Diseases

Aseptic Bone Necrosis – Causes, Symptoms & Treatment

Aseptic Knochennecrosis

Necrotic degradation processes in human bone substance that cannot be traced back to an infection but to a vascular infarction are referred to as aseptic bone necrosis . Depending on the location and form of the aseptic bone necrosis, both sexes can be affected with different frequency.

What is aseptic bone necrosis?

The term aseptic bone necrosis covers necrotizing diseases of the bone system which, in the absence of an infection (aseptic) can be attributed to insufficient blood flow ( ischemia ) in the affected bone areas.

The occlusion of the supplying vessel (vascular infarction) causes a lack of supply of oxygen, nutrients and minerals to the affected bone, as a result of which there is a gradual degradation up to a possible functional failure of the bone area.

In principle, all bones of the human skeletal system can be affected on one or both sides by aseptic bone necrosis. Characteristically, aseptic bone necrosis manifests itself in the form of sudden or gradually increasing pain in the area of ​​the necrotic bone segment, which intensifies under stress and can radiate into neighboring skeletal sections.

In addition, restricted movement of the affected area, especially in the later course of the disease, is possible in the case of aseptic bone necrosis.

causes

Aseptic bone necrosis is usually due to an occlusion of the blood vessel supplying the necrotic bone area. The exact etiology of this occlusion has not yet been clearly elucidated.

In this context, constitutional factors, recurrent or iterative (repeating) microtraumas and locally restricted circulatory disorders are discussed .

In addition, there are therapies with high-dose and systemically applied immunosuppressants (including sirolimus, glucocorticoids) or bisphosphonates (exclusively in the case of aseptic bone necrosis involving the lower jaw), radiation and chemotherapeutic therapies (especially in the case of lymphomas, leukemia ), high pressure or activities in compressed air (diving or compressed air environments such as in mining or tunnelling), chronic nicotine and/or alcohol abuse , sickle cell anemia, Gaucher disease , HbSC disease, endocrine disorders, hyperlipidemia, metabolic disorders ( diabetes mellitus ), vascular and blood coagulation diseases as well as the systemic form of theLupus erythematosus (SLE) as an identified risk factor for aseptic bone necrosis, although the exact causal relationship is not known in every case.

Symptoms, Ailments & Signs

Aseptic bone necrosis shows an insidious course of the disease, which means that symptoms initially go unnoticed, but then manifest themselves more and more strongly. The damage and degradation of the bone and often also the surrounding tissue causes problems in the directly affected area. The patient experiences increasing pain, which is usually described as dull and persistent.

However, stabbing pain can also occur when the affected region is stressed. If the surrounding tissue is affected, it feels numb and can be painful. Damaged muscles lose their strength and resistance. The entire affected area feels numb and can no longer bear weight.

In the advanced stage of the disease, bone fractures usually occur. These are extremely painful and usually occur suddenly under stress. The bone material loses stability. Comminuted and spiral fractures are also diagnosed very frequently. Unlike healthy bone, which is usually fractured by an event, bone affected by bone necrosis is inherently unstable and breaks into many pieces or fibers.

Bone necrosis cannot be reliably diagnosed by the patient himself, but is usually detected during a medical examination or when a fracture has already occurred. If left untreated, it can lead to blood poisoning and death.

Diagnosis & History

In addition to a physical examination, functional tests of the affected bone and joint sections provide the first indications of aseptic bone necrosis. Imaging diagnostic methods such as X-rays or sonography enable statements to be made about possible pathological bone changes such as bone remodeling or destruction (especially in the later course of the disease).

Within the scope of a magnetic resonance or computer tomography, early characteristic remodeling activities of the affected bone segments as well as the extent and form of the bone necrosis can be precisely determined. In the differential diagnosis, aseptic bone necrosis must be distinguished from septic necrosis, tumors and neoplasms of the bone and skeletal system, as well as from bone cysts, osteomyelitis ( bone marrow inflammation ) or osteitis ( bone inflammation ).

