Saving the Hip in Early AVN: Core Decompression, Osteotomy and Other Joint-Preserving Options

The MRI was ordered because the groin ache would not settle. Perhaps you had a course of steroid tablets a year ago, or you have been told your liver tests are high, and now the report says “early avascular necrosis of the femoral head, no collapse”. One doctor says to wait and watch, another mentions drilling the bone, and a relative has heard you will need a hip replacement sooner or later. You are in your thirties or forties, you still ride your two-wheeler to work, and you want to know one thing: can this hip be saved?

Often, when AVN is caught before the ball of the hip has collapsed, there is real room to protect the joint. In this guide, our pain specialists explain each joint-preserving option fairly: protected weight bearing, treating the cause, medicines that have been studied, core decompression with or without bone marrow concentrate, osteotomy, and the point at which a replacement becomes the better choice. We also cover how staging decides the plan and the questions worth asking before you agree to anything.

What does “early” AVN of the hip actually mean?

Avascular necrosis (also called osteonecrosis) happens when a patch of bone in the head of the thigh bone loses its blood supply and the bone cells in that patch die. The dead bone does not crumble overnight. For months, sometimes years, the ball keeps its round shape while the body tries to repair the area. If repair cannot keep up, a crack forms just under the cartilage and the surface slowly flattens. That flattening is called collapse, and it is the turning point.

“Early” AVN means the stage before collapse. You may have a deep groin ache, pain on walking or climbing stairs, or pain that wakes you at night, yet the X-ray can still look normal. MRI picks up the change much earlier, which is why it is the key test. If you want a refresher on the first symptoms, our guide to avascular necrosis of the hip: early signs and treatment options covers them in detail. Groin pain is not always AVN, of course: it can come from hip osteoarthritis, and pain on the outer side is more often trochanteric bursitis.

How staging decides your treatment

Doctors use staging systems such as Ficat-Arlet, Steinberg or the ARCO classification. The names differ, but they ask the same questions: has the ball collapsed, how much of the head is involved, and is the joint already worn?

Beyond the stage number, two details change the outlook. The first is size: a lesion involving a small part of the femoral head has a much better chance of staying stable than one taking up a large share. The second is location: a dead patch on the outer, top part of the ball carries the most body weight and is more likely to collapse. A good MRI report describes both, and a good consultation explains them to you. As with any scan, the images must be read alongside your symptoms and examination, not on their own.

Joint-preserving options, explained fairly

Protected weight bearing

This means using crutches or a walker for a period so less load passes through the weak area. It often eases pain and may give a small lesion time to settle. On its own, though, studies suggest it does not reliably stop a larger symptomatic lesion from progressing. It works best as part of a plan, not as the whole plan. In practice it also means avoiding jumping, running, heavy lifting and deep squatting for a while, which matters for anyone who sits on the floor to eat or uses an Indian-style toilet.

Treating the risk factors

No treatment does well if the cause keeps working in the background. The common causes and links include high-dose or repeated steroids (including the courses many people received during COVID-19), heavy alcohol use, smoking, hip injury, sickle cell disease, lupus and other conditions treated with long-term steroids, and some blood clotting problems. Our article on hip pain after steroid treatment explains the steroid link, and steroid side effects covers what repeated doses do elsewhere in the body.

An important point: never stop prescribed steroids suddenly on your own. If you take them for asthma, kidney disease, rheumatoid arthritis or another condition, speak to the doctor who prescribes them about whether the dose can be reduced safely. Cutting down or stopping alcohol and tobacco, and checking cholesterol with a lipid profile, are steps you can start straight away.

Medicines studied in early disease

Several medicines have been tried to slow progression in pre-collapse AVN. Bisphosphonates (bone-protecting tablets also used for osteoporosis) showed promise in some smaller studies, but larger trials have given mixed results. Statins have been studied mainly as a way to lower risk in people who need steroids. Blood thinners have been tried in people with an identified clotting problem, and drugs that widen blood vessels have also been studied. None is a proven cure, and each has its own side effects. If one is offered, ask what evidence supports it for your stage and how long you will take it.

Core decompression, with or without bone marrow concentrate

Core decompression is a surgical procedure in which one larger channel or several small channels are drilled from the side of the thigh bone into the dead area. The idea is to relieve the raised pressure inside the bone, which is thought to cause pain, and to encourage new blood vessels to grow in. It is done under anaesthesia, usually with X-ray guidance, and is followed by several weeks on crutches.

It works best in pre-collapse disease with small to medium lesions. Results are less good once the ball has started to flatten. Many surgeons now add a biologic adjunct: most commonly bone marrow aspirate concentrate (BMAC), where marrow is drawn from the pelvic bone, concentrated and placed into the channel. Some trials suggest this lowers the chance of progression compared with decompression alone, but studies vary in size and quality, and it is not a guarantee. Bone grafts, sometimes with their own blood supply, are another add-on in specialised centres. Risks include fracture of the thigh bone near the drill site, infection and the procedure simply not halting the disease.

