Figure. Anteroposterior radiograph of the pelvis.
A 62-year-old man presents to the office with several months of pain in the left hip. Medical history includes hypertension and hyperlipidemia. He admits to a 10-year history of alcoholism and reports drinking at least 8 beers per day. Anteroposterior radiograph of the pelvis (Figure) shows advanced avascular necrosis (AVN) of the left femoral head.
Submit your diagnosis to see full explanation.
Nontraumatic avascular necrosis of the hip is a result of the disruption of the arterial supply to the femoral head. Several conditions have been associated with AVN, including chronic alcohol use, hypercoagulable states, steroid use, sickle cell disease, and trauma. Alcoholism and steroid use contribute to >65% of nontraumatic cases of AVN. The most widely accepted etiology of alcoholism-induced AVN is that a fat embolus resulting from hyperlipidemia causes an arterial infarct in the femoral head. Alcoholism can significantly increase serum triglyceride and cholesterol levels as well as fatty deposition into bone marrow. The risk of AVN is also influenced by other factors, such as tobacco use, chronic disease, and genetic predilection. The average duration of alcohol abuse when AVN develops is 9½ years with a range of 8 to 20 years. Most individuals who abuse alcohol and develop AVN are aged >50 years and drink >400 ml of alcohol per week. The risk of developing osteonecrosis due to alcoholism is directly related to the average daily amount of alcohol consumed. Patients with severe collapse of the femoral head, as is the case with this patient, are best treated with a total hip replacement.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
1. Jacobs B. Alcoholism-induced bone necrosis. NY State J Med. 1992 Aug;92(8):334-338.
2. Hatch D. Hip osteonecrosis. OrthoBullets website. https://www.orthobullets.com/recon/5006/hip-osteonecrosis. Updated October 30, 2018. Accessed May 21, 2019.
This article originally appeared on Clinical Advisor