A roller-coaster ride (and I couldn’t get off) - 3

A year ago, she developed bilateral hip pains with progressive limitation in range
of motion causing difficult ambulation. Radiographs showed narrowing of the hip
joint with cystic erosion and flattening of the medial aspect of the left femoral head
consistent with stage III avascular necrosis (AVN); magnetic resonance imaging
(MRI) also confirmed stage I (early) AVN of the right hip. She underwent total hip
replacement on the left and core decompression on the right hip.

Guide questions:
8. Describe the pathogenesis and list the risk factors for
osteonecrosis.
9. Describe the imaging modalities and staging in
osteonecrosis.
[Y] - Sioson, Yvette

Pathogenesis: Osteonecrosis

Shah, K. N., Racine, J., Jones, L. C., & Aaron, R. K. (2015).

Pathophysiology and risk factors for osteonecrosis. Current Reviews in
Musculoskeletal Medicine, 8(3), 201–209. doi: 10.1007/s12178-015-
9277-8
[Y] - Sioson, Yvette

Risk Factors: Osteonecrosis

Chang, C., Greenspan, A., & Gershwin, M. E. (2020). The pathogenesis,

diagnosis and clinical manifestations of steroid-induced osteonecrosis.
Journal of Autoimmunity, 102460. doi:10.1016/j.jaut.2020.102460
V – TURINGAN, KEVIN [Y] - Sioson, Yvette
V – TURINGAN, KEVIN

Pathogenesis of OSTEONECROSIS

• Femoral head involvement - pain in the groin area

• Glucocorticoid-associated osteonecrosis
a. Alteration in the circulating lipids → microemboli in the
arteries
b. Increase in the number and size of the bone marrow
adipocytes → blockage of the venous outflow
c. Changes in the venous endothelial cells → stasis →
increased intraosseous pressure → necrosis
• Hyperemia in the surrounding area →
demineralization → trabecular thinning → collapse

UpToDate.com
V – TUMAMBING, MEA GLOR

Risk factors for osteonecrosis

Traumatic Factors Atraumatic Factors
● Lateral or medial ● Glucocorticoid use ● Hyperlipidemia
femoral neck fractures, ● Alcohol use ● Radiation
particularly with ● Hemoglobinopathies ● Organ
dislocation (Sickle cell disease) transplantation
● Femoral head fractures
● SLE ● Intravascular
● Gaucher's disease coagulation
● Chronic renal failure or ● Thrombophlebitis
hemodialysis ● Cigarette smoking
● Pancreatitis ● Hyperuricemia/gout
● Pregnancy ● HIV infection
● Caisson disease ● Idiopathic
(decompression ● Myeloproliferative
sickness) disorders

Amboss
UpToDate
V – TUMAMBING, MEA GLOR

Mnemonic for possible etiologies of

femoral head necrosis
“A S E P T I C”
A - Alcohol (20-40%)
S - SLE, Sickle cell disease
E - Exogenous steroid (35-40%)
P - Pancreatitis
T - Trauma
I - Infection
C - Caisson disease

Amboss
B- TOLETE, KEITH GAMALIEL V – TUMAMBING, MEA GLOR

OSTEONECROSIS

Imaging Modalities
● Plain Film Radiography
● Magnetic Resonance Imaging
● Radionuclide Bone Scanning

Radiopaedia.org
UpToDate
B- TOLETE, KEITH GAMALIEL

Plain Radiograph

AP View Lateral View

V – TUMAMBING, MEA GLOR

Imaging Modalities
● Plain Film Radiography
○ Anterior-posterior film
○ Frog-leg lateral film
○ Pathognomonic crescent sign
(subchondral radiolucency):
evidence of subchondral collapse
● Magnetic Resonance Imaging
● Radionuclide Bone Scanning

Radiopaedia.org
UpToDate
V – TUMAMBING, MEA GLOR [Y] - Sioson, Yvette

Pathognomonic: “Crescent sign”

Petek, D., Hannouche, D., & Suva, D. (2019). Osteonecrosis of the

femoral head: pathophysiology and current concepts of treatment.
EFORT Open Reviews, 4(3), 85–97. doi: 10.1302/2058-5241.4.180036
Retrieved from http://radiopaedia.org
V – TUMAMBING, MEA GLOR

Imaging Modalities
● Plain Film Radiography
● Magnetic Resonance Imaging
○ Most sensitive (~95%)
○ Changes can be seen early in
the course of disease when
other studies are negative
○ Reactive interface line: focal
serpentine low signal line with
fatty center; first sign on MRI
○ Double line sign: serpiginous
peripheral/outer dark
(sclerosis) and inner bright
(granulation tissue) on T2WI
● Radionuclide Bone Scanning Radiopaedia.org
UpToDate
V – TUMAMBING, MEA GLOR B/TOLETE, K.

Magnetic Resonance Imaging (MRI)

Coronal T1 Coronal T2
[Y] - Sioson, Yvette

Pathognomonic “Double Line Sign”

Retrieved from http://radiopaedia.org

[Y] - Sioson, Yvette V - TUMAMBING

Imaging
●
Modalities
Plain Film Radiography
● Magnetic Resonance Imaging
● Radionuclide Bone Scanning
○ Technetium 99m bone scan
○ For patients with suspected disease who have negative
radiographs, unilateral symptoms, and no risk factors
○ Doughnut sign: cold spot with surrounding high uptake
ring (surrounding hyperemia and adjacent synovitis)

Radiopaedia.org
UpToDate
[Y] - Sioson, Yvette V - TUMAMBING

Radionuclide Bone Scan

Retrieved from http://pubs.rna.org

P - Justine Vigo
/Christian Villacruzes Imaging for Osteonecrosis
Imaging
Comments Findings
Modality
Earliest findings: mild density changes, followed by sclerosis and
Can remain normal for cysts as the disease progresses
The pathognomonic crescent sign (subchondral radiolucency) is
Plain Film months after
evidence of subchondral collapse
Radiography symptoms of Later stages: reveal loss of sphericity or collapse of the femoral head
osteonecrosis begin Joint-space narrowing and degenerative changes in the acetabulum
are visible

Used for patients with

suspected disease
Increased bone turnover at the junction of dead and reactive
Radionuclide who have negative
bone results in increased uptake surrounding a cold area
Bone Scan radiographs, unilateral
(doughnut sign)
symptoms, and no risk
factors

The most sensitive Diffuse edema

Magnetic (~95%) modality and Reactive interface line
Resonance demonstrates changes Double line sign
Imaging well before plain films Rim sign
changes are visible. Secondary degenerative changes

(n.d.). Retrieved May 12, 2020, from Gaillard, F. (n.d.). Avascular necrosis: Radiology Reference
https://www.uptodate.com/contents/osteonecrosis- Article. Retrieved May 12, 2020, from
https://radiopaedia.org/articles/avascular-necrosis
P - Justine Vigo/Christian Villacruzes

Staging of Osteonecrosis
Ficat and Arlet Staging Steinberg Staging

Parsons, S. J., & Steele, N. (2007). Osteonecrosis of the

femoral head: Part 1—Aetiology, pathogenesis, investigation,
classification. Current Orthopaedics, 21, 457–463. doi:
10.1016/j.cuor.2007.11.004
P - Justine Vigo/Christian Villacruzes V - TUMAMBING