Avascular Necrosis

Overview

Avascular necrosis, also known as osteonecrosis, is a condition in which bone tissue dies due to a lack of blood supply. This can lead to tiny breaks in the bone and cause it to collapse over time. It can be caused by trauma, steroid use, excessive alcohol consumption, and other factors. The condition can affect various joints, such as the hip, shoulder, knee, hand, and foot, and can lead to pain and eventually bone collapse if left untreated. Symptoms may not be present in the early stages, but as the condition worsens, joint pain can develop, especially when putting weight on the affected joint.

Understanding the disease

Symptoms

The symptoms of avascular necrosis (osteonecrosis) include:

1. Pain in the affected joint, which may be mild or severe and develop gradually.
2. Pain that may be present even when lying down.
3. Swelling and stiffness in the affected joint.
4. Limited range of motion in the joint.
5. Joint weakness.
6. Pain may be centered in the groin, thigh, or buttock, depending on the affected joint (hip, knee, shoulder, hand, or foot).
7. In advanced stages, joint collapse can occur. It is important to note that some people may have no symptoms in the early stages of avascular necrosis.

Risk Factors

Risk factors for developing avascular necrosis include trauma, steroid use, drinking too much alcohol, bisphosphonate use, and certain medical treatments such as radiation therapy for cancer or organ transplants. Trauma such as hip dislocation or fracture can damage nearby blood vessels and reduce blood flow to bones. Long-term use of high-dose steroids, such as prednisone, is a common cause of avascular necrosis, and alcohol consumption can also lead to fatty deposits in blood vessels, reducing blood flow. The use of bisphosphonate medications for increasing bone density might contribute to developing osteonecrosis of the jaw in some individuals. Other medical conditions associated with avascular necrosis include pancreatitis, Gaucher's disease, HIV/AIDS, systemic lupus erythematosus, sickle cell anemia, and decompression sickness.

Development

Avascular necrosis (osteonecrosis) can develop due to several factors, including:

1. Trauma: Joint or bone trauma, such as a hip dislocation or fracture, can damage nearby blood vessels and reduce blood flow to bones.
2. Steroid use: High-dose corticosteroid use, such as prednisone, can cause avascular necrosis. The exact reason is unknown, but some experts believe that corticosteroids can increase lipid levels in the blood, reducing blood flow.
3. Drinking too much alcohol: Consuming several alcoholic drinks a day for several years can cause fatty deposits to form in blood vessels, leading to reduced blood flow to bones.
4. Bisphosphonate use: Long-term use of medications to increase bone density, such as bisphosphonates, might contribute to developing osteonecrosis of the jaw in some people. This complication has been observed in individuals treated with high doses of these medications for conditions like multiple myeloma and metastatic breast cancer.
5. Certain medical treatments: Radiation therapy for cancer can weaken bone, and organ transplants, especially kidney transplants, are associated with avascular necrosis. In some cases, the cause of avascular necrosis not related to trauma is not fully understood. Genetics, along with the combination of other factors like alcohol use, specific medications, and other diseases, may play a role.

Assessment and Diagnosis

Triage

You should see a healthcare provider for ongoing pain in any joint, as avascular necrosis can cause joint pain or discomfort. It is important to seek immediate medical attention for a possible broken bone or dislocated joint, as these conditions can also affect blood flow to the bone.

Diagnosis

To diagnose avascular necrosis (osteonecrosis), a healthcare provider will typically start with a physical exam, checking for tenderness in the joints and assessing the range of motion. Imaging tests such as X-rays, MRI, CT scan, and bone scans are also used to confirm the diagnosis, especially in the early stages when X-rays may not show any abnormalities.

Management and Treatment

Complications

Untreated avascular necrosis worsens, eventually causing the bone to collapse. The bone may lose its smooth shape, leading to severe arthritis. Some potential complications of avascular necrosis include:

1. Severe arthritis: As the bone collapses, the joint can become affected by severe arthritis, resulting in chronic pain, stiffness, and limited mobility.
2. Joint instability: The collapse of the bone can cause joint instability, leading to a loss of function and difficulty performing daily activities.
3. Limb shortening: In severe cases, the affected bone may be unable to carry the weight of the body, leading to limb shortening.
4. Secondary fractures: The weakened bone becomes more susceptible to fractures, even with minimal trauma.
5. Disability: Untreated avascular necrosis can result in disability, especially if the condition affects multiple joints, such as both hips or both knees.
6. Reduced quality of life: The chronic pain and limited mobility associated with avascular necrosis can significantly impact the affected individual's overall quality of life. It is essential to seek medical attention and follow the recommended treatment plan to manage avascular necrosis and prevent these complications.

Prevention

To reduce the risk of avascular necrosis and improve general health, consider the following preventive measures:

1. Limit alcohol: Heavy drinking is one of the top risk factors for developing avascular necrosis.
2. Keep cholesterol levels low: Tiny bits of fat are the most common substance blocking blood supply to bones. While there is no guaranteed way to prevent avascular necrosis, maintaining a healthy lifestyle and addressing any risk factors can help reduce the likelihood of developing the condition.

Treatment

Treatment options for avascular necrosis (osteonecrosis) include:

1. Analgesics: Pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) may help manage the pain associated with avascular necrosis.
2. Steroid injections: These injections can help reduce inflammation and pain in the affected joint.
3. Joint replacement: In advanced cases, when the joint is severely damaged and painful, a joint replacement surgery may be considered. This is typically done for hips and knees.
4. Bone stimulation: Bone stimulation therapy uses pulsed electromagnetic fields to increase blood flow to the bone and promote bone healing.
5. Medications: Specifically, medications to treat the underlying cause, such as anticoagulants for blood clots or appropriate medications to manage medical conditions like pancreatitis or sickle cell anemia.
6. Weight management: Maintaining a healthy weight can reduce stress on the joints and slow the progression of avascular necrosis.
7. Lifestyle modifications: Quit smoking, limit alcohol consumption, and follow a healthy diet to improve overall health and reduce the risk of complications.
8. Physical therapy: Exercises and physical therapy can help maintain joint mobility and strengthen the surrounding muscles. It is important to consult with a healthcare provider to determine the most appropriate treatment plan based on the severity and stage of the avascular necrosis.

Preparing for medical consultation

To prepare for an appointment for avascular necrosis, you should:

1. Make a list of any symptoms you are experiencing, including any that may seem unrelated to the condition.
2. Write down key personal information, such as previous injury to the painful joint, other health conditions you have, and any major stresses or recent life changes.
3. List all the medications, vitamins, or supplements you are taking, including doses.
4. Consider bringing a family member or friend to the appointment to help remember the information discussed.
5. Gather any previous scans or X-rays (including the images and reports) and other relevant medical records for the appointment. By being well-prepared, you can ensure that you cover all necessary information during the appointment and have a more productive conversation with your healthcare provider.