Avascular Necrosis (Main)
(Redirected from Avascular Necrosis)
- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Regional AVNs
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications
- 12 See Also
- 13 References
- Aseptic necrosis
- Atraumatic necrosis
- Ischemic necrosis
- This page is a home page for all causes of avascular necrosis (AVN), also often referred to as osteonecrosis
- Estimated 20,000 - 30,000 cases per year in the US
- Degenerative bone condition characterized by death of cellular components of bone secondary to interruption of subchondral blood supply
- Low blood supply leads to hypoxia, loss of integrity of cell membrane, necrosis of osteocytes
- Histology marked by appearance of neutrophils, macrophages
- Macroscopically, leads to subchondral collapse and joint degeneration
- Most commonly affects the epiphysis of long bones of weight-bearing joints
- Timeline & Disease progression
- Often goes undiagnosed early in disease course due to most patients being asymptomatic early on
- Important to recognize early to maximize best outcomes for patients
- Can result in subchondral collapse, threatening integrity of joint
- Likely combination of genetic predisposition, metabolic factors and local factors affecting vascular supply
- Frequency and risk varies depending on duration of use, dose and comorbidities
- One study estimated incidence between 21 and 37% after one year of glucocorticoid therapy
- Risk estimated to be less than 3% on low dose prednisone (less than 15-20 mg/day)
- In patients on short-term, low dose methylprednisolone estimated incidence to be 0.13%, however the risk was as high as 1.6% compared to patients who did not receive any methylprednisolone
- Higher doses early on seem to correlate with risk as well
- Proposed mechanisms
- Alcohol use is seen in up to 31% of patients with AVN
- Risk is directly correlated with increased consumption
Systemic Lupus Erythematosus
- Reported in between 3 and 30% of patients with SLE
- Generally associated with glucocorticoid use, although there are case reports in patients who haven't used glucocorticoids
- 80% are associated with either history of glucocorticoids or excessive alcohol use
- In hip dislocations, one study estimated the incidence of AVN to be 14.3%
- Risk also increased in scaphoid and lunate fractures
- Renal Transplantation
- Affects between 50 and 70% of patients
- Incidence estimated to be 15% in first 3 years after transplant
- Use of cyclosporine appears to decrease risk
- Hematopoeitic Cell Transplant
- Direct cellular toxicity
- Thermal injury
- Tobacco Use Disorder
- Extraosseous arterial fracture
- Hip Dislocation
- Hip Fracture
- Iatrogenic post surgery
- Congenital arterial abnormalities
- Extraosseous venous
- Venous abnormalities
- Venous stasis
- Intraosseous extravascular compression
- Elevated bone marrow pressure
- Fatty infiltration of bone marrow
- History of Corticosteroid use
- Cellular hypertrophy and marrow infiltration (Gaucher's disease)
- Bone marrow edema
- Displaced fractures
- Intraosseous intravascular occlusion
- Coagulation disorders such as thrombophilias and hypofibrinolysis
- Sickle Cell Disease
- Systemic Lupus Erythematosus
- Antiphospholipid Antibodies
- Decompression Sickness
- Acute Lymphoblastic Leukemia (ALL)
- History of Transplant
- Inherited Hypercoagulable Thrombophilias
- Radiation Therapy
- Heritable Osteonecrosis (COL2A1)
- Bisphosophonate Use
- Upper Extremity
- Osteonecrosis of the Shoulder
- Panner's Disease (elbow)
- Kienbock's Disease (lunate)
- Scheuermann's Disease (vertebrae)
- Lower Extremity
- Legg-Calve-Perthes Disease (pediatric hip)
- Avascular Necrosis of the Hip (adult hip)
- Osteonecrosis of the Knee (knee)
- Osteonecrosis of the Talus
- Freiberg's Disease (3rd metatarsal)
- Kohler's Disease (navicular)
- Often asymptomatic early in course of disease
- Generally atraumatic with insidious onset of pain
- In the lower extremities, pain is worse with ambulation
- Physical Exam
- May be normal, see specific diseases
- Screening of affected joint is initial imaging modality of choice
- Early in disease course often will appear normal
- As disease progresses, findings include:
- Mild density changes (early)
- Subchondral collapse
- Sclerosis and cysts
- Sensitivity up to 100%
- Focal lesions (T1)
- "double line sign" or high intensity line (T2) is pathognomonic
- Falling out of use in favor of MRI which is more sensitive, specific
- Remains an option in patients who can not obtain an MRI
- Needs to be updated
* Variable, see individual diseases
- Mont et al. reported that 59% of asymptomatic lesions progressed to symptoms or collapse
Rehab and Return to Play
- Variable, see individual diseases
Return to Play
- Variable, see individual diseases
- Inability to return to sport
- Chronic pain
- ↑ Moya-Angeler, Joaquin, et al. "Current concepts on osteonecrosis of the femoral head." World journal of orthopedics 6.8 (2015): 590.
