Orthopedics-Online

Femoral head necrosis

Synonyms in a broader sense

ideopathic aseptic femoral head necrosis, HKN

definition

Femoral head necrosis is understood to mean all acquired diseases in the area of the femoral head that lead to the death of femoral head areas and / or the entire femoral head as a result of insufficient blood flow to the femoral head (= ischemia).

Femoral head necrosis usually develops in adulthood as a complication after the treatment of congenital or traumatic hip dislocation, femoral neck or pelvic fractures.
It leads to movement restrictions and severe, intermittent pain. The end stage of femoral head necrosis can be the so-called coxarthrosis (hip joint arthrosis).

Hip pain

Are you looking for the cause of your hip pain or you don't know exactly what is causing your hip pain?
Then let yourself be guided by our diagnostic Hip pain guide and come to the most likely diagnosis.

Age

usually between the ages of 35 and 45

Appointment with a hip expert?

I would be happy to advise you!

Who am I?
My name is dr. Nicolas Gumpert. I am a specialist in orthopedics and the founder of .
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The hip joint is one of the joints that are exposed to the greatest stress.
The treatment of the hip (e.g. hip arthrosis, hip impingement, etc.) therefore requires a lot of experience.
I treat all hip diseases with a focus on conservative methods.
The aim of any treatment is treatment without surgery.
Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.

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Gender distribution

male> female, up to 50% also on both sides

frequency

Occurrence approx. 1: 1000 - 1: 5000

Symptoms of femoral head necrosis

The symptoms of a Femoral head necrosis are similar in most patients, which is why conclusions can often be drawn about the disease from the symptoms.
However, the symptoms of femoral head necrosis are often very unspecific and can easily be overlooked. On the one hand, hip necrosis is more common in children. This then becomes a load-dependent one Pain in the hip joint as well as in the knee joint.
Since the pain mainly occurs when the child should and must move, the symptoms are often misinterpreted and not perceived as symptoms of femoral head necrosis, but rather as laziness. It is therefore important to pay attention to whether a previously active child suddenly no longer feels like running around or doing sports.

In adults, the symptoms are the Femoral head necrosis similar. There is also stress-related pain in either the hip or knee joint. Usually the pain occurs only on one side, namely on the side on which the femoral head necrosis occurs.
Furthermore, the femoral head necrosis leads to the symptom of Leg length difference, whereby the patient often notices that they are standing slightly crooked or that one leg has to be more angled than the other when sitting.

In general, however, the symptoms of femoral head necrosis are very unspecific and can therefore easily be overlooked. That is why it is easy on any signs Drag in the area of the bar or to watch out for sudden pain.
In addition, the patient should pay attention to whether he can cope with normal hip movements in everyday life without problems or whether he feels pain with different movements, as these can also be symptoms of femoral head necrosis.

Pain in femoral head necrosis

Femoral head necrosis often causes sudden, severe pain in the groin area.

The shooting pain typically occurs at night and at rest.
The mobility of the hip is severely restricted. Those affected have great difficulty turning or extending the leg of the affected hip joint inward.

It is not uncommon for sufferers to report pain in the knee joint.
That can be one reason why hip necrosis is sometimes misinterpreted and diagnosed late. Because of the pain, those affected adopt a typical relieving posture, a so-called "painful limp".

Duration of femoral head necrosis

The course of femoral head necrosis can look very different from person to person. Sudden self-healing is possible during stages 0 and 1, so the duration of the disease is short.

In most cases, the femoral head necrosis progresses and significantly deforms the femoral head.
Without therapy, it takes about two years for the femoral head to collapse and completely destroy the hip joint.

How long is a femoral head necrosis unable to work?

Femoral head necrosis can cause severe discomfort that increases with the stages.
It can happen that one is temporarily unable to work at a certain stage due to the complaints. In this case, surgical rehabilitation of the hip is usually indicated anyway.

After an operation for femoral head necrosis, you are typically unable to work for between six and twelve weeks, depending on the workload.

root cause

As already described in the definition, femoral head necrosis is caused by insufficient blood supply to the femoral head, medically called: ischemia. It should be said that the blood flow to the femoral head is generally to be viewed as critical from an anatomical point of view. The femoral head is supplied with blood from the femoral neck via an individually created artery. Due to the individually applied arterial supply, a so-called “deficiency” of the arterial supply of the femoral head is seen as the causal factor and decisive for the course of the disease.

