Femoral-head osteonecrosis

Early avascular necrosis of the femoral head. Patchy sclerosis seen within the superior aspect of the femoral head. Corresponding signal abnormality seen on the coronal STIR MRI (arrowheads).

Femoral-head osteonecrosis


  • Occurs most commonly in the 20–50 age group.
  • Bilateral: 50% of idiopathic cases, or 80% in steroid-induced cases.
  • Commonly seen following intracapsular fractures of the femoral neck. Increased risk if displaced (up to 80%).
  • Risk factors: steroid use, alcohol abuse, metabolic disease (e.g. Gaucher’s disease), vasculitis (SLE), sickle cell disease, occupational causes (e.g. deep sea divers – caisson disease), venous thromboembolism and bone-marrow transplant.

Clinical features

  • Classically present with pain of insidious onset.
  • Pain often worse at night.
  • Pain is usually severe but may become more bearable after several weeks.

Radiological features

  • The initial radiograph if taken early may be normal.
  • The affected bone becomes sclerotic with later collapse and remodelling.
  • Ficat staging (1968 Ficat and Arlet).
    • 0 – pre-clinical – not included in original classification – normal X-ray and MRI.
    • 1 – pre-radiological – pain, normal X-ray, early MR changes.
    • 2 – sclerosis on X-ray but congruent head.
    • 3 – flattened head with crescent sign.
    • 4 – secondary degenerative changes.


  • Remove any causative factors.
  • Management is targeted towards preservation/restoration of vascularity where possible, or reconstruction in late disease.
  • Techniques used in each disease stage include:
    • 1 – core decompression.
    • 2 – core decompression and strut graft (free or vascularised).
    • 3 – strut graft/total hip replacement.
    • 4 – total hip replacement.


James R. D. M., Erskine J. H., Rakesh R. M. (2008). Musculoskeletal Radiology. A-Z Musculoskeletal and Trauma Radiology, 1st edition, Cambridge University Press, Cambridge, 1, 1-176.


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