Avascular Necrosis 

  • Author: Jeanne K Tofferi, MD, MPH, FACP; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: Jan 19, 2012
 

Background

Avascular necrosis (AVN) is defined as cellular death of bone components due to interruption of the blood supply; the bone structures then collapse, resulting in bone destruction, pain, and loss of joint function. AVN is associated with numerous conditions and usually involves the epiphysis of long bones, such as the femoral and humeral heads and the femoral condyles, but small bones can also be affected. In clinical practice, AVN is most commonly encountered in the hip.[1, 2] Recently, AVN of the jaw associated with bisphosphonate use has also been described.[3]

Early diagnosis and appropriate intervention can delay the need for joint replacement. However, most patients present late in the disease course. Without treatment, the process is almost always progressive, leading to joint destruction within 5 years. Patients taking corticosteroids and organ transplant recipients are particularly at risk of developing AVN. Most available data regarding the natural history, pathology, pathogenesis, and treatment of AVN pertains to femoral head necrosis.

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Pathophysiology

Although the pathophysiology of AVN is not fully understood, the final common pathway is interruption of blood flow to the bone. AVN affects bones with a single terminal blood supply, such as the femoral head, carpals, talus, and humerus. These bones have limited collateral circulation. Interruption of the vascular supply and resultant necrosis of marrow, medullary bone, and cortex are theorized to be caused by the mechanisms listed below. However, individual patients usually have more than one risk factor; this indicates that the pathogenesis of AVN is likely multifactorial.

  • Vascular occlusion: This is characterized by the interruption of the extraosseous blood supply via factors such as direct trauma (eg, fracture, dislocation), nontraumatic stress, and stress fracture.
  • Altered lipid metabolism: Animal studies have led to the hypothesis that increased levels of serum lipids leads to lipid deposition in the femoral head, causing femoral hypertension and ischemia.[4] Lipid-level–lowering drugs in animals reverse this process. Corticosteroid administration was associated with fat emboli in the femoral heads of rabbits.[5]
  • Intravascular coagulation: Disorders of the coagulation system have been implicated in the pathogenesis of AVN. Typically, it is a secondary event triggered by a familial thrombophilia, hypercholesterolemia, allograft organ rejection, other disorders (eg, infection, malignancy), or pregnancy.
  • Healing process: Necrotic bone triggers a process of repair that includes osteoclasts, osteoblasts, histiocytes, and vascular elements. Osteoblasts build new bone on top of the dead bone, leading to a thick scar that prevents revascularization of the necrotic bone, with resultant abnormal joint remodeling and joint dysfunction.
  • Primary cell death: Osteocyte death without other features of AVN has been seen in renal transplant patients, as well as in patients receiving steroids and those who consume significant amounts of alcohol.
  • Mechanical stress: Animal studies have shown an association between increased weight bearing and an increased incidence of AVN of the femoral head.
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Epidemiology

Frequency

United States

The frequency of AVN depends on the site involved. The most common site is the hip; other locations include the carpals, talus, femur, metatarsal, mandible, and humerus. In the United States, approximately 15,000 new cases of AVN are reported each year. AVN accounts for more than 10% of total hip replacement surgeries performed in the United States. Most recently, 380 cases of osteonecrosis of the jaw associated with bisphosphonate use have been reported. Most patients with osteonecrosis of the jaw also had an ongoing malignancy and/or had undergone a recent dental procedure.[6, 3]

International

In most countries, the incidence and prevalence of AVN are unknown. A Japanese survey estimated that 2500-3300 cases of AVN of the hip occur each year; of these, 34.7% were due to corticosteroid use, 21.8% to alcohol abuse, and 37.1% to idiopathic mechanisms.[7] A study from France reported AVN in 4.3% of allogenic bone marrow transplant recipients.[8]

Mortality/Morbidity

Data on mortality rates associated with AVN are not available. Most data involve AVN of the hip. Mortality rates are very low and vary based on the operative procedure used to treat AVN.

