This 2015 JBJS Current Concepts Review by Mont et al. updates a decade of literature on nontraumatic osteonecrosis of the femoral head. It covers pathophysiology, imaging, staging systems, nonoperative management, joint-preserving procedures, and arthroplasty. The synthesis is organized around a stage-directed treatment algorithm to guide management decisions from precollapse through advanced disease.
Osteonecrosis of the femoral head disproportionately affects young, active patients — often those already burdened by the conditions (SLE, organ transplant, HIV, sickle cell disease) that caused it. The central clinical challenge is catching disease before collapse, because once the crescent sign appears on radiograph, you are dealing with an intra-articular fracture that is extremely difficult to heal.
When you see a young patient with hip pain and any of the major risk factors (corticosteroids, alcohol, sickle cell, organ transplant), get an MRI immediately. Plain radiographs will miss precollapse disease. Use the Kerboul angle on MRI to quantify lesion size: angles ≥240° predict near-certain collapse and should push you toward more aggressive joint preservation rather than observation.
For symptomatic precollapse disease, core decompression or percutaneous drilling is first-line surgery. Outcome is strongly tied to lesion size, so operate before the lesion grows. Once the hip collapses, shift directly to THA. Modern cementless implants deliver >90% survivorship at 10+ years, and prior joint-preserving procedures do not compromise that result.
Do not rely on bisphosphonates to alter the natural history. The only Level-I RCT showed no difference versus placebo. And do not offer resurfacing unless criteria are strictly met. Survivorship drops to 36% by 15 years, far below what modern THA delivers.
This 2015 JBJS Current Concepts Review by Mont et al. updates a decade of literature on nontraumatic osteonecrosis of the femoral head. It covers pathophysiology, imaging, staging systems, nonoperative management, joint-preserving procedures, and arthroplasty. The synthesis is organized around a stage-directed treatment algorithm to guide management decisions from precollapse through advanced disease.
Osteonecrosis of the femoral head disproportionately affects young, active patients — often those already burdened by the conditions (SLE, organ transplant, HIV, sickle cell disease) that caused it. The central clinical challenge is catching disease before collapse, because once the crescent sign appears on radiograph, you are dealing with an intra-articular fracture that is extremely difficult to heal.
When you see a young patient with hip pain and any of the major risk factors (corticosteroids, alcohol, sickle cell, organ transplant), get an MRI immediately. Plain radiographs will miss precollapse disease. Use the Kerboul angle on MRI to quantify lesion size: angles ≥240° predict near-certain collapse and should push you toward more aggressive joint preservation rather than observation.
For symptomatic precollapse disease, core decompression or percutaneous drilling is first-line surgery. Outcome is strongly tied to lesion size, so operate before the lesion grows. Once the hip collapses, shift directly to THA. Modern cementless implants deliver >90% survivorship at 10+ years, and prior joint-preserving procedures do not compromise that result.
Do not rely on bisphosphonates to alter the natural history. The only Level-I RCT showed no difference versus placebo. And do not offer resurfacing unless criteria are strictly met. Survivorship drops to 36% by 15 years, far below what modern THA delivers.