Osteonecrosis of the femoral head: Etiology, imaging and treatment
Introduction
Osteonecrosis or avascular necrosis of the femoral head, a recalcitrant disease characterized by death of the osteocytes and the bone marrow, is caused by inadequate blood supply to the affected segment of the subchondral bone. It has also been called “the coronary disease of the hip” by Chandler as the disease simulates the ischemic condition in the heart [1]. Immediately after the ischemic insult the osseous tissue initiates a repair process with osteoclastic resorption of the dead trabeculae and apposition of new bone. The normally functioning joint undergoes fatigue failure of the weakened resorbed trabeculae with subsequent fracture which results in collapse of the subchondral bone, pain, and limitation of hip function.
Osteonecrosis of the femoral head (ONFH) most commonly affects young adults in the third and fourth decade of their life. It is currently diagnosed with an increasing incidence: every year 10,000 to 20,000 new cases are diagnosed in the USA [2], [3] and it is believed that 5–12% of total hip arthroplasties each year are performed to treat this disease [2], [4]. Although one femoral head is initially affected, bilateral involvement in two years may reach up to 72%. With the exception of patients diagnosed with systemic lupus erythematosus (SLE), the disease affects mainly men with a ratio of 7/3 in relation to women [5]. The disease is characterized by an insidious onset without specific clinical symptoms and signs. A poorly localized and vague ache around the hip joint, at the lower pelvis, the medial aspect of the thigh and at the buttocks should always raise suspicion of ONFH. Subsequently, this may lead to early diagnosis, prior to articular surface collapse.
It has been estimated that 30% of the patients with collagen diseases and sickle cell anemia, will develop osteonecrosis of the femoral head in their lifetime. Considering that the non-traumatic etiology ONFH affects mainly patients at risk, such as organ transplant recipients, those receiving steroids, patients with SLE, coagulopathy and dislipidemias, the treating physicians need to be aware of this clinical entity and its absence of specific early complaints. The current paper will review the established knowledge on the etiology, imaging and treatment strategy, in patients suffering from ONFH.
Section snippets
Etiology of osteonecrosis of the femoral head
Patients diagnosed with osteonecrosis can be divided into two groups: (a) patients with no apparent etiologic or risk factor and (b) patients with clearly identified etiology. Thus, osteonecrosis can be idiopathic (primary) or secondary. Diagnosis of idiopathic osteonecrosis nowadays is less frequent than it used to be as more causative factors have recently been identified. A number of diseases or pathological conditions are now associated with ONFH including trauma or surgery at the hip,
Imaging
Regardless of the cause, the compromised blood supply to the femoral head leads to ONFH. The role of imaging has multiple aims: to rule out disorders presented with painful hip that may mimic ONFH, to confirm a clinically suspected ONFH in high risk patients, to investigate multiple skeletal ONFH locations, to stage the disease for optimal treatment planning, to monitor the treatment and to depict any complications of the disease or the treatment.
Treatment options
Management alternatives for ONFH vary from joint salvaging procedures including electrical stimulation, proximal femur rotational osteotomy, core decompression sequestrectomy and replacement with bone cement, non-vascularized cancellous or cortical bone grafting of the lesion, muscle-pedicle bone grafting, and free vascularized fibular grafting. The most commonly used procedures are rotational osteotomy, core decompression, and free vascularized fibular grafting. Factors affecting the outcome
Conclusions
With regard to imaging, either with plain radiographs or with MR, the most important information that the clinicians require, include: (1) estimation that the lesion is not associated with collapse, (2) the size and location of the necrotic segment, (3) in case that the lesion has collapsed, it is useful to evaluate the degree of femoral head depression, and (4) evidence of the acetabular involvement with signs of secondary osteoarthritis. Challenging roles for MR imaging include contribution
References (96)
- et al.
Pathogenesis and natural history of osteonecrosis
Semin Arthritis Rheum
(2002) - et al.
Coagulation abnormalities in patients with hip osteonecrosis
Orthop Clin North Am
(2004) - et al.
The double-line sign of osteonecrosis: evaluation on chemical shift MR images
Eur J Radiol
(1993) - et al.
Density matrix simulations of the effects of J coupling in spin echo and fast spin echo imaging
J Magn Reson
(1999) - et al.
MR imaging findings in transient osteoporosis of the hip
Eur J Radiol
(2004) - et al.
