Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Sep 18, 2015; 6(8): 590-601
Published online Sep 18, 2015. doi: 10.5312/wjo.v6.i8.590
Current concepts on osteonecrosis of the femoral head
Joaquin Moya-Angeler, Arianna L Gianakos, Jordan C Villa, Amelia Ni, Joseph M Lane
Joaquin Moya-Angeler, Arianna L Gianakos, Jordan C Villa, Amelia Ni, Joseph M Lane, Hospital for Special Surgery, New York, NY 10021, United States
Author contributions: Moya-Angeler J was principal investigator; Moya-Angeler J, Gianakos AL and Lane JM contributed to study conception and design, analysis and interpretation of data, drafting of manuscript and critical revision; Villa JC and Ni A contributed to analysis and interpretation of data, drafting of manuscript and critical revision.
Conflict-of-interest statement: The authors of this manuscript report no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Joseph M Lane, MD, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States.
Telephone: +1-212-6061255 Fax: +1-212-6061902
Received: April 8, 2015
Peer-review started: April 9, 2015
First decision: June 3, 2015
Revised: June 16, 2015
Accepted: July 21, 2015
Article in press: July 23, 2015
Published online: September 18, 2015

It is estimated that 20000 to 30000 new patients are diagnosed with osteonecrosis annually accounting for approximately 10% of the 250000 total hip arthroplasties done annually in the United States. The lack of level 1 evidence in the literature makes it difficult to identify optimal treatment protocols to manage patients with pre-collapse avascular necrosis of the femoral head, and early intervention prior to collapse is critical to successful outcomes in joint preserving procedures. There have been a variety of traumatic and atraumatic factors that have been identified as risk factors for osteonecrosis, but the etiology and pathogenesis still remains unclear. Current osteonecrosis diagnosis is dependent upon plain anteroposterior and frog-leg lateral radiographs of the hip, followed by magnetic resonance imaging (MRI). Generally, the first radiographic changes seen by radiograph will be cystic and sclerotic changes in the femoral head. Although the diagnosis may be made by radiograph, plain radiographs are generally insufficient for early diagnosis, therefore MRI is considered the most accurate benchmark. Treatment options include pharmacologic agents such as bisphosphonates and statins, biophysical treatments, as well as joint-preserving and joint-replacing surgeries. the surgical treatment of osteonecrosis of the femoral head can be divided into two major branches: femoral head sparing procedures (FHSP) and femoral head replacement procedures (FHRP). In general, FHSP are indicated at pre-collapse stages with minimal symptoms whereas FHRP are preferred at post-collapse symptomatic stages. It is difficult to know whether any treatment modality changes the natural history of core decompression since the true natural history of core decompression has not been delineated.

Keywords: Osteonecrosis, Femoral head, Conservative treatment, Core decompression, Stem cells, Total hip arthroplasty

Core tip: This paper walks the reader through the most current evidence regarding the etiology, pathogenesis, treatment options and prognosis of patients presenting with osteonecrosis of the femoral head. We emphasize early diagnosis with magnetic resonance imaging, review surgical and non surgical treatment modalities and provide a personalized management algorithm according to the different stages of the disease.