Observation and reflection on special cases series of successful long-term conservative treatment for osteonecrosis of femoral head

doi:10.3877/cma.j.issn.1674-134X.2026.03.015

Abstract

Abstract:

Objective

To analyze the characteristics of patients with osteonecrosis of the femoral head (ONFH) who achieved long-term success with conservative treatment and to summarize clinical experience in the conservative management of ONFH.

Methods

A retrospective analysis was conducted on patients with ONFH who received conservative treatment at the First Affiliated Hospital of Guangzhou University of Chinese Medicine from October 2009 to October 2024, with a continuous follow-up of more than five years. The Association Research Circulation Osseous (ARCO) stage, Japanese Investigation Committee (JIC) classification, and percentage of femoral head involvement were recorded and descriptively analyzed. According to the imaging outcomes, the cases were classified into three types: long-term stable type, medial collapse type, and subchondral fracture repair type.

Results

A total of 16 patients were included, with a follow-up duration of 8 (7, 12) years. Among them, 10 cases were classified as long-term stable type, five as medial collapse type, and one as subchondral fracture repair type. In the long-term stable group, one patient with JIC type C1 had mild femoral head involvement, three patients had severe involvement but with lesions located medially (JIC type A), and the remaining six patients had mild or moderate involvement with JIC type A or B. All the five medial collapse cases had severe femoral head involvement, and four of them exhibited a "collapse-arrest-repair" process. The single subchondral fracture repair case was JIC type C1 with moderate femoral head involvement and preserved lateral cortex; the subchondral fracture line disappeared within eight years.

Conclusions

JIC types A and B are the most suitable candidates for conservative treatment, generally achieving long-term stability. Even when collapse occurs due to a large necrotic area, it tends to be self-limiting or even repair, with a favorable prognosis. For patients with JIC type C1, if the percentage of femoral head involvement is mild or moderate and the lateral cortex is preserved, long-term stability or even healing of subchondral fracture is still possible. However, identification is more difficult. It is recommended to combine quantitative assessments such as the preserved angle of the lateral wall or the China-Japan Friendship Hospital (CJFH) classification.

Key words: Femur head necrosis, Conservative treatment, Follow-up studies

Zixi Jiang, Gengling Guo, Zhiqiang Huang, Xiang Huang, Xuemei Dai, Huantao Mo, Kanghuo Li, Zhenqiu Chen, Zeqing Huang. Observation and reflection on special cases series of successful long-term conservative treatment for osteonecrosis of femoral head[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(03): 375-380.

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Figures/Tables 4

Figure 1 Follow-up images of long-term stable ONFH (osteonecrosis of the femoral head). A and B are primary radiographs of right hip at anteroposterior (AP) and frog-leg lateral (FL) positions, showing high-density medial necrotic lesion with intact contour and no collapse; C is mid-slice image of coronal T1WI MRI of bilateral hips in the follow-up of three months, showing extensive necrosis in right femoral head; D and E are radiographs of right hip at AP and FL positions in the follow-up of 13 years, demonstrating intact contour without collapse

Figure 2 Radiographs of left hip with medial collapse-type ONFH (osteonecrosis of the femoral head) at anteroposterior and frog-leg positions. A and B are primary images, the arrows indicating low-density cystic area; C and D are images in the follow-up of three years, arrows showing high-density sclerotic rim at lesion margin; E and F in the follow-up of eight years, arrows demonstrating collapse and subsidence along the sclerotic rim

Figure 3 Follow-up images of medial collapse-type ONFH (osteonecrosis of the femoral head). A is primary radiograph of right hip at anteroposterior (AP) position, arrow showing low-density break line; B is primary radiograph of right hip at frog-leg lateral (FL) position, arrow showing extensive cysts; C is coronal CT image of bilateral hips at one year follow-up, arrow indicating clear medial break line; D is coronal MRI image of bilateral hips at one year follow-up in maximal lesion section, showing extensive necrosis; E and F are radiographs of right hip at AP and FL positions in two-year follow-up, the arrow in E showing narrowed break line compared to the primary one, the arrow in F showing remaining large cysts; G and H are radiographs of right hip at AP and FL positions in seven-year follow-up, showing increased density at original break line, the arrow indicates the increased cystic density

Figure 4 Radiographs of left hip with subchondral fracture repair-type ONFH (osteonecrosis of the femoral head) at anteroposterior and frog-leg positions. A and B are primary images, the arrow showing subchondral fracture line; C and D are images in the follow-up of four months, the arrow showing fracture line extension; E and F are images in the follow-up of one year showing that original fracture line disappeared, the arrow indicates decreased lesion size; G and H are images in the follow-up of eight years showing that increased density in original fracture area, the arrow indicates further shrinkage

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