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Review
. 2025 Aug 7;14(15):5592.
doi: 10.3390/jcm14155592.

The Role of Proximal Femoral Osteotomy for the Treatment of Avascular Necrosis: A Systematic Review of Clinical and Patient-Reported Outcomes

Paul L Rodham  1   2   3 , Jamila Tukur Jido  4 , Hannah Bethell  5 , Vasileios P Giannoudis  1   2   3 , Michalis Panteli  6 , Nikolaos K Kanakaris  1   2 , Peter V Giannoudis  1   2   3
Affiliations
Review

The Role of Proximal Femoral Osteotomy for the Treatment of Avascular Necrosis: A Systematic Review of Clinical and Patient-Reported Outcomes

Paul L Rodham et al. J Clin Med. .

Abstract

Background/Objectives: Avascular necrosis of the femoral head is a debilitating condition that, if left untreated, leads to progressive arthritis necessitating total hip replacement (THR). In the younger adult population, there is a drive towards joint-preserving procedures, particularly where alternative techniques such as core decompression or vascularised bone grafting are anticipated to fail. Proximal femoral osteotomy is a technique that aims to remove the necrotic segment from the weight bearing area. The presented review aims to examine the efficacy of this technique in the management of avascular necrosis of the femoral head, reporting both rates of conversion to total hip replacement and patient reported outcomes. Methods: This systematic review was conducted according to PRISMA guidelines. A search was conducted of PubMed, Ovid Medline, EMBASE, and the Cochrane Library using pre-defined search terms. Data were extracted, and descriptive data presented. Quality of each study was assessed using the NIH quality assessment tool for case series studies. Results: Fifty-three studies with data for 2686 osteotomies are presented. Progression of radiological arthrosis was present in 40% of cases, with 20.3% of patients having undergone conversion to THR at a mean of 75.4 months (range 20-132 months). Patient-reported outcome measures were recorded in 1416 patients, of which the Harris Hip Score was the most commonly utilised. This score improved from a mean of 58.3 to 84.4 at a mean follow-up of 102 months. Conclusions: Osteotomy represented a valid head-preserving technique in the armamentarium against avascular necrosis of the femoral head, with conversion to THR required in 20.3% of patients at 7 years. In those patients who did not require THR, PROMS were similar to the arthroplasty population.

Keywords: avascular necrosis; femoral head; osteonecrosis; osteotomy; total hip replacement.

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Conflict of interest statement

The authors declare no conflicts of interest. Paul L Rodham, Vasileios P Giannoudis and Peter V Giannoudis are supported in part by the National Institute for Health and Care Research (NIHR), Leeds Biomedical Research Centre (BRC) (NIHR203331). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Figures

Figure 1
Figure 1
Flowchart of the study selection.
Figure 2
Figure 2
Percentage of Osteotomy cases revised to THR. Each dot represents the percentage of cases revised in each study at their final follow-up duration. The dotted line represents the line of best fit of all the studies.
Figure 3
Figure 3
Final Harris Hip Score. Each dot represents the Harris Hip Score in each study at their final follow-up duration. The dotted line represents the line of best fit of all the studies.
Figure 4
Figure 4
Final Merle d’Aubigne score. Each dot represents the Merle d’Aubigne Score in each study at their final follow-up duration. The dotted line represents the line of best fit of all the studies.
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