Aseptic Necrosis (Avascular Necrosis or Osteonecrosis)

  • Medical Author:
    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

  • Medical Editor: Catherine Burt Driver, MD
    Catherine Burt Driver, MD

    Catherine Burt Driver, MD

    Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.

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Aseptic necrosis facts

What is aseptic necrosis?

Aseptic necrosis is a bone condition that results from poor blood supply to an area of bone, causing localized bone death. This is a serious condition because the dead areas of bone do not function normally, are weakened, and can collapse. Aseptic necrosis is also referred to as avascular necrosis or osteonecrosis.

What causes aseptic necrosis?

Aseptic necrosis can be caused by trauma and damage to the blood vessels that supply bone its oxygen. Other causes of poor blood circulation to the bone include a blockage by air or fat (embolism) that obstructs the blood flow through the blood vessels, abnormally thick blood (hypercoagulable state), atherosclerosis (hardening of the arteries), or inflammation of the blood vessel walls (vasculitis). Steroid medications (cortisone, such as prednisone [Deltasone, Liquid Pred] and methylprednisolone [Medrol, Depo-Medrol]) are the most common medications to cause aseptic necrosis. Typical bones affected by steroids include the femur bone of the hip, the humerus bone of the shoulder, and the tibia bone of the knee, sometimes in combinations and frequently affecting both sides of the body (bilateral). Aseptic necrosis of the jawbone has been associated with the use of medications (bisphosphonates) used to treat high blood calcium levels from cancer.

What are risk factors for aseptic necrosis?

Conditions that are risk factors associated with aseptic necrosis include alcoholism, cortisone medications, Cushing's syndrome, radiation exposure, smoking cigarettes, sickle cell disease, pancreatitis, hyperlipidemia, Caisson's disease (dysbarism), Gaucher disease, and systemic lupus erythematosus. Aseptic necrosis of the jawbone has been rarely reported in association with the use of bisphosphonate medication, particularly intravenously including zoledronate (Zometa) and pamidronate (Aredia).

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What are aseptic necrosis symptoms and signs?

Aseptic necrosis begins as a painless bone abnormality. It can remain painless. The involved bone often later develops pain, especially with use. For example, if a hip joint develops avascular necrosis in the ball of the hip joint, pain can be noted, especially upon weight-bearing. As the ball of the hip joint collapses from the degeneration of the bone from aseptic necrosis, pain in the groin can be felt with hip rotation and pain can sometimes be noted with rest after weight-bearing. Aseptic necrosis of the knee is often associated with pain or limping with walking. Aseptic necrosis of the shoulder can be associated with pain and loss of range of motion of the shoulder joint.

How do physicians diagnose aseptic necrosis?

The diagnosis of aseptic necrosis can often, but not always, be made with plain film X-rays. By the time changes are apparent by plain film X-ray testing there has been substantial damage to the bone affected. Bone changes visible on plain film X-ray are, therefore, considered a later-stage finding. Earlier signs of avascular necrosis can be detected with an MRI scan image or suggested by a nuclear bone scan image.

What is the treatment for aseptic necrosis?

The treatment of aseptic necrosis is critically dependent on the stage of the condition. Very early stage aseptic necrosis may be managed nonoperatively with rest, partial-weight-bearing crutches, progressive weight-bearing, and observation. Nevertheless, there is often progression of the joint damage. Early aseptic necrosis (before X-ray image changes are evident) can be treated with a surgical operation called a core decompression. This procedure involves removing a core of bone from the involved area and sometimes grafting new bone into the area. This allows new blood supply to form, preserving the bone. Weight-bearing or impact of the involved joint is restricted.

Later stages of aseptic necrosis (when X-ray image changes are apparent) typically lead to seriously damaged bone and joints, requiring joint replacement surgery.

What is the prognosis of aseptic necrosis?

Aseptic necrosis causes a serious injury to affected bone. Frequently, this leads to permanent destruction of the adjacent joint. Early core decompression is generally necessary to prevent collapse of affected bone. Aseptic necrosis can be complicated by complete loss of joint function.

Is it possible to prevent aseptic necrosis?

People can prevent aseptic necrosis by minimizing the use of steroid medications when possible and by treating underlying medical conditions, such as those described above, that can increase the risk of developing aseptic necrosis. Avoiding trauma to joints can prevent posttraumatic aseptic necrosis. Avoiding smoking can decrease risk of developing aseptic necrosis.

Medically reviewed by Aimee V. HachigianGould, MD; American Board of Orthopaedic Surgery

REFERENCES:

Koopman, William, et al., eds. "Clinical Primer of Rheumatology." Philadelphia: Lippincott Williams & Wilkins, 2003.

Ruddy, Shaun, et al., eds. "Kelley's Textbook of Rheumatology." Philadelphia: W.B. Saunders Co., 2000.

Last Editorial Review: 8/30/2016

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Reviewed on 8/30/2016
References
Medically reviewed by Aimee V. HachigianGould, MD; American Board of Orthopaedic Surgery

REFERENCES:

Koopman, William, et al., eds. "Clinical Primer of Rheumatology." Philadelphia: Lippincott Williams & Wilkins, 2003.

Ruddy, Shaun, et al., eds. "Kelley's Textbook of Rheumatology." Philadelphia: W.B. Saunders Co., 2000.

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