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Osteonecrosis

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Ismail Munir

Overview

Osteonecrosis also known as ischemic bone necrosis &amp; avascular necrosis (AVN), is defined as bone tissue death due to interruption in the blood supply.Osteonecrosis normally involves the epiphysis, but smaller bones can also get affected. It most commonly affects the hip. Other sites include the femur, carpals, talus, mandible, humerus, and metatarsal. 
&nbsp;

An estimated 15,000 new cases of osteonecrosis are reported every year in the United States. Furthermore, osteonecrosis accounts for more than 10% of total hip replacement surgeries performed in the USA<a href="#accordion">[1]</a>.

The frequency of osteonecrosis has increased worldwide, mostly due to the increased use of steroids, bisphosphonates, and radiation therapy to the head and neck<a href="#accordion">[2]</a>. However, the incidence and prevalence of osteonecrosis are not well-reported in most countries. A survey conducted in Japan reported 2500-3300 cases of osteonecrosis of the hip every year, the majority of which were associated with steroid use<a href="#accordion">[1]</a>.

The lack of knowledge regarding the causes and management of osteonecrosis is known to contribute to the occurrence of complications. A survey, conducted in Pakistan, found that 36% of non-dental doctors were aware of the term osteonecrosis of the jaw, but only 7.5% knew the clinical features of the disease<a href="#accordion">[2]</a>. 
&nbsp;

Osteonecrosis is typically classified into two types: traumatic and non-traumatic osteonecrosis: 
&nbsp;

<ul>
	<li style="text-align:justify">Traumatic Osteonecrosis</li>
</ul>

As the name implies, this type of osteonecrosis results from an injury, such as a bone fracture or dislocation disrupting the blood supply to the bone. 
&nbsp;

<ul>
	<li style="text-align:justify">Non-Traumatic Osteonecrosis</li>
</ul>

This type of osteonecrosis results from a disease or health condition that prevents blood from reaching the bone tissue. In non-traumatic osteonecrosis, there is no history of trauma. The same bones along both sides of the body are frequently affected. For instance, one is more likely to get ischemic bone necrosis in their left shoulder if they have it in their right shoulder. 
&nbsp;

Signs and Symptoms

The early stages of osteonecrosis are generally asymptomatic. It might be weeks or months before the individual notices any symptoms. Symptoms typically appear as the condition progresses and weight is put on the affected joints. While the pain may initially only be felt when pressure is applied on the affected bone or lying down, later it can become constant and make it difficult to move the joint.

Some common signs and symptoms of osteonecrosis are:&nbsp; 
&nbsp;

<ul>
	<li style="text-align:justify">Pain in the affected joint</li>
	<li style="text-align:justify">Pain worsened by weight-bearing</li>
	<li style="text-align:justify">Limited range of motion of the affected joint</li>
	<li style="text-align:justify">If the condition is in the leg, the patient may experience limping</li>
	<li style="text-align:justify">Arthritic symptoms get worse in the joint as the disease progresses</li>
	<li style="text-align:justify">If the hip joint is affected, pain may occur in the groin, thigh, or buttock</li>
	<li style="text-align:justify">Occurrence of pain even at rest</li>
	<li style="text-align:justify">If the shoulder joint is involved, overhead movements may be difficult</li>
	<li style="text-align:justify">Osteonecrosis of the jaw may cause pain and pus in the exposed bone</li>
	<li style="text-align:justify">Bone collapse 
	&nbsp;</li>
</ul>

Causes

Approximately 20% of osteonecrosis cases have no obvious cause<a href="#accordion">[4]</a>. Reduced or interrupted blood supply to the bone is the major causative factor in the development of the disease. The reduced blood supply can be due to trauma or non-trauma factors.

In traumatic osteonecrosis, the loss of blood flow is due to damage to the vessels. Hip fractures and dislocations are common causes of osteonecrosis. Approximately 20% of hip dislocations progress to avascular necrosis<a href="#accordion">[4]</a>.

Non-traumatic osteonecrosis is believed to result from tiny blood clots forming in the blood vessels, which reduce blood flow to the bones. Genetics and other factors may also play a role. Some non-traumatic causes of osteonecrosis are listed below: 
&nbsp;

