Republic of the Philippines

Bicol University
COLLEGE OF NURSING
Legazpi City

NCM 112
Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious,
Inflammatory & Immunologic Response, Cellular Aberrations, Acute and Chronic

NAME: BENZON, ZHEMRIE

BONA, ERIE JEZREEL N.
YR. LEVEL: BSN III-C GROUP: 10
BUHION, MA. CRISEL FAYE
GALICIA, AUBREY MARIE

Osteonecrosis
Avascular necrosis

Osteonecrosis, also known as avascular

necrosis (AVN), aseptic necrosis, or ischemic
bone necrosis, is a disease resulting in the death of
bone cells. If the process involves the bones near
a joint, it often leads to the collapse of the joint
surface and subsequent arthritis due to an irregular
joint surface. The exact cause is unknown.
Although it can happen in any bone,
osteonecrosis most commonly affects the ends
(epiphysis) of long bones such as the femur (thigh
bone). Commonly involved bones are the upper
femur (ball part of the hip socket) , the lower femur (a part of the knee joint), the upper humerus (upper
arm bone involving the shoulder joint), and the bones of the ankle joint. The disease may affect just one
bone, more than one bone at the same time, or more than one bone at different times. Orthopedic surgeons
most often diagnose the disease using either an X-ray or a magnetic resonance scan (MRI).

General symptoms

Areas affected by osteonecrosis may remain asymptomatic for weeks to months after the vascular
insult. Usually, pain then develops gradually, although it may be acute. With the progressive collapse of
the joint, pain increases and is exacerbated by motion and weight-bearing, and is relieved by rest.
Because many of the risk factors for the development of osteonecrosis act systemically (eg,
chronic corticosteroid use, excessive alcohol intake, sickle cell disease), osteonecrosis may be multifocal.
In sickle cell disease, osteonecrosis may occur throughout different long bones and cause sudden painful
crises.

Joint-specific symptoms

● Osteonecrosis of the hip

- causes groin pain that may radiate down the thigh or into the buttock. Motion becomes
limited, and a limp usually develops).
 ● SPONK
- usually causes sudden knee pain without preceding trauma; the sudden onset and the
location of pain may help differentiate it from classical osteonecrosis. This pain is most
often on the medial side of the femoral condyle or tibial plateau and manifests with
tenderness, noninflammatory joint effusion, painful motion, and a limp.

● Osteonecrosis of the humeral head

- often causes less pain and disability than hip and knee involvement.

● With advanced osteonecrosis, patients have pain and decreased motion, although the passive
range of motion is less affected than the active range of motion. Symptomatic synovial effusions
can occur, especially in the knee, and the fluid is noninflammatory.

I. Pathophysiology with Etiology

Etiology

- The most common cause of osteonecrosis is trauma. Nontraumatic osteonecrosis affects men
more often than women, is bilateral in > 60% of cases, and occurs primarily in patients between
ages 30 and 50.

A. Traumatic osteonecrosis

The most common cause of traumatic osteonecrosis is a displaced subcapital fracture of the
proximal femur of the hip; osteonecrosis is uncommon after intertrochanteric fractures. The incidence of
osteonecrosis after hip dislocation is related primarily to the severity of the initial injury but may be
higher if the dislocation is not promptly reduced. Fracture or dislocation may cause osteonecrosis by
grossly disrupting or compressing nearby blood vessels.

B. Nontraumatic Risk Factors for Osteonecrosis

- The risk of osteonecrosis is increased when the dose of prednisone or an equivalent

