Updated: 1/29/2019

Avascular Necrosis of the Bone (Osteonecrosis)

Topic
Review Topic
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Evidence
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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
    • 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 
  • 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
  • Prognosis
    • dependent on the extent of the lesion
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
 

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