eMedicine Specialties > Orthopedic Surgery > Knee

Osteonecrosis, Knee: Workup

Author: Amar Rajadhyaksha, MD, Resident, Department of Orthopedic Surgery, New York Medical College
Coauthor(s): Michael Mont, MD, Associate Professor, Department of Orthopaedic Surgery, Johns Hopkins Medical Institution; Michael Levine, MD, Chairman, Department of Orthopedic Surgery, Western Pennsylvania Hospital
Contributor Information and Disclosures

Updated: Aug 15, 2008

Workup

Laboratory Studies

  • Lab tests are limited for osteonecrosis. Some tests that may be helpful include the following:
    • Sickle-cell screening, especially in African Americans
    • Lipid profile
    • Screening for coagulopathies (eg, protein S and protein C deficiencies, factor V Leiden disease)

Imaging Studies

  • Plain radiographs (see Image 1)
    • Always obtain anteroposterior (AP), lateral, and tunnel view plain radiographs when entertaining the diagnosis of osteonecrosis.
    • Initially, no abnormalities may be seen, but as the disease progresses, flattening of the weightbearing portion may occur.
    • A radiolucent area forms in the subchondral bone, surrounded by a rim of sclerosis. Later in the disease course, the subchondral bone collapses, leading to secondary arthritic change and, possibly, a valgus or varus deformity.
    • In spontaneous osteonecrosis of the knee (SPONK), these lesions usually are seen in the medial femoral condyle, whereas in secondary osteonecrosis, both the medial and lateral sides may be affected.5
  • MRI (see Image 2)
    • MRI can depict osteonecrosis before it is visible on plain radiographs.
    • MRI can also reveal the extent of disease more precisely than plain radiographs.
    • In SPONK, lesions are isolated to a single condyle (usually medial) or plateau.
    • In SPONK, on T1-weighted images, osteonecrosis is seen as a discrete area of low signal intensity, replacing the high-intensity signal normally produced by marrow fat.
    • The T2-weighted image shows an area of low signal intensity surrounded by a high-intensity signal caused by edema.
    • The T1- and T2-weighted images in secondary osteonecrosis are similar to those in SPONK but are larger, are more serpiginous, and may be multifocal. Lesions usually are seen in the epiphyseal region of the distal femur or proximal tibia.
  • Technetium-99m scans
    • Bone scans have been used to diagnose SPONK and may show osteonecrotic lesions before plain radiographs do.
    • In SPONK, bone scans usually show a localized area of radioisotope uptake in the medial femoral condyle.
    • Bone scans are less effective for diagnosing secondary osteonecrosis than for diagnosing SPONK.
    • Studies have reported that bone scans provide a correct diagnosis of secondary osteonecrosis in only 40-70% of cases.6
    • Because secondary osteonecrosis commonly presents bilaterally, bilateral symmetric uptake may be read incorrectly as degenerative changes or as a negative study.
    • Bone scans generally are unreliable. Therefore, plain radiographs remain the initial imaging study of choice, with MRI for confirmation.
  • Because specificity and sensitivity of MRI are 98% in osteonecrosis, MRI is the diagnostic study of choice.

Other Tests

  • The following methods are outdated and are mentioned for the sake of completeness. Core biopsy, however, can be useful for pathologic diagnosis of osteonecrosis of the knee.
    • Venography
    • Interosseous pressure measurements

Diagnostic Procedures

  • Core biopsy may be useful for pathologic diagnosis of osteonecrosis of the knee.

Histologic Findings

Macroscopic pathology

Early in osteonecrosis of the knee, there may be slight discoloration and flattening of the articular cartilage. As the disease progresses, a line of demarcation becomes evident, and an osteochondral flap overlies the area of osteonecrosis. Late in the disease course, secondary arthritic changes occur, leading to a cartilage defect filled with necrotic debris and to signs of osteoarthritis (eg, osteophyte formation, eburnated bone).7

Microscopic pathology

On microscopic examination, the osteonecrotic bone shows empty lacunae and fatty degeneration within the center of the lesion. The surrounding area shows evidence of osseous healing, including osteoblastic activity, fibrovascular granulation tissue, and cartilage formation.

Staging

Aglietti devised a classification system for spontaneous osteonecrosis of the knee (SPONK), which was a modification of an earlier classification by Koshino.8

  • Stage I: Plain radiograph findings are normal. Diagnosis must be made from MRI or bone scan.
  • Stage II: Radiographs show flattening of the weightbearing portion of the condyle.
  • Stage III: Radiographs show a radiolucent area surrounded by sclerosis.
  • Stage IV: Radiographs show a more defined ring of sclerosis and subchondral bone collapse forming a calcified plate, sequestrum, or fragment.
  • Stage V: Narrowing of the joint space, osteophyte formation, and/or femoral and tibial subchondral sclerosis is shown.

