Osteonecrosis of the femoral head
Updates to Article Attributes
Avascular necrosis of the hip (AVN) is more common than in other sites, presumably due to a combination of precarious blood supply and high loading when standing.
Clinical presentation
The most common presenting symptom is pain in the region of the affected hip, thigh, groin, and buttock. Although few patients may remain asymptomatic until the late stages.
Pathology
Typically it affects the superior articular surface (between 10-2 o'clock) and begins in the most anterior part of the hip.
Aetiology
It can be thought of as traumatic (secondary to the neck of femur fractures) or non-traumatic. Traumatic AVN is usually unilateral10. In non-traumatic cases, it is mostly bilateral in 70-80% 10.
- traumatic
- chronic corticosteroid therapy
- alcoholism
- smoking
- systemic lupus erythematosus (SLE)
- hyperlipidaemias
- HIV
- haemoglobinopathies
- chronic renal failure
- diabetes mellitus
- pregnancy-related
Radiographic features
A specific staging system (Ficat staging) exists for the hip which includes x-ray, MRI and bone scan appearances, and covers much of the imaging appearances, thus please refer to that article.
Other than describing the general appearance of the affected region, the following are necessary to include in the report as they have a bearing on prognosis and treatment:
- position
- estimating percentage volume of the head involved (axial) and percentage weight-bearing surface involved (coronal)
- coexisting osteoarthritis or secondary degenerative change
- joint effusion
- presence of a potentially unstable osteochondral fragment: rim sign
- subchondral fractures
CT
Often more sensitive than plain film in showing subchondral fractures.
MRI
MRI is the most sensitive modality, with a sensitivity of 71-100% and specificity of 94-100%1. As there is a high rate of bilateral involvement, both hips should be included in the field of view of at least some sequences.
- T1: usually the initial specific findings are areas of low signal intensity representing oedema, which can be bordered by a hyperintense line that represents blood products
- T2: may show a second hyperintense inner line between normal marrow and ischaemic marrow. This appearance is highly specific for AVN hip and is known as "double-line sign".
The Mitchell classification is commonly used to classify AVN based on MR images.
Differential diagnosis
In some situations consider:
- subchondral insufficiency fracture of the femoral head - considered by some as a different entity 9
General imaging differential considerations include:
- haematopoietic marrow (see bone marrow)
- Pitt's pit
- fovea centralis
-
idiopathic transient osteoporosis of the hip (ITOH)
- hyperaemia with diffuse increased uptake of radiotracer by the femoral head, neck, and intertrochanteric region
- chondroblastoma
- fracture
-
infection
- pain and fever
- usually involves both sides of the joint
- metastases
See also
-<p><strong>Avascular necrosis of the hip (AVN)</strong> is more common than in other sites, presumably due to a combination of precarious blood supply and high loading when standing. </p><h4>Clinical presentation</h4><p>The most common presenting symptom is pain in the region of the affected hip, thigh, groin, and buttock. Although few patients may remain asymptomatic until the late stages.</p><h4>Pathology</h4><p>Typically it affects the superior articular surface (between 10-2 o'clock) and begins in the most anterior part of the hip.</p><h5>Aetiology</h5><p>It can be thought of as traumatic (secondary to the <a href="/articles/proximal-femoral-fractures">neck of femur fractures</a>) or non-traumatic. Traumatic AVN is usually unilateral<sup>10</sup>. In non-traumatic cases, it is mostly bilateral in 70-80% <sup>10</sup>.</p><ul>- +<p><strong>Avascular necrosis of the hip (AVN)</strong> is more common than in other sites, presumably due to a combination of precarious blood supply and high loading when standing. </p><h4>Clinical presentation</h4><p>The most common presenting symptom is pain in the region of the affected hip, thigh, groin, and buttock. Although few patients may remain asymptomatic until the late stages.</p><h4>Pathology</h4><p>Typically it affects the superior articular surface (between 10-2 o'clock) and begins in the most anterior part of the hip.</p><h5>Aetiology</h5><p>It can be thought of as traumatic (secondary to the <a href="/articles/proximal-femoral-fractures">neck of femur fractures</a>) or non-traumatic. Traumatic AVN is usually unilateral <sup>10</sup>. In non-traumatic cases, it is mostly bilateral in 70-80% <sup>10</sup>.</p><ul>
-<li>presence of a potentially unstable osteochondral fragment: <a href="/articles/rim-sign-avascular-necrosis">rim sign</a>- +<li>presence of a potentially unstable osteochondral fragment: <a href="/articles/rim-sign-osteonecrosis">rim sign</a>
-</ul><h5>CT</h5><p>Often more sensitive than plain film in showing <a href="/articles/subchondral-fractures">subchondral fractures</a>.</p><h5>MRI</h5><p>MRI is the most sensitive modality, with a sensitivity of 71-100% and specificity of 94-100%<sup>1</sup>. As there is a high rate of bilateral involvement, both hips should be included in the field of view of at least some sequences.</p><ul>- +</ul><h5>CT</h5><p>Often more sensitive than plain film in showing <a href="/articles/subchondral-fractures">subchondral fractures</a>.</p><h5>MRI</h5><p>MRI is the most sensitive modality, with a sensitivity of 71-100% and specificity of 94-100% <sup>1</sup>. As there is a high rate of bilateral involvement, both hips should be included in the field of view of at least some sequences.</p><ul>
-</ul><p>The <a href="/articles/mitchell-classification-of-avascular-necrosis">Mitchell classification</a> is commonly used to classify AVN based on MR images.</p><h4>Differential diagnosis</h4><p>In some situations consider</p><ul><li>- +</ul><p>The <a href="/articles/mitchell-classification-of-avascular-necrosis">Mitchell classification</a> is commonly used to classify AVN based on MR images.</p><h4>Differential diagnosis</h4><p>In some situations consider:</p><ul><li>
-<li><a href="/articles/pitt-pit">Pitt's pit</a></li>- +<li><a href="/articles/synovial-herniation-pit-1">Pitt's pit</a></li>
-<li>metastases</li>- +<li><a title="Metastases to bone" href="/articles/bone-metastases-1">metastases</a></li>
-<a href="/articles/osteonecrosis-2">avascular necrosis</a> - general article</li>-<li><a href="/articles/perthes-disease">Legg-Calve-Perthes disease</a></li>- +<a href="/articles/osteonecrosis-2">osteonecrosis</a> (general article)</li>
- +<li><a href="/articles/perthes-disease">Perthes disease</a></li>
Unable to process the form. Check for errors and try again.