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It usually starts with a deep pain in the groin or buttock that gets worse when walking or climbing stairs, and the person may mistake it for a passing muscle strain. Then the MRI report arrives with the phrase “necrosis of the femoral head,” and the worry begins: Will the joint collapse? Will I need a replacement? Is there anything that can be done before that?
The answer differs from one patient to another. What determines the options is the stage of the disease, the size of the affected area and its location within the femoral head, the symptoms, and the patient’s age and activity level. Some patients, before collapse occurs, may be candidates for procedures that aim to keep the original joint for as long as possible, while hip replacement is the more suitable option for those whose damage has advanced.
Let’s be clear from the start: early treatment is not a substitute for joint replacement, and it does not mean the joint will never need one later. Joint replacement itself is not a treatment failure; it is a medically supported option when the damage becomes advanced. This article explains the options and the limits of the evidence in simple language, and it does not give personal recommendations to any reader.
What Is Osteonecrosis of the Femoral Head?
It is also known as avascular necrosis (AVN) or osteonecrosis. It occurs when the blood supply to the head of the femur is disrupted. The femoral head is the “ball” of the hip joint. Without enough nourishment, the bone in the femoral head dies and then gradually collapses, and the cartilage covering it is affected. In the end, severe arthritis of the joint may develop. As for the exact mechanism behind the disrupted blood supply, it is still not fully clear according to the guidelines, so a single causal chain should not be presented as proven for all patients. The disease mostly affects young and middle-aged adults and is more common in men.
Causes and Risk Factors
Having a risk factor does not necessarily mean the disease will develop, and the absence of a clear risk factor does not rule it out. The international guideline noted that risk factors do not always lead to the disease, and that they increase its likelihood when combined with a genetic predisposition. Known factors include:
- Injuries: Hip fractures and dislocations can damage the blood vessels that supply the femoral head.
- Corticosteroids: Long-term or high-dose use is linked to the disease, although the reason is not known precisely.
- Excessive alcohol use over time.
- Associated diseases and conditions: such as sickle cell disease, lupus, decompression sickness (diver’s disease), and some blood and immune disorders, in addition to clotting disorders, high blood fats, metabolic syndrome, and organ transplantation.
- Smoking and obesity, which are linked to increased risk.
In many cases, no specific cause can be identified.
Symptoms
There may be no symptoms in the early stages. When symptoms do appear, they are usually:
- A deep pain in the groin, buttock, or side of the hip, which may sometimes extend to the thigh and down to the knee. A specialist guideline notes that knee pain may occasionally accompany the condition, along with limited inward rotation of the hip.
- Pain when putting weight on the leg, then pain with movement, which may later turn into a limp and difficulty climbing stairs, standing, and walking.
- Stiffness in the hip that makes putting on socks and shoes difficult.
- Pain at rest, which may appear in some cases as the disease progresses.
One useful observation is that the patient may have severe pain in the joint while still having relatively good movement in the early stages, because the problem is then confined to the femoral head, and movement becomes affected later as arthritis develops.
Because the sources of hip pain are many, the international guideline recommends MRI to determine whether the pain is caused by the necrosis, since bone marrow edema is more strongly linked to pain than fluid collection in the joint is.
Stages of Femoral Head Osteonecrosis
The recent international guideline adopts the updated ARCO classification, which is the basis for choosing treatment. Its stages, as presented in the guideline:
- Stage I: X-rays are normal, but MRI or a bone scan shows the lesion.
- Stage II: Changes such as sclerosis or cysts appear on X-ray or CT, without a subchondral fracture and without flattening of the femoral head.
- Stage III: A fracture beneath the cartilage or within the necrotic area appears, or flattening of the head; it is divided into early and late according to the depth of the depression.
- Stage IV: Arthritis of the joint with narrowing of the joint space and changes in the socket.
These stages do not measure the size of the lesion; the experts decided to develop a separate system to predict progression. Therefore, the size of the necrotic area and its location are assessed independently, and a larger size and a location closer to the outer side of the femoral head were linked to relatively worse outcomes in observational studies. A particular stage does not mean that every patient in it needs one specific procedure.
How Is Osteonecrosis Diagnosed?
Diagnosis begins with a clinical examination and medical history, and with identifying the movements that provoke the pain. Then come the images:
- X-rays: They may look normal in the early stages and show changes later.
