intensity on
fracture T1WI and T2WI, with bone marrow
edema pattern
Pigmented villonodular Young adults No gender None Unilateral Yes X-rays and CT: hip joint space
synovitis differences narrowing; MRI: extensive thickening
of the joint lining or an extensive
mass, possibly with destructive bone
changes
Bone Infarction Unclear Unclear Unclear Bilateral No MRI: high signal intensity on T2WI,
characteristic double-line sign, which
consists of a hyperintense inner ring
and a hypointensity outer ring

CT, computed tomography; MRI, magnetic resonance imaging.

 TABLE 3 Association Research Circulation Osseous (ARCO) international classification of osteonecrosis44

Stage 0 1 2 Early 3 Late 3 4

Findings All present Normal on X-ray and CT; abnormal No crescent sign; X-ray: Crescent sign; X-ray: X-ray: collapse; flattening of Osteoarthritis sign:
normal or on scintigraph, and/or MRI sclerosis, osteolysis, flattening of articular articular surface of femoral head. joint space
non- and focal porosis surface of femoral head; narrowing, acetabular
diagnostic no collapse changes, and joint
destruction
Techniques X-ray, CT, Scintigraph, MRI, quantitate on MRI X-ray, CT, scintigraph, X-ray, CT, quantitate on X- X-ray, CT, quantitate on X-ray X-ray
scintigraph, MRI, quantitate on MRI ray
MRI and X-ray
Location NO Medial Central Lateral NO

B C
A
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017
ORTHOPAEDIC SURGERY
7

Quantitation NO Involvement of femoral head: Length of crescent: Surface collapse and dome NO
minimal A <15%; moderate B A <15% depression
15%–30%; extensive C >30% B 15%–30%
C >30%
GUIDELINE FOR ONFH

A: <15%/<2 mm
B: 15%–30%/2–4 mm
C: >30%/>4 mm

CT, computed tomography; MRI, magnetic resonance imaging.

17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
 17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8
ORTHOPAEDIC SURGERY GUIDELINE FOR ONFH
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017

TABLE 4 Chinese staging of osteonecrosis of the femoral head45

Stage Clinical findings Radiographic signs Pathological changes

I (pre-clinical, no-collapse) No MRI Necrosis of bone marrow

According to size of necrotic are Bone scan Necrosis of osteocytes
I a, small <15%
I b, medium 15%–30%
I c, large >30%
II (early stage, no-collapse) No or slight pain MRI Necrotic area absorbed
X-rays Bone repair
According to size of necrotic area CT
II a, small <15%
II b, medium 15%–30%
II c, large >30%
III (medium stage, pre-collapse)† On set of pain MRI T2-WI: bone marrow edema, CT: Subchondral fracture or fracture
Slight claudication subchondral fracture, X-rays: Femoral head through necrotic bone
According to length of crescent Moderate pain contour interrupted Crescent sign
Limited internal rotation
III a, small <15% Pain in internal rotation
III b, medium 15%–30%
III c, large >30%
IV (middle–late stage, collapse)‡ Moderate to severe pain X-rays: femoral head collapse with normal Femoral head collapse
Claudication joint space
According to depth of collapse Limited internal rotation
IV a, slight <2 mm Aggravated pain when strenuous
internal rotation
IV b, medium 2–4 mm Limited abduction and adduction
IV c, severe >4 mm
V (late-stage, osteoarthritis) Severe pain X-ray: flattening of femoral head, narrow joint Cartilage involved,
Severe claudication space, acetabular cystic changes osteoarthritis
Limited range of motion or sclerosis

* Estimation of necrotic area: necrotic area should be estimated in stages I and II on a mid-coronal section of the femoral head on MRI or CT (small <15%,
medium 15%–30%, large >30%), the volume of the necrotic area being estimated through the involved layers. † When X-ray films show no-collapse, patients with
painful hips need to undergo MRI and CT examination. Necrosis has progressed to collapse (stage III) if bone marrow edema or subchondral fracture have
occurred. ‡ When collapse has occurred and patients have experienced pain for more than 6 months, articular cartilage will have clearly degenerated (stage V).
CT, computed tomography; MRI, magnetic resonance imaging.

include low-molecular-weight heparin, alprostadil, and war- Immobilization and Traction

