Illustration by Smart-Servier Medical Art

AVASCULAR
NECROSIS OF
THE HIP
dr. Muhammad Andry Usman, PhD, Sp.OT (K)

DEPARTMENT OF ORTHOPEDIC &

TRAUMATOLOGY
HASANUDDIN UNIVERSITY
 Introduction
Illustration by Smart-Servier Medical Art

● Death of bone from ischemia

● Secondary to the loss of its vascular supply
○ Traumatic
○ Non-traumatic
VASCULARIZATION
Without proper blood flow, the bone tissue dies and is no longer able to
maintain or repair itself, causing the femoral head to collapse and
flatten.
EPIDEMIOLOGY
● Incidence
○ 20,000 new cases per year in the US
● Demographics
○ male > females
○ average age at presentation is 35 to 50
● Anatomic location
○ bilateral hips involved 80% of the time
○ multifocal osteonecrosis
○ 3% of patients with osteonecrosis have multifocal involvement
 Etiology
Non-traumatic Traumatic

• High dose • Hip dislocation

corticosteroid use • Hip fracture
• Alcohol abuse
• Liver disease
• Smoking
Patophysiology
Moya-Angeler, J. (2015). Current concepts on
osteonecrosis of the femoral head. World
Journal of Orthopedics, 6(8), 590.
https://doi.org/10.5312/wjo.v6.i8.590
CLINICAL FEATURES

Early onset Late onset

• No specific complaints
• Morning stiffness
• Deep groin pain with
ambulation
• Pain referred to the knee
• Flexion contracture of
the hip
• Painful internal rotation
• Limited range of motion

High Alert: Young patient with persistent groin pain and unresponsive
to rest and activity modification
Remember to check the contralateral hip (often bilateral)
RADIOLOGIC FINDINGS

Plain X-Ray
○AP
○Frog-lateral of hip
○AP and lateral of contralateral hip
●Pathognomonic ‘crescent sign’
○Represents pre-collapse of the weakened necrotic subchondral bone
●End stage
○collapse of the femoral head and subsequent arthritic changes noted on both the femoral
head and acetabulum
Progression of AVN
 RADIOLOGIC
FINDINGS
MRI
● Gold Standard in diagnosis
avascular necrosis (highest sensitivity
and specificity)
● Order when radiographs negative and
Illustration by Smart-Servier Medical Art

osteonecrosis still suspected

● Presence of bone marrow edema on
MRI is predictive of worsening pain
and future progression of disease
 RADIOLOGIC
FINDINGS
MRI
● Double density appearance
● T1: dark (low intensity band) , typically in the
superior portion of the femoral head, outlining
a central area of marrow.
Illustration by Smart-Servier Medical Art

● T2: focal brightness (marrow edema), The

inner border of the peripheral band shows a
high signal in 80% of cases.
● ‘double line’ sign  pathognomonic AVN.
FICAT
CLASSIFICATION

Petek, D., Hannouche, D., & Suva, D. (2019). Osteonecrosis of the femoral head: Pathophysiology and current concepts of treatment. EFORT Open Reviews, 4(3), 85–97.
doi:10.1302/2058-5241.4.180036
STEINBERG CLASSIFICATION (MODIFIED FICAT)

Petek, D., Hannouche, D., & Suva, D. (2019). Osteonecrosis of the femoral head: Pathophysiology and current concepts of treatment. EFORT Open Reviews, 4(3), 85–97.
doi:10.1302/2058-5241.4.180036
DIAGNOSTIC
WORKUP
ALGORITHM
Treatment
● Once AVN Started : Treatment depends on
○ Stage of disease
○ Symtoms
○ Age
○ Patient Health
● AVN is irreversible
● No drugs can restore blood supply to femoral head
Treatment

Non-
Operative
operative

● Pharmacological agents: ● Core decompression

statins, anticoagulants, ● Bone graft
bisphosphonates ● THA & bipolar
● Protected weight bearing hemiarthoplasty
 Non Operative Treatment
• Observation & protected weightbearing
• Bisphosphonate
• Decrease risk for head collapse
• Indicated for pre-collapse AVN (Ficat
stages 0-II)

Trials have shown that alendronate prevents femoral head collapse in osteonecrosis with subchondral lucency
Other studies have also shown no benefit of preventing Illustration
collapse by with bisphosphonates
Smart-Servier Medical Art
OPERATIVE TREATMENT

Collapse
No Collapse
(Advanced Stage)
• Restore blood • Bipolar
supply to femoral Hemiarthroplasty
head • THA
• Core
decompression
• Bone graft
 OPERATIVE
CORE DECOMPRESSION

● Reduce bone-marrow pressure

● Induce neovascularization

● The multiple small-diameter core

decompression technique utilizes
Illustration by Smart-Servier Medical Art

a 3.2 to 3.4-mm drill.

● The procedure is performed under
fluoroscopic guidance as an
outpatient procedure

Marker DR, Seyler TM, McGrath MS. Treatment of Early Stage Osteonecrosis of the
Femoral Head. J Bone Joint Surg Am. 2008;90 Suppl 4:175-87
 OPERATIVE
BONE GRAFTS
Illustration by Smart-Servier Medical Art

Marker DR, Seyler TM, McGrath MS. Treatment of Early Stage Osteonecrosis of the
Femoral Head. J Bone Joint Surg Am. 2008;90 Suppl 4:175-87
 OPERATIVE
BONE GRAFTS
Illustration by Smart-Servier Medical Art

Marker DR, Seyler TM, McGrath MS. Treatment of Early Stage Osteonecrosis of the Femoral Head. J Bone Joint Surg Am. 2008;90 Suppl 4:175-87
Illustration by Smart-Servier Medical Art
OPERATIVE
JOINT REPLACEMENT
MANAGEMENT
& TREATMENT
ALGORITHM

Moya-Angeler, J. (2015). Current concepts on

osteonecrosis of the femoral head. World
Journal of Orthopedics, 6(8), 590.
https://doi.org/10.5312/wjo.v6.i8.590
 PROGNOSIS

● Risk of femoral head collapse  Modified Kerboul

combined necrotic angle
● Calculated by adding the arc of the femoral head necrosis on
a mid-sagittal and mid-coronal MR image
Illustration by Smart-Servier Medical Art

■ Low-risk group = <190°

■ Moderate-risk group = 190° and 240°
■ High-risk group = >240°
SUMMARY
● Hip AVN: Reduced blood flow to the femoral head secondary to a variety
of risk factors
● Diagnosis :
○ Plain radiographs (in moderate/late disease)
○ MRI (to detect early or subclinical osteonecrosis)
● Treatment is generally observation with management of the underlying
systemic condition.
● Operative management is indicated for advanced disease with presence of
subchondral collapse, femoral head flattening and/or degenerative joint
disease.
Thank You

Do you have any questions?