Avascular bone necrosis (osteonecrosis) is due to too low oxygen supply and causes bone tissue to die, most often in the end parts of the bones (epiphyses) such as in the femur towards the hip joints or down towards the knees. The humerus is often attacked by the shoulders. Smaller bones in the feet, hands and vertebrae can also be attacked. The condition is also called aseptic or ischemic bone necrosis.
Avascular bone necrosis is caused by low blood supply to the skeleton in various conditions:
- bisphosphonates in cancer treatment (rare in osteoporosis treatment).
- Necrosis of the jawbone
- Blood disease
- Pancreatitis (pancreatitis)
- Diabetes mellitus
- Diving sickness (Caisson's disease)
- Gaucher's disease
- HIV / AIDS infection
- Chemotherapy in cancer treatment
- Dislocations ("out of joint")
- Corticosteroids (Prednisone) in high doses
- Kidney transplant
- Sickle cell anemia
- Radiation injuries in cancer treatment
- Systemic lupus erythematosus (SLE),
In children, avascular bone necrosis occurs at various locations (see table below), most commonly at the hip at Legg-Calve-Perthes disease and epiphysiolysis (epiphysiolysis capitis femoris).
Symptoms of avascular bone necrosis
Pain occurs early and is a typical symptom. Most people get symptoms from weight-bearing areas in the skeleton. If the bone cruciate ligament is close to the hip joint (most common location), the pain is often felt in the groin and pelvis, especially with strain and movement. A few are asymptomatic.
In the early stages, the diagnosis can be difficult to make. The medical history, age at onset and location can provide clues. The clinical examination is often without special findings. Laboratory tests are usually inconspicuous and are most useful in ruling out infection.
MRI however, often shows clear changes in the skeleton. If the bone structure collapses, X-rays will also be useful, and clinical examination often shows reduced mobility.
Avascular bone necrosis is detected on the basis of medical history with symptoms and early MRI examination. Later in the process, X-rays also show typical changes.
Various types of avascular bone necrosis
Osteonecrosis in children and adolescents (From Gran & Palm, Revma Compendium, 2022)
|Calve-Legg Perthe||The femoral head||2-20 years, most often 4-8 years||gutter|
|Köhler I||Big toe||6-9 years|
|Köhler II (Freibergs disease)||Metatarsal head of toe 2 or 3||6-14 years||Both|
|Osgood Schlatter||Aseptic necrosis of the tibial tuberosity||10-15 years||Both|
|Severe disease||Heel||6-10 years||Both|
|Scheuermann's disease||Thoracic column (Type 1), thoracolumbar (Type 2)||Teenagers||Both|
|Osteochondritis dissection||Often knees||10-20 years||gutter|
List of location and own name:
Shoulder: Hass disease: Shoulder (humerus head)
collarbone: Friedrich disease: Collar (medial)
Wrist: Wrist (distal ulna)
Hand: Caffey disease: hand or knee (whole hand or intercondylar on tibia). Dietrich disease: Hand (metacarpal heads). Kienbock disease: Hand (os lunatum). Mauclaire disease: Hand (metacarpal heads). Preise illness: Hand (scaphoid). Thiemann disease: Hands or feet (base of the phalanges).
Back Whirls: Kümmell disease: Vertebra
Hip: Epiphysiolysis in children (epiphysiolysis capitis femoris)
Add-Calvé-Perthes disease: in children, hip (thigh bone head)
Pelvic: From Neck-Odelberg disease: Pelvic (ischiopubic synchondrosis)
Knee: Ahlback disease: knee (medial femoral condyle, ie SONK). Caffey disease: hand or knee (whole hand or intercondylar on tibia). Kohler disease: Knee or foot in children (patella or os navicularis.
Foot: Freiberg disease: Foot (head of 2nd metatarsal). Iselin Disease: Foot (base of 5 metatars). Mueller-Weiss disease: Foot in adults (os navicularis). Sever disease: Foot, heel (calcaneus epiphysis). Thiemann disease: Hands or feet (base of phalanxes).
Similar conditions, differential diagnoses
- Arthritis / joint disease
- CRMO (child)
- Osteomyelitis (infection)
- Tumor (benign or cancerous)
An optimal treatment for osteonecrosis remains to be found. In the early stages, it is recommended to relieve the affected area, for example by using crutches and using painkillers or NSAIDs as required. For pain, zoledronic acid (Aclasta) is also used, possibly with repeated infusions, but then outside the approved indication (experimental treatment). Most will still need surgery eventually. In case of major joint damage in the hips, knees or shoulders, the insertion of a joint prosthesis is often chosen.