farin compounded with lipid-lowering drugs. Application of
drugs that inhibit osteoclasts and increase osteogenesis are
recommended, such as phosphate preparations and Madopar
etc48–50. These drugs can be used alone and can be applied
in patients with a history of hip surgery.
Traditional Chinese Medicine Treatment
In accordance with the holistic concept of traditional Chi-
nese medicine (TCM), the principles of dynamic and static
combinations, an equal emphasis on bones and muscles,
combined internal and external therapies, and doctor–patient
cooperation methods are followed. Activating blood circula-
tion, clearing dampness, resolving phlegm, and reinforcing
the kidney to strengthen the bone are other TCM techniques
used to treat the early stages of ONFH51–53.
Physiotherapies
These therapies include extracorporeal shockwave therapy,
electromagnetic stimulation, and hyperbaric oxygen54–56.
These methods may be adopted in the early stages (ARCO
stage 0 to stage I) and the middle stages (ARCO stage II to
stage IIIb) of ONFH.
Operative Treatment
Non-operative treatment is usually not very effective in
ONFH; hence, most ONFH patients choose operative treat-
ment to alleviate pain and retain mobility. Management
alternatives for ONFH include joint salvaging procedures
such as core decompression, non-vascularized bone grafting,
osteotomy, vascularized bone grafting, and joint
arthroplasty1,6–8. The most commonly used procedures are
core decompression and vascularized bone grafting in the
early stages (ARCO stage 0 to stage I) and middle stages
(ARCO stage II to stage IIIb).
Core Decompression
Core decompression is currently the most common proce-
dure used in the early stages of ONFH. Core decompression
aims to decrease the intraosseous pressure and possibly
enhance vascular ingrowth, thereby alleviating pain and
delaying or negating the need for total hip arthroplasty. This

9
ORTHOPAEDIC SURGERY
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017
technique uses a tunnel or percutaneous drilling through the
proximal femur into the necrotic lesion57,58. Core decom-
pression has been shown to have a significantly higher suc-
cess rate than nonsurgical management of early-stage
disease. The experts recommend that multiple small holes
should be drilled to maximize efficacy of the procedure.
Core decompression is usually combined with implants
of bone marrow stromal cells (implantation of autologous
bone marrow cells). Many studies have reported the efficacy
of this surgical technique59–61. Experts suggest that the core
decompression with bone marrow stromal cells could be
used for a large number of patients diagnosed with ONFH in
established centers that use a long-term follow-up reporting
system.
Non-vascularized Bone Grafting
This procedure provides decompression of the femoral head,
removal of necrotic bone, and structural support and scaf-
folding to allow repair and remodeling of subchondral
bone62. The methods include impaction bone grafting and a
strut bone graft with autogenous bone, allogeneic bone, and
bone substitution material63–66.
Osteotomy
Osteotomies are used to move the segment of necrotic bone
away from the weight-bearing region, thereby relieving
stress. Two general types of osteotomies are used: angular
intertrochanteric (varus and valgus) and rotational transtro-
chanteric. Total hip replacements performed after an osteot-
omy are often technically more difficult than replacements
performed in patients with ONFH who have never had an
osteotomy, and may not be successful in the long term67,68.
Vascularized Bone Grafting
The rationale for vascularized bone grafting is that it allows
decompression, provides structural support, and restores a
vascular supply that had been deficient or nonexistent for a
long period of time. Multiple published reports have dis-
cussed the use of vascularization around hip and fibular
grafts6–8,69,70. Presently, seven distinct approaches for vascu-
larization around a hip bone graft are used: iliac graft vas-
cularization71,72; vascularized greater trochanter graft73–76;
greater trochanter flap with a branch of the transverse lat-
eral circumflex femoral artery73–76; vascularized pedicled
bone flap with the deep iliac circumflex vessels; greater tro-
chanter flap with a branch of the transverse lateral circum-
flex femoral artery and iliac graft vascularization77; iliac
graft with the deep branch of the medial circumflex femoral
artery or a pedicled ilium periosteal flap; and a quadratus
femoris muscle pedicle. The surgical technique of the vascu-
larized iliac bone flap combined with a tantalum screw has
a good short-term effect78,79. The result of vascularized fib-
ular grafts was confirmed according to the technical charac-
teristics of the grafts and the surgeons’ proficiency in using
the grafts80–82.
17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GUIDELINE FOR ONFH
Joint Arthroplasty
Total hip replacement is indicated once the femoral head
has collapsed and the hip joint has degenerated such that
the articulation is compromised83–88. Recently, however,
enthusiasm has been generated among some investigators
who anticipate better results from resurfacing that incorpo-
rates improvements in techniques and biomaterials. Some
elements should be taken into consideration as follows:
corticosteroid use increases the rates of infection; osteopo-
rosis leads to placement of the prosthetic into the acetabu-
lum; high difficulty of operation is associated with hip
replacements after operative treatment; and the curative
effect in traumatic ONFH is better than in non-
traumatic ONFH.
Stages and Treatment
The choice of treatment for ONFH should take into consid-
eration stage, classification, volume of necrosis, joint func-
tion, age of the patient, patient occupation, and other
factors (Fig. 1).
Patients who have no clinical symptoms and a lesion
area <15% in a non-weight-bearing area can receive regular
follow-up care. Asymptomatic ONFH patients who have a
necrotic lesion that is more than 30% of the femoral head in
a weight-bearing area should receive active treatment before
High risk population or patients with clinical hip pain
Radiographs of bilateral hips (AP and axial)
No ONFH ONFH
MRI of bilateral hips
Inconspicuous ONFH-ARCO stage
Follow-up
No pain Pain CT CT
Early Late
Stage and age dependent therapy
Fig. 1 Clinical diagnosis flow chart of osteonecrosis of the femoral
head (ONFH). ARCO, Association Research Circulation Osseous; CT,
computed tomography; MRI, magnetic resonance imaging.

