Avascular necrosis

Last updated: August 29, 2023

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Summarytoggle arrow icon

Avascular necrosis is a condition in which bone tissue becomes ischemic and begins to suffer pathologic decomposition, leading to joint dysfunction. Avascular necrosis (AVN) affects all age groups and is caused by direct trauma, medications, cellular insult, or mechanical compression, often in the context of predisposing conditions. Susceptible joints include the hip, knee, shoulder, wrist, and ankle. Disease type is typically characterized by location, often with eponymous names. Joint movement is decreased and pain is localized to the affected joint. Patients may be asymptomatic in early stages. X-ray is used for initial imaging, and MRI is required for definitive diagnosis. Management is typically surgical and may include total joint replacement in later stages.

For management specific to avascular necrosis of the hip, see “Osteonecrosis of the femoral head.”

Overviewtoggle arrow icon

Affected structures [2][3][4]

The bone tissue ischemia and necrosis characteristic of AVN most commonly affect the epiphysis of long bones.

Specific types of avascular necrosis

Overview of special types of avascular necrosis




Clinical features

Osgood-Schlatter disease

  • Age of onset: 9–14 years

  • >

Panner disease [5]

  • Age of onset: 5–10 years

  • Typically associated with repetitive strain injury due to overuse of the elbow (e.g., from pitching baseballs)

Kienbock disease

  • Age of onset: 20–30 years

  • Typically associated with repetitive impact trauma (e.g., from playing volleyball)

Legg-Calvé-Perthes disease

  • Femoral head

  • Age of onset: 4–10 years

  • >

  • Idiopathic disease

  • Mismatch between the rapid growth of the femoral epiphyses and the slower development of adequate blood supply to the area

Subchondral insufficiency fracture (Ahlback disease)

  • Age of onset: 55–70 years

  • >

  • Acute knee pain without significant trauma

Blount disease

  • Infantile age of onset: 1–3 years

  • Juvenile age of onset: 4–10 years

  • Adolescent age of onset: > 10 years

Sinding-Larsen-Johansson disease

  • Inferior pole of the patella

  • Age of onset: 10–14 years

  • More common in physically active adolescents (e.g., those who play sports)
  • Tenderness at the inferior end of the patella
  • Pain increases with exercise, kneeling, jumping, or running.

Calcaneal apophysitis (Sever disease)

  • Age of onset: 8–12 years

  • >

  • Typically due to overuse in children who play sports involving running and jumping
  • Tenderness at the base of the heel

Kohler disease

  • Age of onset: 5–10 years

  • >

Freiberg disease

  • Metatarsal head (most often II, but also III–V)

  • Age of onset: 10–18 years

  • >

  • More common in children with a long metatarsal II
  • Pain in the forefoot

Etiologytoggle arrow icon

Clinical featurestoggle arrow icon

  • Early stage: usually asymptomatic [6]
  • Advanced stage: limited movement, pain, and/or swelling in the affected joint [7][8]

Diagnosticstoggle arrow icon

  • Clinical evaluation: history of trauma, glucocorticoid use, or other risk factors for AVN
  • X-ray [2][7][9]
    • First line to rule out acute fracture; may be nondiagnostic in early stages
    • Findings include subchondral fracture, sclerosis, cystic changes, and bone collapse.
  • MRI without contrast ; [7][9]
    • Gold standard (highly sensitive) [2]
    • Findings depend on the stage and the bone affected.

Glucocorticoid use and chronic heavy drinking are the most common causes of nontraumatic avascular necrosis. [6]

Treatmenttoggle arrow icon

Treatment varies depending on location and stage of disease; refer to orthopedics for management as surgery is often required for definitive treatment. See also “Treatment of AVN of the femoral head.” [6]

Early detection and prompt treatment significantly improve prognosis. [6]

Referencestoggle arrow icon

  1. Ha AS, Chang EY, Bartolotta RJ, et al. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol. 2022; 19 (11): p.S409-S416.doi: 10.1016/j.jacr.2022.09.009 . | Open in Read by QxMD
  2. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  3. Cooper C, Steinbuch M, Stevenson R, et al. The epidemiology of osteonecrosis: findings from the GPRD and THIN databases in the UK. Osteoporos Int. 2009; 21 (4): p.569-577.doi: 10.1007/s00198-009-1003-1 . | Open in Read by QxMD
  4. Claessen FMAP, Louwerens JKG, Doornberg JN, van Dijk CN, Eygendaal D, van den Bekerom MPJ. Panner’s disease: literature review and treatment recommendations. Journal of Children's Orthopaedics. 2015; 9 (1): p.9-17.doi: 10.1007/s11832-015-0635-2 . | Open in Read by QxMD
  5. Chang C, Greenspan A, Beltran J, Gershwin ME. Osteonecrosis. Kelley and Firestein's Textbook of Rheumatology. 2017: p.1764-1787.e5.doi: 10.1016/b978-0-323-31696-5.00103-0 . | Open in Read by QxMD
  6. Afshar A, Tabrizi A. Avascular Necrosis of the Carpal Bones Other Than Kienböck Disease. J Hand Surg. 2020; 45 (2): p.148-152.doi: 10.1016/j.jhsa.2019.05.022 . | Open in Read by QxMD
  7. Larson E, Jones LC, Goodman SB, Koo K-H, Cui Q. Early-stage osteonecrosis of the femoral head: where are we and where are we going in year 2018?. Int Orthop. 2018; 42 (7): p.1723-1728.doi: 10.1007/s00264-018-3917-8 . | Open in Read by QxMD
  8. Choi HR, Steinberg ME, Y. Cheng E. Osteonecrosis of the femoral head: diagnosis and classification systems. Current Reviews in Musculoskeletal Medicine. 2015; 8 (3): p.210-220.doi: 10.1007/s12178-015-9278-7 . | Open in Read by QxMD
  9. Hua K chi, Yang X gang, Feng J tao, et al. The efficacy and safety of core decompression for the treatment of femoral head necrosis: a systematic review and meta-analysis. J Orthop Surg. 2019; 14 (1).doi: 10.1186/s13018-019-1359-7 . | Open in Read by QxMD
  10. $Contributor Disclosures - Avascular necrosis. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.

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