What is avascular necrosis?

Avascular necrosis, or osteonecrosis, is the name given to bone death, a condition that occurs when the blood supply to an area of the bone is cut off either temporarily or permanently.

Bone is living tissue, which is supplied by many blood vessels. Bone that does not have a supply of blood (avascular) for an extended period of time becomes brittle and eventually collapses. This can lead to severe cases of arthritis and dysfunction in the affected joint.

The thighbone (femur) is the most commonly affected bone, followed by the shoulder. Other large joints, including the knee, ankle and wrist, can also be affected.

This condition is also known as ischaemic bone necrosis, aseptic necrosis and bone infarction.

Avascular necrosis, bone collapse.Healthy femoral bone alongside femoral bone with avascular necrosis. 

Joint

A connecting surface or tissue between two bones.

Causes

The inside of the bones consists of a strong, honeycomb-like structural tissue, called trabecular tissue. This tissue forms a lattice pattern along the bone stress lines next to bone marrow cavities. Without a fresh blood supply, the trabecular tissue ceases to provide structure or strength to the bone, which often causes the bone to collapse. Certain bones are more at risk, as they rely only on one or very few blood vessels for their blood supply. The ball-shaped end of the femur, which forms part of the hip joint, relies on blood vessels that pass through the thinner shaft of the femur, which can be broken during a fall.

The most common causes of avascular necrosis are as follows:

Traumatic

Injury to the bone, such as a fracture or dislocation that interrupts the blood supply to the bone by severing or damaging the blood vessels, can result in avascular necrosis.

Non-traumatic

  • Corticosteroid medications - when taken in high dosages or long-term, these medications have been found to cause avascular necrosis, but the exact reasons why have not been identified;
  • Chemotherapy or radiotherapy treatment - these can damage blood vessels as a side effect of treatment, and;
  • Long-term and excessive alcohol consumption - the exact effect of alcohol on bones has not been determined.

Bone marrow

The spongy, vascular or fatty tissue found inside bones, responsible for producing blood cells.

Chemotherapy

A medication-based treatment, usually used in the treatment of cancers. There are numerous, different types of chemotherapy drugs that can be prescribed by a specialist. These can commonly be used alongside other cancer treatments such as surgery and radiotherapy.

Corticosteroid

A medication that resembles the cortisol hormone produced in the brain. It is used as an anti-inflammatory medication.

Fracture

A complete or incomplete break in a bone.

Joint

A connecting surface or tissue between two bones.

Radiotherapy

A treatment that uses ionising radiation to kill or control growth of malignant cancer cells.

Dislocation

A displacement of a body part, such as a joint, from its normal position.

Risk factors

There are several risk factors that can result in avascular necrosis:

Bisphosphonates

A group of drugs that prevent the loss of bone mass by reducing the normal turnover of bone. They are used to treat osteoporosis and other bone diseases.

Chemotherapy

A medication-based treatment, usually used in the treatment of cancers. There are numerous, different types of chemotherapy drugs that can be prescribed by a specialist. These can commonly be used alongside other cancer treatments such as surgery and radiotherapy.

Corticosteroid

A medication that resembles the cortisol hormone produced in the brain. It is used as an anti-inflammatory medication.

Fracture

A complete or incomplete break in a bone.

Organ transplants

The transfer of an organ from one individual to another This can be from a live donor, or from someone who has died that previously expressed their wish for their organs to be donated.

Pancreatitis

Inflammation of the pancreas.

Radiotherapy

A treatment that uses ionising radiation to kill or control growth of malignant cancer cells.

Sickle-cell anaemia

A hereditary form of anaemia in which a defective form of haemoglobin cause red blood cells to be an abnormal crescent shape. This causes the cells to break down prematurely, which can then lead to anaemia.

Dislocation

A displacement of a body part, such as a joint, from its normal position.

Gaucher disease

Gaucher disease is a rare genetic condition that results in the abnormal accumulation of fatty cells in numerous organs within the body. A potential complication is when the fatty cells accumulate in bone marrow, restricting normal blood flow and thus leading to bone death. 

Types

Osteonecrosis of the jaw

Osteonecrosis of the jaw is a rare and serious condition, in which the cells of the jawbone begin to die. This can sometimes develop following radiotherapy to the head and neck area, bisphosphonates treatment, or after a tooth extraction while having either of the two treatments. The symptoms of osteonecrosis of the jaw include severe pain and development of an infection or pus in the exposed area. 

Spontaneous osteonecrosis of the knee

Spontaneous osteonecrosis of the knee is when a section of the knee bone dies. It is more common in women and has been linked to osteoporosis. The symptoms usually start in the inner knee, and include localised swelling and tenderness.