10
ORTHOPAEDIC SURGERY
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017
the occurrence of symptoms. Core decompression or non-
surgical treatment options can be taken89.
ARCO stage 0: If one extremity is diagnosed with ONFH,
the contralateral side should be highly suspected. A
follow-up MRI is recommended every 3–6 months.
ARCO stage I and II: In patients who are symptomatic
or have a necrotic lesion that is 15%–30% of the
ONFH, non-surgical treatment such as drug therapy
may not be the best option; however, joint surgery using
core decompression may be a more feasible treatment
option57,58,90–92. Becoming qualified for stem cell trans-
plantation or autologous bone marrow mononuclear cell
transplantation is recommended at this stage. For
patients who are classified as ARCO stage IIc, vascular-
ized or non-vascularized bone grafting (combined effec-
tively with support materials), osteotomy, and other
options should be considered66–68,80,93–95.
ARCO early stage III: Vascularized bone grafting (com-
bined effectively with support materials) is the recom-
mended treatment66–68,80,81.
ARCO later stage III: Joint arthroplasty or vascularized
bone grafting (for a young patient) are the recommended
treatment options81.
ARCO stage IV: A total hip replacement (THR) should be
discussed with the patient. If the patient is young and
wants joint-preserving operative intervention, vascularized
bone grafting is the recommended treatment.
Young adults: Core decompression (with implants includ-
ing bone marrow stromal cells), vascularized bone graft-
ing, and non-vascularized bone grafting (15%–30% of
necrosis volume) are the recommended treatment options.
Middle-aged adults: Core decompression, vascularized
bone grafting, nonvascularized bone grafting, and joint
arthroplasty are the treatment recommendations.
Older individuals (>55 years of age): Joint arthroplasty,
bipolar/tripolar hemiarthroplasty, or total hip replacement
is the recommended treatment options.
Therapy Assessment and Rehabilitation
Therapy Assessment
Assessment of ONFH therapy can be determined by clinical
and imaging evaluations96. Several hip rating scale systems
(e.g. Harris, Western Ontario and McMaster Universities
Osteoarthritis Index [WOMAC]) can be used to evaluate
clinical outcomes. Meanwhile, gait analysis is recommended
to add to the clinical data.
Imaging evaluation can be conducted using X-ray and
MRI scans. A concentric circle template can be used to
observe the shape of the femoral head, the joint space, and
the change in the acetabulum. Additional DSA should be
performed in the vascular bone transplant cases to assess the
supplemental blood and recovery77.
17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GUIDELINE FOR ONFH
Rehabilitation Training
Experts suggest that it is necessary to establish detailed rec-
ord keeping for continual assessment of therapy outcomes in
ONFH patients. Rehabilitation training is an effective way to
restore function and to prevent the ONFH patient from suf-
fering from muscle disuse atrophy. Rehabilitation training
should be focused on active rather than adjuvant treatment,
gradually increasing the time and intensity and choosing an
adequate way to exercise according to the stage of ONFH,
the treatment, the hip rating scale and the result of the gait
analysis97,98. The following exercises were the consensus
among the experts:
Lie supine with leg lifts: The patient lies supine and raises
the affected leg, with the hip and knee flexed at 90 . This
exercise should be performed 200 times per day but
divided into three to four sessions. These exercises are
especially useful in the conservative treatment of ONFH
and during the postoperative period while the patient is
recuperating in hospital.
Division and reunion: The patient sits on a chair with
their feet at shoulder width and their hands on their
knees. The patient then shifts the left leg to the left and
the right leg to the right, stretching them fully in front
and then adducting the limbs. This should be performed
300 times per day but divided into three to four ses-
sions. These exercises are also used in the conservative
treatment of ONFH and during the postoperative partial
weight-bearing stage.
Raise the leg in an erect position: The patient is asked to
grasp onto a fixture, maintaining the erect position, and to
raise the affected leg, keeping the body and legs at 90 ,
and the hip and knee flexed at 90 . This exercise should
be repeated up to 300 times per day but divided into three
to four sessions. This exercise may also be useful in the
conservative treatment of ONFH and postoperatively dur-
ing the partial weight-bearing stage.
Squat with the help of a fixture: The patient is asked to
grasp onto a fixture, maintaining the erect position, with
feet at shoulder width. The patient then performs a
squat and stands up. This exercise is repeated up to
300 times per day but divided into three to four ses-
sions. This exercise could be useful in the conservative
treatment of ONFH and postoperatively during the total
weight-bearing stage.
Adduction and abduction: The patient is asked to grasp
onto a fixture, adduct, abduct, and perform a circle move-
ment of the affected limb. This exercise is performed at
least 300 times per day but divided into three to four ses-
sions. These exercises are useful in the conservative treat-
ment of ONFH and postoperatively during the total
weight-bearing stage.
Walking with a pair of crutches or cycling training: This
method of ambulation or exercise may be used in the con-
servative treatment of ONFH and postoperatively during
the total weight-bearing stage.

