From the Guidelines
Management of avascular necrosis (AVN) requires a multifaceted approach based on disease stage and patient factors, with the primary goal of preventing articular collapse and delaying or preventing the need for joint replacement, as emphasized in the 2022 update of the American College of Radiology (ACR) Appropriateness Criteria for Osteonecrosis 1, 2. For early-stage AVN, conservative measures include:
- Protected weight-bearing using crutches or a walker for 6-12 weeks
- Pain management using NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily)
- Physical therapy focusing on non-weight-bearing exercises to maintain joint mobility
- Bisphosphonates such as alendronate (70mg weekly) may help slow disease progression by inhibiting osteoclast activity, as suggested by studies on osteonecrosis management 3, 4 For more advanced cases, surgical interventions become necessary, including:
- Core decompression to reduce intraosseous pressure and improve blood flow
- Joint-preserving procedures like osteotomy or vascularized bone grafting for later stages
- Total joint replacement (arthroplasty) as the definitive treatment for end-stage disease with significant joint destruction Lifestyle modifications are crucial throughout treatment, including:
- Smoking cessation
- Alcohol limitation
- Avoiding corticosteroids when possible, as these factors can worsen AVN by compromising blood supply and bone metabolism Regular follow-up imaging (X-rays every 3-6 months, MRI as needed) is essential to monitor disease progression and treatment response, as recommended by the ACR Appropriateness Criteria for Osteonecrosis 1, 2. Key considerations in AVN management include:
- Early diagnosis to exclude other causes of pain and allow for possible early surgical prevention
- Imaging for preoperative planning and monitoring of disease progression
- Patient education on lifestyle modifications and the importance of adherence to treatment plans
- Multidisciplinary care involving orthopedic specialists, radiologists, and primary care physicians to ensure comprehensive management of AVN.
From the Research
Management of Avascular Necrosis (AVN)
The management of AVN can be divided into several approaches, including:
- Conservative management: This includes rest, reduction of weight bearing, and minimization of glucocorticoid dose or complete withdrawal of the drug if the underlying conditions allow 5.
- Pharmacological management: Bisphosphonates have been shown to prevent disease progression, bone collapse, and the requirement for surgery in AVN 6, 7. However, the efficacy of bisphosphonates in reducing the rate of collapse of the femoral head in AVN is controversial 5.
- Surgical management: This includes core decompression, osteotomy, bone grafting, and joint replacement 8, 5. Recent advances in the treatment of AVN include the use of tantalum rod and the development of more wear-resistant bearing surface in hip arthroplasty 5.
Treatment Options for Specific Locations of AVN
- AVN of the talus: Prolonged protective weight bearing provides the best outcomes in early talar AVN. Core decompression may be an attractive treatment option if conservative therapy fails, and arthrodesis should be saved as a salvage procedure 8.
- Non-femoral AVN: A combination of oral alendronate and intravenous zolendronic acid provides a pragmatic solution for the management of non-femoral AVN, where no standard treatment exists 7.
Diagnostic Approaches
- Magnetic resonance imaging (MRI) or bone scintigraphy is more sensitive than plain radiograph for diagnosing early-stage AVN 5.
- A high index of suspicion should be exhibited for bone and joint pain at typical sites, and universal screening of asymptomatic AVN should be considered for long-term glucocorticoid users 5.