Ask the Expert: Avascular Necrosis

by Dr. Charles Cornell
Female Hip Joint - Anatomy Bones

In this week’s edition of Ask the Expert, Dr. Charles Cornell, Orthopedic Surgeon, answers questions in relation to avascular necrosis.

Q1. What is avascular necrosis?

Avascular necrosis (AVN) is a disorder of bone that results from vascular injury. Bone is nourished by microscopic blood vessels that do not have cross circulation. In the femoral head, or ball of the hip joint, small microscopic parallel vessels provide blood supply to the bone of the femoral head. If those vessels become clogged, the area of bone supplied by that vessel dies. It appears that large circulating fat complexes or blood clots are most likely responsible for creating these clogs. Generally, many of the vessels become clogged at the same time causing a large infarct of the femoral head bone. Once the bone dies, the body responds by removing the dead bone and replacing it with new living bone. This is a slow process that occurs over many months. The disorder resulting from AVN is caused by the fact that the dead bone is resorbed faster than the new bone is formed so the structure of the bone is weakened. The weakening can be so extensive that the bone of the femoral head cannot carry normal weight bearing loads and fractures leading to collapse of the structure of the normally round femoral head. When this occurs, the perfect fit between the ball and socket of the hip is lost leading to arthritis. The collapse itself can also be painful. When collapse occurs, hip replacement is usually needed.

Q2. What are some of the causes of avascular necrosis?

Avascular necrosis of the femoral head (AVN) is associated with use of certain drugs and with certain diseases. Alcoholism and prolonged use of steroid medications can lead to AVN. Sickle cell anemia causes avascular necrosis and hip disease is a common morbidity associated with this blood disease. Rheumatologic diseases, most notably systemic lupus erythematous and the immune vascular diseases, are frequently associated with the development of AVN. HIV infection and AIDS is currently one of the most commonly associated diseases with this disorder. Finally, patients who recipients of organ transplants frequently develop AVN which may be associated with the transplant itself as well as the anti-rejection medications that are required. In my own experience, many patients present with no obvious risk factor for development of the disorder. I refer to these cases as “idiopathic AVN”. In these cases, it is important to rule out other diagnoses that can present similarly. These include insufficiency fractures and transient osteoporosis. These disorders are similar but usually result from calcium and vitamin D deficiency or some other metabolically caused bone weakness. Whenever I suspect AVN, I have the patient undergo a thorough diagnostic work-up to detect any deficiency or other cause of bone weakness.

Q3. What should you do if you are diagnosed with avascular necrosis?

If you are diagnosed with AVN, seek out treatment from a specialist interested in the disease. Endocrinologists, rheumatologists and orthopedic surgeons are the subspecialties that usually treat this disorder. Treatment remains very controversial and traditional surgical procedures such as core decompression have been prescribed. In my view, there is almost no scientific support for surgical treatment of the early stages of this disorder. From our understanding of the pathologic process, core decompression and vascularized grafting procedures make little sense and published clinical reports provide little evidence of consistent success. We have had excellent and consistent success treating our patients with bisphosphonate drugs which inhibit bone resorption. These drugs are also used to treat osteoporosis. These agents inhibit the bone resorbing cells called osteoclasts but allow the bone forming cells, osteoblasts, to continue the process of new bone formation unopposed. We believe this treatment is successful because it stops the bone resorption that weakens the bone yet allows repair to continue unopposed. Patients should seek out specialists familiar with this approach.

Q4. What happens if you do not diagnose avascular necrosis early?

Unfortunately, AVN is relatively asymptomatic in the early stages. Pain in the affected hip often does not present until the bone structure is weakened and collapse has begun. As a result, many patients don’t present until the hip is already damaged. If you are diagnosed with AVN, treatment from a specialist should be sought immediately. If you are diagnosed with AVN in the early stages, AVN can be successfully treated with a bisphosphonate drug.

Q5. Is there any current research available for avascular necrosis?

There is a lot of research being performed to improve the treatment of AVN. Most research concerns better drug treatment. There are new antiresorptive drugs being developed as well as drugs which stimulate the bone forming cells. It would make sense that applying a drug that stimulates the ingrowth of new bone would add to the effect of slowing bone resoprtion in preserving the intact bone structure before collapse occurs. Modifications of surgical procedures are also being developed in which stem cell implants are placed into the necrotic area to speed repair. I see this as a promising method to address the intermediate stages where some damage to the structure of the femoral head has occurred but before the collapse is bad enough to result in hip arthritis requiring hip replacement. Finally, research is also being performed to assess the outcome of total hip replacement when it is needed. In the 1980’s when hip replacements were usually implanted with cement, the long term durability of the artificial hips was noted to be poor. However, modern implants seem to perform well for AVN and current research is being done to verify this.


