From the Guidelines
Vascular necrosis, also known as avascular necrosis or osteonecrosis, is primarily caused by interrupted blood supply to the bone, leading to bone tissue death, and its management should focus on early diagnosis and treatment to prevent articular collapse and the need for joint replacements. The condition is thought to affect adults in their third to fifth decades of life, with common sites including the femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus 1. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease 1.
Causes of Vascular Necrosis
- Trauma
- Corticosteroid therapy
- Alcohol use
- HIV
- Lymphoma/leukemia
- Blood dyscrasias
- Chemotherapy
- Radiation therapy
- Gaucher disease
- Caisson disease
Management of Vascular Necrosis
- Early diagnosis through MRI imaging is essential for better outcomes, as osteonecrosis is progressive and can lead to complete joint destruction if left untreated 1.
- Early-stage osteonecrosis can be managed with noninvasive therapies, such as statins, bisphosphonates, anticoagulants, extracorporeal shock wave therapy, and hyperbaric oxygen, although the evidence for these treatments is limited 1.
- Invasive therapies, including core decompression, can be performed in various locations, including the femoral head, humeral head, and talus, and can be supplemented with injection of autologous bone marrow cells, vascular fibular grafting, or electric stimulation 1.
- For late-stage femoral or humeral head osteonecrosis with articular collapse, resurfacing hemiarthroplasty may be needed, whereas total joint arthroplasty is performed in cases of severe secondary osteoarthritis 1.
- Lifestyle modifications, including smoking cessation, alcohol limitation, and avoiding high-impact activities, are crucial for managing osteonecrosis and preventing further bone damage 1.
From the Research
Causes of Vascular Necrosis
- Avascular necrosis can be caused by various factors, including corticosteroid treatment, hypercholesterolemia, sickle cell disease, alcohol abuse, and nonsteroidal anti-inflammatory drug (NSAID) therapy 2, 3
- Trauma, dysbaric conditions, chemotherapy, lymphoma, and Gaucher disease are also known risk factors for avascular necrosis 2
- The use of NSAIDs, such as diclofenal sodium, can lead to avascular necrosis of the femoral head 3
Management of Vascular Necrosis
- The management of avascular necrosis depends on the stage of the disease, with conservative treatment recommended for early stages (stage I and II) and joint arthroplasty for more advanced stages (III and IV) 4
- Bisphosphonates, such as alendronate and zolendronic acid, have been shown to prevent disease progression, bone collapse, and the requirement for surgery in avascular necrosis of the femoral head 5, 6
- A combination of oral alendronate and intravenous zolendronic acid may provide a pragmatic solution for the treatment of non-femoral avascular necrosis 6
- Conservative treatment options include shoulder range of motion exercises and nonsteroidal anti-inflammatory agents, while surgical options include arthroplasty or core decompression 2