Avascular Necrosis of the Hip Management

Introduction to Management

The optimal management of avascular necrosis of the hip requires a combination of non-pharmacological and pharmacological treatment modalities, with surgical intervention reserved for advanced cases or those failing conservative management, as recommended by the American College of Rheumatology 1

MRI is the preferred diagnostic method for early detection and staging of avascular necrosis of the hip 2, 3

Bisphosphonates may improve bone density and prevent progression of avascular necrosis of the hip, with the American College of Rheumatology recommending their use 2, 3
Calcium and Vitamin D supplementation is essential for bone health, especially with bisphosphonate therapy, as stated by the American College of Rheumatology 2
Regular paracetamol administration should be the first-line analgesic, according to the American Society of Anesthesiologists 4
Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with extreme caution, particularly in elderly patients or those with renal dysfunction, as they can increase bleeding risk 4
Opioids should be used cautiously, especially in patients with renal dysfunction, with reduced dosing and frequency 4
Avoid codeine as it is constipating, emetic, and associated with cognitive dysfunction in elderly patients 4

Osteotomy is considered in young adults with symptomatic hip avascular necrosis, especially with dysplasia or varus/valgus deformity, according to the American College of Rheumatology 1
Total hip replacement (THR) is indicated for patients with radiographic evidence of hip avascular necrosis who have refractory pain and disability, as recommended by the American College of Rheumatology 1

For patients on bisphosphonates, monitor for rare complications like atypical femoral fractures and osteonecrosis of the jaw, as advised by the American College of Rheumatology 2
Monitor for signs of expanding hematoma, infection, neurovascular compromise, and femoral nerve compression 4
Ensure adequate nutrition to support healing, particularly in elderly patients who may be malnourished 4
Elderly patients are particularly susceptible to pressure damage; ensure proper positioning during rest periods 4
Once acute pain subsides, gentle mobilization should be encouraged 4
Physical therapy may be beneficial to restore normal gait and function 4
Secondary prevention of falls should be considered, especially in elderly patients 4

If the patient is on anticoagulants (e.g., warfarin, aspirin, clopidogrel), assess the risk-benefit ratio of continuing therapy 4
For patients on warfarin with significant hematoma, consider checking INR and adjusting therapy if necessary 4
Aspirin may be withheld during recovery unless indicated for unstable angina or recent/frequent transient ischemic attacks 4
Clopidogrel generally should not be stopped, especially in patients with drug-eluting coronary stents 4