General Guideline Principles for Hip Osteonecrosis

for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Hip Osteonecrosis.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

We have extensive experience in treating this condition. You can read more about it here

We have answered several questions here

Hip Osteonecrosis

Related Terms

Introduction of Hip Osteonecrosis

Osteonecrosis (aka, avascular necrosis) involves bone death Some cases are regarded as occupational disorders, especially in the context of dysbarism (atmospheric compression/decompression) workers, such as divers and other workers in compressed air environments, who experience a reduced blood supply to the femur as a result of nitrogen gas in the blood during excessively rapid decompression. Another documented cause is severe trauma.

It is believed that significant, discrete trauma poses a risk. Non-traumatic occupational physical aspects, however, are debatable. The focus of treatment is focused on reducing the exposure(s) believed to be at fault.

Sometimes, an osteotomy procedure, vascularized and non vascularized bone grafting, and a surgical “coring” procedure are used. Arthroplasty may be necessary in severe situations.

Diagnostic Studies of Hip Osteonecrosis for workers compensation patients

Initial Assessment

Most hip diseases can be accurately diagnosed using the history, physical exam, and radiographs. The knee, spine, abdomen, and genitourinary tract should all be reviewed during the system reviews and examinations.

Imaging studies are most frequently used to diagnose osteonecrosis. Magnetic resonance imaging (MRI with or without gadolinium, etc.) is typically the imaging of choice if the diagnosis of hip discomfort is still ambiguous following radiographs.

Diagnostic Criteria for Non-Red-Flag Conditions

  1. Bone Scanning with SPECT is recommended – for select use in patients with acute, subacute, or chronic pain to assist in the diagnosis of osteonecrosis and other conditions with increased polyostotic bone metabolism, particularly when more than one joint needs evaluation.

    Indications: Bone scanning is mostly used in cases of osteonecrosis since it can be useful in identifying regions of enhanced bone metabolism.

    Frequency/Dose/Duration: one assessment Bone scan use is Supported by the Data


  2. CT for Evaluating Osteonecrosis

    CT for Evaluating Osteonecrosis are recommended for diagnosing patients with osteonecrosis, including those who require advanced imaging but can’t get an MRI or who don’t have access to helical CT.

    Indications: Thought to be osteonecrosis-related hip discomfort, however MRI is contraindicated.

    Frequency/Dose/Duration: Typically, one assessment. If there is a substantial clinical change or to assess progress/resolution, a second assessment may be necessary.

    Rationale: When sophisticated imaging of calcified bones is needed for the majority of hip problems, computerised tomography is thought to be preferable to MRI. There is no obvious advantage of CT over MRI for osteonecrosis. However, the use of CT is restricted, even in environments without helical CT, as it is generally believed that helical CT is preferred for the identification of fracturing.


  3. Helical CT for Evaluating Osteonecrosis

    Helical CT for Evaluating Osteonecrosis is recommended for assessing patients with osteonecrosis who cannot receive an MRI due to medical reasons.

    Indications: considered to be caused by osteonecrosis, particularly in light of worries regarding fracture and collapse. Also suggested for people who require an osteonecrosis examination but who cannot undergo an MRI.

    Frequency/Dose/Duration: Typically, one assessment. If there is a substantial clinical change or to assess progress/resolution, a second assessment may be necessary.

    Rationale: When sophisticated imaging of calcified structures is needed to diagnose most hip problems, helical CT is thought to be better than MRI. There is no obvious advantage of CT over MRI for osteonecrosis. Helical CT is advised for specific applications because it is believed to be more effective than CT at identifying fracture.


  4. MRI for Diagnosing Osteonecrosis

    MRI for Diagnosing Osteonecrosis is recommended for subacute or persistent hip pain presumed to be caused by osteonecrosis, especially if the diagnosis is undetermined or if further testing and/or staging are required.

    Frequency/Dose/Duration: typically one assessment. If there is a substantial clinical change or the need to assess progress or resolution, a second assessment may be necessary.

    Rationale: When it comes to detecting bone collapse, helical computed tomography is thought to be superior to MRI. For imaging bone marrow edema, which is inversely linked with prognosis, MRI is thought to be preferable. As a result, each test has benefits.


  5. X-Rays for Diagnosing Osteonecrosis

    X-Rays for Diagnosing Osteonecrosis is recommended for all individuals who have osteonecrosis, it is believed.

    Frequency/Dose/Duration: It is typical to routinely acquire x-rays to monitor the progression of the condition.

    Rationale: X-rays are useful for evaluating the majority of individuals with hip pain, both to make a diagnosis and to help narrow down the range of possible diagnoses. X-rays taken at the early stages of osteonecrosis may be normal or somewhat osteopenic. A high degree of suspicion must be maintained.


  6. Ultrasound for Osteonecrosis

    Ultrasound for Osteonecrosis is not recommended for diagnosing osteonecrosis

Medications of Hip Osteonecrosis

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even if the majority of research indicates it is just marginally less effective than NSAIDs.

There is proof that NSAIDs are less dangerous and just as effective in treating pain as opioids, such as tramadol.

  1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Osteonecrosis

    Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Osteonecrosis are recommended for the treatment of severe, mild, or persistent osteonecrosis Warning signs Treatment with NSAIDs is advised for osteonecrosis that is acute, subacute, or chronic. First, try over-the-counter (OTC) medications to see whether they work.

