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Treatment of nontraumatic hip osteonecrosis (avascular necrosis of the femoral head) in adults

Treatment of nontraumatic hip osteonecrosis (avascular necrosis of the femoral head) in adults
Literature review current through: Jan 2024.
This topic last updated: Feb 10, 2023.

INTRODUCTION — The treatment of nontraumatic osteonecrosis remains one of the most controversial subjects in the orthopedic literature. If the disease is caught in an early stage, the goal of therapy is to preserve the native joint for as long as possible. However, given that osteonecrosis often progresses, the mainstay of treatment is surgical, using either a joint-preserving procedure, if possible, or joint replacement.

The treatment and prognosis of osteonecrosis affecting specific joints is reviewed here. The clinical manifestations and diagnosis of osteonecrosis is presented separately. (See "Clinical manifestations and diagnosis of osteonecrosis (avascular necrosis of bone)".)

The treatment of traumatic (fracture-associated) osteonecrosis is discussed separately. (See "Severe upper extremity injury in the adult patient" and "Severe lower extremity injury in the adult patient" and "Surgical management of severe upper extremity injury" and "Surgical management of severe lower extremity injury" and "Surgical reconstruction of the upper extremity".)

GENERAL MANAGEMENT PRINCIPLES — The optimal treatment of nontraumatic osteonecrosis is unknown. The goal of treatment is to preserve the joint for as long as possible while taking into consideration the patient's quality of life, including the patient's age, mobility, occupation, and lifestyle. Three main therapeutic options for management of osteonecrosis include nonsurgical management, procedures to prevent or limit joint collapse (ie, joint preservation), and joint replacement when advanced collapse has occurred. The role of nonsurgical management is limited, since lesions frequently progress quickly [1-3]. Factors influencing the aggressiveness of treatment include the presence (or absence) of symptoms; the size and stage of the lesion, including the presence and amount of structural collapse; and the patient's comorbidities.

Some data suggest that various joint-preserving treatments may help prevent joint collapse. However, drawing conclusions from the available data has been challenging, since most studies are small and heterogenous with different staging schemes used and nonstandardized quantification of clinical and radiographic responses. Treatment practices also vary widely depending upon the particular geographic region and from institution to institution.

Assessment of extent of involvement and location — Imaging is essential to assess the extent of hip involvement and location of disease.

Standard radiographs are typically obtained initially for patients with clinical suspicion of osteonecrosis. While radiographs have low sensitivity and inter-rater reliability for the diagnosis of precollapse lesions, when disease has advanced to severe arthritis with acetabular changes, plain radiographs may be adequate to plan the treatment course since joint preservation may not be an option.

Magnetic resonance imaging (MRI) is generally required preoperatively to demonstrate the level of anatomic detail required to plan surgery. The sensitivity and specificity of MRI for the diagnosis of osteonecrosis of the femoral head is >99 percent [4-7]. In addition, MRI is better than plain radiography for assessing the extent of involvement and location of the lesion, which influences treatment choice and prognosis. (See "Clinical manifestations and diagnosis of osteonecrosis (avascular necrosis of bone)", section on 'Imaging studies'.)

Several radiologic classification systems are available, but we generally use the updated Association Research Circulation Osseous (ARCO) staging system [8] to determine the best treatment approach. (See "Clinical manifestations and diagnosis of osteonecrosis (avascular necrosis of bone)", section on 'Radiologic classification systems' and 'Approach to management' below.)

The extent of involvement and location of disease determine the choice of treatment. As an example, from the ARCO staging system for the hip, the extent of involvement is:

<15 percent of involved bone

15 to 30 percent of involved bone

>30 percent of involved bone

Supportive care — Supportive care for osteonecrosis consists of measures such as bed rest, offloading as tolerated (using assistive walking devices including crutches, canes, and walkers), and the use of analgesics and other potential therapies [9,10]. Nonsteroidal antiinflammatory drugs (NSAIDs) may relieve pain. Opioid medications may be used for short periods of time when other pain medications are inadequate for moderate to severe pain while awaiting definitive surgery. Physical therapy may also help relieve some symptoms. (See "NSAIDs: Therapeutic use and variability of response in adults" and "Management of acute pain in opioid naïve adults in the ambulatory setting".)

Although there are no medical treatments known to prevent progression, pharmacologic treatments have been tried. These include bisphosphonates, lipid-lowering agents, and anticoagulants and are discussed further below. (See 'Unproven therapies' below.)

Surgical options — Surgical options for osteonecrosis generally include procedures that preserve the joint, and when the joint cannot be preserved, total joint replacement. The choice depends upon the extent of involvement and location of disease.

Joint-preserving procedures — Joint-preserving procedures aim to prevent or limit progression of disease and include core decompression and its variants (ie, percutaneous drilling, adjunctive grafting, stem cell therapy), bone grafting (vascularized, nonvascularized), and osteotomies. Joint-preserving procedures are more useful and more commonly used in symptomatic younger patients without bone collapse (precollapse) or selected patients with minimal collapse. (See 'Precollapse' below and 'Minimal collapse' below.)

Core depression and variants — Core decompression is a minimally invasive surgical technique used to manage early-stage disease (ie, precollapse). Core decompression involves drilling a tract into the bone to create a channel for new blood vessels. The rationale for core decompression as a treatment modality is that cellular swelling and inflammatory cell infiltration during the process of necrosis increases intraosseous pressure; by drilling into the lesion and creating a core tract, the pressure is reduced [11-13]. Several studies have reported favorable outcomes with core decompression for the management of patients with early-stage disease of the hip [1,14,15]. (See 'Small- to medium-sized lesions' below.)

Some surgeons have described a variant of core decompression of the hip using multiple small-diameter drillings rather than a large single-bore drilling [16-18]. This approach may provide the same clinical benefit as core decompression while reducing the risk of postoperative femoral neck fracture [16-19].

