What is the treatment for avascular necrosis of the hip?

Treatment of Avascular Necrosis of the Hip

Treatment depends on disease stage: early pre-collapse disease (stages I-II) requires protected weight-bearing, core decompression with bone substitute filling for younger patients, and bisphosphonates to prevent collapse, while late-stage disease with articular collapse (stages III-IV) necessitates total hip arthroplasty. 1, 2

Stage-Based Treatment Algorithm

Early Pre-Collapse Disease (Stages I-II)

When the articular surface remains intact on imaging:

• Protected weight-bearing is the cornerstone of management for patients showing only MRI changes without radiographic collapse 1, 2
• Weight reduction and walking aids (canes or walkers) reduce symptoms and mechanical stress on the femoral head 1, 2
• Bisphosphonates should be prescribed to prevent bone collapse in early stages 1, 2
• Core decompression with bone substitute filling is recommended for early-stage disease, particularly in younger patients who want to preserve their native joint 1
• Lesions involving less than 30% of the femoral head have less than 5% progression to collapse, making these patients excellent candidates for conservative management 1, 3

Late-Stage Disease (Stages III-IV)

When articular collapse has occurred:

• Total hip arthroplasty is necessary for late-stage AVN with articular collapse 1
• Cemented femoral fixation should be used in elderly patients with poor bone quality to reduce periprosthetic fracture risk 1, 2
• AVN causes up to one-third of all total hip arthroplasties in patients under 60 years of age 1, 2

Special Considerations for Young Adults

• For young adults with symptomatic hip AVN, especially with dysplasia or varus/valgus deformity, joint-preserving procedures such as osteotomy should be considered before proceeding to arthroplasty 1, 2
• These procedures can delay or prevent the need for total hip replacement in appropriately selected patients 2

Adjunctive Pharmacological Management

• NSAIDs and analgesics provide symptomatic pain relief but do not alter disease progression 2
• The efficacy of bisphosphonates in reducing femoral head collapse remains somewhat controversial in the literature, though guidelines support their use 1, 2, 4

Critical Prognostic Factors

• Late presentation is a major negative prognostic factor 1, 2
• Untreated AVN inevitably leads to early degenerative joint disease 1, 2
• Early diagnosis through MRI in patients with persistent hip pain but normal radiographs is essential for optimal outcomes 1, 2

Common Pitfalls to Avoid

• Do not rely on plain radiographs alone for early diagnosis—MRI is the preferred diagnostic method and should be performed bilaterally as AVN can be bilateral 1, 2
• Do not delay surgical intervention in young patients with early-stage disease who are good candidates for core decompression, as this window of opportunity closes once collapse occurs 1
• Do not assume unilateral disease—always image both hips as AVN is frequently bilateral 1, 2