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Osteonecrosis (avascular necrosis of bone)

Authors
Lynne C Jones, PhD
Michael A Mont, MD
Section Editor
Don L Goldenberg, MD
Deputy Editor
Monica Ramirez Curtis, MD, MPH

INTRODUCTION

Osteonecrosis, also known as aseptic necrosis, avascular necrosis (AVN), atraumatic necrosis, and ischemic necrosis, is a pathologic process that has been associated with numerous conditions and therapeutic interventions. In patients in whom there is direct damage to bone vasculature (eg, femoral neck fracture) or direct injury of bone or marrow elements (eg, radiation injury, dysbarism, or caisson disease), the cause is clearly identifiable. However, in many patients, the mechanisms by which this disorder develops are not fully understood.

Compromise of the bone vasculature, leading to the death of bone and marrow cells (bone marrow infarction), and ultimate mechanical failure appear to be common to most proposed etiologies. The process is most often progressive, resulting in joint destruction within a few months to two years in the majority of patients [1,2].

EPIDEMIOLOGY

The exact prevalence of osteonecrosis is unknown. In the United States, there are an estimated 20,000 to 30,000 patients newly diagnosed each year [3], with even larger numbers worldwide, and it is the underlying diagnosis in approximately 10 percent of all total hip replacements (THR) in the United States [4]. The male-to-female ratio varies depending upon the associated comorbidities. For example, alcohol-associated osteonecrosis is more common in men, while osteonecrosis associated with systemic lupus erythematosus (SLE) is more common in women. The mean age at diagnosis also depends upon comorbidities, but is typically less than 50 years.

ETIOLOGY AND PATHOGENESIS

A variety of traumatic and atraumatic factors contribute to the etiology of osteonecrosis (table 1). A definitive etiologic role has been established for some of these factors, based upon longitudinal cohort studies or meta-analyses, but not for the majority, which are considered associated risk factors [5]. Use of glucocorticoids and excessive alcohol intake are associated with more than 80 percent of atraumatic cases [6].

The pathogenesis of osteonecrosis is an area of controversy. Most experts believe that it is the result of the combined effects of genetic predisposition, metabolic factors, and local factors affecting blood supply, such as vascular damage, increased intraosseous pressure, and mechanical stresses [4,6,7]. The early stages of the natural history are unclear, as these stages are largely asymptomatic and the patient does not present until later. It is generally agreed that there is an interruption of the blood circulation within the bone; subsequently, the adjacent area becomes hyperemic, resulting in demineralization, in trabecular thinning, and, later, in collapse.

                                               