Instilling bone graft or stem cells into the drilled tract is sometimes used as an adjunctive procedure to core decompression [20-28]. It is uncertain whether there is an added benefit of the adjunctive treatment strategies for core decompression. While the evidence supporting core decompression with adjunctive cell therapy is promising, randomized trials are needed to establish definitive treatment protocols. Traditionally, after core decompression, the core tract was left open [29] or filled with bone graft [26,30,31]. Subsequent studies reported satisfactory results when core decompression has been combined with other procedures including filling the core tract with demineralized bone matrix [32], bone graft substitutes [33], or stem cell products [34,35]. The popularity of cell-based treatment for osteonecrosis of the femoral head has continued to grow since it was first introduced in 2002 [36]. In a systematic review of 10 studies with a total of 380 hips, all 10 studies reported an improvement in patient-reported outcomes with cell therapy compared with controls [35]. Moreover, it has been found that compared with core decompression alone, implantation of bone marrow cells into the femoral head for early-stage osteonecrosis of the femoral head lowers the rate of conversion to total hip arthroplasty [37].

Bone grafting — Implantation of a bone graft into a surgically created osseous void may provide structural support and act as a scaffold onto which new bone can form [38]. Either nonvascularized bone grafting or vascularized bone grafting can be used, both of which provide structural support; however, vascularized bone grafting also improves perfusion to ischemic bone. Bone grafting in this manner is predominantly used to treat symptomatic patients with minimal collapse of the femoral head. (See 'Minimal collapse' below.)

Nonvascularized bone grafting – There are three methods by which to introduce nonvascularized bone graft into the hip (ie, trapdoor, lightbulb, and Phemister techniques (figure 1 and figure 2)) [39-44]. The most common technique is the lightbulb procedure. Materials impacted into the femoral head have included demineralized bone matrix, bone morphogenetic-rich allograft bone chips, and a thermoplastic carrier [43]. Studies evaluating nonvascularized bone grafting comprise small retrospective reviews, which have reported good to excellent outcomes [39-43], with one study reporting no further need for surgery in 80 percent at three years follow-up [42].

Vascularized bone grafting – Vascularized grafting, typically using the fibula, is another approach that supports the subchondral bone but also improves perfusion of the bone and provides mesenchymal stem cells [45,46]. Vascularized bone grafting may delay progression in some, but not all, hips (52.3 percent in a systematic review [47]). However, in a review of 151 hips staged precollapse and early postcollapse disease followed for at least 10 years, 17 percent (13 of 76) required conversion to total hip arthroplasty [48]. (See "Clinical manifestations and diagnosis of osteonecrosis (avascular necrosis of bone)", section on 'Radiologic classification systems'.)

Osteotomy — Osteotomy involves making precision cuts into the bone and has been used to treat osteonecrosis. The goal is to redistribute the weightbearing forces away from the area of necrosis [49]. These procedures include intertrochanteric or rotational osteotomies of the proximal femur to shift the affected areas of the femoral head away from the weightbearing zones of the hip. The application of these technically demanding procedures is limited because of lesion size and the subsequent difficulty converting osteotomies to total hip arthroplasty, when needed. For these reasons, osteotomies are seldom used in the United States for femoral head osteonecrosis.

There is limited data supporting the use of an osteotomy for young patients with disease that has progressed to femoral head collapse. Results of clinical trials using osteotomy vary [50-54]; the best outcomes have been reported in the Japanese literature. The results have not been reproduced in Western literature. There are some reports of excellent results with angular osteotomies. In one report, intertrochanteric osteotomy was performed in 128 hips of 90 patients who were then followed for two to nine years; excellent results were obtained clinically and radiographically in 98 hips, and the success rate was 90 percent in hips with precollapse osteonecrosis [55]. Progressive collapse in the newly created weightbearing area occurred in 25 hips in which the lesions had been extensive. Nevertheless, in this study and others, it has been shown that subsequent total hip arthroplasty following this type of osteotomy can be difficult [56,57].

Total hip arthroplasty — For patients with osteonecrosis, total hip arthroplasty removes necrotic bone from the femoral head and replaces it with a prosthesis (figure 3). Total hip arthroplasty is required for patients with advanced collapse. Techniques for total hip arthroplasty are reviewed separately. (See 'Advanced collapse' below and "Total hip arthroplasty".)

Unproven therapies — Investigational therapies and interventions that have been used but are not proven or reliably used to treat osteonecrosis include bisphosphonates, statin therapy, anticoagulation, vasodilators, extracorporeal shock wave therapy (ESWT), electrical/electromagnetic stimulation, and hyperbaric oxygen. We do not recommend any of these therapies in the routine management of osteonecrosis. Each of these are reviewed briefly below.

Pharmacologic agents — Various pharmacologic agents have been used to help prevent progression of osteonecrosis and, in an attempt to reverse the disease, to promote the growth of viable bone in the necrotic lesion. These agents are likely to only be efficacious for small lesions and for precollapse disease, prior to any degree of biomechanical compromise. Several agents have been evaluated and include bisphosphonates, statins, anticoagulants, and vasodilators. The selection of agent is based upon the specific pathophysiology or possible cause of osteonecrosis in a particular patient. As an example, a patient with osteonecrosis in the setting of coagulation disorders may benefit from anticoagulation. Although some of the findings are promising, additional studies are needed to establish the efficacy of these individual agents before routine use of any of them is recommended.

The following is a brief summary of these pharmacologic agents:

Bisphosphonates – Slowing bone resorption of necrotic bone with bisphosphonates may be beneficial in the treatment of osteonecrosis of major joints, but the evidence is mixed. Enthusiasm for bisphosphonate use has been diminished by the reports of an association between bisphosphonate use and osteonecrosis of the jaw [58].

In an uncontrolled study, alendronate (10 mg/day) was administered to 294 patients (395 involved hips) for three years [59]. After a mean follow-up of four years, only 31 hips with osteonecrosis underwent total hip arthroplasty. There was also an improvement in pain and clinical function, as well as a reduction in the rate of femoral head collapse. However, this improvement did not appear to last in those followed for eight years.

A beneficial effect of bisphosphonates was also noted in a study that randomly assigned 40 patients (54 affected hips) with stage II or III osteonecrosis (University of Pennsylvania classification system) involving ≥30 percent of the femoral head to alendronate (70 mg/week for 25 weeks) or control [60]. In this unblinded study, the proportion of hips that developed collapse was significantly smaller for those who received alendronate compared with controls (2 of 29 [7 percent] versus 19 of 25 [76 percent], respectively).