In the area of femoral head necrosis, a distinction is made between:

primary (idiopathic) femoral head necrosis and
secondary femoral head necrosis

Read more about this: Causes of femoral head necrosis

While no accompanying or underlying diseases can be identified with primary femoral head necrosis and, apart from the frequent occurrence of the disease on both sides, only an increased affliction of the male sex between the ages of 35 and 45 can be proven, secondary femoral head necrosis is directly related to other diseases known. For both sub-forms, however, the cause and causality are largely unknown.

Primary (idiopathic) femoral head necrosis
Ideally, this form of femoral head necrosis affects men between the ages of 35 and 45 years. Often the disease is not limited to just one femoral head. This and the fact that the disease usually occurs during the period of maximum (professional) performance explains the often strong psychological and social stress on the patient.

Secondary femoral head necrosis
One assumes a direct connection with other diseases. The underlying causes are complex and can be based on the following diseases.
known causes:

Hip joint injuries of various types (e.g. femoral neck fracture)
Sickle cell disease (genetic, inherited blood disorder)
Caisson disease (= decompression sickness that occurs when there is a rapid drop in pressure or when staying at high altitude, also known as: Diving disease or compressed air sickness. There is a formation of nitrogen bubbles in the vascular system and as a consequence a circulatory disorder)
Gaucher's disease (hereditary sugar metabolism disease which, among other things, can lead to organ enlargement)
Lupus erythematosus (autoimmune disease with heart, liver, kidney and joints)
You can find more information on this topic at: Lupus erythematosus
Vascular diseases (e.g. thrombosis)
Connective tissue diseases
Cortisone therapy (both as a local joint injection and as a systemic therapy)
Radiation in the pelvic area
Cytostatic therapy (for tumor diseases)
rheumatic diseases
Unfavorable lifestyle habits, such as alcohol abuse

Femoral head necrosis after a femoral neck fracture

A femoral neck fracture is a common cause of femoral head necrosis in old age.
The femoral neck typically breaks as a result of an accident, often as part of a fall.

In addition to the bone fracture, femoral head vessels that run in the femoral neck close to the femoral head can be damaged.
This can lead to tissue death in the area of the femoral head.
One speaks of post-traumatic femoral head necrosis.

The picture on the left shows impaired blood flow to the femoral head in an animal. While the femoral neck appears to be vitally well supplied with blood, there is no longer any evidence of blood supply in the upper femoral head area. From a medical point of view, this “dead” area is referred to as necrotic or avital.

Risk factors

Hyperuricemia (high levels of uric acid in the blood)
Please also note our topic: Gout
Alcohol and nicotine abuse
Hyperlipidemia (too much blood lipids)

clinic

The clinical Symptoms of femoral head necrosis amount to a restriction of movement with pain occurring at intervals. The symptoms often change due to the stress and irritation of the joint. The pain can accumulate in the groin and buttocks area and radiate into the thigh or knee, causing start-up, running-in and stress pain. In more advanced stages, resting and lower back pain can also occur.

Stages of femoral head necrosis

There are four stages of femoral head necrosis.

They differentiate how far the femoral head necrosis has progressed and how much the bone has been broken down by the disease. This division of femoral head necrosis into stages helps doctors to differentiate and generalize the various processes and degrees of severity.

in the first stage of femoral head necrosis it happens that small areas of the femoral head are no longer properly supplied with blood and are therefore no longer properly supplied with nutrients. This first stage of femoral head necrosis is also called Early stage and is often associated with no noticeable symptoms.
in the second stage of femoral head necrosis it then happens that the bone is remodeled and restructured due to the insufficient supply of blood. This can often be seen well with the help of an X-ray.
in the Stage 3 of the femoral head necrosis it happens that the joint surface collapses more and more because the bone has become unstable due to the remodeling processes and can no longer hold the body's weight properly. At the latest now the patient will experience symptoms with sometimes severe pain and restrictions in the freedom of movement of the hip joint.
From the last / 4th stage of femoral head necrosis one speaks when the femoral head is completely deformed as such can no longer be properly recognized. This division of femoral head necrosis into stages is important for the diagnostics used and for the therapeutic options.

Which sports can you do with femoral head necrosis?

In the case of femoral head necrosis, you should choose sports that are painless and do not put strain on the affected hip.
Swimming and aqua jogging are ideal sports.
Nordic walking and cycling are also possible. You should refrain from sports that involve rapid starting and stopping - such as ball sports.

diagnosis

Anamnesis (medical history)
An anamnesis is carried out by taking stock in the family area, as well as by taking a personal anamnesis, in which particular attention is given to previous hip joint diseases or operations, but also to accidents, pain in other joints or metabolic diseases.