<ul>
	<li style="text-align:justify">Systemic lupus erythematosus</li>
	<li style="text-align:justify"><a href="https://merisehat.pk/disease/osteoporosis-80">Osteoporosis </a></li>
	<li style="text-align:justify">Hyperlipidemia</li>
	<li style="text-align:justify">Pregnancy</li>
	<li style="text-align:justify"><a href="https://merisehat.pk/disease/diabetes-type-1-and-2">Diabetes</a></li>
	<li style="text-align:justify">Bone disorders</li>
	<li style="text-align:justify">Blood disorders, such as <a href="https://merisehat.pk/disease/sickle-cell-anemia">sickle cell anemia</a>, hemophilia</li>
	<li style="text-align:justify">Bisphosphonates</li>
	<li style="text-align:justify">Radiation therapy</li>
	<li style="text-align:justify">Kidney transplantation </li>
	<li style="text-align:justify">Alcohol Abuse</li>
	<li style="text-align:justify">Smoking</li>
	<li style="text-align:justify">Prolonged steroid use</li>
	<li style="text-align:justify">Allogeneic bone marrow transplantation </li>
	<li style="text-align:justify"><a href="https://merisehat.pk/disease/hiv-61">HIV</a></li>
	<li style="text-align:justify">Malignancy (marrow infiltration, malignant fibrous histiocytoma)</li>
	<li style="text-align:justify"><a href="https://merisehat.pk/disease/gauchers-disease">Gaucher&rsquo;s disease</a></li>
	<li style="text-align:justify">Inflammatory bowel disease </li>
	<li style="text-align:justify">Decompression sickness (common in scuba divers) 
	&nbsp;</li>
</ul>

There are no specific screening tests for osteonecrosis. The healthcare professional will obtain a complete medical history and conduct a physical exam to assess for any tenderness or limited movement.

Since the early stages of the disease are mostly asymptomatic, diagnosing or detecting the disease is difficult. Early screening with MRI scans is often advised6. The MRI will reveal a double-line sign at the affected region.&nbsp; 
&nbsp;

Diagnosis

To diagnose osteonecrosis, the doctor will first take a detailed history from the individual. They will inquire about the use of certain medications, history of any trauma, any existing medical conditions, and the patient&rsquo;s family history. Next, they will perform a physical exam to assess for tenderness around the joints and any limited range of motion.

The following imaging scans are usually recommended to diagnose osteonecrosis: 
&nbsp;

<ul>
	<li style="text-align:justify">Radiography: Plain radiography is not an accurate method for detecting bone infarction because radiographic features of AVN do not appear until several months after the start of symptoms. Plain imaging does, however, play a part in the alternative diagnosis. Moreover, it may be used to evaluate high-risk individuals. 
	&nbsp;</li>
	<li style="text-align:justify">Computed Tomography (CT scan): CT images show decreased attenuation in the center or around the edges. The identification of bone infarcts using CT is not precise, as it is with conventional radiography. However, compared to when using conventional radiography, CT scans can aid in the early diagnosis of ischemic bone necrosis. Compared to MRI and bone scintigraphy, the accuracy of CT in the detection of ischemic bone necrosis is weaker. Early CT characteristics of a bone infarct, similar to plain radiography, lack precision, especially in the metaphyseal area of the long bones. Uncertain radiolucencies can resemble cancerous and infectious processes.<a href="#accordion">[1]</a> 
	&nbsp;</li>
	<li style="text-align:justify">Magnetic Resonance Imaging (MRI): Early avascular necrosis can be found using MRI scans. The MRI is thought to be more accurate than conventional scintigraphy. The identification of spontaneous infarction in the area of the knee is accurate with magnetic resonance imaging. In particular, MRI helps evaluate how the femoral head responds to core decompression, which may cause ischemia regions to contract and edema to go away. The infarcted area&#39;s MRI features, on the other hand, frequently remain relatively stable over time.</li>
	<li style="text-align:justify">Bone Scan: It is also known as a nuclear bone scan or bone scintigraphy. The specialist may suggest a bone scan if the X-rays are normal and there aren&rsquo;t any risk factors. This test requires that the patient get an IV with a harmless radioactive substance before the scan. The substance travels to the injured or healing regions and appears as bright spots on the scan. A single bone scan finds any bones affected by osteonecrosis. 
	&nbsp;</li>
</ul>

Treatment

The treatment of avascular necrosis will depend on the degree of damage to the bones. If smaller bones that don&rsquo;t bear weight are affected, the following treatments may be suggested:

<ul>
	<li style="text-align:justify">Rest</li>
	<li style="text-align:justify">Heat treatment</li>
	<li style="text-align:justify">Cold Packs</li>
	<li style="text-align:justify">Physical therapy to ease joint tenderness and increase motion range</li>
	<li style="text-align:justify">Walking aids </li>
	<li style="text-align:justify">Nonsteroidal anti-inflammatory drugs (NSAIDs): Over-the-counter medications like ibuprofen or naproxen sodium (Synflex) might help relieve pain associated with osteonecrosis. Stronger NSAIDs are available by prescription.</li>
	<li style="text-align:justify">Electrical stimulation - Electrical currents help promote new bone formation to replace the damaged bone. It can be applied directly to the affected region or during surgery. 
	&nbsp;</li>
</ul>

In severe cases, there is a need for surgery to cure AVN. Surgical treatments can include:

<ul>
	<li style="text-align:justify">Core Decompression: This procedure involves drilling small holes or cores into the affected bone, to improve the blood flow. It may be combined with bone grafts or injections. </li>
	<li style="text-align:justify">Joint Replacement: This involves the replacement of a damaged joint with an artificial one. Hip joint replacements and knee replacements are 95% effective at relieving pain and restoring mobility in people with osteonecrosis.</li>
	<li style="text-align:justify">Bone Graft: Along with core decompression, bone grafting is frequently carried out. A surgeon will transplant) a tiny piece of healthy bone from another area of the body to replace the dead bone. The surgeon may also utilize a donor or artificial bone transplant as an alternative. This procedure helps support the joint and promotes blood flow. A vascular bone transplant is the name of the treatment if the surgeon additionally removes blood vessels along with the bone fragment. A bone transplant recovery might take many months.</li>
	<li style="text-align:justify">Osteotomy: Another option is an osteotomy. A surgeon adjusts or reshapes the healthy bone that is left after removing the dead bone. This makes the joint more stable and helps in utilizing it more effectively by reducing stress on it. To recuperate from this procedure, the person may need to engage in only restricted activity for several months. 
	&nbsp;</li>
</ul>

If left untreated, osteonecrosis may lead to the following complications:

<ul>
	<li style="text-align:justify">Osteoarthritis </li>
	<li style="text-align:justify">Permanent decreased mobility</li>
	<li style="text-align:justify">Joint replacement (severe cases)</li>
	<li style="text-align:justify">Collapsed bone</li>
	<li style="text-align:justify">Articular surface distortion 
	&nbsp;</li>
</ul>

The following factors increase the risk of osteonecrosis

<ul>
	<li style="text-align:justify">Injury</li>
	<li style="text-align:justify">Steroid use</li>
	<li style="text-align:justify">Alcohol and smoking</li>
	<li style="text-align:justify">Bisphosphonate use </li>
	<li style="text-align:justify">Hypercoagulable state</li>
	<li style="text-align:justify">Gaucher Disease</li>
	<li style="text-align:justify">Blood disorders, such as sickle cell anemia</li>
	<li style="text-align:justify">Radiation treatments</li>
	<li style="text-align:justify">Chemotherapy</li>
	<li style="text-align:justify">HIV</li>
	<li style="text-align:justify">Pancreatitis</li>
	<li style="text-align:justify">Decompression disease</li>
	<li style="text-align:justify">Hyperlipidemia 
	&nbsp;</li>
</ul>

The following measures can help reduce the risk of osteonecrosis:

<ul>
	<li>Quitting alcohol and smoking</li>
	<li>Maintaining low levels of cholesterol</li>
	<li>Monitoring steroid use 
	&nbsp;</li>
</ul>

Osteonecrosis of the jaw, in particular, can be prevented by the following measures:

<ul>
	<li style="text-align:justify">Brushing teeth </li>
	<li style="text-align:justify">Bi-monthly dental exams</li>
	<li style="text-align:justify">In case of mandible issues or swelling &amp; redness, immediate dentist consultation is suggested</li>
	<li style="text-align:justify">In case of bisphosphonate therapy, plan any necessary dental surgery first. 
	 
	&nbsp;</li>
</ul>

The U.S. FDA (Food and Drug Administration) has approved the Patient Specific Talus Spacer 3D-printed talus implant for humanitarian use. The Patient Specific Talus Spacer is the first in the world and one of its kind implants to replace the talus; the bone in the ankle joint that connects the leg and the foot, for the treatment of osteonecrosis of the ankle joint. This implant provides a joint-sparing alternative to other surgical interventions commonly used in an advanced stage of osteonecrosis that may disable the motion of the ankle joint.<a href="#accordion">[3]</a> 
&nbsp;

Key Points

<ul>
	<li style="text-align:justify">Osteonecrosis develops when a bone loses its blood flow permanently or temporarily. </li>
	<li style="text-align:justify">Osteonecrosis or AVN can develop as a consequence of trauma, medication use, or excessive alcohol consumption.&nbsp;</li>
	<li style="text-align:justify">Some common symptoms are joint discomfort and restricted range of motion.</li>
	<li style="text-align:justify">To increase usefulness or prevent further harm to the afflicted bone or joint, doctors may use medications, assistive technology, and surgery. 
	&nbsp;</li>
</ul>

[1] Sunny B Patel MD. Avascular Necrosis. Practice Essentials, Pathophysiology, Etiology.

[2] Alam M, Khan ZM, Alam L, Faraid V, Khan A. Addressing Osteonecrosis: A preventable catastrophe-A multi-center study. Pakistan Journal of Medical Sciences. 2023;39(1)

[3] Pascart T, Paccou J, Colard T, et al. T1-weighted MRI images accurately represent the volume and surface of architectural mineral damage of osteonecrosis of the femoral head: Comparison with high-resolution computed tomography. Bone. 2020 Jan. 130:115099.

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