- MRI: The international guideline recommends it as the preferred test for diagnosis, because it detects the lesion before it appears on ordinary X-rays. The guidelines describe the recommendation as strong, while acknowledging that the quality of the supporting evidence is very low and that the recommendation relies heavily on expert opinion.
- CT: MRI or CT is preferred over ordinary X-rays for detecting the subchondral fracture that separates stages II and III.
The images may reveal a lesion in the opposite hip that causes no pain. Patient sources state that the necrosis may affect both hips in many cases, so doctors usually recommend imaging the other hip as well.
As for cases discovered without symptoms, the international guideline says there are no trials that settle whether observation or treatment is better. The experts believe treatment may be considered according to the risk of developing symptoms and collapse and the size of the affected area, with a preference for procedures with fewer complications, and that observation is more acceptable in older patients. No single test is always enough to determine the plan.
Can It Be Treated Without Surgery?
Non-surgical measures are used to relieve pain and reduce the load on the joint, including:
- Modifying activity and using crutches or walking aids to reduce the load.
- Non-steroidal anti-inflammatory drugs and painkillers when medically appropriate.
- Exercises that strengthen the hip and leg muscles and maintain movement, while paying attention to weight.
But these measures have clear limits. Medications may relieve pain, but they do not reverse the necrosis itself. Osteoporosis drugs that are sometimes mentioned may slow progression, but the evidence on them is conflicting. The latest international guideline concluded that the evidence for many supportive treatments, such as bisphosphonates, shock wave therapy, electromagnetic fields, and hyperbaric oxygen, is insufficient to recommend them in the early stages. Therefore, none of them is presented as a standard treatment.
Treatment of Early Stages Before Collapse
Joint-preserving procedures are called that because they try to keep the original femoral head before it collapses. Their evidence varies widely, so this section presents what the international guideline panel said, with the strength of its recommendations as stated, without reducing them to a general phrase such as “the guidelines recommend treatment.”
Core decompression. The surgeon drills one large hole or several small holes in the femoral head to relieve pressure inside the bone and create pathways for new blood vessels to grow. It is different from hip arthroscopy, which treats problems inside the joint. The guideline panel says core decompression can be considered for patients who have no subchondral fracture and no collapse (stages I and II), with low-quality evidence and a weak recommendation. Patient sources describe core decompression as sometimes succeeding in preventing collapse and the development of arthritis, say that this depends on the stage and size of the disease, and note that it does not usually succeed after the bone has collapsed.
Adding bone marrow concentrate. The international guideline states that adding bone marrow concentrate to core decompression may reduce the risk of femoral head collapse, but the evidence is of low quality, the recommendation is weak, and there are not enough comparative data to determine which treatment is best before collapse. A systematic analysis of randomized and observational studies sees that combining it with regenerative treatments improves pain and function, but its ability to slow disease progression remains uncertain because of differences between studies and their short follow-up. Mayo Clinic describes this type of procedure as relatively new and in need of further study.
Vascularized fibular graft. A piece of the fibula, the small bone in the leg, is taken along with its artery and vein and transplanted into the femoral neck and head. The guideline panel says it can be considered as an option for preserving the femoral head in stages I and II, but while weighing its higher surgical burden and complications compared with simpler procedures, with very low-quality evidence and a weak recommendation.
Non-vascularized fibular graft. The guideline panel recommends against adding it to core decompression to prevent collapse, because there is no clear benefit and it carries the burden of harvesting the graft, with very low-quality evidence and a weak recommendation.
Corrective osteotomy. This procedure changes the direction of loading so that it shifts away from the necrotic area. The guideline panel says it may occasionally be considered for selected cases, while weighing the deformity it may cause and its effect on later joint replacement, with very low-quality evidence and a weak recommendation.
Other treatments. There are many treatments in the literature, including some medications, platelet-rich plasma, mesenchymal cells, bone morphogenetic proteins, tantalum rods, shock wave therapy, electromagnetic fields, and hyperbaric oxygen. For each of them, the guideline panel found only one or two small, heterogeneous studies, so it issued no recommendation for routine use of any of them.
The analyses differ in their overall impression. A network analysis of randomized trials found that several types of grafts relatively slowed disease progression compared with core decompression alone, without clear differences in the need for replacement between treatments, and its authors acknowledged the small number of studies, the short follow-up, and that most were conducted in a single country. This difference in conclusions shows that the evidence is still not settled.