For secondary osteonecrosis, Mont and Hungerford developed a staging system that is a modification of the Ficat and Arlet staging of osteonecrosis of the hip.9,10,11,12,13,14,15

  • Stage I - Plain radiographs reveal no change, but MRI scan findings are positive.
  • Stage II - Radiographs reveal cystic and sclerotic changes in the distal femur and/or proximal tibia.
  • Stage III - Subchondral collapse is seen as the crescent sign.
  • Stage IV - Evidence of degenerative changes is present on both sides of the joint (eg, joint space narrowing, osteophytes). At this stage, it may be difficult to distinguish osteonecrosis from osteoarthritis of the knee on plain radiographs.

More on Osteonecrosis, Knee

Overview: Osteonecrosis, Knee
Workup: Osteonecrosis, Knee
Treatment: Osteonecrosis, Knee
Follow-up: Osteonecrosis, Knee
Multimedia: Osteonecrosis, Knee
References
[ CLOSE WINDOW ]

References

  1. Ahlback S, Bauer GC, Bohne WH. Spontaneous osteonecrosis of the knee. Arthritis Rheum. Dec 1968;11(6):705-33. [Medline].

  2. Zizic TM, Marcoux C, Hungerford DS. Corticosteroid therapy associated with ischemic necrosis of bone in systemic lupus erythematosus. Am J Med. Nov 1985;79(5):596-604. [Medline].

  3. Soucacos PN, Beris AE, Xenakis TH, et al. Knee osteonecrosis: Distinguishing features and differential diagnosis. In: Urbaniak JR, Jones JP, eds. Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL: The American Academy of Orthopaedic Surgeons;1997: 413-24.

  4. Williams JS Jr, Bush-Joseph CA, Bach BR Jr. Osteochondritis dissecans of the knee. Am J Knee Surg. Fall 1998;11(4):221-32. [Medline].

  5. Ohdera T, Miyagi S, Tokunaga M, Yoshimoto E, Matsuda S, Ikari H. Spontaneous osteonecrosis of the lateral femoral condyle of the knee: a report of 11 cases. Arch Orthop Trauma Surg. Jul 1 2008;[Medline].

  6. Sakai T, Sugano N, Nishii T, Haraguchi K, Yoshikawa H, Ohzono K. Bone scintigraphy for osteonecrosis of the knee in patients with non-traumatic osteonecrosis of the femoral head: comparison with magnetic resonance imaging. Ann Rheum Dis. Jan 2001;60(1):14-20. [Medline].

  7. Takeda M, Higuchi H, Kimura M, Kobayashi Y, Terauchi M, Takagishi K. Spontaneous osteonecrosis of the knee: histopathological differences between early and progressive cases. J Bone Joint Surg Br. Mar 2008;90(3):324-9. [Medline].

  8. Aglietti P, Insall JN, Buzzi R. Idiopathic osteonecrosis of the knee. Aetiology, prognosis and treatment. J Bone Joint Surg Br. Nov 1983;65(5):588-97. [Medline].

  9. Mont MA, Hungerford DS. Osteonecrosis of the shoulder, knee, and ankle. In JR Urbaniak and JP Jones, eds. Osteonecrosis: Etiology, Diagnosis, and Treatment. Rosemont, IL: The American Academy of Orthopaedic Surgeons;1997: 429-436.

  10. Ficat RP, Arlet J. Necrosis of the femoral head. In: Hungerford DS, ed. Ischemia and Necrosis of Bone. Baltimore: Williams and Wilkins;1980: 171-82.

  11. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br. Jan 1985;67(1):3-9. [Medline].

  12. Ficat RP. [Aseptic necrosis of the femur head. Pathogenesis: the theory of circulation]. Acta Orthop Belg. Mar-Apr 1981;47(2):198-9. [Medline].

  13. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. Mar 1995;77(3):459-74. [Medline].

  14. Mont MA, Rifai A, Baumgarten K. Osteonecrosis of the Knee, Insall and Scott. Surgery of the knee. 2001;438-456.

  15. Ficat RP, Arlet J. Functional investigation of bone under normal conditions. In: Hungerford DS, ed. Ischemia and Necrosis of Bone. Baltimore: Williams and Wilkins;1980: 29-52.

  16. Ecker ML, Lotke PA. Osteonecrosis of the medial part of the tibial plateau. J Bone Joint Surg Am. Apr 1995;77(4):596-601. [Medline].

  17. Lotke PA, Ecker ML. Osteonecrosis of the knee. J Bone Joint Surg [Am]. Mar 1988;70(3):470-3. [Medline].

  18. Lotke PA, Ecker ML. Osteonecrosis-like syndrome of the medial tibial plateau. Clin Orthop. Jun 1983;(176):148-53. [Medline].

  19. Bayne O, Langer F, Pritzker KP. Osteochondral allografts in the treatment of osteonecrosis of the knee. Orthop Clin North Am. Oct 1985;16(4):727-40. [Medline].

  20. Matsusue Y, Yamamo T, Hama H. Arthroscopic multiple osteochondral transplantation to the chondral defect in the knee associated with anterior cruciate ligament rupture. Arthroscopy. 1993;9:318.

  21. Hangody L, Kish G, Karpatiz. Osteochondral plugs: Autogenous osteochondral mosaicplasty for the treatment of focal chondral and osteochondral articular defects. Operative Techniques Orthop. 1997;7:12.

