Secondary Osteonecrosis of the Knee

Secondary Osteonecrosis of the Knee

Articlesecondaryosteonecrosisknee
Bone, Muscle, & Joint
Sports Medicine
+1
Contributed byMaulik P. Purohit MD MPHOct 19, 2018

What are the other Names for this Condition? (Also known as/Synonyms)

  • Atraumatic Osteonecrosis of the Knee
  • Ischemic Osteonecrosis of the Knee

What is Secondary Osteonecrosis of the Knee? (Definition/Background Information)

  • Osteonecrosis (or avascular necrosis) is a serious bone disorder characterized by the temporary or permanent disruption of blood supply to the bone, which causes cells and tissues within the affected bone to die. In many, osteonecrosis affects the ends of the long bones in the body and the knee is a common location
  • Secondary Osteonecrosis of the Knee is a form of knee osteonecrosis occurring secondary to an underlying condition. Such conditions or factors include the use of steroids, cancer therapy, alcoholism; or, it may even be idiopathic (of unknown origin)
  • Secondary Osteonecrosis of the Knee is more often diagnosed in young and middle-aged adults. In a majority of cases (80% of the cases), both the knees are affected (bilateral condition); also, the condition is known to involve several bones (such as the thigh bone, kneecap, and knee bone)
  • Individuals, who develop Secondary Osteonecrosis of the Knee, begin to slowly experience pain within the affected bone/joint that usually increases with time. This may be accompanied by tenderness, swelling, and reduced range of knee joint movement
  • Treatment associated with Secondary Osteonecrosis of the Knee includes both nonsurgical and surgical methods. With early diagnosis and appropriate treatment, the prognosis is usually good. However, the prognosis also depends upon the severity of the signs and symptoms and the underlying cause

Who gets Secondary Osteonecrosis of the Knee? (Age and Sex Distribution)

  • Secondary Osteonecrosis of the Knee is mostly observed in individuals below the age of 45 years
  • Both males and females are affected
  • All racial and ethnic groups are at risk for the condition and no predilection is observed

What are the Risk Factors for Secondary Osteonecrosis of the Knee? (Predisposing Factors)

The risk factors associated with Secondary Osteonecrosis of the Knee may include:

  • Excessive consumption of alcohol
  • Prolonged consumption of steroids, such as prednisone or glucocorticoids
  • Long-term tobacco smoking
  • Myeloproliferative disorder: A bone marrow disorder characterized by the abnormal increase of red blood cells
  • Cancer treatment using radiotherapy or chemotherapy
  • Systemic lupus erythematosus (SLE): Autoimmune systemic inflammatory conditions that occur when an individual’s immune system create antibodies, which accidentally attack healthy tissues and organs within the body
  • Decompression sickness: A disorder characterized by abnormal formation of nitrogen bubbles within the blood and tissues, usually seen in divers, when they move up from the water (high-pressure medium) to the surface (low-pressure medium) too soon
  • Sickle cell anemia: An inherited condition characterized by crescent-shaped red blood cells in the body, obstructing blood flow and causing reduced amounts of oxygen transportation
  • Gaucher’s disease: A rare inherited disorder caused by excessive accumulation of fatty substances (lipid) in the cells and certain organs. This excess build-up of fatty substances can prevent the liver, spleen, lungs, bone marrow, and in rare cases the brain, from functioning properly
  • Crohn’s disease: A disease causing inflammation of the digestive tract lining
  • Antiphospholipid syndrome; an autoimmune disorder
  • High cholesterol level causing hyperlipidemia
  • Excess level of uric acid in blood causing hyperuricemia
  • Arterial embolism: Blood flow obstruction to an organ or body part, caused due to an embolus (a blood clot or fat particle) within the artery
  • Thrombosis: Blood clot that occurs within blood vessels
  • Vasculitis: A condition that causes inflammation of blood vessels
  • Pregnancy, in some cases

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Secondary Osteonecrosis of the Knee? (Etiology)

In knee osteonecrosis, there is a loss of blood supply to the bone leading to its destruction and necrosis (tissue death). This blood supply loss may occur from a variety of factors. In some cases, the exact cause of osteonecrosis may remain unidentified (idiopathic).

