para>NSAIDs risks
Avoid acetaminophen dose >4 g in healthy adults <70 years of age; >2 g in those with hepatic impairment or >70 years of age.
Surgery/Other Procedures
- Core decompression reduces pressure within the bone, increases blood flow, and stimulates new blood vessels. Significant reduction in pain reported (1)[A].
- Bone grafts transplant healthy bone to the diseased area. Technically difficult procedure.
- Osteotomy reshapes the bone and reduces stress on the affected area in advanced stage AVN.
- Arthroplasty or total joint replacement is often required due to damage to the joint.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
Depending on the severity of the disease, patients usually attempt conservative therapy and use MRI to determine progression of the disease. Orthopedic consultation advised early.
Prognosis
AVN can be an ongoing process. Depending on the stage at which treatment is initiated, and patient's response to treatment, may have long-term arthritis and require joint replacement.
Complications
Arthritis, chronic pain
References
1.Assouline-Dayan Y, Chang C, Greenspan A, et al. Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum. 2002;32(2):94-124.
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2.Aaron RK, Voisinet A, Racine J, et al. Corticosteroid-associated avascular necrosis: dose relationships and early diagnosis. Ann N Y Acad Sci. 2011;1240(1):38-46.
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3.Jones JP Jr. Alcoholism, hypercortisonism, fat embolism and osseous avascular necrosis. Clin Orthop Relat Res. 2001;393:4-12.
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4.Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am. 2005;87(10):2155-2159.
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5.Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop Relat Res. 2001;(386):173-178
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Additional Reading
- http://nonf.org/index.html
- Wilson JJ, Furukawa M. Evaluation of the patient with hip pain. Am Fam Physician. 2014;89(1):27-34.
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Codes
ICD09
- 733.40 Aseptic necrosis of bone, site unspecified
- 733.42 Aseptic necrosis of head and neck of femur
- 733.41 Aseptic necrosis of head of humerus
- 733.43 Aseptic necrosis of medial femoral condyle
- 733.44 Aseptic necrosis of talus
- 733.49 Aseptic necrosis of bone, other
ICD10
- M87.9 Osteonecrosis, unspecified
- M87.059 Idiopathic aseptic necrosis of unspecified femur
- M87.219 Osteonecrosis due to previous trauma, unspecified shoulder
- M87.256 Osteonecrosis due to previous trauma, unspecified femur
- M87.20 Osteonecrosis due to previous trauma, unspecified bone
- M87.273 Osteonecrosis due to previous trauma, unspecified ankle
SNOMED
- 397758007 Avascular necrosis of bone (disorder)
- 444849002 avascular necrosis of bone of hip (disorder)
- 203475004 Avascular necrosis of the head of humerus (disorder)
- 449816009 Avascular necrosis of femoral condyle (disorder)
- 203478002 Avascular necrosis of the talus (disorder)
Clinical Pearls
- Higher on differential for hip and other joint pain in 30- to 50-year-old patient, men > women
- Risk factors include chronic corticosteroid use, alcoholism, radiation, and chemotherapy.
- X-rays are for diagnosis and staging, but early disease may only be seen on MRI.
- Treatment initially aimed at graded weight bearing but often requires surgical intervention for pain control and to reduce long-term morbidity.