Non-traumatic osteonecrosis of the femoral head is a potentially devastating condition, the prevalence of which is increasing. Many joint-preserving forms of treatment, both medical and surgical, have been developed in an attempt to slow or reverse its progression, as it usually affects young patients.

However, it is important to evaluate the best evidence that is available for the many forms of treatment considering the variation in the demographics of the patients, the methodology and the outcomes in the studies that have been published, so that it can be used effectively.

The purpose of this review, therefore, was to provide an up-to-date, evidence-based guide to the management, both non-operative and operative, of non-traumatic osteonecrosis of the femoral head.

Cite this article: Bone Joint J 2017;99-B:1267–79.

We present the long-term results of simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head. We followed 26 hips in 20 patients, with a mean age at the time of surgery of 36 years, for a mean of 12.5 years. The mean varus angulation was 23°.

The outcome in 19 of the hips (73%) was good or excellent; seven (27%) had a fair or poor result, with four needing some form of prosthetic arthroplasty.

Simple varus intertrochanteric osteotomy is indicated, even if the extent of the capital infarct comprises more than 50% of the diameter of maximum radial distance from the circumference, provided that after operation the medial necrotic lesion measures less than two-thirds of the weight-bearing area, and the superolateral bone is normal.

We performed a prospective study using MRI to evaluate early necrosis of the femoral head in 48 patients receiving high-dose corticosteroids for the treatment of various autoimmune-related disorders. The mean interval from the initiation of corticosteroid therapy to the first MRI examination was 2 months (0.5 to 6). MRI was repeated, and the mean period of follow-up was 31 months (24 to 69).

Abnormalities were found on MRI in 31 hips (32%). The initial changes showed well-demarcated, band-like zones which were seen at a mean of 3.6 months after initiation of treatment with steroids. In 14 of these hips (45%) there was a spontaneous reduction in the size of the lesions about one year after treatment had started, but there was no further change in size with a longer follow-up.

We present the histological findings of bone retrieved from beneath the femoral components of failed metal-on-metal hip resurfacing arthroplasties. Of a total of 377 patients who underwent resurfacing arthroplasty, 13 required revision; for fracture of the femoral neck in eight, loosening of a component in three and for other reasons in two. None of these cases had shown histological evidence of osteonecrosis in the femoral bone at the time of the initial implantation.

Bone from the remnant of the femoral head showed changes of osteonecrosis in all but one case at revision. In two cases of fracture which occurred within a week of implantation, the changes were compatible with early necrosis of the edge of the fracture. In the remaining six fractures, there were changes of established osteonecrosis. In all but one of the non-fracture cases, patchy osteonecrosis was seen.

We conclude that histological evidence of osteonecrosis is a common finding in failed resurfaced hips. Given that osteonecrosis is extensive in resurfaced femoral heads which fail by fracture, it is likely to play a role in the causation of these fractures.

Aims

One method of femoral head preservation following avascular necrosis (AVN) is core decompression and insertion of a tantalum rod. However, there may be a high failure rate associated with this procedure. The purpose of this study was to document the clinical and radiological outcomes following total hip arthroplasty (THA) subsequent to failed tantalum rod insertion.

In fifty-two knees with spontaneous osteonecrosis the diagnosis was based on a subchondral transradiancy in the weight-bearing surface of the medial femoral condyle. Strontium-85 scintimetry showed a unique pattern, indicating a lively repair reaction by localised high values. Thirteen of fifteen knees followed between two and twenty-three years developed osteoarthritis. The prognosis was based on the size of the transradiancy and the focality of the lesion as determined by scintimetry. It is suggested that scintimetry permits differentiation between primary osteoarthritis and arthritis secondary to osteonecrosis.

Objectives

We aimed to determine the effect of surgical approach on the histology of the femoral head following resurfacing of the hip.

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN.

Cite this article: Bone Joint J 2013;95-B:135-41.

A vascular necrosis (AVN) of the head of the femur is a potentially crippling disease which mainly affects young adults. Although treatment by exposure to hyperbaric oxygen (HBO) is reported as being beneficial, there has been no study of its use in treated compared with untreated patients. We selected 12 patients who suffered from Steinberg stage-I AVN of the head of the femur (four bilateral) whose lesions were 4 mm or more thick and/or 12.5 mm or more long on MRI. Daily HBO therapy was given for 100 days to each patient. All smaller stage-I lesions and more advanced stages of AVN were excluded. These size criteria were chosen in order to compare outcomes with an identical size of lesion in an untreated group described earlier. Overall, 81% of patients who received HBO therapy showed a return to normal on MRI as compared with 17% in the untreated group. We therefore conclude that hyperbaric oxygen is effective in the treatment of stage-I AVN of the head of the femur.

We studied the prognostic value of MRI in 32 radiographically normal, asymptomatic hips in 25 patients at risk of osteonecrosis from glucocorticoids or alcoholism. The early findings were band-like hypointense zones on spin-echo images. No operations were performed. Life-table survival curves showed that femoral heads in which the hypointense zone traversed the middle portion of the head were most at risk of subsequent segmental collapse.

We report the outcome of 39 patients who underwent a modified Pauwels’ intertrochanteric osteotomy for nonunion of a femoral neck fracture following failed osteosynthesis. There were 31 men and eight women with a mean age of 47.2 years (34 to 59). By Pauwels’ classification, there were 11 Type II fractures and 28 Type III fractures. The mean follow-up was 7.9 years (2 to 19). In the 11 patients whose initial treatment had been osteotomy, union was achieved in nine (81.8%). In 28 patients whose initial treatment had been with a lag screw or a dynamic hip screw, union was achieved in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients (87.5%) with pre-operative shortening. The mean neck-shaft angle improved significantly from 100.5° (80° to 120°) to 131.6° (120° to 155°) (p = 0.004). The mean modified Harris hip score was 85.6 points (70 to 97) and the mean modified Merle d’Aubigné score was 14.3 (11 to 18). Good to excellent functional outcomes were achieved in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy is a reliable method of treating ununited fractures of the femoral neck following failed osteosynthesis: coxa vara and shortening can also simultaneously be addressed.

Cite this article: Bone Joint J 2014;96-B:1198–1201.

The new Ionising Radiation (Medical Exposure) Regulations 2000 (IR (ME)ER) were implemented in January 2001. These regulations state that “the referrer must record in the patient’s notes that a radiograph was taken and what it showed”. As a result it is now incumbent upon the orthopaedic surgeon to document formally the findings of all requested radiographs. We present a case in which a left upper bronchial carcinoma was detected initially on a radiograph of the left shoulder. It highlights the importance of careful examination of the entire radiographic image and the documenting of the findings.

A 59-year-old woman with calcific tendinitis in her right shoulder underwent extracorporeal shock-wave lithotripsy. Three years and four months later she presented with osteonecrosis of the head of the right humerus. It is known that shock waves in patients with urological disorders can damage blood vessels. A possible reason for the development of osteonecrosis in this patient may have been damage to the blood supply of the head of the humerus.