Bone Marrow Preparations: What Do the Names Mean?
These procedures are often called “stem cell treatment” in advertisements, but this general label mixes together different preparations, and the results of one type should not be transferred to another. Types that appear in the literature include:
- Bone marrow concentrate: Marrow is drawn from the pelvic bone, concentrated, and then injected at the site of core decompression. The international guideline uses the term Bone Marrow Concentrate, abbreviated BMC, while other studies use the term Bone Marrow Aspirate Concentrate, abbreviated BMAC. The literature may use different names for marrow preparations, and the methods of preparing them vary between centers, so it should not be assumed that the two abbreviations describe exactly the same preparation.
- Bone marrow mononuclear cells: A fraction separated from the marrow, sometimes described as the buffy coat. The method of isolating them differs from that of simple concentrate.
- Cultured mesenchymal cells: Cells grown in the laboratory before being returned. They are not a concentrate prepared and returned in the same session.
- Platelet-rich plasma (PRP): A preparation made from blood, not from bone marrow cells.
Researchers point out that the cells called stem cells make up a small part of bone marrow concentrate, and that concentration does not make it equivalent to stem cell treatment. For this reason, this article does not use the phrase “stem cells” as a general description of all these preparations.
For clarification about a well-known Belgian study: it was a small prospective controlled study that compared core decompression alone with core decompression plus implantation of concentrated bone marrow cells. According to the study’s original text, the hips were allocated alternately and not randomly, with the allocation concealed from patients and assessors. The study found improvement in patients’ pain and in disease progression in favor of the cell group, without a difference in the need for replacement, and its authors stated that it was not designed in the first place to evaluate that. It is therefore useful as preliminary evidence, and it is not considered a randomized trial.
If you are offered a procedure that involves a preparation of this kind, it is wise to ask the surgeon: What exactly is the preparation? How is it prepared? What is the evidence for using it at my stage? And is it offered as part of a treatment protocol or a research protocol? It should not be said that any of these procedures rebuilds the femoral head or prevents replacement.
When Does Hip Replacement Become Appropriate?
When the femoral head collapses, patient sources describe total hip replacement as the most successful option, saying that it relieves pain and restores function in the majority of patients with osteonecrosis. In this procedure, the ball and the socket are replaced with an artificial joint. You can read the details of the procedure on the page Hip Replacement Surgery in Turkey.
The guideline panel says that joint-preserving procedures in stage III are associated with relatively smaller functional improvement than replacement and with less predictable results, and that the decision should be shared between the patient and the doctor, especially in younger patients because of the value of preserving the joint, with very low-quality evidence and a weak recommendation. On the other hand, the panel believes that when there are symptoms before any fracture or collapse (stages I and II), alternatives to replacement should be considered; this is a strong recommendation, but one based on consensus, not on studies.
Replacement is not a treatment failure. It is a decision that balances comfort and function on one side against thinking about the lifespan of the artificial joint and the need to revise it in the future on the other.
Complications of replacement: what is generally known, and what is observed in osteonecrosis. There are general complications of joint replacement surgery whatever the cause of the arthritis, including infection, blood clots, dislocation, loosening of the joint components, fracture of the bone around the artificial joint, and the need for revision surgery. As for the comparison between patients with osteonecrosis and patients with ordinary arthritis, a systematic review of observational studies found that patients with osteonecrosis had a relatively higher rate of revision surgery, and that fracture around the artificial joint and joint infection also appeared relatively more often in some results, while dislocation did not clearly differ between them. The authors were cautious in interpreting this because factors such as the patient’s age and activity may affect the results. Other comparisons should not be attributed to osteonecrosis without a source that supports each one separately.
How Does the Surgeon Choose the Right Treatment?
The decision does not depend on the images alone. The surgeon balances:
- The stage of the disease, and whether there is collapse or a subchondral fracture.
- The size of the necrotic area and its location within the femoral head.
- The condition of the cartilage and the joint, and hip movement.
- Age, activity level, and type of work.
- The severity of symptoms, associated diseases, and the patient’s goals and preferences.
