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If you suddenly cannot bear weight on the hip, seek medical care today. Sudden collapse of the femoral head causes severe pain and disability. Also seek urgent care for a hot swollen hip with fever.

Home  /  Treatments  /  Joint replacement  /  Avascular necrosis of the hip

Avascular necrosis of the hip

The blood supply to the ball of the hip joint fails and the bone begins to die. Caught before the surface collapses, the hip can sometimes be saved. After collapse, replacement is usually the only option.

This is the orthopaedic condition where timing matters most, and where delay is most costly. It also affects a much younger group than ordinary arthritis — frequently people in their thirties and forties.

Clinically reviewed by Dr. Annie Varughese, Consultant Orthopaedic Surgeon Clinical oversight Dr. Annie Varughese, MD, FACC Last reviewed August 2026 Editorial and medical review policy
Typical age
30 to 50
Far younger than ordinary hip arthritis
Deciding test
MRI
X-rays are normal in early disease
Before collapse
Hip may be saved
Core decompression and other procedures
After collapse
Usually replacement
With a young patient's implant considerations
On this page
  1. What it is
  2. Symptoms and warning signs
  3. How it is diagnosed
  4. Treatment options
  5. How the choice is made
  6. How urgent is your case
  7. What to send us
  8. Questions patients ask
The condition

What avascular necrosis is

The femoral head — the ball of the hip joint — has a precarious blood supply carried by a small number of vessels. If those vessels are interrupted, the bone they feed dies. The dead bone initially retains its shape, which is why early disease causes pain without any visible change on X-ray.

Over months the dead segment weakens and eventually the smooth spherical surface collapses. Once it does, the joint surface is permanently deformed and secondary arthritis follows quickly.

The commonest causes are prolonged corticosteroid treatment, heavy alcohol use, sickle cell disease, previous hip fracture or dislocation, and radiotherapy. In a substantial proportion no cause is ever identified. Sickle cell disease is a particularly important cause among patients travelling from Sudan, Yemen and parts of Africa, and it frequently affects both hips.

The critical distinction is before or after collapse. Before, there are procedures that may preserve your own hip. After, the joint is mechanically damaged and replacement becomes the realistic answer — which in a patient of thirty-five means facing the likelihood of revision surgery later in life.

Symptoms

Symptoms and warning signs

Common symptoms
  • Groin pain, often starting gradually
  • Pain on weight bearing that worsens over months
  • Pain at rest and at night as it progresses
  • Restricted hip movement, particularly internal rotation
  • Limp
  • Pain in both hips, since the condition is frequently bilateral
  • Sometimes no symptoms at all in the early stage of the second hip
Warning signs of an emergency
  • Sudden inability to bear weight
  • Sudden severe increase in pain, suggesting collapse
  • Hot swollen hip with fever
  • Fever with sickle cell crisis and hip pain
  • New numbness or weakness in the leg
  • Rapidly worsening pain over days

A normal X-ray does not exclude avascular necrosis

In the early stages — precisely the stage at which the hip might still be saved — X-rays are frequently normal. Only MRI reliably detects it. If you have hip pain with recognised risk factors such as steroid treatment, sickle cell disease or heavy alcohol use, and your X-ray is normal, ask for an MRI. And because the condition affects both hips in a large proportion of patients, the MRI should include both, even if only one hurts.

Diagnosis

How it is diagnosed

MRI is the essential test and X-ray alone is not sufficient.

Initial tests

  • X-ray of the pelvis — normal in early disease; later shows sclerosis, the crescent sign, and eventually collapse
  • MRI of both hips — detects the condition before any X-ray change and shows the size and location of the dead segment
  • Blood tests — including sickle cell screening where relevant, and clotting studies in selected patients
  • History of risk factors — steroid use, alcohol, sickle cell, previous hip injury

The deciding tests

  • Staging on MRI — Ficat or ARCO staging, which determines whether hip-preserving surgery is still possible
  • Size and location of the lesion — a small lesion away from the weight-bearing area behaves very differently from a large one beneath it
  • CT — occasionally used to assess subtle collapse not clear on plain films

Ask for the stage, and whether the head has collapsed

These two facts determine everything. Send the MRI report and, if possible, the images. We need to know the stage, the size of the affected segment, whether it involves the weight-bearing surface, and whether the femoral head remains spherical. If the report does not say, that is worth clarifying before any treatment decision.

Options

Treatment options

Before collapse there are hip-preserving options. After collapse there generally are not.

Before collapse

Core decompression, with or without grafting

A channel is drilled into the dead segment to relieve pressure and encourage new blood vessels to grow in. Bone graft or biological material may be added. It works best in small, early lesions and is considerably less effective in large ones under the weight-bearing surface. It is not guaranteed, but it may preserve your own hip for years.

