Osteonecrosis: Overview

Alternative names: Avascular Necrosis of Bone.

Osteonecrosis is the destruction of a bone (necrosis) often due to an inadequate supply of blood to a bone.  It most commonly affects the joints and bones of the hips, knees and shoulder.  It often occurs as a result of bone injuries or in conjunction with other diseases and conditions.

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Incidence; Causes and Development

Osteonecrosis is a common progressive disorder that can occur at any age, but is more frequently seen in people between 30 and 60 years of age.  Osteonecrosis of the hip is slightly more common in men while Osteonecrosis that affects the knees is seen three times more often in women.  It is also more common in those people with rheumatic diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus), steroid users (such as cortisone), alcoholics, diabetics, and skin divers who have experienced a rapid reduction of air pressure (bends).

Osteonecrosis is the death of bone tissue associated with various diseases.  A common cause is trauma that can cause a dislocation or fracture of the neck of the femur bone.  Bones may also be affected by the use of certain drugs such as corticosteroids (glucocorticoids), or radiation and chemotherapy used in treating cancer patients.  Osteonecrosis may also be a complication of kidney transplantation, sickle cell disease, alcoholism and other disorders.

Osteonecrosis is a slowly progressive disease frequently caused by a reduction of blood flow to a bone causing the bone to crack and eventually collapse.  This condition usually occurs as the result of other diseases, injuries or conditions.

Signs and Symptoms

Pain is the primary symptom.  It is a chronic and mild pain, usually occurring when standing, walking or lifting.  The pain becomes worse when weight bearing activities exert pressure on the bones or joints.  The pain may progress, eventually occurring while at rest or even disturbing sleep.  Other symptoms include muscle spasms, joint stiffness and limitation of motion.  Osteonecrosis most commonly affects the head of the femoral bone but may also involve the head of the humerus bone, the round protruding area at the end of the femur bone (condyles), the shin bone (distal tibia) and ankle (talus).

Diagnosis and Tests

X-rays can be helpful in diagnosing Osteonecrosis and determining the extent of bone damage.

Symptoms of the following disorder may be similar to those of Osteonecrosis.  Comparisons may be useful for a differential diagnosis:

Osteopetrosis is a combination of several rare genetically caused symptoms grouped together as one disorder.  It can be inherited as either a dominant or recessive trait and is marked by increased bone density, brittle bones, and in some cases skeletal abnormalities.  Although symptoms may not initially be apparent to people with mild forms of this disorder, trivial injuries may cause bone fractures due to abnormalities of the bone.  The dominantly transmitted form is milder than the recessive form and may not be diagnosed until adolescence or adulthood when symptoms first appear.  More serious complications occur in the recessive form which may be diagnosed from examination of skeletal X-rays during infancy or childhood.

The following disorders may be associated with the development of Osteonecrosis.  They are not necessary for a differential diagnosis:

Vasculitis is a common disorder characterized by an inflammation of the blood vessel walls.  This inflammation causes a narrowing of the inside of the vessel and can obstruct the flow of blood to the tissues (ischemia).  The lack of blood may cause damage to the tissues (necrosis), possible formation of blood clots (thrombosis), or a weakening or ballooning which can possibly cause a rupture of the vessel wall (aneurysm).  Osteonecrosis can occur in people with vasculitis when blood flow has been obstructed to the bone or joint.

Rheumatoid Arthritis is an inflammatory autoimmune disease in which the body's natural defenses against foreign agents (antibodies & lymphocytes) attack healthy joints.  This disorder is characterized by a lack of appetite (anorexia), fatigue, painful and deformed joints, early morning stiffness chiefly in the hands, knees, feet, jaw, and spine.  People with Arthritis are at increased risk of also developing Osteonecrosis.

Lupus (also known as SLE or Systemic Lupus Erythematosus) is an inflammatory connective tissue disease that can affect many parts of the body including the joints, skin and internal organs.  Lupus is a disease of the body's immune system, most often striking young women between the ages of 15 and 35 years.  People who have Lupus are also at increased risk of developing Osteonecrosis.

Legg-Calve-Perthes Syndrome is a rare disease affecting the hip joint.  Abnormalities in bone growth early in life may result in permanent deformity of the hip joint several years later.  Osteonecrosis of the femoral head is often seen in those people with Legg-Calve-Perthes Disease.

Gaucher's Disease is an inherited disease of lipid metabolism caused by the failure to produce the enzyme glucocerebrosidase.  It is the most common of the 14 known lipid storage disorders which includes Tay-Sachs, Fabry's Disease, and Niemann-Pick Disease.  There are three types of Gaucher's Disease Type I, II and III.  All three are characterized by the presence of Gaucher (lipid-laden) cells in the bone marrow and other organs such as the spleen and liver.  Bone deterioration (Osteonecrosis) is a major symptom of this disease and can affect any part of the body.

Sickle Cell Disease is an inherited blood disease.  Symptomatic of this disease are the "crisis periods" which often occur in conjunction with other infections.  It is characterized by joint pain (arthralgia), fever, severe abdominal pain, vomiting, and damage to the head of the femur bone (osteonecrosis).

Polycythemia Vera is a chronic proliferative disorder of the bone marrow.  It is characterized by an increase in the number of red blood cells (erythrocytosis) and hemoglobin concentration in the blood.  Osteonecrosis can occur in Polycythemia Vera.

Caisson Disease, also called "Decompression Sickness" or the "Bends", is a disorder caused by the formation of nitrogen bubbles in the tissues and blood.  This occurs from a very rapid reduction of air pressure after rising quickly from deep water with high atmospheric pressure, to normal air pressure.  It is characterized by painful joints, bone deterioration (Osteonecrosis), chest tightness, giddiness, abdominal pain, vomiting and visual difficulties.  In some with this disorder there may also be convulsions and paralysis.

Treatment and Prevention

Treatment of Osteonecrosis consists of diagnosing, treating or eliminating the underlying cause.  Bones damaged or weakened by this disorder will usually heal and regenerate with appropriate treatment.

Limiting or avoiding alcohol, weight bearing activities, standing or walking may help in the recovery process.  Bed rest and reducing stress to the affected area are helpful.

The pain associated with this disorder can be relieved with aspirin or non-steroidal anti-inflammatory drugs such as ibuprofen.  Warm baths, heating pads and electric blankets may also be helpful in relieving the muscle spasms and pain associated with Osteonecrosis.

Surgery may be necessary when there is a dislocation, fracture or if the bone has collapsed.  The most often used method of treatment for advanced Osteonecrosis of either the knee or hip is replacement of the affected area with a prosthetic joint.

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