Perthes' disease

Perthes' disease, also known as coxa plana or Legg-Calve-Perthes disease, is a type of avascular necrosis that affects the hip joints of children - most often boys - aged between 3-11 years, for reasons that are currently unknown. During this condition, there is a reduced supply of blood to the round head of the thighbone, known as the femoral head, which fits into the hip socket. This causes loss of bone cells and softening and collapse of the hip joint, which results in pain, limping and reduced movement.

However, most children will recover fully and without complications, using treatments such as braces, pain-relief medications and rest from high-impact activities.

Bisphosphonates

A group of drugs that prevent the loss of bone mass by reducing the normal turnover of bone. They are used to treat osteoporosis and other bone diseases.

Infection

Entry into the body of microorganisms that can reproduce and cause disease.

Joints

A connecting surface or tissue between two bones.

Pus

A bodily fluid that is the result of an inflammatory response at an infection site. Its colour can range from whitish to yellow to green, depending on the composition. Pus is mainly composed of dead bacteria, white blood cells and cellular debris.

Radiotherapy

A treatment that uses ionising radiation to kill or control growth of malignant cancer cells.

Signs and symptoms

During the first stages of avascular necrosis, there are often no signs or symptoms. Once the bone damage worsens, however, the following symptoms may develop:

  • Pain that does not stop during rest;
  • Stiffness and limited range of movement;
  • Limping and pain in the groin area while walking;
  • Pain that becomes worse, or severe if a bone collapses, and;
  • Severe and painful osteoarthritis in the affected joint once the bone collapses.

Joint

A connecting surface or tissue between two bones.

Groin

The area where the abdomen joins the thighs.

Methods for diagnosis

Medical history

A doctor can suspect avascular necrosis based on a person's medical history and a physical examination. To help confirm the diagnosis, the following tests may also be carried out.

 X-ray

An X-ray is usually the first recommended imaging test for any bone condition. However, as X-rays are not always useful for detecting avascular necrosis in its early stages, they are used more often to track the condition's progression.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) creates an image that can detect changes in the density and structure of your bones. MRI is considered the best option for diagnosing avascular necrosis, as the scans can reveal any chemical changes in the bone marrow, as well as the presence of abnormal tissue, prior to development of any symptoms.

Computerised tomography scan

A computerised tomography (CT) scan can provide detailed imaging of the interior bone structure, revealing any areas of avascular necrosis.

Bone scan

In a bone scan a radioactive substance is injected into the bloodstream. Its circulation is detected by a gamma camera, revealing any problem with blood flow to the bones.

Biopsy

A bone biopsy can provide supportive evidence of avascular necrosis, but as it requires surgery, non-invasive tests such as MRI are usually preferred.

Biopsy

The removal of a tissue sample for microscopic laboratory examination. It is used to determine the presence, cause and type of the disease.

Bone marrow

The spongy, vascular or fatty tissue found inside bones, responsible for producing blood cells.

Computerised tomography

A scan that uses X-rays to create a 3D image of the body. This can detect abnormalities more effectively than a simple X-ray can.

Magnetic resonance imaging

A type of imaging that uses a magnetic field and low-energy radio waves, instead of X-rays, to obtain images of organs.

X-ray

A scan that uses ionising radiation beams to create an image of the body’s internal structures.

Gamma camera

A camera used in imaging scans of the body. It detects radiation from radioactive material that has been introduced into the person's body to highlight areas of interest.

Types of treatment

The type of treatment offered will depend on the level of damage in the bones, age, activity levels, life expectancy and presence of other health conditions. If avascular necrosis is in its early stages, more treatment options are available than in cases of severe avascular necrosis. Treatment options will typically be decided by a specialist and can include the following options:

Non-surgical treatments

Protected weight-bearing

Protected weight-bearing involves taking weight off the affected joint by using supportive aids such as crutches. This treatment can help with pain relief, but will not cure the condition.

Medications

Currently, there is no medication that directly stops the progress of or cures avascular necrosis. However, some medications may be beneficial early in the condition. These include:

  • Lipid-lowering medications - these break down the fatty (lipid) deposits in the blood vessels, which otherwise can reduce blood flow;  
  • Anticoagulants - these prevent formation of blood clots that can reduce blood flow to the bones;
  • Hypertension medication - lowers blood pressure and improves blood circulation;
  • Non-steroidal anti-inflammatory medication (NSAIDs) - to reduce inflammation in the affected area, and;
  • Bisphosphonates - used to treat osteoporosis with favourable outcomes observed in cases of avascular necrosis. [1]   

Electrical stimulation

Pulsed electrical stimulation has been used to encourage bone growth, and some evidence has suggested that it is effective in the treatment of early-stage avascular necrosis.

