Surgical management techniques for avascular necrosis of the femoral head: a systematic review

Abstract Early surgical intervention for avascular necrosis (AVN) of the femoral head can preserve the hip joint and delay the need for total hip arthroplasty (THA). Therefore, the purpose of this study is to compare the efficacy of various surgical modalities to treat femoral head AVN as assessed by THA-free survivorship, radiographic failure, and patient reported outcomes measures (PROMs). PubMed, Cochrane, and Scopus were queried in March 2024. Studies reporting THA conversion rates at minimum 2-year follow-up after index surgery for femoral head AVN were included. Seventy study cohorts met inclusion criteria across all interventions: Core Decompression (CD) (n = 20), CD with Orthobiologics (CDO) (n = 15), Vascularized Bone Grafting (VBG) (n = 19), and Rotational Osteotomy (RO) (n = 16), representing 6 573 patients [CD n: 910; CDO: 779; VBG: 3998; RO: 886]. Conversion to THA rates among the various surgical techniques were: 41.8% for CD, 29.7% for CDO, 9.7% for VBG, and 24.3% for RO. Post-operative radiographic failure rates included: 47.0% for CD, 37.1% for CDO, 33.3% for VBG, and 31.2% for RO. Finally, all four surgical techniques reported improved post-operative PROMs compared to pre-operative scores. VBG patients report lower rates of conversion to THA compared to those undergoing other surgical management techniques. CD patients had the highest rates of radiographic failure and THA-free survivorship that both decreased with orthobiologic augmentation. Furthermore, patients had improvement in post-operative PROMs compared to pre-operative scores regardless of surgical technique.