Updated: 11/23/2021

Avascular Necrosis of the Bone (Osteonecrosis)

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  • Snapshot
    • A 54-year-old woman presents with right groin and buttock pain. She denies any recent history of trauma or fall on the affected area. Medical history is significant for multiple sclerosis (MS) that required systemic steroids due to a MS exacerbation. On physical exam, there is decreased passive and active range of motion of the hip. Magnetic resonance imaging demonstrates serpiginous peripheral sclerosis with inner granulation tissue.
  • Introduction
    • Clinical definition
      • reduced vascular supply to the bone resulting in progressive and painful degeneration of the bone
        • also termed osteonecrosis
  • Epidemiology
    • Incidence
      • typically occurs in the anterolateral femoral head
    • Demographics
      • dependent on the cause of osteonecrosis
        • e.g., systemic lupus erythematosus associated with osteonecrosis is more likely to be seen in women
  • Etiology
    • Pathogenesis
      • impaired blood supply leads to infarction of the associated bone and bone marrow
        • vascular insufficiency can result form
          • mechanical blood vessel injury
          • blood vessel compression
          • venous occlusion
          • thromboembolism
    • Traumatic
      • fractures
        • e.g., femoral head, femur, and scaphoid bone
      • dislocation
        • e.g., slipped capital femoral epiphysis
    • Atraumatic
      • idiopathic (Legg-Calve-Perthes disease)
      • alcohol use
      • corticosteroids
        • think of disorders that use corticosteroids such as
          • systemic lupus erythematosus
          • acute lymphoblastic leukemia
          • transplantation
      • Gaucher disease
      • sickle cell disease
      • caisson disease ("the bends")
      • bisphosphonate therapy
  • Presentation
    • Symptoms
      • asymptomatic
        • seen in a small portion of patients
      • pain
        • groin pain suggests osteonecrosis of the femoral head
          • thigh and buttock pain is also suggestive
        • pain in weight bearing joints
        • pain can occur at rest and at night
    • Physical exam
      • non-specific
        • limited passive and active range of motion of the hip joint with hip involvement
        • a limp can be seen
  • Imaging
    • Radiographs
      • indication
        • perform in patients with a clinical presentation concerning for osteonecrosis
    • Magnetic resonance imaging (MRI)
      • indication
        • gold-standard for the diagnosis of osteonecrosis
      • modalities
        • without contrast
  • Studies
    • Making the diagnosis
      • based on clinical presentation and imaging findings
  • Differential
    • Stress fracture
    • Degenerative joint disease
  • Treatment
    • Management approach
      • to preserve the native joint as long as possible
      • treatment modalities are dependent on the location and extent of disease
  • Complications
    • Collapse of femoral head in cases of femoral involvement
    • Degenerative joint disease
    • Focal osteoporosis
  • Prognosis
    • Dependent on the extent of the lesion
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Questions (2)

(M3.OR.15.10) A 39-year-old African-American woman presents to the emergency room with hip pain. She has a past medical history significant for sarcoidosis which was recently diagnosed 6 months ago and is currently being treated. She reports that the pain started 2 weeks ago and is localized to the left hip and groin. The pain has been getting progressively more intense. Her temperature is 98.1°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for pain with manipulation without restriction of range of motion of the hip. Which of the following is the most sensitive test for this condition?

QID: 102728

CT of the hip

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MRI of the hip

71%

(5/7)

Radiograph of the hip

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Radionuclide scan of the hip

14%

(1/7)

Ultrasound of the hip

0%

(0/7)

M 10 E

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(M3.HE.13.11) A 7-year-old boy with sickle cell disease is brought into the clinic by his mother for knee and hip pain. The child has been admitted several times in the past for pain crises managed with fluids and hydromorphone. He started complaining of worsening hip pain over the last several days and now walks with a limp. His temperature is 97.9°F (36.6°C), blood pressure is 84/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 99% on room air. On physical exam, the hip appears normal and is cool to the touch. There is decreased range of motion at the hip and pain with ambulation. Which of the following is the most appropriate next step in management?

QID: 103302

Arthrocentesis

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(8/19)

CT

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Ibuprofen and acetaminophen

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(5/19)

MRI

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(1/19)

Radiograph

11%

(2/19)

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