The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 12

Scientific Articles | December 01, 2004

Fate of Very Small Asymptomatic Stage-I Osteonecrotic Lesions of the Hip

P. Hernigou, MD¹; A. Poignard, MD¹; A. Nogier, MD¹; O. Manicom, MD¹

¹ Hôpital Henri Mondor, 94010 Creteil, France

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Investigation performed at Hôpital Henri Mondor, Creteil, France

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J Bone Joint Surg Am, 2004 Dec 01;86(12):2589-2593

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Abstract

Background: The prognosis for a patient with osteonecrosis of the hip is generally considered to be worse if a large volume of the femoral head is involved, the patient is symptomatic, and the stage of the lesion is advanced. In 1990, we began a prospective study to detect collapse in asymptomatic hips with a very small stage-I osteonecrotic lesion in the femoral head. We hypothesized that such patients would have a favorable prognosis. These hips were followed for a minimum of ten years after the diagnosis.

Methods: A small asymptomatic stage-I osteonecrotic lesion (not seen on plain radiographs) was diagnosed with magnetic resonance imaging in forty patients (forty hips) contralateral to a hip with symptomatic osteonecrosis. The criterion for inclusion in the study was a lesion with a volume of <5 cm³ involving <10% of the volume of the femoral head. Plain radiographs were made annually in six different projections for all patients. At the most recent follow-up evaluation (average, eleven years), patients with a symptomatic hip but without evidence of collapse on plain radiographs underwent a computerized tomography scan.

Results: Thirty-five (88%) of the forty hips became symptomatic, and twenty-nine (73%) demonstrated collapse. The mean interval between the diagnosis and the first symptoms was eighty months. Symptoms always preceded collapse by at least six months. The mean interval between the diagnosis and the collapse was ninety-two months (range, seventy-two to 140 months). The diagnosis of collapse could be made on only one or two of the six radiographic views obtained for each patient at each evaluation. The diagnosis of collapse for two patients was made only on a computerized tomography scan at the most recent follow-up evaluation. At the time of final follow-up, the twenty-nine hips with collapse had symptoms of intractable pain and required surgery.

Conclusions: This study confirms that the diagnosis of collapse is difficult in hips with a very small stage-I osteonecrotic lesion. Multiple radiographic views and computerized tomography scans may be required to demonstrate small areas of collapse. Clinical and radiographic signs of progression of the disease in asymptomatic hips with a very small asymptomatic lesion progress more slowly than do those signs in hips with a large symptomatic stage-II lesion. Because hips with a small area of osteonecrosis do collapse in a large percentage of patients, such patients should be followed carefully over a long period of time.

Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

The natural history of advanced symptomatic osteonecrosis of the hip has been shown by many authors to be progression to collapse and painful degenerative arthritis. However, only a few investigators have attempted to evaluate the risk of progression of asymptomatic early-stage disease. Recently, several authors have used magnetic resonance imaging for the early detection of osteonecrosis and have attempted to relate the size¹ or the position² of the lesion, the stage^3,4 of the disease, and symptoms of pain^1-3 to radiographic signs of progression of the osteonecrosis. Some reports^2,3,5 have suggested that, compared with large lesions, small osteonecrotic lesions have a lower probability of collapse during the first two or three years following diagnosis and that hips with asymptomatic osteonecrosis have a lower probability of collapse of the femoral head than do symptomatic hips. The current literature on asymptomatic osteonecrosis is not clear with regard to either the risk of collapse associated with early-stage disease or the factors influencing clinical and radiographic signs of progression. This lack of clarity may be explained by differences in these studies with respect to such parameters as duration of follow-up, the position and size of the lesions, and the inclusion of patients with different radiographic stages of asymptomatic hip osteonecrosis. Therefore, there is no agreement on the natural history of an asymptomatic hip with osteonecrosis or on the necessity for medical or surgical treatment of these hips.

In 1990, we began a prospective study to detect collapse among asymptomatic hips with a very small stage-I osteonecrotic lesion of the femoral head. We hypothesized that these patients would have a favorable prognosis. The patients were followed for a minimum of ten years after the diagnosis. The aim of this report is to provide information on the natural history of very small asymptomatic osteonecrotic lesions of the femoral head.

Materials and Methods

Materials and Methods | Results | Discussion | References

Patients

Forty consecutive patients (forty hips) at risk for the development of osteonecrosis of the hip were found to have stage-I osteonecrosis, according to the system of Steinberg et al.⁶, when evaluated with plain radiographs and magnetic resonance imaging. Thirty patients had symptomatic osteonecrosis of the contralateral hip, and the other ten patients underwent the magnetic resonance imaging of the hips because of osteonecrosis in the knee or shoulder.