Usually appropriate whenEarly stage disease with the femoral head still spherical, particularly with a smaller lesion.
Before collapse

Vascularised bone grafting or osteotomy

A graft of bone with its own blood supply is transferred into the dead area, or the femur is cut and rotated so that healthy bone takes the weight-bearing load. These are technically demanding procedures with longer recovery, performed in specialist centres, and reserved for younger patients where preserving the natural hip has real value.

Usually appropriate whenYounger patients with pre-collapse or very early post-collapse disease, at centres experienced in these techniques.
After collapse

Total hip replacement

Once the head has collapsed, replacement reliably relieves pain and restores function. The complication in this group is age — a patient of thirty-five may need one or two revisions across their lifetime, which makes implant choice, bearing surface and preserving bone stock more important than in an older patient.

Usually appropriate whenThe femoral head has collapsed, or arthritis has developed secondary to it.
Alongside

Treating the underlying cause

Reducing or stopping corticosteroids where medically possible, stopping alcohol, and optimising management of sickle cell disease. This does not reverse existing damage but it protects the other hip, which in this condition is at substantial risk.

Usually appropriate whenAlways, and particularly important where only one hip is currently affected.
The decision

How the choice is made

Stage first

Pre-collapse and post-collapse are effectively different diseases with different treatments. The MRI settles this.

Then lesion size and location

A small lesion away from the weight-bearing dome may never progress. A large one beneath it usually will.

Then your age

In a patient of thirty-five, preserving the natural hip has considerable value because every replacement has a finite lifespan and revisions become progressively harder.

If your MRI shows early disease, we will discuss hip preservation before replacement — even though a replacement is the larger and more expensive operation.

Urgency

How urgent is your case

Usually safe to plan travel
  • Established diagnosis with stable pain
  • Imaging complete including MRI
  • No active infection
  • Sickle cell disease stable and well managed
Needs local assessment before travel
  • Sudden inability to bear weight
  • Acute sickle cell crisis
  • Hot swollen hip with fever
  • Active infection anywhere
  • Uncontrolled underlying disease requiring high-dose steroids

We will tell you which column you are in

Avascular necrosis progresses over months rather than days, but the window for hip preservation closes. Do not postpone the MRI.

Next step

What to send us

Photographs taken on your phone are fine. Reports in Arabic, Russian or Bengali are fine — we translate them ourselves.

Most useful

  • MRI report of both hips, with the stage
  • X-rays of the pelvis
  • Details of steroid use, alcohol, or sickle cell disease
  • Your age and which hips are painful

Also helpful

  • MRI images if you can obtain them
  • Blood tests including sickle cell screening
  • Any previous hip surgery or injury
  • Current medication list
Send my reports for review See published cost ranges
Questions

Questions patients ask

Possibly, if the femoral head has not yet collapsed and the affected segment is not too large. Core decompression and grafting procedures aim to preserve your own hip and can succeed for years. Once the surface has collapsed, these procedures generally do not help and replacement is the realistic option. The MRI stage determines which applies.

Yes, and this is the single most important point on this page. Early avascular necrosis is invisible on X-ray. If you have risk factors — steroid treatment, sickle cell disease, heavy alcohol use, previous hip injury — and hip pain with a normal X-ray, ask for an MRI of both hips.

Because the condition affects both hips in a large proportion of patients, and the second hip is frequently silent in its early stage — which is exactly the stage at which it might be preserved. Finding it early on the asymptomatic side is one of the most valuable things an MRI can do.

That depends on the stage. If the head has collapsed and you are in constant pain, replacement will restore your life and the modern results are good. But at thirty-five you should expect revision surgery at some point, which is why preserving your own hip is worth serious consideration if the stage allows it, and why implant choice matters more in your case.

No, it will not reverse bone that has already died. But reducing or stopping steroids where your other medical conditions allow protects the unaffected hip and other joints, and it is worth discussing with the doctor who prescribed them. Never stop steroid treatment abruptly on your own.

Yes, in important ways. Sickle cell patients need careful management around surgery — hydration, oxygenation, temperature control and sometimes transfusion — to reduce the risk of a crisis. Both hips are frequently affected. The operation is performed successfully in these patients routinely, but it should be done where haematology support is available, and we take that into account when choosing the hospital.

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Contact

Send us your reports

Send the MRI report for both hips with the stage. Whether the femoral head has collapsed decides whether your own hip can be saved.

Your reports go directly to our medical team. We do not share your records with hospitals until you tell us to.

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