Dr. Charles N. Cornell
is a Joint Replacement Surgeon and Clinical Director of Orthopedic Surgery at Hospital for Special Surgery. Dr. Cornell is board certified by the American Board of Orthopedic Surgeons and was admitted as a Fellow to the American Academy of Orthopedic Surgeons as well as the American College of Surgeons. Dr. Cornell’s areas of expertise include avascular necrosis, fractures and trauma, and total joint replacement, care of arthritis and geriatric orthopedics.

Topics: Orthopedics
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The information provided in this blog by HSS and our affiliated physicians is for general informational and educational purposes, and should not be considered medical advice for any individual problem you may have. This information is not a substitute for the professional judgment of a qualified health care provider who is familiar with the unique facts about your condition and medical history. You should always consult your health care provider prior to starting any new treatment, or terminating or changing any ongoing treatment. Every post on this blog is the opinion of the author and may not reflect the official position of HSS. Please contact us if we can be helpful in answering any questions or to arrange for a visit or consult.

Comments

mike soto says:

i have AVN in the early stage but i have severe hip pain…I also have enlarged lymph nodes on the left groin and pelvic sidewall…not sure what to do.?

HSS on the Move says:

Hi Mike, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Early AVN can be treated with bisphosphonates. They can help with the pain. I don’t think the lymph nodes are related if the hip issue is really AVN.” It is best to consult with your treating physician. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

prasad bhandari says:

thanks for your valuable info.

HSS on the Move says:

Hi Prasad, we’re glad you enjoyed the article!

Thomas Hopkins says:

Dr Cornell, I have a vascular necrosis of my shoulders. It is pre-collapse of the humeral head. Is surgery my only alternative. Or can treatment with a frog like reclast make a difference? Is treatment the same for the shoulders as the hips? Thank you.

HSS on the Move says:

Hi Thomas, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Collapse of the humeral head is rare, but pain can be an issue. The pain does respond to biphosphonate therapy and I would agree that Reclast infusion would be indicated.” It is best to consult with your treating physician. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

HSS on the Move says:

Hi Thomas, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Collapse of the humeral head is rare, but pain can be an issue. The pain does respond to biphosphonate therapy and I would agree that Reclast infusion would be indicated.” It is best to consult with your treating physician. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Carol says:

Hi Dr. Cornell, I was diagnosed with avascular necrosis of my right hip which was caused by a short term/high dose steroid prescription. A total hip replacement was done 1 1/2 years ago with an uncemented stem. After reading your article, I was wondering if there is anything I should be watching out for. I was also wondering if AVN is completely resolved with replacement of the affected joint.
Thank you in advance for your response.

HSS on the Move says:

Hi Carol, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “The AVN is resolved with the hip replacement. All should be well. Be sure to supplement calcium and vitamin D3. Talk with your primary MD about an appropriate supplement.” It is best to consult with your treating physician. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

HSS on the Move says:

Hi Carol, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “The AVN is resolved with the hip replacement. All should be well. Be sure to supplement calcium and vitamin D3. Talk with your primary MD about an appropriate supplement.” It is best to consult with your treating physician. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Felipe Costa says:

Dear Dr. Cornell
I have an aneurysmal bone cyst in my calcaneus and an AVN of the talus. The cyst has appeared before the AVN of talus. Do you think is probably that the AVN of talus would be associated with the ABC of calcaneus?
Thanks

HSS on the Move says:

Hi Felipe, thank you for reaching out. For more information on avascular necrosis, please visit http://www.hss.edu/condition-list_avn-avascular-necrosis.asp. It is best to consult with your treating physician so they can better advise. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

AHM Rezaul Karim says:

Dear Sir, I am from Bangladesh would like to know that my younger brother (30 years) has been suffering from AVN (left hip) for 2 years. On 2012 core decompression was done but no successful result is obtained. As a result he has been suffering from pain and other difficulties. Now the doctors of Bangladesh suggest to go for hip replacement. But considering his age, is there any medical treatment exists without hip replacement. I would be highly grateful if you kindly inform me. If you give me your email address, then i would send the soft copy of medical reports.