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Literature review current through: Nov 2016. | This topic last updated: Tue Nov 08 00:00:00 GMT+00:00 2016.
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References
Top
  1. Rajpura A, Wright AC, Board TN. Medical management of osteonecrosis of the hip: a review. Hip Int 2011; 21:385.
  2. Mont MA, Jones LC, Hungerford DS. Nontraumatic osteonecrosis of the femoral head: ten years later. J Bone Joint Surg Am 2006; 88:1117.
  3. Moya-Angeler J, Gianakos AL, Villa JC, et al. Current concepts on osteonecrosis of the femoral head. World J Orthop 2015; 6:590.
  4. Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis). N Engl J Med 1992; 326:1473.
  5. Shah KN, Racine J, Jones LC, Aaron RK. Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med 2015; 8:201.
  6. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 1995; 77:459.
  7. Chang CC, Greenspan A, Gershwin ME. Osteonecrosis: current perspectives on pathogenesis and treatment. Semin Arthritis Rheum 1993; 23:47.
  8. Shigemura T, Nakamura J, Kishida S, et al. Incidence of osteonecrosis associated with corticosteroid therapy among different underlying diseases: prospective MRI study. Rheumatology (Oxford) 2011; 50:2023.
  9. Gladman DD, Chaudhry-Ahluwalia V, Ibañez D, et al. Outcomes of symptomatic osteonecrosis in 95 patients with systemic lupus erythematosus. J Rheumatol 2001; 28:2226.
  10. Kamen DL, Alele JD. Skeletal manifestations of systemic autoimmune diseases. Curr Opin Endocrinol Diabetes Obes 2010; 17:540.
  11. Jones JP Jr. Fat embolism and osteonecrosis. Orthop Clin North Am 1985; 16:595.
  12. Solomon L. Idiopathic necrosis of the femoral head: pathogenesis and treatment. Can J Surg 1981; 24:573.
  13. Nishimura T, Matsumoto T, Nishino M, Tomita K. Histopathologic study of veins in steroid treated rabbits. Clin Orthop Relat Res 1997; :37.
  14. Vreden SG, Hermus AR, van Liessum PA, et al. Aseptic bone necrosis in patients on glucocorticoid replacement therapy. Neth J Med 1991; 39:153.
  15. Dilisio MF. Osteonecrosis following short-term, low-dose oral corticosteroids: a population-based study of 24 million patients. Orthopedics 2014; 37:e631.
  16. Zizic TM, Marcoux C, Hungerford DS, et al. Corticosteroid therapy associated with ischemic necrosis of bone in systemic lupus erythematosus. Am J Med 1985; 79:596.
  17. Abeles M, Urman JD, Rothfield NF. Aseptic necrosis of bone in systemic lupus erythematosus. Relationship to corticosteroid therapy. Arch Intern Med 1978; 138:750.
  18. Matsuo K, Hirohata T, Sugioka Y, et al. Influence of alcohol intake, cigarette smoking, and occupational status on idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res 1988; :115.
  19. Fukushima W, Fujioka M, Kubo T, et al. Nationwide epidemiologic survey of idiopathic osteonecrosis of the femoral head. Clin Orthop Relat Res 2010; 468:2715.
  20. Shigemura T, Nakamura J, Kishida S, et al. The incidence of alcohol-associated osteonecrosis of the knee is lower than the incidence of steroid-associated osteonecrosis of the knee: an MRI study. Rheumatology (Oxford) 2012; 51:701.
  21. Dimant J, Ginzler EM, Diamond HS, et al. Computer analysis of factors influencing the appearance of aseptic necrosis in patients with SLE. J Rheumatol 1978; 5:136.
  22. Sugano N, Ohzono K, Masuhara K, et al. Prognostication of osteonecrosis of the femoral head in patients with systemic lupus erythematosus by magnetic resonance imaging. Clin Orthop Relat Res 1994; :190.
  23. Aranow C, Zelicof S, Leslie D, et al. Clinically occult avascular necrosis of the hip in systemic lupus erythematosus. J Rheumatol 1997; 24:2318.
  24. Mont MA, Glueck CJ, Pacheco IH, et al. Risk factors for osteonecrosis in systemic lupus erythematosus. J Rheumatol 1997; 24:654.
  25. Asherson RA, Lioté F, Page B, et al. Avascular necrosis of bone and antiphospholipid antibodies in systemic lupus erythematosus. J Rheumatol 1993; 20:284.
  26. Mok MY, Farewell VT, Isenberg DA. Risk factors for avascular necrosis of bone in patients with systemic lupus erythematosus: is there a role for antiphospholipid antibodies? Ann Rheum Dis 2000; 59:462.
