Avascular necrosis 1498676 226077198 2008-07-16T18:53:28Z 207.59.58.94 /* Notable individuals affected */ {{Infobox_Disease | Name = Avascular necrosis | Image = Head of femur avascular necrosis.jpg| Caption = [[Femur head]] showing a flap of [[cartilage]] from underlying '''avascular necrosis'''. Specimen from [[total hip replacement]] surgery.| DiseasesDB = 1174 | ICD10 = {{ICD10|M|87||m|86}} | ICD9 = {{ICD9|733.4}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = med | eMedicineTopic = 2924 | MeshID = D010020 | }} '''Avascular necrosis''' is a disease resulting from the temporary or permanent loss of the [[blood]] supply to the bones.<ref name=DiGiovanni>DiGiovanni, C.W., et al., Osteonecrosis in the foot. J Am Acad Orthop Surg, 2007. 15(4): p. 208-17.</ref> Without blood, the bone tissue dies and causes the bone to collapse.<ref name=DiGiovanni/> If the process involves the bones near a joint, it often leads to collapse of the joint surface. This disease also is known as '''osteonecrosis''', '''aseptic (bone) necrosis''', and '''ischemic bone necrosis'''.<ref name=DiGiovanni/> ==Causes== There are many causes of avascular necrosis such as [[alcoholism]]<ref>Chao, Y.C., et al., Investigation of alcohol metabolizing enzyme genes in Chinese alcoholics with avascular necrosis of hip joint, pancreatitis and cirrhosis of the liver. Alcohol Alcohol, 2003. 38(5): p. 431-6.</ref>, excessive [[glucocorticoid|steroid]] use<ref>Juery, P., Avascular necrosis after a steroid injection. CMAJ, 2007. 176(6): p. 814; author reply 814.</ref>, post trauma <ref>Baksi, D.P., Treatment of post-traumatic avascular necrosis of the femoral head by multiple drilling and muscle-pedicle bone grafting. Preliminary report. J Bone Joint Surg Br, 1983. 65(3): p. 268-73.</ref> <ref>Lee, C.K. and H.R. Hansen, Post-traumatic avascular necrosis of the humeral head in displaced proximal humeral fractures. J Trauma, 1981. 21(9): p. 788-91.</ref>, [[caisson disease]] (decompression sickness)<ref>{{cite journal |last=Zhang |first=L. D. |coauthors=J. F. Kang; H. L. Xue. |title=Distribution of lesions in the head and neck of the humerus and the femur in dysbaric osteonecrosis |journal=Undersea Biomed. Res. |volume=17 |issue=4 |pages=353–358 |date=[[1990]] |issn=0093-5387 |oclc=2068005 |pmid=2396333 |url=http://archive.rubicon-foundation.org/2570 |accessdate=2008-04-06 }}</ref><ref>Lafforgue, P., Pathophysiology and natural history of avascular necrosis of bone. Joint Bone Spine, 2006. 73(5): p. 500-7.</ref>, vascular compression<ref>Laroche, M., Intraosseous circulation from physiology to disease. Joint Bone Spine, 2002. 69(3): p. 262-9.</ref>, [[hypertension]], [[vasculitis]], [[thrombosis]], damage from [[radiation]], [[bisphosphonates]] (particularly the [[mandible]]) <ref>Dannemann, C., et al., Jaw osteonecrosis related to bisphosphonate therapy: a severe secondary disorder. Bone, 2007. 40(4): p. 828-34.</ref> and [[sickle cell anaemia]]<ref>Marti-Carvajal, A., R. Dunlop, and L. Agreda-Perez, Treatment for avascular necrosis of bone in people with sickle cell disease. Cochrane Database Syst Rev, 2004(4): p. CD004344.</ref>. In some cases it is [[idiopathic]] (no cause is found).<ref name=day>Day S, O.R., Chao E, Rubin C, Aro H, einhorn T, Bone injury, regeneration, and repair, in Orthopaedic Basic Science, A.A.o.O. Surgeons, Editor. 2000. p. 372-399.</ref> Rheumatoid arthritis and lupus are also common causes of AVN. ==Presentation== While it can, by definition, affect any bone, and half of cases show multiple sites of damage, this disease primarily affects the joints at the [[shoulder]], [[knee]], and [[hip]]. Although it can happen in any bone, avascular necrosis most commonly affects the ends ([[epiphysis]]) of long bones such as the [[femur]], the bone extending from the knee joint to the hip joint. Other common sites include the [[humerus]] (the bone of the upper arm)<ref name=chapman>Chapman, C., C. Mattern, and W.N. Levine, Arthroscopically assisted core decompression of the proximal humerus for avascular necrosis. Arthroscopy, 2004. 