From the Guidelines
The treatment for vascular necrosis (avascular necrosis) should prioritize early diagnosis and intervention to prevent articular collapse and the need for joint replacements, with a focus on conservative measures, core decompression, and addressing underlying causes, as recommended by the most recent guidelines 1. The goal of treatment is to relieve pain, improve function, and prevent further bone and joint damage by restoring blood supply to the affected area before collapse occurs. Initial treatment includes:
- Pain management with NSAIDs like ibuprofen or naproxen
- Physical therapy to maintain joint mobility
- Reduced weight-bearing using crutches or walkers
- Bisphosphonates such as alendronate (70mg weekly) may help slow disease progression by inhibiting bone resorption, as suggested by recent studies 1. For early-stage avascular necrosis, core decompression surgery can relieve pressure within the bone and improve blood flow, with some studies suggesting its efficacy in preventing articular collapse [1, @11@]. More advanced cases may require:
- Bone grafting
- Osteotomy (bone reshaping)
- Joint-preserving procedures like vascularized bone grafts
- In severe cases with significant joint destruction, total joint replacement (arthroplasty) becomes necessary, accounting for 10% of indications for total hip replacements in the United States [@24@]. Treatment should also address underlying causes, such as:
- Stopping corticosteroids when possible
- Managing alcohol consumption
- Treating conditions like sickle cell disease or clotting disorders, as these can contribute to the development of osteonecrosis [@8-10@]. It is essential to note that the true prevalence of osteonecrosis is likely underestimated, and early diagnosis is crucial to prevent long-term sequelae, particularly in epiphyseal osteonecrosis, which can lead to subchondral fracture and secondary osteoarthritis [@5@, @10@].
From the Research
Treatment Options for Vascular Necrosis
- The treatment for avascular necrosis (AN) aims to improve blood support in the avascular area and alleviate pain 2.
- Non-surgical procedures such as extracorporeal shock wave therapy (ESWT) and non-weight bearing may be used to treat stages I-II of AVN 3.
- Joint-sparing techniques like core drilling and bone marrow aspirate injections may also be used in the early stages of AVN 3.
- In advanced stages (III-IV), joint-sacrificing procedures like hindfoot arthrodesis or ankle arthrodesis, or replacement surgery such as total talar replacement (TTR) or combined total ankle replacement (TAR) may be necessary 3.
- The use of bisphosphonates in the treatment of AN has shown favorable results in non-controlled studies, particularly in diminishing pain, improving mobility, and lowering the incidence of articular collapse 2.
- However, there is still insufficient data to justify the use of bisphosphonates for this indication, and more studies are needed 2.
Medication Management
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics, but their use has been associated with increased risks of heart failure, elevated blood pressure, and thrombotic events 4.
- The risk of ischemic stroke associated with NSAIDs varies across individual agents and conditions of use, with diclofenac and aceclofenac increasing the risk, while ibuprofen and naproxen do not 5.
- Paracetamol does not increase the risk of ischemic stroke, even in patients with a high background cardiovascular risk 5.
- NSAIDs have also been linked to rare but clinically significant cases of necrotising fasciitis, although a causal relationship cannot be established 6.