Osteonecrosis of the femoral head
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- updated 15 Jul 2022:
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AvascularOsteonecrosis of the femoral head, previously known as avascular necrosis of the hip (AVN), is morethe most common than in other sitessite for osteonecrosis, presumably due to a combination of precarious blood supply and high loading when standing.
Idiopathic osteonecrosis of the femoral head epiphysis in children (Perthes disease) is typically considered separately; thus the remainder of the article pertains to osteonecrosis in the skeletally mature population.
Epidemiology
Typically affects adults under 50 years of age 12.
Clinical presentation
The most common presenting symptom is pain in the region of the affected hip, thigh, groin, and buttock. AlthoughHowever, 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 AVNosteonecrosis is usually unilateral 10. In non-traumatic cases, it is mostly bilateral in 70-80% 10.
traumatic
chronic corticosteroid therapy
alcoholism
smoking
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
CT
OftenCT is 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; this appearance is highly specific forAVNosteonecrosis of the hip and is known as the "double-line sign".
Staging
Several staging systems for osteonecrosis of the hip exist. The earliest and most commonly used is the Ficat and Arlet classification which includes x-ray, MRI and bone scan appearances. The Steinberg classification is similar but quantifies the involvement of the femoral head. The Mitchell classification is commonly used to classify AVN based on MRutilised for MRI images. The ARCO classification is the most recent, developed in 2019 10.
Differential diagnosis
In some situations consider:
subchondral insufficiency fracture of the femoral head
-: typically consideredby some asa different entity 9
General imaging differential considerations include:
haematopoietic marrow (see bone marrow)
-
idiopathic transient osteoporosis of the hip (ITOH)
hyperaemia with diffuse increased uptake of radiotracer by the femoral head, neck, and intertrochanteric region
fracture
-
pain and fever
usually involves both sides of the joint
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>-<li>traumatic</li>-<li>chronic corticosteroid therapy</li>-<li>alcoholism</li>-<li>smoking</li>- +<p><strong>Osteonecrosis of the femoral head</strong>, previously known as <strong>avascular necrosis of the hip (AVN)</strong>, is the most common site for <a href="/articles/osteonecrosis-2" title="Osteonecrosis">osteonecrosis</a>, presumably due to a combination of precarious blood supply and high loading when standing. </p><p>Idiopathic osteonecrosis of the femoral head epiphysis in children (<a href="/articles/perthes-disease" title="Perthes disease">Perthes disease</a>) is typically considered separately; thus the remainder of the article pertains to osteonecrosis in the skeletally mature population.</p><h4>Epidemiology</h4><p>Typically affects adults under 50 years of age <sup>12</sup>.</p><h4>Clinical presentation</h4><p>The most common presenting symptom is pain in the region of the affected hip, thigh, groin, and buttock. However, 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 osteonecrosis is usually unilateral <sup>10</sup>. In non-traumatic cases, it is mostly bilateral in 70-80% <sup>10</sup>.</p><ul>
- +<li><p>traumatic</p></li>
- +<li><p>chronic corticosteroid therapy</p></li>
- +<li><p>alcoholism</p></li>
- +<li><p>smoking</p></li>
- +<li><p><a href="/articles/systemic-lupus-erythematosus">systemic lupus erythematosus (SLE</a>)</p></li>
- +<li><p><a href="/articles/hyperlipidaemias">hyperlipidaemias</a></p></li>
- +<li><p><a href="/articles/hiv">HIV</a></p></li>
- +<li><p><a href="/articles/haemoglobinopathies">haemoglobinopathies</a></p></li>
- +<li><p><a href="/articles/chronic-kidney-disease">chronic renal failure</a></p></li>
- +<li><p><a href="/articles/diabetes">diabetes mellitus</a></p></li>
- +<li><p><a href="/articles/pregnancy-related-osteonecrosis-1" title="Pregnancy related avascular necrosis ">pregnancy-related</a></p></li>