20(9): p. 1003-6.</ref> <ref>Mansat, P., et al., Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: nineteen shoulders followed up for a mean of seven years. J Shoulder Elbow Surg, 2005. 14(2): p. 114-20.</ref>, knees <ref>Jacobs, M.A., P.E. Loeb, and D.S. Hungerford, Core decompression of the distal femur for avascular necrosis of the knee. J Bone Joint Surg Br, 1989. 71(4): p. 583-7.</ref> <ref>Bergman, N.R. and J.A. Rand, Total knee arthroplasty in osteonecrosis. Clin Orthop Relat Res, 1991(273): p. 77-82.</ref>, shoulders <ref name=chapman/><ref>Mansat, P., et al., Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: nineteen shoulders followed up for a mean of seven years. J Shoulder Elbow Surg, 2005. 14(2): p. 114-20.</ref>, ankles and the [[Osteonecrosis of the jaw|jaw]]<ref>Baykul, T., M.A. Aydin, and S. Nasir, Avascular necrosis of the mandibular condyle causing fibrous ankylosis of the temporomandibular joint in sickle cell anemia. J Craniofac Surg, 2004. 15(6): p. 1052-6.</ref>. The disease may affect just one bone, more than one bone at the same time, or more than one bone at different times.<ref name=wisconsin>{{cite web |author=Wisconsin, M.C.o. |title=Avascular Necrosis. |accessdate=2007-11-06 |url=http://healthlink.mcw.edu/article/926046182.html }}</ref> Avascular necrosis usually affects people between 30 and 50 years of age; about 10,000 to 20,000 people develop avascular necrosis of the head of the femur in the US each year. When it occurs in children at the femoral head, it is known as [[Legg-Calvé-Perthes syndrome]].<ref>Gross, G.W., G.A. Articolo, and J.R. Bowen, Legg-Calve-Perthes Disease: Imaging Evaluation and Management. Semin Musculoskelet Radiol, 1999. 3(4): p. 379-391.</ref> ==Diagnosis== Orthopaedic doctors most often diagnose the disease except when it affects the [[osteonecrosis of the jaw|jaws]], when it is usually diagnosed and treated by dental and maxillofacial surgeons. Because early x-rays are usually normal in the early stage of the disease , bone scintigraphy <ref>Maillefert, J.F., et al., Bone scintigraphy equipped with a pinhole collimator for diagnosis of avascular necrosis of the femoral head. Clin Rheumatol, 1997. 16(4): p. 372-7.</ref>and MRI <ref>Bluemke, D.A. and E.A. Zerhouni, MRI of avascular necrosis of bone. Top Magn Reson Imaging, 1996. 8(4): p. 231-46.</ref> are the diagnostic modalities of choice since both can detect minimal changes at early stages of the disease. Late radiographic signs include a radiolucency area following the collapse of subchondral bone (crescent sign) and ringed regions of radiodensity resulting from saponification and calcification of marrow fat following medullary infarcts. ==Treatment== Avascular necrosis is especially common in the hip joint. A variety of methods are now used to treat avascular necrosis<ref name=wisconsin/>, the most common being the [[total hip replacement]], or THR. However, THRs have a number of downsides including long recovery times and short life spans. THRs are an effective means of treatment in the geriatric population, however doctors shy away from using them in younger patients due to the reasons above. A new, more promising treatment is metal on metal resurfacing. It is a form of a THR, however in this procedure, only the head of the femur is removed as opposed to a THR in which the entire neck is removed. Metal on metal resurfacing is still experimental in America but has been endorsed in Great Britain as an excellent alternative to a THR. Bone is always undergoing change or remodelling<ref name=Hall>Hall, B., The Osteoblast and Osteocyte. Vol. 1. 