Use of Walking Aids for Bilateral AVN Hip
Patients with bilateral avascular necrosis of the hip should use walking aids (cane or crutches) to reduce weight-bearing stress on the affected joints, particularly in early-stage disease (pre-collapse stages I-II) where joint preservation is the primary goal. 1
Rationale for Walking Aid Use in Bilateral AVN
The American College of Rheumatology conditionally recommends that patients with symptomatic hip pathology should use walking aids when necessary to reduce mechanical stress on the joint. 1 While these guidelines specifically address osteoarthritis, the biomechanical principles apply directly to AVN, where reducing weight-bearing forces is even more critical to prevent femoral head collapse. 2
For bilateral AVN specifically, walking aids serve multiple critical functions:
Reduction of weight-bearing forces on both femoral heads, which is essential in pre-collapse stages (Arlet-Ficat stages I-II) where conservative management aims to preserve the joint surface and prevent progression. 2, 3
Pain management through mechanical unloading, which complements pharmacological approaches and may reduce the need for higher doses of analgesics. 1
Prevention of disease progression by minimizing repetitive microtrauma to the ischemic bone, though the evidence for this is based on biomechanical principles rather than high-quality trials. 3, 4
Specific Walking Aid Recommendations
For bilateral involvement, bilateral axillary crutches or a walker are biomechanically superior to a single cane, as they provide more substantial unloading of both hips simultaneously. 1 A single cane is insufficient when both hips are affected, as it can only effectively unload one side at a time.
The walking aid prescription should be integrated with:
Structured exercise programs (land-based or aquatic) that maintain cardiovascular fitness and muscle strength without excessive joint loading, as strongly recommended by the American College of Rheumatology. 1
Physical therapy supervision to ensure proper gait mechanics with assistive devices and to combine thermal agents and manual therapy with exercise. 1
Weight reduction counseling if the patient is overweight or obese, as this provides additional mechanical benefit. 1
Stage-Specific Considerations
In early-stage AVN (stages I-II with preserved joint surface):
Walking aids are part of conservative management aimed at joint preservation, combined with core decompression or other joint-preserving procedures. 2, 3
Rest and reduction of weight-bearing are fundamental conservative measures during this critical window. 4
The goal is to prevent progression to collapse (stages III-IV), where arthroplasty becomes necessary. 2
In advanced-stage AVN (stages III-IV with femoral head collapse):
Walking aids provide symptomatic relief while awaiting definitive surgical treatment (arthroplasty). 5, 2
For elderly patients with multiple comorbidities, hemiarthroplasty or total hip arthroplasty is the treatment of choice when pain and disability are sufficient. 5
Cemented femoral stems are strongly recommended in elderly patients with likely osteoporosis. 6, 7, 8
Critical Pitfalls to Avoid
Do not delay walking aid prescription while pursuing diagnostic workup or awaiting surgical consultation, as continued full weight-bearing accelerates disease progression in pre-collapse stages. 2, 3
Do not rely solely on walking aids without addressing underlying risk factors such as corticosteroid use, hypercholesterolemia, or alcohol abuse, which must be modified when possible. 2, 4
Do not prescribe a single cane for bilateral disease, as this provides inadequate bilateral unloading and may create asymmetric gait patterns that worsen outcomes. 1
Ensure proper fitting and gait training by physical therapy, as improper use of assistive devices can lead to falls, upper extremity overuse injuries, or inadequate joint protection. 1