11
ORTHOPAEDIC SURGERY
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017
List of Consultant Specialists
J i-ying Chen, Wei-heng Chen, Wan-shou Guo, Wei He,
Yong-cheng Hu, Peng-de Kang, Zi-rong Li, Bao-yi Liu,
Qiang Liu, You-wen Liu, Hui Qu, Tie-bing Qu, Ji-rong Shen,
Zhan-jun Shi, Pei-jiang Tong, Ai-min Wang, Kun-zheng
References
1. Mont MA, Zywiel MG, Marker DR, McGrath MS, Delanois RE. The natural
history of untreated asymptomatic osteonecrosis of the femoral head: a
systematic literature review. J Bone Joint Surg Am, 2010, 92: 2165–2170.
2. Zhao DW. To strengthen the understanding of the pathophysiology in
osteonecrosis of femoral head. Zhonghua Guan Jie Wai Ke Za Zhi Dian Zi Ban,
2014, 5: 1–3 (in Chinese).
3. Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the
femoral head: ten years later. J Bone Joint Surg Am, 2006, 88: 1117–1132.
4. Cooper C, Steinbuch M, Stevenson R, Miday R, Watts NB. The epidemiology of
osteonecrosis: findings from the GPRD and THIN databases in the UK.
Osteoporos Int, 2010, 21: 569–577.
5. Kang JS, Park S, Song JH, Jung YY, Cho MR, Rhyu KH. Prevalence of
osteonecrosis of the femoral head: a nationwide epidemiologic analysis in Korea.
J Arthroplasty, 2009, 24: 1178–1183.
6. Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR. Nontraumatic
osteonecrosis of the femoral head: where do we stand today? A ten-year update.
J Bone Joint Surg Am, 2015, 97: 1604–1627.
7. Zhao DW, Hu YC. Chinese experts’ consensus on the diagnosis and treatment
of osteonecrosis of the femoral head in adults. Orthop Surg, 2012, 4: 125–130.
8. The Microsurgery Department of the Orthopedics Branch of the Chinese
Medical Doctor Association, The Osteonecrosis and Bone Defect Group of the
Chinese Association of Reparative and Reconstructive Surgery. Chinese experts’
consensus on the diagnosis and treatment of osteonecrosis of the femoral head
in adults (2012). Zhong Hua Gu Ke Za Zhi, 2012, 32: 606–610.
9. Powell C, Chang C, Gershwin ME. Current concepts on the pathogenesis and
natural history of steroid-induced osteonecrosis. Clin Rev. Allergy Immunol, 2011,
41: 102–113.
10. Kang JS, Moon KH, Kwon DG, Shin BK, Woo MS. The natural history of
asymptomatic osteonecrosis of the femoral head. Int Orthop, 2013, 37:
379–384.
11. Zhao DW, Yang L, Tian FD, et al. Incidence of osteonecrosis of the femoral
head in divers: an epidemiologic analysis in Dalian. Zhonghua Gu Ke Za Zhi,
2012, 32: 521–525 (in Chinese).
12. Zhao DW, Yu M, Hu K, et al. Prevalence of nontraumatic osteonecrosis of the
femoral head and its associated risk factors in the Chinese population: results from
a nationally representative survey. Chin Med J (Engl), 2015, 128: 2843–2850.
13. Panteli M, Rodham P, Giannoudis PV. Biomechanical rationale for implant
choices in femoral neck fracture fixation in the non-elderly. Injury, 2015, 46:
445–452.
14. Thompson GH, Lea ES, Chin K, Son-Hing JP, Gilmore A. Closed bone graft
epiphysiodesis for avascular necrosis of the capital femoral epiphysis. Clin
Orthop Relat Res, 2013, 471: 2199–2205.
15. Ehlinger M, Moser T, Adam P, et al. Early prediction of femoral head
avascular necrosis following neck fracture. Orthop Traumatol Surg Res, 2011,
97: 79–88.
16. Bartonícek J, Vávra J, Bartoška R, Havránek P. Operative treatment of
avascular necrosis of the femoral head after proximal femur fractures in
adolescents. Int Orthop, 2012, 36: 149–157.
17. Palma LD, Santucci A, Verdenelli A, Bugatti MG, Meco L, Marinelli M.
Outcome of unstable isolated fractures of the posterior acetabular wall
associated with hip dislocation. Eur J Orthop Surg Traumatol, 2014, 24:
341–346.
18. Tannast M, Pleus F, Bonel H, Galloway H, Siebenrock KA, Anderson SE.
Magnetic resonance imaging in traumatic posterior hip dislocation. J Orthop
Trauma, 2010, 24: 723–731.
19. Gangji V, Rooze M, De Maertelaer V, Hauzeur JP. Inefficacy of the
cementation of femoral head collapse in glucocorticoid-induced osteonecrosis. Int
Orthop, 2009, 33: 639–642.
20. Wang Y, Yin L, Li Y, Cui Q. Preventive effects of puerarin on alcohol-induced
osteonecrosis. Clin Orthop Relat Res, 2008, 466: 1059–1067.
21. Mukisi-Mukaza M, Gomez-Brouchet A, Donkerwolcke M, Hinsenkamp M,
Burny F. Histopathology of aseptic necrosis of the femoral head in sickle cell
disease. Int Orthop, 2011, 35: 1145–1150.
22. Hua L, Zhang J, He JW, et al. Symptomatic osteonecrosis of the femoral head
after adult orthotopic liver transplantation. Chin Med J (Engl), 2012, 125:
2422–2426.
23. Wessel JH, Dodson TB, Zavras AI. Zoledronate, smoking, and obesity are
strong risk factors for osteonecrosis of the jaw: a case–control study. J Oral