- ↑ 2.0 2.1 Shah KN, Racine J, Jones LC, Aaron RK. Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med. 2015 Sep;8(3):201-9.
- ↑ Shigemura, Tomonori, et al. "Incidence of osteonecrosis associated with corticosteroid therapy among different underlying diseases: prospective MRI study." Rheumatology 50.11 (2011): 2023-2028.
- ↑ Dilisio, Matthew F. "Osteonecrosis following short-term, low-dose oral corticosteroids: a population-based study of 24 million patients." Orthopedics 37.7 (2014): e631-e636.
- ↑ Abeles, Micha, Jeffery D. Urman, and Naomi F. Rothfield. "Aseptic necrosis of bone in systemic lupus erythematosus: relationship to corticosteroid therapy." Archives of Internal Medicine 138.5 (1978): 750-754.
- ↑ Jones Jr, J. P. "Fat embolism and osteonecrosis." The Orthopedic Clinics of North America 16.4 (1985): 595-633.
- ↑ SoLoMoN, L. O. U. I. S. "Idiopathic necrosis of the femoral head: pathogenesis and treatment." Canadian journal of surgery. Journal canadien de chirurgie 24.6 (1981): 573.
- ↑ Nishimura, Tatsuya, et al. "Histopathologic study of veins in steroid treated rabbits." Clinical orthopaedics and related research 334 (1997): 37-42.
- ↑ Matsuo, Keisuke, et al. "Influence of alcohol intake, cigarette smoking, and occupational status on idiopathic osteonecrosis of the femoral head." Clinical orthopaedics and related research 234 (1988): 115-123.
- ↑ Dimant, J., et al. "Computer analysis of factors influencing the appearance of aseptic necrosis in patients with SLE." The Journal of rheumatology 5.2 (1978): 136-141.
- ↑ Mont, Michael A., and David S. Hungerford. "Non-traumatic avascular necrosis of the femoral head." JBJS 77.3 (1995): 459-474.
- ↑ Slobogean, G. P., et al. "Complications following young femoral neck fractures." Injury 46.3 (2015): 484-491.
- ↑ IBELS, LLOYD S., et al. "Aseptic necrosis of bone following renal transplantation: experience in 194 transplant recipients and review of the literature." Medicine 57.1 (1978): 25-46.
- ↑ Tauchmanovà, Libuse, et al. "Avascular necrosis in long‐term survivors after allogeneic or autologous stem cell transplantation: a single center experience and a review." Cancer: Interdisciplinary International Journal of the American Cancer Society 97.10 (2003): 2453-2461.
- ↑ Schulte, Claudia MS, and Dietrich W. Beelen. "Avascular osteonecrosis after allogeneic hematopoietic stem-cell transplantation: diagnosis and gender matter." Transplantation 78.7 (2004): 1055-1063.
- ↑ Gómez-Puerta, Jose A., et al. "High prevalence of prothrombotic abnormalities in multifocal osteonecrosis: description of a series and review of the literature." Medicine 92.6 (2013): 295.
- ↑ Jones, Lynne C., et al. "Procoagulants and osteonecrosis." The Journal of rheumatology 30.4 (2003): 783-791.
- ↑ Miller, Kirk D., et al. "High prevalence of osteonecrosis of the femoral head in HIV-infected adults." Annals of internal medicine 137.1 (2002): 17-25.
- ↑ Liu, Yu-Fen, et al. "Type II collagen gene variants and inherited osteonecrosis of the femoral head." New England Journal of Medicine 352.22 (2005): 2294-2301.
- ↑ Markisz, John A., et al. "Segmental patterns of avascular necrosis of the femoral heads: early detection with MR imaging." Radiology 162.3 (1987): 717-720.
- ↑ Mont, Michael A., et al. "Bone scanning of limited value for diagnosis of symptomatic oligofocal and multifocal osteonecrosis." The Journal of rheumatology 35.8 (2008): 1629-1634.
- ↑ Mont MA, Zywiel MG, Marker DR, McGrath MS, Delanois RE. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am. 2010 Sep 15;92(12):2165-70.
John Kiel on 30 June 2019 20:48:14
21 July 2020 14:24:58