April 19, 2020
treatment options for avascular necrosis AVN of the hip cover

Avascular Necrosis of Hip: Treatment Options

Treatment options for AVN of the hip are typically separated into operative and nonoperative management. Many factors will affect options for management. There is no definitive or clear pattern on speed of progression, which complicates decision making. It is important to rule out secondary causes of avascular necrosis of the femoral head (AVNFH) and ask historical questions about chronic steroid use, alcohol use, clotting disorders, sickle cell disease, autoimmune disease, or trauma. 

Historically, age and staging are the most important factors in regards to definitive treatment options. The goal of all forms of treatment is to maintain the patient’s anatomy as long as possible, delaying the need for arthroplasty in young patients. It is ideal to delay arthroplasty due to the possibility of one or more revision surgeries during their lifetime. Older age, severely collapsed femoral head, and arthritic patients are accepted as candidates for arthroplasty.

In general, nonoperative management studies have conflicting results. It is important to identify risk factors and treat them accordingly e.g. anticoagulation if clotting disorder is present, halt alcohol use, etc. Bisphosphonates act to slow bone resorption and treatment with this class has conflicting evidence. One uncontrolled study with 294 patients showed improvement in pain and clinical function when taking alendronate 10 mg daily. The benefit was shown at three years, but not eight years [1]. Another study with 40 patients showed less collapse [7 vs. 76 percent] while taking alendronate 70 mg weekly [2]. One two year randomized controlled trial did not find a significant difference in outcome with oral alendronate versus placebo and a 2016 meta-analysis concluded bisphosphonate therapy did not significantly reduce the progression to collapse [3-4]. 

Statins are sometimes used to treat steroid-induced AVN. One retrospective analysis reported a lower incidence of AVN in 284 patients over a seven year period that were starting chronic glucocorticoid therapy (1% compared to 3-20%) [5]. More trials are currently ongoing, but none have been significant thus far. Iloprost, which is a prostacyclin analog, was shown to have lower VAS (Visual analog scores) in patients in ARCO stages 1 and 2 over a 3 year period and is an option for treatment [6].
staging of avascular necrosis AVN of the hip

Image 1. Staging of AVN of the hip (courtesy of AAOS)

Nonpharmacologic options with overall limited evidence include electrical stimulation, hyperbaric oxygen and extracorporeal shock wave therapy (ESWT). Most studies have been prospective or retrospective, but results have been encouraging for patients in early stages (0-2 in Ficat or ARCO). There have been mild improvements in clinical and radiographic procedures with these studies [7-11]. Similar results have been found with ESWT with improvements in pain and function, but results varied in regards to radiology. Studies were similar with a smaller sample size and were uncontrolled and not blinded [11-15]. The evidence with hyperbaric oxygen is very limited and one study in 68 patients showed improvement on MRI in 88% of patients with Steinberg stages I-II AVN, along with improvement in clinical scores [16].

Platelet rich plasma (PRP) and mesenchymal stem cells (MSCs) have also been used for nonoperative treatment of AVNFH. PRP is a centrifuged fraction of plasma that is a thrombocyte concentrate; it is an autologous source of cellular growth factors that aids in and augments tissue repair along with the other cells of wound healing. MSCs are capable of enhancing tissue regeneration by differentiating into various mesenchymal phenotypes, such as osteoblasts, chondrocytes, and adipocytes [44]. They are often used in conjunction and there are very limited studies on usage without surgery. 

