Is diabetes a risk factor for avascular necrosis (AVN)?

Is Diabetes a Risk Factor for Avascular Necrosis?

Diabetes appears to increase the risk of avascular necrosis (AVN) in sites other than the jaw, though the evidence is limited and the relationship is not as strongly established as with other major risk factors like corticosteroids or alcohol abuse.

Evidence Quality and Strength

The relationship between diabetes and AVN is supported by moderate-quality evidence:

• A 2022 systematic review and meta-analysis found that diabetes non-significantly increased AVN risk (odds ratio: 1.90,95% CI: 0.93-3.91), but became statistically significant after excluding one outlier study (OR: 2.46,95% CI: 1.14-5.32) 1
• The analysis showed significant heterogeneity (I² = 65%), indicating variability across different patient populations studied 1
• The included studies examined diverse populations: primary/secondary femoral head AVN, kidney transplant recipients, systemic lupus erythematosus patients, and others 1

Established Major Risk Factors (For Context)

Guidelines consistently identify these as the primary risk factors for AVN:

• Corticosteroid therapy (especially high-dose and prolonged treatment) is the most strongly established risk factor 2
• Alcohol abuse significantly increases risk 2
• Hemoglobinopathies (particularly sickle cell disease) 2
• Prior dialysis in transplant patients 3, 2
• Hyperlipidemia and hypercoagulability states 2

Clinical Context Where Diabetes May Contribute

Diabetes has been implicated in AVN development in specific clinical scenarios:

• Case reports document AVN in diabetic patients on corticosteroid replacement therapy, with AVN developing within 14-18 months of starting steroids 4
• Diabetes is mentioned among systemic diseases associated with tarsal bone AVN, though trauma and foot deformity are more common causes 5
• Recent literature identifies diabetes as a condition requiring alertness for AVN development in the talus 6

Practical Clinical Implications

When evaluating patients with diabetes for AVN risk:

• MRI is the preferred diagnostic method for early detection, especially in patients with persistent joint pain but normal radiographs 2
• Diabetes combined with other risk factors (particularly corticosteroids, chronic kidney disease, or polyvascular disease) creates synergistic risk amplification 3
• In kidney transplant patients, both diabetes and prior dialysis duration independently contribute to AVN risk 3

Important Caveats

• The available evidence is limited by heterogeneity across different patient populations and AVN sites 1
• Diabetes is not listed among the primary risk factors in major orthopedic guidelines, unlike corticosteroids and alcohol 2
• The mechanism by which diabetes might contribute to AVN is not well-established, though microvascular disease and metabolic factors are theoretically plausible 1
• Large, well-designed, population-based studies are needed to definitively establish the relationship 1

Clinical Recommendation

While diabetes should be considered a potential contributing factor for AVN—particularly when combined with other established risk factors—it does not warrant the same level of concern as corticosteroid use, alcohol abuse, or hemoglobinopathies. Maintain heightened clinical suspicion for AVN in diabetic patients who also have other risk factors, present with unexplained joint pain, or are receiving corticosteroid therapy 2, 1, 4.