Avascular Necrosis Follow-up

Updated: Dec 05, 2020
  • Author: Sunny B Patel, MD; Chief Editor: Herbert S Diamond, MD  more...
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Follow-up

Deterrence/Prevention

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, initiate use steroid-sparing agents
  • 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

For patients undergoing pelvic radiotherapy, a variety of pharmacological interventions for preventing AVN have been studied, including supplemental calcium and/or vitamin D, bisphosphonates, selective estrogen receptor modulators, hormone replacement therapy (estrogen or testosterone), denosumab, and calcitonin. However, a Cochrane review concluded that the evidence relating to those interventions is of very low certainty. [45]

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Complications

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.

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Prognosis

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. [46]

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)
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Patient Education

Patients should discuss with their primary provider if they are at risk for AVN. Patients should be advised to report joint symptoms as soon as possible to facilitate early diagnosis and treatment.

If possible, at risk patients or those with radiographic findings of AVN should be evaluated by a specialist (preferably rheumatologist or orthopedic surgeon).

For patient education information, see Avascular Necrosis (Aseptic Necrosis or Osteonecrosis).

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