Initial changes of non-traumatic osteonecrosis of femoral head in fat suppression images: bone marrow edema was not found before the appearance of band patterns
Magn Reson Imaging
(2001) - et al.
Initial MRI findings of non-traumatic osteonecrosis of the femoral head in renal allograft recipients
Magn Reson Imaging
(1997) - et al.
Early results in the treatment of avascular necrosis of the femoral head with electrical stimulation
Orthop Clin North Am
(1984) - et al.
Non-union of femoral neck fractures with osteonecrosis of the femoral head: treatment with combined free vascularized fibular grafting and subtrochanteric valgus osteotomy
Orthop Clin N Am
(2004) - et al.
Analysis of failures after vascularized fibular grafting in femoral head necrosis
Orthop Clin North Am
(2004)
Core decompression in atraumatic osteonecrosis of the hip
J Arthroplasty
Outcomes of limited femoral resurfacing arthroplasty compared with total hip arthroplasty for osteonecrosis of the femoral head
J Arthroplasty
Osteonecrosis of the femoral head treated with cementless total hip arthroplasty. A comparison with other diagnoses
J Arthroplasty
Primary total hip arthroplasty using noncemented porous-coated femoral components in patients with osteonecrosis of the femoral head
J Arthroplasty
Results and complications of total hip arthroplasties in patients with sickle-cell hemoglobinopathies. Role of cementless components
J Arthroplasty
Hip arthroplasty in patients with chronic renal failure
J Arthroplasty
Resurfacing of only the femoral head for osteonecrosis. Long-term follow-up study
J Arthroplasty
Coronary disease of the hip
J Int Coll Surg
Non traumatic necrosis of bone (osteonecrosis)
N Engl J Med
Osteonecrosis of the femoral head
J Am Acad Orthop Surg
A quantitative system for staging avascular necrosis
J Bone Joint Surg Am
Risk factors potentially activating intravascular coagulation and causing nontraumatic osteonecrosis
Thrombophilia as a multigenic disease
Haematologica
Potential aetiological factors concerning the development of osteonecrosis of the femoral head
Eur J Clin Invest
Genetic background of osteonecrosis: associated with thrombophilic mutations?
Clin Orthop Relat Res
Thrombophilia and hypofibrinolysis
Clin Orthop Relat Res
Idiopathic bone necrosis of the femoral head: early diagnosis and treatment
J Bone Joint Surg Br
Nontraumatic necrosis of bone (osteonecrosis)
N Engl J Med
Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings
Radiology
Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation
Radiology
Early osteonecrosis of the femoral head: detection in high-risk patients with MR imaging
Radiology
The diagnostic values of magnetic resonance imaging in non traumatic osteonecrosis of the femoral head
J Bone Joint Surg Am
Radiographically negative avascular necrosis: setection with MR imaging
Radiology
Early detection of avascular necrosis of the femoral head by MRI
J Bone Joint Surg Br
Segmental patterns of avascular necrosis of the femoral heads: early detection with MR imaging
Radiology
MR imaging of avascular necrosis and transient marrow edema of the femoral head
Radiographics
Chemical shift and the double-line in MRI of early femoral avascular necrosis
J Comput Assist Tomogr
Chemical shift misregistration effect in Magnetic Resonance Imaging
Radiology
Artifacts in musculoskeletal magnetic resonance imaging: identification and correction
Skeletal Radiol
Artifacts in body MR imaging: their appearance and how to eliminate them
Eur Radiol
MR of the normal and ischemic hip
Magn Reson Annu
MR imaging of bone marrow edema and joint effusion in patients with osteonecrosis of the femoral head: relationship to pain
AJR Am J Roentgenol
Hematopoietic and fatty bone marrow distribution in the normal and ischemic hip: new observations with 1.5-T MR imaging
Radiology
Apparent avascular necrosis of the hip: appearance and spontaneous resolution of MR findings in renal allograft recipients
Radiology
Detection of acute avascular necrosis of the femoral head in dogs: dynamic contrast-enhanced MR imaging versus spin echo and STIR sequences
AJR
Avascular necrosis of the hip: comparison of contrast-enhanced and nonenhnacned MR imaging with histologic correlation
Radiology
Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images
Radiology
Femoral capital osteonecrosis: MR finding of diffuse marrow abnormalities without focal lesions
Radiology
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