Osteonecrosis refers to the death (necrosis) of bone or bone sections due to an infarction of the bone. Bone necrosis can occur at any age. The prognosis of osteonecrosis ranges from complete healing to complete destruction of the bones in question, depending on the location of the disorder.
What is osteonecrosis?
Osteonecrosis is characterized by severe pain at the affected site. There are three forms of osteonecrosis. These include the aseptic, septic, and post-traumatic forms. While septic osteonecrosis is caused by an infection, the aseptic form is a collective term for all necrosis of the bone not caused by an infection. Posttraumatic osteonecrosis occurs after an injury or fracture to the bone and may be triggered via infection or other processes secondary to the trauma. Each form of osteonecrosis is directly caused by occlusion of a blood vessel supplying the bone in question.
Causes
When the nutrient supply to a bone or a section of bone is interrupted, its death or, in other words, osteonecrosis occurs. The only immediate cause of this undersupply is the disruption of blood flow to the affected area. However, how the occlusion of the blood vessel occurs must be clarified in each individual case. Both infectious and non-infectious processes may precede this event. Furthermore, the triggering factor may be an injury at the corresponding site. However, occlusion of the blood vessel may also occur as a result of other diseases, such as hemoglobinopathies (blood diseases). Furthermore, biophosphonates, which are used as drugs for the treatment of osteoporosis, are a risk factor for osteonecrosis in the area of the jaw bones. Among other things, they inhibit the formation of new blood vessels in the bone tissue, so that the jaw bones then become particularly susceptible to osteonecrosis when subjected to further stresses.
Symptoms, complaints and signs
Osteonecrosis is initially manifested by pain, which can vary depending on the extent and location of the necrosis. Thus, there may be bone pain and joint pain, and subsequently, tension pain and nerve pain. Initially, the pain occurs only with physical exertion before it develops into a chronic complication. In some patients, joint effusion occurs as a result of necrosis. This is associated with pulsating pain and tenderness to touch in the affected area. The skin initially feels overheated before the body temperature drops as a result of decreasing blood flow. Then the necroses occasionally show externally, usually in the form of dark swellings. Small defects often heal on their own. Large necroses usually affect other parts of the body, destroying bones and joints in the process. The disease is often accompanied by sleep problems, personality changes and depression. In most cases, the patient is also unable to move as fluidly as before. Bone necrosis takes a progressive course and increases in intensity. If it is treated early, late effects can be avoided. In the absence of treatment, the disease can result in serious physical and psychological symptoms, such as paralysis or depression.
Diagnosis and course
The course of osteonecrosis depends on the size and location of the affected area. Spontaneous healing has been observed in cases in which the focus of necrosis is small and located far from the joints. If the destructive process is close to a joint or if bone resorption occupies a large area, spontaneous healing is unlikely. Immediate action must then be taken to prevent complete joint destruction. Diagnosing osteonecrosis can be difficult in some circumstances because sometimes the infarction event begins painlessly at first, with pain developing slowly over weeks or months. However, there are also courses with sudden onset of pain. Restriction of movement is less common and indicates extensive damage to the bones or joints. In very rare cases, joint effusion may occur. If osteonecrosis is suspected, a medical history is first taken. This is followed by functional tests on the relevant bones and joints.Imaging techniques, such as magnetic resonance imaging (MRI), ultrasound, or an X-ray examination corroborate the diagnosis of osteonecrosis, with MRI (magnetic resonance imaging) being the most reliable diagnostic procedure.
Complications
The prognosis of individual osteonecroses can be completely different. Both spontaneous healing and severe complications occur. Almost always, osteonecrosis is associated with severe pain, although this may occur some time after the actual bone infarction. In more severe cases, movement restrictions are also observed in addition to the pain. The severity of these limitations and the chances of recovery often depend on the location and severity of the bone infarction. In particularly severe cases, complete destruction of the corresponding joint may occur. If necessary, a joint effusion also occurs. In a joint effusion, fluid accumulates in the joint. The fluid may be bloody or purulent, among other things. A joint effusion often indicates a degenerative process of the bones. In cases of severe osteonecrosis, surgical treatment is usually unavoidable. If the joint is completely destroyed, often only the use of an artificial joint will help. Chronically painful courses of the disease with severe movement restrictions greatly impair the quality of life of patients. As a result, mental illnesses and even depression can occur. Permanent pain can also lead to chronic sleep disturbances, which are often the cause of irritability and aggressive behavior. The same symptoms often develop because of the artificial joint, when the patient has difficulty accepting his or her permanent disability.
When should you see a doctor?