The mean age of the forty patients (thirty men and ten women) was forty-one years (range, twenty-seven to fifty-three years), and the mean duration of clinical and radiographic follow-up was 136 months (range, 120 to 144 months). Additional medical diagnoses included systemic lupus erythematosus (two patients) and asthma (one patient). Risk factors included steroid use (eleven patients) and alcohol abuse (twenty patients). The average dose of corticosteroids was 600 mg of prednisone (range, 400 to 3000 mg), but no patient continued to receive steroids after the diagnosis of osteonecrosis was made. The patients who abused alcohol did not discontinue doing so. No risk factor could be identified for the nine other patients, and the osteonecrosis was considered to be idiopathic. The criteria for inclusion into the study were an asymptomatic hip with evidence of osteonecrosis on magnetic resonance imaging, a volume of the osteonecrosis of <5 cm³ (Fig. 1-A) and <10% of the femoral head, and no evidence of osteonecrosis of the femoral head on plain radiographs.

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Fig. 1-A: T1-weighted spin-echo magnetic resonance image (repetition time, 500 msec; echo time, 30 msec) of the hip made at the initial evaluation. The volume of the osteonecrosis is only 3 cm (5% of the volume of the femoral head). The plain radiograph showed normal findings. Fig. 1-B Six years later, collapse of the femoral head was seen on an anteroposterior radiograph.

Imaging

The diagnosis of femoral head osteonecrosis was made with use of magnetic resonance imaging. All magnetic resonance images were acquired with a 1.5-T superconducting unit. T1-weighted spin-echo images were acquired with a repetition time of 400 to 600 msec and an echo time of 20 to 40 msec. A repetition time of 1500 to 2240 msec and an echo time of 30 to 100 msec were used to acquire images of varying T2 weightings (transverse relaxation times). Coronal and sagittal sections were acquired. The diagnosis of osteonecrosis on magnetic resonance imaging was based on abnormal band-like signals and hypointense band-like zones on T1-weighted images and matching hyperintense zones on short tau inversion recovery (STIR) images.

The method used in this study for the volumetric analysis of osteonecrosis with magnetic resonance imaging has been previously reported⁷ and was estimated to have an accuracy of ±2 cm³. We defined a "very small" lesion as one with a volume of <5 cm³ involving <10% of the volume of the femoral head (Fig. 1-A). The percentage of the volume of the femoral head with osteonecrotic involvement was calculated by dividing the volume of the necrotic bone by the volume of the femoral head. The measurement⁷ was estimated to have an accuracy of 3%.

All forty patients were evaluated every year at the same institution. Follow-up consisted of interviews, clinical examination, and radiographs, and the patients were evaluated with use of the Harris hip score at each visit. Because the literature was not clear on the degree of the risk of progression of very small osteonecrotic lesions at the beginning of this study, no specific treatment before the appearance of collapse was carried out in these patients. Because collapse may be difficult to demonstrate in hips with a small osteonecrotic lesion (Fig. 1-B), the patients had six radiographs made at the initial evaluation, annually, and at the time of the most recent follow-up (at an average of eleven years; range, ten to twelve years). These views included an anteroposterior standard radiograph of the hip with the limb in internal, neutral, and external rotation (Fig. 2); an anteroposterior radiograph of the hip with an ascendant x-ray beam at 30°; a frog-leg lateral radiograph; and the false-profile view of the hip described by Lequesne to show a lateral weight-bearing view of the hip.

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Fig. 2: Anteroposterior radiographs of the hip in different rotations. Collapse (arrows) is evident only on the anteroposterior radiograph with the hip in neutral rotation in this case.

At the time of final follow-up, patients with a symptomatic hip but without evidence of collapse on plain radiographs underwent a computerized tomography scan. All radiographs were graded with the method of Steinberg et al.⁶. Stage I was defined as a hip with normal radiographs but an abnormal magnetic resonance image; Stage II, as a hip with an abnormal magnetic resonance image and an abnormal radiograph showing sclerotic or cystic changes in the femoral head but no crescent sign; Stage III, as a femoral head with a crescent sign (a radiolucent line) on a plain radiograph or the computerized tomography scan; and Stage IV, as flattening of >1 mm as measured with a template overlay of circles in 1-mm-diameter increments. Because the terms crescent sign and collapse are used to indicate major radiographic signs in most of the classifications but are sometimes ambiguous, we use the term crescent sign only for hips with stage-III involvement and the term collapse only for hips with stage-IV disease. Kaplan-Meier survivorship curves were calculated with hip pain or collapse of the femoral head as the end points. The chi-square test was used to analyze differences between groups of patients, with the level of significance set at p < 0.05.