HSS on the Move says:

Hello, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “If the core decompression failed, the best treatment is likely total hip replacement. If the head has collapsed, there is no alternative. If the architecture of the hip is still relatively normal, a trial of biphosphonates and Vitamin D should be attempted.” It is best for your brother to consult with his treating physician so they can better advise. If your brother wishes to receive care at HSS, please contact our International Center at 212-606-1186 or by email at international@hss.edu.

Maryann Kriegsman says:

I had bilateral total knee replacement 3 years ago. I did fall on both knees 4 times. The discomfort has gotten progressively worse. I now have pain in both knees with severe pain on steps. I have been diagnosed with AVN. The surgeon has suggested a bi-lateral release of the patella but said the chance of success is only 60%. The surgeon has said that I may have to learn to live with the pain.I also have gone through several sessions of physical therapy without success. Do you have any suggestions or do you know of any doctors in central New Jersey that specialize in AVN, Thank you.

HSS on the Move says:

Hi Maryann, thanks for reaching out. It is best for you to consult with your treating physician who is most familiar with your medical history and course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance. For more information, visit http://www.hss.edu/physician-referral-service.

sherry says:

My husband has just been diagnosed with early stage AVN in his right hip. They have prescribed surgery by coring out the bone and inserting cement. After reading this, am I understanding that this is not a good option with the cement? He is in his 50′s.

HSS on the Move says:

Hi Sherry, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “It has been our experience that core decompression is not necessary and is not particularly effective. We have had better success with drug treatment avoiding the surgical procedure. Additionally, at 50 years of age we would perform a work-up to be sure AVN is the correct diagnosis.” It is best that your husband consults with his treating physician. If he wishes to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Ellen Bambrick says:

My son who is 30 years old has been recently diagnosed with AVN Stage 4 in both hips. Underlying cause is still unkown. Is hip replacement the only alternative.

HSS on the Move says:

Hi Ellen, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Although AVN occurs commonly in young males, there is usually an identifiable cause. If the hip involvement is indeed stage IV, then hip replacement is the best treatment. However, I would try a course of medical therapy first to see if the pain can be reduced. This can often delay the need for hip replacement for several years. Please be sure your son has had a metabolic bone evaluation by a specialist before he has surgery.” It is best for your son to seek an in-person consultation with a treating physician. If he wishes to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

RITESH AGARWAL says:

Dear Sir
I m diagnosed with AVN OF HIP ONE MONTH BACK. AS PER DOC IT IS STAGE 2 IN LEFT AND 1 IN RIGHT. I HAVE STARTED BISOPHANATE DRUG AS ADVISED. PLS ADVISE IF THIS IS THE RIGHT TREATMENT FOR AVN.PLS HELP

HSS on the Move says:

Hi Ritesh, thanks for reaching out. For more information on AVN, click here: http://www.hss.edu/condition-list_avn-avascular-necrosis.asp. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Ritesh says:

Sir after 3 months of bisophanate drug my pain has increased and left hip remain in.stage 2 but my right hip jump to stage 2 from 1. Please help with whether I should continue drugs ? Is there any sten cell treatment available ? Pls help

HSS on the Move says:

Hi Ritesh, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Increased pain can occur. The progression from stage I to stage II is probably not real as the grading before collapse is quite subjective. Be sure that Vitamin D3 2000iu is being taken every day along with calcium supplements (calcium citrate 2 pills daily). Use crutches to unweight the right painful hip.” It is best for you to consult with your treating physician so that they can determine the best course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

suresh says:

I was diagnosed with avn 10 years ago. I”m still working , go fishing etc ,is this normal. What was the longest 1 had to wait before surgery

HSS on the Move says:

Hi Suresh, thanks for reaching out. For more information on AVN, click here: http://www.hss.edu/condition-list_avn-avascular-necrosis.asp. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Pawan Mittal says:

My 22 year old son suffering from Myelopathy(suspected and undignosed Granulmatous/Sarcoidosis/Tuberuculosis) was given Prednisolone 40Mg for 21 days,35 Mg for 10 days,25 Mg for 15 days,20 Mg for 10 days,and continuing on tapered dose,develped AVN in right Hip termed as Stage 2nd) and being treated under Dr Sanjay Agrawala of Hinduja Hospital,Mumbai.He was administered Injection Aclasta and being administered 70 Mg of Alendronic acid weekly with Calcium and Vitamin E intake for past 18 days.He is on crutches and still not feeling better as far as pain in right hip is concerned.I shall be thankful if you can please inform that his treatment is on right course or any other treatment is more preferable.

