Avascular Necrosis — Treatment Without Joint Replacement

A diagnosis of avascular necrosis does not always mean immediate joint replacement. In early stages, joint-preserving methods are possible — which ones, and what can realistically be expected from them.

What Is Avascular Necrosis

Avascular necrosis (AVN) is death of bone tissue due to disrupted blood supply. Most commonly affects the femoral head (70%), less often — femoral condyles, talus, humeral head. ICD-10: M87.

Causes

Corticosteroids (30% of all cases) — even a short course of prednisolone
Alcohol (20%)
Trauma (femoral neck fracture, dislocation)
Systemic lupus erythematosus, sickle cell anaemia
Idiopathic (20–30% — cause unknown)

ARCO stages

Stage	MRI / X-ray	What it means
1	Bone marrow oedema, normal X-ray	Early stage; joint-preserving treatment is most promising
2	Necrotic lesion, head contour preserved	High risk of collapse; joint-preserving methods still possible
3	Subchondral fracture, collapse of the head	The joint can rarely be preserved
4	Secondary osteoarthritis	The main option is joint replacement

Joint-preserving treatment

Offloading and addressing causes: a cane or crutches, reducing corticosteroids together with the treating physician where possible, stopping alcohol.
Core decompression — drilling a channel into the femoral head to relieve pressure; sometimes bone marrow concentrate (BMAC) is injected into the channel. In some studies this lowered the risk of collapse compared with decompression alone, but results are inconsistent.
Osteotomies and bone grafting are used in selected younger patients.
Joint replacement — after collapse of the head and with secondary osteoarthritis.

What results to expect

The chances of preserving the joint are highest before the head collapses, so in people at risk with groin pain an early MRI is important. After collapse, joint-preserving methods rarely help. No method can guarantee that the disease will stop. More on the avascular necrosis of the femoral head page.

Who it is not suitable for and possible risks

Contraindications

Active infection — at the injection site or systemic, with fever.
Active cancer or ongoing chemotherapy.
Blood clotting disorders or a low platelet count. Anticoagulants are discussed with the physician.
Pregnancy and breastfeeding — the procedure is usually postponed.
A corticosteroid injection into the same area in recent weeks.
Severe stage IV osteoarthritis with axial deformity and joint destruction — joint replacement is usually discussed instead.

Possible risks

Pain and swelling at the injection site for 1–3 days.
Bruising where blood or fat tissue is taken.
Rarely, infection. The procedure is therefore performed under sterile conditions with ultrasound or X-ray guidance.
The effect may be absent or smaller than expected.

If any of these apply to you, mention it in your request. The coordinator will check with the clinic physician whether treatment is possible. Contact a coordinator.

Scientific evidence

Studies of regenerative methods show mixed results. Clinic physicians rely on research including the following:

Hernigou P et al. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res, 2002.
Evans JT et al. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet, 2019.

Next steps: Treatment methods · Treatment cost · How treatment in Germany is organised

Frequently asked questions

Can avascular necrosis of the femoral head be treated without surgery?

At early stages (ARCO I–II, no collapse of the head) treatment includes unloading the joint, addressing the cause (alcohol, corticosteroid doses) and sometimes core decompression. Once the head has collapsed, hip replacement is usually discussed.

What are the first symptoms of femoral head necrosis?

Groin or buttock pain on loading, later also at rest and at night, and reduced internal rotation of the hip. Early stages are not visible on X-ray, so an MRI is needed.

What causes avascular necrosis?

Most often long-term corticosteroid use, heavy alcohol use or a femoral neck injury; less often sickle cell disease, clotting disorders or chemotherapy.

How does RegenPAS help organise treatment?

RegenPAS is a patient service centre in Munich, not a clinic. We review your images and symptoms and send a request to several partner clinics at once. Clinics that can accept you send their own conditions and price; prices differ between clinics, and you choose the option that suits you. The coordinator replies within 24 hours, and a clinic physician’s preliminary opinion follows in 1–3 business days. We then arrange the appointment, visa invitation, interpreter, transfers and accommodation. Treatment decisions are made by the clinic physician. Contact a coordinator.

How much does treatment cost and how long do I need to stay in Munich?

The cost depends on the method, the diagnostics needed and the clinic itself: prices differ between clinics. We request offers from several clinics and send you their conditions and quotes so you can compare. Price guidance is on the treatment cost page. For an outpatient procedure, 2–3 days in Munich are usually enough: examination, procedure and follow-up visit.