The three most commonly used methods are Ficat staging, Steinberg staging and ARCO staging.
Ficat staging
Ficat et al. (1980) proposed a well-established four-stage staging system based on radiographic presentation and functional examination of the bone (including measurement of intertrochanteric intramedullary pressure, intramedullary venography and core biopsy), which was modified in 1985.
Stage 0: The patient is asymptomatic and the X-ray film is normal;
Stage I: X-ray film shows normal, or mild diffuse osteoporosis, the patient has symptoms of pain and limited hip movement, and functional examination of bone may detect positive results;
Stage II: X-ray shows extensive osteoporosis, osteosclerosis or cystic changes, normal contour of the femoral head, histopathological changes on marrow core biopsy, and obvious clinical symptoms;
Stage III: X-ray shows sclerosis and cystic changes in the femoral head, collapse of the femoral head, crescentic sign, normal joint space, and obvious increase in clinical symptoms;
Stage IV: osteoarthritis stage, X-rays show collapse of the femoral head, narrowing of the joint space, obvious clinical symptoms of pain, and obvious restriction of hip joint movement in all directions.
Steinberg staging (University of Pennsylvania staging method)
In 2002, scholars from The University of Pennsylvania proposed their staging method based on X-ray plain film, bone scan and MRI, and the University of Pennsylvania staging method
Stage 0 Normal plain film, bone scan and MRI
Stage I Normal plain film with abnormal bone scan or/and MRI
A-Mild femoral head lesion <15% in extent < font="">
B-Moderate 15-30%
C-Severe:>30%
Stage II Translucency and sclerotic changes in the femoral head on plain film
A-Mild:<15%< font="">
B-moderate:15-30%
C Severe:>30%
Stage III Subchondral collapse on plain film (crescent sign), no flattening of the femoral head
A mild:<< font=""> 15% of joint surface length
B Moderate:15-30% of articular surface length
C Severe:> 30% of articular surface length
Stage IV Flattening of the femoral head on plain film
A Mild:<15%< font="">articular surface or collapse <2mm< font="">
B Moderate:15-30% articular surface or collapse 2-4mm
C Severe:>30% articular surface or collapse >4mm
Stage V Joint space narrowing or acetabular lesion
A Mild
B Moderate
C Severe
Stage VI Severe degenerative changes
International Staging of Femoral Head Necrosis (ARCO)
Stage 1 Positive bone scan or/and MRI
A MRI femoral head lesion extent <15%< font="">
B femoral head lesion extent 15-30%
C femoral head lesion extent >30%
Stage 2 Patches of uneven density, sclerosis and cyst formation in the femoral head, no evidence of collapse on plain film and CT, positive MRI and bone scan, no changes in the acetabulum
A MRI femoral head lesion extent <15%< font="">
B magnetic resonance femoral head lesion range 15-30%
C MRI femoral head lesion range >30%
Stage 3 Crescentic sign on x-ray frontal and lateral views
A Crescentic sign <15% of the length of the < font=""> articular surface or collapse < < 2mm< font="">
B Crescentic sign length 15-30% of joint surface length or collapse 2-4mm
C Crescent length >30% of articular surface length or collapse >4mm
Stage 4 Collapse and flattening of the articular surface, narrowing of the joint space, necrotic changes in the acetabulum, cystic changes, cysts and bone spurs
In fact, the more extensive the lesion of femoral head necrosis, the worse the prognosis.
One of the disadvantages of Ficat staging is that there are no quantitative criteria, and there is no link between the extent of the lesion, its degree and the staging. The Ficat staging is usually used to determine the radiographic score when using the score method to judge the outcome of treatment, even if the extent of the lesion increases, it does not reduce the score.
ARCO staging puts subchondral fracture and femoral head collapse in one stage, and puts mild joint space narrowing and severe osteoarthrosis in the same stage. We find in our daily work that there is a big difference in the treatment effect of subchondral fracture and femoral head collapse, and the treatment effect of mild and severe osteoarthritis is also different.
Steinberg’s staging is more reasonable and can be used to judge the treatment effect.