  27. Jones LC, Mont MA, Le TB, et al. Procoagulants and osteonecrosis. J Rheumatol 2003; 30:783.
  28. Gómez-Puerta JA, Peris P, Reverter JC, et al. High prevalence of prothrombotic abnormalities in multifocal osteonecrosis: description of a series and review of the literature. Medicine (Baltimore) 2013; 92:295.
  29. Vasoo S, Sangle S, Zain M, et al. Orthopaedic manifestations of the antiphospholipid (Hughes) syndrome. Lupus 2005; 14:339.
  30. PHEMISTER DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg Am 1949; 31A:55.
  31. Slobogean GP, Sprague SA, Scott T, Bhandari M. Complications following young femoral neck fractures. Injury 2015; 46:484.
  32. Goldblatt J, Sacks S, Beighton P. The orthopedic aspects of Gaucher disease. Clin Orthop Relat Res 1978; :208.
  33. Miyanishi K, Kamo Y, Ihara H, et al. Risk factors for dysbaric osteonecrosis. Rheumatology (Oxford) 2006; 45:855.
  34. Kunstreich M, Kummer S, Laws HJ, et al. Osteonecrosis in children with acute lymphoblastic leukemia. Haematologica 2016; 101:1295.
  35. Heneghan MB, Rheingold SR, Li Y, et al. Treatment of Osteonecrosis in Children and Adolescents With Acute Lymphoblastic Leukemia. Clin Lymphoma Myeloma Leuk 2016; 16:223.
  36. Niinimäki R, Hansen LM, Niinimäki T, et al. Incidence of Severe Osteonecrosis Requiring Total Joint Arthroplasty in Children and Young Adults Treated for Leukemia or Lymphoma: A Nationwide, Register-Based Study in Finland and Denmark. J Adolesc Young Adult Oncol 2013; 2:138.
  37. Inaba H, Pui CH. Glucocorticoid use in acute lymphoblastic leukaemia. Lancet Oncol 2010; 11:1096.
  38. Ibels LS, Alfrey AC, Huffer WE, Weil R 3rd. Aseptic necrosis of bone following renal transplantation: experience in 194 transplant recipients and review of the literature. Medicine (Baltimore) 1978; 57:25.
  39. Metselaar HJ, van Steenberge EJ, Bijnen AB, et al. Incidence of osteonecrosis after renal transplantation. Acta Orthop Scand 1985; 56:413.
  40. Lopez-Ben R, Mikuls TR, Moore DS, et al. Incidence of hip osteonecrosis among renal transplantation recipients: a prospective study. Clin Radiol 2004; 59:431.
  41. Nehme D, Rondeau E, Paillard F, et al. Aseptic necrosis of bone following renal transplantation: relation with hyperparathyroidism. Nephrol Dial Transplant 1989; 4:123.
  42. Tauchmanovà L, De Rosa G, Serio B, et al. Avascular necrosis in long-term survivors after allogeneic or autologous stem cell transplantation: a single center experience and a review. Cancer 2003; 97:2453.
  43. Schulte CM, Beelen DW. Avascular osteonecrosis after allogeneic hematopoietic stem-cell transplantation: diagnosis and gender matter. Transplantation 2004; 78:1055.
  44. Zalavras CG, Vartholomatos G, Dokou E, Malizos KN. Factor V Leiden and prothrombin gene mutations in femoral head osteonecrosis. Thromb Haemost 2002; 87:1079.
  45. Arruda VR, Belangero WD, Ozelo MC, et al. Inherited risk factors for thrombophilia among children with Legg-Calvé-Perthes disease. J Pediatr Orthop 1999; 19:84.
  46. Björkman A, Svensson PJ, Hillarp A, et al. Factor V leiden and prothrombin gene mutation: risk factors for osteonecrosis of the femoral head in adults. Clin Orthop Relat Res 2004; :168.
  47. Björkman A, Burtscher IM, Svensson PJ, et al. Factor V Leiden and the prothrombin 20210A gene mutation and osteonecrosis of the knee. Arch Orthop Trauma Surg 2005; 125:51.
  48. Miller KD, Masur H, Jones EC, et al. High prevalence of osteonecrosis of the femoral head in HIV-infected adults. Ann Intern Med 2002; 137:17.
  49. Martin K, Lawson-Ayayi S, Miremont-Salamé G, et al. Symptomatic bone disorders in HIV-infected patients: incidence in the Aquitaine cohort (1999-2002). HIV Med 2004; 5:421.
  50. Liu YF, Chen WM, Lin YF, et al. Type II collagen gene variants and inherited osteonecrosis of the femoral head. N Engl J Med 2005; 352:2294.
  51. Su P, Li R, Liu S, et al. Age at onset-dependent presentations of premature hip osteoarthritis, avascular necrosis of the femoral head, or Legg-Calvé-Perthes disease in a single family, consequent upon a p.Gly1170Ser mutation of COL2A1. Arthritis Rheum 2008; 58:1701.
