Aseptic Necrosis. Pathogenesis

An original view on the pathogenesis of aseptic (avascular) necrosis of the femoral head.

According to our view, the pathogenesis of aseptic (avascular) necrosis of the femoral head is based on mechanical damage to the ligamentum capitis femoris (LCF) or its dysfunction. Due to excessive stress on the LCF, it can rupture completely or partially, or tear off with or without a bone fragment. The most common mechanism of injury is forced adduction or rotation of the hip in the horizontal plane (pronation-supination). Damage can occur immediately or gradually, with prolonged existence of bioeffective stresses in the LCF. Partial damage to the LCF with elongation and dysfunction is not excluded at the initial stage. We consider the commonly held opinion about the vascular genesis of the disease to be incorrect.

Due to the violation of the integrity of the LCF, the hip joint in the single-support period of the step is not converted into a lever of the second kind. Accordingly, in all phases of walking, as well as in any vertical position, only the upper sector of the femoral head and acetabulum are loaded. The actual average daily stresses in them naturally increases. They, being higher than the level of optimal daily average stresses, cause the appearance of bioeffective stresses. The latter, in turn, induce biological adaptive processes (for more details, see the Law of Bioinduction).

One of the first manifestations is the formation of compact bone tissue in the subchondral zone of the femoral head (radiological symptom of "eggshell"). If, due to traumatic impact, along with damage to the LCF, an impression fracture of the upper pole of the femoral head does not occur, it develops gradually. The high intensity of internal forces in the upper sector of the femoral head leads to fractures of individual trabeculae in areas of stress concentration, which further weakens bone tissue and reduces the level of optimal average daily stresses.

Mechanical processes form a kind of bone-cartilaginous sequestrum at the upper pole of the femoral head. Along its periphery, bioeffective stresses induce adaptive processes, and granulation tissue appears, which is gradually transformed into fibrous tissue. Bone cysts develop in the femoral head, and the separated part of the bone undergoes lysis. Osteophytes appear at the edges of the femoral head and acetabulum due to metaplasia of fibrous tissue induced by bio-effective stresses. Thanks to osteophytes, the area of the contacting elements of the hip joint increases, which partly reduces the level of actual average daily stresses in them.

Restructuring of the acetabulum is also observed: the semilunar surface expands, the acetabular canal is eliminated, and the cartilaginous cover is worn out. Due to the death of part of the head of the femur and slow adaptive changes, it cannot fully adapt to the situation that has arisen. The inability to neutralize bio-effective stresses in the hip joint area leads to its further deterioration not only mechanically but also through biological processes.

The disruption of congruence and functioning of the hip joint leads to a change in the level of actual average daily stresses in all adjacent elements of the musculoskeletal system. Bioeffective stresses appear in them, leading to pathological changes. The energy intensity of locomotion increases, including due to an increase in the activity of the abductor group of muscles of the hip joint, which keep the pelvis in the single-support step period and in single-support vertical poses.

Keywords: ligamentum capitis femoris, ligamentum teres, ligament of head of femur, hip joint, biomechanics, aseptic necrosis, avascular necrosis, pathogenesis

In translating to English, the author is assisted by ChatGPT (version 3.5) and the Google Translate service.

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The first version of the text in:

Архипов-Балтийский СВ. Рассуждение о морфомеханике. Норма. В 2 т. Т. 2. Гл. 5-6. испр. и доп. изд. Калининград, 2004. (Archipov-Baltic SV. Reasoning about Morphomechanics. The norm – Kaliningrad, 2004. [Rus]) [aleph.rsl.ru]

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ETIOLOGY AND PATHOGENESIS

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1902RilkeRM

Works of art that mention ligamentum capitis femoris (LCF) are extremely rare. One such work is the poem «Der Schauende» ( He Who Visions, The Seer, The Man Watching, The Beholder) b y Rainer Rilke. Below is the original text in German. Der Schauende 1. Ich sehe den Bäumen die Stürme an, die aus laugewordenen Tagen an meine ängstlichen Fenster schlagen, und höre die Fernen Dinge sagen, die ich nicht ohne Freund ertragen, nicht ohne Schwester lieben kann. 2. Da geht der Sturm, ein Umgestalter, geht durch den Wald und durch die Zeit, und alles ist wie ohne Alter: die Landschaft, wie ein Vers im Psalter, ist Ernst und Wucht und Ewigkeit. 3. Wie ist das klein, womit wir ringen, was mit uns ringt, wie ist das groß; ließen wir, ähnlicher den Dingen, uns so vom großen Sturm bezwingen, - wir würden weit und namenlos. 4. Was wir besiegen, ist das Kleine, und der Erfolg selbst macht uns klein. Das Ewige und Ungemeine will nicht von uns gebogen sein. Das ist der Enge...

