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Osteonecrosis of Hip
Brady K. Huang, MD; Cheryl A. Petersilge, MD, MBA; B. J. Manaster, MD, PhD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Synonyms

              • Osteonecrosis (ON), ischemic necrosis, avascular necrosis (AVN), aseptic necrosis
                • ON is favored term
            • Definitions

              • Necrosis of cellular elements of bone most commonly 2° to ischemia

            IMAGING

            • General Features

              • Radiographic Findings

                • CT Findings

                  • MR Findings

                    • Nuclear Medicine Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Staging, Grading, & Classification

                              • Gross Pathologic & Surgical Features

                                • Microscopic Features

                                  CLINICAL ISSUES

                                  • Presentation

                                    • Demographics

                                      • Natural History & Prognosis

                                        • Treatment

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Reporting Tips

                                              Selected References

                                              1. Crim J et al: Comparison of radiographic and pathologic diagnosis of osteonecrosis of the femoral head. AJR Am J Roentgenol. 216(4):1014-21, 2021
                                              2. Mont MA et al: Nontraumatic osteonecrosis of the femoral head: where do we stand today?: a 5-year update. J Bone Joint Surg Am. 102(12):1084-99, 2020
                                              3. Yoon BH et al: The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head. J Arthroplasty. 35(4):933-40, 2020
                                              4. Large TM et al: Posttraumatic avascular necrosis after proximal femur, proximal humerus, talar neck, and scaphoid fractures. J Am Acad Orthop Surg. 27(21):794-805, 2019
                                              5. Hu LB et al: Osteonecrosis of the femoral head: using CT, MRI and gross specimen to characterize the location, shape and size of the lesion. Br J Radiol. 88(1046):20140508, 2015
                                              6. Koren L et al: Hyperbaric oxygen for stage I and II femoral head osteonecrosis. Orthopedics. 38(3):e200-5, 2015
                                              7. Lee GC et al: How do radiologists evaluate osteonecrosis? Skeletal Radiol. 43(5):607-14, 2014
                                              8. Theysohn JM et al: Hip imaging of avascular necrosis at 7 Tesla compared with 3 Tesla. Skeletal Radiol. 43(5):623-32, 2014
                                              9. Vahid Farahmandi M et al: Midterm results of treating femoral head osteonecrosis with autogenous corticocancellous bone grafting. Trauma Mon. 19(4):e17092, 2014
                                              10. Viana SL et al: MRI of subchondral fractures: a review. Skeletal Radiol. 43(11):1515-27, 2014
                                              11. Sakamoto Y et al: Osteonecrosis of the femoral head extending into the femoral neck. Skeletal Radiol. 42(3):433-6, 2013
                                              12. Weinstein RS: Glucocorticoid-induced osteonecrosis. Endocrine. 41(2):183-90, 2012
                                              13. Ikemura S et al: MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. AJR Am J Roentgenol. 195(1):W63-8, 2010
                                              14. Iwasaki K et al: Subchondral insufficiency fracture of the femoral head after liver transplantation. Skeletal Radiol. 38(9):925-8, 2009
                                              15. Min BW et al: Untreated asymptomatic hips in patients with osteonecrosis of the femoral head. Clin Orthop Relat Res. 466(5):1087-92, 2008
                                              16. Ha YC et al: Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am. 88 Suppl 3:35-40, 2006
                                              17. Ito H et al: Relationship between bone marrow edema and development of symptoms in patients with osteonecrosis of the femoral head. AJR Am J Roentgenol. 186(6):1761-70, 2006
                                              18. Huang GS et al: MR imaging of bone marrow edema and joint effusion in patients with osteonecrosis of the femoral head: relationship to pain. AJR Am J Roentgenol. 181(2):545-9, 2003
                                              19. Stevens K et al: Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol. 180(2):363-8, 2003
                                              20. Fujioka M et al: Initial changes of non-traumatic osteonecrosis of femoral head in fat suppression images: bone marrow edema was not found before the appearance of band patterns. Magn Reson Imaging. 19(7):985-91, 2001
                                              21. Zurlo JV: The double-line sign. Radiology. 212(2):541-2, 1999
                                              22. Poggi JJ et al: Changes on magnetic resonance images after traumatic hip dislocation. Clin Orthop Relat Res. (319):249-59, 1995
                                              23. Steinberg ME et al: A quantitative system for staging avascular necrosis. J Bone Joint Surg Br. 77(1):34-41, 1995
                                              24. Vande Berg BE et al: MR imaging of avascular necrosis and transient marrow edema of the femoral head. Radiographics. 13(3):501-20, 1993
                                              25. Mitchell DG et al: Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings. Radiology. 162(3):709-15, 1987
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Clinical Issues

                                                        TERMINOLOGY

                                                        • Synonyms

                                                          • Osteonecrosis (ON), ischemic necrosis, avascular necrosis (AVN), aseptic necrosis
                                                            • ON is favored term
                                                        • Definitions

