How is avascular necrosis (AVN) treated?

Updated: Dec 05, 2020
  • Author: Sunny B Patel, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Medical management of avascular necrosis (AVN) primarily depends on the location and severity of disease, as well as the patient's age and general health. Treatment outcomes correlate directly with the stage of the disease. No medical treatment has proven effective in preventing or arresting the disease process.

Conservative measures include limited weight bearing with crutches and pain medications. This may be beneficial and is a reasonable initial course of action if the involved segment is smaller than 15% and far from the weight-bearing region. Immobilization may be helpful in some cases (eg, AVN of the distal femur or tibia). In advanced AVN, the disease course is unaffected by activity and will eventually require surgery.

Treatment with bisphosphonates may be helpful. Although large-scale, randomized, double-blind studies have not been performed, a systematic review of eight articles involving 788 hips suggested that alendronate has short-term efficacy in reducing pain, improving articular function, slowing of bone collapse progression, and delaying the need for total hip arthroplasty in adults with AVN [21]

Iloprost, a vasoactive prostaglandin analog that is approved for inhalational treatment of pulmonary hypertension, has shown clinical and radiographic benefits in early-stage AVN when administered intravenously. Iloprost produces vasodilation and increases microcirculation, reducing bone marrow edema and relieving pain and other accompanying symptoms; it inhibits platelet aggregation and diminishes the concentration of oxygen free radicals and leukotrienes. [22, 23]

Statin therapy to prevent corticosteroid-induced AVN may be helpful. Pritchett reported a 1% incidence of AVN in 284 patients who were on statin therapy during the entire period of corticosteroid treatment (average, 7.5 y). [24] The use of high-dose corticosteroids carries a reported 3-20% incidence of AVN.

Extracorporeal shockwave therapy (ESWT) has shown beneficial effects in early AVN of the femoral head. ESWT may relieve pain and improve hip function of the hip, and induce regression of AVN. [25, 26] ESWT may be combined with alendronate therapy. [25]

Hyperbaric oxygen therapy (HBOT) has demonstrated beneficial effects in early AVN of the femoral head, leading to a reduction in self-reported pain scores, localized edema, and lesion size on radiographic imaging. [27, 28]  The efficay of HBOT may result from modulation of inflammatory markers and reactive oxygen species. [28]  HBOT has also proved useful in treatment of osteonecrosis of the jaw. [29]  

 


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