Avascular Necrosis Follow-up
- Author: Jeanne K Tofferi, MD, MPH, FACP; Chief Editor: Herbert S Diamond, MD more...
The following precautions can be taken to minimize the risk of developing avascular necrosis (AVN) and to improve outcomes in these patients:
- Use the minimum effective dose of systemic corticosteroids; when possible, use steroid-sparing agents; statins may reduce the incidence of AVN with prolonged corticosteroid use
- Early diagnosis and treatment are important; the earlier AVN is detected, the more treatment (and less invasive) options available to the patient
- Provide patient education for high-risk patients, including those receiving high-dose corticosteroids, those with Gaucher disease, those with hemoglobinopathies, and those who have undergone renal transplant
See the list below:
- The natural history of AVN involves subchondral necrosis, subchondral fracture and collapse of bone, deformity of the articular surface, and osteoarthritis.
- In later stages, sclerosis and total destruction of the joint may occur.
- Nonunion of fracture and secondary muscle wasting are potential complications.
The prognosis of AVN depends on the disease stage at the time of diagnosis and the presence of any underlying conditions. More than 50% of patients with AVN require surgical treatment within 3 years of diagnosis. Half of patients with subchondral collapse of the femoral head develop AVN in the contralateral hip.
Poor prognostic factors include the following:
- Age older than 50 years
- Advanced disease (stage 3 or worse) at the time of diagnosis
- Necrosis of more than one third of the weight-bearing area of the femoral head on MRI
- Lateral involvement of femoral head (compared with medial lesions)
- Non-modifiable risk factors such as cumulative dose of corticosteroids (corticosteroid-induced AVN)
See the list below:
- Patients who are at high risk should be informed about the possibility of AVN. They should be advised to report symptoms as soon as possible to facilitate early diagnosis and treatment.
Bose VC, Baruah BD. Resurfacing arthroplasty of the hip for avascular necrosis of the femoral head: a minimum follow-up of four years. J Bone Joint Surg Br. 2010 Jul. 92(7):922-8. [Medline].
Steffen RT, Athanasou NA, Gill HS, Murray DW. Avascular necrosis associated with fracture of the femoral neck after hip resurfacing: histological assessment of femoral bone from retrieval specimens. J Bone Joint Surg Br. 2010 Jun. 92(6):787-93. [Medline].
Woo SB, Hellstein JW, Kalmar JR. Narrative [corrected] review: bisphosphonates and osteonecrosis of the jaws. Ann Intern Med. 2006 May 16. 144(10):753-61. [Medline].
Qi WX, Tang LN, He AN, Yao Y, Shen Z. Risk of osteonecrosis of the jaw in cancer patients receiving denosumab: a meta-analysis of seven randomized controlled trials. Int J Clin Oncol. 2014 Apr. 19(2):403-10. [Medline].
Kawai K, Tamaki A, Hirohata K. Steroid-induced accumulation of lipid in the osteocytes of the rabbit femoral head. A histochemical and electron microscopic study. J Bone Joint Surg Am. 1985 Jun. 67(5):755-63. [Medline].
Wang GJ, Sweet DE, Reger SI, et al. Fat-cell changes as a mechanism of avascular necrosis of the femoral head in cortisone-treated rabbits. J Bone Joint Surg Am. 1977 Sep. 59(6):729-35. [Medline].
Bagan JV, Murillo J, Jimenez Y, et al. Avascular jaw osteonecrosis in association with cancer chemotherapy: series of 10 cases. J Oral Pathol Med. 2005 Feb. 34(2):120-3. [Medline].
Khan AA, Sándor GK, Dore E, Morrison AD, Alsahli M, Amin F, et al. Bisphosphonate associated osteonecrosis of the jaw. J Rheumatol. 2009 Mar. 36(3):478-90. [Medline].
Ninomiya S. An epidemiological survey of idiopathic avascular necrosis of the femoral head in Japan. Annual Report of Japanese Investigation Committee for Intractable Disease. 1989.
