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OSTEONECROSIS OF THE KNEE (AVASCULAR NECROSIS)

 Osteonecrosis is a painful condition which develops when blood supply to a segment of bone femur of tibia is disrupted. Improper blood supply to the affected portion of bone dies leading to destruction of knee joint and ultimately leading to end-stage Arthritis.

DEMOGRAPHICS

Women are more commonly affected, typically three times that of males, and it is more common in those 60+ years of age.

CATEGORIES

Osteonecrosis can be divided into three categories

  • Primary; Spontaneous osteonecrosis
  • Secondary; Idiopathic necrosis (atraumatic, ischemic)
  • Post-arthroscopic

ANATOMY

The knee joint is mainly made up of femur (lower end), tibia (upper end) and patella. It is covered by articular cartilage, capsule & synovial membrane.

Osteonecrosis occurs in

  • Medial femoral condyle (inside of the knee)
  • Lateral femoral condyle (outside of knee)
  • Tibial plateau (flat top of tibia)

CAUSE

According to Osteon Theory the fat globules form inside the micro vessels of the bone causing the blockage of the vessels and reduced circulation.

Osteonecrosis can also occur due to any trauma resulting in bone contusion or stress fracture.

Other causes include;

  • Obesity
  • Sickle cell anemia
  • Thalassemia
  • Lupus
  • Kidney transplant
  • Dialysis patient
  • HIV patients
  • Fat storage diseases
  • Patients receiving steroid treatment (corticosteroids)
  • High alcohol consumption
  • Myeloproliferative disorders
  • Tobacco consumption

SICKEL CELL ANEMIA & THALASSEMIA

In thalassemia and sickle cell anemia, the avascular necrosis is a result of a change of shape of the blood cells, which cause them to clump and block off the small, micro vessels in the bone.

CORTICOSTEROIDS

Steroid-induced osteonecrosis is usually the result of prolonged high-dose steroid therapy as sometimes necessary in the treatment of lupus and other diseases, or more rarely, in patients who receive a large single dose. Steroid-induced osteonecrosis may affect multiple joints such as the hip, knee, and shoulder, and can be seen in younger patient groups.

Many diseases, such as asthma and rheumatoid arthritis, are treated with oral steroid medications

ALCOHOL INTAKE

 Overconsumption of alcohol over time can cause fatty deposits to form in the blood vessels as well as elevated cortisone levels, resulting in a decreased blood supply to the bone.

SYMPTOMS

Symptoms may include;

  • Swelling over the front and inside of the knee
  • Sensitivity to touch around the knee
  • Limited range of motion in the joint
  • Joint swelling, warmth, or redness
  • Tenderness
  • Range of passive (assisted) and active (self-directed) motion
  • Instability of the joint
  • Pain when weight is placed on the knee
  • Any signs of injury to the muscles, tendons, and ligaments surrounding the knee

TREATMENT

Treatment for osteonecrosis depends on a number of factors, including:

  • The stage of the disease
  • The amount of bone affected
  • The underlying cause of the disease

Nonsurgical

  • Physiotherapy, focusing on pain relief and therapy exercise directed at quadriceps strengthening
  • Treating the underlying metabolic cause of the disease if it exists
  • Reduced weight bearing
  • Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Activity modification

Surgical

  • Arthroscopic debridement
  • Core decompression
  • Osteochondral grafting
  • Autologous chondrocyte implantation (ACI). 
  • Osteotomy
  • Total or unicompartmental (partial) knee replacement
  • High tibial osteotomy

STAGES

Osteonecrosis develops in stages. The first symptom is typically pain on the inside of the knee. This pain may occur suddenly and be triggered by a specific activity or minor injury. As the disease progresses, it becomes more difficult to stand and put weight on the affected knee, and moving the knee joint is painful.

  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4

DIFFERENTIAL DIAGNOSIS

Differentiate from

  • Osteochondritis
  • Transient osteoporosis
  • Occult fractures

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