AVN of Femoral Head (Advanced / Reconstruction)
Avascular necrosis (AVN) of the femoral head (also called osteonecrosis) begins when the blood supply to the femoral head is disrupted, causing bone cells to die. In early stages, hip-preservation procedures such as core decompression or free vascularized fibular grafting can halt progression. But when the disease advances to Stage III or IV, the subchondral bone collapses and the articular surface is irreparably damaged. At this point, total hip arthroplasty (THA) becomes the definitive treatment, reliably eliminating pain and restoring function. Maryland Orthopedic Specialists' Adult Reconstruction team has extensive experience managing advanced AVN, including the unique considerations for the often-younger patient population this disease affects.
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Schedule an appointment with a specialist experienced in treating avn of femoral head (advanced / reconstruction).
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What is avn of femoral head (advanced / reconstruction)?
Osteonecrosis of the femoral head is classified by the Ficat-Arlet and ARCO (Association Research Circulation Osseous) systems: - Stage I–II: MRI-visible changes without collapse; hip-preservation appropriate. - Stage III: Subchondral collapse (the "crescent sign" on X-ray) indicating failure of the supporting trabecular bone.
Osteonecrosis of the femoral head is classified by the Ficat-Arlet and ARCO (Association Research Circulation Osseous) systems:
- Stage I–II: MRI-visible changes without collapse; hip-preservation appropriate.
- Stage III: Subchondral collapse (the "crescent sign" on X-ray) indicating failure of the supporting trabecular bone. Pain escalates significantly.
- Stage IV: Collapse of the femoral head with secondary acetabular cartilage loss; frank osteoarthritis. Hip preservation is no longer feasible.
Common risk factors include corticosteroid use, alcohol abuse, sickle cell disease, systemic lupus erythematosus, hypercoagulable states, Gaucher disease, and prior hip trauma or dislocation. In a substantial proportion of cases, no cause is identified (idiopathic).
Advanced AVN disproportionately affects patients in their 30s–50s (considerably younger than the typical primary osteoarthritis population), which has major implications for implant selection, bearing surface choice, and long-term planning.
Symptoms — do you recognize these?
- Deep groin pain, often with radiation to the anterolateral thigh
- Sudden worsening of pain at the time of subchondral collapse
- Antalgic gait (limp)
- Progressive loss of hip range of motion, particularly internal rotation and abduction
- Pain at rest and with sleep in advanced disease
Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations.
How we diagnose it
- Plain radiographs: Weight-bearing AP pelvis and lateral hip views confirm collapse (crescent sign at Stage III; flattening and acetabular involvement at Stage IV).
- MRI: The gold standard for early diagnosis (Stage I–II) and for characterizing lesion size and extent. By Stage III–IV, diagnosis is typically apparent on X-ray.
- CT scan: Provides three-dimensional detail of femoral head morphology and acetabular involvement, essential for pre-operative templating in cases with significant deformity.
- Staging: Formal ARCO staging guides treatment planning and allows for meaningful communication about prognosis.
- Laboratory studies: CBC, ESR, CRP, and hip aspiration when infection must be excluded pre-operatively.
Treatment options
Hip-Preservation (Stages I–II Only)
Core decompression, bone grafting, and free vascularized fibular graft are appropriate only before subchondral collapse. Once Stage III is confirmed, these procedures carry very low success rates and are generally not indicated.
Total Hip Arthroplasty (Hip Replacement)
Complete hip joint replacement removing the arthritic femoral head and acetabulum and replacing them with metal, ceramic, and polyethylene components. Anterior approach technique is available for eligible patients, preserving more muscle tissue.
Click for more Surgical ProcedureRevision Hip Arthroplasty
Surgical revision of a failed hip replacement, addressing worn components, loosening, instability, or periprosthetic infection. Requires specialized revision implant systems and reconstruction techniques beyond primary replacement.
Click for moreRecovery & rehabilitation
Recovery from THA for advanced AVN follows the same modern rapid-recovery protocol as THA for osteoarthritis:
- Immediate weight-bearing as tolerated
- Outpatient or 23-hour discharge for medically appropriate patients
- Physical therapy beginning on the day of surgery
- Return to light activity: 4–6 weeks
- Return to full recreational activity: 3–6 months
Patients with sickle cell disease or other systemic conditions require careful perioperative medical management, including hematology consultation.
Long-term outcomes: Published data from multiple large series demonstrate THA survivorship for AVN comparable to THA for primary osteoarthritis (approximately 85–95% at 15–20 years) when modern cementless implants and HXLPE or ceramic bearings are used. Earlier series using older bearing technologies showed inferior results in younger patients; this concern is substantially mitigated by current implants.
Frequently Asked Questions
Is total hip replacement really the best option once the femoral head collapses?
I'm only 42. Am I too young for a hip replacement?
Will I need a revision surgery eventually?
Does the cause of my AVN affect outcomes?
How long will I be on crutches after hip replacement for AVN, and when can I drive?
Meet the specialists
John J. Christoforetti, MD
Orthopedic Surgery · Sports Medicine · Hip, Knee & Shoulder Arthroscopy · Shoulder Replacement
Meet Dr. Christoforetti →Related conditions
References
- Mont MA, Pivec R, Banerjee S, Issa K, Elmallah RK, Jones LC. High-dose corticosteroid use and risk of hip osteonecrosis: meta-analysis, systematic review, and evidence-based recommendation. J Arthroplasty. 2015;30(9):1650–1655. https://doi.org/10.1016/j.arth.2015.03.036
- Johannson HR, Zywiel MG, Marker DR, Jones LC, McGrath MS, Mont MA. Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop. 2011;35(4):465–473. https://doi.org/10.1007/s00264-010-1086-3
- Beaule PE, Dorey FJ, Patterson B, Amstutz HC. Poor eight to sixteen-year survivorship of metal-on-metal surface arthroplasties with femoral head osteonecrosis. J Bone Joint Surg Am. 2004;86(6):1153–1161. https://doi.org/10.2106/00004623-200406000-00004
- Hernigou P, Hernigou J. Femoral head osteonecrosis: from the risk factors to the surgical treatment. J Clin Orthop Trauma. 2020;11(1):19–25. https://doi.org/10.1016/j.jcot.2019.10.007
- American Academy of Orthopaedic Surgeons. Osteonecrosis of the Hip. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/osteonecrosis-of-the-hip/
- Ragab AA, Kraay MJ, Goldberg VM. Clinical and radiographic outcomes of total hip arthroplasty with insertion of an anatomically designed femoral component without cement for the treatment of osteonecrosis of the femoral head. J Bone Joint Surg Am. 1999;81(2):210–218. https://doi.org/10.2106/00004623-199902000-00009