1990: The Telford Press. 494.</ref>. The bone is broken down by osteoclasts and rebuilt by osteoblasts<ref name=Hall/>. Some doctors also prescribe [[bisphosphonates]] (e.g. [[alendronate]]) which reduces the rate of bone breakdown by osteoclasts, thus preventing collapse (specifically of the hip) due to AVN<ref>Agarwala, S., et al., Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford), 2005. 44(3): p. 352-9.</ref>. Other treatments include Core Decompression, where internal bone pressure is relieved by drilling a hole into the bone, and living bone chip and electrical device to stimulate new vascular growth are implanted; and the Free Vascular Fibular Graft (FVFG), in which a portion of the fibula, along with its blood supply, is removed and transplanted into the femoral head<ref>Judet, H. and A. Gilbert, Long-term results of free vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res, 2001(386): p. 114-9.</ref>. The amount of disability that results from avascular necrosis depends on what part of the bone is affected, how large an area is involved, and how effectively the bone rebuilds itself. The process of bone rebuilding takes place after an injury as well as during normal growth<ref name=Hall/>. Normally, bone continuously breaks down and rebuilds--old bone is reabsorbed and replaced with new bone. The process keeps the skeleton strong and helps it to maintain a balance of minerals<ref name=Hall/>. In the course of avascular necrosis, however, the healing process is usually ineffective and the bone tissues break down faster than the body can repair them. If left untreated, the disease progresses, the bone collapses<ref name=DiGiovanni/>, and the joint surface breaks down<ref name=day/>, leading to pain and arthritis<ref name=day/>. ==Notable individuals affected== Avascular necrosis cut short the [[National Football League|football]] and [[Major League Baseball|baseball]] careers of star athlete [[Bo Jackson]].<ref>{{cite web |url=http://espn.go.com/sportscentury/features/00016045.html |title=ESPN.com: Bo knows stardom and disappointment |accessdate=2007-09-09 |format= |work=}}</ref> Other sports stars with this condition are former [[NFL]] [[running back]] [[Garrison Hearst]], [[cycling|cyclist]] [[Floyd Landis]], former [[NFL]] [[quarterback]] [[Brett Favre]], professional wrestler [[Billy Graham (wrestler)|"Superstar" Billy Graham]], wrestler Joe Heat, [[NBA]] player [[Jorge Garbajosa]] and the drummer/singer of the band, The Monkees, [[Micky Dolenz]]. ==References== {{Reflist|2}} ==External links== *[http://www.niams.nih.gov/Health_Info/Osteonecrosis/osteonecrosis_ff.asp Avascular Necrosis] at the [[National Institute of Health]] *[http://www.merck.com/mmhe/sec05/ch064/ch064a.html AVN] at [[Merck Manual]] *[http://www.emedicine.com/sports/topic35.htm Femoral head avascular necrosis] at [[eMedicine]] *[http://www.aboutjoints.com/patientinfo/topics/osteonecrosis/Osteonecrosis.html Avascular Necrosis] and [http://www.aboutjoints.com/patientinfo/topics/core/core.htm Core decompression] information from aboutjoints.com *[http://www.osteonecrosis.org/ Center for Osteonecrosis Research] *[http://www.nonf.org/ National Osteonecrosis Foundation] *[http://www.jewishhospitalcincinnati.com/cholesterol/osteonec.htm Detailed background information on the chemistry and biological processes behind Avascular Necrosis] *[http://rad.usuhs.edu/medpix/medpix_image.html?mode=&imid=39792&pt_id=11532&quiz=no MedPix Images] [Imaging Osteonecrosis] *[http://www.boneandcancerfoundation.org/osteonecrosis.html Osteonecrosis of the Jaw (ONJ):Information for Cancer Patients] {{Diseases of the musculoskeletal system and connective tissue}} [[Category:Skeletal disorders]] [[Category:Diving medicine]] [[bg:Асептична некроза]] [[de:Osteonekrose]]