Hyperbaric oxygen

Hyperbaric oxygen treatment involves entering a pressurised chamber where the lungs can absorb up to three times more oxygen than normal. The treatment has been shown to provide significant improvements in pain, range of mobility and bone healing in some cases of early-stage avascular necrosis. [2]

Exercise

Working with a physiotherapist to design and use strengthening exercises may be helpful with increasing flexibility and range of movement.

Surgical treatment 

Surgery is not typically recommended, except in cases of bone damage or collapse. Surgical procedures include:

Bone graft

This procedure involves taking healthy bone from another part of the body and implanting it into the area affected by avascular necrosis. This can be done together with a core decompression procedure.

Bone core decompression

This procedure involves replacing a section of dead bone with a bone graft. Historically, bone core decompression was used as a diagnostic procedure to test bone marrow density, but as patients reported pain relief after the procedure, it became a therapy. It has been shown to regenerate bone growth and prevent the exterior of the bone from collapsing, eliminating the need for a joint replacement.

Osteotomy

This less common procedure involves cutting away the dead bone from a weight-bearing area and reshaping the bone to allow healthy bone and cartilage to bear the weight instead.

Joint replacement

If the avascular necrosis is in its later stages and the bone has collapsed, a complete joint replacement may be required. The surgeon will replace damaged bone with a prosthetic joint. Both the ball and socket of the hip may be replaced.

Bisphosphonates

A group of drugs that prevent the loss of bone mass by reducing the normal turnover of bone. They are used to treat osteoporosis and other bone diseases.

Bone marrow

The spongy, vascular or fatty tissue found inside bones, responsible for producing blood cells.

Cartilage

A tough, flexible connective tissue found in various parts of the body including the joints and larynx.

Inflammation

A body’s protective immune response to injury or infection. The accumulation of fluid, cells and proteins at the site of an infection or physical injury, resulting in swelling, heat, redness, pain and loss of function.

Joint

A connecting surface or tissue between two bones.

NSAIDs

Non-steroidal anti-inflammatory drugs are commonly used to manage arthritis-related pain and inflammation and other musculoskeletal disorders. NSAIDs include aspirin and ibuprofen.

Physiotherapist

A healthcare professional trained in treating injury or disability with physical remedies, such as massage or exercise.

Clots

The thickened or solid mass formed from a liquid, such as blood. Blood clots normally form at an injury site to prevent further blood loss.

1. Cardozo, J.B., Andrafe, D.M. and Santiagi, M.B. (2008) The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clinical Rheumatology 27:685-688.

2. Camporesi, E.M., Vezzani, G. and Bosco, G. (2010) Hyperbaric oxygen therapy in femoral head necrosis. The Journal of Arthroplasty 25:118-123.

Potential complications

If left untreated, avascular necrosis can lead to bone collapse, arthritis and physical disability.

1. Cardozo, J.B., Andrafe, D.M. and Santiagi, M.B. (2008) The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clinical Rheumatology 27:685-688.

2. Camporesi, E.M., Vezzani, G. and Bosco, G. (2010) Hyperbaric oxygen therapy in femoral head necrosis. The Journal of Arthroplasty 25:118-123.

Prognosis

Avascular necrosis is a condition that requires medical treatment in its early stages, to try and reduce the chances of bone collapse or surgery. Though it cannot be cured, if detected early on, the symptoms can be managed and bone damage minimised. 

1. Cardozo, J.B., Andrafe, D.M. and Santiagi, M.B. (2008) The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clinical Rheumatology 27:685-688.

2. Camporesi, E.M., Vezzani, G. and Bosco, G. (2010) Hyperbaric oxygen therapy in femoral head necrosis. The Journal of Arthroplasty 25:118-123.

Prevention

In many cases, avascular necrosis cannot be prevented, but you can lower your risk by avoiding long-term use of corticosteroids, if you can, and avoiding excessive alcohol consumption.

Corticosteroids

A medication that resembles the cortisol hormone produced in the brain. It is used as an anti-inflammatory medication.

1. Cardozo, J.B., Andrafe, D.M. and Santiagi, M.B. (2008) The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clinical Rheumatology 27:685-688.

2. Camporesi, E.M., Vezzani, G. and Bosco, G. (2010) Hyperbaric oxygen therapy in femoral head necrosis. The Journal of Arthroplasty 25:118-123.