TREATMENT STRATEGIES FOR AVASCULAR NECROSIS OF THE FEMORAL HEAD: A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.31435/ijitss.3(51).2026.6600Keywords:
Avascular Necrosis of the Femoral Head, Non-Surgical Treatment, Surgical TreatmentAbstract
Introduction: Avascular necrosis of the femoral head (ANFH) is a progressive condition caused by impaired blood supply to the subchondral bone, leading to femoral head collapse, cartilage damage, and secondary hip osteoarthritis. Major risk factors include corticosteroid therapy, trauma, and chronic alcohol consumption. ANFH primarily affects young, active adults aged 20–40 years. MRI is essential for early diagnosis. Early detection allows hip-preserving treatment, whereas advanced disease often requires total hip arthroplasty. Without appropriate treatment, secondary degenerative changes may develop in 70–80% of patients.
Aim of the study: The aim of this review was to assess the current evidence regarding the treatment of avascular necrosis of the femoral head, with particular emphasis on non-surgical and hip-preserving surgical treatment options. The review evaluates their clinical and radiographic outcomes, effectiveness in preventing disease progression and delaying total hip arthroplasty, and identifies the most appropriate treatment strategies according to disease stage.
Methods and materials: We reviewed the literature available in the PubMed database using the following keywords: “Avascular necrosis of the femoral head”; “Non-surgical treatment”; “Bisphosphonates”; “Statins”; “Iloprost”; “Hyperbaric oxygen therapy”; “Core decompression”; “Osteotomy”; “Nonvascularized bone graft”; “Vascularized bone graft”; and “Total hip arthroplasty”.
Conclusion: The treatment of avascular necrosis of the femoral head should be tailored to disease stage and patient characteristics. Early diagnosis is crucial for enabling joint-preserving treatment and delaying disease progression. Pharmacological therapies may benefit selected patients, although their efficacy remains inconclusive. Hip-preserving surgery shows promising results, particularly in early-stage ANFH. In advanced disease with femoral head collapse, total hip arthroplasty remains the most effective treatment, improving pain, hip function, and quality of life.
References
Guerado, E., & Caso, E. (2016). The physiopathology of avascular necrosis of the femoral head: An update. Injury, 47 Suppl 6, S16–S26. https://doi.org/10.1016/S0020-1383(16)30835-X
Seijas, R., Sallent, A., Rivera, E., & Ares, O. (2019). Avascular necrosis of the femoral head. Journal of Investigative Surgery: the Official Journal of the Academy of Surgical Research, 32(3), 218–219. https://doi.org/10.1080/08941939.2017.1398282
Leonhardt, Y., & Wörtler, K. (2026). Hüftkopfnekrose [Avascular necrosis of the femoral head]. Radiologie (Heidelberg, Germany), 66(2), 100–108. https://doi.org/10.1007/s00117-025-01540-z
Mankin, H. J. (1992). Nontraumatic necrosis of bone (osteonecrosis). The New England Journal of Medicine, 326(22), 1473–1479. https://doi.org/10.1056/NEJM199205283262206
Tripathy, S. K., Goyal, T., & Sen, R. K. (2015). Management of femoral head osteonecrosis: Current concepts. Indian Journal of Orthopaedics, 49(1), 28–45. https://doi.org/10.4103/0019-5413.143911
Moya-Angeler, J., Gianakos, A. L., Villa, J. C., Ni, A., & Lane, J. M. (2015). Current concepts on osteonecrosis of the femoral head. World Journal of Orthopedics, 6(8), 590–601. https://doi.org/10.5312/wjo.v6.i8.590
Konarski, W., Poboży, T., Śliwczyński, A., Kotela, I., Krakowiak, J., Hordowicz, M., & Kotela, A. (2022). Avascular necrosis of femoral Head-Overview and current state of the art. International Journal of Environmental Research and Public Health, 19(12), 7348. https://doi.org/10.3390/ijerph19127348
Roth, A., Beckmann, J., Bohndorf, K., Fischer, A., Heiß, C., Kenn, W., Jäger, M., Maus, U., Nöth, U., Peters, K. M., Rader, C., Reppenhagen, S., Smolenski, U., Tingart, M., Kopp, I., Sirotin, I., & Breusch, S. J. (2016). S3-Guideline non-traumatic adult femoral head necrosis. Archives of Orthopaedic and Trauma Surgery, 136(2), 165–174. https://doi.org/10.1007/s00402-015-2375-7