  52. Miyamoto Y, Matsuda T, Kitoh H, et al. A recurrent mutation in type II collagen gene causes Legg-Calvé-Perthes disease in a Japanese family. Hum Genet 2007; 121:625.
  53. Zizic TM, Marcoux C, Hungerford DS, Stevens MB. The early diagnosis of ischemic necrosis of bone. Arthritis Rheum 1986; 29:1177.
  54. LaPorte DM, Mont MA, Mohan V, et al. Multifocal osteonecrosis. J Rheumatol 1998; 25:1968.
  55. Mont MA, Zywiel MG, Marker DR, et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am 2010; 92:2165.
  56. Mazieres B. Osteonecrosis. In: Rheumatology, Hochberg MC, Silman AJ, Smolen JS, et al. (Eds), Mosby, London 2003. p.1877.
  57. Dumont M, Danais S, Taillefer R. "Doughnut" sign in avascular necrosis of the bone. Clin Nucl Med 1984; 9:44.
  58. Mont MA, Ulrich SD, Seyler TM, et al. Bone scanning of limited value for diagnosis of symptomatic oligofocal and multifocal osteonecrosis. J Rheumatol 2008; 35:1629.
  59. Markisz JA, Knowles RJ, Altchek DW, et al. Segmental patterns of avascular necrosis of the femoral heads: early detection with MR imaging. Radiology 1987; 162:717.
  60. Guerra JJ, Steinberg ME. Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995; 77:616.
  61. Nagasawa K, Tsukamoto H, Tada Y, et al. Imaging study on the mode of development and changes in avascular necrosis of the femoral head in systemic lupus erythematosus: long-term observations. Br J Rheumatol 1994; 33:343.
  62. Hungerford DS, Jones LC. Asymptomatic osteonecrosis: should it be treated? Clin Orthop Relat Res 2004; :124.
  63. Ha YC, Jung WH, Kim JR, et al. Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am 2006; 88 Suppl 3:35.
  64. Etienne G, Mont MA, Ragland PS. The diagnosis and treatment of nontraumatic osteonecrosis of the femoral head. Instr Course Lect 2004; 53:67.
  65. Amanatullah DF, Strauss EJ, Di Cesare PE. Current management options for osteonecrosis of the femoral head: part 1, diagnosis and nonoperative management. Am J Orthop (Belle Mead NJ) 2011; 40:E186.
  66. Davies M, Cassar-Pullicino VN, Darby AJ. Subchondral insufficiency fractures of the femoral head. Eur Radiol 2004; 14:201.
  67. Yamamoto T, Bullough PG. The role of subchondral insufficiency fracture in rapid destruction of the hip joint: a preliminary report. Arthritis Rheum 2000; 43:2423.
  68. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br 1985; 67:3.
  69. Berend KR, Gunneson EE, Urbaniak JR. Free vascularized fibular grafting for the treatment of postcollapse osteonecrosis of the femoral head. J Bone Joint Surg Am 2003; 85-A:987.
  70. Ohzono K, Saito M, Sugano N, et al. The fate of nontraumatic avascular necrosis of the femoral head. A radiologic classification to formulate prognosis. Clin Orthop Relat Res 1992; :73.
  71. Nakamura J, Kishida S, Harada Y, et al. Inter-observer and intra-observer reliabilities of the Japanese Ministry of Health, Labor and Welfare type classification system for osteonecrosis of the femoral head. Mod Rheumatol 2011; 21:488.
  72. Steinberg ME, Brighton CT, Corces A, et al. Osteonecrosis of the femoral head. Results of core decompression and grafting with and without electrical stimulation. Clin Orthop Relat Res 1989; :199.
  73. Marcus ND, Enneking WF, Massam RA. The silent hip in idiopathic aseptic necrosis. Treatment by bone-grafting. J Bone Joint Surg Am 1973; 55:1351.
  74. Steinberg ME, Bands RE, Parry S, et al. Does lesion size affect the outcome in avascular necrosis? Clin Orthop Relat Res 1999; :262.
  75. Stulberg BN, Singer R, Goldner J, Stulberg J. Uncemented total hip arthroplasty in osteonecrosis: a 2- to 10-year evaluation. Clin Orthop Relat Res 1997; :116.
  76. ARCO staging system for osteonecrosis. http://arco-intl.org/Newsletters/Gardeniers-1993-5-2/Gardeniers-1993.htm (Accessed on December 05, 2012).
  77. Gardeniers JWM, Gosling-Gardeniers AC, Rijnen WHC. The ARCO staging system: Generation and evolving since 1991. In: Osteonecrosis, Koo KH, Mont MA, Jones LC (Eds), Springer, New York 2014. p.215.
  78. Mont MA, Carbone JJ, Fairbank AC. Core decompression versus nonoperative management for osteonecrosis of the hip. Clin Orthop Relat Res 1996; :169.
  79. Mont MA, Baumgarten KM, Rifai A, et al. Atraumatic osteonecrosis of the knee. J Bone Joint Surg Am 2000; 82:1279.
