Avascular Necrosis

Avascular necrosis (AVN) is a disorder resulting from a temporary or permanent loss of blood supply to the bone. Blood carries essential nutrients and oxygen to the bones. When the blood supply is disrupted (avascular), the bone tissues begin to break down (necrosis). This can weaken the bone and eventually result in its collapse. If this occurs near a joint, it can lead to the collapse of the joint surface, resulting in pain and inflammation (arthritis). AVN is also referred to as osteonecrosis, aseptic necrosis, or ischemic bone necrosis.

AVN can occur in any bone, but most commonly affects the ends (epiphysis) of long bones such as the thigh bone (femur), causing hip and knee problems. Other common sites include the bones of the upper arms, shoulders, and ankles. AVN can occur in a single bone, but more commonly occurs in several bones at one time (multifocal AVN). AVN can sometimes be disabling, depending on what part of the bone is affected, how large an area is involved, and how well the bone rebuilds itself.

Causes of AVN

AVN is caused by interruption of the blood supply to the bone. If blood vessels are blocked with fat, become too thick or too small, or get too weak, they may not be able to provide the amount of blood necessary for the bone tissue to survive. Corticosteroids (such as prednisone and dexamethasone) given during cancer treatment can affect the bone and blood vessels, resulting in AVN.

Other factors that increase the risk of AVN in people who received corticosteroid therapy include treatment with high doses of radiation to weight-bearing bones, treatment with orthovoltage radiation (commonly used before 1970), being older than 10 at the time of treatment, and having sickle cell disease. AVN is most likely to occur during cancer treatment, but it can sometimes happen after completion of cancer therapy.

Steroids and AVN

Corticosteroids are commonly used for treatment of many cancers, such as leukemia and lymphoma. Dexamethasone is also sometimes used for treatment of nausea and vomiting associated with chemotherapy and to control brain swelling. There is no clear explanation as to how steroids cause AVN, but it is believed that they interfere with the body’s ability to break down fatty substances. These substances can clog the blood vessels, causing them to narrow. This reduces the amount of blood that gets into the bone.

Symptoms of AVN

People in the early stages of AVN may not have any symptoms. However, as the disorder progresses, most people will experience some joint pain. At first, the person may only experience pain when bearing weight on the affected bone or joint. As the disorder progresses, symptoms may be present even at rest. Pain may develop gradually and its intensity can range from mild to severe.

If AVN progresses and the bone and surrounding joint surfaces collapse, the pain can increase considerably and may become severe enough to limit movement in the affected joint. The period of time between the first symptoms of AVN and the loss of joint function is different for each person and ranges from several months to years.

Diagnosing AVN

An X-ray is usually the first test performed when AVN is suspected. It can help distinguish AVN from other causes of bone pain, such as fracture. Once the diagnosis is made, and in the later stages of AVN, X-rays are useful in monitoring the course of the condition.

MRI is sometimes used to diagnose AVN because it can detect AVN in the earliest stages, when symptoms are not yet present.

Bone scans may also be used to diagnose AVN. They are useful because one scan can show all the areas in the body affected by AVN. However, bone scans do not detect AVN at the earliest stages.

CT scan provides a three-dimensional image of the bone and can be useful in determining the extent of bone damage.

Surgical procedures, such as a bone biopsy, can conclusively diagnose AVN but are not commonly done.

Treating AVN

The goals of treatment for AVN are to improve the person’s use of the affected joint, reduce pain, stop bone damage, and ensure joint survival. Treatment can be categorized as conservative or surgical. In order to determine the most appropriate treatment, the following factors are taken into consideration:

  • The person’s age
  • The stage of the disorder (early or late)
  • The location and the amount of bone affected (small or large)
  • The status of cancer and cancer treatment

Conservative treatments

  • Medication - to reduce pain.
  • Reduced weight bearing - to slow the damage and promote natural healing. Crutches may be recommended to limit weight or pressure on the affected joint.
  • Range of motion exercises – to keep the joints flexible. This is also important to maintain movement and increase circulation in the joints. This can promote healing and may relieve pain.
  • Electrical stimulation - to induce bone growth.

Conservative treatments may be used alone or in combination, but they do not always provide lasting improvement. Some people may require surgery to permanently repair or replace the joint.

Surgical Treatment

  • Core decompression – is a surgery that removes the inner layer of bone. This may reduce pressure within the bone and create an open area for new blood vessels to grow. Sometimes a piece of healthy bone with good blood vessels (bone graft) is put in this area to speed up the process. This procedure works best in the early stages of AVN and should help relieve pain and promote healing.
  • Osteotomy – is a surgery that involves taking out a piece of bone, usually a wedge, to reposition the bone so that the tissue lacking blood supply (avascular area) bears less weight than an adjacent healthy area.
  • Arthroplasty – is also referred to as joint replacement. The affected bone is removed and replaced with an artificial joint. This treatment may be needed in the late stages of AVN or when a joint is destroyed.

Health Promoting Behaviors/Interventions

  • Avoid activities that put stress on your joints, including running, jumping, football, soccer, volleyball, basketball, and similar sports. Activities that are good for joints with AVN are swimming and bicycling.
  • Be consistent with recommended exercises.
  • Rest joints when they hurt.
  • Let your healthcare provider or physical therapist know if there are any changes in your symptoms.
  • Take pain or anti-inflammatory medications as prescribed.