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Avascular necrosis 

Avascular necrosis
Avascular necrosis
Oxford Textbook of Rheumatology (4 ed.)

Stefan Rehart

and Martina Henniger


Avascular necrosis (AVN) represents an important disease process of the cartilage-bone complex, which can occur at any age. According to aetiology one may discriminate between rare idiopathic avascular necroses and more common forms that occur as an effect of the underlying disease or rather the therapy, the secondary avascular necroses. Pathophysiologically it is assumed that a circulatory disorder leads to an ischaemic necrosis of bone, bone marrow, and adjunct cartilage. Sites of the human skeleton with predilection to AVN are the femoral head, humeral head, femoral condyle, proximal tibia, and ossicles of the foot and hand. Clinical signs are unspecific, but in the region of the load-bearing lower extremities pain occurs usually early. Plain radiographs, MRI, and sometimes also skeletal scintigraphy are used for diagnosis and staging. Usually 4-5 stages are distinguished; there are extra classification systems for individual entities. Spontaneous healing in terms of a return to normal without further damage can be found in small, circumscribed areas, but the bigger and the nearer the joint the more unlikely this is. Depending on region, stage of disease, age of the patient, concomitant diseases and cause, several conservative and surgical therapies may be applied. Conservative treatments include exoneration and relief of the extremity, physiotherapy, and if necessary medical treatment. The need for surgical intervention becomes more likely as AVN increases in size and gets closer to the joint. Surgical therapies include core decompression, revascularizing techniques, vascular bone transplant, corrective/transposition osteotomy, arthrodesis/joint reinforcement, or joint replacement.

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