    Frequency/Dose/Duration: Many patients could find it reasonable to use as needed.

    Indications for Discontinuation: Osteonecrosis healing, lack of effectiveness, or the emergence of unfavourable effects that need stopping the treatment.


  2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

    NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended for people at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor antagonists, and proton pump inhibitors together.

    Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a prolonged course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

    Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

    Indications for Discontinuation: Intolerance, the emergence of negative effects, or the stopping of NSAIDs.


  3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended Acetaminophen or aspirin as first-line therapy seem to be the least dangerous in terms of cardiovascular side effects. If necessary, non-selective NSAIDs are recommended to COX-2-specific medications.

    To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in individuals receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.


  4. Aetaminophen for Treatment of Osteonecrosis Pain

    Aetaminophen for Treatment of Osteonecrosis Pain is recommended for the management of osteonecrosis pain, especially in patients who have NSAID contraindications.

    Indications: Acute, subacute, chronic, and post-operative osteonecrosis pain in all individuals.

    Frequency/Dose/Duration: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of liver toxicity

    Indications for Discontinuation: harmful effects of pain relief repercussions or intolerance.


  5. Opioids of Hip Osteonecrosis

    Opioids of Hip Osteonecrosis is recommended for brief use (no more than seven days) as an NSAID supplementary treatment.

    Indications: In order to control pain, a brief prescription of opioids is frequently necessary, especially at night, as an adjuvant to more effective medications (notably NSAIDs, acetaminophen).

    Frequency/Dose/Duration: As needed during the day, solely at night thereafter, and finally completely discontinued.

    Rationale for Recommendation: When NSAIDs are ineffective in relieving a patient’s pain, opioids should be used sparingly, especially at night. Opioids should only be taken sparingly and briefly, particularly at night to induce sleep.


  6. Bisphosphonates

    Bisphosphonates are not recommended for treatment of osteonecrosis.


  7. Anticonvulsant Agents (including Topriamate)

    Anticonvulsant Agents (including Topriamate) are not recommended for the management of osteonecrosis-related pain.


  8. Gabapentin and Pregabalin

    Gabapentin and Pregabalin is not recommended for osteonecrosis-related discomfort.


  9. Glucocorticosteroids

    Glucocorticosteroids are not recommended in order to treat osteonecrosis.

Treatments of Hip Osteonecrosis

Finding and treating reversible risk factors is the primary focus of early treatment for mild to severe cases of osteonecrosis. It is advised to cut back on or stop doing things that trigger symptoms noticeably, including avoiding dysbaric exposures. Most moderately severe or severe instances are treated surgically right away, especially if a collapse has already taken place.

Initial Care

The initial stage in evaluating osteonecrosis is determining the severity of the condition. Decompression atmosphere removal is a common early intervention. The majority of patients with osteonecrosis-related hip pain may find relief from nonprescription analgesics tolerable. Surgical intervention is necessary if either the illness is getting worse or the condition is advancing.

De/compression is the main activity to be concerned with in cases of acute and subacute osteonecrosis. Decompression treatments shouldn’t often be administered to patients with osteonecrosis until the condition has improved.

In individuals with osteonecrosis (especially those with more severe illness at risk of collapse), high force and/or high impact force (e.g., jumping) should typically be avoided until the condition is either significantly improved or resolved. No matter whether stage of osteonecrosis you have (acute, subacute, or chronic), sticking to the decompression tables is strongly recommended.

Surgery of Hip Osteonecrosis

  1. Core Decompression Surgery

    Core Decompression Surgery is recommended in order to treat osteonecrosis.

    Indications: individuals with typically moderate to Those with severe osteonecrosis who are either in adjustment of risk factors and/or (ii) perception of risk collapsing and delaying further while addressing danger factors. Treatment with hyperbaric oxygen is seen as being excessively dangerous.

    We have significant experience in core decompression and you can read about it here

    We have edicationed others on the subject


  2. Arthroplasty for Osteonecrosis

    Arthroplasty for Osteonecrosis is recommended to treat severe disease that is unresponsive to non-operative treatment or osteonecrosis with collapse.

    Indications: Patients who have collapsed femoral heads qualify for arthroplasty right away. Those with severe osteonecrosis who are resistant to risk factor adjustment and/or (ii) thought to be at immediate risk of collapse are further prospects.

    Rationale: Arthroplasties are frequently used as a treatment once the head of the femur collapses.

Other Treatments of Hip Osteonecrosis

  1. Dysbaric Exposures or Other Symptom-Providing Activities or Other Risk Factors

    Dysbaric Exposures or Other Symptom-Providing Activities or Other Risk Factors are recommended reduction or cessation of actions that provide serious osteonecrosis risks, such as avoiding dysbaric exposures.


  2. Non-Weight Bearing Activities

    Non-Weight Bearing Activities are not recommended for people who have osteonecrosis.


  3. Hyperbaric Oxygen

    Hyperbaric Oxygen is recommended in order to treat osteonecrosis.

    Stage 2 of Osteonecrosis Ficat. It might make sense. to try HBO on patients who have osteonecrosis that is more advanced.

    Frequency/Dose/Duration: Up to 30 treatments.

    Indications for Discontinuation: Course completion, intolerance resolution, clinical resolution, and collapse of osteonecrosis.

What our office can do if you have Hip Osteonecrosis from workers compensation injury

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.

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No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18


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I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

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