By contrast, a two-year randomized trial in which patients with osteonecrosis received either oral alendronate or placebo did not find a significant difference in outcomes between these two groups [61]. Twenty-one of the 32 patients receiving bisphosphonates progressed radiologically, with four patients undergoing total hip arthroplasty. This was similar to the results of the placebo group, with progression noted in 21 of 32 patients and with 5 patients undergoing total hip arthroplasty. Another trial found that there was no difference in outcomes between patients with osteonecrosis of the hip who received ESWT alone compared with those who received ESWT plus bisphosphonate treatment [62]. In separate meta-analyses, it was noted that bisphosphonate therapy did not significantly reduce the progression to collapse and that there was notable heterogeneity between trials [63-65].

VasodilatorsIloprost, a prostacyclin analog, is thought to decrease intraosseous hypertension and increase blood flow to the ischemic area of the osteonecrotic lesion. A prospective study evaluated the effects of iloprost on osteonecrosis in 95 patients, ARCO stages I to IV [66]. After an average follow-up of almost three years, pain and functional scores significantly improved in patients treated with iloprost [67]. Due to the paucity of literature on this topic, more research investigating the utility of iloprost for the management of osteonecrosis is warranted.

Statins – Lipid-lowering agents are thought to prevent osteonecrosis by reducing the differentiation of marrow pluripotent cells into fat cells, which may lead to increased intraosseous pressure. A retrospective analysis of renal transplant patients found that those who were on statin therapy developed osteonecrosis at a rate of 4.4 percent compared with 7 percent in those who were not [68]. While the use of statins does not appear to prevent osteonecrosis in this patient population, a large-scale randomized trial may reveal otherwise [69].

Anticoagulants – Anticoagulants (eg, vitamin K inhibitors, low molecular weight heparins, direct thrombin inhibitors) have been used to prevent progression of osteonecrosis when possibly related to thrombophilia. Limited data from a meta-analysis including four observational studies suggested that while anticoagulants were helpful for preventing progression of primary osteonecrosis of the femoral head in patients without collapse, anticoagulants did not appear to prevent progression of osteonecrosis for patients with secondary osteonecrosis [70]. Another study evaluated 60 patients with systemic lupus erythematosus (SLE) requiring high-dose glucocorticoid treatment and assigned approximately half of the patients to anticoagulation with warfarin [71]. Although the differences were not statistically significant, fewer patients in the warfarin group developed osteonecrosis compared with the control group (21 versus 33 percent, respectively). Another prospective study evaluated the effectiveness of enoxaparin in 35 patients with early stages of osteonecrosis with a thrombophilic disorder compared with historical controls [72]. After a mean follow-up of two years, progression of disease was observed in 20 percent of those receiving enoxaparin versus 80 percent of historical controls. Further studies are needed to elucidate the benefit of anticoagulants for the treatment of osteonecrosis, especially in specific patient populations.

Extracorporeal shock wave therapy — ESWT is thought to promote bone healing through the stimulation of neovascularization. In one study, the effects of ESWT were compared with core decompression and bone grafting for patients with osteonecrosis of the hip [73]. Patients receiving ESWT demonstrated improved pain and function scores at two-year follow-up, with fewer hips eventually undergoing total hip arthroplasty (three versus nine). It has been suggested that ESWT may be more effective for early-stage disease [74,75].

Electrical stimulation — Pulsed electromagnetic fields may stimulate osteogenesis as their mechanism of action and have appeared to be beneficial in some studies. One study found that at a mean follow-up of over two years, 50 of 53 (94 percent) of the hips with early-stage osteonecrosis avoided total hip arthroplasty with the use of pulsed electromagnetic devices, while 12 of 23 hips (52 percent) with more advanced osteonecrosis underwent total hip arthroplasty [76-78].

Hyperbaric oxygen — Hyperbaric oxygen may improve osteonecrosis by increasing oxygen early in the ischemic case, but the evidence is mixed. One study evaluated hyperbaric oxygen use compared with compressed air on pain and radiographic outcomes in early osteonecrotic lesions of the hip (Ficat stage II) [79]. Patients who received hyperbaric oxygen had a significantly lower pain score compared with controls. After seven years, all patients demonstrated lesion improvement on MRI and none underwent total hip arthroplasty [80]. In a study, treatment with hyperbaric oxygen in osteonecrosis patients resulted in a decreased amount of the circulating proinflammatory cytokines tumor necrosis factor (TNF) alpha and interleukin (IL) 6 [81]. This may ultimately result in improved healing of the osteonecrotic lesion. These results give reason to believe that further investigation of hyperbaric oxygen as a treatment for osteonecrosis of the femoral head is warranted [78].

APPROACH TO MANAGEMENT — The approach to managing patients who have femoral head osteonecrosis is guided by symptoms and radiologic parameters including size, location, and the presence or absence of collapse. Based on these factors, a decision can be made to use supportive care, joint-preserving surgery, or total hip arthroplasty. The authors' preferred treatment approach is outlined below.

Precollapse

Asymptomatic patients — An asymptomatic hip with osteonecrosis is typically discovered as the contralateral hip of a patient with one symptomatic joint [3]. There is no consensus on the appropriate treatment of patients with asymptomatic osteonecrosis of the femoral head, particularly when there is no evidence of femoral collapse.

The natural history of asymptomatic, medium-sized and, especially, large osteonecrotic hip lesions is eventual progression to end-stage disease and collapse of the joint. In a systematic review that included 664 hips, 59 percent of hips studied progressed to symptoms or collapse, which was related to the extent of involvement, location of disease, and radiographic stage at the time of diagnosis [3].

Our management approach is guided by the size of the lesion [3,82]:

For asymptomatic patients with a small lesion (involving <15 percent of the femoral head), we suggest supportive care rather than surgery (eg, a joint-preserving procedure). This approach is largely based on observational data that asymptomatic lesions that involve less than 15 percent of the femoral head may resolve without surgical intervention [3,9]. In a systematic review, small, medially located lesions had the best prognosis, with a prevalence of collapse of less than 10 percent [3]. (See 'Supportive care' above.)

