From the Guidelines
The treatment of avascular necrosis (AVN) should be guided by its stage and severity, with early intervention being crucial for better outcomes, as recommended by the most recent guidelines 1. The goal of treatment is to alleviate pain, improve function, and prevent further damage to the affected joint. For early-stage AVN, conservative management includes:
- Protected weight-bearing using crutches or a walker
- Physical therapy to maintain joint mobility
- Pain management with NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily)
- Bisphosphonates such as alendronate (70mg weekly) may help slow disease progression by inhibiting osteoclast activity, as suggested by recent studies 1.
For more advanced cases, surgical interventions become necessary.
- Core decompression is often used for early-stage disease, involving drilling into the affected bone to reduce pressure and improve blood flow.
- Bone grafting may be performed alongside decompression, using either the patient's own bone or donor tissue to support the damaged area.
- For late-stage AVN with significant joint collapse, joint replacement surgery (arthroplasty) is typically required, as indicated by the latest guidelines 1. In younger patients, joint-preserving procedures like osteotomy (realigning the bone to shift weight away from the damaged area) might be considered. Throughout treatment, addressing underlying causes such as corticosteroid use, alcohol consumption, or blood disorders is essential to prevent recurrence or progression in other joints, as emphasized by recent research 1.
Key considerations in the management of AVN include:
- Early diagnosis to exclude other causes of pain and allow for possible early surgical prevention
- Imaging for preoperative planning, with magnetic resonance imaging (MRI) being the preferred method of diagnosis for AVN, as recommended by recent studies 1
- Monitoring for disease progression and adjusting treatment accordingly, with regular follow-up and assessment of joint function and pain levels.
From the Research
Treatment Options for Avascular Necrosis (AVN)
- The treatment for AVN is varied and depends on the stage and location of the disease.
- Bisphosphonates, such as alendronate and zolendronic acid, have been shown to be effective in preventing disease progression, bone collapse, and the requirement for surgery in AVN of the femoral head 2, 3, 4.
- A combination of oral alendronate and intravenous zolendronic acid has been found to provide a pragmatic solution for the treatment of non-femoral AVN, where no standard treatment exists 2.
- Joint-preserving surgery, such as core decompression, can be performed up to ARCO stage III, and has been shown to be effective in providing short-term pain relief and improving function 5.
- Total hip replacement is often necessary in advanced cases of AVN, and has been found to lead to good results, regardless of the underlying disease 5.
Bisphosphonate Therapy
- Bisphosphonates have been found to reduce pain and improve function in patients with AVN, and can help to retard the progression of the disease 3, 4.
- Alendronate, in particular, has been found to be effective in the treatment of AVN of the hip, with significant reductions in pain and disability scores, and improvements in walking and standing time 4.
- The use of bisphosphonates in the treatment of AVN is supported by several studies, although more research is needed to fully understand their efficacy and safety in this context 3, 6.
Surgical Intervention
- Surgical intervention, such as total hip replacement, is often necessary in advanced cases of AVN, and can provide significant improvements in function and quality of life 5.
- Joint-preserving surgery, such as core decompression, can be effective in providing short-term pain relief and improving function, but may not be suitable for all patients 5.
- The selection of surgical procedure depends on the extent of necrosis, and the individual patient's needs and circumstances 5.