The factors responsible for Secondary Osteonecrosis of Ankle include: (sometimes, a combination of factors are noted)

  • Excessive alcohol consumption and prolonged use of corticosteroids, which together account for most of the cases (over 90% of the cases)
  • Individuals with HIV infection or AIDS
  • Perthes disease: Children who develop a rare childhood hip disorder caused by the temporary loss of blood flow to the ball portion of the hip joint
  • Peripheral vascular disease: The contraction and hardening of blood vessels within the legs and feet
  • Slipped capital femoral epiphysis: Adolescents develop this unusual condition, due to a weakness of the growth plate causing the femur/thighbone head to slip backwards
  • Sickle cell anemia: A genetic condition caused by odd-shaped red blood cells that tend to obstruct the flow of blood to different body parts
  • Systemic lupus erythematosus (or lupus): An auto-immune systemic inflammatory condition that occurs when an individual’s immune system create antibodies that accidentally attack healthy tissues and organs within the body
  • Decompression sickness: A disorder characterized by abnormal formation of nitrogen bubbles within the blood and tissues, usually seen in divers when they move up from the water to the surface too soon
  • Radiation therapy, which uses high-energy beams to shrink tumors and destroy cancer cells
  • Use of certain medications, such as during chemotherapy, steroids (usually high-dose), or immunosuppressive medications for organ transplant
  • Excess fat in the body; obesity

What are the Signs and Symptoms of Secondary Osteonecrosis of the Knee?

The signs and symptoms of Secondary Osteonecrosis of the Knee may be mild or severe and can vary from one individual to another. Initially, there may not be any noticeable symptoms.

The signs and symptoms of Secondary Osteonecrosis of the Knee may include:

  • Noticeable pain and tenderness in the affected bone; there is a slow onset of pain and other symptoms
  • The pain increases when weight/pressure is applied to the bone
  • Pain while sleeping
  • The pain may be either dull or sharp and shooting pain
  • Swelling of tissue around the affected kneecap or knee joint
  • Decreased range of motion of the affected joint/bone
  • During the later stages, osteophytes or bony projections may form around the affected knee region. These lesions may range in size from 2-5 cm or may even be larger
  • In about 4 in 5 cases, both the knee joints are affected. The condition may involve the ends of both the femur (thigh bone) and tibia (shin bone)

Additionally, signs and symptoms of the underlying condition (if any) may be observed.

How is Secondary Osteonecrosis of the Knee Diagnosed?

Diagnostic methods that a physician may use to help diagnose Secondary Osteonecrosis of the Knee include:

  • Physical examination and evaluation of medical history
  • Assessment of the signs and symptoms
  • Tests and procedures to evaluate the underlying condition
  • Functional evaluation of the affected knee joint
  • X-ray of the knee: X-rays can help the physician rule-out other possible causes of knee discomfort. During the early stages of osteonecrosis, it is difficult to locate the appearance of any abnormal bone changes. However, X-rays can usually identify the presence of osteonecrosis during the later stages
  • Magnetic resonance imaging (MRI) of the knee joint: An MRI is an imaging technique that creates images of soft tissues and bones, which helps detect any bone abnormalities during the early stages of osteonecrosis
  • Bone scan, if needed: A bone scan is a diagnostic method used to identify any bone abnormalities by injecting tiny amounts of radioactive material into the bloodstream
  • Computerized tomography (CT) of the knee joint: A CT scan takes a series of X-ray images from several different angles, which are then merged to create cross-sectional images of bones and soft tissues of the body. This allows a physician to examine the bone or joint and its surrounding structures

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Secondary Osteonecrosis of the Knee?

The complications associated with Secondary Osteonecrosis of the Knee may include:

  • Further deterioration of the involved bone; if left untreated, the bone or joint may collapse
  • Walking difficulties, walking with a limp
  • Chronic disability and complete immobility when both knees are affected
  • Complications that may arise from the underlying/associated condition, if any present
  • Complications that may arise from surgery to the knee

How is Secondary Osteonecrosis of the Knee Treated?