Patients who do not undergo surgery are followed periodically for clinical evaluation of pain and range of motion. Typically, there are no weightbearing restrictions for patients who have small, asymptomatic lesions. Routine follow-up of patients with osteonecrosis does not typically require serial magnetic resonance imaging (MRI). Anteroposterior and lateral radiographs can generally be used to evaluate the contour of the femoral head in patients with osteonecrosis of the hip.

For asymptomatic patients with medium lesions (involving 15 to 30 percent of the femoral head), we suggest surgery with a joint-preserving procedure such as core decompression (with or without adjunctive procedures) or bone grafting rather than supportive therapy [3,9,83]. The rationale for this approach is based on indirect evidence from symptomatic patients with medium-sized lesions, given that asymptomatic patients with medium-sized lesions are likely to progress in the same manner as symptomatic patients [3]. (See 'Small- to medium-sized lesions' below.)

For asymptomatic patients with large lesions (involving >30 percent of the femoral head), we manage patients with supportive therapy until symptoms develop. These patients are highly likely to progress to collapse and may need to undergo total hip arthroplasty [3,9,83]. In a systematic review, 85 percent of patients with large lesions (37 percent of the cohort) failed a joint-preserving procedure [3]. This approach avoids subjecting the patient to a joint-preserving procedure that is not likely to benefit the patient. (See 'Femoral head collapse' below and 'Advanced collapse' below.)

Symptomatic patients — For symptomatic patients with no evidence of femoral head collapse (eg, Association Research Circulation Osseous [ARCO] stage I or II), our management approach is largely guided by the volume of bone affected and the likelihood of progression to collapse. The risk of collapse can be estimated using the modified Kerboul method [84,85]. (See "Clinical manifestations and diagnosis of osteonecrosis (avascular necrosis of bone)", section on 'Risk of progression to collapse'.)

Small- to medium-sized lesions — For patients with symptomatic, small- (involving <15 percent of the femoral head) or medium- (involving 15 to 30 percent of the femoral head) sized osteonecrosis lesions of the hip that are precollapse (eg, ARCO stage I or II), we suggest core decompression rather than supportive therapy or bone grafting. In some cases, however, bone grafting is a reasonable alternative to core decompression. The optimal surgical approach to core decompression, with or without adjunctive therapies (eg, nonvascularized bone grafting, cell-based augmentation), remains uncertain.

Several studies report favorable results with core decompression of the hip or its variants (eg, percutaneous drilling, instillation of bone graft or stem cells) in approximately 60 to 80 percent of patients who have early-stage osteonecrosis of the hip [1,11,14,15,86,87]. (See 'Core depression and variants' above.)

In the largest meta-analysis of 32 studies including 2441 hips, core decompression was found to be a safe and effective method with an overall success rate of 65 percent, which was superior to nonoperative treatment methods [88]. The success rates for core decompression are higher when done at earlier stages. Using the Ficat staging criteria, the success rate for stage I, II, and III was 78, 59, and 27 percent, respectively.

The effectiveness of percutaneous drillings was evaluated in patients with small- or medium-sized precollapse lesions [13]. In this study, 32 of 45 hips (71 percent) had a successful clinical result at a mean follow-up of approximately two years. Another study followed 164 cases for a mean time period of 35 months to evaluate the therapeutic effect of multiple small-diameter drillings [89]. The authors reported that this technique was equal to or surpassed traditional core decompression and has the advantage of minimal osseous destruction, delaying femoral head collapse, and improving blood circulation in the necrotic areas.

Large-sized lesions — We suggest not using a joint-preserving therapy for patients with large lesions (involving >30 percent of the femoral head) that are precollapse, given the increased risk of collapse and likely need for total hip arthroplasty. The use of a joint-preserving procedure in such patients increases the complexity of the hip replacement surgery and may compromise the outcome.

Femoral head collapse — Most patients presenting with some degree of collapse will likely require surgical intervention. While earlier treatment can provide an opportunity to prevent further collapse, many patients present late in the course of disease and will likely undergo hip arthroplasty for advanced collapse. Approximately 80 to 85 percent of patients who present with symptoms will experience collapse of the femoral head within two years [3].

Minimal collapse — For symptomatic early lesions with less than 2 mm of depression (eg, ARCO stage IIIA), we suggest vascularized or nonvascularized bone grafting rather than core decompression or total hip arthroplasty. These techniques may delay progression and reduce the need for future hip arthroplasty in some, but not all, patients. Bone grafting techniques include nonvascularized fibular grafting (eg, the trapdoor procedure [39] and the lightbulb procedure [41,90,91]). Either nonvascularized or vascularized bone grafting can be used [27,43,45-48]. (See 'Bone grafting' above.)

Data in support of bone grafting procedures in patients with minimal collapse of the femoral head come from several small observational studies:

A systematic review including 21 studies and 166 hips that underwent free vascularized fibular grafting for osteonecrosis found that the average graft survival time before total hip arthroplasty was 5.2 years; radiographic progression of disease was detected in 47.7 percent of hips [47].

In a retrospective review of 29 hips that were precollapse or early collapse, the overall clinical success rate for hip-preserving procedures (Phemister technique with nonvascularized bone graft) was 65.5 percent after a mean follow-up of 14 years. Female sex, ARCO stage III disease (compared with ARCO stage II), lateral-type lesion, and necrotic index ≥0.67 were independent risk factors for conversion to total hip arthroplasty [44].

In another retrospective review of 26 ARCO stage IIIA (<2 mm collapse) hips, 18 of the 26 hips underwent conversion from their free-vascularized fibular grafts to total hip arthroplasty with a mean hip survival time of 85 months (95%, CI 61-108). The mean Harris hip score for the eight hips that still survived at the time of follow-up had improved, but all had progressive collapse of the femoral head [92].

In a retrospective review of vascularized fibular grafts, among the 65 Ficat III hips followed for at least 10 years, 6 (9.2 percent) were converted to total hip arthroplasty [48].

Advanced collapse — Patients with advanced collapse (eg, ARCO stage IIIB or IV) generally require total hip arthroplasty; most joint-preserving therapies are not feasible. Hemiarthroplasty procedures are seldom used due to associated high failure rates because of acetabular degeneration. Resurfacing procedures are less commonly used in adults and may have a role in adolescents and younger adults [93-97]. Osteotomies have been used in younger patients with advanced collapse, though it remains an uncommon approach. (See 'Osteotomy' above.)

