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Avascular Necrosis (AVN), also known as Osteonecrosis, is a progressive bone-decay condition that results from insufficient blood supply to the affected area of the body. The lack of blood supply starves the bone of essential resources and eventually the integrity of the bone tissue declines. There are four stages of Avascular Necrosis. Stages one and two are considered pre-collapse, meaning the bone tissue is still resilient enough to respond to multiple treatment options. Stages three and four are referred to as post-collapse and in most cases will require total or partial replacement surgery to be treated.

Osteonecrosis most commonly occurs in the hip joint, but is also found in other major joints including the knee, ankle, wrist, and elbow. At the Institute for Advanced Reconstruction (IFAR), we have treated patients with AVN in all of these major joints. While there are a few treatment options for patients with avascular necrosis, the team at IFAR specializes in Free Periosteal Core Decompression, which has shown to yield the best immediate and long-term results compared to alternative treatment methods. This procedure is more of a true treatment, as it addresses the root cause of the bone decay, blood supply, rather than just managing the symptoms.


Osteonecrosis Symptoms

The symptoms of osteonecrosis may closely reflect typical joint pain associated with overuse injuries, trauma, or arthritis. However, patients suffering from AVN will generally progress through the four stages rapidly. Osteonecrosis patients can progress from stage one to stage four in less than 18 months, with many patients experiencing rapid decline in just a few months. This makes early detection key in receiving proper treatment and resources for managing this progressive condition. Watch for AVN symptoms, especially if you have recently experienced a traumatic injury (bone fracture, car crash, slip and fall) and call our office to schedule a diagnostics appointment immediately.

Symptom of avascular necrosis include:

  • Worsening joint pain
  • Bone cysts
  • Pain while at rest
  • Bone spurs
  • Cartilage deterioration
  • Bone collapse
  • Limping or discomfort while moving
  • Joint inflammation
  • Loss of mobility

Causes & Risk Factors

While there is no singular known cause of AVN, doctors know that the root of the condition starts when there is insufficient, or a loss of blood supply to an area of bone. Over time, the bone becomes starved and in a matter of months or at most a few years, it cracks, develops spurs, and eventually collapses.

Here’s what we know about the cause of osteonecrosis:

  • Most cases of AVN are due to unknown causes
  • Traumatic force to the affected area can impact vascular performance, leading to insufficient blood flow
  • Bone fractures can create blockages that cutoff blood supply to some or all of the patient’s bone

Since avascular necrosis has no known cause, doctors may rely on the presence of risk factors that impact blood flow in tandem with diagnostic imaging to monitor the state of the affected joint and determine a proper diagnosis.

Risk factors for osteonecrosis include:

  • Smoking
  • Use of oral or intravenous steroids
  • Chemotherapy and radiation therapy
  • Clotting disorders
  • Metabolic conditions like Gaucher’s disease
  • Excessive alcohol consumption
  • Conditions that affect the blood like sickle cell disease and thalassaemia
  • Extended use of bisphosphonates (bone density medications)

Diagnosing Avascular Necrosis

As multiple conditions, as well as general wear and tear, can impact joint health, diagnosis of avascular necrosis can be challenging. The doctor will perform an initial physical examination to track pain levels at different areas of the affected joint. This will also inform the doctor of the ease and full range of motion of the joint. Taking into consideration your full list of symptoms and risk factors, the next step will be imaging tests.

  • X-rays: for monitoring the condition and progression of late-stage osteonecrosis.
  • MRI and CT scans: for detailed imaging of the affected bone.
  • Radionuclide bone scans: evaluate the flow of blood through an area of bone.

Doctors will utilize the full results of your examination and scans to determine if you do in fact have AVN and at what stage of progression the bone is in to develop the best possible approach to relieve your symptoms and treat the impacted joint.

Avascular Necrosis Treatment

A healthy joint utilizes a harmonious combination of bones, tendons, articular cartilage, and synovial fluid to support frictionless movement and absorb the shock of regular and exertive activities. Through general wear and tear or due to trauma, these components can become compromised, creating a slow or exponential decline in joint health and functionality.

In the case of avascular necrosis, blood flow has been severely slowed, or blocked to a given area of bone tissue. In a matter of months or no longer than two years, this condition will progress to the point of total bone death without medical intervention.

Patients can experience relief from their symptoms and delay the progression of AVN with a few different procedures. That said, with the severity of the condition and rapid nature of its progression, we recommend that patients consider a treatment option that thoroughly addresses the root cause of AVN, blood supply. Additionally, for patients in the post-collapse stages of AVN (Stages 3 & 4), the only treatment option available is total joint replacement surgery. The treatments for AVN are as follows:

  • Medication - Nonsteroidal anti-inflammatory drugs, cholesterol-lowering medications, blood thinners, pharmaceuticals that expand the blood vessels.
  • Lifestyle changes - Changes to diet and exercise routine to reduce fat and cholesterol intake and promote better blood flow to the affected joint.
  • Core decompression - Drilling a hole into the affected bone and removing dead tissue. This reduces pressure on the remaining bone tissue and improves blood flow. The results of core decompression for AVN are variable. Patients may experience immediate relief and some regression of the disease, but aggressive AVN cases will likely require additional treatment.
  • Free vascularized bone graft - This procedure includes core decompression, with the addition of a bone graft from the patient to provide further stability of the joint. Infection, chronic pain, and nerve damage are possible side-effects of a bone graft.
  • Joint replacement surgery - Partial or complete replacement of the affected bone tissue with metallic and/or plastic components. Patients may experience sustained relief, but with the potential for infection, recalls, and deterioration of the replaced joint.
  • Stem cell therapy - Stem cells have shown significant promise in their ability to regenerate damaged or dead body tissue. While current research is promising for the use of stem cell injections in treating severe, chronic conditions like AVN, further studies are required before a conclusive treatment is established.
  • Free periosteal core decompression - Core decompression involves the drilling of a hole in the affected bone to create room for the surgeon to remove dead bone and cartilage. This procedure results in the relief of pressure placed on the bone.

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