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20-September-2008 10:21:21 - Avascular necrosis Avascular necrosis Classification and external resources Femur head showing a flap of cartilage from underlying avascular necrosis. Specimen from total hip replacement surgery. ICD-10 M87. ICD-9 733.4 DiseasesDB 1174 eMedicine med/2924 MeSH D010020 Avascular necrosis is a disease resulting from the temporary or permanent loss of the blood supply to the bones.1 Without blood, the bone tissue dies and causes the bone to collapse.1 If the process involves the bones near a joint, it often leads to collapse of the joint surface. This disease also is known as osteonecrosis, aseptic bone necrosis, and ischemic bone necrosis.1 Contents 1 Causes 2 Presentation 3 Diagnosis 4 Treatment 5 Notable individuals affected 6 References 7 External links Causes There are many causes of avascular necrosis such as alcoholism2, excessive steroid use3, post trauma 4 5, caisson disease decompression sickness67, vascular compression8, hypertension, vasculitis, thrombosis, damage from radiation, bisphosphonates particularly the mandible 9, sickle cell anaemia10, and Gaucher's Disease11. In some cases it is idiopathic no cause is found.12 Rheumatoid arthritis and lupus are also common causes of AVN. Presentation While it can, by definition, affect any bone, and half of cases show multiple sites of damage, this disease primarily affects the joints at the shoulder, knee, and hip. Although it can happen in any bone, avascular necrosis most commonly affects the ends epiphysis of long bones such as the femur, the bone extending from the knee joint to the hip joint. Other common sites include the humerus the bone of the upper arm13 14, knees 15 16, shoulders 1317, ankles and the jaw18. The disease may affect just one bone, more than one bone at the same time, or more than one bone at different times.19 Avascular necrosis usually affects people between 30 and 50 years of age; about 10,000 to 20,000 people develop avascular necrosis of the head of the femur in the US each year. When it occurs in children at the femoral head, it is known as Legg-Calvé-Perthes syndrome.20 Diagnosis Orthopaedic doctors most often diagnose the disease except when it affects the jaws, when it is usually diagnosed and treated by dental and maxillofacial surgeons. Because early x-rays are usually normal in the early stage of the disease , bone scintigraphy 21and MRI 22 are the diagnostic modalities of choice since both can detect minimal changes at early stages of the disease. Late radiographic signs include a radiolucency area following the collapse of subchondral bone crescent sign and ringed regions of radiodensity resulting from saponification and calcification of marrow fat following medullary infarcts. Treatment Avascular necrosis is especially common in the hip joint. A variety of methods are now used to treat avascular necrosis19, the most common being the total hip replacement, or THR. However, THRs have a number of downsides including long recovery times and short life spans. THRs are an effective means of treatment in the geriatric population, however doctors shy away from using them in younger patients due to the reasons above. A new, more promising treatment is metal on metal resurfacing. It is a form of a THR, however in this procedure, only the head of the femur is removed as opposed to a THR in which the entire neck is removed. Metal on metal resurfacing is still experimental in America but has been endorsed in Great Britain as an excellent alternative to a THR. Bone is always undergoing change or remodelling23. The bone is broken down by osteoclasts and rebuilt by osteoblasts23. Some doctors also prescribe bisphosphonates e.g. alendronate which reduces the rate of bone breakdown by osteoclasts, thus preventing collapse specifically of the hip due to AVN24. Other treatments include Core Decompression, where internal bone pressure is relieved by drilling a hole into the bone, and living bone chip and electrical device to stimulate new vascular growth are implanted; and the Free Vascular Fibular Graft FVFG, in which a portion of the fibula, along with its blood supply, is removed and transplanted into the femoral head25. The amount of disability that results from avascular necrosis depends on what part of the bone is affected, how large an area is