The outcomes of total hip arthroplasty for the treatment of osteonecrosis have improved over time, and success rates are comparable with hip arthroplasties performed for osteoarthritis. In a 2011 systematic review of total hip arthroplasty for osteonecrosis, revision rates were higher for operations performed before 1990 compared with those performed later (17 versus 3 percent) [98]. Several studies of total hip arthroplasty using uncemented and cemented femoral components have indicated excellent long-term results for patients with osteonecrosis that are comparable with results for patients with osteoarthritis [99-102]. As an example, a case-control study of 282 patients, 149 with osteonecrosis and 133 with hip osteoarthritis reported similar 10-year implant survival rates between the two groups. For both groups, the overall 10-year survival for aseptic loosening was 98.9 percent and 10-year survival for major revision was 93.9 percent. The primary cause in most studies for revision surgery was loss of fixation of the acetabular component secondary to wear [99].

Historically, total hip arthroplasty has high failure rates in patients with osteonecrosis due to sickle cell disease [103]. With careful attention to perioperative care and multidisciplinary management, outcomes for total hip arthroplasty in sickle cell patients has improved [104,105].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Osteonecrosis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Avascular necrosis of the hip (The Basics)")

SUMMARY AND RECOMMENDATIONS

The treatment of nontraumatic osteonecrosis remains one of the most controversial subjects in orthopedic literature. If the osteonecrosis is caught in an early stage, the goal of therapy is to preserve the native joint for as long as possible. However, given that hip osteonecrosis often progresses, the mainstay of treatment is surgical using either a joint-preserving procedure, if possible, or total hip arthroplasty. (See 'Introduction' above.)

Factors influencing the aggressiveness of treatment of nontraumatic hip osteonecrosis include the presence (or absence) of symptoms; the size and stage of the lesion, including the presence and amount of structural collapse; and the patient's comorbidities. Three main therapeutic options for management of osteonecrosis include supportive care, joint-preserving procedures (eg, core decompression and its variants, bone grafting), and total hip arthroplasty when advanced collapse has occurred. (See 'General management principles' above and 'Supportive care' above and 'Surgical options' above and 'Total hip arthroplasty' above.)

Investigational options for medical management are used but do not reliably improve symptoms or prevent progression of disease. These include bisphosphonates, statin therapy, anticoagulation, vasodilators, extracorporeal shock wave therapy (ESWT), electrical/electromagnetic stimulation, and hyperbaric oxygen. We do not recommend any of these therapies in the routine management of osteonecrosis. (See 'Unproven therapies' above.)

The location of disease and extent of involvement of bone determine the choice of treatment. These can be determined using a combination of standard radiographs and magnetic resonance imaging (MRI), which are generally obtained when surgery will be performed to help determine the best approach. (See 'Assessment of extent of involvement and location' above.)

Osteonecrosis in a hip that is not a source of symptoms is typically discovered incidentally in a patient who has symptoms in the contralateral hip. There is no consensus on the appropriate treatment of patients with asymptomatic osteonecrosis of the femoral head, particularly when there is no evidence of femoral collapse. Our approach to the management of asymptomatic lesions is guided by the size of the lesions and is as follows (see 'Asymptomatic patients' above):

For asymptomatic patients with a small-sized lesion (involving <15 percent of the femoral head), we suggest supportive care rather than any form of a joint-preserving surgery (Grade 2C). This approach is largely based on observational data that asymptomatic lesions that involve less than 15 percent of the femoral head may resolve without surgical intervention.

For asymptomatic patients with a medium-sized lesion (involving between 15 and 30 percent of the femoral head), we suggest a joint-preserving surgical procedure such as core decompression (or one of its variants) or bone grafting rather than supportive therapy (Grade 2C). The rationale for this approach is also based on indirect evidence from symptomatic patients with medium-sized lesions, which are more likely to progress to collapse.

For asymptomatic patients with large-sized lesions (involving >30 percent of the femoral head), we manage patients with supportive therapy until symptoms develop. These patients are highly likely to progress to femoral head collapse, which will likely be treated with total hip arthroplasty.

Our management of symptomatic patients with no evidence of femoral head collapse (eg, Association Research Circulation Osseous [ARCO] stage I or II) is largely guided by the size of the lesion and the likelihood of progression to collapse (see 'Symptomatic patients' above):

For patients with symptomatic small- or medium-sized osteonecrosis lesions of the hip that are precollapse (eg, ARCO stage I or II), we suggest core decompression (or one of its variants) rather than supportive therapy or bone grafting (Grade 2C). In some patients with precollapse lesions, bone grafting may be a reasonable alternative to core decompression. The optimal surgical approach to core decompression (eg, core decompression alone or a variant of core decompression) remains uncertain. (See 'Small- to medium-sized lesions' above.)

For patients with large-sized lesions that are precollapse, we typically do not use a joint-preserving therapy given the increased risk of collapse and likely need for total hip arthroplasty. (See 'Large-sized lesions' above.)

Our management of symptomatic patients who have progressed to femoral head collapse is largely guided by the degree of femoral head depression (see 'Femoral head collapse' above):

For symptomatic early lesions with less than 2 mm of depression (eg, ARCO stage IIIA), we suggest a bone grafting procedure rather than core decompression or total hip arthroplasty (Grade 2C). (See 'Minimal collapse' above.)

Patients with advanced collapse (eg, ARCO stage IIIB or IV) generally require total hip arthroplasty as joint-preserving therapies are not feasible. (See 'Advanced collapse' above.)