Pak published two case reports for 4 patients with stage IV ONFH who received treatment by the injection of a PRP and adipose derived stem cell mixture into the femoral head under ultrasound guidance, which showed the long-term improvement in pain and motion range and the regeneration of bone by MRI for at least 7 to 12 months [40-42]. In another case report from Pak et al. [43], one patient received a PRP and adipose derived stem cell mixture treatment once and PRP treatment every week for 4 weeks for subsequent treatment. Eventually, this patient displayed the complete resolution of hip pain and motion function abnormalities at a 21-month follow-up, and MRI showed significant signal changes in both the T1 and T2 views of the femoral head before and after treatment. More randomized and long term studies are needed.
In young patients, many will elect for joint preservation surgery for many reasons. Core decompression (CD) reduces the pressure in the bone, opens up the hardening zone that hinders the repair of osteonecrosis, stimulates the formation of blood vessels around the decompression tunnel, enhances the replacement of the new bone, and delays the progression of osteonecrosis . This is the most common joint preservation surgery [18]. A recent meta-analysis showed an overall success rate of 65% with higher success rates occurring with earlier stages (Fig. 1). Although there is a paucity of studies within the last 10 years assessing long-term (>10 years) outcomes, one study with 128 hips had a 10 year follow up. The hip survival rates those in Ficat stages I, II, and III of disease were 96, 74, and 35 %, respectively [23].
staging and success rate avascular necrosis AVN hip

Table 1. Staging and success rate of AVN of the hip (Adopted from [23])

More recent methods include combining CD with autologous bone marrow concentrate from the iliac crest or ex-vivo marrow. The success rate of CD with ex-vivo marrow was 74% and the success rate of CD with autologous bone was 81%. Both were higher than the overall success rate for CD alone (65%) [19]. Li et al. compared the use of bone marrow cell therapy (BMC) to core decompression alone in a meta-analysis of 4 studies of 219 total hips and demonstrated that significantly less patients in the BMC cohort required additional surgeries and/or procedures than those in the core decompression cohort [22].

Both vascularized (VBG) and non-vascularized bone grafts (NVBG) have also been used for supplementation. NVBGs can be categorized as autograft versus allograft, cancellous, and cortical. Vascularized bone grafts are categorized as free or pedicled grafts. Free vascularized bone grafts involve removal of bone from its original (donor) blood supply, transplanting it to the affected area, and anastomosing the graft to the local blood supply. Historically, free vascularized bone graft (VBG) applications for the upper extremity have included reconstructions after tumor resection, significant infections, or trauma [20]. 

Image 2. Illustration of microsurgical vascularized bone graft for hip AVN (courtesy of pennmedicine.org)

The best results have been reported with free vascularized bone grafts with 70% and 91% in two small case series and a separate review found the best results with the absence of collapse and less than age 40 [20]. Kim et al. in 2005 compared 19 patients (23 hips) who underwent free vascularized fibular graft with 19 patients (23 hips) who underwent non-vascularized fibular graft. After a mean follow-up of 4 years, the vascularized patients enjoyed significantly better increase in outcome scores (70 % increase versus 35 % in the non-vascularized group), as well as significantly decreased postoperative dome depression and rate of collapse when compared to the non-vascularized group [21].
Advanced core decompression (ACD) is a relatively new technique that allows more efficient removal of necrotic tissue from the femoral head followed by refilling of the drill hole and the defect with an injectable bone graft substitute. It was introduced within the past five years and usually used concentrated autologous bone marrow aspirate, which is osteoinductive and osteogenetic, as opposed to osteoconductive. Early results have shown similar hip survival overall, but ACD was shown to be slightly better for Steinberg stage 2 hips [24].
Transtrochanteric rotational osteotomy (TRO) has become one of the hip-preserving alternatives for AVNFH. The principle of TRO is to replace necrotic bone with healthy bone in weight-bearing area through anterior or posterior rotation after intertrochanteric osteotomy [25]. It is typically used only for small lesions with less than 15 percent involvement in which the lesion can be rotated away from a weight bearing surface. The clinical outcomes of TRO remain controversial because the promising results of several Japanese studies could not be confirmed by American and European studies [26-28]. One recent meta-analysis concluded hip survival was better in Asain populations [29].
In more advanced cases in younger patients, more limited options exist. Vascularized iliac bone grafting was combined with tantalum rods to achieve better results in large lesions and advanced stages of disease. One retrospective study with 56 hips with AVNFH (ARCO stages 2-4) were followed for 5 years. The 5-year joint-preserving success rate of entire group was 87.5%, with 95% for Association Research Circulation Osseous stage II hips, 92% for Association Research Circulation Osseous stage III hips, and 63.6% for Association Research Circulation Osseous stage IV hips. Mean Harris Hip score (clinical hip score) of the 49 hips improved significantly from 50 to 91 points. Forty-three (76.8%) of 56 hips remained stable on radiographs [30].