- +</ul><h4>Radiographic features</h4><p>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:</p><ul>
- +<li><p>position </p></li>
- +<li><p>estimating percentage volume of the head involved (axial) and percentage weight-bearing surface involved (coronal)</p></li>
- +<li><p>coexisting <a href="/articles/osteoarthritis">osteoarthritis</a> or secondary degenerative change</p></li>
- +<li><p>joint effusion</p></li>
- +<li><p>presence of a potentially unstable osteochondral fragment: <a href="/articles/rim-sign-osteonecrosis">rim sign</a></p></li>
- +<li><p><a href="/articles/subchondral-fractures">subchondral fractures</a></p></li>
- +</ul><h5>CT</h5><p>CT is 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>
- +<li><p><strong>T1:</strong> 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</p></li>
- +<li><p><strong>T2:</strong> may show a second hyperintense inner line between normal marrow and ischaemic marrow; this appearance is highly specific for osteonecrosis of the hip and is known as the "<a href="/articles/double-line-sign">double-line sign</a>"</p></li>
- +</ul><h5>Staging</h5><p>Several staging systems for osteonecrosis of the hip exist. The earliest and most commonly used is the <a href="/articles/ficat-and-arlet-classification-of-avascular-necrosis-of-femoral-head">Ficat and Arlet classification</a> which includes x-ray, MRI and bone scan appearances. The <a href="/articles/steinberg-staging-of-avascular-necrosis-1" title="Steinberg staging of avascular necrosis">Steinberg classification</a> is similar but quantifies the involvement of the femoral head. The <a href="/articles/mitchell-classification-of-avascular-necrosis">Mitchell classification</a> is commonly utilised for MRI images. The <a href="/articles/arco-classification-of-osteonecrosis" title="ARCO classification of osteonecrosis">ARCO classification</a> is the most recent, developed in 2019 <sup>10</sup>.</p><h4>Differential diagnosis</h4><p>In some situations consider:</p><ul><li><p><a href="/articles/subchondral-insufficiency-fracture">subchondral insufficiency fracture</a> of the femoral head: typically considered a different entity <sup>9</sup></p></li></ul><p>General imaging differential considerations include:</p><ul>
- +<li><p>haematopoietic marrow (see <a href="/articles/bone-marrow">bone marrow</a>)</p></li>
- +<li><p><a href="/articles/synovial-herniation-pit-1">Pitt's pit</a></p></li>
- +<li><p><a href="/articles/fovea-centralis">fovea centralis</a></p></li>
-<a href="/articles/systemic-lupus-erythematosus">systemic lupus erythematosus (S</a><a href="/articles/systemic-lupus-erythematosus">LE</a>)</li>-<li><a href="/articles/hyperlipidaemias">hyperlipidaemias</a></li>-<li><a href="/articles/hiv">HIV</a></li>-<li><a href="/articles/haemoglobinopathies">haemoglobinopathies</a></li>-<li><a href="/articles/chronic-kidney-disease">chronic renal failure</a></li>-<li><a href="/articles/diabetes">diabetes mellitus</a></li>-<li>pregnancy-related</li>-</ul><h4>Radiographic features</h4><p>A specific staging system (<a href="/articles/ficat-and-arlet-classification-of-avascular-necrosis-of-femoral-head">Ficat staging</a>) 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. </p><p>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:</p><ul>-<li>position </li>-<li>estimating percentage volume of the head involved (axial) and percentage weight-bearing surface involved (coronal)</li>-<li>coexisting <a href="/articles/osteoarthritis">osteoarthritis</a> or secondary degenerative change</li>-<li>joint effusion</li>-<li>presence of a potentially unstable osteochondral fragment: <a href="/articles/rim-sign-osteonecrosis">rim sign</a>- +<p><a href="/articles/transient-osteoporosis-of-the-hip-1">idiopathic transient osteoporosis of the hip (ITOH)</a></p>
- +<ul><li><p>hyperaemia with diffuse increased uptake of radiotracer by the femoral head, neck, and intertrochanteric region</p></li></ul>
-<li><a href="/articles/subchondral-fractures">subchondral fractures</a></li>-</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>- +<li><p><a href="/articles/chondroblastoma">chondroblastoma</a></p></li>
- +<li><p>fracture</p></li>