  1. Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res 1996; :169.
  2. Musso ES, Mitchell SN, Schink-Ascani M, Bassett CA. Results of conservative management of osteonecrosis of the femoral head. A retrospective review. Clin Orthop Relat Res 1986; :209.
  3. Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am 2010; 92:2165.
  4. Pierce TP, Jauregui JJ, Cherian JJ, et al. Imaging evaluation of patients with osteonecrosis of the femoral head. Curr Rev Musculoskelet Med 2015; 8:221.
  5. Hauzeur JP, Pasteels JL, Schoutens A, et al. The diagnostic value of magnetic resonance imaging in non-traumatic osteonecrosis of the femoral head. J Bone Joint Surg Am 1989; 71:641.
  6. Chen LH. Clinical value of CT and MRI in diagnosis of early osteonecrosis of femoral head in adults. Mod Inst Med Treat 2015; :8.
  7. Luo ZA. Clinical value of CT and MRI n diagnosis of early osteonecrosis of femoral head in adults. China Med Device Inform 2017; 23:93.
  8. Yoon BH, Mont MA, Koo KH, et al. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head. J Arthroplasty 2020; 35:933.
  9. Hungerford DS, Jones LC. Asymptomatic osteonecrosis: should it be treated? Clin Orthop Relat Res 2004; :124.
  10. Osmani F, Thakkar S, Vigdorchik J. The Utility of Conservative Treatment Modalities in the Management of Osteonecrosis. Bull Hosp Jt Dis (2013) 2017; 75:186.
  11. Stulberg BN, Davis AW, Bauer TW, et al. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop Relat Res 1991; :140.
  12. Neumayr LD, Aguilar C, Earles AN, et al. Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease. Results of a multicenter study at a mean of three years after treatment. J Bone Joint Surg Am 2006; 88:2573.
  13. Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res 2004; :131.
  14. Miyahara HS, Rosa BB, Hirata FY, et al. What is the role of core decompression in the early stages of osteonecrosis of the femoral head? Evaluation of the surgical result by functional score and radiological follow-up. Rev Bras Ortop 2018; 53:537.
  15. Pierce TP, Jauregui JJ, Elmallah RK, et al. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med 2015; 8:228.
  16. Brown PJ, Mannava S, Seyler TM, et al. Multiple Small Diameter Drillings Increase Femoral Neck Stability Compared with Single Large Diameter Femoral Head Core Decompression Technique for Avascular Necrosis of the Femoral Head. Surg Technol Int 2016; 29:247.
  17. Haberal B, Şahin O, Şimşek EK, et al. Outcomes for core decompression with multiple drilling of the osteonecrosis of the femoral head in patients with solid organ transplantation. Eklem Hastalik Cerrahisi 2018; 29:159.
  18. Li J, Li ZL, Zhang H, et al. Long-term Outcome of Multiple Small-diameter Drilling Decompression Combined with Hip Arthroscopy versus Drilling Alone for Early Avascular Necrosis of the Femoral Head. Chin Med J (Engl) 2017; 130:1435.
  19. Cilla M, Checa S, Preininger B, et al. Femoral head necrosis: A finite element analysis of common and novel surgical techniques. Clin Biomech (Bristol, Avon) 2017; 48:49.
  20. Yuan HF, Zhang J, Guo CA, Yan ZQ. Clinical outcomes of osteonecrosis of the femoral head after autologous bone marrow stem cell implantation: a meta-analysis of seven case-control studies. Clinics (Sao Paulo) 2016; 71:110.
  21. Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am 2006; 88:1117.
  22. Gangji V, Hauzeur JP, Matos C, et al. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. A pilot study. J Bone Joint Surg Am 2004; 86-A:1153.
  23. Pepke W, Kasten P, Beckmann NA, et al. Core Decompression and Autologous Bone Marrow Concentrate for Treatment of Femoral Head Osteonecrosis: A Randomized Prospective Study. Orthop Rev (Pavia) 2016; 8:6162.
  24. Steinberg ME, Larcom PG, Strafford B, et al. Core decompression with bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res 2001; :71.
  25. Lespasio MJ, Sodhi N, Mont MA. Osteonecrosis of the Hip: A Primer. Perm J 2019; 23.
  26. Zeng Y, Qi X, Feng W, et al. One-sided hip-preserving and concurrent contralateral total hip arthroplasty for the treatment of bilateral osteonecrosis of the femoral head in different stages: short-medium term outcomes. BMC Musculoskelet Disord 2015; 16:133.
  27. Rijnen WH, Gardeniers JW, Buma P, et al. Treatment of femoral head osteonecrosis using bone impaction grafting. Clin Orthop Relat Res 2003; :74.
  28. Keizer SB, Kock NB, Dijkstra PD, et al. Treatment of avascular necrosis of the hip by a non-vascularised cortical graft. J Bone Joint Surg Br 2006; 88:460.
  29. Ficat RP, Arlet J. Necrosis of the femoral head. In: Ischemia and Necrosis of Bone, 3rd ed, Hungerford DS (Ed), Lippincott Williams & Wilkins, Philadelphia 1980. p.171.
  30. Cao L, Guo C, Chen J, et al. Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial. Clin Orthop Relat Res 2017; 475:2230.
  31. Steinberg ME. Core decompression. Semin Arthroplasty 1998; 9:213.
  32. Aaron RK, Ciombre DM, Lord CF. Core decompression augmented with human decalcified bone matrix graft for osteonecrosis of the femoral head. In: Osteonecrosis: Etiology, Diagnosis and Treatment, Urbaniak JR, Jones JP (Eds), American Association of Orhopaedic Surgeons, Rosemont, IL 1997. p.301.
  33. Landgraeber S, Warwas S, Claßen T, Jäger M. Modifications to advanced Core decompression for treatment of Avascular necrosis of the femoral head. BMC Musculoskelet Disord 2017; 18:479.
  34. Hernigou P, Trousselier M, Roubineau F, et al. Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress. Clin Orthop Surg 2016; 8:1.
  35. Piuzzi NS, Chahla J, Schrock JB, et al. Evidence for the Use of Cell-Based Therapy for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review of the Literature. J Arthroplasty 2017; 32:1698.
