Osteonecrosis of the femoral head

Last updated: April 3, 2023

Summarytoggle arrow icon

Osteonecrosis of the femoral head is a consequence of insufficient vascular supply to the femoral head. Most cases are either idiopathic or associated with alcohol, corticosteroid therapy, or trauma. The condition manifests with groin pain, which may radiate to the knee or ipsilateral buttock, and a limited range of motion at the hip. Diagnosis is based on x-ray, followed by MRI. No curative treatments have been identified and there is no consensus on the best treatment options. Initial nonsurgical treatment focuses on preventing collapse of the femoral head, but surgical treatment is commonly required. Core decompression may improve the prognosis in early stages. If the disease progresses, arthroplasty may be necessary.

For avascular necrosis of the femoral head in children, see “Legg-Calvé-Perthes disease.”

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Though often idiopathic, several traumatic and atraumatic factors may contribute to the development of osteonecrosis.

ASEPTIC: Alcohol, Sickle cell disease/SLE, Exogenous steroid, Pancreatitis, Trauma, Infection, Caisson disease (decompression sickness)

Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Consider osteonecrosis in patients presenting with groin pain and a history of corticosteroid use or alcohol use disorder.

Diagnosticstoggle arrow icon

Diagnostic studies are used to rule out other causes of hip pain and allow for early detection and implementation of treatments to prevent and/or slow disease progression. [4]

Imaging [5][6]

In patients with sickle cell anemia and osteonecrosis of the hip, consider evaluating for osteonecrosis of other joints. [9]


There are several staging systems for osteonecrosis of the femoral head; in general, the following four important findings are used to assess severity:

  • Evidence of bone collapse or impending bone collapse
  • Size of the necrotic component
  • Amount of femoral head depression
  • Acetabular involvement

Treatmenttoggle arrow icon

Nonoperative management can provide relief in early stages of the disease, but operative treatment is usually necessary for most patients.

  • Nonoperative management: for symptomatic relief in early disease stages and patients who are not surgical candidates [4][6][8]
  • Surgical treatment: may improve prognosis if performed in early stages [4][8][10]

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. WEATHERSBY HT. The origin of the artery of the ligamentum teres femoris.. J Bone Joint Surg Am. 1959; 41-A (2): p.261-3.
  2. Moya-Angeler J, Gianakos AL, Villa JC et al. Current concepts on osteonecrosis of the femoral head. World J Orthop. 2015; 6 (8): p.590-601.doi: 10.5312/wjo.v6.i8.590 . | Open in Read by QxMD
  3. Babis GC, Sakellariou V, Parvizi J, Soucacos P. Osteonecrosis of the femoral head. Orthopedics. 2011; 34 (1): p.39-48.doi: 10.3928/01477447-20101123-19 . | Open in Read by QxMD
  4. Sherman SC. Simon's Emergency Orthopedics, 8th edition. McGraw Hill Professional ; 2018
  5. Ha AS, Chang EY, Bartolotta RJ, et al. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol. 2022; 19 (11): p.S409-S416.doi: 10.1016/j.jacr.2022.09.009 . | Open in Read by QxMD
  6. Konarski W, Poboży T, Śliwczyński A, et al. Avascular Necrosis of Femoral Head—Overview and Current State of the Art. Int J Environ Res Public Health. 2022; 19 (12): p.7348.doi: 10.3390/ijerph19127348 . | Open in Read by QxMD
  7. Choi HR, Steinberg ME, Y. Cheng E. Osteonecrosis of the femoral head: diagnosis and classification systems. Current Reviews in Musculoskeletal Medicine. 2015; 8 (3): p.210-220.doi: 10.1007/s12178-015-9278-7 . | Open in Read by QxMD
  8. Chang C, Greenspan A, Beltran J, Gershwin ME. Osteonecrosis. Kelley and Firestein's Textbook of Rheumatology. 2017: p.1764-1787.e5.doi: 10.1016/b978-0-323-31696-5.00103-0 . | Open in Read by QxMD
  9. Flouzat-Lachaniete CH, Roussignol X, Poignard A, Mukasa MM, Manicom O, Hernigou P. Multifocal Joint Osteonecrosis in Sickle Cell Disease. The Open Orthopaedics Journal. 2009; 3 (1): p.32-35.doi: 10.2174/1874325000903010032 . | Open in Read by QxMD
  10. Larson E, Jones LC, Goodman SB, Koo K-H, Cui Q. Early-stage osteonecrosis of the femoral head: where are we and where are we going in year 2018?. Int Orthop. 2018; 42 (7): p.1723-1728.doi: 10.1007/s00264-018-3917-8 . | Open in Read by QxMD

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