• Thorsten M. Seyler
  • David Marker
  • Michael A. Mont


  • Osteonecrosis or vascular necrosis refers to the final result of a number of different pathways leading to bone death and ultimately to joint destruction. The femoral head is the most common site of osteonecrosis.

  • Osteonecrosis develops bilaterally in more than 80% of cases. Besides the hip, the most common sites for necrosis are knees, shoulders, ankles, and elbows. ■ The most common risk factors for osteonecrosis are glucocorticoid use, excessive alcohol consumption, and cigarette smoking.

  • The fi rst symptom associated with the disease is typically a deep, throbbing groin pain. This pain, usually intermittent and of gradual onset, occasionally appears abruptly.

  • A variety of non-operative treatment interventions are available at some centers, including vasodilators, lipid-lowering agents, prostacyclin analogues, various types of anticoagulants, bisphosphonates, hyperbaric oxygen therapy, and extracorpeal shock wave therapy. Rigorous data on the effi cacy of these approaches are currently not available.

  • There are currently four general categories of operative treatment options aimed toward preserving the femoral head and delaying (or preventing) total arthroplasty: (1) core decompression; (2) osteotomy; (3) nonvascularized bone grafting; and (4) vascularized bone grafting.

  • ■ Many patients eventually undergo total joint arthroplasty or resurfacing arthroplasty.


Femoral Head Total Joint Arthroplasty Extracorpeal Shock Wave Therapy Core Decompression Shock Wave Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME. Pathogenesis and natural history of ON. Semin Arthritis Rheum 2002;32:94–124.PubMedGoogle Scholar
  2. 2.
    Levin D, Norman D, Zinman C, Misselevich I, Reis DN, Boss JH. Osteoarthritis-like disorder in rats with vascular deprivation-induced necrosis of the femoral head. Pathol Res Pract 1999;195:637–647.PubMedGoogle Scholar
  3. 3.
    Atsumi T, Kuroki Y, Yamano K. A microangiographic study of idiopathic ON of the femoral head. Clin Orthop 1989:186–194.Google Scholar
  4. 4.
    Kikkawa M, Imai S, Hukuda S. Altered postnatal expression of insulin-like growth factor-I (IGF-I) and type X collagen preceding the Perthes disease-like lesion of a rat model. J Bone Miner Res 2000;15:111–119.PubMedCrossRefGoogle Scholar
  5. 5.
    Jones LC, Hungerford DS. Osteonecrosis: etiology, diagnosis, and treatment. Curr Opin Rheumatol 2004;16:443–449.PubMedCrossRefGoogle Scholar
  6. 6.
    Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 1995; 77:459–474.PubMedGoogle Scholar
  7. 7.
    Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am 2006;88:1117–1132.PubMedCrossRefGoogle Scholar
  8. 8.
    Koo KH, Kim R, Kim YS, et al. Risk period for developing osteonecrosis of the femoral head in patients on steroid treatment. Clin Rheumatol 2002;21:299–303.PubMedCrossRefGoogle Scholar
  9. 9.
    Liu YF, et al. Type II collagen gene variants and inherited osteonecrosis of the femoral head. N Engl J Med 2005; 352:2294–2301.PubMedCrossRefGoogle Scholar
  10. 10.
    Mont MA, Marulanda GA, Jones LC, et al. Systemic analysis of classifi cation systems of osteonecrosis of the femoral head. J Bone Joint Surg Am. 2006;88(Suppl 3):126–130.Google Scholar
  11. 11.
    Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop 1996:169–178.Google Scholar
  12. 12.
    Mont MA, Tomek IM, Hungerford DS. Core decompression for avascular necrosis of the distal femur: long term followup. Clin Orthop 1997:124–130.Google Scholar
  13. 13.
    Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop 2004:131–138.Google Scholar
  14. 14.
    Mont MA, Seyler TM, Marker DR, Marulanda GA, Delanois RE. Use of metal-on-metal total hip resurfacing for osteonecrosis of the femoral head: an analysis of 42 hips compared to osteoarthritis. J Bone Joint Surg Am. 2006;88(Suppl 3):90–97.PubMedCrossRefGoogle Scholar
  15. 15.
    Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop 2001: 173–178.Google Scholar
  16. 16.
    Agarwala S, Jain D, Joshi VR, et al. Effi cacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford) 2005;44:352–359.Google Scholar
  17. 17.
    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;87:2155–2159.PubMedCrossRefGoogle Scholar
  18. 18.
    Disch AC, Matziolis G, Perka C, et al. The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost. J Bone Joint Surg Br 2005;87:560–564.PubMedCrossRefGoogle Scholar
  19. 19.
    Glueck CJ, Freiberg RA, Sieve L, et al. Enoxaparin prevents progression of stages I and II osteonecrosis of the hip. Clin Orthop 2005:164-170.Google Scholar

Copyright information

© Springer Science+Business Media, LLC. 2008

Authors and Affiliations

  • Thorsten M. Seyler
    • 1
  • David Marker
    • 1
  • Michael A. Mont
    • 1
  1. 1.Rubin Institute for Advanced OrthopedicsSinai Hospital of BaltimoreBaltimoreUSA

Personalised recommendations