Lai, K. A., Shen, W. J., Yang, C. Y., Shao, C. J., Hsu, J. T., & Lin, R. M. (2005). The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. The Journal of bone and joint surgery. American Volume, 87(10), 2155–2159. https://doi.org/10.2106/JBJS.D.02959
Agarwala, S., & Shah, S. B. (2011). Ten-year follow-up of avascular necrosis of femoral head treated with alendronate for 3 years. The Journal of Arthroplasty, 26(7), 1128–1134. https://doi.org/10.1016/j.arth.2010.11.010
Chen, C. H., Chang, J. K., Lai, K. A., Hou, S. M., Chang, C. H., & Wang, G. J. (2012). Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis: A two-year multicenter, prospective, randomized, double-blind, placebo-controlled study. Arthritis and Rheumatism, 64(5), 1572–1578. https://doi.org/10.1002/art.33498
Yuan, H. F., Guo, C. A., & Yan, Z. Q. (2016). The use of bisphosphonate in the treatment of osteonecrosis of the femoral head: A meta-analysis of randomized control trials. Osteoporosis International: a Journal Established as Result of Cooperation Between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 27(1), 295–299. https://doi.org/10.1007/s00198-015-3317-5
Luo, R. B., Lin, T., Zhong, H. M., Yan, S. G., & Wang, J. A. (2014). Evidence for using alendronate to treat adult avascular necrosis of the femoral head: A systematic review. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 20, 2439–2447. https://doi.org/10.12659/MSM.891123
Pritchett, J. W. (2001). Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clinical Orthopaedics and Related Research, (386), 173–178. https://doi.org/10.1097/00003086-200105000-00022
Ajmal, M., Matas, A. J., Kuskowski, M., & Cheng, E. Y. (2009). Does statin usage reduce the risk of corticosteroid-related osteonecrosis in renal transplant population? The Orthopedic Clinics of North America, 40(2), 235–239. https://doi.org/10.1016/j.ocl.2009.01.004
Disch, A. C., Matziolis, G., & Perka, C. (2005). The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost. The Journal of bone and joint surgery. British Volume, 87(4), 560–564. https://doi.org/10.1302/0301-620X.87B4.15658
Claßen, T., Becker, A., Landgraeber, S., Haversath, M., Li, X., Zilkens, C., Krauspe, R., & Jäger, M. (2016). Long-term clinical results after iloprost treatment for bone marrow edema and avascular necrosis. Orthopedic Reviews, 8(1), 6150. https://doi.org/10.4081/or.2016.6150
Salameh, M., Moghamis, I. S., Kokash, O., & Ahmed, G. O. (2021). Hyperbaric oxygen therapy for the treatment of Steinberg I and II avascular necrosis of the femoral head: A report of fifteen cases and literature review. International Orthopaedics, 45(10), 2519–2523. https://doi.org/10.1007/s00264-021-05120-3
Sen, R. K. (2009). Management of avascular necrosis of femoral head at pre-collapse stage. Indian Journal of Orthopaedics, 43(1), 6–16. https://doi.org/10.4103/0019-5413.45318
Mont, M. A., Ragland, P. S., & Etienne, G. (2004). Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clinical Orthopaedics and Related Research, (429), 131–138. https://doi.org/10.1097/01.blo.0000150128.57777.8e
Vega, J. F., Cervantes, J. E., Yee, B. F., & Nho, S. J. (2026). Core decompression for osteonecrosis of the femoral head. Video Journal of Sports Medicine, 6(1), 26350254251368924. https://doi.org/10.1177/26350254251368924
Pawar, N., Vaish, A., & Vaishya, R. (2021). Core decompression and bone marrow aspirate concentrate injection for Avascular Necrosis (AVN) of the femoral head: A scoping review. Journal of Clinical Orthopaedics and Trauma, 24, 101691. https://doi.org/10.1016/j.jcot.2021.101691
Andronic, O., Weiss, O., Shoman, H., Kriechling, P., & Khanduja, V. (2021). What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head? International Orthopaedics, 45(3), 605–613. https://doi.org/10.1007/s00264-020-04790-9
Dean, M. T., & Cabanela, M. E. (1993). Transtrochanteric anterior rotational osteotomy for avascular necrosis of the femoral head. Long-term results. The Journal of bone and joint surgery. British Volume, 75(4), 597–601. https://doi.org/10.1302/0301-620X.75B4.8331115
Langlais, F., & Fourastier, J. (1997). Rotation osteotomies for osteonecrosis of the femoral head. Clinical Orthopaedics and Related Research, (343), 110–123.
