What is the management for a 29-year-old male with bilateral Avascular Necrosis (AVN) of the hips, stage 3 on the left and stage 2 on the right, without a history of trauma, alcohol use, or smoking?

Management of Bilateral AVN in a Young Adult

For this 29-year-old with bilateral non-traumatic AVN (stage 3 left hip, stage 2 right hip), the right hip should undergo core decompression with or without bone grafting immediately to prevent progression, while the left hip requires total hip arthroplasty given the advanced stage with likely articular collapse. 1, 2

Immediate Diagnostic Workup

Before proceeding with treatment, identify the underlying etiology of bilateral AVN in this young patient:

• Screen for corticosteroid exposure (most common non-traumatic cause), even if patient denies use—ask specifically about inhaled steroids, topical steroids, and injections 1, 3, 4
• Obtain lipid panel to assess for hypercholesterolemia 3
• HIV testing is mandatory in bilateral AVN without obvious cause 1
• Evaluate for hematologic disorders including sickle cell disease, coagulopathies 1, 5, 6
• Assess for autoimmune conditions such as systemic lupus erythematosus 6
• Measure vitamin D levels and assess for metabolic bone disease 1

Stage-Specific Surgical Management

Right Hip (Stage 2 - Pre-Collapse)

Core decompression is the primary surgical intervention for stage 2 AVN to prevent progression to collapse 1, 2:

• Stage 2 disease has preserved articular surface, making joint-preserving procedures appropriate 1, 3
• Success rates are highest when intervention occurs before collapse 2, 5
• Consider augmentation with vascularized bone grafts or tantalum rod for enhanced outcomes 1, 4
• Electrical stimulation may be added as adjunctive therapy 2

Left Hip (Stage 3 - Post-Collapse)

Total hip arthroplasty is the treatment of choice for stage 3 AVN with articular collapse 1, 2:

• Stage 3 indicates subchondral fracture and articular surface collapse, making conservative treatment futile 1, 3
• Total hip replacement provides more consistent and durable results than bipolar hemiarthroplasty in young patients 2
• Cemented arthroplasty improves function and reduces residual pain compared to uncemented 1
• At age 29, anticipate need for revision surgery in the future, but quality of life improvement justifies intervention 2

Critical Timing Considerations

Do not delay surgical intervention—the earlier treatment begins, the better the outcomes 2, 5:

• Femoral heads with necrotic volume >30% progress to collapse in 46-83% of cases 1
• Stage 2 lesions treated conservatively have poor prognosis and will likely progress 3, 5
• Bilateral involvement (present in 70-80% of non-traumatic cases) necessitates staged procedures, typically addressing the more symptomatic/advanced side first 1

Adjunctive Medical Management

While surgery is definitive, optimize medical factors:

• Bisphosphonates may slow progression in early-stage disease, though data are limited and controversial 1, 4
• Vitamin D and calcium supplementation if deficient 1
• Lipid management with statins if hypercholesterolemia present 1
• Minimize or eliminate corticosteroids if this is the underlying cause 4
• Weight-bearing restrictions and protected ambulation until surgery 4

Common Pitfalls to Avoid

• Do not pursue "conservative" non-surgical management alone—this approach has been generally unsuccessful in non-traumatic AVN 2, 5
• Do not perform routine radiographic screening of asymptomatic joints, but if patient develops hip pain on either side, obtain MRI of both hips given high bilaterality rate 1
• Do not use bipolar hemiarthroplasty in young patients—total hip replacement is superior 2
• Do not delay imaging if new joint pain develops—multifocal AVN can involve knees (44%), ankles (17%), and shoulders (15%) 1

Postoperative Considerations

• Physical therapy or unsupervised home exercise are both acceptable after total hip arthroplasty 1
• Long-term surveillance of the contralateral hip and other joints is essential given the systemic nature of the condition 1, 3
• Address modifiable risk factors (alcohol cessation if applicable, corticosteroid minimization) to prevent additional sites of AVN 1, 3, 4