  80. Musso ES, Mitchell SN, Schink-Ascani M, Bassett CA. Results of conservative management of osteonecrosis of the femoral head. A retrospective review. Clin Orthop Relat Res 1986; :209.
  81. Gupta S, Gupta H, Mandhyan D, Srivastava S. Bisphophonates related osteonecrosis of the jaw. Natl J Maxillofac Surg 2013; 4:151.
  82. Agarwala S, Shah S, Joshi VR. The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years. J Bone Joint Surg Br 2009; 91:1013.
  83. Lai KA, Shen WJ, Yang CY, et al. The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Joint Surg Am 2005; 87:2155.
  84. Chen CH, Chang JK, Lai KA, et al. Alendronate in the prevention of collapse of the femoral head in nontraumatic osteonecrosis: a two-year multicenter, prospective, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2012; 64:1572.
  85. Wang CJ, Wang FS, Yang KD, et al. Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate. Arch Orthop Trauma Surg 2008; 128:901.
  86. Yuan HF, Guo CA, Yan ZQ. The use of bisphosphonate in the treatment of osteonecrosis of the femoral head: a meta-analysis of randomized control trials. Osteoporos Int 2016; 27:295.
  87. Jäger M, Zilkens C, Bittersohl B, et al. Efficiency of iloprost treatment for osseous malperfusion. Int Orthop 2011; 35:761.
  88. Claßen T, Becker A, Landgraeber S, et al. Long-term Clinical Results after Iloprost Treatment for Bone Marrow Edema and Avascular Necrosis. Orthop Rev (Pavia) 2016; 8:6150.
  89. Pritchett JW. Statin therapy decreases the risk of osteonecrosis in patients receiving steroids. Clin Orthop Relat Res 2001; :173.
  90. Nagasawa K, Tada Y, Koarada S, et al. Prevention of steroid-induced osteonecrosis of femoral head in systemic lupus erythematosus by anti-coagulant. Lupus 2006; 15:354.
  91. Glueck CJ, Freiberg RA, Sieve L, Wang P. Enoxaparin prevents progression of stages I and II osteonecrosis of the hip. Clin Orthop Relat Res 2005; :164.
  92. Wang CJ, Wang FS, Huang CC, et al. Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting. J Bone Joint Surg Am 2005; 87:2380.
  93. Wang CJ, Huang CC, Yip HK, Yang YJ. Dosage effects of extracorporeal shockwave therapy in early hip necrosis. Int J Surg 2016; 35:179.
  94. Massari L, Fini M, Cadossi R, et al. Biophysical stimulation with pulsed electromagnetic fields in osteonecrosis of the femoral head. J Bone Joint Surg Am 2006; 88 Suppl 3:56.
  95. Camporesi EM, Vezzani G, Bosco G, et al. Hyperbaric oxygen therapy in femoral head necrosis. J Arthroplasty 2010; 25:118.
  96. Koren L, Ginesin E, Melamed Y, et al. Hyperbaric oxygen for stage I and II femoral head osteonecrosis. Orthopedics 2015; 38:e200.
  97. Stulberg BN, Davis AW, Bauer TW, et al. Osteonecrosis of the femoral head. A prospective randomized treatment protocol. Clin Orthop Relat Res 1991; :140.
  98. Koo KH, Kim R, Ko GH, et al. Preventing collapse in early osteonecrosis of the femoral head. A randomised clinical trial of core decompression. J Bone Joint Surg Br 1995; 77:870.
  99. Urbaniak JR, Coogan PG, Gunneson EB, Nunley JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting. A long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am 1995; 77:681.
  100. Yoo MC, Kim KI, Hahn CS, Parvizi J. Long-term followup of vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res 2008; 466:1133.
  101. Keizer SB, Kock NB, Dijkstra PD, et al. Treatment of avascular necrosis of the hip by a non-vascularised cortical graft. J Bone Joint Surg Br 2006; 88:460.
  102. Seyler TM, Marker DR, Ulrich SD, et al. Nonvascularized bone grafting defers joint arthroplasty in hip osteonecrosis. Clin Orthop Relat Res 2008; 466:1125.
  103. Yang S, Wu X, Xu W, et al. Structural augmentation with biomaterial-loaded allograft threaded cage for the treatment of femoral head osteonecrosis. J Arthroplasty 2010; 25:1223.
  104. Gangji V, Hauzeur JP, Matos C, et al. Treatment of osteonecrosis of the femoral head with implantation of autologous bone-marrow cells. A pilot study. J Bone Joint Surg Am 2004; 86-A:1153.
  105. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res 2002; :14.
  106. Hernigou P, Trousselier M, Roubineau F, et al. Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress. Clin Orthop Surg 2016; 8:1.
