The Journal of Bone and Joint Surgery 82:858 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Spontaneous Osteonecrosis of the Knee: The Result of Subchondral Insufficiency Fracture*
Takuaki Yamamoto, M.D., Ph.D. and
Peter G. Bullough, M.B., Ch.B.
Investigation performed at the Department of Orthopaedic
Pathology, The Hospital for Special Surgery, New York, N.Y.
*Although none of the authors has received or will receive benefits
for personal or professional use from a commercial party related
directly or indirectly to the subject of this article, benefits
have been or will be received but are directed solely to a research
fund, foundation, educational institution, or other nonprofit organization
with which one or more of the authors is associated. Funds were
received in total or partial support of the research or clinical
study presented in this article. The funding sources were a Research
Fellowship from Sumitomo Life Social Welfare Services Foundation
and a Grant-in-Aid for JSPS Fellows.
Department of Orthopaedic Surgery, Graduate School of Medical
Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka
812-8582 Japan. E-mail address: yamataku{at}ortho.med.kyushu-u.ac.jp
Department of Laboratory Medicine, The Hospital for Special Surgery,
535 East 70th Street, New York, N.Y. 10021. E-mail address: bulloughp@hss.edu.
Background: Spontaneous osteonecrosis of
the knee is a superficial subchondral lesion classically seen in
the medial femoral condyle; in general, it is markedly different
in its clinicopathological presentation from the classic wedge-shaped
subchondral osteonecrotic lesions seen in the hip, knee, and other joints.
Recent reports on subchondral insufficiency fracture of the femoral
head, which has marked morphological similarities with spontaneous
osteonecrosis of the knee, led us to reevaluate a series of patients
who had had operative treatment because of a clinical and pathological
diagnosis of spontaneous osteonecrosis of the knee.
Methods: We reviewed the cases of fourteen patients
who had had operative treatment of spontaneous osteonecrosis of
the knee in order to reevaluate the gross and histological morphology
of this lesion. The patients included eight women and six men who
ranged in age from fifty-nine to eighty-eight years. In all patients,
the diagnosis of spontaneous osteonecrosis of the knee had been
based on clinical presentation, imaging studies, and pathological findings.
The appearance of the lesion on plain radiographs was categorized
into four stages, which corresponded to the gross and histological
findings. In stage 1, the radiographic appearance is normal; in
stage 2, a radiolucent oval area is seen subchondrally or there
is slight flattening of the convexity of the condyle, or both; in
stage 3, the radiolucent area is expanded and is surrounded by a
sclerotic halo; and in stage 4, secondary osteoarthritic changes
are apparent.
Results: No patient had a stage-1 lesion. Three
patients, all of whom had a stage-2 lesion, were considered to have
a subchondral insufficiency fracture of the medial femoral condyle.
Another six patients, all of whom had a stage-3 lesion, were considered
to have a subchondral fracture and associated focal osteonecrosis
that was confined to the area between the fracture line and the
articular surface. The remaining five patients, three of whom had
a stage-3 lesion and two of whom had a stage-4 lesion, had indeterminate
findings because the lesion had become detached from the condyle.
Conclusions: Our histopathological findings
suggest that the primary event leading to spontaneous osteonecrosis
of the knee is a subchondral insufficiency fracture and that the
localized osteonecrosis seen in association with this disease is
the result of a fracture.
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