C/o pain hip, no trauma
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hip X-ray avascular necrosis femoral head AP lateral view
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avascular necrosis femoral head radiographic findings classification management
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Patient: V. Aruna Kumari, 56Y F | Right Hip AP + Lateral | No trauma
Radiological Findings
On both the AP and lateral views:
- Subchondral sclerosis and cystic lucencies in the right femoral head — patchy heterogeneous density
- Flattening and early collapse of the superior weight-bearing surface of the femoral head — loss of normal spherical contour
- Crescent sign suggested on the AP view (subchondral lucency below the articular cortex)
- Joint space appears relatively preserved at this stage — no significant secondary OA yet
- No fracture line, no periosteal reaction, no osteolytic lesion
- Acetabulum appears intact
Diagnosis
Avascular Necrosis (AVN) / Osteonecrosis of the Femoral Head — Right side
Likely Ficat-Arlet Stage II–III (radiographic changes present: sclerosis, cysts, early head collapse, but joint space relatively maintained).
Etiology — No Trauma Context
In a 56-year-old female with no history of trauma, the non-traumatic causes to consider:
| Risk Factor | Comment |
|---|---|
| Corticosteroid use | Most common non-traumatic cause |
| Alcohol excess | Second most common |
| Sickle cell disease | Vascular occlusion |
| SLE / connective tissue disease | Often steroid-mediated |
| Hypothyroidism / dyslipidemias | Lipid emboli theory |
| Idiopathic | ~20% of cases |
Ficat-Arlet Staging (Radiographic)
| Stage | X-ray Findings |
|---|---|
| I | Normal |
| II | Sclerosis / cysts, normal head shape |
| III | Crescent sign, early head flattening/collapse |
| IV | Collapse + joint space narrowing + acetabular changes |
This case fits Stage II–III.
Further Workup
- MRI hip (bilateral) — gold standard for early staging, assess contralateral hip (bilateral in ~50% of cases)
- CBC, LFTs, lipid profile, serum cortisol if steroid use suspected
- Haemoglobin electrophoresis if sickle cell suspected
- ANA/anti-dsDNA if autoimmune suspected
Management (Stage III)
- Non-surgical (adjunctive): Bisphosphonates, statins, anticoagulants (limited evidence)
- Surgical:
- Core decompression ± bone grafting — if pre-collapse or early collapse (Stage II–IIIA)
- Osteotomy — to off-load necrotic segment
- Total Hip Arthroplasty (THA) — definitive treatment once significant collapse/OA occurs (Stage III–IV)
At 56 years and Stage II–III, core decompression with or without structural bone grafting or THA depending on the extent of collapse on MRI would be the next decision point.
Key action: Order bilateral hip MRI to confirm staging and assess the left hip before planning intervention. (Bailey & Love's Surgery, 28th Ed., p. 572)
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