Avascular Necrosis (Osteonecrosis)

What is avascular necrosis?

AVN can cause pain and affect joint function. Pain management, physical therapy, and occupational therapy can help patients with symptoms. 

Some patients may need surgery to reduce pressure within the bone, preserve the joint, or treat damage caused by AVN. If there is severe damage or joint collapse (the joint is no longer in its typical smooth shape), your child may eventually need a joint replacement. 

Symptoms of avascular necrosis

Early stages of AVN can be hard to detect. Your child may not have pain or other symptoms until bone damage is severe. But as AVN progresses, they can have joint and bone pain. 

Signs and symptoms of AVN may include: 

• Limp or change in their gait (walking pattern) 
• Not using the affected joint 
• Reduced range of motion (amount of movement in a joint) 
• Pain that may come and go or be constant 
• Stiffness or “catching” in a joint 
• Problems walking up or down stairs 

Pain and disability usually depend on: 

• What areas of the bone are affected 
• How much AVN is present 
• How quickly damage happens 
• How well the bone repairs itself 

Pain is not always a good indicator of how severe the AVN is. Small areas of AVN can be very painful for some patients. For other patients, large areas of AVN may not be painful at all. AVN can sometimes result in the collapse of bone, and pain may suddenly worsen. 

AVN develops when there is a loss of blood supply to the bone. When blood vessels are too small or become damaged or clogged, nutrients and oxygen cannot get to the bone. When this happens, bone tissue begins to die.   

Risk factors for AVN include: 

• Certain medicines, such as corticosteroids 
• Injury or trauma to the bone or joint 
• Radiation therapy 
• Certain medical conditions, including acute lymphoblastic leukemia (ALL), sickle cell disease, diabetes, and HIV infection  

Talk with your child's care team about factors that may increase your child's risk of AVN.

Diagnosis of avascular necrosis

To diagnose AVN, your child’s care provider may: 

• Do a physical exam and review your child’s health history  
• Ask about symptoms  
• Order imaging tests such as magnetic resonance imaging (MRI) scan,  X-rays, computerized tomography (CT) scan , or bone scan  

MRI can help find AVN early, sometimes before pain or other symptoms start. Your care team will decide whether imaging is needed based on your child's symptoms and treatment history. 

Treatment of avascular necrosis

AVN management depends on pain symptoms and the degree of bone damage. The main goals of treatment for AVN are managing pain, maintaining joint function, and preventing further damage. 

Your child’s care team will create a care plan to help manage AVN. They will consider: 

• Your child’s age 
• Your child’s overall health 
• Any treatment schedule for other illnesses 
• AVN stage 
• Bones and joints affected 
• Pain severity 

Ways to help treat AVN include: 

• Physical therapy to improve range of motion 
• Occupational therapy to improve comfort and participation in daily tasks 
• Heat or cold therapy 
• Manage pain with medicine as prescribed to reduce pain and swelling 
• Adjusting activities to fit your child’s needs 

Let your care team know if your child has joint pain or limping or if symptoms get worse. 

Surgery for avascular necrosis

Some patients may need surgery to reduce pressure inside the bone and encourage healing. These options can include:

Core decompression

Core decompression removes the inner layer of bone. This may reduce pressure within the bone and create channels for new blood vessels to grow. Sometimes, a piece of healthy bone with good blood vessels is put into this area to speed up the process. This procedure works best in the earliest stages of AVN.

Bone graft

Surgery to treat AVN may include a bone graft to replace and rebuild damaged bone. This involves transplanting healthy bone tissue from another part of the body or from a donor. Artificial material may also be used. If cartilage is damaged, the graft may include both bone and cartilage. In some cases, blood vessels are transplanted along with the bone tissue. In AVN, a bone graft is most often used along with core decompression.

Osteotomy

An osteotomy is a surgery that changes the position of the bone so that the area with reduced blood flow carries less weight. This helps move pressure away from the damaged area and into a healthier part of the bone.

Joint replacement (arthroplasty) 

 Joint replacement involves removing the damaged bone and replacing it with an artificial joint.

Complementary or integrative therapies

Your child may find help from complementary approaches, such as massage, acupuncture, biofeedback, and relaxation techniques.

These approaches may help:

• Reduce pain
• Decrease muscle tension
• Improve relaxation
• Help your child cope with symptoms

Talk to your care team before trying any new therapy to make sure it is safe for your child. Complementary therapies should be used along with other medical treatments recommended by your care team.

Prognosis for avascular necrosis

Avascular necrosis can range from mild to severe. It can cause pain and affect movement and the ability to do daily activities. Damage to the bone can eventually lead to collapse of the joint surface and osteoarthritis.  

The prognosis for AVN can depend on the amount of damage and your child’s age. Younger patients often have better outcomes.  

Ways to manage avascular necrosis include: 

• Follow instructions from your child’s physical therapist if physical therapy is part of your child’s treatment plan. 
• Keep follow-up appointments, including visits with an orthopedic (bone) specialist if recommended. 
• Use mobility aids, such as crutches, wheelchairs, sliding boards, canes, and walkers, to reduce weight or pressure on the affected joint. 
• Use assistive devices and equipment, such as a sock aid, reacher, or shower chair, to make daily tasks easier and more comfortable. 
• Limit high-impact or weight-bearing activities that put extra stress on the joint, such as running, jumping, climbing, or heavy lifting. 
• Avoid high-impact activities, such as running, basketball, soccer, gymnastics, or jumping, if recommended by your child’s care team. 

Questions to ask your care team

• Is my child at risk for avascular necrosis, and what factors increase that risk?
• What signs or symptoms should I watch for?
• How can we manage pain and other symptoms?
• Is my child's AVN going to get worse, stay the same, or get better?
• Will physical therapy or mobility aids help my child?
• Is surgery recommended for my child’s AVN, and what are the benefits and risks?
• Can my child do physical activity, sports, or other activities?
• What activities should my child avoid?
• What follow-up care does my child need?

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