Osteonecrosis of the

Femoral Head
Matthew Orton
Radiology Presentation
7/20/2007
 HPI
 A 20 yo male with SLE reports to ER
complaining of chronic L hip pain and
new L knee pain that has not
resolved since fall 1 week ago.
 PCP diagnosed SLE in 2004.
 Meds: Lisinoprol, Prednisone, Zantac,
HCTZ, Imuran, Volteran,
• Sclerosis and density changes
• Loss of smooth spherical or collapse of
•“Crecent Sign” = subcondral femoral head.
radiolucancy •Joint space narrowing , degenerative changes.
MRI of Femoral Head Osteonecrosis
 Coronal T1 MRI of
both hips shows
diffuse low signal
throughout the left
femoral head, neck,
and proximal shaft.

 Axial T2 MRI of
both hips shows
diffuse high signal
in the left femoral
head consistent
with the avascular
necrosis.

Images from: brighamrad.harvard.edu

 Osteonecrosis of Femoral Head
 Osteonecrosis = aseptic necrosis, avascular necrosis, Nontraumatic
ischemic necrosis and osteochondritis dessicans.
Corticosteroid
 Mechanism compromise of bone vasculature leading
to death of bone and marrow cells and ultimately Sickle cell
mechanical failure. Process is often progressive and Systemic lupus
results in joint destruction in 3-5 years if untreated. erythematosus
• Exact pathogenesis still under debated. Some theories
include intravascular necrosis, increased intraosseous Gaucher’s
pressure, mechanical stresses, or metabolic factors. Disease
 Prevalence is 10,000-20,000 cases diagnosed in Chronic renal
US/year. M:F = 8:1. 5% of patients with SLE will
develop osteonecrosis. failure or
hemodialysis
 Staging
• Stage 0 — All diagnostic studies normal, diagnosis by Radiation
histology Excessive ETOH
• Stage 1 — Plain radiographs and computed tomography
normal, magnetic resonance imaging positive and biopsy
positive.
Traumatic
• Stage 2 — Radiographs positive but no collapse.
• Stage 3 — Early flattening of dome, crescent sign, Femoral Neck
computed tomography or tomograms may be needed. Fracture
• Stage 4 — Flattening of femoral head with joint space
narrowing, possible other signs of early osteoarthritis Femoral
Dislocation
 Treatment of Osteonecrosis of
Femoral Head
 Conservative management ( rest and pain
control) if <15% femoral head involved.
 Bisphosphonates can slow progression
 Core decompression may slow
progression.
 Osteotomy move areas of necrosis away
from major load bearing and try to
redistribute on healthy bone.
 Joint replacements (higher rate of
complications and revisions)
 References
1. Donohue, JP.UptoDate: Osteonecrosis
(avascular necorsis of bone). 2007.
2. Jones LC, Hungerford DS. Osteonecrosis:
etiology, diagnosis, and treatment. Curr
Opin Rheum 2004; 16: 443-449.
3. Galindo M, Mateo I, Pablos JI. Multiple
avasular necrossis of bone and
polyarticular septic arthritis in patients
with systemic lupus erythematosus.
Rheumatol Int 2005; 25: 72-76.