From the Guidelines
The patient's condition, which includes avascular necrosis of the left hip, marrow edema, stress fractures at the femoral head, a severe labral tear, and multiple femoral neck stress fractures, requires immediate medical attention and a comprehensive treatment plan.
Treatment Options
- Core decompression can be performed to prevent articular collapse and delay or prevent the need for joint replacement, as suggested by 1.
- Percutaneous screw fixation may be necessary for lateral tension-type femoral neck stress fractures, which are inherently unstable and prone to displacement, as mentioned in 1.
- Non–weight-bearing regimen can be used to treat medial compression-type femoral neck stress fractures, which are considered low-risk, as stated in 1.
- Resurfacing hemiarthroplasty or total joint arthroplasty may be needed for late-stage femoral or humeral head osteonecrosis with articular collapse, as discussed in 1.
- MRI is the preferred second-line study after initial negative radiographs to prevent delayed diagnosis of high-risk fractures in the femoral head and neck, as recommended in 1.
Considerations
- The patient's history of gout and physically fit status as a CrossFit athlete should be taken into account when developing a treatment plan, as these factors may impact the patient's overall health and recovery.
- Normal laboratory results and electrocardiogram (ECG) suggest that the patient does not have any underlying conditions that may affect treatment, as mentioned in the patient's history.
- The patient's age (60 years) and severe labral tear should be considered when evaluating the risk of osteonecrosis and stress fractures, as older adults are more prone to these conditions, as discussed in 1.
From the Research
Treatment Options for Avascular Necrosis and Related Conditions
The treatment options for a 60-year-old male with avascular necrosis of the left hip, marrow edema, and stress fractures at the femoral head, also presenting with a severe labral tear and multiple femoral neck stress fractures, can be considered based on the following:
- Conservative treatment is recommended in the earlier stages of avascular necrosis (stage I and II of the Arlet and Ficat classification), where the joint surface is preserved 2.
- For patients with advanced disease (stage III and IV of the Arlet and Ficat classification), where the articular surface collapses, joint arthroplasty is the main treatment 2.
- Non-surgical methods, including pharmacotherapy and physiotherapy, are dedicated to patients in the early pre-collapse stages of the disease 3.
- Surgery is recommended for patients with advanced disease 3.
- Arthroscopic treatment of labral tears in patients aged 60 years or older should be approached with caution, as the 2-year survivorship rate is 70%, and patients should be counseled on the possibility of subsequent conversion to total hip arthroplasty (THA) 4.
Considerations for Femoral Neck Stress Fractures
- Prompt diagnosis and treatment of femoral neck stress fractures are crucial to prevent long-term functional deficit and avascular necrosis of the femoral head 5.
- The risk of avascular necrosis following femoral neck fractures is generally high, especially in patients with displaced fractures 6.
- The time from injury to surgery does not correlate with avascular necrosis incidence 6.
Considerations for Labral Tears
- Patients aged 60 years or older with poor preoperative patient-reported outcome scores, high pain scores, radiographic evidence of borderline dysplasia, and severe chondral damage may be poor candidates for hip arthroscopy 4.
- Arthroscopic treatment of labral tears in patients aged 60 years or older can result in significant improvements in patient-reported outcome scores and pain scores, but the reoperation rate is high (37%) 4.