The Journal of Bone and Joint Surgery (American). 2008;90:477-484.
doi:10.2106/JBJS.F.01582
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Fate of Untreated Asymptomatic Osteonecrosis of the Femoral Head

Kwang Woo Nam, MD1, Yong Lae Kim, MD2, Jeong Joon Yoo, MD3, Kyung-Hoi Koo, MD4, Kang Sup Yoon, MD5 and Hee Joong Kim, MD3

1 Department of Orthopaedic Surgery, Cheju National University Hospital, 154 Samdo2dong, Jeju, 690-716, South Korea
2 Department of Orthopaedic Surgery, Inchon Medical Center Hospital, 318-1 SongnimDong, DongGu, Inchon, 401-711, South Korea
3 Department 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: oskim{at}snu.ac.kr
4 Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 300 Gumidong Bundanggu, Seongnam, 463-707, South Korea
5 Department of Orthopaedic Surgery, Seoul Municipal Boramae Hospital, 395 Shindaebangdong Dongjackgu, Seoul, 156-707, South Korea
Investigation performed at the Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

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.


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