Osteonecrosis Disease

BASICS

DESCRIPTION

Death of the cellular components of bony tissue

System(s) affected: Musculoskeletal
Genetics: The underlying condition of hemoglobinopathies, especially sickle cell disease, diabetes, and type II or IV hyperlipemia are inheritable and associated with a high incidence of osteonecrosis. Other forms have no proven genetic relationship.
Incidence/Prevalence in USA: Dependent upon the underlying condition
Predominant age: 3rd to 6th decade
Predominant sex: Male > Female

SIGNS AND SYMPTOMS

The symptoms may be acute as in osteonecrosis of sickle cell disease or renal transplant. Usually insidious in other forms. Diagnosis may not be made for two years after onset of symptoms
Pain, the prominent symptom, is made worse with activity
Loss of motion of the affected joint
Stiffness (especially early morning)
Swelling if the involved joint is superficial
Locking may occur if a loose body has developed
Proximal femur is the most common site and more prevalent in males in the 3rd-6th decade
The distal femur, especially the medial femoral condyle, is the second most frequent site. This area is unique in that night pain is a prominent early symptom. Most common in females in the 6th-7th decade.
Other sites in decreasing frequency are the proximal humerus, talus, carpal lunate (Kienböck's disease) and the humeral capitulum

CAUSES

Idiopathic
Fractures, especially the femoral neck
Traumatic (fractures, dislocation)
Dislocations
Legg-Calvé-Perthes (seen in 6–12 year age group)
Hemoglobinopathies (especially sickle cell disease)
Metabolic (hemoglobinopathies, alcohol, steroids, renal failure/transplantation)

RISK FACTORS

Gaucher's disease - especially likely as a postoperative infection
Diabetes mellitus
Alcoholism - the most frequent cause
Type II or IV hyperlipemia
Cortisone therapy (may be seen with Cushing's disease)
Obesity
Oral contraceptives
Organ transplant, especially kidney
Pregnancy
Decompression sickness ("bends")

DIAGNOSIS

LABORATORY

N/A
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

The subchondral fracture occurs during bone repair as necrotic bone is resorbed. Later, a collapse of the bone occurs with subsequent irregularities at the joint surface. This will eventually produce osteoarthritic changes.

SPECIAL TESTS

Bone scan shows decreased bone uptake (sometimes increased uptake depending on the stage). Later, the uptake increases as reparative processes begin within the bone.

IMAGING

MRI will show a decreased signal intensity of the involved bone and is the most sensitive diagnostic exam.

DIAGNOSTIC PROCEDURES

The presence of a crescent sign is practically diagnostic (see Differential Diagnosis of osteonecrosis). It is caused by a subchondral fracture.

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient normally; inpatient if surgery indicated

GENERAL MEASURES

Only four conditions can be treated to decrease the incidence of osteonecrosis
- Alcoholism - abstinence is obvious, but quite difficult to attain
- Dysbarism - new tables of decompression, if followed, will lower osteonecrosis incidence of divers
- Transplant patients - decreased doses of cortisone and regulation of calcium and phosphorous metabolism
- Sickle cell disease - treat a crisis vigorously with hydration, possible exchange transfusion and oxygenation, especially hyperbaric oxygen

SURGICAL MEASURES

Bone grafts, arthroplasty, allografts and arthrodesis may be used, dependent upon the joint involved

ACTIVITY

As tolerated

DIET

No special diet

PATIENT EDUCATION

The patient should be instructed in the use of crutches and/or canes when the lower extremity is involved. Proper use of a walking cane can decrease the pressure on the femoral head 20-30% when walking.

FOLLOW UP

PREVENTION/AVOIDANCE

Early diagnosis and treatment of underlying disease

POSSIBLE COMPLICATIONS

Progression of disease
The progression of osteonecrosis leads to osteoarthritis of the involved joint to a varying degree. Arthroplasty of the hip carries a much poorer prognosis than osteoarthritis alone. It should be postponed as long as possible.

EXPECTED COURSE AND PROGNOSIS

Gaucher's disease is associated with a high risk of infection following surgery

MISCELLANEOUS

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric: Legg-Calvé-Perthes occurs in the 6-12 year age group. Prognosis is better in younger patients.
Geriatric: N/A
Others: N/A

PREGNANCY

Is a risk factor

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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