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Avascular Necrosis (Main)

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Other Names

  • Osteonecrosis
  • AVN
  • Aseptic necrosis
  • Atraumatic necrosis
  • Ischemic necrosis

Background

  • This page is a home page for all causes of avascular necrosis (AVN), also often referred to as osteonecrosis

History

Epidemiology

  • Estimated 20,000 - 30,000 cases per year in the US[1]

Pathophysiology

  • General
    • Degenerative bone condition characterized by death of cellular components of bone secondary to interruption of subchondral blood supply[2]
    • 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

Etiology

  • General
    • Likely combination of genetic predisposition, metabolic factors and local factors affecting vascular supply

Glucocorticoids

  • General
    • 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[3]
    • 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%[4], 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[5]
  • Proposed mechanisms
    • Alterations in circulating lipids, resultant microemboli[6]
    • Bone marrow adipocyte hypertrophy blocks venous outflow[7]
    • Changes in venous endothelial cells, leading to stasis, increased intraosseuous pressure, necrosis[8]

Alcohol

  • Alcohol use is seen in up to 31% of patients with AVN[9]
  • Risk is directly correlated with increased consumption

Systemic Lupus Erythematosus

  • Reported in between 3 and 30% of patients with SLE[10]
  • Generally associated with glucocorticoid use, although there are case reports in patients who haven't used glucocorticoids

Trauma

  • 80% are associated with either history of glucocorticoids or excessive alcohol use[11]
  • In hip dislocations, one study estimated the incidence of AVN to be 14.3%[12]
  • Risk also increased in scaphoid and lunate fractures

Transplant History

  • Renal Transplantation
    • Affects between 50 and 70% of patients
    • Incidence estimated to be 15% in first 3 years after transplant[13]
    • Use of cyclosporine appears to decrease risk
  • Hematopoeitic Cell Transplant
    • One study estimated the prevalence ranged ranged from 2% (autologous) to 10% (allogenic)[14]
    • May also dependent on sex of donor and recipient with female-to-female recipient having the highest risk[15]

Risk Factors


Regional AVNs


Clinical Features

  • History
    • 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

Evaluation

Radiographs

  • 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

MRI

  • Sensitivity up to 100%[20]
  • Findings:
    • Focal lesions (T1)
    • "double line sign" or high intensity line (T2) is pathognomonic

Bone Scintography

  • Falling out of use in favor of MRI which is more sensitive, specific[21]
  • Remains an option in patients who can not obtain an MRI

Classification

  • Needs to be updated

Management

* Variable, see individual diseases

Prognosis

  • Mont et al. reported that 59% of asymptomatic lesions progressed to symptoms or collapse[22]

Rehab and Return to Play

Rehabilitation

  • Variable, see individual diseases

Return to Play

  • Variable, see individual diseases

Complications

  • Inability to return to sport
  • Chronic pain

See Also


References


  1. Moya-Angeler, Joaquin, et al. "Current concepts on osteonecrosis of the femoral head." World journal of orthopedics 6.8 (2015): 590.
  2. 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.
  3. Shigemura, Tomonori, et al. "Incidence of osteonecrosis associated with corticosteroid therapy among different underlying diseases: prospective MRI study." Rheumatology 50.11 (2011): 2023-2028.
  4. 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.
  5. 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.
  6. Jones Jr, J. P. "Fat embolism and osteonecrosis." The Orthopedic Clinics of North America 16.4 (1985): 595-633.
  7. 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.
  8. Nishimura, Tatsuya, et al. "Histopathologic study of veins in steroid treated rabbits." Clinical orthopaedics and related research 334 (1997): 37-42.
  9. 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.
  10. 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.
  11. Mont, Michael A., and David S. Hungerford. "Non-traumatic avascular necrosis of the femoral head." JBJS 77.3 (1995): 459-474.
  12. Slobogean, G. P., et al. "Complications following young femoral neck fractures." Injury 46.3 (2015): 484-491.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. Jones, Lynne C., et al. "Procoagulants and osteonecrosis." The Journal of rheumatology 30.4 (2003): 783-791.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
Created by:
John Kiel on 30 June 2019 20:48:14
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Last edited:
21 July 2020 14:24:58
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