HSS on the Move says:

Hi Pawan, we appreciate you reaching out to us. However, we think it would be best for your son to consult with his treating physician or seek an in-person consultation for a second opinion. If he is interested in receiving care at HSS, please contact our International Center at 212-606-1185 or by email at international@hss.edu for further assistance. For more information on the International Center at HSS, please visit http://www.hss.edu/international-center.asp.

Katie says:

I have AVN of my right talus following a type 3-4 talar neck fracture dislocation in 2000. I still see surgeon every year for x-ray and folllow up. PT has seen my films and has noticed some depressions and lesions. I am concerned that this finding is suggestive of collapse given that the prognosis was 100% for AVN and 80% for collapse. There is end-stage arthritis that is secondary to AVN. Absolutely no ROM in any direction. When I walk, it feels as though it has either caught or as if you”ve stubbed your toe…only it”s in the lateral, medial, and anterior portion of the ankle and foot. I also have tarsal tunnel syndrome. Should I be concerned about collapse? Does it sound as if it has already begun to collapse? Doctor has mentioned fusion and replacement. Which would be a better option? Pain is somewhat of a problem…but, manageable at most times. ROM, stiffness, talar tunnel, and function are the real problems. Surgeon says that I have a completely non functional foot and ankle. Should I inquire about a talectomy? Sorry for the length…I am being a bit hyperverbose. Thanks for in advance for taking my question.

HSS on the Move says:

Hi Katie, thank you for reaching out. It would be best for you to seek a consultation with a physician so that they can determine the best course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Mary says:

Hi,

I was diagnosed with AVN of the left hip in 2010 after the birth of my daughter. I did see Dr Charles Cornell and he provided me with some great advice regarding my hip. The condition has progressed but I have no symptoms.

Upon Dr. Cornell’s advice …I am taking calcium cit rate and vitamin D. I cannot recall exactly how much citrate to take and I am wondering if you could let me know. I do believe the dosage was 600 mg twice a day. Does this sound right?

thanks
Mary

HSS on the Move says:

Hi Mary, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says that the dose you are taking is correct. Please let us know if we can be of further assistance.

glynne hiller says:

I”m ninety one; fell off my bike 3 years ago on windy day going uphill; shattered my pelvis. After operation I was finally able to swim and walk a mile on the sands..
In a thrice all has changed for the worse. Local bone doctor advises hip surgery quickly. Is it possible to make an appt. with Dr. Charles Cornell asap? I feel confident he will know how to deal with unusual problem

HSS on the Move says:

Hi Glynne, thank you for reaching out. We have sent your inquiry to a representative of our Physician Referral Service, Andrea Houston, and she shall be contacting you shortly.

mary cusson says:

Dr. I was diagnosed with AVN a year ago. I just looked into having a hip replacement and my Dr. said that hip replacement surgery for AVN is not as successful as surgery for an arthiritic hip.
What is your opinion?
Thank you

HSS on the Move says:

Hi Mary, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “The idea that THR doesn’t work as well for AVN is an old idea from the early 1970’s and 80’s when THR’s were cemented. Modern THR implanted without cement and using modern day components are very successful. There is no reason to avoid THR for later stages of AVN as current outcomes are excellent.” If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

debbie says:

Hi. My daughter is a disabled Marine vet who broke her hip 6 yrs ago. Right from the start she has told the VA that something was t right. Found out yesterday she has Stage 4 AVN. Tissue dead and no blood flow to hip. Is total hip replacement the way to go? She is 26 yrs old with a 1 and 2 yr old. Her quality of life is very limited due to the pain. Hope u can help me. Thank u.

HSS on the Move says:

Hi Debbie, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “For AVN following a hip fracture, a total hip replacement is the only option.” If your daughter wishes to seek consult at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Elisabeth says:

Hi, I have AVN in the right hip but also kidney insufficiency. Can antiresorptive drugs be taken with kidney issues?

HSS on the Move says:

Hi Elisabeth, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Antiresorptives are not appropriate for chronic renal failure patients. It is important however to replace 1.25 OH vitamin D and to take the phosphate lowering drugs. Our protocol is not recommended for chronic renal failure patients.” It is best for you to consult with a physician so that they can determine the best course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Adrienne St John says:

I have AVN of both humerus for 10 years after cortisone therapy for MS. I am 73 and do yoga 5 days a week. Should I be avoiding postures like handstands?

HSS on the Move says:

Hi Adrienne, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “If the shoulders are painful, I would avoid positions that overload the shoulder. However, if there is no pain during or after the exercises, I would say it is probably safe to continue.”