Morbidity rates are high and depend on the underlying cause. Morbidity rates associated with AVN of the hip are high; the prevalence of long-term disability is significant. Despite advances in orthopedic procedures, most patients with advanced AVN require more than one hemiarthroplasty or total hip replacement during their lifetime.

Race

AVN has no racial predilection except for cases associated with sickle cell disease and hemoglobin S and SC disease, which predominantly occur in people of African and Mediterranean descent.

Sex

With the exception of AVN associated with systemic lupus erythematosus, AVN is more common in men, with an overall male-to-female ratio of 8:1.

Age

AVN is a disease of middle age that most often occurs during the fourth or fifth decade of life and is bilateral in 55% of cases.

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Contributor Information and Disclosures
Author

Jeanne K Tofferi, MD, MPH, FACP  Assistant Chief, Department of Rheumatology, Walter Reed Army Medical Center

Jeanne K Tofferi, MD, MPH, FACP is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

William Gilliland, MD, MPHE, FACP, FACR  Staff Rheumatologist, Walter Reed Army Medical Center; Professor of Medicine, Assistant Dean of Curriculum, Uniformed Services University of the Health Sciences

Disclosure: Nothing to disclose.

Specialty Editor Board

Bryan L Martin, DO  Associate Dean for Graduate Medical Education, Designated Institutional Official, Associate Medical Director, Director, Allergy Immunology Program, Professor of Medicine and Pediatrics, Ohio State University College of Medicine

Bryan L Martin, DO is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Osteopathic Internists, American College of Physicians, American Medical Association, and American Osteopathic Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Lawrence H Brent, MD  Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Abbott Honoraria Speaking and teaching; Centocor Consulting fee Consulting; Genentech Grant/research funds Other; HGS/GSK Honoraria Speaking and teaching; Omnicare Consulting fee Consulting; Pfizer Honoraria Speaking and teaching; Roche Speaking and teaching; Savient Honoraria Speaking and teaching; UCB Honoraria Speaking and teaching

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD  Adjunct Professor of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

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Avascular necrosis in the femoral head resulting from corticosteroid therapy.
Avascular necrosis of the shoulder showing subchondral radiolucent lines (crescent sign).
Avascular necrosis of both femoral heads. This T1-weighted image shows decreased signal intensity in both femoral heads.
MRI of the distal femur and proximal tibia. This T2-weighted image shows increased signal intensity in the marrow.
Table. Staging of Avascular Necrosis
StageClinical and Laboratory Findings
Stage 0
  • Patient is asymptomatic.
  • Radiography findings are normal.
  • Histology findings demonstrate osteonecrosis.
Stage I
  • Patient may or may not be symptomatic.
  • Radiography and CT scan findings are unremarkable.
  • AVN is considered likely based on MRI and bone scan results (may be subclassified by extent of involvement [see below]).
  • Histology findings are abnormal.
Stage II
  • Patient is symptomatic.
  • Plain radiography findings are abnormal and include osteopenia, osteosclerosis, or cysts.
  • Subchondral radiolucency is absent.
  • MRI findings are diagnostic.
Stage III
  • Patient is symptomatic.
  • Radiographic findings include subchondral lucency (crescent sign) and subchondral collapse.
  • Shape of the femoral head is generally preserved on radiographs and CT scans.
  • Subclassification depends on the extent of crescent, as follows:
    • Stage IIIa: Crescent is less than 15% of the articular surface.
    • Stage IIIb: Crescent is 15-30% of the articular surface.
    • Stage IIIc: Crescent is more than 30% of the articular surface.
Stage IV
  • Flattening or collapse of femoral head is present.
  • Joint space may be irregular.
  • CT scanning is more sensitive than radiography.
  • Subclassification depends on the extent of collapsed surface, as follows:
    • Stage IVa: Less than 15% of surface is collapsed.
    • Stage IVb: Approximately 15-30% of surface is collapsed.
    • Stage IVc: More than 30% of surface is collapsed.
Stage V
  • Radiography findings include narrowing of the joint space, osteoarthritis with sclerosis of acetabulum, and marginal osteophytes.
Stage VI
  • Findings include extensive destruction of the femoral head and joint.
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