This 2020 Current Concepts Review synthesizes evidence published since 2015 on nontraumatic osteonecrosis of the femoral head (ONFH). It covers risk factor recognition, updated staging, and the full spectrum of joint-preserving and replacement strategies. The paper serves as the fourth in a series of JBJS reviews on this topic by Mont et al.
Any patient on chronic corticosteroids or with heavy alcohol use who reports hip pain needs an MRI — not just radiographs. Radiographs miss early-stage disease, and the treatment window for joint preservation closes once collapse exceeds 2 mm.
For precollapse lesions (ARCO I–IIIA), push toward core decompression with BMAC augmentation. The data show this cuts THA conversion in half compared to decompression alone. Once you're dealing with ARCO IIIB (>2 mm collapse) or stage IV acetabular involvement, head-preserving strategies lose their advantage and THA is the right call.
When you consent a younger patient for THA for ONFH, you can cite equivalent 10-year outcomes to osteoarthritis patients. The 15-year revision rate difference was not statistically significant. The long-term concern is polyethylene wear given higher activity levels. Highly cross-linked liners are the standard in this population.
This 2020 Current Concepts Review synthesizes evidence published since 2015 on nontraumatic osteonecrosis of the femoral head (ONFH). It covers risk factor recognition, updated staging, and the full spectrum of joint-preserving and replacement strategies. The paper serves as the fourth in a series of JBJS reviews on this topic by Mont et al.
Any patient on chronic corticosteroids or with heavy alcohol use who reports hip pain needs an MRI — not just radiographs. Radiographs miss early-stage disease, and the treatment window for joint preservation closes once collapse exceeds 2 mm.
For precollapse lesions (ARCO I–IIIA), push toward core decompression with BMAC augmentation. The data show this cuts THA conversion in half compared to decompression alone. Once you're dealing with ARCO IIIB (>2 mm collapse) or stage IV acetabular involvement, head-preserving strategies lose their advantage and THA is the right call.
When you consent a younger patient for THA for ONFH, you can cite equivalent 10-year outcomes to osteoarthritis patients. The 15-year revision rate difference was not statistically significant. The long-term concern is polyethylene wear given higher activity levels. Highly cross-linked liners are the standard in this population.