Total hip arthroplasty (THA) remains a mainstay in treatment with advanced disease and in developed countries it is estimated to be responsible for 5 to 12% of total hip arthroplasties. It is preferred to be done in patients older than 40 years old. Younger patients have been shown to have a greater amount of aseptic loosening, a higher rate of linear wear of the polyethylene liner and a higher rate of osteolysis. More recent techniques including a cemented stem and cementless cup have yielded excellent long-term outcomes [32]. 

Image 3. Before and after a hip replacement for AVN (courtesy of researchgate.net)

Some papers suggest that steroid-induced and alcohol-related AVN are associated with a less satisfactory outcome after THA compared with other causes of AVN [32-34] . Dorr et al identified AVN, especially alcohol-induced AVn as a negative prognostic indicator in patients younger than 40 years of age who were treated with THA [34]. Kim et al compared the results of 50 third-generation cemented femoral components and 98 second-generation cementless femoral components in 98 patients with AVn with a mean age of 47.3 years [36]. The survival rate with revision as an endpoint was 98% for both groups at 10 years. The same authors, in a study with the use of a ceramicon-ceramic bearing in 93 cementless THAs in 64 patients with AVN younger than 45 years old, reported no revision or loosening after a mean follow-up of 11.1 years [37]. More recently, studies have focused on long term effects and quality of life with ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene and traditional metal on polyethylene. Functional outcomes, complication rate, radiographic results and quality of life have shown similar outcomes with a slightly higher complication rate due to wear with metal on polyethylene [38-39].
In summary, many factors have to be taken into account when determining treatment options. Some providers will order laboratory studies to help guide treatment. Most patients below 40 years old without femoral head collapse will elect for nonoperative or joint preserving surgery. Nonoperative management including pharmacologic options have had mixed success, but have been shown to be safe. Core decompression is typically paired with either bone grafting or cell therapy and has generally yielded better results when compared to core decompression alone. In patients with advanced stages or osteoarthritis, total hip arthroplasty remains a mainstay in treatment. There are newer techniques such as advanced core decompression and hip arthroplasty using different components that have shown promise.