Patricia Bramich says:

Hi, I was diagnosed with avn in my left hip last August. Earlier in the year I had had pmr in right arm and treated with steroids which cleared it up. Once avn was diagnosed the steroids were stopped. Had full hip replacement in December by which time right hip was really bad so had another replacement in Feb this year. It now seems avn is in my right shoulder and I have severe arthritis.. How often does it spread? My left shoulder is also getting painful. Nobody seems to know what is causing this to spread so rapidly. I am seeing a consultant end of May but I am in alot of pain.My hips are doing well but I just don””t know where this is going to end and why I have got it. I am 66 and was very active – swimming, walking, helping with my grandchildren and now my life is just on hold. I wonder if you could give any advice. I am also waiting for a CT scan. I have had xrays. Everything takes such a long time,

Thank you for your help

HSS on the Move says:

Hi Patricia, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “It is hard to blame the shoulder pain on AVN alone. It is not uncommon to develop AVN or osteoarthritis in the shoulders and hips. It sounds like you have an autoimmune process which is being called PMR. It is possible that it may be seronegative RA or psoriatic arthritis. Discuss this with your rheumatologist. If the shoulder disease is bad, shoulder replacement may be the best option.” If you wish to seek consult at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Jeremy says:

Hello Dr. CORNELL, My name is Jeremy, I currently serve in the US Army and I have avascular necrosis of the left femoral head. I was mis_diagnosed for three years and I have been now diagnosed for 5 years. Because I am in the service I have been afraid of getting the surgery for fear of losing my career. The pain now has gotten to the point where I will be contacting my physician about setting up the THR. Unfortunately the military isn””t very proactive on alternative therapies. I AM EXTREMELY AFRAID that i will not only be able to continue my career but that i will not be able to play sports with my son. Any advice would be appreciated.

HSS on the Move says:

Hi Jeremy, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “If the condition is advanced and there is femoral head collapse, a THR is needed. This should allow you to perform all activities with only limits on running. In my experience, I have done THR’s on several army officers who continued their careers. If you are special forces, you probably can’t do that, but any other type of support, etc. should be fine.” To learn more about total hip replacements, visit http://www.hss.edu/condition-list_hip-replacement.asp. If you wish to seek consultation at Hospital for Special Surgery, please contact our Physician Referral Service at 877-606-1555 for further assistance.

jomana says:

Dear dr.cornel
i had lecumia on 2003 and i take alot of corticosteroid, and chemotherapy drugs untill 2008 and now i””m cure from leuckemia but i have AVN , it was diagnoised on my 2 hips, 2 sholders and the 2 knees, dr advice me 2 years ago with aclasta i.v i take it 2 time! I hear alendronate is better can i take it also?! is physico therapy can help me? Or what should i do, please advice me

HSS on the Move says:

Hi Jomana, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “If you have received Reclast, than you have been adequately treated and alendronate would not be added. Two doses of Reclast should be the maximal therapy.” If issues persist, you should seek further consultation with your treating physician who is familiar with your diagnosis so that they can determine the best course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Sonia says:

Hello:
My son was diagnosed with AVN advance stages. He is in a lot of pain and can hardly walk. What can be done?

HSS on the Move says:

Hi Sonia, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “If the stage is advanced, then only a total hip replacement can help.” For more information on hip replacements, please visit http://www.hss.edu/condition-list_hip-replacement.asp. Should your son seek consultation at Hospital for Special Surgery, he can contact our Physician Referral Service at 877-606-1555 for assistance in finding the physician that best meets his medical needs at HSS.

James Byron says:

After 7 surgeries spanning 4 years including 2 revisions and deep tissue septic infection I have been diagnosed with AVN of the right femur and greater trochanter. My last surgery in January 2014 presented that the top half of my right femur including my trochanter have AVN. The original injury took place in February 2011 resulting from a traumatic fall 3 months after THR of the right hip. The femur was fractured in multiple places as well as the trochanter. One month after surgery I was admitted in septic shock and have been taking a chronic suppressive antibiotic ever since as a precaution. My second right hip revision is beginning to loosen. A recent bone scan reveals healthy bone in distal half of femur but my surgeon does not believe another revision would be successful given the repeated failures and possible infection. I have been on crutches for the better part of 4 years with less than 50 per cent weight bearing. Some doctors who have been consulted have suggested a girdle stone. My surgeon does not think this is a good option for me as I was an active man and am only 66 yrs old and In otherwise good health. At the moment there is no surgical corrective plan in place. I remain on suppressive antibiotics until there is a decision on the next step. I am on borrowed time as the revision continues to fail and the pain continues to escalate. I would be very interested in Dr. Cornell””s opinion of a course of action.

