Bone necrosis
Classification according to ICD-10 | |
---|---|
M87 | Bone necrosis. V GT |
M87.0 | Idiopathic aseptic bone necrosis |
M87.1 | Drug bone necrosis |
M87.2 | Bone necrosis from previous trauma |
M87.3 | Other secondary bone necrosis |
M87.8 | Other bone necrosis (neck, head, ribs, trunk, skull, spine) |
M87.9 | Bone necrosis, unspecified |
M90 * | Osteopathies in diseases classified elsewhere |
M90.3 * | Bone necrosis in caisson disease |
M90.4 * | Bone necrosis due to hemoglobinopathy |
M90.5 * | Bone necrosis in other diseases classified elsewhere |
ICD-10 online (WHO version 2019) |
Bone necrosis or osteonecrosis (abbreviation ON ; English: osteonecrosis ; colloquially: bone infarction ) describes a tissue destruction ( infarction ) of the bone or a section of bone with death ( necrosis ) of the affected bone or section of bone, which is subsequently dismantled or remodeled. This creates a weakened point in the bone structure, whereby the extent of the infarct and the subsequent defect in the bone substance can be different.
All forms are based on an inadequate blood supply to the bone with insufficient supply of oxygen , nutrients and minerals. This is why the term avascular necrosis, English avascular osteonecrosis (AVN), is also in use.
If one only wants to exclude bone necrosis caused by infection, one speaks of aseptic bone necrosis (alternative designation aseptic osteonecrosis ; abbreviation: AON , AKN ; English aseptic osteonecrosis or aseptic bone necrosis ).
clinic
The substance defects of the bone can sometimes have no consequences or lead to severe, irreversible damage to joints and bones. The course is variable depending on the localization, the extent, the possibly existing risk factors, the age and the ultimate trigger. Both spontaneous healing and total joint destruction are known. In principle, all bones in the body can be affected. Both unilateral and bilateral (symmetrical) damage are known. Bone necrosis can occur at any age.
to form
Aseptic bone necrosis can be divided into different forms based on several factors. The divisions are made according to
- root cause
- Affected joint and bones
- Expression (severity)
root cause
According to the likely underlying cause of the osteonecrosis, the following types of osteonecrosis can be distinguished:
- post-traumatic bone necrosis, from an injury.
- septic bone necrosis, as part of or as a result of an infection .
- aseptic bone necrosis, not caused by infection.
Risk factors
Certain diseases or external factors promote the occurrence of aseptic bone necrosis. These include:
- Diseases
- Sickle cell disease
- HbSC disease
- Gaucher's disease
- Systemic lupus erythematosus (SLE)
- Environmental factors
- Working in compressed air (tunneling, mining, building bridges in rivers)
- Diving
- Exposure to ionizing radiation . See under osteoradionecrosis .
- Chemotherapy for acute leukemia ( ALL , AML ) and lymphoma ( NHL , Hodgkin lymphoma ). Osteochemonecrosis.
- Systemic use of corticosteroids
- Systemic use of bisphosphonates (only applies to aseptic bone necrosis of the lower jaw)
- The medicine sirolimus
Classification according to the affected bone or joint
Table 1. Overview of the forms of aseptic bone necrosis by location | ||||
---|---|---|---|---|
Affected bone | section | Name of the disease | ||
German name | Technical name | German name | Technical name | |
Body trunk | ||||
Vertebral bodies | Vertebra (plana) | Vertebral bodies | Calvé's disease s. Vertebra plana | |
Ischium | Os ischii | Van Neck's disease | ||
Pubic bone | Pubis | Pierson's disease | ||
Upper extremity | ||||
Collarbone | Clavicle | middle end | media end | Friedrich's disease |
Humerus | Humerus | (Elbow) | Capitulum | Panner's disease |
Humerus | Humerus | (Elbow) | Trochlea | Hegemann's disease |
Moon leg (hand) | Lunate bone | Kienböck's disease | ||
Scaphoid bone (hand) | Scaphoid bone | Preiser's disease, Preiser's disease | ||
Metacarpal bones | Metacarpal bone | Brains | Dietrich's disease | |
Phalanx | Phalanx medialis | Base | Thiemann's disease | |
Lower extremity | ||||
Thigh bone | Femur | Femoral head | Head femoris | Perthes disease , femoral head necrosis |
Thigh bone | Femur | role | Condyle | Ahlbäck's disease , Ahlbåck's disease |
Kneecap | patella | top | Apex patellae | Sinding-Larsen-Johansson disease |
Shin | Tibia | Kneecap tendon attachment hump | Tibial tuberosity | Osgood-Schlatter disease , Osgood-Schlatter syndrome, Osgood-Schlatter disease |
Shin | Tibia | Medial portion of the proximal epiphysis | Blount's disease | |
Heel bone | Calcaneus | Apophysis | Sever-Haglund disease, Haglund syndrome | |
Scaphoid bone (foot) in children and adolescents | Os naviculare pedis | Köhler's disease I, Köhler-Albau 's disease, Köhler's disease | ||
Scaphoid (foot) in the adult | Os naviculare pedis | Müller-Weiss syndrome | ||
Sesame bone (big toe) | Os sesamoide hallucis | Renander's disease | ||
Metatarsal bones II – V | Metatarsal II – V | Brains | Caput | Köhler-Freiberg 's disease, Köhler's disease II |
Severity (stages)
The staging of aseptic bone necrosis can be done according to the classification of the Association for Research of Circulation Osseous (ARCO). This combines a Japanese classification, which is based on the location of the necrosis, with a classification from Philadelphia (USA), which is primarily based on the size of the necrosis.