Pain:
- Localization of the pain and analysis of it with regard to radiation, duration, progression and intensity
Function restriction:
- Resilience, limping, mobility, length of the pain-free walking distance, possibly necessary walking aids, ...
Special joint history:
- Accidents, rheumatic diseases (rheumatism, chronic polyarthritis, psoriatic arthritis, possible hip joint operations, pain in other joints, metabolic diseases, ...
X-ray of the hip joint in two planes
CT (computed tomography)
MRT (magnetic resonance tomography, nuclear spin tomography)

What do you see in an MRI of the hip?

The MRI examination is of great importance in the diagnosis of femoral head necrosis, as it can show the disease in its early stages.
The MRI images show various abnormalities depending on the stage of the bone necrosis.

In the reversible early stage, the so-called ARCO 1, one sees an area of necrosis in the area of the femoral head in the MRI, while in the irreversible early stage, ARCO 2, one sees a characteristic “double-line sign”.
This sign is caused by the juxtaposition of sclerosed tissue, healthy bone and granulation tissue.
In the ARCO 3 stage, the transition stage, there is evidence of a fracture in the MRI.
In the late stage, ARCO 4, signs of osteoarthritis can be seen on the MRI, such as a narrowing of the joint space and changes in the shape of the acetabulum.

The MRI images of the hip show the areas of necrosis zones marked with the red arrow. The femoral head appears already hollowed out cystically. This gives the impression of a sub-chamber. There is a risk here that the femoral head collapses.
Read more about diagnostics on: MRI of the hip

Risks

Possible consequences and complications:

General Risks and Complications of Femoral Head Necrosis:

As with all surgical interventions, complications in the form of hematoma formation, wound healing disorders, wound infection, deep vein thrombosis, embolism, vascular injuries and nerve injuries can also occur with femoral head necrosis. General risks tend to be more common than specific complications.

Special complications:

A joint change can cause it in particular to Leg length differences come. Due to a dislocation, the muscles, especially the Glutes, claimed differently. One then speaks of one Gluteal insufficiency (= Weakness of the gluteal muscles with a typical waddling gait). The change can result in a broadening of the hip silhouette. The osteotomy does not always heal without complications, so a delay can occur. Also so-called Pseudarthroses (= Formation of wrong joints), implant failure, correction losses, pain persistence are among the special complications.

Endoprosthetic hip replacement:

In more advanced stages, the destroyed parts of the joint are surgically removed. In advanced stages of destruction of the hip joint, the destroyed parts of the joint are removed and replaced with artificial ones Hip joint improved and a pain relief is effected. Artificial hip joints run the risk of loosening over time, so that one has to rely on the endoprosthetic Hip replacement should only be considered when the destruction of the hip joint has progressed further and the patient is suffering from very severe pain.

More detailed information can be found under the heading: artificial hip joint

Follow-up treatment after surgical measures:

After taking operational action will be X-ray controls Necessary to, for example, the Osteotomy (= Change) to be able to assess or to assess the installation of the endoprosthetic hip replacement. Furthermore, a special storage as well as a targeted one is required Thrombosis prophylaxisthat must be considered in principle for every operation.

In order to strengthen the muscles or - in the case of an osteotomy - to specifically build up muscle parts, postoperative physiotherapy can be used as a follow-up treatment for femoral head necrosis. As a rule, mobilization takes place at an early stage, whereby the build-up of stress depends on the individual circumstances.

So that the dislocation of the hip joint is prevented as much as possible, especially after an endoprosthetic operation, the patient should be advised of the possibility of elevated sitting (= Dislocation prophylaxis). In this regard, permitted and unfavorable movements and loads should also be discussed.

Postoperative clinical and radiological checks and prophylaxis with regard to calcification in the muscle area should be carried out regularly hip operated, for example with medication NSAIDs (= Indomethacin) or by radiation.

Therapy of femoral head necrosis

The treatment of femoral head necrosis depends on how far the disease has progressed.
The reason why there is insufficient blood flow to the femoral head is also decisive. For example, it comes because of a high nicotine- and Alcohol consumption to femoral head necrosis, the treatment of femoral head necrosis can consist in doing without both stimulants in order to ensure adequate blood flow to the bone.

If the patient is still in stage one, the treatment for femoral head necrosis is one here Drilling most suitable. In a small operation, drilling a small canal ensures that new blood vessels are formed above the femoral head, which then ensure that the bone is supplied with sufficient blood again and is therefore not broken down.
At a more advanced stage, advanced therapy for femoral head necrosis must be sought. In this case, the bone may have to be cut in a major operation (Osteotomy) so that it can then be reassembled adequately and can support the weight of the hip.

