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

Crecent Sign = subcondral
radiolucancy

Loss of smooth spherical or collapse of

femoral head.
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,

ischemic necrosis and osteochondritis dessicans.
Mechanism compromise of bone vasculature leading
to death of bone and marrow cells and ultimately
mechanical failure. Process is often progressive and
results in joint destruction in 3-5 years if untreated.
Exact pathogenesis still under debated. Some theories
include intravascular necrosis, increased intraosseous
pressure, mechanical stresses, or metabolic factors.

Prevalence is 10,000-20,000 cases diagnosed in

US/year. M:F = 8:1. 5% of patients with SLE will
develop osteonecrosis.
Staging

Nontraumatic
Corticosteroid
Sickle cell
Systemic lupus
erythematosus
Gauchers
Disease
Chronic renal
failure or
hemodialysis

Radiation
Stage 0 All diagnostic studies normal, diagnosis by
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.
Femoral Neck
Stage 3 Early flattening of dome, crescent sign,
Fracture
computed tomography or tomograms may be needed.
Stage 4 Flattening of femoral head with joint space
Femoral
narrowing, possible other signs of early osteoarthritis
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.

2.

3.

Donohue, JP.UptoDate: Osteonecrosis

(avascular necorsis of bone). 2007.
Jones LC, Hungerford DS. Osteonecrosis:
etiology, diagnosis, and treatment. Curr
Opin Rheum 2004; 16: 443-449.
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.