Maxillofac Surg, 2008, 66: 625–631.
17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GUIDELINE FOR ONFH
Wang, Yan Wang, Yi-sheng Wang, Xi-sheng Weng, Hai-
shan Wu, Da-chuan Xu, Zuo-qin Yan, Shu-hua Yang, Zong-
sheng Yin, Xiao-bing Yu, Aihemaitijiang Yusufu, Ai-xi Yu,
Yu Zhang, Chang-qing Zhang, and De-wei Zhao.
24. Takahashi S, Fukushima W, Kubo T, Iwamoto Y, Hirota Y, Nakamura H.
Pronounced risk of non-traumatic 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, 17: 730–736.
25. Steinberg DR, Steinberg ME. The University of Pennsylvania classification of
osteonecrosis. In: Koo KH, Mont MA, Jones LC, eds. Osteonecrosis. Heidelberg:
Springer, 2014; 201–206.
26. Mitchell DG, Rao VM, Dalinka MK, et al. Femoral head avascular necrosis:
correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical
findings. Radiology, 1987, 162: 709–715.
27. Ha YC, Jung WH, Kim JR, Seong NH, Kim SY, Koo KH. Prediction of collapse
in femoral head osteonecrosis: a modified Kerboul method with use of magnetic
resonance images. J Bone Joint Surg Am, 2006, 88 (Suppl. 3): 35–40.
28. Li JD, Zhao DW, Cui DP, Yang L, Liu BY. Quantitative analysis and
comparison of osteonecrosis extent of alcoholic ONFH using magnetic resonance
imaging and pathology. Zhongguo Gu Yu Guan Jie Sun Shang Za Zhi, 2011, 26:
689–691 (in Chinese).
29. Malizos KN, Karantanas AH, Varitimidis SE, Dailiana ZH, Bargiotas K,
Maris T. Osteonecrosis of the femoral head: etiology, imaging and treatment. Eur
J Radiol, 2007, 63: 16–28.
30. Huang ZG, Zhang XZ, Wei HY, et al. Application of CT and MRI in volumetric
measurement of necrotic lesion in patient with avascular necrosis of the femoral
head. Zhong Hua Fang She Xue Za Zhi, 2012, 46: 820–824.
31. Sun W, Li ZR, Yang YR, et al. Experimental study on phasecontrast imaging
with synchrotron hard X-ray for repairing osteonecrosis of the femoral head.
Orthopedics, 2011, 34: e530–e534.
32. Dihlmann W. CT analysis of the upper end of the femur: the asterisk sign and
ischaemic bone necrosis of the femoral head. Skeletal Radiol, 1982, 8: 251–258.
33. Mitchell DG, Kressel HY, Arger PH, Dalinka M, Spritzer CE, Steinberg ME.
Avascular necrosis of the femoral head: morphologic assessment by MR imaging,
with CT correlation. Radiology, 1986, 161: 739–742.
34. Conway WF, Totty WG, McEnery KW. CT and MR imaging of the hip.
Radiology, 1996, 198: 297–307.
35. Ryu KN, Jin W, Park JS. Radiography, MRI, CT, bone scan and PET-CT. In:
Koo KH, Mont MA, Jones LC, eds. Osteonecrosis. Heidelberg: Springer, 2014;
179–195.
36. Resnick D, Sweet DE, Madewell JE. Osteonecrosis: pathogenesis, diagnostic
techniques, specific situations, and complications. In: Resnick D, ed. Bone and
Joint Imaging, 3rd edn. Philadelphia: Saunders, 2005; 1067–1088.
37. Motomura G, Yamamoto T, Karasuyama K, Iwamoto Y. Bone SPECT/CT of
femoral head subchondral insufficiency fracture. Clin Nucl Med, 2015, 40: 752–754.
38. Dasa V, Adbel-Nabi H, Anders MJ, Mihalko WM. F-18 fluoride positron
emission tomography of the hip for osteonecrosis. Clin Orthop Relat Res, 2008,
466: 1081–1086.
39. Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Transient
osteoporosis. J Am Acad Orthop Surg, 2008, 16: 480–489.
40. Patel S. Primary bone marrow oedema syndromes. Rheumatology (Oxford),
2014, 53: 785–792.
41. Guler O, Ozyurek S, Cakmak S, Isyar M, Mutlu S, Mahirogullari M. Evaluation
of results of conservative therapy in patients with transient osteoporosis of hip.
Acta Orthop Belg, 2015, 81: 420–426.
42. Ikemura S, Yamamoto T, Motomura G, Nakashima Y, Mawatari T, Iwamoto Y.
The utility of clinical features for distinguishing subchondral insufficiency fracture
from osteonecrosis of the femoral head. Arch Orthop Trauma Surg, 2013, 133:
1623–1627.
43. Yamamoto T. Subchondral insufficiency fractures of the femoral head. Clin
Orthop Surg, 2012, 4: 173–180.
44. JWM G, Gosling-Gardeniers AC, WHC. R. The ARCO staging system:
generation and evolution since 1991. In: Koo KH, Mont MA, Jones LC, eds.
Osteonecrosis. Heidelberg: Springer, 2014; 215–218.
45. Joint Surgery Group of the Orthopaedic Branch of the Chinese Medical
Association. Guideline for diagnostic and treatment of osteonecrosis of the
femoral head. Orthop Surg, 2015, 7: 200–207.
46. Yamaguchi R, Yamamoto T, Motomura G, et al. Effects of an antiplatelet drug
on the prevention of steroid-induced osteonecrosis in rabbits. Rheumatology,
2012, 51: 789–793.
47. Peled E, Davis M, Axelman E, Norman D, Nadir Y. Heparanase role in the
treatment of avascular necrosis of femur head. Thromb Res, 2013,
131: 94–98.

