Hip

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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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.

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.

Surgical Procedure

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.

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Revision 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.

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Frequently Asked Questions

Is total hip replacement really the best option once the femoral head collapses?

Yes. Once subchondral collapse (Stage III) has occurred, the structural architecture of the femoral head cannot be reconstructed. Core decompression and vascularized grafts have failed at this stage. THA reliably restores pain-free function.

I'm only 42 — am I too young for a hip replacement?

There is no minimum age for THA. The decision is based on functional limitation, pain, and quality of life. With modern bearing surfaces and cementless fixation, implant survivorship in younger patients is excellent. Your surgeon will discuss bearing surface options tailored to your activity level and lifetime needs.

Will I need a revision surgery eventually?

Possibly — no implant lasts forever. However, with current technology, many patients in their 40s will have their original implant for 20+ years. Should revision become necessary, our team has expertise in complex revision surgery.

Does the cause of my AVN affect outcomes?

The underlying etiology does not significantly affect THA outcomes in most cases. Patients with ongoing risk factors (continued high-dose corticosteroids, active alcohol abuse) may have slightly higher complication rates; addressing these factors is important.

How long will I be on crutches after hip replacement for AVN, and when can I drive?

Most patients use a walker or crutches for two to four weeks after total hip replacement, transitioning to a cane as strength and balance improve. Full weight-bearing is typically allowed immediately after surgery with modern implant fixation techniques. Driving usually resumes at four to six weeks if surgery was on the right side and you are not taking prescription pain medication; left-sided surgery in an automatic vehicle may allow earlier return. Your MOS care team will guide you through activity milestones and monitor your recovery to ensure the implant is integrating properly before advancing your activity level.

Meet the specialists

Christopher S. Raffo, MD

Orthopedic Surgery · Sports Medicine

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James S. Gardiner, MD

Orthopedic Surgery · Sports Medicine

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Brian McCormick, MD

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Related conditions

Hip Osteoarthritis

Medically reviewed by Christopher S. Raffo, MD

Last reviewed May 1, 2026

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