  36. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res 2002; :14.
  37. Kang JS, Suh YJ, Moon KH, et al. Clinical efficiency of bone marrow mesenchymal stem cell implantation for osteonecrosis of the femoral head: a matched pair control study with simple core decompression. Stem Cell Res Ther 2018; 9:274.
  38. Mont MA, Cherian JJ, Sierra RJ, et al. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update. J Bone Joint Surg Am 2015; 97:1604.
  39. Mont MA, Einhorn TA, Sponseller PD, Hungerford DS. The trapdoor procedure using autogenous cortical and cancellous bone grafts for osteonecrosis of the femoral head. J Bone Joint Surg Br 1998; 80:56.
  40. Rosenwasser MP, Garino JP, Kiernan HA, Michelsen CB. Long term followup of thorough debridement and cancellous bone grafting of the femoral head for avascular necrosis. Clin Orthop Relat Res 1994; :17.
  41. Yildiz C, Erdem Y, Koca K. Lightbulb technique for the treatment of osteonecrosis of the femoral head. Hip Int 2018; 28:272.
  42. Seyler TM, Marker DR, Ulrich SD, et al. Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis. Clin Orthop Relat Res 2008; 466:1125.
  43. Mont MA, Etienne G, Ragland PS. Outcome of nonvascularized bone grafting for osteonecrosis of the femoral head. Clin Orthop Relat Res 2003; :84.
  44. Wu CT, Yen SH, Lin PC, Wang JW. Long-term outcomes of Phemister bone grafting for patients with non-traumatic osteonecrosis of the femoral head. Int Orthop 2019; 43:579.
  45. Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. J Bone Joint Surg Am 2003; 85-A:987.
  46. Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am 1995; 77:681.
  47. Ligh CA, Nelson JA, Fischer JP, et al. The Effectiveness of Free Vascularized Fibular Flaps in Osteonecrosis of the Femoral Head and Neck: A Systematic Review. J Reconstr Microsurg 2017; 33:163.
  48. Yoo MC, Kim KI, Hahn CS, Parvizi J. Long-term followup of vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res 2008; 466:1133.
  49. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 1995; 77:459.
  50. Mont MA, Fairbank AC, Krackow KA, Hungerford DS. Corrective osteotomy for osteonecrosis of the femoral head. J Bone Joint Surg Am 1996; 78:1032.
  51. Morita D, Hasegawa Y, Okura T, et al. Long-term outcomes of transtrochanteric rotational osteotomy for non-traumatic osteonecrosis of the femoral head. Bone Joint J 2017; 99-B:175.
  52. Kubo Y, Yamamoto T, Motomura G, et al. Patient-reported outcomes of femoral osteotomy and total hip arthroplasty for osteonecrosis of the femoral head: a prospective case series study. Springerplus 2016; 5:1880.
  53. Sonoda K, Yamamoto T, Motomura G, et al. Outcome of transtrochanteric rotational osteotomy for posttraumatic osteonecrosis of the femoral head with a mean follow-up of 12.3 years. Arch Orthop Trauma Surg 2015; 135:1257.
  54. Lee YK, Park CH, Ha YC, et al. Comparison of Surgical Parameters and Results between Curved Varus Osteotomy and Rotational Osteotomy for Osteonecrosis of the Femoral Head. Clin Orthop Surg 2017; 9:160.
  55. Sugioka Y, Katsuki I, Hotokebuchi T. Transtrochanteric rotational osteotomy of the femoral head for the treatment of osteonecrosis. Follow-up statistics. Clin Orthop Relat Res 1982; :115.
  56. Simank HG, Brocai DR, Brill C, Lukoschek M. Comparison of results of core decompression and intertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Cox regression and survivorship analysis. J Arthroplasty 2001; 16:790.
  57. Fuchs B, Knothe U, Hertel R, Ganz R. Femoral osteotomy and iliac graft vascularization for femoral head osteonecrosis. Clin Orthop Relat Res 2003; :84.
  58. Gupta S, Gupta H, Mandhyan D, Srivastava S. Bisphophonates related osteonecrosis of the jaw. Natl J Maxillofac Surg 2013; 4:151.
  59. Agarwala S, Shah S, Joshi VR. The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years. J Bone Joint Surg Br 2009; 91:1013.
  60. Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am 2005; 87:2155.
  61. Chen CH, Chang JK, Lai KA, et al. Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis: a two-year multicenter, prospective, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2012; 64:1572.
  62. Wang CJ, Wang FS, Yang KD, et al. Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate. Arch Orthop Trauma Surg 2008; 128:901.
  63. Yuan HF, Guo CA, Yan ZQ. The use of bisphosphonate in the treatment of osteonecrosis of the femoral head: a meta-analysis of randomized control trials. Osteoporos Int 2016; 27:295.
  64. Li D, Yang Z, Wei Z, Kang P. Efficacy of bisphosphonates in the treatment of femoral head osteonecrosis: A PRISMA-compliant meta-analysis of animal studies and clinical trials. Sci Rep 2018; 8:1450.
  65. Lee YK, Ha YC, Cho YJ, et al. Does Zoledronate Prevent Femoral Head Collapse from Osteonecrosis? A Prospective, Randomized, Open-Label, Multicenter Study. J Bone Joint Surg Am 2015; 97:1142.
  66. Jäger M, Zilkens C, Bittersohl B, et al. Efficiency of iloprost treatment for osseous malperfusion. Int Orthop 2011; 35:761.
  67. Claßen T, Becker A, Landgraeber S, et al. Long-term Clinical Results after Iloprost Treatment for Bone Marrow Edema and Avascular Necrosis. Orthop Rev (Pavia) 2016; 8:6150.
  68. Ajmal M, Matas AJ, Kuskowski M, Cheng EY. Does statin usage reduce the risk of corticosteroid-related osteonecrosis in renal transplant population? Orthop Clin North Am 2009; 40:235.
  69. Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop Relat Res 2001; :173.
  70. Guo P, Gao F, Wang Y, et al. The use of anticoagulants for prevention and treatment of osteonecrosis of the femoral head: A systematic review. Medicine (Baltimore) 2017; 96:e6646.
  71. Nagasawa K, Tada Y, Koarada S, et al. Prevention of steroid-induced osteonecrosis of femoral head in systemic lupus erythematosus by anti-coagulant. Lupus 2006; 15:354.