12
ORTHOPAEDIC SURGERY
VOLUME 9 • NUMBER 1 • FEBRUARY, 2017
48. Fanord F, Fairbairn K, Kim H, Garces A, Bhethanabotla V, Gupta VK.
Bisphosphonate-modified gold nanoparticles: a useful vehicle to study the
treatment of osteonecrosis of the femoral head. Nanotechnology, 2011, 22:
035102.
49. 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, 64: 1572–1578.
50. Huang LX, Dong TH, Xie DH, Xu M. Reliminary observation of clinical results
of treatment for early non-traumatic osteonecrosis of the femoral head with
Madopar. Zhonghua Gu Ke Za Zhi, 2010, 30: 641–645 (in Chinese).
51. He W. Scientific view of the treatment of Chinese traditional medicine for
non-traumatic osteonecrosis of femoral head. Zhonghua Guan Jie Wai Ke Za Zhi
Dian Zi Ban, 2013, 7: 284–286 (in Chinese).
52. Chen WH, Zhou Y, He HJ, et al. Treating early-to-middle stage nontraumatic
osteonecrosis of femoral head patients by Jianpi Huogu recipe: a retrospective
study. Zhongguo Zhong Xi Yi Jie He Za Zhi, 2013, 33: 1054–1058 (in Chinese).
53. Zhao DW, Huang SB, Wang BJ, et al. Therapeutic evaluation of WeishiHuogu I
in treating avascular necrosis of femoral head in early-middle stage. Zhonghua
Guan Jie Wai Ke Za Zhi Dian Zi Ban, 2014, 5: 4–7 (in Chinese).
54. Wang CJ, Wang FS, Ko JY, et al. Extracorporeal shockwave therapy shows
regeneration in hip necrosis. Rheumatology (Oxford), 2008, 47: 542–546.
55. Massari L, Fini M, Cadossi R, Setti S, Traina GC. Biophysical stimulation with
pulsed electromagnetic fields in osteonecrosis of the femoral head. J Bone Joint
Surg Am, 2006, 88 (Suppl. 3): S56–60.
56. Cui C, Chang W, Yu AX, Cheng SH, Li HC. Hemorrheologic changes in steroid-
induced avascular necrosis of femoral head after hyperbaric oxygen treatment.
Wu Han Da Xue Xue Bao Yi Xue Ban, 2007, 28: 103–106.
57. Bae JY, Kwak DS, Park KS, Jeon I. Finite element analysis of the multiple
drilling technique for early osteonecrosis of the femoral head. Ann Biomed Eng,
2013, 41: 2528–2537.
58. Kang P, Pei F, Shen B, Zhou Z, Yang J. Are the results of multiple drilling and
alendronate for osteonecrosis of the femoral head better than those of multiple
drilling? A pilot study. Joint Bone Spine, 2012, 79: 67–72.
59. Persiani P, De CC, Graci J, Noia G, Gurzì M, Villani C. Stage-related results in
treatment of hip osteonecrosis with core-decompression and autologous
mesenchymal stem cells. Acta Orthop Belg, 2015, 81: 406–412.
60. Zhao D, Cui D, Wang B, et al. Treatment of early stage osteonecrosis of the
femoral head with autologous implantation of bone marrow-derived and cultured
mesenchymal stem cells. Bone, 2012, 50: 325–330.
61. Mao Q, Jin H, Liao F, Xiao L, Chen D, Tong P. The efficacy of targeted
intraarterial delivery of concentrated autologous bone marrow containing
mononuclear cells in the treatment of osteonecrosis of the femoral head: a five
year follow-up study. Bone, 2013, 57: 509–516.
62. Zhang HJ, Liu YW, Du ZQ, et al. Therapeutic effect of minimally invasive
decompression combined with impaction bone grafting on osteonecrosis of the
femoral head. Eur J Orthop Surg Traumatol, 2013, 23: 913–919.
63. Yang S, Wu X, Xu W, Ye S, Liu X, Liu X. Structural augmentation with
biomaterial-loaded allograft threaded cage for the treatment of femoral head
osteonecrosis. J Arthroplasty, 2010, 25: 1223–1230.
64. Xiao X, Wang W, Liu D, et al. The promotion of angiogenesis induced by three-
dimensional porous beta-tricalcium phosphate scaffold with different
