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osteonecrosis

Classification: - when osteonecrosis occurs at a bone end, it is known as avascular necrosis - when it occurs in the diaphysis of a bone, it is referred to as a bone infarct - eponyms have been used to designate osteonecrosis at particular sites. Etiology: 1) sickle cell disease 2) Gaucher's disease 3) systemic lupus erythematosus (SLE) - especial when treated with glucocorticoids [10] 4) pancreatitis 5) alcoholism 6) steroids: glucocorticoids, androgens - incidence of glucocorticoid-associated osteonecrosis varies among different underlying diseases [10] - systemic lupus erythematosus high risk 7) barotrauma 8) bisphosphonate use in metastatic bone disease - cases due to oral bisphosphonates less compelling [3,5] 9) denosumab 10) renal transplantation 11) radiation therapy 12) HIV-1 ? Pathology: (sites of occurrence) 1) femoral head (most common) 2) femoral condyles 3) humerus 4) talus 5) navicular 6) scaphoid 7) tibial condyle 8) lunate 9) jaw, mandible, maxilla 10) can occur in any bone 11) often bilateral Clinical manifestations: 1) acute onset of pain, often persisting at rest 2) continuous groin, thigh & buttock pain (hip osteonecrosis)* [2] - exacerbated by weight-bearing - diminished by hip abduction - pain with passive internal & external rotation [14] ; * often bilateral, check both hips [14] Radiology: 1) X-ray may suggest osteonecrosis - initially subchondral sclerosis with femoral head lucency (demineralization) progressing to joint space narrowing, acetbular changes & flattening of femoral head [14] 2) magnetic resononce imaging (MRI) preferred over scintigraphy Differential diagnosis: - hip fracture - severe pain, reduced range of motion - hip dislocation - severe pain, reduced range of motion Management: 1) core decompression (early) 2) total joint replacement (late) 3) treatment controversial

Specific

avascular osteonecrosis of femur avascular osteonecrosis; aseptic necrosis Freiberg's infarction Kienbock's disease Kohler's disease Legg-Calve-Perthes disease; pseudocoxalgia; avascular necrosis of the hip osteonecrosis of the jaw Panner's disease sequestrum

General

bone disease; osteopathia necrosis

References

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  3. Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws, American Association of Oral and Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2007 Mar;65(3):369-76. PMID: 17307580 http://www.aaoms.org/docs/position_papers/osteonecrosis.pdf - Khosla S, Burr D, Cauley J, Dempster DW, Ebeling PR, Felsenberg D, Gagel RF, Gilsanz V, Guise T, Koka S, McCauley LK, McGowan J, McKee MD, Mohla S, Pendrys DG, Raisz LG, Ruggiero SL, Shafer DM, Shum L, Silverman SL, Van Poznak CH, Watts N, Woo SB, Shane E; American Society for Bone and Mineral Research. Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2007 Oct;22(10):1479-91. PMID: 17663640 http://dx.doi.org/10.1359/JBMR.0707ONJ - Bilezikian JP. Osteonecrosis of the jaw--do bisphosphonates pose a risk? N Engl J Med. 2006 Nov 30;355(22):2278-81. PMID: 17135582 - Pazianas M, Miller P, Blumentals WA, Bernal M, Kothawala P. A review of the literature on osteonecrosis of the jaw in patients with osteoporosis treated with oral bisphosphonates: prevalence, risk factors, and clinical characteristics. Clin Ther. 2007 Aug;29(8):1548-58. Review. PMID: 17919538 - Mavrokokki T, Cheng A, Stein B, Goss A. Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia. J Oral Maxillofac Surg. 2007 Mar;65(3):415-23. PMID: 17307586 - Grant BT, Amenedo C, Freeman K, Kraut RA. Outcomes of placing dental implants in patients taking oral bisphosphonates: a review of 115 cases. J Oral Maxillofac Surg. 2008 Feb;66(2):223-30. PMID: 18201600 - Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, Satterfield S, Wallace RB, Bauer DC, Palermo L, Wehren LE, Lombardi A, Santora AC, Cummings SR; FLEX Research Group. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX): a randomized trial. JAMA. 2006 Dec 27;296(24):2927-38. PMID: 17190893 - Cartsos VM, Zhu S, Zavras AI. Bisphosphonate use and the risk of adverse jaw outcomes: a medical claims study of 714,217 people. J Am Dent Assoc. 2008 Jan;139(1):23-30. PMID: 18167381 - Odvina CV, Zerwekh JE, Rao DS, Maalouf N, Gottschalk FA, Pak CY. Severely suppressed bone turnover: a potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005 Mar;90(3):1294-301. Epub 2004 Dec 14. PMID: 15598694
  4. Prescriber's Letter 16(3): 2009 Summary of the Latest Guidelines on Bisphosphonate-Induced Osteonecrosis Detail-Document#: 250303 (subscription needed) http://www.prescribersletter.com
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  14. NEJM Knowledge+ Rheumatology
  15. National Institute of Arthritis and Muscluloskeletal and Skin Diseases (NIAMS) Osteonecrosis https://www.niams.nih.gov/health-topics/osteonecrosis