Joint-Preserving Surgery for Osteonecrosis

If osteonecrosis is limited to small lesions that have not spread outside the affected joint, orthopaedic surgeons at NYU Langone’s Hospital for Joint Diseases offer a range of surgical procedures to stop the progression of the disease, preserve the joint, and relieve pain. These procedures are often performed in the hip or knee, but if osteonecrosis is diagnosed in another joint, such as the shoulder or elbow, your doctor can discuss whether surgery is right for you.

Doctors may recommend joint-preserving surgery for people under age 40 or for older people in good health who aren’t being treated for other medical conditions, such as systemic lupus erythematosus or rheumatoid arthritis, which require corticosteroid or immunosuppressant therapy. Taking corticosteroids may prevent a joint-preserving procedure from being effective.

Depending on the severity of osteonecrosis, doctors may prescribe bisphosphonates or other medications in addition to recommending surgery.

Core Decompression

In core decompression, a surgeon uses a drill to remove diseased tissue from the inside of the bone affected by osteonecrosis. This procedure relieves pressure within the bone, increasing blood flow and allowing new blood vessels to form.

A doctor may also perform one or more additional procedures at the same time as core decompression. These allow the surgeon to insert a bone graft or organic materials into the decompressed bone to help tissue regenerate.


Surgeons may take healthy bone tissue from another part of your body and use it to replace the diseased bone. This type of bone graft is called an autograft. The transplanted tissue grows in its new location, and the new, healthy bone cells generate strong bone tissue.

Vascularized Bone Graft

When a segment of bone is taken from another part of your body—typically the lower leg or ankle—doctors may remove an intact artery and vein as well. This is called a vascularized bone graft. These transplanted blood vessels help to restore blood supply to the bone.

Vascularized bone grafts are used only in those with healthy blood vessels. People who smoke or have peripheral artery disease may not be candidates. The possibility of complications at the donor site may also affect the decision to use a vascularized graft.


If bone can’t be taken from a person’s own body because the bones or supporting blood vessels aren’t healthy enough, doctors use bone tissue that was donated to a bone bank. Called an allograft, this type of bone graft may take longer to incorporate into the bone, but when incorporated, it produces similar results as a graft taken from your own bone.

Allograft bone can be combined with other biologic materials to help the transplanted tissue incorporate into the surrounding bone.  

Biologic Injections

Another procedure sometimes performed during core decompression is the injection of organic materials called biologics. These can be living cells that have been customized to perform a specific function—in this case, to regenerate healthy bone cells or to produce growth factors and other chemical substances that aid in bone healing.

Doctors inject biologics into the interior of the bone during core decompression, and they are absorbed into the bone.

Stem Cell Transplantation

Stem cell transplantation is an experimental technique performed at NYU Langone that uses stem cells harvested from a person’s own bone marrow to stimulate the growth of new, healthy bone cells.

First, doctors use local anesthesia to numb the area, then extract bone marrow from the pelvic bone using a needle. After the stem cells are separated from blood and other substances, doctors inject them into the hollow part of the diseased bone, where they create new bone cells and speed healing.

What to Expect After Core Decompression

Typically, procedures that involve core decompression—which may or may not also include a bone graft or injection of organic materials—take 6 to 12 months to heal fully. You may or may not need to stay overnight in the hospital. Sutures are usually removed during a follow-up appointment scheduled two weeks after surgery, and additional appointments are usually scheduled monthly so your surgeon can monitor how your bones heal.

You may be on crutches for 6 to 12 weeks immediately after your surgery. Doctors can monitor healing progress using X-rays or MRI scans. During that time, your surgeon works closely with NYU Langone physical therapists to customize a timeline for your return to physical activity.

Arthroscopic Cleansing

Arthroscopic cleansing is a minimally invasive surgical technique doctors use to remove bone chips or loose pieces of cartilage that may be causing pain or affecting a joint’s range of motion. This surgery is often performed at the same time as core decompression, but if the results of diagnostic tests indicate that removing loose pieces of bone or cartilage may improve joint movement, and osteonecrosis is not severe enough to warrant core decompression, arthroscopy may be performed on its own.

Surgeons perform arthroscopy using regional anesthesia. After making small incisions around the joint, a surgeon inserts a pencil-sized instrument called an arthroscope, which has a light and a camera lens at its tip, into one of the incisions. This enables the doctor to view the interior of the joint on a monitor. He or she can detect any damage to the bones where they meet in the joint.

After the arthroscope is positioned correctly, the surgeon inserts small surgical instruments through a second incision and uses them to remove loose pieces of bone or cartilage.

What to Expect After Arthroscopic Cleansing

Arthroscopic surgery is almost always an outpatient procedure, and you can expect to go home within hours of surgery. Most people who have this procedure performed on the hip or knee are able to walk with crutches almost immediately after the procedure. Our pain management specialists ensure you have the medication you need to remain comfortable during recovery.

Doctors recommend using crutches for two to three weeks, and your surgeon schedules a follow-up appointment for two weeks after surgery to remove stitches and confirm that the incision wounds are healing. Your surgeon also examines your hip or knee and asks you to move your leg gently in different directions to assess its range of motion after surgery.

Our doctors recommend starting physical therapy in the days after surgery. Physical therapy helps you to rebuild muscle strength, flexibility, and range of motion in the joint.


If an osteonecrosis lesion in the femur, or thighbone, has not spread beyond the hip or knee joint, and if the bones in the joint have not collapsed, a surgeon may perform a procedure called an osteotomy. In this procedure, a surgeon cuts small pieces of bone from the femur at the hip or knee joint, altering the alignment of the limb and therefore changing the way the body’s weight is balanced on the joint.

The goal of this realignment is to redistribute the body’s weight away from the lesion and onto a strong, healthy part of the bone, limiting further damage and preserving the joint.

Surgeons perform osteotomy using general or regional anesthesia. Your doctor can help you decide which approach is best for you.

What to Expect After Osteotomy

After surgery, you remain in the hospital for several days while the bone begins to heal. During this time, our pain management specialists ensure that you recover comfortably and have the medication you need. In addition, a physical therapist visits you and assesses your range of motion. He or she also helps you stand and walk using crutches or a walker.

Doctors schedule a follow-up appointment to remove stitches or staples two weeks after surgery. Crutches or a cane are required for at least six additional weeks.

Doctors recommend starting physical therapy to rebuild strength and range of motion in the hip or knee as soon as you can walk without pain.

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