Diagnostic Imaging Pathways - Hip (Avascular Necrosis)
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Population Covered By The Guidance
This pathway provides guidance for imaging patients with suspected avascular necrosis of the hip.
Date of review: August 2013
Date of next review: 2017/2018
Published: October 2013
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Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Avascular Necrosis of the Left Femoral Head Image 1 (Plain Radiograph): Flattening of the left femoral head is consistent with avascular necrosis. |
| 2 |  |
Avascular Necrosis of the Left Femoral Head Image 2 (Magnetic Resonance Imaging): MRI images of avascular necrosis demonstrating flattening and sclerosis of the superior articular surface of the left femur (arrow). Cortical fragmentation and marrow oedema are present within the femoral head. |
| 3 |  |
Avascular Necrosis of Bilateral Femoral Heads Image 3 (Magnetic Resonance Imaging): Coronal T1 imaged showing bilateral avascular necrosis of differing age. |
| 4 |  |
Avascular Necrosis of the Femoral Head Image 4 (H&E, x2.5): Histological section showing the features of avascular bone necrosis. There is necrosis of the bony trabeculae with empty lacunae and almost complete absence of haemopoeitic marrow elements. |
Teaching Points
Teaching Points
- Avascular necrosis refers to death of bone and marrow cells due to interruption of the blood supply, with resultant mechanical failure and often joint destruction
- Initial imaging is with plain films
- If there is ongoing clinical suspicion with normal plain film radiography, MRI is the most accurate imaging modality
- Nuclear scintigraphy is a reasonable alternative to MRI
avasc
Avascular Necrosis (AVN) of the Hip
- AVN refers to death of bone and marrow cells due to interruption of their blood supply, with resultant mechanical failure and often joint destruction
- A number of traumatic and non-traumatic factors can cause AVN 1
- Traumatic
- Femoral neck fracture
- Hip dislocation
- Non-traumatic
- Corticosteroid use
- Alcohol use
- Systemic Lupus Erythematosis
- Collagen storage disorders
- Chemotherapy
- Radiotherapy
- Pregnancy
- The disease may involve both femoral heads in up to 72% of patients 2,3
xray
Plain Radiographs
- Initial study of choice for suspected avascular necrosis (anteroposterior (AP) and frog-leg views). 4,5 Consider AP pelvis as part of initial investigation as condition may be bilateral
- When standard radiographs demonstrate the classic changes of osteonecrosis (crescent sign or articular collapse) further diagnostic imaging is unwarranted, unless knowledge of asymptomatic AVN in the opposite hip is clinically important 5
- Advantages: inexpensive and readily available
- Limitations: insensitive for detecting early changes 6
mri
Magnetic Resonance Imaging
- Most accurate imaging modality for detection and staging of suspected avascular necrosis, with a reported 88-100% sensitivity and 72-87% specificity 6-11
- Indicated in patients with clinically suspected radiographically occult avascular necrosis 4
- Advantages
- Superior soft tissue contrast
- Ability to detect bone marrow changes, including inflammatory and reactive hyperaemic changes, enables early detection of disease 12
- Offers more specific diagnosis in patients with hip pain of uncertain aetiology 11
- Allows assessment of the lesion size and location, which are shown to relate to prognosis and need for treatment. 13-16 MRI can be used to predict future collapse 17
- Offers more specific diagnosis in patients with hip pain of uncertain aetiology 18,19
- Disadvantages
- Recent studies are evaluating the use of an abbreviated MRI examination for its time and cost saving potential 19,22
b_scan
Three-Phase Bone Scan
- Superior to plain radiographs but inferior to MRI for early detection of avascular necrosis 6,12
- Approximately 75% sensitive and specific for avascular necrosis 7,8
- Useful screening modality if the site of pathology has not been localised
- Improved accuracy with the addition of SPECT 23
- Limitations
- Poor spatial resolution
- Lacks specificity 7
Computed Tomography (CT)
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Watson RM, Roach NA, Dalinka MK. Avascular necrosis and bone marrow edema syndrome. Radiol Clin North Am. 2004;42(1):207. (Review article)
- Assouline Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME. Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum. 2002;32(2):94-124. (Review article)