  72. Glueck CJ, Freiberg RA, Sieve L, Wang P. Enoxaparin prevents progression of stages I and II osteonecrosis of the hip. Clin Orthop Relat Res 2005; :164.
  73. Wang CJ, Wang FS, Huang CC, et al. Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting. J Bone Joint Surg Am 2005; 87:2380.
  74. Wang CJ, Huang CC, Yip HK, Yang YJ. Dosage effects of extracorporeal shockwave therapy in early hip necrosis. Int J Surg 2016; 35:179.
  75. Zhang Q, Liu L, Sun W, et al. Extracorporeal shockwave therapy in osteonecrosis of femoral head: A systematic review of now available clinical evidences. Medicine (Baltimore) 2017; 96:e5897.
  76. Massari L, Fini M, Cadossi R, et al. Biophysical stimulation with pulsed electromagnetic fields in osteonecrosis of the femoral head. J Bone Joint Surg Am 2006; 88 Suppl 3:56.
  77. Bassett CA, Schink-Ascani M, Lewis SM. Effects of pulsed electromagnetic fields on Steinberg ratings of femoral head osteonecrosis. Clin Orthop Relat Res 1989; :172.
  78. Steinberg ME, Brighton CT, Corces A, et al. Osteonecrosis of the femoral head. Results of core decompression and grafting with and without electrical stimulation. Clin Orthop Relat Res 1989; :199.
  79. Camporesi EM, Vezzani G, Bosco G, et al. Hyperbaric oxygen therapy in femoral head necrosis. J Arthroplasty 2010; 25:118.
  80. Koren L, Ginesin E, Melamed Y, et al. Hyperbaric oxygen for stage I and II femoral head osteonecrosis. Orthopedics 2015; 38:e200.
  81. Bosco G, Vezzani G, Mrakic Sposta S, et al. Hyperbaric oxygen therapy ameliorates osteonecrosis in patients by modulating inflammation and oxidative stress. J Enzyme Inhib Med Chem 2018; 33:1501.
  82. Steinberg ME, Bands RE, Parry S, et al. Does lesion size affect the outcome in avascular necrosis? Clin Orthop Relat Res 1999; :262.
  83. Nam KW, Kim YL, Yoo JJ, et al. Fate of untreated asymptomatic osteonecrosis of the femoral head. J Bone Joint Surg Am 2008; 90:477.
  84. Ha YC, Jung WH, Kim JR, et al. Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am 2006; 88 Suppl 3:35.
  85. Koo KH, Kim R. Quantifying the extent of osteonecrosis of the femoral head. A new method using MRI. J Bone Joint Surg Br 1995; 77:875.
  86. Ficat P, Arlet J, Vidal R, et al. [Therapeutic results of drill biopsy in primary osteonecrosis of the femoral head (100 cases)]. Rev Rhum Mal Osteoartic 1971; 38:269.
  87. Koo KH, Kim R, Ko GH, et al. Preventing collapse in early osteonecrosis of the femoral head. A randomised clinical trial of core decompression. J Bone Joint Surg Br 1995; 77:870.
  88. Hua KC, Yang XG, Feng JT, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg Res 2019; 14:306.
  89. Wang ZG, Wang Y, Liu YJ, et al. [Clinical evaluation of small diameter decompression and arthroscopy in the treatment of early avascular necrosis of femoral head]. Zhonghua Yi Xue Za Zhi 2007; 87:2041.
  90. Liu P, Zhang QD, Wang Y, et al. One-stage total hip arthroplasty and "light-bulb" procedure for bilateral non-traumatic osteonecrosis of femoral head in different stages. Chin Med J (Engl) 2019; 132:2883.
  91. Zhang HJ, Liu YW, Du ZQ, et al. Therapeutic effect of minimally invasive decompression combined with impaction bone grafting on osteonecrosis of the femoral head. Eur J Orthop Surg Traumatol 2013; 23:913.
  92. Chen CC, Lin CL, Chen WC, et al. Vascularized iliac bone-grafting for osteonecrosis with segmental collapse of the femoral head. J Bone Joint Surg Am 2009; 91:2390.
  93. Amstutz HC, Le Duff MJ. Hip resurfacing for osteonecrosis: two- to 18-year results of the Conserve Plus design and technique. Bone Joint J 2016; 98-B:901.
  94. Nakasone S, Takao M, Sakai T, et al. Does the extent of osteonecrosis affect the survival of hip resurfacing? Clin Orthop Relat Res 2013; 471:1926.
  95. Pyda M, Koczy B, Widuchowski W, et al. Hip resurfacing arthroplasty in treatment of avascular necrosis of the femoral head. Med Sci Monit 2015; 21:304.
  96. Revell MP, McBryde CW, Bhatnagar S, et al. Metal-on-metal hip resurfacing in osteonecrosis of the femoral head. J Bone Joint Surg Am 2006; 88 Suppl 3:98.
  97. Sayeed SA, Johnson AJ, Stroh DA, et al. Hip resurfacing in patients who have osteonecrosis and are 25 years or under. Clin Orthop Relat Res 2011; 469:1582.
  98. Johannson HR, Zywiel MG, Marker DR, et al. Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop 2011; 35:465.
  99. Ancelin D, Reina N, Cavaignac E, et al. Total hip arthroplasty survival in femoral head avascular necrosis versus primary hip osteoarthritis: Case-control study with a mean 10-year follow-up after anatomical cementless metal-on-metal 28-mm replacement. Orthop Traumatol Surg Res 2016; 102:1029.
  100. Hungerford MW, Hungerford DS, Jones LC. Outcome of uncemented primary femoral stems for treatment of femoral head osteonecrosis. Orthop Clin North Am 2009; 40:283.
  101. Kim YH, Oh SH, Kim JS, Koo KH. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. J Bone Joint Surg Am 2003; 85-A:675.
  102. Solarino G, Piazzolla A, Notarnicola A, et al. Long-term results of 32-mm alumina-on-alumina THA for avascular necrosis of the femoral head. J Orthop Traumatol 2012; 13:21.
  103. Moran MC, Huo MH, Garvin KL, et al. Total hip arthroplasty in sickle cell hemoglobinopathy. Clin Orthop Relat Res 1993; :140.
  104. Farook MZ, Awogbade M, Somasundaram K, et al. Total hip arthroplasty in osteonecrosis secondary to sickle cell disease. Int Orthop 2019; 43:293.
  105. Azam MQ, Sadat-Ali M. Quality of Life in Sickle Cell Patients After Cementless Total Hip Arthroplasty. J Arthroplasty 2016; 31:2536.
Topic 5613 Version 27.0

References

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