When bone pain or limited motion is noticed, a doctor should be consulted. The above symptoms indicate osteonecrosis, which can lead to chronic pain and other complications if left untreated. Affected individuals should consult a physician if they experience any unusual symptoms, and the physician can diagnose osteonecrosis using an ultrasound examination and other examination methods. Individuals who have had osteomyelitis before are among those at risk for developing osteonecrosis. The disease can occur in middle-aged men, older women, and other groups of people, depending on the type. Because of the large number of possible osteonecroses, symptoms must be considered in light of any risk factors. Metabolic disorders, vascular occlusion, and trauma are factors that must be clarified when signs of osteonecrosis occur. The same applies to alcoholism and cortisone medication as well as angio- and coagulopathies. Osteonecrosis is treated by an orthopedic surgeon. Other points of contact are physiotherapists and sports physicians. If the condition occurs in the setting of cancer, a psychooncologist should be consulted.
Treatment and therapy
Treatment of osteonecrosis depends on its severity and location. In many milder cases, sparing of the affected body parts is already sufficient. These should then be immobilized and not loaded with weights. It is not uncommon for this period of rest to lead to spontaneous healing. In more severe cases, treatment without surgical intervention is often no longer possible. In the case of smaller necroses, healing can be achieved by drilling into the bone (Pridie procedure). However, if the disease process is already far advanced, a bone transplantation with or without cartilage or the use of an artificial joint sometimes becomes necessary. In recent years, more innovative procedures have expanded the therapeutic options. For example, vasodilator drugs (iloprost) or electrostimulating procedures are sometimes additionally used to enhance bone growth. Which therapy should ultimately be used to treat osteonecrosis must be decided separately by the physician in each individual case because of the wide variety of disease processes.
Outlook and prognosis
The prognosis of osteonecrosis depends on the size and location of the affected bone area. The prognosis is positive if the necrotizing area is small and in an easily accessible location. Necroses in the area of the joints are much more difficult to treat, especially if the necroses are extensive. However, spontaneous healing is possible in all forms of osteonecrosis.Depending on its course, the disease can heal without consequences or lead to complete destruction of the joint. The causative disease is also decisive for the prognosis. If the osteonecrosis is due to Ahlbäck’s disease, the prospects for recovery are relatively good. If it is a septic bone necrosis, the prognosis is much worse, as the necrosis is sometimes accompanied by inflammation and blood poisoning. The disease is associated with severe pain and limitation of movement. Rarely, osteonecrosis can result in joint effusion, which carries further risks. The prospect of a symptom-free life is only given again after recovery. The prognosis is made by the responsible specialist. Usually this is an orthopedist or osteopath.
Prevention
A general recommendation for the prevention of osteonecrosis cannot be given. The disease is dependent on many unknown factors. However, certain underlying diseases that can lead to osteonecrosis may require permanent therapy.
Follow-up
In most cases of osteonecrosis, the measures of aftercare are relatively limited, so that affected persons with this disease are primarily dependent on a rapid and, above all, an early diagnosis of the disease. Early diagnosis of the disease always has a very positive effect on the further course of the disease and can prevent the occurrence of complications and other complaints. Most patients are dependent on a surgical intervention, which can alleviate the symptoms. After such an operation, the affected person should in any case rest and take it easy, refraining from exertion or from stressful and physical activities. In many cases, the help and support of the patient’s own family is also very important. Psychological support is also necessary and useful in many cases and can prevent the development of depression and other psychological upsets. Osteonecrosis does not usually reduce the life expectancy of the affected person, although a general prediction about the further course cannot usually be made.
What you can do yourself
It is imperative that this disease be treated by a physician, otherwise it will worsen. However, if treatment is started early, osteonecrosis can heal completely. Of course, it is important to take it easy on the affected areas of the body and keep it still. Since osteonecrosis is accompanied by very severe pain, it often leads to various accompanying symptoms. These include sleep disturbances, for example. Before patients now resort to sleeping pills, simple remedies can also help here. Naturopaths recommend, for example, the administration of zinc, magnesium and vitamin B6 before bedtime. This combination is supposed to make it easier to fall asleep. Melatonin also has a similar effect. Naturopaths and naturopathically trained physicians are happy to advise here. It is possible that the pain of osteonecrosis may also lead to a depressive mood or even a change in personality. In this case, accompanying psychotherapeutic treatment is absolutely advisable. Relaxation techniques can also help patients. In addition to Reiki, yoga and meditation, these include progressive muscle relaxation according to Jacobson. It is easy to learn and can often be found in the courses offered by adult education centers. To help osteonecrosis heal completely, electrical muscle stimulation (EMS) has also proven effective. Various doctors and physiotherapists offer these so-called TENS/EMS therapies. However, there are also EMS devices for home use, which can then be applied several times a day.