involved, and how effectively the bone rebuilds itself. The process of bone rebuilding takes place after an injury as well as during normal growth23. Normally, bone continuously breaks down and rebuilds--old bone is reabsorbed and replaced with new bone. The process keeps the skeleton strong and helps it to maintain a balance of minerals23. In the course of avascular necrosis, however, the healing process is usually ineffective and the bone tissues break down faster than the body can repair them. If left untreated, the disease progresses, the bone collapses1, and the joint surface breaks down12, leading to pain and arthritis12. Notable individuals affected Avascular necrosis cut short the football and baseball careers of star athlete Bo Jackson.26 Other sports stars with this condition are former NFL running back Garrison Hearst, cyclist Floyd Landis, NFL quarterback Brett Favre, professional wrestler Superstar Billy Graham, wrestler Joe Heat, NBA player Jorge Garbajosa and the drummer/singer of the band, The Monkees, Micky Dolenz. References ^ a b c d DiGiovanni, C.W., et al., Osteonecrosis in the foot. J Am Acad Orthop Surg, 2007. 154: p. 208-17. ^ Chao, Y.C., et al., Investigation of alcohol metabolizing enzyme genes in Chinese alcoholics with avascular necrosis of hip joint, pancreatitis and cirrhosis of the liver. Alcohol Alcohol, 2003. 385: p. 431-6. ^ Juery, P., Avascular necrosis after a steroid injection. CMAJ, 2007. 1766: p. 814; author reply 814. ^ Baksi, D.P., Treatment of post-traumatic avascular necrosis of the femoral head by multiple drilling and muscle-pedicle bone grafting. Preliminary report. J Bone Joint Surg Br, 1983. 653: p. 268-73. ^ Lee, C.K. and H.R. Hansen, Post-traumatic avascular necrosis of the humeral head in displaced proximal humeral fractures. J Trauma, 1981. 219: p. 788-91. ^ Zhang, L. D.; J. F. Kang; H. L. Xue. 1990. Distribution of lesions in the head and neck of the humerus and the femur in dysbaric osteonecrosis. Undersea Biomed. Res. 17 4: 353-358. ISSN 0093-5387. PMID 2396333. OCLC 2068005. Retrieved on 2008-04-06. ^ Lafforgue, P., Pathophysiology and natural history of avascular necrosis of bone. Joint Bone Spine, 2006. 735: p. 500-7. ^ Laroche, M., Intraosseous circulation from physiology to disease. Joint Bone Spine, 2002. 693: p. 262-9. ^ Dannemann, C., et al., Jaw osteonecrosis related to bisphosphonate therapy: a severe secondary disorder. Bone, 2007. 404: p. 828-34. ^ Marti-Carvajal, A., R. Dunlop, and L. Agreda-Perez, Treatment for avascular necrosis of bone in people with sickle cell disease. Cochrane Database Syst Rev, 20044: p. CD004344. ^ The Merck Manual, 18th ion, chapter 38, page 311 1 ^ a b c Day S, O.R., Chao E, Rubin C, Aro H, einhorn T, Bone injury, regeneration, and repair, in Orthopaedic Basic Science, A.A.o.O. Surgeons, or. 2000. p. 372-399. ^ a b Chapman, C., C. Mattern, and W.N. Levine, Arthroscopically assisted core decompression of the proximal humerus for avascular necrosis. Arthroscopy, 2004. 209: p. 1003-6. ^ Mansat, P., et al., Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: nineteen shoulders followed up for a mean of seven years. J Shoulder Elbow Surg, 2005. 142: p. 114-20. ^ Jacobs, M.A., P.E. Loeb, and D.S. Hungerford, Core decompression of the distal femur for avascular necrosis of the knee. J Bone Joint Surg Br, 1989. 714: p. 583-7. ^ Bergman, N.R. and J.A. Rand, Total knee arthroplasty in osteonecrosis. Clin Orthop Relat Res, 1991273: p. 77-82. ^ Mansat, P., et al., Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: nineteen shoulders followed up for a mean of seven years. J Shoulder Elbow Surg, 2005. 142: p. 114-20. ^ Baykul, T., M.A. Aydin, and S. Nasir, Avascular necrosis of the mandibular condyle causing fibrous ankylosis of the temporomandibular joint in sickle cell anemia. J Craniofac Surg, 2004. 156: p. 1052-6. ^ a b Wisconsin, M.C.o.. Avascular Necrosis.. Retrieved on 2007-11-06. ^ Gross, G.W., G.A. Articolo, and J.R. Bowen, Legg-Calve-Perthes Disease: Imaging Evaluation and Management. Semin Musculoskelet Radiol, 1999. 34: p. 379-391. ^ Maillefert, J.F., et al., Bone scintigraphy equipped with a pinhole collimator for diagnosis of avascular necrosis of the femoral head. Clin Rheumatol, 1997. 164: p. 372-7. ^ Bluemke, D.A. and E.A. Zerhouni, MRI of avascular necrosis of bone. Top Magn Reson Imaging, 1996. 