Aaron RK, Voisinet A, Racine J, Ali Y, Feller ER. Corticosteroid-associated avascular necrosis: dose relationships and early diagnosis. Ann N Y Acad Sci. 2011 Dec. 1240(1):38-46. [Medline].
Lawson-Ayayi S, Bonnet F, Bernardin E, et al. Avascular necrosis in HIV-infected patients: a case-control study from the Aquitaine Cohort, 1997-2002, France. Clin Infect Dis. 2005 Apr 15. 40(8):1188-93. [Medline].
Mehta P, Nelson M, Brand A, Boag F. Avascular necrosis in HIV. Rheumatol Int. 2013 Jan. 33(1):235-8. [Medline].
Enright H, Haake R, Weisdorf D. Avascular necrosis of bone: a common serious complication of allogeneic bone marrow transplantation. Am J Med. 1990 Dec. 89(6):733-8. [Medline].
Fink JC, Leisenring WM, Sullivan KM, et al. Avascular necrosis following bone marrow transplantation: a case-control study. Bone. 1998 Jan. 22(1):67-71. [Medline].
Diz P, López-Cedrún JL, Arenaz J, Scully C. Denosumab-related osteonecrosis of the jaw. J Am Dent Assoc. 2012 Sep. 143(9):981-4. [Medline].
[Guideline] Murphey MD, Roberts CC, Bencardino JT, Appel M, Arnold E, Chang EY, et al. ACR Appropriateness Criteria Osteonecrosis of the Hip. J Am Coll Radiol. 2016 Feb. 13 (2):147-55. [Medline].
Luo RB, Lin T, Zhong HM, Yan SG, Wang JA. Evidence for using alendronate to treat adult avascular necrosis of the femoral head: a systematic review. Med Sci Monit. 2014 Nov 26. 20:2439-47. [Medline].
Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop. 2001 May. (386):173-8. [Medline].
Wang CJ, Cheng JH, Huang CC, Yip HK, Russo S. Extracorporeal shockwave therapy for avascular necrosis of femoral head. Int J Surg. 2015 Dec. 24 (Pt B):184-7. [Medline].
Gao F, Sun W, Li Z, Guo W, Wang W, Cheng L, et al. High-Energy Extracorporeal Shock Wave for Early Stage Osteonecrosis of the Femoral Head: A Single-Center Case Series. Evid Based Complement Alternat Med. 2015. 2015:468090. [Medline].
Van Laere C, Mulier M, Simon JP, et al. Core decompression for avascular necrosis of the femoral head. Acta Orthop Belg. 1998 Sep. 64(3):269-72. [Medline].
Aldridge JM 3rd, Urbaniak JR. Avascular necrosis of the femoral head: role of vascularized bone grafts. Orthop Clin North Am. 2007 Jan. 38(1):13-22, v. [Medline].
Hasegawa Y, Iwata H, Torii S, et al. Vascularized pedicle bone-grafting for nontraumatic avascular necrosis of the femoral head. A 5- to 11-year follow-up. Arch Orthop Trauma Surg. 1997. 116(5):251-8. [Medline].
Urbaniak JR, Coogan PG, Gunneson EB, et al. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am. 1995 May. 77(5):681-94. [Medline].
Zuo W, Sun W, Zhao D, Gao F, Su Y, Li Z. Investigating Clinical Failure of Bone Grafting through a Window at the Femoral Head Neck Junction Surgery for the Treatment of Osteonecrosis of the Femoral Head. PLoS One. 2016. 11 (6):e0156903. [Medline]. [Full Text].
Sugano N, Takaoka K, Ohzono K, et al. Rotational osteotomy for non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Br. 1992 Sep. 74(5):734-9. [Medline].
Cheung KW, Chiu KH, Chung KY. Long-term result of cementless femoral stem in avascular necrosis of the hip. Hip Int. 2014 Sep 1. [Medline].
Gangji V, Hauzeur JP. Cellular-based therapy for osteonecrosis. Orthop Clin North Am. 2009 Apr. 40(2):213-21. [Medline].
Lau RL, Perruccio AV, Evans HM, Mahomed SR, Mahomed NN, Gandhi R. Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord. 2014 May 16. 15:156. [Medline]. [Full Text].
