The Role of Perfusion MRI in Detecting Avascular Necrosis of the Femoral Head in Children: A Systematic Review
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Nikhil J Manoj1, Jade Yip1, Anna Bridgens2
1City St George's, University of London.
Background:
Avascular necrosis (AVN) is associated with poor outcomes in pediatric hip disorders, including developmental dysplasia of the hip (DDH), slipped capital femoral epiphysis (SCFE), and Legg-Calve-Perthes disease (LCPD). Perfusion MRI (pMRI), a dynamic assessment of femoral head perfusion, and contrast-enhanced MRI (CE-MRI), a static assessment of femoral head perfusion, might be able to predict femoral head hypoperfusion, particularly before the onset of irreversible structural change, and the progression of structural changes once perfusion has been compromised, improving therapeutic options and outcomes.
Methods:
A systematic review was conducted in accordance with the Cochrane Handbook for Diagnostic Test Accuracy and PRISMA guidelines. MEDLINE, Embase, Web of Science, and Cochrane databases were searched from inception to October 2025. Studies assessing pMRI or CE-MRI as a diagnostic or prognostic tool for AVN of the femoral head in patients under 18 years were included. Diagnostic accuracy for AVN screening, prognostic associations with femoral head deformity, and validated radiographic scoring systems were included as outcomes. The risk of bias was assessed using the QUADAS-2 and QUIPS tools.
Results:
Thirteen studies comprising 538 patients (567 hips) met the inclusion criteria. Nine evaluated pMRI or CE-MRI as screening tools for AVN in DDH and SCFE, and 4 assessed prognostic value in LCPD. Analysis using weighted averages demonstrated a sensitivity of 90%, specificity of 60%, positive predictive value (PPV) of 58%, and a negative predictive value (NPV) of 90% for pMRI. Prognostic studies consistently showed associations between femoral head hypoperfusion and adverse radiographic outcomes, including higher lateral pillar class, increased deformity index, and worse sphericity deviation scores.
Conclusion:
Perfusion MRI has potential as a screening tool for early detection of AVN in pediatric hip disorders and as a prognostic indicator in LCPD. However, heterogeneity in the data and a limited number of included studies mandate cautious interpretation of the results. High-quality prospective studies are necessary to validate clinical utility.
Level Of Evidence:
Level III-systematic review of level-III studies.
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