  107. Pepke W, Kasten P, Beckmann NA, et al. Core Decompression and Autologous Bone Marrow Concentrate for Treatment of Femoral Head Osteonecrosis: A Randomized Prospective Study. Orthop Rev (Pavia) 2016; 8:6162.
  108. Yuan HF, Zhang J, Guo CA, Yan ZQ. Clinical outcomes of osteonecrosis of the femoral head after autologous bone marrow stem cell implantation: a meta-analysis of seven case-control studies. Clinics (Sao Paulo) 2016; 71:110.
  109. Sugioka Y, Katsuki I, Hotokebuchi T. Transtrochanteric rotational osteotomy of the femoral head for the treatment of osteonecrosis. Follow-up statistics. Clin Orthop Relat Res 1982; :115.
  110. Simank HG, Brocai DR, Brill C, Lukoschek M. Comparison of results of core decompression and intertrochanteric osteotomy for nontraumatic osteonecrosis of the femoral head using Cox regression and survivorship analysis. J Arthroplasty 2001; 16:790.
  111. Saito S, Saito M, Nishina T, et al. Long-term results of total hip arthroplasty for osteonecrosis of the femoral head. A comparison with osteoarthritis. Clin Orthop Relat Res 1989; :198.
  112. Ritter MA, Meding JB. A comparison of osteonecrosis and osteoarthritis patients following total hip arthroplasty. A long-term follow-up study. Clin Orthop Relat Res 1986; :139.
  113. Johannson HR, Zywiel MG, Marker DR, et al. Osteonecrosis is not a predictor of poor outcomes in primary total hip arthroplasty: a systematic literature review. Int Orthop 2011; 35:465.
  114. Hungerford MW, Hungerford DS, Jones LC. Outcome of uncemented primary femoral stems for treatment of femoral head osteonecrosis. Orthop Clin North Am 2009; 40:283.
  115. Kim YH, Oh SH, Kim JS, Koo KH. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head. J Bone Joint Surg Am 2003; 85-A:675.
  116. Solarino G, Piazzolla A, Notarnicola A, et al. Long-term results of 32-mm alumina-on-alumina THA for avascular necrosis of the femoral head. J Orthop Traumatol 2012; 13:21.
  117. Kim YH, Kim JS, Park JW, Joo JH. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head: a concise follow-up, at an average of seventeen years, of a previous report. J Bone Joint Surg Am 2011; 93:1806.
  118. Myers TG, Cui Q, Kuskowski M, et al. Outcomes of total and unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee. J Bone Joint Surg Am 2006; 88 Suppl 3:76.
  119. Mont MA, Payman RK, Laporte DM, et al. Atraumatic osteonecrosis of the humeral head. J Rheumatol 2000; 27:1766.
  120. Styles LA, Vichinsky EP. Core decompression in avascular necrosis of the hip in sickle-cell disease. Am J Hematol 1996; 52:103.
  121. Hernigou P, Bachir D, Galacteros F. Avascular necrosis of the femoral head in sickle-cell disease. Treatment of collapse by the injection of acrylic cement. J Bone Joint Surg Br 1993; 75:875.
  122. Hsu JE, Wihbey T, Shah RP, et al. Prophylactic decompression and bone grafting for small asymptomatic osteonecrotic lesions of the femoral head. Hip Int 2011; 21:672.
  123. Nam KW, Kim YL, Yoo JJ, et al. Fate of untreated asymptomatic osteonecrosis of the femoral head. J Bone Joint Surg Am 2008; 90:477.
  124. Mont MA, Marker DR, Zywiel MG, Carrino JA. Osteonecrosis of the knee and related conditions. J Am Acad Orthop Surg 2011; 19:482.
  125. Mont MA, Tomek IM, Hungerford DS. Core decompression for avascular necrosis of the distal femur: long term followup. Clin Orthop Relat Res 1997; :124.
  126. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; :13.
  127. Marulanda G, Seyler TM, Sheikh NH, Mont MA. Percutaneous drilling for the treatment of secondary osteonecrosis of the knee. J Bone Joint Surg Br 2006; 88:740.
  128. Rijnen WH, Luttjeboer JS, Schreurs BW, Gardeniers JW. Bone impaction grafting for corticosteroid-associated osteonecrosis of the knee. J Bone Joint Surg Am 2006; 88 Suppl 3:62.
  129. Lee K, Goodman SB. Cell therapy for secondary osteonecrosis of the femoral condyles using the Cellect DBM System: a preliminary report. J Arthroplasty 2009; 24:43.
  130. Cruess RL. Steroid-induced avascular necrosis of the head of the humerus. Natural history and management. J Bone Joint Surg Br 1976; 58:313.