corticosteroid is > 20 mg/day for several weeks or months, resulting in a cumulative dose
usually > 2000 mg, although case reports have described osteonecrosis subsequent to
much less corticosteroid exposure. Notably, corticosteroid-associated osteonecrosis is
often multifocal and can affect both weight-bearing as well as non–weight-bearing joints
like the shoulders. The risk of osteonecrosis is also increased when > 3 drinks/day (> 500
mL ethanol/week) are consumed for several years. Some genetic factors increase
susceptibility to osteonecrosis. Subtle clotting abnormalities due to deficiencies in protein
C, protein S, or antithrombin III or anticardiolipin antibodies can be detected in a high
percentage of patients with osteonecrosis.
- Some disorders that are associated with osteonecrosis are treated with corticosteroids (eg,
systemic lupus erythematosus). Evidence suggests that the risk of osteonecrosis in many
of these disorders is related primarily to corticosteroid use rather than to the disorder.
About 20% of cases of osteonecrosis are idiopathic. Osteonecrosis of the jaw has been
reported in several patients who have received high-dose IV bisphosphonate therapy.
Nontraumatic osteonecrosis of the hip is bilateral in about 60% of patients.
- Spontaneous osteonecrosis of the knee (SPONK or SONK) is a process localized to the
femoral condyle or tibial plateau in older women (occasionally men). SPONK is thought
to be caused by an insufficiency fracture (a type of fragility fracture caused by normal
 wear and tear on the osteoporotic bone that occurs without direct trauma). However,
osteonecrosis of the knee can also result from trauma or any of the nontraumatic risk
factors of osteonecrosis.

The most common factors are the following:

a. Chronic corticosteroid use

b. Excessive alcohol consumption
c. Alcohol
d. Chemotherapy
e. Coagulation disorders (eg, antiphospholipid syndrome, inherited thrombophilia,
hypofibrinolytic disorders)
f. Corticosteroids
g. Cushing syndrome
h. Decompression sickness
i. Dyslipidemia
j. Gaucher disease
k. Miscellaneous disorders (eg, chronic kidney disease, rare inherited metabolic disorders)
l. Hemoglobinopathy (eg, sickle cell disease)
m. HIV infection
n. Liver disease
o. Organ transplantation
p. Pancreatitis
q. Radiation
r. Systemic lupus erythematosus (SLE) and other autoimmune connective tissue disorders
s. Smoking
t. Tumors

Pathophysiology

- Osteonecrosis involves the death of cellular elements of the bone marrow. Mechanisms of
nontraumatic osteonecrosis may include embolization by blood clots or lipid droplets,
intravascular thrombosis, and
extravascular compression.
- After the vascular insult, the repair
processes attempt to remove necrotic
bone and marrow and replace them
with viable tissue. If the infarct is
small, particularly if it is not subject
to a major weight-bearing area, the
collapse of the infarcted area outstrips
attempts at repair, and the infarcted
area collapses.
- The femoral head is no longer round.
- Because osteonecrosis usually affects
the ends (epiphysis and metaphysis)
of long bones, the overlying articular
cartilage surface becomes flattened
and irregular, with areas of collapse
that may eventually lead to osteoarthritis and increased pain.
II. Laboratory / Diagnostic Examination

Diagnosis
 - During a physical exam your doctor will likely press around your joints, checking for tenderness.
Your doctor might also move the joints through a variety of positions to see if your range of
motion has been reduced.

Imaging tests

- Many disorders can cause joint pain. Imaging tests can help pinpoint the source of pain. Options
include:

● X-Rays

- X-rays use electromagnetic waves to create pictures of bones inside the body. A doctor
can confirm the presence of osteonecrosis lesions on an X-ray if the disease has
progressed. X-rays also are used to monitor the progression of the disease throughout
treatment.

● MRI Scans

- An MRI scan can reveal small lesions that form within a bone as a result of
osteonecrosis. The condition is often diagnosed using an MRI scan even when no
evidence is visible on an X-ray. For this reason, MRI scans are preferable for early
detection.
- An MRI scan uses a magnetic field and radio waves to create computerized, three-
dimensional images of bones and joints. Doctors use these images to examine bones from
a variety of angles, allowing them to detect lesions or other damage.

● Bone scan

- A small amount of radioactive material is injected into your vein. This tracer travels to
the parts of your bones that are injured or healing and shows up as bright spots on the
imaging plate.