1. 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.
2. 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.
3. 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.
4. 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.
5. Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop Relat Res 2001; :173
.6. 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(1):6150. Published 2016 Mar 31. doi:10.4081/or.2016.6150
7. Wang CJ, Huang CC, Yip HK, Yang YJ. Dosage effects of extracorporeal shockwave therapy in early hip necrosis. Int J Surg 2016; 35:179
8. 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.
9. Camporesi EM, Vezzani G, Bosco G, et al. Hyperbaric oxygen therapy in femoral head necrosis. J Arthroplasty 2010; 25:118.
10. Koren L, Ginesin E, Melamed Y, et al. Hyperbaric oxygen for stage I and II femoral head osteonecrosis. Orthopedics 2015; 38:e200
11. Cebrian JL, Milano GL, Francis A, Lopiz Y, Marco F, Lopez-Duran L. Role of electromagnetic stimulation in the treatment of osteonecrosis of the femoral head in early stages. J Biomed Sci Eng. 2014:252–7.
12. Bassett CA, Schink-Ascani M, Lewis SM. Effects of pulsed electromagnetic fields on Steinberg ratings of femoral head osteonecrosis. Clin Orthop Relat Res. 1989;246:172–185.
13. F. Gao, W. Sun, Z. Li et al., “High-Energy Extracorporeal Shock Wave for Early Stage Osteonecrosis of the Femoral Head: A Single-Center Case Series,” Evidence-Based Complementary and Alternative Medicine, vol. 2015, 2015.
14. C.-J. Wang, C.-C. Huang, J.-W. Wang, T. Wong, and Y.-J. Yang, “Long-term results of extracorporeal shockwave therapy and core decompression in osteonecrosis of the femoral head with eight- to nine-year follow-up,” Biomedical Journal, vol. 35, no. 6, pp. 481–485, 2012.
15. J. Y. Lee, J. W. Kwon, J. S. Park et al., “Osteonecrosis of Femoral Head Treated with Extracorporeal Shock Wave Therapy: Analysis of Short-term Clinical Outcomes of Treatment with Radiologic Staging,” in Hip & pelvis, pp. 250–257, 2015.
16. Koren L, Ginesin E, Melamed Y, Norman D, Levin D, Peled E (2015). Hyperbaric oxygen for stage I and II femoral head osteonecrosis. Orthopedics 38: e200–e205.
17. Steinberg ME, Larcom P, Strafford B, Hosick WB, Corces A, Bands RE, et al. Treatment of osteonecrosis of the femoral head by Core decompression, bone grafting, and electrical stimulation. UPOJ. 1997;10:24–29
18. Pierce TP, Jauregui JJ, Elmallah RK, Lavernia CJ, Mont MA, Nace J. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 2015;8(3):228–232. doi:10.1007/s12178-015-9280-0
19. Fairbank AC, Bhatia D, Jinnah RH, Hungerford DS. Long-term results of core decompression for ischaemic necrosis of the femoral head. J Bone Joint Surg. 1995;77(1):42.
20. Zuo W, Sun W, Zhao D, Gao F, Su Y, et al. (2016) Correction: Investigating Clinical Failure of Bone Grafting through a Window at the Femoral Head Neck Junction Surgery for the Treatment of Osteonecrosis of the Femoral Head. PLOS ONE 11(7): e0160163
21. Li X, Xu X, Wu W. Comparison of bone marrow mesenchymal stem cells and core decompression in treatment of osteonecrosis of the femoral head: a meta-analysis. Int J Clin Exp Pathol. 2014;7(8):5024.
22. Hua, K., Yang, X., Feng, J. 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 14, 306 (2019). https://doi.org/10.1186/s13018-019-1359-7
23. 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(1):479. Published 2017 Nov 21. doi:10.1186/s12891-017-1811-y
24. Kim SY, Kim YG, Kim PT, Ihn JC, Cho BC, Koo KH. Vascularized compared with nonvascularized fibular grafts for large osteonecrotic lesions of the femoral head. J Bone Joint Surg Am. 2005;87(9):2012–2018. doi: 10.2106/JBJS.D.02593
25. Sugioka Y. Transtrochanteric anterior rotational osteotomy for the femoral head in the treatment of osteonecrosis affecting the hip: a new osteotomy operation. Clin Orthop Relat Res1978; 130:191–201.
