Total Hip Arthroplasty for Advanced Femoral Head Osteonecrosis in a 24-Year-Old Competitive Wrestler: A Case Report

Patient profile and history

A 24-year-old male competitive freestyle wrestler (74 kg weight class) presented with a 6-month history of insidious right groin pain, initially attributed to muscular strain. The pain became constant and progressively limited hip flexion and internal rotation. He reported taking oral prednisone 20 mg/day for approximately 7 months for allergic rhinitis, corresponding to an estimated cumulative exposure of approximately 4.2 g prednisone-equivalent if the reported daily dose was maintained throughout this period. He was subsequently found to be heterozygous for Factor V Leiden. The documented thrombophilia work-up was otherwise negative, including evaluation for other inherited and acquired hypercoagulable conditions. There was no history of trauma, significant alcohol use, sickle cell disease, or systemic lupus erythematosus (Table 1).

The corticosteroid exposure and Factor V Leiden status were considered potential contributors rather than definitive causes. The approximately 4.2 g cumulative prednisone-equivalent exposure represents a substantially longer exposure than previously described in the case, but a causal dose-response relationship cannot be established from this individual case. The thrombophilia evaluation was negative apart from Factor V Leiden heterozygosity, and therefore no additional inherited or acquired thrombophilic abnormality was identified.

Physical examination

Pre-operative range of motion of the right hip was as follows: flexion 110° (painful at end-range), internal rotation 15° (markedly restricted), external rotation 25°, and abduction 35°. The flexion, abduction, and external rotation (FABER) and log-roll tests were both positive.

Plain radiographs demonstrated flattening of the superolateral femoral head, a subchondral crescent sign, and early joint-space narrowing (Fig. 1a). Magnetic resonance imaging (MRI) revealed an extensive lesion involving more than 50% of the femoral head, with subchondral collapse, extensive bone marrow edema, a double-line sign on T2-weighted fat-suppressed sequences, and secondary chondral thinning (Fig. 1b and c). The collapse component met the criteria for late Association Research Circulation Osseous (ARCO) Stage III (Stage IIIB, >2 mm depression); however, because the radiographs also demonstrated joint-space narrowing/secondary degenerative change, the final stage was classified as ARCO Stage IV under the 2019 revised ARCO system ^[10]. No post-operative MRI was performed; post-operative assessment was based on serial plain radiographs and clinical evaluation.

Right-sided advanced ONFH with post-collapse deformity and secondary osteoarthritis, classified as ARCO Stage IV (with ARCO Stage IIIB collapse features)/Ficat Stage III, with potential corticosteroid and thrombophilic contributors.

Despite the patient’s young age, joint-preserving options were considered. Core decompression is best supported for pre-collapse disease, whereas vascularized bone grafting and osteotomy may be considered in selected post-collapse hips but have heterogeneous results and greater technical demands ^[3,5,6]. In this patient, more than 2 mm of femoral head flattening, involvement of more than 50% of the femoral head, early acetabular chondral compromise, and the requirement for reliable restoration of high-demand function made the expected result of joint-preserving surgery less predictable. THA was therefore selected after discussion of the alternatives, including the potential for later revision in a 24-year-old patient. This was a case-specific treatment decision and not a conclusion that THA is superior to all joint-preserving procedures. The patient subsequently underwent cementless THA through a minimally invasive posterior approach; the surgical details and prosthetic components are summarized in Table 3.

At 6-month follow-up, the patient reported minimal pain and near-full range of motion. The Harris hip score (HHS) ^[11] improved from 72/100 (fair) to 94/100 (excellent), and the Merle d’Aubigné-Postel score ^[12] improved from 11/18 (moderate) to 17/18 (excellent). Pain on the Visual Analogue Scale (VAS) fell from 7/10 to 1.5/10. Internal rotation improved from 15° to 35°, flexion from 110° to 135°, external rotation from 25° to 40°, and abduction from 35° to 50° (Table 2). At 9 months, these scores and range-of-motion measurements remained approximately unchanged from the 6-month assessment. Serial post-operative plain radiographs, including the 9-month assessment, showed stable, well-positioned components without obvious radiographic loosening, osteolysis, or other abnormality (Fig. 2). No post-operative MRI was performed. Objective endurance testing was performed as part of the sports assessment and did not identify a clinically significant endurance limitation. The patient had progressed from supervised drills to participation in wrestling matches by 9 months and reported no hip-related problems.