-<strong>T1:</strong> 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</li>-<li>-<strong>T2:</strong> 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 "<a href="/articles/double-line-sign">double-line sign</a>".</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>-<a href="/articles/subchondral-insufficiency-fracture">subchondral insufficiency fracture</a> of the femoral head - considered by some as a different entity <sup>9</sup>-</li></ul><p>General imaging differential considerations include:</p><ul>-<li>haematopoietic marrow (see <a href="/articles/bone-marrow">bone marrow</a>)</li>-<li><a href="/articles/synovial-herniation-pit-1">Pitt's pit</a></li>-<li><a href="/articles/fovea-centralis">fovea centralis</a></li>-<li>-<a href="/articles/transient-osteoporosis-of-the-hip-1">idiopathic transient osteoporosis of the hip (ITOH)</a><ul><li>hyperaemia with diffuse increased uptake of radiotracer by the femoral head, neck, and intertrochanteric region</li></ul>-</li>-<li><a href="/articles/chondroblastoma">chondroblastoma</a></li>-<li>fracture</li>-<li>-<a href="/articles/septic-arthritis">infection</a><ul>-<li>pain and fever</li>-<li>usually involves both sides of the joint</li>- +<p><a href="/articles/septic-arthritis">infection</a></p>
- +<ul>
- +<li><p>pain and fever</p></li>
- +<li><p>usually involves both sides of the joint</p></li>
-<li><a title="Metastases to bone" href="/articles/bone-metastases-1">metastases</a></li>- +<li><p><a href="/articles/bone-metastases-1" title="Metastases to bone">metastases</a></p></li>
-<li>-<a href="/articles/osteonecrosis-2">osteonecrosis</a> (general article)</li>-<li><a href="/articles/perthes-disease">Perthes disease</a></li>-<li><a href="/articles/ficat-and-arlet-classification-of-avascular-necrosis-of-femoral-head">Ficat and Arlet staging</a></li>-<li><a href="/articles/steinberg-staging-of-avascular-necrosis-1">Steinberg staging of avascular necrosis</a></li>-<li><a href="/articles/mitchell-classification-of-avascular-necrosis">Mitchell classification of avascular necrosis</a></li>-<li><a href="/articles/arco-classification-of-osteonecrosis">ARCO classification of osteonecrosis</a></li>- +<li><p><a href="/articles/osteonecrosis-2">osteonecrosis</a> (general article)</p></li>
- +<li><p><a href="/articles/perthes-disease">Perthes disease</a></p></li>
- +<li><p><a href="/articles/ficat-and-arlet-classification-of-avascular-necrosis-of-femoral-head">Ficat and Arlet staging</a></p></li>
- +<li><p><a href="/articles/steinberg-staging-of-avascular-necrosis-1">Steinberg staging of avascular necrosis</a></p></li>
- +<li><p><a href="/articles/mitchell-classification-of-avascular-necrosis">Mitchell classification of avascular necrosis</a></p></li>
- +<li><p><a href="/articles/arco-classification-of-osteonecrosis">ARCO classification of osteonecrosis</a></p></li>
References changed:
- 10. Poole-Wilson PA, Langer GA. Effect of pH on ionic exchange and function in rat and rabbit myocardium. (1975) The American journal of physiology. 229 (3): 570-81. <a href="https://doi.org/10.1152/ajplegacy.1975.229.3.570">doi:10.1152/ajplegacy.1975.229.3.570</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/2014">Pubmed</a> <span class="ref_v4"></span>
- 11. Yoon B, Mont M, Koo K et al. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head. J Arthroplasty. 2020;35(4):933-40. <a href="https://doi.org/10.1016/j.arth.2019.11.029">doi:10.1016/j.arth.2019.11.029</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31866252">Pubmed</a>
- 12. Hines J, Jo W, Cui Q et al. Osteonecrosis of the Femoral Head: An Updated Review of ARCO on Pathogenesis, Staging and Treatment. J Korean Med Sci. 2021;36(24):e177. <a href="https://doi.org/10.3346/jkms.2021.36.e177">doi:10.3346/jkms.2021.36.e177</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/34155839">Pubmed</a>
- 10) Poole-Wilson PA, Langer GA. Effect of pH on ionic exchange and function in rat and rabbit myocardium. (1975) The American journal of physiology. 229 (3): 570-81. <a href="https://doi.org/10.1152/ajplegacy.1975.229.3.570">doi:10.1152/ajplegacy.1975.229.3.570</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/2014">Pubmed</a> <span class="ref_v4"></span>
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