Osteonecrosis

Osteonecrosis is a painful condition that involves the death of bone cells due to decreased blood flow. It is also called avascular necrosis (AVN) or aseptic necrosis. It is a painful condition that is most commonly occurring in the hips or knees and is often more symptomatic with any gravity-dependent activities, such as walking. Shoulders, hands, ankles and feet are less often affected. Rarely, osteonecrosis affects the jaw in the context of Medication-Related Osteonecrosis of the Jaw (MRONJ) due to medications like bisphosphonates (like alendronate, zolendronic acid) or denosumab used for osteoporosis. Corticosteroid use, heavy drinking, lupus and severe trauma or injury may cause osteonecrosis. Rarer causes of osteonecrosis include HIV, decompression disease (“the bends”), blood disorders such as sickle cell anemia, radiation therapy, and organ transplant.

What Are the Signs/ Symptoms?

Osteonecrosis usually occurs between the ages of 20 and 50 years and an early sign of osteonecrosis is local pain in the affected bone or joint. Hip osteonecrosis may cause pain in the groin. Pain from hip or knee osteonecrosis may be worse during weight-bearing or walking. Nearby joints may develop osteoarthritis. Diagnosis of osteonecrosis begins with an X-ray of the painful area usually followed by a bone scans or a magnetic resonance imaging (MRI) for better evaluation.

What Are Common Treatments?

Treatment of osteonecrosis depends on how early it’s caught. Early osteonecrosis includes modifying activity to reduce weightbearing on affected joints and pain medications based on severity of active symptoms. Patients with worsening osteonecrosis may have core decompression surgery (drilling small channels into the bone to reduce pressure and improve blood flow), bone grafting surgery (dead bone is removed and replaced with healthy bone from another part of the body to restore blood flow) or osteotomy surgery (cutting and repositioning the bone to reduce stress on the damaged part). Patients with bone collapse may need total joint replacement of the hip or knee. Some studies show short-term bisphosphonate treatment may slow, improve or prevent bone collapse in the hip or knee.

Care/Management Tips

Steps to prevent osteonecrosis include reducing corticosteroid doses and avoiding heavy drinking and the use of tobacco. If patients must take corticosteroids, they should take the smallest possible dose for the shortest time necessary. Smoking and alcohol consumption also raise the risk of osteonecrosis and are adjustable risk factors to lower risk.

Updated September 2025 by Pankti Reid, MD, MPH, and reviewed by the American College of Rheumatology Communications and Marketing Committee.

This information is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.