The treatment of Secondary Osteonecrosis of the Knee includes non-surgical and surgical methods and may depend on the severity of the condition (mild or severe). A healthcare provider may start with non-surgical treatment methods before adopting surgical procedures and techniques. These include:

  • Applying ice to the region can help with pain and reduce swelling
  • Avoiding further stress/weight on the involved knee, such as by using a pair of crutches; preventing further bone damage
  • Non-steroidal anti-inflammatory oral medications, such as ibuprofen and naproxen, may be used to help decrease pain and swelling
  • Use of bisphosphonate medications help in slowing or preventing progression of the condition
  • Medications for osteonecrosis may decrease the progression of this condition
  • Corticosteroid injections help provide temporary relief of symptoms and in improving the range of motion. It is important to note that corticosteroid injections may only give temporary relief. Prolonged episodes of such injections can injure the joints in the long-run
  • Electrical stimulation therapy to aid in the growth of the affected bone
  • After the symptoms has decreased, it is important to begin some light motion exercises.  Physical therapy may help restore strength, as well as provide flexibility to the muscles

Surgical treatment measures include:

  • High tibial osteotomy: The affected bone is surgically removed/cut and reshaped or realigned; usually, in younger patients
  • Core decompression: Core decompression is used to treat early-stage osteonecrosis. In this surgical procedure the pressure within the bone is decreased by removing a part of the bone causing the abnormal pressure
  • Partial or total replacement of the involved joint: The involved joint is replaced through a surgical procedure using a prosthetic implant. A physician will recommend this surgical procedure, if the condition is limited to a certain portion of the joint
  • Cartilage grafting: Cartilage grafting is a surgical procedure to replace the damaged cartilage, which may be damaged due to osteonecrosis or any traumatic injury
  • Bone grafting or osteochondral autografting: It is a technique that involves removing a healthy bone from within the body and replacing the affected bone
  • Knee arthroscopy: Arthroscopic surgery is a minimally invasive surgical procedure that is used to visualize, diagnose, and repair the knee joint using small instruments
  • Total knee arthroplasty: In total knee arthroplasty, the involved joint cartilage is completely removed. It is then replaced by a metal and plastic prosthetic implant. This surgical procedure is recommended, if the entire joint is acutely affected

Additionally, suitable treatment of any underlying condition/disorder should be undertaken.

How can Secondary Osteonecrosis of the Knee be Prevented?

A few recommendations to help prevent Secondary Osteonecrosis of the Knee include:

  • Avoid excessive intake of alcoholic beverages
  • Monitor long-term consumption of steroidal medications
  • Individuals, who participate in any high-risk sports, such as football or hockey, should wear appropriate safety equipment to help prevent a serious injury
  • Undertaking adequate treatment for health conditions such as lupus
  • Wear proper equipment while scuba-diving to avoid decompression sickness
  • Maintain a low cholesterol diet
  • Avail proper treatment that can help control or minimize blood vessel damage, associated with vasculitis
  • Proper treatment of Crohn’s disease will help prevent the development of osteonecrosis
  • Undertake proper treatment of myeloproliferative disorder
  • Take treatments to improve the blood flow to organs or any body part, when necessary
  • Proper treatment of blood clots that occur within blood vessels

What is the Prognosis of Secondary Osteonecrosis of the Knee? (Outcomes/Resolutions)

  • If treated early, a high percentage of individuals who develop Secondary Osteonecrosis of the Knee may show an improvement and experience favorable outcomes; the bone may rebuild itself
  • In general, the amount of bone damaged by this condition significantly affects its prognosis. A delay in treatment or an absence of treatment can severely affect the prognosis and cause functional loss of the involved bone
  • The overall prognosis is also dictated by the severity of the underlying disorder/medical condition

Additional and Relevant Useful Information for Secondary Osteonecrosis of the Knee:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/health-topics/orthopedc-disorders/

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Maulik P. Purohit MD MPH picture
Approved by

Maulik P. Purohit MD MPH

Assistant Medical Director, Medical Editorial Board, DoveMed Team

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