Hernigou P, Trousselier M, Roubineau F, Bouthors C, Chevallier N, Rouard H, et al. Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress. Clin Orthop Surg. 2016 Mar. 8 (1):1-8. [Medline]. [Full Text].
Goker B, Block JA. Risk of contralateral avascular necrosis (AVN) after total hip arthroplasty (THA) for non-traumatic AVN. Rheumatol Int. 2006 Jan. 26(3):215-9. [Medline].
Agarwala S, Jain D, Joshi VR, et al. Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford). 2005 Mar. 44(3):352-9. [Medline].
Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am. 2005 Oct. 87(10):2155-9. [Medline].
[Guideline] Aldridge JM 3rd, Urbaniak JR. Avascular necrosis of the femoral head: etiology, pathophysiology, classification, and current treatment guidelines. Am J Orthop. 2004 Jul. 33(7):327-32. [Medline].
Allen MR, Burr DB. The pathogenesis of bisphosphonate-related osteonecrosis of the jaw: so many hypotheses, so few data. J Oral Maxillofac Surg. 2009 May. 67(5 Suppl):61-70. [Medline].
Arce K, Assael LA, Weissman JL, Markiewicz MR. Imaging findings in bisphosphonate-related osteonecrosis of jaws. J Oral Maxillofac Surg. 2009 May. 67(5 Suppl):75-84. [Medline].
Assouline-Dayan Y, Chang C, Greenspan A, et al. Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum. 2002 Oct. 32(2):94-124. [Medline].
Bachiller FG, Caballer AP, Portal LF. Avascular necrosis of the femoral head after femoral neck fracture. Clin Orthop Relat Res. 2002 Jun. 87-109. [Medline].
Bernasek TL, Stahl JL, Pupello D. Pyrolytic carbon endoprosthetic replacement for osteonecrosis and femoral fracture of the hip: a pilot study. Clin Orthop Relat Res. 2009 Jul. 467(7):1826-32. [Medline]. [Full Text].
Dodson TB. Intravenous bisphosphonate therapy and bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2009 May. 67(5 Suppl):44-52. [Medline].
Dudkiewicz I, Covo A, Salai M, et al. Total hip arthroplasty after avascular necrosis of the femoral head: does etiology affect the results?. Arch Orthop Trauma Surg. 2004 Mar. 124(2):82-5. [Medline].
Freiberger JJ. Utility of hyperbaric oxygen in treatment of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2009 May. 67(5 Suppl):96-106. [Medline].
Gliklich R, Wilson J. Epidemiology of bisphosphonate-related osteonecrosis of the jaws: the utility of a national registry. J Oral Maxillofac Surg. 2009 May. 67(5 Suppl):71-4. [Medline].
Hasse B, Ledergerber B, Egger M, Flepp M, Bachmann S, Bernasconi E, et al. Antiretroviral treatment and osteonecrosis in patients of the Swiss HIV Cohort Study: a nested case-control study. AIDS Res Hum Retroviruses. 2004 Sep. 20(9):909-15. [Medline].
Jones LC, Hungerford MW, Khanuja HS, Hungerford DS. Outcome measures for evaluation of treatments for osteonecrosis. Orthop Clin North Am. 2009 Apr. 40(2):179-91. [Medline].
Kunchur R, Need A, Hughes T, Goss A. Clinical investigation of C-terminal cross-linking telopeptide test in prevention and management of bisphosphonate-associated osteonecrosis of the jaws. J Oral Maxillofac Surg. 2009 Jun. 67(6):1167-73. [Medline].
Martí-Carvajal AJ, Solà I, Agreda-Pérez LH. Treatment for avascular necrosis of bone in people with sickle cell disease. Cochrane Database Syst Rev. 2014 Jul 10. 7:CD004344. [Medline].
Roposch A, Stöhr KK, Dobson M. The effect of the femoral head ossific nucleus in the treatment of developmental dysplasia of the hip. A meta-analysis. J Bone Joint Surg Am. 2009 Apr. 91(4):911-8. [Medline].
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