Osteonecrosis of the femoral head: Etiology, imaging and treatment

doi:10.1016/j.ejrad.2007.03.019

European Journal of Radiology

Volume 63, Issue 1, July 2007, Pages 16-28

https://doi.org/10.1016/j.ejrad.2007.03.019 Get rights and content

Abstract

Osteonecrosis of the femoral head is a disabling clinical entity affecting young adults that usually leads to destruction of the hip joint. A high index of suspicion is necessary for the diagnosis due to the insidious onset of the bone infarcts and the lack of specific clinical signs at the early stages. Many etiology-associated factors have been identified reducing thus the number of idiopathic cases. A number of joint salvaging treatment options are available if early diagnosis can be achieved. MR imaging has been proved to be a highly accurate method both for early diagnosis and for staging of the disease. Replacement of the hip joint is the last resort for pain relief and function, although non-desirable because of the young age of the affected population.

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

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