Avascular necrosis (AVN), also known as osteonecrosis, is a condition where bone tissue dies because its blood supply has been interrupted. This loss of blood flow causes the bone to weaken and eventually collapse, often leading to joint destruction and severe pain. The disease most frequently affects the ends of long bones, particularly the femoral head in the hip joint. Because AVN progression depends heavily on the stage of diagnosis, treatment requires a specialized, coordinated approach involving several medical professionals.
Initial Diagnosis and Referral
The patient’s journey often begins with a primary care physician (PCP) or general practitioner who evaluates persistent joint pain unresponsive to standard care. These providers screen for risk factors such as high-dose steroid use, heavy alcohol consumption, or a history of trauma, which raise suspicion for AVN. If the physical exam reveals limited range of motion or joint tenderness, the PCP refers the patient to specialists for definitive diagnosis.
Diagnosis is confirmed through advanced imaging, which is the domain of the radiologist. While early-stage X-rays may appear normal, the radiologist relies on magnetic resonance imaging (MRI) as the standard, given its high sensitivity for detecting subtle changes in bone marrow. The radiologist stages the disease based on imaging findings, determining if the affected bone has already collapsed or if it is still intact. This staging is essential for guiding treatment, separating patients into groups requiring conservative care versus those who need surgical intervention.
Conservative Management Specialists
For avascular necrosis detected in its earliest stages, before the bone surface has collapsed, specialists focus on non-surgical methods to relieve pain and slow disease progression. A rheumatologist often manages the underlying systemic causes of AVN, such as autoimmune conditions or blood disorders contributing to reduced blood flow. They may prescribe medications like bisphosphonates, which inhibit bone-resorbing cells to help prevent bone collapse.
Pain management specialists provide pharmacological interventions to alleviate discomfort and improve function. This includes prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) or performing image-guided injections directly into the joint space. Physical therapists are also integral, designing low-impact exercise programs that maintain joint mobility and muscle strength without placing excessive stress on the affected bone. They focus on non-weight-bearing exercises and may instruct the patient on the proper use of crutches to restrict weight-bearing for several months.
Surgical Treatment Experts
When conservative treatments fail or if AVN is diagnosed after the bone has begun to collapse, the primary treatment falls to orthopedic surgeons. Patients require a specialist with specific expertise in joint preservation or reconstruction, not a general orthopedic surgeon. The choice of surgical procedure is determined by the stage of the disease and the extent of the bone damage.
For pre-collapse lesions, a joint-preserving procedure like core decompression is often recommended, performed by surgeons specializing in hip or joint preservation. This technique involves drilling a small channel into the dead bone area to relieve pressure and create pathways for new blood vessels to grow. It is sometimes combined with the injection of bone marrow aspirate concentrate. Another procedure, an osteotomy, involves cutting and repositioning the bone to shift the weight-bearing load away from the damaged area, requiring advanced training in bone reshaping.
If the bone has collapsed significantly, the definitive treatment is a joint replacement procedure, such as a total hip arthroplasty. This is performed by an orthopedic surgeon with a subspecialty in adult joint reconstruction. This involves removing the damaged joint components and replacing them with metal and plastic implants. The high volume of these complex procedures ensures the necessary precision for optimal long-term function and implant longevity. In rare cases involving bone tumors, an orthopedic oncologist may be involved to manage both the necrosis and the underlying cancer.
Post-Surgical Rehabilitation
Following surgery, a coordinated rehabilitation team takes over to restore function. A Physical Medicine and Rehabilitation (PM&R) physician, or physiatrist, acts as the medical leader of this team, overseeing the patient’s comprehensive recovery plan. They manage medical issues related to recovery, such as pain control and bracing, while coordinating the efforts of other therapists.
Physical therapists focus on restoring the full range of motion, rebuilding muscle strength around the treated joint, and progressively reintroducing weight-bearing activities. Occupational therapists teach the patient how to safely perform activities of daily living, such as dressing and bathing, often using adaptive equipment to protect the joint during recovery. Specialized rehabilitation nurses provide direct care and education on incision management and medication adherence during the transition back to the home environment.