Osteonecrosis Q & A

In late stages, it is sometimes difficult to distinguish osteonecrosis from other degenerative problems such as advanced osteoarthritis. If there are advanced x-ray changes, then there is likely no treatment options for osteonecrosis except for possible joint replacement. In the early stages of osteonecrosis, diagnosis is made by MRI and depending on the changes seen, can be specific as well as sensitive.

Avascular necrosis (AVN) is also known as osteonecrosis is a condition in which the bone does not get enough blood supply and dies. It is most commonly seen in the hip after a fracture which disrupts blood supply to the head of the femur. AVN is most common in large joints– hips, knees and shoulders. Use of high dose prednisone is a risk factor for AVN, particularly in SLE patients. Alcohol use, sickle cell anemia and HIV are also risk factors. Some SLE patients have increased blood clots due to abnormal antibodies and this should be looked at as well. You need to see a rheumatologist or a smart internist to help with the work-up.

Once AVN starts and the x-rays show damage, the joints often progressively become destroyed to the point where they need replacement. Early diagnosis before x-ray damage is done with MRI or bone scan. Dr. Michael Mont at Sinai Hosp in Baltimore is the local orthopedic expert.

Gold shots are almost never given in the U.S. anymore. In fact, it has been very hard to get becasue there is no company who is making it. By contrast to the newer agents, gold is not very well tolerated and the initial weekly injections are a hassle.

Prednisone below 10 mg daily will likely not have an effect on your AVN and thus if you require it, it may be a reasonable consideration.

The problem you describe is called osteonecrosis or avascular necrosis. It is a condition ususally of a large joint such as a hip, knee or shoulder in which blood supply is compromised to the bone and the bone dies. The most common cause of osteonecrosis of the hip is after a hip fracture. However, there are certain medical problems that also cause the condition including problems with excessive blood clotting, sickle cell anemia and other blood disorders. A rheumatic condition called vasculitis can occasionally be a cause as well. High does of prednisone for long periods of time are also associated with osteonecrosis. Unfortuantely many patients requrie joint replacement. If the osteoncrosis is very early a surgical procedure called core decompression can sometimes save the joint.

>Avascular necrosis (AVN) also called osteonecrosis is a condition in which blood supply to the bone is disrupted and the bone dies. AVN ususally affects large weight bearing joints such as the hips or knees but on occasion can affect the shoulders, ankles or wrists. The most common cause of AVN is fractures after trauma that disrupts the blood supply– particularly common after certain hip fractures. Certain blood disorders such as sickle cell anemia or problems that cause excessive blood clotting can cause AVN. Acohol abuse and high doses of prednisone have also been associated with AVN. In your case, I agree that you need a careful evaluation for diseases that can cause AVN.

Unfortunately, many cases of AVN cannot be treated medically and joint replacement is required. In the early stages, a procedure called core decompression can be tried.

Osteonecrosis, if this is the correct diagnosis, can be very serious and lead to destruction of the joint. It occurs when the blood supply is disrupted to the bones in the joint causing death of the bone. Fractures are the most common cause of this problem. Rarely, it is caused by blood disorders such as sickle cell anemia or disorders where the blood clots too much. I cannot second guess either the diagnosis of your orthopedic surgeon or the decision to adopt a wait and see approach. Given that this can be a serious problem, you may want to get more than one opinion.