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Fate of Untreated Asymptomatic Osteonecrosis of the Femoral Head

Nam, Kwang Woo MD; Kim, Yong Lae MD; Yoo, Jeong Joon MD; Koo, Kyung-Hoi MD; Yoon, Kang Sup MD; Kim, Hee Joong MD

Journal of Bone & Joint Surgery - American Volume: 01 March 2008 - Volume 90 - Issue 3 - p 477–484
doi: 10.2106/JBJS.F.01582
Scientific Articles

Background: Magnetic resonance imaging has made it possible to detect asymptomatic lesions of osteonecrosis of the femoral head before abnormalities appear on plain radiographs. The extent of a necrotic lesion is known to be an important prognostic factor. In this study, we evaluated the fate of untreated asymptomatic osteonecrosis of the femoral head with an emphasis on the size of the lesion. We hypothesized that a lesion smaller than a certain size would not progress to symptomatic disease.

Methods: One hundred and five initially asymptomatic hips of patients with bilateral nontraumatic osteonecrosis of the femoral head who had been followed without any treatment for at least five years or until pain developed were enrolled in this study. The extent of a lesion was estimated according to the area of the lesion based on a two-dimensional analysis on magnetic resonance images or on plain radiographs at the time of diagnosis.

Results: Sixty-two hips became symptomatic, and forty-three hips remained asymptomatic for more than five years (average, eight years and seven months). Of the twenty-one hips with a small necrotic lesion (<30% of the area of the femoral head), one became painful; of the twenty-four hips with a medium-sized necrotic lesion (30% to 50% of the area of the femoral head), eleven became painful; and of the sixty hips with a large necrotic lesion (>50% of the area of the femoral head), fifty became painful. Forty-six of the sixty-two hips that became symptomatic required surgery. Pain developed within five years after the diagnosis in fifty-eight (94%) of the sixty-two symptomatic hips.

Conclusions: No treatment appears to be necessary for asymptomatic necrotic lesions with an area smaller than 30% of the femoral head, as the vast majority of these lesions will remain asymptomatic for more than five years.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

1Department of Orthopaedic Surgery, Cheju National University Hospital, 154 Samdo2dong, Jeju, 690-716, South Korea

2Department of Orthopaedic Surgery, Inchon Medical Center Hospital, 318-1 SongnimDong, DongGu, Inchon, 401-711, South Korea

3Department of Orthopaedic Surgery (J.J.Y. and H.J.K.) and Medical Research Center (H.J.K.), Seoul National University Hospital, 28 Yongondong Chongnogu, Seoul, 110-744, South Korea. E-mail address for H.J. Kim:

4Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 300 Gumidong Bundanggu, Seongnam, 463-707, South Korea

5Department of Orthopaedic Surgery, Seoul Municipal Boramae Hospital, 395 Shindaebangdong Dongjackgu, Seoul, 156-707, South Korea

Copyright 2008 by The Journal of Bone and Joint Surgery, Incorporated
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