Because the decision requires experience in both joint-preserving procedures and replacement, ask the surgeon about their experience at the stage you are in and about the available alternatives, and do not settle for a single report. You can learn about the specialty in general from the Orthopedic Surgery page.
What Do “Results” Mean in Studies?
Definitions of success differ between studies, and they should not be combined into a single judgment. Some measure improvement in pain and function, some measure the absence of collapse on images, and some measure the need for joint replacement, and these are different results. Therefore, improvement in pain does not necessarily mean the necrosis has stopped progressing, and the absence of collapse during the follow-up period does not mean the joint will never need replacement later. Also, most studies are small, some mix different stages, and their follow-up is relatively short.
Risks and Complications
Risks differ from one procedure to another. The guideline panel states that surgeries in general may carry infection, blood clots, equipment failure, and the possibility of needing revision surgery, especially in younger patients. Risks specific to each procedure include:
- Core decompression: Pain at the site, a collection of blood (hematoma), continued progression of the necrosis, and the need for another procedure. Cases of fracture of the upper femur have been recorded after procedures that involve drilling the bone, including a recent case report and an older series on a related procedure. These sources are not enough to determine how common this complication is, so the instructions for protecting the leg after the procedure should be followed.
- Adding bone marrow concentrate: Longer operating time, additional cost, the need for facilities to process the cells, and pain at the site where the marrow is drawn. One study reported a positive marrow culture without clinical infection in a patient, which is a reason not to assume the procedure is free of risk.
- Vascularized fibular graft: A complex procedure with complications at the graft harvest site.
- Corrective osteotomy: Longer recovery, possible deformity, problems with bone healing, and added complexity for later joint replacement.
- Hip replacement: The general complications and the possible differences in osteonecrosis patients are explained in the replacement section above.
Recovery and Rehabilitation
There is no single plan that suits all patients, and this article does not mention durations or timelines, because they differ by procedure and by each patient’s condition and are set by the surgeon’s instructions.
- After core decompression: The patient needs to use a walker or crutches to reduce the load on the bone while it heals, with rehabilitation that progresses from small movements to larger ones according to the stage and the procedure.
- After a vascularized fibular graft: A procedure that needs a healing period, and weight-bearing on the leg progresses gradually using an assistive device according to the surgeon’s instructions.
- After hip replacement: Physiotherapy is an essential part of recovery, and daily activities progress according to the medical team’s assessment.
- Returning to work: It varies greatly between patients. A systematic review reported that return is more likely in younger patients and less likely in those whose jobs are physically demanding.
Cost of Femoral Head Osteonecrosis Treatment in Turkey
O9 Medical estimates the cost of treating femoral head osteonecrosis in Turkey at a range from 5,500 to 14,000 US dollars. This is an initial estimated range, and the cost within it varies according to the stage of the disease and the type of procedure required.
This range does not mean that all procedures, tests, accommodation, or medications are included in it. Therefore, ask before agreeing what the package includes and what it does not include, including tests and imaging, accommodation, follow-up, and any biological preparation. The final price depends on the medical assessment, the treatment plan, and the services agreed upon.
Traveling to Turkey and Follow-Up After Treatment
Before traveling, it is helpful to send your MRI and X-ray images and medical reports for review, because the stage of the lesion and its size are what determine the appropriate procedure. Discuss the alternative options with the surgeon and whether the proposed procedure is supported by evidence for your case. To compare centers, you can look at Best Orthopedic and Joint Surgery Hospitals in Turkey.
As for air travel after surgery, there are no evidence-based guidelines on it according to a survey study in the United Kingdom; surgeons’ advice varied greatly, and airlines and insurers had different restrictions. Because both surgery and travel are associated with a risk of blood clots, leave the decision on the timing of your return to the surgeon according to your condition, and do not rely on a general date. Before returning, plan for follow-up and rehabilitation in your home country with a doctor or physiotherapist, and carry a written summary of the procedure and the instructions.
Signs That Require Urgent Assessment After Surgery
These are general guidelines, and they do not replace your surgical team’s instructions. Contact the medical team or go to the emergency room immediately if you develop severe sudden pain, or inability to bear weight after having been able to, or fever, redness, swelling, or discharge at the wound, or swelling and pain in the leg, or shortness of breath or chest pain.
Medical note: this information is for general education. It does not replace consultation with a specialist doctor and is not a diagnosis or a prescription.