III. Medical-Surgical Interventions

Medications and therapy

How do healthcare providers treat avascular necrosis?

- The treatment will depend on the amount of damage to the bones. Potential treatments that might
have if the bone damage is limited to smaller bones that don't bear weight include:
● Cold packs.
● Heat treatment.
● Rest.
● Nonsteroidal anti-inflammatory drugs (NSAIDs).
● Physical therapy to ease joint tenderness and increase range of motion.
● Walking aids such as canes and crutches.

Nonsteroidal Anti-inflammatory Drugs

- Bone loss due to osteonecrosis may be painful, especially in the hip and knee joints,
which bear much of the body’s weight. Nonsteroidal anti-inflammatory drugs, or
NSAIDs, work by reducing inflammation in the soft tissues surrounding the joint,
 relieving pain and swelling. These over-the-counter pain relievers include ibuprofen,
naproxen, and aspirin.
- Long-term use of NSAIDs can cause side effects, including upset stomach or ulcers. If
joint pain persists for more than a month, talk to your doctor before continuing use.

Statins

- Statins are medications that lower cholesterol levels by reducing the amount of fatty
substances called lipids in the bloodstream. If statins remove lipids from blood vessels
leading to a diseased bone, more blood can reach the bone, allowing it to rebuild bone
tissue. This may slow or stop the progression of osteonecrosis.
- Statins can cause liver abnormalities and muscle damage, so your doctor takes your
overall health and medical history into consideration before prescribing them for long-
term use.

Physical Therapy

- When prescribed in addition to medication, physical therapy may slow down the
progression of osteonecrosis and provide some pain relief. During the early stages of
treatment, if the disease has affected the hip or knee, physical therapists at NYU
Langone’s Rusk Rehabilitation may suggest using crutches or a cane to help you move
around without putting any weight on the affected joint.
- You may use crutches or a cane for six weeks or more, depending on your age, the
location of the lesion, and the severity of the disease. This gives the lesions time to heal
and may prevent further joint damage.
- Our rehabilitation experts also offer heat and ice therapy, which may provide pain relief
deep within the joint, as well as acupuncture and acupressure, in which very thin needles
or massage are used to stimulate blood flow and reduce inflammation. These therapies
are available onsite at NYU Langone.
- After you can put weight on the affected joint without pain, our physical therapists can
customize a routine of simple, low-impact exercises to maintain range of motion in the
affected joint as well as build strength in muscles that surround and support the joint. For
example, stretching exercises and movements such as leg lifts or squats can prevent the
joint from becoming stiff.
- In addition, adding exercise such as tai chi or swimming to your regular workout routine
can help you maintain flexibility in the joint without putting too much stress on the
bones. These exercises may prevent the disease from limiting your ability to walk and
participate in everyday activities. They also improve blood flow throughout the body,
which may help the bone heal more quickly.
- A physical therapist can also help you alter the way you walk to avoid limping or putting
too much stress on the affected joint. This helps ensure that you are able to use the joint
without feeling pain for the long term.
- The duration of physical therapy varies depending on the location of a lesion and how
quickly your body responds to medication and physical therapy. After four to eight
weeks, your therapist and physician assess your progress and determine whether
additional treatment is required

Surgical Interventions

What is the treatment for more advanced forms of avascular necrosis?

- In most cases, you'll need surgery to treat the avascular necrosis. Surgical options can include:

● Core decompression:
 - The surgeon drills small holes (cores) in your affected bone to improve blood flow to the
affected bone. This procedure might be combined with injections or bone grafts to
promote healing.

● Joint replacement:

- They replace your damaged joint with an artificial one. Hip replacements and knee
replacements are 95% effective at relieving pain and restoring mobility in people with
avascular necrosis.

● Bone reshaping (osteotomy):

- A wedge of bone is removed above or below a weight-bearing joint, to help shift your
weight off the damaged bone. Bone reshaping might enable you to postpone joint
replacement.

● Joint replacement:

- If your diseased bone has collapsed or other treatments aren't helping, you might need
surgery to replace the damaged parts of your joint with plastic or metal parts.