Drilling can also be used as a therapy for femoral head necrosis in an advanced stage. Another possibility of therapy for femoral head necrosis is the Reversal sculptures and Cancellous bone fillings. However, since reverse plastic surgery has only been performed very rarely, patients at an advanced stage are more likely to resort to one Hip prosthesis as Therapy of femoral head necrosis back because this ensures that the patient can fully insert the hip again within a few weeks without feeling pain.

Read more on the topic: Treatment of femoral head necrosis

Step-by-step scheme of therapeutic approach

Orientation criteria

Necrosis stage, extent of necrosis, etiology of femoral head necrosis (cause), pain, age of the patient, psychological distress, concomitant diseases

The measures listed below are options for treatments, suggestions, so to speak. However, the attending physician must always include individual circumstances in order to achieve the best possible treatment. The above criteria must always be taken into account.

Stage 1 and 2:

In these stages of the femoral head necrosis, it is possible to drill into the necrotic focal point in order to achieve bleeding first and, in the long term, the formation of new blood vessels. The set goal is therefore to re-supply necrotic hip joint areas with blood. Postoperatively, a six-week relief must be expected, which should be followed by a partial load of about the same length. A full load can be expected after about 10 to 12 weeks, although individual differences can also occur here.

Stage 2 and 3:

In these stages of the femoral head necrosis, an intertrochanteric osteotomy is usually chosen. The aim is to turn the necrosis focus out of the load. Appropriate further treatment measures can also be taken. The postoperative relief period is in the range of 4 to 5 months.

Stage 4, secondary coxarthrosis

As a rule, only a total endoprosthesis of the hip joint can help here. As a rule, non-cemented prostheses are used. Since the disease usually occurs quite early, the total endoprosthesis is one of the last steps. Artificial joints cannot be exchanged indefinitely. Therefore, further treatment methods must first be considered.

The drilling as a therapy option

A drilling of the femoral head necrosis is mainly in the first stage indicated because the patient has not yet lost any bone.

The drilling of the femoral head necrosis in stages 1 and 2 is under anesthesia (either general anesthetic or Regional anesthesia) carried out. In order to see exactly where the doctor has to drill into the femoral head, it is necessary to carry out the operation with the help of a mobile X-ray device, whereby the radiation exposure is kept as low as possible.

During the drilling of the femoral head necrosis, the patient is in the supine position, whereby the leg on which the drilling is to be performed should be freely movable. The femoral head necrosis is drilled using wires and is intended to promote blood flow to the bone.
Since some of the bone has already died in femoral head necrosis, it is possible that parts of the bone can no longer be preserved despite drilling and are broken down. The hope, however, is that new blood vessels are formed by drilling into the femoral head necrosis, which then ensure that the old dead bone is broken down, instead new healthy bone is rebuilt so that the hip joint is resilient and no longer hurts.

In the first stage, drilling the femoral head necrosis is the standard therapy, as this is where the greatest success is achieved.
Drilling the femoral head necrosis can also be helpful in stage 2 or 3, but it is usually not enough as the sole treatment. Overall, the success of drilling into the femoral head necrosis depends very much on the extent to which the patient is cooperative after the operation (Compliance shows).
If a patient suffers from femoral head necrosis due to their heavy nicotine consumption, drilling into the femoral head necrosis only helps if the patient stops smoking from now on.

In general, however, the drilling shows good results. However, since many patients only discover femoral head necrosis at an advanced stage and classify it as a disease, the hip often has to be completely replaced (Hip replacement with endoprosthetics).

When is an operation necessary?

As a rule, femoral head necrosis is only operated on at an advanced stage.
The operation serves to relieve the damaged part of the femoral head or to enrich it with bone substances.

Surgical methods are drilling of the femoral head, an osteotomy, bone grafts and, as a last resort, the use of an artificial hip joint.

What degree of disability do you get with femoral head necrosis?

In Germany, the degree of disability (GdB) is determined on request by a medical expert.
The degree of disability encompasses physical, mental, emotional and social effects of the disability on health.

The degree of disability can vary depending on the functional impairment caused by the femoral head necrosis. A degree of disability of 30, possibly even higher, is possible.

forecast

Since the disease progresses differently from person to person, it is not possible to make a scientifically based prognosis with regard to the course of the disease, temporal progression or even with regard to operational success. It is important to mention that - in addition to the individual course of the disease - the disease can also come to a complete standstill or progress again in the meantime.