84: p. 231-46. ^ a b c d Hall, B., The Osteoblast and Osteocyte. Vol. 1. 1990: The Telford Press. 494. ^ Agarwala, S., et al., Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology Oxford, 2005. 443: p. 352-9. ^ Judet, H. and A. Gilbert, Long-term results of free vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res, 2001386: p. 114-9. ^ ESPN.com: Bo knows stardom and disappointment. Retrieved on 2007-09-09. External links Osteonecrosis / Avascular Necrosis at the National Institute of Health Osteonecrosis / Avascular necrosis at Merck Manual for patients Osteonecrosis / Avascular necrosis at Merck Manual for medical professionals Femoral head avascular necrosis at eMedicine Avascular Necrosis and Core decompression information from aboutjoints.com Center for Osteonecrosis Research National Osteonecrosis Foundation Detailed background information on the chemistry and biological processes behind Avascular Necrosis MedPix Images Imaging Osteonecrosis Osteonecrosis of the Jaw ONJ:Information for Cancer Patients v d e Diseases of the musculoskeletal system and connective tissue M, 710-739 Arthropathies Arthritis Septic arthritis - Reactive arthritis - Rheumatoid arthritis - Psoriatic arthritis - Felty syndrome - Juvenile idiopathic arthritis - Still's disease - crystal Gout, Chondrocalcinosis - Osteoarthritis Heberden's node, Bouchard's nodes - Monoarthritis/Polyarthritis Specific joints shoulder Winged scapula - elbow Cubitus valgus, Cubitus varus - hand Wrist drop, Boutonniere deformity, Swan neck deformity hip Protrusio acetabuli, Coxa valga, Coxa vara - leg Foot drop, Flat feet, Club foot, Unequal leg length - patella Luxating patella, Chondromalacia patellae - foot Bunion/hallux valgus, Hallux varus, Hallux rigidus, Hammer toe general terms Valgus deformity, Varus deformity Other Hemarthrosis - Arthralgia - Osteophyte - Hypermobility Systemic CT disorders vasculitis: Arteritis Polyarteritis nodosa, Takayasu's arteritis, Temporal arteritis - arterioles/capillaries Wegener's granulomatosis, Kawasaki disease, Churg-Strauss syndrome, Microscopic polyangiitis hypersensitivity/autoimmune: Hypersensitivity vasculitis - Goodpasture's syndrome - Systemic lupus erythematosus Drug-induced - Dermatomyositis Juvenile dermatomyositis - Polymyositis - Scleroderma - Sjögren's syndrome - Behçet's disease - Polymyalgia rheumatica - Eosinophilic fasciitis Dorsopathies spinal curvature Kyphosis, Lordosis, Scoliosis - Scheuermann's disease - Spondylolysis - Torticollis - Spondylolisthesis Spondylopathies Ankylosing spondylitis, Spondylosis, Spinal stenosis - Schmorl's nodes - Degenerative disc disease - Coccydynia - Back pain Radiculopathy, Neck pain, Sciatica, Low back pain Soft tissue disorders Muscle Myositis Pyomyositis - Myositis ossificans Fibrodysplasia ossificans progressiva Synovium and tendon Synovitis/Tenosynovitis Calcific tendinitis, Stenosing tenosynovitis, Trigger finger, DeQuervain's syndrome - Irritable hip - Ganglion cyst Bursa Bursitis Olecranon, Prepatellar, Trochanteric - Baker's cyst Fascia/fibroblastic Fasciitis Plantar fasciitis, Nodular fasciitis, Necrotizing fasciitis - Dupuytren's contracture - Fibromatosis Shoulder lesions Adhesive capsulitis - Rotator cuff tear - Subacromial bursitis Enthesis Enthesopathies Iliotibial band syndrome, Achilles tendinitis, Patellar tendinitis, Golfer's elbow, Tennis elbow, Metatarsalgia, Bone spur, Tendinitis Other, NEC Muscle weakness - Rheumatism - Myalgia - Neuralgia - Neuritis - Panniculitis - Fibromyalgia Osteopathies disorders of bone density and structure: Osteoporosis - Osteomalacia - continuity of bone Pseudarthrosis, Stress fracture - Monostotic fibrous dysplasia - Skeletal fluorosis - Aneurysmal bone cyst - Hyperostosis - Osteosclerosis Osteomyelitis - Avascular necrosis - Paget's disease of bone - Algoneurodystrophy - Osteolysis - Infantile cortical hyperostosis Chondropathies Juvenile osteochondrosis Legg-Calvé-Perthes syndrome, Osgood-Schlatter disease, Köhler disease, Sever's disease - Osteochondritis - Tietze's syndrome - Relapsing polychondritis See also congenital Retrieved from http://en..org/wiki/Avascular_necrosis Categories: Skeletal disorders | Diving medicine Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages БългарÑ?ки Deutsch Español This page was last modified on 12 August 2008, at 02:21
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