From the Guidelines
Treatment for avascular necrosis should prioritize early diagnosis and intervention to prevent articular collapse and the need for joint replacements, with core decompression being a viable surgical option for early stages, as supported by the most recent guidelines 1.
Overview of Avascular Necrosis
Avascular necrosis, also known as osteonecrosis, is a condition characterized by bone death due to inadequate vascular supply, commonly affecting the femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus 1. The true prevalence of osteonecrosis is likely underestimated due to many asymptomatic cases, especially in metadiaphyseal cases.
Risk Factors and Diagnosis
Risk factors for osteonecrosis include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease 1. Early diagnosis is crucial to exclude other causes of pain and allow for possible early surgical prevention to prevent articular collapse and the need for joint replacements. Imaging plays a vital role in diagnosis and preoperative planning.
Treatment Options
Treatment options for avascular necrosis depend on the disease stage and severity. For early-stage avascular necrosis, core decompression is a recommended surgical option, which can be supplemented with injection of autologous bone marrow cells, vascular fibular grafting, or electric stimulation 1. Noninvasive therapies, such as statins, bisphosphonates, anticoagulants, extracorporeal shock wave therapy, and hyperbaric oxygen, have limited supporting data 1. In late-stage cases with articular collapse, resurfacing hemiarthroplasty or total joint arthroplasty may be necessary.
Key Considerations
The treatment approach should be individualized based on patient age, affected joint, disease stage, and underlying causes, with the goal of preserving the natural joint whenever possible and preventing further bone deterioration. The necrotic volume of epiphyseal osteonecrosis has been shown to be predictive of future articular collapse, highlighting the importance of early intervention 1.
Summary of Recommendations
- Early diagnosis and intervention are crucial to prevent articular collapse and the need for joint replacements.
- Core decompression is a viable surgical option for early-stage avascular necrosis.
- Treatment should be individualized based on patient age, affected joint, disease stage, and underlying causes.
- The goal of treatment is to preserve the natural joint whenever possible and prevent further bone deterioration, as supported by the most recent guidelines 1.
From the Research
Treatment Options for Avascular Necrosis
The treatment options for avascular necrosis (AN) are varied and depend on the stage and location of the disease. Some of the treatment options include:
- Bisphosphonates: Bisphosphonates have been shown to be effective in reducing pain and improving mobility in patients with AN 2, 3, 4, 5.
- Combination therapy: A combination of oral alendronate and intravenous zolendronic acid has been shown to be effective in treating non-femoral avascular necrosis 3.
- Conservative management: Conservative management options such as hyperbaric oxygen therapy, extracorporeal shock wave therapy, and pulsed electromagnetic field therapy may also be effective in treating AN 6.
- Surgical intervention: In some cases, surgical intervention may be necessary to treat AN, particularly in advanced stages of the disease.
Benefits of Bisphosphonates
Bisphosphonates have been shown to have several benefits in the treatment of AN, including:
- Reduction in pain: Bisphosphonates have been shown to reduce pain in patients with AN 2, 3, 5.
- Improvement in mobility: Bisphosphonates have been shown to improve mobility in patients with AN 2, 3.
- Delay in disease progression: Bisphosphonates have been shown to delay the progression of AN, particularly when started in the pre-collapse stages of the disease 5.
- Reduction in the need for surgical intervention: Bisphosphonates have been shown to reduce the need for surgical intervention in patients with AN 5.
Considerations for Treatment
When considering treatment options for AN, several factors should be taken into account, including:
- Stage of the disease: The stage of the disease should be considered when selecting a treatment option, with earlier stages being more amenable to conservative management 6, 5.
- Location of the disease: The location of the disease should also be considered, with non-femoral avascular necrosis being treated with combination therapy 3.
- Availability of resources: The availability of resources, such as hospital facilities and equipment, should also be considered when selecting a treatment option 6.