interconnection sizes via activation of PI3K/ Akt pathways. Sci Rep, 2015, 5: 9409.
65. Gao P, Zhang H, Liu Y, et al. Beta-tricalcium phosphate granules improve
osteogenesis in vitro and establish innovative osteoregenerators for bone tissue
engineering in vivo. Sci Rep, 2016, 6: 23367.
66. Feng B, Zhang J, Wang Z, et al. The effect of pore size on tissue ingrowth and
neovascularization in porous bioceramics of controlled architecture in vivo.
Biomed Mater, 2011, 6: 015007.
67. Hamanishi M, Yasunaga Y, Yamasaki T, Mori R, Shoji T, Ochi M. The clinical
and radiographic results of intertrochanteric curved varus osteotomy for idiopathic
osteonecrosis of the femoral head. Arch Orthop Trauma Surg, 2014, 134:
305–310.
68. Ito H, Tanino H, Yamanaka Y, et al. Long-term results of conventional varus
half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the
femoral head. J Bone Joint Surg Br, 2012, 94: 308–314.
69. Zhao DW. Minimally invasive surgery and microscopic repair in osteonecrosis
of femoral head. Zhonghua Xian Wei Wai Ke Za Zhi, 2015, 38: 209–210
(in Chinese).
70. Zhao DW. New methods and selection for head preserving therapy in
osteonecrosis of femoral head. Zhonghua Yi Xue Za Zhi, 2011, 91: 3313–3315
(in Chinese).
71. Yang L, Zhao DW, Guo L, et al. Comparison analysis of the outcomes
between ascending branch iliac graft and the transverse branch of greater
trochanter bone graft with the lateral femoral circumflex artery in osteonecrosis of
femoral head. Dang Dai Yi Xue, 2012, 8: 16–17.
72. Zhao D, Xu D, Wang W, Cui X. Iliac graft vascularization for femoral head
osteonecrosis. Clin Orthop Relat Res, 2006, 442: 171–179.
17577861, 2017, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/os.12302 by Nat Prov Indonesia, Wiley Online Library on [22/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
GUIDELINE FOR ONFH
73. Zhao D, Wang B, Guo L, Yang L, Tian F. Will a vascularized greater trochanter
graft preserve the necrotic femoral head?. Clin Orthop Relat Res, 2010, 468:
1316–1324.
74. Wang BJ, Zhao DW, Guo L, et al. Clinical outcome of vascularized iliac bone
flap transplantation for bilateral osteonecrosis of the femoral head. Zhongguo Gu
Yu Guan Jie Wai Ke, 2014, 7: 15–18.
75. Zhao D, Xiaobing Y, Wang T, et al. Digital subtraction angiography in
selection of the vascularized greater trochanter bone grafting for treatment of
osteonecrosis of femoral head. Microsurgery, 2013, 33: 656–659.
76. Wang B, Zhao D, Liu B, Wang W. Treatment of osteonecrosis of the femoral
head by using the greater trochanteric bone flap with double vascular pedicles.
Microsurgery, 2013, 33: 593–599.
77. Zhao D, Cui D, Lu F, et al. Combined vascularized iliac and greater trochanter
graftings for reconstruction of the osteonecrosis femoral head with collapse:
reports of three cases with 20 years follow-up. Microsurgery, 2012, 32:
546–551.
78. Zhao D, Zhang Y, Wang W, et al. Tantalum rod implantation and vascularized
iliac grafting for osteonecrosis of the femoral head. Orthopedics, 2013, 36:
789–795.
79. Zhao D, Liu B, Wang B, et al. Autologous bone marrow mesenchymal stem
cells associated with tantalum rod implantation and vascularized iliac grafting for
the treatment of end-stage osteonecrosis of the femoral head. Biomed Res Int,
2015, 2015: 240506.
80. Xue F, Zhang CQ, Chai LZ, Chen SB, Ding L. Free vascularized fibular grafting
for osteonecrosis of femoral head: a systemic review. Zhongguo Gu Yu Guan Jie