The ARCO classification is best investigated for aseptic bone necrosis of the femoral head (femoral head necrosis) and relates primarily to lesions of the epiphysis , i.e. bone sections near the joints that can lead to joint wear when the cartilage breaks into the necrosis area. Bone necrosis of the diaphysis and metaphysis can at best be divided into the ARCO stages.
- Stadium ARCO 0
In the initial stage, no pathological changes can be seen in conventional X-rays. In rare cases, a subtle loosening of the fine bone structure ( trabecula ) can be seen in the affected area: however, the extent of this loosening is usually so small that it cannot be reliably recognized. In the magnetic resonance imaging (MRI) is an image at this stage analogous to bone marrow edema (KMÖ, transient osteoporosis , bone marrow edema , BME) to detect. Using the short tau inversion recovery (STIR) recording sequence, a signal hyperintensity (bright flashing in the gray-scale magnetic resonance image) is determined (compare Fig. 1a and 2 light edges). A reliable differentiation between the principally reversible picture of a BME / BME and the stage ARCO I of aseptic bone necrosis is not possible by means of the magnetic resonance tomogram.
- ARCO stage 1
Reversible early stage (MRI positive / reactive edge zone)
- ARCO stage 2
Irreversible early stage (X-ray positive)
- ARCO stage 3
Transitional stage (subchondral fractures)
- ARCO stage 4
Late stage (calotte impression)
- ARCO stage 5
Late stage (secondary osteoarthritis)
- ARCO stage 6
Late stage (joint destruction)
Symptoms
None of the symptoms are specific to this disease, as many other diseases could also be responsible for the symptoms. Pain over the section of bone or joint affected by the bone necrosis is common. The pain can appear suddenly. However, it also develops gradually increasing in intensity. Radiation in adjacent unaffected skeletal sections is possible. Typically, the pain occurs at rest and intensifies when the affected bone section or joint is stressed. However, pain can only be present when the affected bone or joint section is stressed, which then also occurs at rest as the disease progresses. The pain can often only appear weeks, sometimes months after the infarction in the bone.
Restrictions in movement of the affected bone or joint are less common than pain. In addition, they typically occur later than the pain in the course of the disease and are usually already signs of advanced damage. But this is not necessarily the case; Restrictions of movement can also occur parallel to pain. In children - especially small children - the sequence of symptoms can sometimes be reversed. The affected toddler is noticed for the first time by limping or lack of movement of the affected leg or arm.
diagnosis
Diagnosis
The diagnosis of aseptic bone necrosis includes the physical examination of the likely affected joint section with functional tests of the joints and bones as well as imaging procedures. As a rule, abnormal bone changes are preceded by loads or injuries of various types. This is different with bone necrosis, the symptoms develop gradually. Conventional imaging methods such as x-rays or sonography only provide indications of the diagnosis if the first bone remodeling or bone destruction has occurred. When using magnetic resonance imaging with contrast media, a diagnosis can also be made if there is only typical bone remodeling activity.
Differential diagnosis
Other diseases are to be distinguished from bone necrosis:
- Bone cyst
- Bone tumor
- Inflammation of the bone ( osteitis ) and inflammation of the bone marrow ( osteomyelitis )
therapy
Therapy depends on the stage and includes:
- mechanical relief (e.g. forearm crutches),
- Femoral head relief bore,
- Conversion osteotomies and (hip) endoprostheses.
- In the initial stage, hyperbaric oxygen therapy can be used either alongside or alone. This has a particularly positive effect on the painful bone marrow edema.
The treatment of bone necrosis is also based on the aforementioned prognostic factors: the larger and closer to the joint, the more likely surgical treatment is required. If there is damage to or even destruction of the joint surfaces in the context of bone necrosis close to the joint, an operative intervention can usually not be avoided. Depending on the extent of the bone necrosis, drilling ( Pridie drilling ), bone transplants (with and without cartilage) and, if the severity of the disease is severe, artificial joint replacements ( endoprostheses ) are carried out. Conservative treatment consists of weight relief and rest. However, spontaneous healing has also been described.