1823CooperA

According to the author, the ligamentum capitis femoris (LCF) is intended to prevent dislocations in all directions. A. Cooper discusses traumatic obturator dislocation of the hip joint and LCF injury in more detail. Cooper A. Abhandlung über Luxationen und Fracturen der Gelenke des Unterkiefers, der obern Extremitäten und der Knochen des Rumpfes. Aus dem Englischen. Weimar : Landes-Industrie-Comptoir, 1823. [fragments] Quote p. 1 4 8 Das ligamentum teres hat die Bestimmung, Luras tionen nach allen Richtungen hin zu verhindern, besonders aber nach abwärts, denn wenn die Schenkel weit ausein andergespreizt werden, wie z. B. bei'm Fechten, so würde der Kopf des linken Oberschenkelknochens in Gefahr feyn, aus seiner Gelenkhöhle zu schlüpfen, was aber durch dieses Ligament verhindert wird. The ligamentum teres is designed to prevent dislocations in all directions, especially downwards, because when the thighs are widely ab...

LCF in 2026 (May)

LCF in 2026 (May ) (Quotes from articles and books published in May 2026 mentioning the ligamentum capitis femoris) Kim, P. S., Kang, C., Lee, J. K., & Hwang, J. M. (2026). Hip arthroscopy to treat symptomatic paralabral cysts: a retrospective analysis of clinical outcomes. Arthroscopy and Orthopedic Sports Medicine , 13 (1), 27-34. [i] e-aosm.org Ko, H. Y. (2026). Vascular Anatomy of the Extremities and Lungs. In Practical Functional Anatomy for Spinal Cord Injury Rehabilitation: A Guide for Physiatrists and Rehabilitation Specialists (pp. 191-223). Singapore: Springer Nature Singapore. [ii] link.springer.com Aiba, H., Yamaguchi, M., Kimura, H., & Murakami, H. (2026). Advances in limb-salvage surgery and reconstruction for pediatric bone and soft tissue tumors. Frontiers in Pediatrics , 14 , 1817788. [iii] pmc.ncbi.nlm.nih.gov Bajwa, A., Villar, R., ...

A Novel Technique for Proximal Fixation

Arkhipov SV. A Novel Technique for Proximal Fixation of Ligamentum Capitis Femoris Reconstruction: The Gifts of the Magi for Orthopedic Surgeons. About Round Ligament of Femur. January 14, 2026. DOI: 10.13140/RG.2.2.25269.33763 https://roundligament.blogspot.com/2026/01/the-gifts-of-magi-for-orthopedic.html Abstract Purpose: To describe an experimental technique for proximal fixation in ligamentum capitis femoris (ligamentum teres femoris; LCF) reconstruction using pubic and ischial portions anchored in corresponding pelvic bone tunnels, tested on synthetic hip joint models, and to propose it’s for arthroscopic application with visualization via an inferior portal and femoral tunnel. Methods: Synthetic polyurethane bone analogs (Synbone) of the pelvis and proximal femur were used to fabricate hip joint models. Acetabular cartilage analogs were created from self-curing plastic compound. Femoral tunnels were drilled along the neck axis from the subtrochanteric region below the tub...

1740KulmusJA

Fragments from the book Kulmus JA. Tables anatomiques (1734). The author briefly writes about the anatomy, properties and attachment of the ligamentum capitis femoris (LCF). There are known translations of the treatise into Latin ( 1732KulmusJA ) and French ( 1734KulmusJA ). Quote p. 51 [Deu] Translation [Eng] с . In the upper part of the head there is a recess in which the round ligament is attached. Quote p. 54 [Deu] Translation [Eng] 2.) The round ligament is short but very strong; it arises at the bottom of the acetabulum and joins the fossa at the top of the femoral condyle. External links Kulmus JA. Anatomische Tabellen: Nebst dazu gehörigen Anmerckungen und Kupffern, Daraus des gantzen Menschlichen Cörpers Beschaffenheit und Nutzen deutlich zu ersehen; Welche Den Anfängern der Anatomie zu bequemer Anleitung verfasset hat… Nuremberg, Frankfort, Leipzig: J.A. von Creutz, MDCCXXXX [1740]. [ archive.org ] Authors & Affiliations Johann Adam Kulmus (...