Results

Materials and Methods | Results | Discussion | References

During the study period, thirty-five (88%) of the forty hips became symptomatic and twenty-nine hips (73%) demonstrated collapse. The mean duration of clinical and radiographic follow-up was 136 months (range, 120 to 144 months). The mean interval between the diagnosis and the first symptoms (mild pain) was eighty months (range, sixty-three to 134 months). Thirty-five of the forty hips first became symptomatic after five years, and the longest delay between the diagnosis and the first symptoms (mild pain) was 134 months (Fig. 3).

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Fig. 3: Kaplan-Meier survivorship curve depicting occurrence of pain after the diagnosis was made with magnetic resonance imaging.

The onset of pain occurred when the disease was in radiographic stage I in twelve patients and after it had progressed to stage II in twenty-three patients. When collapse occurred, it was always preceded by pain of at least six months' duration. The mean interval between the onset of pain and collapse was twelve months (range, six to thirty-eight months).

Twenty-nine (73%) of the forty hips demonstrated collapse within twelve years after the diagnosis. The average time for progression from stage I to stage II was thirty-four months (range, six to seventy-two months). The mean interval between a diagnosis of stage-II disease and collapse was fifty-eight months (range, twenty-four to 112 months). The mean time between the diagnosis and collapse (Fig. 4) was ninety-two months (range, seventy-two to 140 months).

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Fig. 4: Kaplan-Meier survivorship curve depicting progression to collapse after the diagnosis was made with magnetic resonance imaging.

The diagnosis of collapse was difficult to make in these hips; it could be made on only one or two of the six radiographs performed for each patient at each evaluation and, for two patients, could be made only on a computerized tomography scan at the final follow-up evaluation.

At the time of final follow-up, five hips (two with stage-I and three with stage-II disease) were asymptomatic, six hips were in stage II and symptomatic, and twenty-nine hips had collapse. Symptoms increased after collapse and, at the most recent follow-up evaluation, all twenty-nine hips had progressed to stage IV or stage V, with a mean Harris hip score of 56 points (range, 41 to 62 points), and required surgery. Nine hips underwent core decompression, and twenty hips were treated with total hip arthroplasty.

With the numbers available, no significant difference (p = 0.74) was found in the risk of progression to symptoms and collapse between the thirty patients with bilateral hip involvement and the ten patients with involvement of only one hip but osteonecrosis of a shoulder or knee. Patients with a diagnosis of idiopathic osteonecrosis had no significant (p > 0.05) difference with regard to either clinical or radiographic outcome when compared with those who had osteonecrosis associated with alcohol or steroid use.

Discussion

Materials and Methods | Results | Discussion | References

To determine the prognosis of an asymptomatic hip in a patient with osteonecrosis, the extent of the lesion is often used to evaluate the risk of progression^8-11. In previous studies assessing hips with asymptomatic stage-I disease^8,12-15, only twenty-seven (33%) of eighty-three hips progressed to symptoms (pain) but the duration of follow-up was short (average, two years). Other shorter-term follow-up reports^1-3,9 have indicated that most hips that progress to collapse do so within the first two years after the diagnosis and that a relatively small percentage of the remaining hips demonstrate collapse subsequently.

In the present study, we evaluated the risk of progression in forty hips with a very small asymptomatic stage-I osteonecrotic lesion that had been followed for a minimum of ten years. Pain and collapse developed in twenty-nine (73%) of the hips. Twenty of the twenty-nine hips had undergone total hip arthroplasty by the time of the final follow-up examination.

The first important finding in our study is that pain did not develop earlier than five years after the diagnosis of stage-I osteonecrosis with magnetic resonance imaging in forty previously asymptomatic hips. There was a variable relationship between radiographic changes and the onset of symptoms. In twenty-three hips, radiographic evidence of progression to stage II preceded the onset of symptoms by at least six months, whereas in twelve hips, the first symptoms preceded the radiographic progression to stage II. The second important finding of this study is that, in all hips that went on to collapse, the first symptoms of pain always preceded collapse by at least six months.