  22. Koshino T. The treatment of spontaneous osteonecrosis of the knee by high tibial osteotomy with and without bone-grafting or drilling of the lesion. J Bone Joint Surg [Am]. Jan 1982;64(1):47-58. [Medline].

  23. Forst J, Forst R, Heller KD, Adam G. Spontaneous osteonecrosis of the femoral condyle: causal treatment by early core decompression. Arch Orthop Trauma Surg. 1998;117(1-2):18-22. [Medline].

  24. Mont MA, Tomek IM, Hungerford DS. Core decompression for avascular necrosis of the distal femur: long term followup. Clin Orthop. Jan 1997;(334):124-30. [Medline].

  25. Parratte S, Argenson JN, Dumas J, Aubaniac JM. Unicompartmental knee arthroplasty for avascular osteonecrosis. Clin Orthop Relat Res. Nov 2007;464:37-42. [Medline].

  26. Myers TG, Cui Q, Kuskowski M, Mihalko WM, Saleh KJ. Outcomes of total and unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee. J Bone Joint Surg Am. Nov 2006;88 Suppl 3:76-82. [Medline].

  27. Marmor L. Unicompartmental arthroplasty for osteonecrosis of the knee joint. Clin Orthop. Sep 1993;(294):247-53. [Medline].

  28. Bergman NR, Rand JA. Total knee arthroplasty in osteonecrosis. Clin Orthop. Dec 1991;(273):77-82. [Medline].

  29. Ritter MA, Eizember LE, Keating EM, Faris PM. The survival of total knee arthroplasty in patients with osteonecrosis of the medial condyle. Clin Orthop Relat Res. Jun 1991;108-14. [Medline].

  30. Mont MA, Myers TH, Krackow KA. Total knee arthroplasty for corticosteroid associated avascular necrosis of the knee. Clin Orthop. May 1997;(338):124-30. [Medline].

  31. Yates PJ, Calder JD, Stranks GJ, Conn KS, Peppercorn D, Thomas NP. Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. Knee. Mar 2007;14(2):112-6. [Medline].

  32. Lotke PA, Abend JA, Ecker ML. The treatment of osteonecrosis of the medial femoral condyle. Clin Orthop Relat Res. Nov-Dec 1982;109-16. [Medline].

  33. Banzer W, Hübscher M, Schikora D. Laser-Needle Therapy for Spontaneous Osteonecrosis of the Knee. Photomed Laser Surg. Jul 22 2008;[Medline].

  34. Deie M, Ochi M, Adachi N, Nishimori M, Yokota K. Artificial bone grafting [calcium hydroxyapatite ceramic with an interconnected porous structure (IP-CHA)] and core decompression for spontaneous osteonecrosis of the femoral condyle in the knee. Knee Surg Sports Traumatol Arthrosc. Aug 2008;16(8):753-8. [Medline].

  35. Koshino T, Okamoto R, Takamura K. Arthroscopy in spontaneous osteonecrosis of the knee. Orthop Clin North Am. Jul 1979;10(3):609-18. [Medline].

  36. Miller GK, Maylahn DS, Drennan DB. The treatment of idiopathic osteonecrosis of the femoral condyle with Arthroscopic Debridement. Arthroscopy. 1986;2:21.

  37. Soucacos PN, Xenakis TH, Beris AE. Idiopathic osteonecrosis of the medial femoral condyle. Classification and treatment. Clin Orthop. Aug 1997;(341):82-9. [Medline].

  38. Zizic TM, Hungerford DS. Avascular necrosis of bone. In: Kelley WN, Harris ED, Ruddy S, Sledge CB, eds. Textbook of Rheumatology. Vol 2. Philadelphia: WB Saunders;1985: 1689-1710.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

osteonecrosis, knee osteonecrosis, osteonecrosis of knee, spontaneous osteonecrosis of the knee, SPONK, secondary osteonecrosis, avascular necrosis, AVN, aseptic necrosis, ischemic necrosis, idiopathic necrosis, knee pain, knee arthritis, bone death, mass bone death, bone disease, necrosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Amar Rajadhyaksha, MD, Resident, Department of Orthopedic Surgery, New York Medical College
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Mont, MD, Associate Professor, Department of Orthopaedic Surgery, Johns Hopkins Medical Institution
Michael Mont, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Stryker Orthopaedics Consulting fee Consulting; Wright Medical Technology, Inc. Consulting fee Consulting

Michael Levine, MD, Chairman, Department of Orthopedic Surgery, Western Pennsylvania Hospital
Michael Levine, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, American Medical Association, Orthopaedic Research Society, Pennsylvania Medical Society, Pennsylvania Orthopaedic Society, and Phi Beta Kappa
Disclosure: encore medical Consulting fee Consulting; glaxo smith kline Honoraria Speaking and teaching

Medical Editor

Albert W Pearsall IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Alabama; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M DeBerardino, MD, Associate Professor of Orthopaedic Surgery, University of Connecticut Health Center
Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine
Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Honoraria Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None; Arthrex, Inc. Consulting fee Speaking and teaching

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
Disclosure: Zimmer Stock Implant Designer

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.