Advanced degenerative arthritis and osteonecrosis of the femoral head

Case contributed by Dr Mohamed Mahmoud Elthokapy

Presentation

Chronic left hip pain and deformity, with a recent increase in pain and more limited movement

Patient Data

Age: 45 years
Gender: Female

The left hip joint shows markedly reduced joint space with a superolateral displacement of the left femoral head which appears collapsed, deformed with a widened neck. Associated exuberant osteophyte lipping as well as sclerosis and subarticular pseudocysts of opposing articular surfaces.

The left hip joint shows significantly reduced joint space more superior-laterally with marginal osteophytes as well as articular surfaces multiple osteochondral ulcers and subchondral pseudocysts are involving mainly the femoral head. Associated surrounding patchy areas of marrow edema pattern seen involving the femoral head and neck eliciting low T1, high T2 & STIR signal. Associated chondral irregularity and denudation with subchondral fissuring and degenerative/reactive changes are also noted.

The left femoral head's spherical contour is altered and relatively deformed with enlargement of the femoral head and neck (coxa magna).

Associated mild left hip joint effusion with mild synovial thickening likely reactive synovitis.

Case Discussion

The clinical scenario is that a female patient on steroid therapy complained of left chronic hip pain many years ago, claimed old trauma a few years ago, and she didn't seek medical advice at the time.  The pain was accommodated, then recently presented with severe pain, and an inability to move her left hip as well as limping.  Imaging studies revealed left hip advanced secondary osteoarthritis with coxa Magna with femoral head avascular necrosis (AVN), a small joint effusion, and likely reactive synovitis.

Avascular necrosis of the femoral head can occur due to subtle injuries which can not be foreseen or avoided. Optimal surgical treatment in advanced stages is total hip arthroplasty.

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