Sugioka, Y. (1978). Transtrochanteric anterior rotational osteotomy of the femoral head in the treatment of osteonecrosis affecting the hip: A new osteotomy operation. Clinical Orthopaedics and Related Research, (130), 191–201.
Atsumi, T., Kajiwara, T., Hiranuma, Y., Tamaoki, S., & Asakura, Y. (2006). Posterior rotational osteotomy for nontraumatic osteonecrosis with extensive collapsed lesions in young patients. The Journal of bone and joint surgery. American Volume, 88 Suppl 3, 42–47. https://doi.org/10.2106/JBJS.F.00767
Quaranta, M., Miranda, L., Oliva, F., Aletto, C., & Maffulli, N. (2021). Osteotomies for avascular necrosis of the femoral head. British Medical Bulletin, 137(1), 98–111. https://doi.org/10.1093/bmb/ldaa044
Banerjee, S., Issa, K., Pivec, R., Kapadia, B. H., Khanuja, H. S., & Mont, M. A. (2013). Osteonecrosis of the hip: Treatment options and outcomes. The Orthopedic Clinics of North America, 44(4), 463–476. https://doi.org/10.1016/j.ocl.2013.07.004
Seyler, T. M., Marker, D. R., Ulrich, S. D., Fatscher, T., & Mont, M. A. (2008). Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis. Clinical Orthopaedics and Related Research, 466(5), 1125–1132. https://doi.org/10.1007/s11999-008-0211-x
Keizer, S. B., Kock, N. B., Dijkstra, P. D., Taminiau, A. H., & Nelissen, R. G. (2006). Treatment of avascular necrosis of the hip by a non-vascularised cortical graft. The Journal of bone and joint surgery. British Volume, 88(4), 460–466. https://doi.org/10.1302/0301-620X.88B4.16950
Tang, C. L., Mahoney, J. L., McKee, M. D., Richards, R. R., Waddell, J. P., & Louie, B. (1998). Donor site morbidity following vascularized fibular grafting. Microsurgery, 18(6), 383–386. https://doi.org/10.1002/(sici)1098-2752(1998)18:6<383::aid-micr8>3.0.co;2-5
Aluisio, F. V., & Urbaniak, J. R. (1998). Proximal femur fractures after free vascularized fibular grafting to the hip. Clinical Orthopaedics and Related Research, (356), 192–201. https://doi.org/10.1097/00003086-199811000-00026
Vail, T. P., & Urbaniak, J. R. (1996). Donor-site morbidity with use of vascularized autogenous fibular grafts. The Journal of bone and joint surgery. American Volume, 78(2), 204–211. https://doi.org/10.2106/00004623-199602000-00006
Fang, T., Zhang, E. W., Sailes, F. C., McGuire, R. A., Lineaweaver, W. C., & Zhang, F. (2013). Vascularized fibular grafts in patients with avascular necrosis of femoral head: A systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery, 133(1), 1–10. https://doi.org/10.1007/s00402-012-1627-z
McGrory, B. J., York, S. C., Iorio, R., Macaulay, W., Pelker, R. R., Parsley, B. S., & Teeny, S. M. (2007). Current practices of AAHKS members in the treatment of adult osteonecrosis of the femoral head. The Journal of bone and joint surgery. American Volume, 89(6), 1194–1204. https://doi.org/10.2106/JBJS.F.00302
Seyler, T. M., Cui, Q., Mihalko, W. M., Mont, M. A., & Saleh, K. J. (2007). Advances in hip arthroplasty in the treatment of osteonecrosis. Instructional Course Lectures, 56, 221–233.
Pierce, T. P., Elmallah, R. K., Jauregui, J. J., Verna, D. F., & Mont, M. A. (2015). Outcomes of total hip arthroplasty in patients with osteonecrosis of the femoral head-a current review. Current Reviews in Musculoskeletal Medicine, 8(3), 246–251. https://doi.org/10.1007/s12178-015-9283-x
Kim, Y. H., Oh, S. H., Kim, J. S., & Koo, K. H. (2003). Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. The Journal of bone and joint surgery. American Volume, 85(4), 675–681. https://doi.org/10.2106/00004623-200304000-00014
Issa, K., Johnson, A. J., Naziri, Q., Khanuja, H. S., Delanois, R. E., & Mont, M. A. (2014). Hip osteonecrosis: Does prior hip surgery alter outcomes compared to an initial primary total hip arthroplasty? The Journal of Arthroplasty, 29(1), 162–166. https://doi.org/10.1016/j.arth.2013.04.028
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Paweł Grzesikowski
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
