An Explainable Plane-Wise ConvNet Approach for Detecting Femoral Head Osteonecrosis from Magnetic Resonance Images

Background/Objectives: Osteonecrosis of the femoral head (ONFH) is difficult to diagnose, particularly in the early stages, because radiological findings may be subtle. Delayed or inaccurate staging may increase the risk of femoral head collapse and functional loss. Although magnetic resonance imaging is highly sensitive for early-stage lesion detection, interpretation may vary depending on observer experience. Therefore, reliable and explainable automated decision support approaches are needed. Methods: In this study, a deep learning-based approach was proposed to classify ONFH into early and late stages according to the Ficat–Arlet staging system. Stage I–II cases were defined as early-stage, whereas Stage III–IV cases were defined as late-stage. Axial and coronal MR images were evaluated separately to investigate plane-dependent classification performance. The images were converted into a three-channel format, resized to a common spatial resolution, normalized, and augmented during training. Feature extraction was performed using transfer learning with modern convolutional neural network architectures. ConvNeXt Tiny was used as the main classification backbone. Weighted loss was applied to reduce the effect of class imbalance, and the decision threshold was optimized on validation data to reduce missed clinically critical late-stage cases. Results: A dataset collected from the Orthopedics and Traumatology Department of Firat University Hospital was used in the experimental evaluation. The dataset was divided into training and test sets using an 80:20 split, and 10-fold cross-validation was additionally performed to assess model stability. In the hold-out test, the axial plane model achieved 94.51% accuracy, 96.80% sensitivity, 93.49% specificity, 0.9162 F1-score, and 0.981 AUC. In the coronal plane model, 92.84% accuracy, 96.13% sensitivity, 90.96% specificity, 0.9072 F1-score, and 0.988 AUC were obtained. The 10-fold cross-validation results provided a more conservative estimate of generalization performance. Conclusions: The findings indicate that deep learning-based plane-wise analysis of MR images can distinguish early- and late-stage ONFH with high performance. Grad-CAM-based visual explanations showed that the model focused mainly on clinically relevant subchondral and weight-bearing regions of the femoral head. The proposed approach may serve as an explainable decision support tool for reducing observer-dependent variability in clinical staging. Future studies should validate the method using external, multicenter datasets and paired patient-level axial–coronal images.