26. Belal MA, Reichelt A. Clinical results of rotational osteotomy for treatment of avascular necrosis of the femoral head. Arch Orthop Trauma Surg 1996; 115:80–84. doi: 10.1007/bf00573446.
27. Inao S, Ando M, Gotoh E, Matsuno T. Minimum 10-year results of Sugioka’s osteotomy for femoral head osteonecrosis. Clin Orthop Relat Res 1999; 368:141–148.
28. Iwasada S, Hasegawa Y, Iwase T, Kitamura S, Iwata H. Transtrochanteric rotational osteotomy for osteonecrosis of the femoral head 43 patients followed for at least 3 years. Arch Orthop Trauma Surg 1997; 116:447–453. doi: 10.1007/bf00387576.
29. Xu, Ying-Xing, et al. “Hip survival rate in the patients with avascular necrosis of femoral head after transtrochanteric rotational osteotomy: a systematic review and meta-analysis.” (2019): 2960-2971.
30. D. Zhao, Y. Zhang, W. Wang, et al. Tantalum rod implantation and vascularized iliac grafting for osteonecrosis of the femoral head. Orthopedics, 36 (6) (2013 Jun), pp. 789-795
31. Hamilton TW, Goodman SM, Figgie M. SAS Weekly Rounds : Avascular necrosis. HSS J 2009 ; 5 : 99-113.
32. Kim, Young-Hoo, et al. “Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head: a concise follow-up, at an average of seventeen years, of a previous report.” JBJS 93.19 (2011): 1806-1810.
33. Chiu KH, Shen WY, Ko CK, Chan KM. Osteonecrosis of the femoral head treated with cementless total hip arthroplasty. A comparison with other diagnoses. J Arthroplasty 1997 ; 12 : 683-688.
34. Dorr LD, Kane TJ, Conaty JP. Arthroplasty in patients 45 years old or younger. A 16-year follow-up study. J Arthroplasty 1994 ; 9 : 453-456.
35. Dudkiewicz I, Covo A, Salai M et al. Total hip arthroplasty after avascular necrosis of the femoral head : does etiology affect the results ? Arch Orthop Trauma Surg 2004 ; 124 : 82-85
36. Kim YH, Choi Y, Kim JS. Cementless total hip arthroplasty with ceramic-on-ceramic bearing in patients younger than 45 years with femoral-head osteonecrosis. Int Orthop 2010 ; 34 : 1123-1127.
37. Kim YH, Oh SH, Kim JS. Primary total hip arthroplasty with a second-generation cementless total hip prosthesis in patients younger than fifty years of age. J Bone Joint Surg 2003 ; 85-A : 109-114.
38. Atrey A, Wolfstadt JI, Hussain N, Khoshbin A, Ward S, Shahid M, et al. The ideal total hip replacement bearing surface in the young patient: a prospective randomized trial comparing alumina ceramic-on-ceramic with ceramic-on-conventional polyethylene:15-year follow-up. J Arthroplast. 2018;33(6):1752–6.
39. Feng, B., Ren, Y., Cao, S. et al. Comparison of ceramic-on-ceramic bearing vs ceramic-on-highly cross-linked polyethylene-bearing surfaces in total hip arthroplasty for avascular necrosis of femoral head: a prospective cohort study with a mid-term follow-up. J Orthop Surg Res 14, 388 (2019).
40. D. van der Jagt, L. Mokete, J. Pietrzak, C. G. Zalavras, and J. R. Lieberman, “Osteonecrosis of the femoral head: evaluation and treatment,” The Journal of the American Academy of Orthopaedic Surgeons, vol. 23, no. 2, pp. 69-70, 2015.
41. J. Pak, “Autologous adipose tissue-derived stem cells induce persistent bone-like tissue in osteonecrotic femoral heads,” Pain Physician, vol. 15, no. 1, pp. 75–85, 2012.
42. J. Pak, “Regeneration of human bones in hip osteonecrosis and human cartilage in knee osteoarthritis with autologous adipose-tissue-derived stem cells: a case series,” Journal of Medical Case Reports, vol. 5, no. 1, 2011.
43. J. Pak, J. H. Lee, J. H. Jeon, and S. H. Lee, “Complete resolution of avascular necrosis of the human femoral head treated with adipose tissue-derived stem cells and platelet-rich plasma,” The Journal of International Medical Research, vol. 42, no. 6, pp. 1353–1362, 2014.
44. Han, Jun, et al. “The Use of Platelet-Rich Plasma for the Treatment of Osteonecrosis of the Femoral Head: A Systematic Review.” BioMed Research International 2020 (2020).