- Piyakunmala K, Sangkomkamhang T, Chareonchonvanitch K. Is magnetic resonance imaging necessary for normal plain radiography evaluation of contralateral non-traumatic asymptomatic femoral head in high osteonecrosis risk patient. J Med Assoc Thai. 2009;92 Suppl 6:S147-51. (Level III evidence)
- Karantanas AH. Accuracy and limitations of diagnostic methods for avascular necrosis of the hip. Expert Opin Med Diagn. 2013;7(2):179-87. (Review article)
- Expert Panel on Musculoskeletal Imaging, Seeger LL, Daffner RH, Weissman BN, Arnold E, Bancroft L, et al. ACR Appropriateness Criteria: Avascular necrosis (osteonecrosis) of the hip. American College of Radiology; 2009 [cited 2013 April 1]. (Evidence based guideline) View the reference
- Lee MJ, Corrigan J, Stack JP, Ennis JT. A comparison of modern imaging modalities in osteonecrosis of the femoral head. Clin Radiol. 1990;42(6):427-32. (Level III evidence)
- Beltran J, Herman LJ, Burk JM, Zuelzer WA, Clark RN, Lucas JG, et al. Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation. Radiology. 1988;166(1 Pt 1):215-20. (Level II evidence)
- Markisz JA, Knowles RJR, Schneider R, Altchek DW, Whalen JP, Cahill PT. Segmental patterns of avascular necrosis of the femoral heads: early detection with MR imaging. Radiology. 1987;162(3):717-20. (Level III evidence)
- Mitchell MD, Kundel HL, Steinberg ME, Kressel HY, Alavi A, Axel L. Avascular necrosis of the hip: comparison of MR, CT, and scintigraphy. AJR Am J Roentgenol. 1986;147(1):67-71. (Level II/III evidence)
- Mitchell DG, Alavi A, Rao VM, Dalinka MK, Spritzer CE, Steinberg ME, et al. Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings. Radiology. 1987;162(3):709-15. (Level IV evidence)
- Thickman D, Axel L, Kressel HY, Steinberg M, Chen H, Velchick M, et al. Magnetic resonance imaging of avascular necrosis of the femoral head. Skeletal Radiol. 1986;15(2):133-40. (Level II/III evidence)
- Coleman BG, Kressel HY, Dalinka MK, Scheibler ML, Burk DL, Cohen EK. Radiographically negative avascular necrosis: detection with MR imaging. Radiology. 1988;168(2):525-8. (Level IV evidence)
- Lafforgue P, Dahan E, Chagnaud C, Schiano A, Kasbarian M, Acquaviva PC. Early-stage avascular necrosis of the femoral head: MR imaging for prognosis in 31 cases with at least 2 years of follow-up. Radiology. 1993;187(1):199-204. (Level II/III evidence)
- Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br. 1995;77(1):34-41. (Level II/III evidence)
- Takao M, Sugano N, Nishii T, Miki H, Sato Y, Tamura S, et al. Longitudinal quantitative evaluation of lesion size change in femoral head osteonecrosis using three-dimensional magnetic resonance imaging and image registration. J Orthop Res. 2006;24(6):1231-39. (Level III evidence)
- Zhao F-c, Li Z-r, Zhang N-f, Wang B-l, Sun W, Cheng L-m, et al. Lesion size changes in osteonecrosis of the femoral head: a long-term prospective study using MRI. Int Orthop. 2010;34(6):799-804. (Level II evidence)
- Ha Y-C, Jung WH, Kim J-R, Seong NH, Kim S-Y, Koo K-H. Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am. 2006;88 Suppl 3:35-40. (Level I evidence)
- Glickstein MF, Burk DL, Schiebler ML, Cohen EK, Dalinka MK, Steinberg ME, et al. Avascular necrosis versus other diseases of the hip: sensitivity of MR imaging. Radiology. 1988;169(1):213-5. (Level III evidence)
- Khurana B, Okanobo H, Ossiani M, Ledbetter S, Al Dulaimy K, Sodickson A. Abbreviated MRI for patients presenting to the emergency department with hip pain. AJR Am J Roentgenol. 2012;198(6):W581-8. (Level II evidence)
- Stevens K, Tao C, Lee S-U, Salem N, Vandevenne J, Cheng C, et al. Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol. 2003;180(2):363-8. (Level II/III evidence)
- Yeh L-R, Chen CKH, Huang Y-L, Pan H-B, Yang C-F. Diagnostic performance of MR imaging in the assessment of subchondral fractures in avascular necrosis of the femoral head. Skeletal Radiol. 2009;38(6):559-64. (Level III evidence)
- Khanna AJ, Yoon TR, Mont MA, Hungerford DS, Bluemke DA. Femoral head osteonecrosis: detection and grading by using a rapid MR imaging protocol. Radiology. 2000;217(1):188-92. (Level II/III evidence)
- Kim KY, Lee SH, Moon DH, Nah HY. The diagnostic value of triple head single photon emission computed tomography (3H-SPECT) in avascular necrosis of the femoral head. Int Orthop. 1993;17(3):132-8. (Level II/III evidence)
- Hsieh M-S, Tsai M-D, Yeh Y-D. Three-dimensional hip morphology analysis using CT transverse sections to automate diagnoses and surgery managements. Comput Biol Med. 2005;35(4):347-71. (Level IV evidence)
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