Our third important finding is that 73% (twenty-nine) of the forty hips with a stage-I lesion at the time of presentation had collapsed within twelve years after the diagnosis. Given the time-course for the onset of symptoms with these very small, originally asymptomatic lesions and the time-course for the occurrence of collapse, we suggest that, to determine whether a surgical intervention can alter the natural history of such a lesion and can prevent collapse, the operation should be performed very early and the patient should be evaluated for at least eight years after the diagnosis. We would add that the diagnosis of collapse is difficult in hips with a very small osteonecrotic lesion, and several radiographic views or a computerized tomography scan are often necessary to rule out collapse.

The unfavorable long-term outcome for most of the originally asymptomatic hips in this study suggests that patients at higher risk for the development of osteonecrosis—i.e., those with contralateral osteonecrosis of the hip or multifocal osteonecrosis—should have early magnetic resonance imaging of the uninvolved hip or hips. Although conservative surgical treatment was not addressed in this study, we propose that such procedures will have the best results in hips with osteonecrosis when they are performed early. Our finding that most of the asymptomatic hips with osteonecrosis eventually collapsed argues for considering a prophylactic conservative surgical procedure in the hip with an asymptomatic lesion while the patient is undergoing surgical intervention of the symptomatic contralateral hip.

We also recommend evaluating patients at six-month intervals after presentation and as soon as possible after the onset of pain because the first symptoms always preceded collapse by at least six months in our series. As the diagnosis of collapse is difficult to make in hips with a very small lesion, plain radiographs sometimes are not sufficient to evaluate the radiographic progression to collapse. The patient should be counseled concerning the risk of collapse as soon as the symptoms have appeared, even if the collapse is not seen on several different radiographic views. ?

References

Materials and Methods | Results | Discussion | References

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Sugano N, Takaoka K, Ohzono K, Matsui M, Masuhara K, Ono K. Prognostication of nontraumatic avascular necrosis of the femoral head. Significance of location and size of the necrotic lesion. Clin Orthop.1994; 303: 155-64.303155 1994 [PubMed]

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: 199-204.187199 1993 [PubMed]

Beltran J, Knight CT, Zuelzer WA, Morgan JP, Shwendeman LJ, Chandnani VP, Mosure JC, Shaffer PB. Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging. Radiology.1990;175: 533-6.175533 1990 [PubMed]

Shimizu K, Moriya H, Akita T, Sakamoto M, Suguro T. Prediction of collapse with magnetic resonance imaging of avascular necrosis of the femoral head. J Bone Joint Surg Am.1994;76: 215-23.76215 1994

Steinberg ME, Hayken GD, Steinberg DR. A quantitative system for staging avascular necrosis. J Bone Joint Surg Br.1995;77: 34-41.7734 1995

Hernigou P, Lambotte JC. Volumetric analysis of osteonecrosis of the femur. Anatomical correlation using MRI. J Bone Joint Surg Br. 2001;83: 672-5.83672 2001 [PubMed][CrossRef]

Takatori Y, Kokubo T, Ninomiya S, Nakamura S, Morimoto S, Kusaba I. Avascular necrosis of the femoral head. Natural history and magnetic resonance imaging. J Bone Joint Surg Br.1993;75: 217-21.75217 1993

Koo KH, Kim R. Quantifying the extent of osteonecrosis of the femoral head. A new method using MRI. J Bone Joint Surg Br.1995;77: 875-80.77875 1995 [PubMed]

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Davidson JL, Coogan PG, Gunneson EE, Urbaniak JR. The asymptomatic contralateral hip in osteonecrosis of the femoral head. In: Urbaniak JR, Jones JP, editors. Osteonecrosis: etiology, diagnosis, and treatment. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1997. p 231-40.231 1997

Fordyce MJ, Solomon L. Early detection of avascular necrosis of the femoral head by MRI. J Bone Joint Surg Br.1993;75: 365-7.75365 1993

Mulliken BD, Renfrew DL, Brand RA, Whitten CG. Prevalence of previously undetected osteonecrosis of the femoral head in renal transplant recipients. Radiology.1994;192: 831-4.192831 1994 [PubMed]

Kopecky KK, Braunstein EM, Brandt KD, Filo RS, Leapman SB, Capello WN, Klatte EC. Apparent avascular necrosis of the hip: appearance and spontaneous resolution of MR findings in renal allograft recipients. Radiology.1991; 179: 523-7.179523 1991 [PubMed]

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Topics

head of femur ; hip region ; hip joint ; pain ; osteonecrosis ; vibration

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P. Hernigou, A. Poignard, A. Nogier, O. Manicom; Fate of Very Small Asymptomatic Stage-I Osteonecrotic Lesions of the Hip. The Journal of Bone & Joint Surgery. 2004 Dec;86(12):2589-2593.

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