                                                          • Necrosis of cellular elements of bone most commonly 2° to ischemia

                                                        IMAGING

                                                        • General Features

                                                          • Radiographic Findings

                                                            • CT Findings

                                                              • MR Findings

                                                                • Nuclear Medicine Findings

                                                                  • Imaging Recommendations

                                                                    DIFFERENTIAL DIAGNOSIS

                                                                      PATHOLOGY

                                                                      • General Features

                                                                        • Staging, Grading, & Classification

                                                                          • Gross Pathologic & Surgical Features

                                                                            • Microscopic Features

                                                                              CLINICAL ISSUES

                                                                              • Presentation

                                                                                • Demographics

                                                                                  • Natural History & Prognosis

                                                                                    • Treatment

                                                                                      DIAGNOSTIC CHECKLIST

                                                                                      • Consider

                                                                                        • Reporting Tips

                                                                                          Selected References

                                                                                          1. Crim J et al: Comparison of radiographic and pathologic diagnosis of osteonecrosis of the femoral head. AJR Am J Roentgenol. 216(4):1014-21, 2021
                                                                                          2. Mont MA et al: Nontraumatic osteonecrosis of the femoral head: where do we stand today?: a 5-year update. J Bone Joint Surg Am. 102(12):1084-99, 2020
                                                                                          3. Yoon BH et al: The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head. J Arthroplasty. 35(4):933-40, 2020
                                                                                          4. Large TM et al: Posttraumatic avascular necrosis after proximal femur, proximal humerus, talar neck, and scaphoid fractures. J Am Acad Orthop Surg. 27(21):794-805, 2019
                                                                                          5. Hu LB et al: Osteonecrosis of the femoral head: using CT, MRI and gross specimen to characterize the location, shape and size of the lesion. Br J Radiol. 88(1046):20140508, 2015
                                                                                          6. Koren L et al: Hyperbaric oxygen for stage I and II femoral head osteonecrosis. Orthopedics. 38(3):e200-5, 2015
                                                                                          7. Lee GC et al: How do radiologists evaluate osteonecrosis? Skeletal Radiol. 43(5):607-14, 2014
                                                                                          8. Theysohn JM et al: Hip imaging of avascular necrosis at 7 Tesla compared with 3 Tesla. Skeletal Radiol. 43(5):623-32, 2014
                                                                                          9. Vahid Farahmandi M et al: Midterm results of treating femoral head osteonecrosis with autogenous corticocancellous bone grafting. Trauma Mon. 19(4):e17092, 2014
                                                                                          10. Viana SL et al: MRI of subchondral fractures: a review. Skeletal Radiol. 43(11):1515-27, 2014
                                                                                          11. Sakamoto Y et al: Osteonecrosis of the femoral head extending into the femoral neck. Skeletal Radiol. 42(3):433-6, 2013
                                                                                          12. Weinstein RS: Glucocorticoid-induced osteonecrosis. Endocrine. 41(2):183-90, 2012
                                                                                          13. Ikemura S et al: MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. AJR Am J Roentgenol. 195(1):W63-8, 2010
                                                                                          14. Iwasaki K et al: Subchondral insufficiency fracture of the femoral head after liver transplantation. Skeletal Radiol. 38(9):925-8, 2009
                                                                                          15. Min BW et al: Untreated asymptomatic hips in patients with osteonecrosis of the femoral head. Clin Orthop Relat Res. 466(5):1087-92, 2008
                                                                                          16. Ha YC et al: Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am. 88 Suppl 3:35-40, 2006
                                                                                          17. Ito H et al: Relationship between bone marrow edema and development of symptoms in patients with osteonecrosis of the femoral head. AJR Am J Roentgenol. 186(6):1761-70, 2006
                                                                                          18. Huang GS et al: MR imaging of bone marrow edema and joint effusion in patients with osteonecrosis of the femoral head: relationship to pain. AJR Am J Roentgenol. 181(2):545-9, 2003
                                                                                          19. Stevens K et al: Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol. 180(2):363-8, 2003
                                                                                          20. Fujioka M et al: Initial changes of non-traumatic osteonecrosis of femoral head in fat suppression images: bone marrow edema was not found before the appearance of band patterns. Magn Reson Imaging. 19(7):985-91, 2001
                                                                                          21. Zurlo JV: The double-line sign. Radiology. 212(2):541-2, 1999
                                                                                          22. Poggi JJ et al: Changes on magnetic resonance images after traumatic hip dislocation. Clin Orthop Relat Res. (319):249-59, 1995
                                                                                          23. Steinberg ME et al: A quantitative system for staging avascular necrosis. J Bone Joint Surg Br. 77(1):34-41, 1995
                                                                                          24. Vande Berg BE et al: MR imaging of avascular necrosis and transient marrow edema of the femoral head. Radiographics. 13(3):501-20, 1993
                                                                                          25. Mitchell DG et al: Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings. Radiology. 162(3):709-15, 1987