Sun Shang Za Zhi, 2014, 29: 322–324 (in Chinese).
81. Wang GM, Zhang CQ, Ding H, Chen SB. Patients with necrosis of the femoral
head and taking hormone for a long time after fibular graft: eight hips receiving
total hip replacement. Zhongguo Zu Zhi Gong Cheng Yan Jiu, 2014, 18:
8547–8552 (in Chinese).
82. Tian L, Wang KZ, Dang XQ, Wang CS. Long-term effects of vascularized
fibular graft transplantation for avascular necrosis of femoral head. Zhonghua
Guan Jie Wai Ke Za Zhi Dian Zi Ban, 2012, 6: 34–38 (in Chinese).
83. Nakasone S, Takao M, Sakai T, Nishii T, Sugano N. Does the extent of
osteonecrosis affect the survival of hip resurfacing?. Clin Orthop Relat Res,
2013, 471: 1926–1934.
84. Issa K, Johnson AJ, Naziri Q, Khanuja HS, Delanois RE, Mont MA. Hip
osteonecrosis: does prior hip surgery alter outcomes co to an initial primary total
hip arthroplasty?. J Arthroplasty, 2014, 29: 162–166.
85. Li J, He C, Li D, Zheng W, Liu D, Xu W. Early failure of the Durom prosthesis
in metal-on-metal hip resurfacing in Chinese patients. J Arthroplasty, 2013, 28:
1816–1821.
86. Mont MA. CORR insights®: does the extent of osteonecrosis affect the
survival of hip resurfacing?. Clin Orthop Relat Res, 2013, 471: 1935–1936.
87. Bedard NA, Callaghan JJ, Liu SS, Greiner JJ, Klaassen AL, Johnston RC.
Cementless THA for the treatment of osteonecrosis at 10-year follow-up: have we
improved compared to cemented THA?. J Arthroplasty, 2013, 28: 1192–1199.
88. Bergh C, Fenstad AM, Furnes O, et al. Increased risk of revision in patients
with non-traumatic femoral head necrosis. Acta Orthop, 2014, 85: 11–17.
89. Nam KW, Kim YL, Yoo JJ, et al. Fate of untreated asymptomatic
osteonecrosis of the femoral head. J Bone Joint Surg Am, 2008, 90: 477–484.
90. Helbig L, Simank HG, Kroeber M, Schmidmaier G, Grützner PA, Guehring T.
Core decompression combined with implantation of a demineralised bone matrix
for non-traumatic osteonecrosis of the femoral head. Arch Orthop Trauma Surg,
2012, 132: 1095–1103.
91. Rajagopal M, Balch Samora J, Ellis TJ. Efficacy of core decompression as
treatment for osteonecrosis of the hip: a systematic review. Hip Int, 2012, 22:
489–493.
92. Zhang TY, Zhao DW, Wang ZL, et al. Core decompression treatment of
ischaemia and venous congestion caused femoral head necrosis of curative
effect observation in canine. Shan Dong Yi Yao, 2014, 54: 32–34
(in Chinese).
93. Sun W, Li ZR, Gao FQ, et al. Porous bioceramic beta-tricalcium phosphate for
treatment of osteonecrosis of the femoral head. Zhongguo Zu Zhi Gong Cheng
Yan Jiu, 2014, 18: 2474–2479 (in Chinese).
94. Liu B, Wei S, Yue D, Guo W. Combined tantalum implant with bone grafting
for the treatment of osteonecrosis of the femoral head. J Invest Surg, 2013, 26:
158–162.
95. Liu ZH, Guo WS, Li ZR, et al. Porous tantalum rods for treating osteonecrosis
of the femoral head. Genet Mol Res, 2014, 13: 8342–8352.
96. Chen ZW, Chen WH, Wang RT, et al. Proposal on bringing WOMAC and
holistic health evaluation scale into outcome evaluation of hip protection therapy
for ANFH. Shi Jie Zhong Yi Yao, 2014, 9: 517–519.
97. Kisner C, Colby LA. The hip. In: Kisner C, Colby LA, eds. Therapeutic
Exercise: Foundations and Techniques, 5th edn. Philadelphia: F.A. Davis
Company, 2007; 643–687.
98. Zeng ZH, Yu AX, Yu GR, et al. Postoperative rehabilitation treatment in ONFH.
Zhonghua Wu Li Yi Xue Yu Kang Fu Za Zhi, 2005, 27: 557–558 (in Chinese).