THA was traditionally reserved for older patients due to concerns regarding long-term component survivorship ^[13,14]. Contemporary cementless fixation and highly cross-linked polyethylene have broadened its use in younger patients with advanced ONFH ^[15], but long-term revision remains an important concern. Contemporary systematic reviews demonstrate substantial functional improvement after THA in young patients, while also showing that survivorship and complication profiles vary with age, diagnosis, implant design, and duration of follow-up ^[16,17]. These data provide context for counseling but cannot be used to predict the long-term outcome of this individual 24-year-old patient. The present 9-month radiographic stability is reassuring but remains insufficient to assess polyethylene wear, osteolysis, aseptic loosening, instability, or lifetime revision risk.

In this case, the marked improvement in HHS and Merle d’Aubigné-Postel score illustrates restoration of pain-free function, but these general hip scores do not by themselves establish wrestling-specific performance. Athlete-focused instruments such as the Kerlan-Jobe Orthopaedic Clinic (KJOC) athletic hip score and activity scales such as the University of California, Los Angeles (UCLA) activity scale or the High-Activity Arthroplasty Score (HAAS) can provide additional information about sport participation and activity level ^[18–20]. These measures were not prospectively collected in the present case and therefore cannot be retrospectively added without introducing unsupported data. The patient’s return to wrestling was additionally assessed clinically and included objective endurance testing, which did not demonstrate a clinically significant endurance limitation.

Several considerations are specific to young athletic patients undergoing THA. The posterior approach carries a recognized dislocation risk, and high-impact/contact activity may expose the implant to traumatic injury and potentially increased mechanical demands. Evidence on return to sport after THA is largely derived from heterogeneous patient populations and shows lower and less certain return rates for high-intensity sports than for low- or moderate-impact activities ^[20]. The literature therefore supports cautious, criterion-based progression rather than an assumption that contact sport is universally safe. In this individual, the patient progressed to wrestling matches by 9 months without reported symptoms or clinical problems. Nevertheless, 9 months remains insufficient to evaluate long-term polyethylene wear, osteolysis, aseptic loosening, instability, periprosthetic fracture, or revision risk.

Rehabilitation and return-to-sport assessment: The post-operative rehabilitation framework was structured in phases consistent with published THA rehabilitation literature ^[21,22] (Table 4). Early rehabilitation emphasizes gait training, restoration of functional mobility and appropriate hip range of motion, followed by progressive strengthening of the operated limb, including quadriceps and hip-abductor musculature. After approximately 8 weeks, literature supports progression to weight-bearing strengthening, with particular emphasis on hip-abductor eccentric strengthening, together with aerobic/endurance and balance-oriented exercise ^[21]. Rehabilitation should be progressed according to patient-specific functional responses rather than a fixed timetable, with task-specific training added as strength, gait, balance and endurance improve ^[22]. For this athlete, progression was subsequently directed toward sport-specific conditioning, including endurance assessment and graded wrestling drills before return to matches at 9 months. Published return-to-sport literature suggests that high-impact/contact activities require careful counseling and monitoring because evidence for their long-term safety after THA remains limited ^[20].

Limitations

This report has several limitations. It describes a single patient, so the findings cannot be generalized to young athletes with advanced ONFH. Follow-up is 9 months; although the patient remains clinically well with stable radiographs, it is still insufficient to establish implant survivorship, polyethylene wear, osteolysis, aseptic loosening, instability, periprosthetic fracture, or lifetime revision risk. Post-operative assessment was based on serial plain radiographs and clinical evaluation; no post-operative MRI was performed, and advanced imaging or standardized radiographic migration/osteolysis measurements were not obtained. Athlete-specific patient-reported measures were not collected, although objective endurance testing was performed. The return to wrestling matches represents an important individual functional outcome but cannot establish the safety of contact sport.

The rehabilitation program was based on a phased, literature-informed approach incorporating gait and functional recovery, progressive strengthening, weight-bearing hip-abductor work, endurance and balance training, followed by sport-specific conditioning ^[21,22]. However, as with most rehabilitation literature, there is no universally validated protocol or single evidence-based timetable for progression after THA ^[22]. The patient’s return to wrestling matches at 9 months therefore represents an individualized clinical decision rather than a general recommendation. In addition, the case remains a single observation without a comparative treatment arm; the relative effectiveness of THA versus core decompression, vascularized grafting, osteotomy, or other joint-preserving procedures cannot be inferred.

Conflict of Interest:

Nil

Source of Support:

Nil

Consent

The authors confirm that informed consent was obtained from the patient for publication of this article

How to Cite this Article

Raj S, Sharma K, Jose A, Das S, Kumar R, Goni V. Total Hip Arthroplasty for Advanced Femoral Head Osteonecrosis in a 24-Year-Old Competitive Wrestler: A Case Report. Journal of Orthopaedic Case Reports 2026 October;16(10): 208-214.