● Regenerative medicine treatment:

- Bone marrow aspirate and concentration is a newer procedure that might be appropriate
for early-stage avascular necrosis of the hip. Stem cells are harvested from your bone
marrow. During surgery, a core of dead hip bone is removed and stem cells inserted in its
place, potentially allowing for growth of new bone. More study is needed.

III. Nursing Interventions

In the early stages of avascular necrosis, symptoms might be eased with medication and therapy.
The following are some management for osteonecrosis:

● Rest

- Reducing the weight and stress on your affected bone can slow the damage. You might
need to restrict your physical activity or use crutches to keep weight off your joint for
several months.

● Exercises

- A physical therapist can teach you exercises to help maintain or improve the range of
motion in your joint.

● Electrical stimulation

- Electrical currents might encourage your body to grow new bone to replace the damaged
bone. Electrical stimulation can be used during surgery and applied directly to the
damaged area. Or it can be administered through electrodes attached to your skin.
● Temperature therapy
 - When joint pain is present, applying ice or heat may help reduce pain. Heat stimulates
blood flow, increases range of motion, and reduces stiffness in painful joints. Ice numbs
painful joints and reduces inflammation.

● Risk factor reduction

- Several lifestyle factors are associated with avascular necrosis. Limiting alcohol
consumption, lowering high cholesterol levels and quitting the habit of smoking may
prevent the condition from worsening or from developing in other parts of the body.

You might not be able to prevent avascular necrosis, but there are steps you can take to reduce your risk:

● Cut back on alcohol

- Heavy drinking is a leading risk factor for AVN.

● Keep your cholesterol in check

- Small bits of fat are the most common thing blocking blood supply to your bones.

● Use steroids carefully

- Your doctor should keep tabs on you while you’re taking these medications. Let them
know if you’ve used them in the past. Taking them over and over again can worsen bone
damage.

● Don't smoke

- It boosts your Avascular Necrosis risk.

Here are some food suggestions that can be included in your diet:

● Omega-3 Fatty Acids: Omega-3 Fatty Acids have inflammation fighting properties and these are
found in abundance in fishes, such as salmon, tuna, etc.

● Vitamin C: Cartilage development requires vitamin C and deficiency leads to weakened cartilage
causing osteoarthritis. Hence, include fruits and vegetables like oranges, grapefruit kiwi, guava,
pineapple, strawberries, cauliflower, tomatoes, and bell peppers.

● Soya: Soya is also rich in omega-3 fatty acids that have inflammation fighting properties. Also, it
is low in fat, rich in protein and fiber, hence very good for overall health.

● Vitamin D: Vitamin D has also been found to help in preventing cartilage breakdown and
decreasing joint space narrowing. Foods like eggs, fortified milk and seafood like shrimp are
found to be rich in vitamin D.

● Use the right oil: Extra virgin olive oil, walnut oil, avocado oil, all help in fighting osteoarthritis.

● Dairy products: Low-fat milk, yoghurt, and cheese are rich in calcium and vitamin D
responsible for increasing bone strength.
● Beta-carotene: Foods rich in beta-carotene also have free radical fighting properties. This is
present in vegetables such as carrot, sweet potatoes, greens like lettuce, tomatoes, asparagus,
peppermint leaves, etc.
● Broccoli: This is rich in vitamins K and C. It also contains sulforaphane, which has been found to
slow down osteoarthritis progression. Also it is rich in calcium that helps in bone development.

● Green Tea: This contains polyphenols, which are antioxidants that help in reduction of
inflammation and cartilage destruction.

● Garlic, onions, and leeks: Include foods that contain garlic, onions, and leeks as these have
properties that can delay the progression of osteoarthritis.

● Nuts: Include nuts such as pine nuts, walnuts, pistachios, and almonds in the diet. These are rich
in proteins, zinc, vitamin E, etc. These also help in weight loss, which helps with osteoarthritis
symptoms.