Osteotomy

An osteotomy cuts and repositions the upper thigh bone so that healthy bone, rather than the dead patch, takes the main load. Rotational and angular (varus or valgus) osteotomies are the main types. It can work well for carefully selected younger patients with a limited lesion, but it is a bigger operation with a longer recovery, and it can make a later hip replacement more technically demanding. It is offered by relatively few surgeons, so ask about their experience with it.

When hip replacement becomes the better option

Saving the natural hip is worth trying when the odds are reasonable. It is not worth chasing at any cost. Replacement is usually the better choice when the ball has collapsed significantly, when arthritis has developed on the socket side as well, when the lesion is very large, or when pain and stiffness keep you from work, sleep and family life despite proper care. Modern hip replacements generally relieve pain well, and choosing one at the right time is not a failure. Our article on orthopaedic medicine vs orthopaedic surgery explains how the two fields fit together, and the same thinking we use for second opinions before surgery applies to the hip too.

Questions to ask before you choose

• What is my exact stage, and has the ball started to collapse?
• How large is the dead area, and is it in the weight-bearing part of the head?
• Is the other hip affected? Was it included in the MRI?
• What is likely to happen if we only monitor for the next few months?
• For a procedure: how many have you done, what results do your patients get at my stage, and how long will I be on crutches?
• What is causing my AVN, and what are we doing about that cause?
• How will we know it is working, and when is the next scan?

How Dr Heal approaches early AVN of the hip

Our hip pain treatment for early AVN is built around your stage and your cause, not a fixed package. A typical plan looks like this:

1. Careful assessment and MRI review. A detailed history (steroids, alcohol, smoking, injuries, other illnesses), a hip and spine examination, and a line-by-line look at your MRI, including the other hip. Blood tests and imaging can be done in our in-house laboratory and radiology at our facilities.
2. Find and reduce the cause. Through functional medicine and clinical nutrition, we look at blood sugar, lipids, vitamin D and B12, alcohol and tobacco, and we work with your other doctors on any steroid-dependent condition.
3. Steroid-free regenerative care where suitable. For selected pre-collapse hips, we may use a regenerative preparation made by Dr Heal Pharma, which contains no steroid, painkiller or antibiotic. Its aim is to support the body’s own repair rather than mask pain; it is not a promise to reverse dead bone. Read more about regenerative medicine.
4. Guided rehabilitation. Protected walking with crutches when needed, then hip and core strengthening, gait training and safe ways to manage stairs, floor sitting and bike rides, with regular reviews.
5. Honest follow-up and referral. We track pain, walking and repeat imaging at sensible intervals. If your hip is collapsing, or a procedure such as core decompression, osteotomy or replacement would serve you better, we tell you plainly and help you take that next step.

You can also read about our wider joint pain and arthritis treatment, browse all treatments, or meet our pain specialists.

What you can do at home to protect the hip

• Use the crutches you are given. Partial load on the hip for the advised period is part of the treatment, not a sign of weakness.
• Stop smoking and cut out alcohol. Both reduce blood flow to bone and slow healing, as they do in fracture healing.
• Keep your weight in check. Every extra kilo adds load to the hip with each step; see how weight loads your joints.
• Eat for bone. Enough protein, calcium-rich foods and vegetables help; our guide to diet and arthritis pain has practical Indian meal ideas.
• Swap high-impact activity for low-impact. Swimming, a stationary cycle with a high seat, and upper-body exercise keep you fit without pounding the hip.
• Do not rely on painkillers for months. Masking pain can lead you to overload a weak joint. Read why painkillers are not the answer, and protect your sleep, which affects how pain feels.

Frequently asked questions

Can early AVN of the hip heal completely?

Some small lesions, particularly ones found by chance and not under the main load, stay stable for years or even shrink. Larger or painful lesions are more likely to progress. The aim of early treatment is to keep the ball round and the hip working for as long as possible.

Is core decompression worth it at stage 1 or 2?

It gives its best results before collapse, especially with small to medium lesions. Whether it is right for you depends on lesion size, location, your symptoms and the cause. Ask the surgeon about results at your exact stage.

Does adding bone marrow concentrate make decompression better?

Some studies suggest it lowers the chance of progression compared with decompression alone, but the evidence is still developing and results vary between centres. It is a reasonable option to discuss, not a guarantee.

How often should my hip be scanned?

It depends on your stage and symptoms. Many doctors repeat an X-ray or MRI every few months in the first year, and sooner if pain suddenly worsens. Both hips should be checked at the start.

Can I keep working and riding my two-wheeler?

Desk work is usually possible with breaks. Riding, kick-starting and pushing a heavy bike put sudden load on the hip, so ask your doctor before restarting, and avoid it while you are on crutches.

Where can I get early AVN of the hip assessed in Bengaluru?

Dr Heal Pain Cure Hospital assesses hip pain and reviews AVN MRI scans at its HSR Layout and Banashankari branches. Both are open 24 hours, and patients come to us from across Karnataka.

This article is for general information and is not a substitute for a medical consultation. Please see a doctor for advice about your own symptoms.