In the case of aseptic bone necrosis, the course and prognosis depend on the severity and extent of the bone vessel infarction and the resulting damage to the affected joint or bone section and the time of diagnosis or the start of therapy. In some cases, spontaneous healing of aseptic bone necrosis can be observed.

When should you go to the doctor?

In the event of sudden bone pain and restricted movement, a doctor must be consulted immediately. As part of the medical diagnosis, it can then be determined whether aseptic bone necrosis is present.

If it is another disease of the bones or the musculoskeletal system, the doctor will refer the person concerned to the appropriate specialist. If aseptic bone necrosis is actually present, surgical measures must usually be initiated immediately.

People who suffer from sickle cell anemia, Gaucher disease, metabolic disorders, vascular and blood coagulation diseases or HbSC disease are particularly at risk of bone necrosis. Patients undergoing chemotherapy or radiation therapy are also increasingly suffering from aseptic bone necrosis. These risk groups should consult a doctor if they have unusual symptoms and have the cause clarified.

As part of the surgical treatment, the patient often receives an artificial hip replacement or a transplant with bone chips. If there are any complaints during the aftercare, this must be reported to the responsible doctor immediately. There may be inflammation or the body is rejecting the hip replacement. In any case, with aseptic bone necrosis, it is necessary to consult the doctor regularly in order to avoid complications.

complications

Aseptic bone necrosis, as a general term, includes the breakdown of one or more bones in the body. The symptom is not caused by an infection, but is caused by a vascular infarction. This no longer supplies the bone structure and the surrounding tissue with sufficient blood. As a result, the bone structure is destroyed.

Men and women are equally affected by aseptic bone necrosis. However, there are risk groups. These include patients with metabolic diseases, sickle cell anemia, divers, mountain farmers and alcoholics as well as those taking immunosuppressive drugs or undergoing radiation or chemotherapy. Ignoring the early signs of bone pain, which occurs at rest as well as with exertion, makes the symptom worse.

Complications include restricted movement, chronic permanent pain, rapid muscle wasting of the affected bone, loss of function in the arm or leg if the shoulder or hip is affected. In some cases, the affected area can be so painful that it also affects adjacent sections of the skeleton. The symptom is identified using imaging techniques. Since every ischemia of the bone is different, the therapeutic measures vary.

In general, aseptic bone necrosis can be successfully treated if it is detected early. In the case of a particularly acute infestation, medication and radiation or chemotherapy are used. If bones or joints are completely destroyed, surgical procedures for an artificial replacement are necessary. The latter methods can cause complications in terms of tolerability for those affected.

Treatment & Therapy

In the case of aseptic bone necrosis, the therapeutic measures correlate to a large extent with the stage and extent of the disease and the general health of the person specifically affected.

For mild forms, treatment aims at mechanical relief of the necrotic bone segment with forearm braces or orthoses , immobilization and physical therapy with possible traction treatment. At the beginning of the disease, hyperbaric oxygenation (oxygen therapy) can be used concomitantly or as a monotherapy, which has been shown to be particularly efficient in painful bone marrow edema.

In more severe forms of aseptic bone necrosis, surgical measures such as femoral head relief drilling (Pridie drilling), medullary chamber decompression, conversion osteotomies such as varus osteotomy in Perthes disease (femoral head necrosis) and transplantations with bone chips are indicated. For example, as part of the Pridie drilling, the defective section of cartilage is drilled into to allow blood vessels to grow and stimulate tissue regeneration accordingly.

Marrow cavity decompression or core decompression (in the case of femur or femoral head necrosis) is aimed at reducing the intraosseous (within the bone) pressure and slowing down the progression of the necrotizing processes.

In the case of a punch cylinder reversal plastic, the necrotic areas are also removed and the body’s own spongiosa (spongy bone trabecular system) is introduced, while the necrotic focus is rotated out of the main stress zone with an intertrochanteric osteotomy, the intraosseous pressure is minimized and vascularization (formation of small blood vessels) is stimulated.