Human Children. Retelling of Chapter 13

Short retelling of chapter 13 of the essay: Arkhipov S.V. Human Children: The Origins of Biblical Legends from a Physician's Perspective. Joensuu: Author's Edition, 2025. [In Russian] Chapter 13. PROPHETIC DREAMS After his wanderings and battles, Abraham settles in “Mamre’s oaks in Hebron.” Following these events, he experiences a divine “word in a vision” and a dream promising him lands “from Egypt’s river to the great river, Euphrates.” His family relocates to a desert along the Shur road, near the well “Beer-Lahai-Roi,” between Kadesh and Bered. In another divine appearance, Abraham is commanded to circumcise all males’ foreskins, rename Sarai as Sarah, and is told he’ll father a child at 100, despite Sarah’s barrenness at 89. That day, Abraham circumcises his son Ishmael, household males, and, at 99, himself. In Mamre’s oaks, during “daytime heat,” a mirage foretells fatherhood. The dream shifts, showing Sodom and Gomorrah’s destruction and Lot’s miraculous rescue. ...

LCF in 2025 (July)

LCF in 2025 ( July ) (Quotes from articles and books published in July 2025 mentioning the ligamentum capitis femoris.) Tekcan, D., Bilgin, G., & Güven, Ş. Evaluation of Risk Factors for Developmental Dysplasia of the Hip. HAYDARPAŞA NUMUNE MEDICAL JOURNAL , 65 (2), 99-103. [i] jag.journalagent.com Domb, B. G., & Sabetian, P. W. (2025). Greater Trochanteric Pain Syndrome: Gluteal Tendinopathy, Partial Tear, Complete Tear, Iliotibial Band Syndrome, and Bursitis. In Orthopaedic Sports Medicine (pp. 1-17). Springer, Cham. [ii] link.springer.com Kuhns, B. D., Becker, N., Patel, D., Shah, P. P., & Domb, B. G. (2025). Significant Heterogeneity in Existing Literature Limits Both Indication and Outcome Comparability Between Studies Involving Periacetabular Osteotomy For Acetabular Dysplasia With or Without Arthroscopy Despite Improvement for Both: A Systematic Review. Arthroscopy . [iii] ...

1851HyrtlJ

The author expresses a classic view on the functions of the ligamentum capitis femoris (LCF): a conductor of blood vessels and a limiter of adduction of the femur. J. Hyrtl believed that it was impossible to completely dislocate the hip without tearing the LCF. Hyrtl J. Lehrbuch der Anatomie des Menschen, mit Rücksicht auf physiologische Begründung und praktische Anwendung. Wien: W. Braumüller, 1851. [fragment] Quote p. 265 In der Höhle des Gelenks liegt das runde Band des Schenkelkopfes (Lig. teres), welches an der Incisura acetabuli entspringt, und bei richtiger Neigung des Beckens, senkrecht zur Grube des Schenkelkopfes aufsteigt. Es beschränkt dieses Band die Zuziehung des Schenkels, und schreibt zugleich den durch die Incisura acetabuli eindringenden Blutgefässen den Weg vor, den sie zum Oberschenkelkopfe zu nehmen haben. Da das Band, wenn es in die Höhle des Gelenkes vorragen würde, durch Reibung viel zu leiden hätte, so...

1730CheseldenW

Fragments from the book Cheselden W. The Anatomy of the Human Body (1730). The author draws attention to the role of ligamentum capitis femoris (LCF) in counteracting hip dislocation and maintaining the femoral head in the joint. The work notes that the LCF is “powerful” and “short” - “about two inches” i.e. approximately 5 cm! This error will be corrected in a subsequent treatise ( 1733CheseldenW ) . Quote pp. 43 - 44 Chap. VII. Of the Ligaments At the upper part of the articulation of the Os Femoris and Os Innominatum, is a strong ligament of great consequence; it contributing very much to preserve that joint from being luxated by the weight of the body. And from the lower edge of the Acetabulum of the Os Innominatum, runs a ligament to the middle of the head of the Os Femoris, about two inches long (which the Motion in this joint requires) called Teres, or Rotundum, whose use is to prevent the Os Femoris from being luxated upwards, but down wards it will le...

Human Children. Retelling of Chapter 14

Short retelling of chapter 14 of the essay: Arkhipov S.V. Human Children: The Origins of Biblical Legends from a Physician's Perspective. Joensuu: Author's Edition, 2025. [In Russian] Chapter 14. ESAU AND JACOB At 40, Isaac marries Rebekah, his cousin’s daughter. Their marriage is long childless until Rebekah conceives twins, detected prenatally, possibly by her large belly or palpation. Genesis states that at 60, Isaac fathers the twins, born naturally after 20 years of marriage. The first, Esau, emerges “red, all hairy like a cloak,” followed by Jacob, unremarkable but grasping Esau’s heel. Over time, their differences deepen: Esau, a skilled hunter, roams fields; Jacob, gentle, stays in tents. Famine forces the family from “Beer-Lahai-Roi” in the Negev to “Gerar’s Philistine king,” then to “Gerar’s valley,” and finally to Beersheba. At 40, Jacob, urged by Rebekah, deceives blind Isaac to steal Esau’s inheritance, sparking enmity. Rebekah advises Jacob to flee to rela...

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