Web links
Individual evidence
- ↑ CM Aguilar, LD Neumayr u. a .: Clinical evaluation of avascular necrosis in patients with sickle cell disease: Children's Hospital Oakland Hip Evaluation Scale - a modification of the Harris Hip Score. In: Archives of physical medicine and rehabilitation. Volume 86, Number 7, July 2005, pp. 1369-1375, ISSN 0003-9993 . PMID 16003666 .
- ^ RL Nagel, ME Fabry, MH Steinberg: The paradox of hemoglobin SC disease. In: Blood Reviews . Volume 17, Number 3, September 2003, pp. 167-178, ISSN 0268-960X . PMID 12818227 . (Review).
- ^ SW Rodrigue, DI Rosenthal u. a .: Risk factors for osteonecrosis in patients with type 1 Gaucher's disease. In: Clinical Orthopedics and Related Research . Number 362, May 1999, pp. 201-207, ISSN 0009-921X . PMID 10335299 .
- ↑ SN Oh, WH Jee et al. a .: Osteonecrosis in patients with systemic lupus erythematosus: MR imaging and scintigraphic evaluation. In: Clinical imaging. Volume 28, Number 4, 2004 Jul-Aug, pp. 305-309, ISSN 0899-7071 . doi : 10.1016 / S0899-7071 (03) 00192-X . PMID 15246483 .
- ↑ EP child Wall, JR Nellen, DR mirror Hoff: Aseptic necrosis in compressed air tunnel workers using current OSHA decompression schedules. In: Journal of occupational medicine. Volume 24, Number 10, October 1982, pp. 741-745, ISSN 0096-1736 . PMID 7143120 .
- ↑ K. Miyanishi, Y. Kamo et al. a .: Risk factors for dysbaric osteonecrosis. In: Rheumatology . Volume 45, Number 7, July 2006, pp. 855-858, ISSN 1462-0324 . doi: 10.1093 / rheumatology / kel013 . PMID 16436490 .
- ↑ U. Höller, S. Hoecht u. a .: Osteoradionecrosis after radiation therapy of gynecological tumors. In: Radiation Therapy and Oncology . Volume 177, Number 6, June 2001, pp. 291-295, ISSN 0179-7158 . PMID 11446317 .
- ↑ EJ Karimova, SN Rai et al. a .: MRI of knee osteonecrosis in children with leukemia and lymphoma: Part 1, observer agreement. In: American Journal of Roentgenology . Volume 186, Number 2, February 2006, pp. 470-476, ISSN 0361-803X . doi: 10.2214 / AJR.04.1598 . PMID 16423955 .
- ↑ D. van Schaardenburg, HR van den Brink, HJ Wieringa: Short-term steroid therapy, sometimes with long-term sequelae. In: Nederlands tijdschrift voor geneeskunde. Volume 145, Number 37, September 2001, pp. 1769-1773, ISSN 0028-2162 . PMID 11582637 . (Review).
- ↑ J. Steinhagen, W. Rüther: Aseptic bone necrosis after steroid therapy. In: Journal of Rheumatology. Volume 63, Number 3, June 2004, pp. 242-243, ISSN 0340-1855 . doi: 10.1007 / s00393-004-0556-9 . PMID 15224230 .
- ^ TJ O'Brien, GR Mack: Multifocal osteonecrosis after short-term high-dose corticosteroid therapy. A case report. In: Clinical orthopedics and related research. Number 279, June 1992, pp. 176-179, ISSN 0009-921X . PMID 1600653 .
- ↑ E. Merigo, M. Manfredi u. a .: Jaw bone necrosis without previous dental extractions associated with the use of bisphosphonates (pamidronate and zoledronate): a four-case report. In: Journal of Oral Pathology & Medicine . Volume 34, Number 10, November 2005, pp. 613-617, ISSN 0904-2512 . doi: 10.1111 / j.1600-0714.2005.00351.x . PMID 16202082 .
- ↑ S. Bhandari, J. Eris: Drug points: Premature osteonecrosis and sirolimus treatment in renal transplantation. In: BMJ. Volume 323, Number 7314, September 2001, p. 665, ISSN 0959-8138 . PMID 11566830 . PMC 55926 (free full text).
- ↑ P. Ueblacker, AB Imhoff: Overview osteonecroses. In: Arthroscopy. May 2003; 16, pp. 102-103.
- ↑ KM Baumgarten, MA Mont u. a .: Atraumatic osteonecrosis of the patella. In: Clinical orthopedics and related research. Number 383, February 2001, pp. 191-196, ISSN 0009-921X . PMID 11210953 .
- ↑ a b J. Reumont et al.: HBO therapy for aseptic knee joint bone necrosis . In: Trauma and Occupational Disease . tape 6 , no. 1 , April 1, 2004, p. 35-40 , doi : 10.1007 / s10039-003-0826-9 .