If advanced bone destruction can be detected, endoprosthetics (artificial joint replacement) are usually indicated to treat the aseptic bone necrosis.

Outlook & Forecast

The prognosis of aseptic bone necrosis depends on the existing bone vessel infarction. Its expression and influence on the supply of the bones and joints is decisive for the prospect of healing.

Without medical care, the patient suffers pain and restricted mobility. Since the organism does not heal itself, the symptoms either remain unmediated or continuously increase in intensity. The prospect of a cure in this way is extremely unlikely.

With medical care of the vessels, the probability of a positive prognosis increases significantly. If there are other previous illnesses, the chances of recovery decrease again. In patients without additional diseases and with a stable immune system, recovery occurs within a few weeks or months.

A complete freedom from symptoms is possible, but not always the case. Corrections are made during surgery. In severe cases, transplants or replacement of the damaged joints are required. The healing path is delayed because the organism has to come to terms with the new circumstances and the patient learns a new body awareness.

Following the inpatient stay, targeted training and exercises are taught as part of the rehabilitation therapy . In these, the movement sequences are optimized and adapted to the changed possibilities.

prevention

Since the exact causes of aseptic bone necrosis have not yet been clearly clarified, the disease cannot be prevented. However, chronic alcohol abuse, for example, which is considered a possible risk factor, should be treated accordingly. In addition, the risk of radiation therapy-related aseptic bone necrosis (osteoradionecrosis) can be reduced by the prophylactic administration of anti- inflammatory drugs.

aftercare

Patients must regularly consult an orthopedist as part of the follow-up care. The doctor will carry out various routine examinations such as an ultrasound examination and, if necessary, conduct further discussions that should allow an assessment of the condition. These regular follow-up checks determine whether the necrosis has receded or spread.

Based on this, further measures are then initiated, through which the healing process is further optimized. Aseptic bone necrosis progresses progressively and therefore requires long-term follow-up care. Patients must initially see their doctor monthly or every two weeks. If the trend is positive, the intervals can be extended.

However, patients must have screening at least every four to six months, regardless of the course of previous aseptic bone necrosis. If complications have been identified, further investigations are necessary in any case. Follow-up also includes a mobility check.

A physiotherapist will examine the patient and, if necessary, give tips for further treatment. Which measures are necessary in detail as part of the aftercare always depends on the individual course of the disease. Patients should contact their doctor during treatment and discuss further steps with them.

You can do that yourself

In addition to medical therapy, patients with aseptic bone necrosis can themselves contribute to improving the disease and their well-being. Adhering to rest periods and avoiding stress are beneficial to therapy . A mechanical relief by orthoses or crutches can be useful, as well as not taking cortisone-containing medication. The attending doctor puts together the ideal medication.

Physiotherapy and massage help maintain and improve joint mobility. Exercises and acupressure techniques can also be learned in physiotherapy, which can then be used at home. It is advisable to support medical therapy with moderate exercise. The blood flow should be gently increased. Yoga and moderate exertion such as cycling on the bicycle ergometer, swimming or walking are good supplements. The movement has a positive effect on mood as well as on metabolism and circulation.

A balanced diet is also part of the therapy for aseptic bone necrosis. The focus here is on controlling or reducing blood lipid levels and weight. The Mediterranean diet with a high proportion of omega-3 fatty acids , little red meat and lots of fish is ideal. Fresh vegetables and fruit should not be missing. Avoiding alcohol and nicotine , on the other hand, promotes the success of the therapy. Likewise, good self-monitoring and early visit to the doctor if symptoms appear or worsen.

Lisa Newlon
Website | + posts

Hello! I am Lisa Newlon, and I am a medical writer and researcher with over 10 years of experience in the healthcare industry. I have a Master’s degree in Medicine, and my deep understanding of medical terminology, practices, and procedures has made me a trusted source of information in the medical world.