HSS on the Move says:

Hi James, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “This situation requires a consultation before a definitive opinion can be made, but likely we would recommend a 2 stage procedure with resection of the infected bone and proximal femur with placement of a temporary antibiotic spacer for 6 weeks. We would then typically perform a proximal femoral replacement. The secret to success is the removal of all infected bone.” If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

matthew neisius says:

I””m 33 year old male. Who was diagnosed with acute lymphoblastic leukemia at the age of 28. I finished with all leukemia treatments about 2 years ago. In that time I have lost both hips, and both shoulder joints. I had all 4 replaced with in a 14 month time spans. Now to find out that my Plvis is dieing and also my shoulder blades Are dead. What would be my out come. I can””t seem get any answers.

HSS on the Move says:

Hi Matthew, thank you for reaching out. It is best that you seek an in-person consultation with a physician so that they can determine the best course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

ashley says:

Im a 28 yr old female who has stage 4 AVN in my left hip. I had vascularized bone graft in 2005, and did well up until about a year ago when my hip began to bother me with stiffness and pain (but no further degeneration shown in the hip on xrays…still stage 4). How long should a bone graft relieve AVN problems, and where do I go from here (is hip replacement my only option and should I be worried being only 28 with a fake hip?)

HSS on the Move says:

Hi Ashley, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Following the vascularized bone graft the next option is really only THR. The time for that depends on your symptoms. If you are severely painful then you should proceed. Also, if your hip function is becoming poor you should proceed. It would be good to get you a bit older if possible but I wouldn’t sacrifice your quality of life to delay for just a few years.” It is best to consult with your physician on determining the best course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Cynthia Cott says:

Hello Dr. Cornell,
I””ve been diagnosed with bilateral AVN of the femoral heads, Ficat Stage 2 (probably due to alcohol consumption, however I had quit 3 years prior to the onset of symptoms). There is approximately 40% to 50% involvement of the weight bearing area of the femoral heads. I also have significant bone marrow edema in the symptomatic hip. The onset of pain came on suddenly last December, with only one hip symptomatic. I cannot walk without the use of a cane, as weight bearing is quite painful (I have no pain at rest). In your opinion, would Bisphosphonate be worth trying rather than a THR?
I appreciate your help in this matter!!!!

HSS on the Move says:

Hi Cynthia, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “Yes, I would definitely consider the bisphosphonate protocol. You would be an excellent candidate for this. Start taking Vitamin D3 over the counter capsules 2,000IU every day and use the cane or crutches to unload the hip. See a physician in your area who will help you with the bisphosphonate protocol. They would be welcome to contact us for the use of the protocol.” If you wish to receive care at Hospital for Special Surgery, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Cynthia Cott says:

Thank you so much Dr. Cornell! I wish I didn””t reside on the other side of the country! Strangely, the severe pain has been receding over the past few weeks and I””m able to walk without the use of a cane (I guess I better start using it to decrease the weight bearing). Would my primary physician be able to administer this or would I need to see a specialist? Thanks again ever so much!

Murugan Valiyavan says:

I was diagnosed with AVN on June 01, 2015. After taking MRI, my orthopedic surgeon told me that since the lesions of both hips are less than 10%, I don’t need any treatment. He also said it will correct itself. I took a print oI notice your Q&A section above for the question number 4, you recommending bisphosphonate drugs for early stage.
Should I take bisphosphonate as well? Did you ever someone recover from AVN at 10% lesions?

The MRI says no cyst, no edema

HSS on the Move says:

Hi Murugan, thank you for reaching out. Dr. Charles Cornell, Orthopedic Surgeon, says: “For 10% involvement stage I, I agree that no treatment is needed.”

Ven says:

Hi Charles,

Please suggest me on below report, if i need to go for CD or medicines, much appreciated on your help

Below is summary of my MRI:

Bilateral formal heads Left>Right
Stage II – III on left
Stage II on Right

No other significant abnormality in hip joints
Minimal left hip joint effusion seen, right hip joint spaces are normal.

Focal irregular serpigeneous altered signal intensity areas seen in anterosuperior aspect of right formal head which are isointense on T2W and STIR sequences with irregular thin T2W peripheral hypointense rim.

Rest of visualized bones are normal in signal intensity.

HSS on the Move says:

Hi Ven, thank you for reaching out. It would be best for you to consult with your treating physician so that they can determine the best course of treatment.

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