The Journal of Bone and Joint Surgery 82:1279 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Atraumatic Osteonecrosis of the Knee*
Michael A. Mont, M.D.,
Keith M. Baumgarten, M.D.,
Aiman RifaI, D.O.,
David A. Bluemke, M.D.Ph.D.,
Lynne C. Jones, Ph.D. and
David S. Hungerford, M.D.
Investigation performed at the Division of Arthritis Surgery,
Department of Orthopaedic Surgery, The Johns Hopkins University
School of Medicine, Baltimore, Maryland
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
Division of Arthritis Surgery, Department of Orthopaedic Surgery,
The Johns Hopkins University School of Medicine, The Good Samaritan
Hospital, Professional Office Building, G-1, 5601 Loch Raven Boulevard,
Baltimore, Maryland 21239. E-mail address for M. A. Mont: rhondamont{at}aol.com
Background: The purposes of this study were
to define the clinical, demographic, and radiographic patterns of atraumatic
osteonecrosis of the distal part of the femur and the proximal part
of the tibia at presentation and to report the outcome of treatment
of this condition.
Methods: Two hundred and forty-eight knees in
136 patients who were younger than the age of fifty-five years were
treated at our institution between July 1, 1974, and September 15,
1998, for atraumatic osteonecrosis of the distal part of the femur
or the proximal part of the tibia, or both. Demographic and radiographic
features were characterized. The results of nonoperative treatment,
core decompression, arthroscopic dÈbridement, and total knee arthroplasty
were evaluated.
Results: There were 106 female patients and
thirty male patients, and their mean age was thirty-six years (range,
fifteen to fifty-four years) at the time of diagnosis. One hundred
and one patients (74 percent) had involvement of other large joints,
with eighteen (13 percent) presenting initially with knee symptoms.
One hundred and one patients (74 percent) had a disease that affected
the immune system; sixty-seven of them had systemic lupus erythematosus.
One hundred and twenty-three patients (90 percent) had a history
of corticosteroid use. Technetium-99m bone-scanning missed lesions
in sixteen (29 percent) of fifty-six knees. Eight (20 percent) of
forty-one initially symptomatic knees treated nonoperatively had
a successful clinical outcome (a Knee Society score of at least 80
points and no additional surgery) at a mean of eight years. The
knees that remained severely symptomatic for three months were treated
with either core decompression (ninety-one knees) or total knee
arthroplasty (seven knees). Seventy-two (79 percent) of the ninety-one
knees treated with core decompression had a good or excellent clinical
outcome at a mean of seven years. Efforts to avoid total knee arthroplasty
with repeat core decompression or arthroscopic dÈbridement led to
a successful outcome in fifteen (60 percent) of twenty-five knees.
Thirty-four (71 percent) of forty-eight knees treated with total
knee arthroplasty had a successful clinical outcome at a mean of
nine years.
Conclusions: Atraumatic osteonecrosis of the
knee predominantly affects women, and in our study it was associated
with corticosteroid use in 90 percent of the patients. Evaluation
should include standard radiographic and magnetic resonance imaging
of all symptomatic joints. Prognosis was negatively related to large
juxta-articular lesions. Nonoperative treatment should be reserved
for asymptomatic knees only. Core decompression was successful (a
Knee Society score of at least 80 points and no additional surgery)
in 79 percent of the knees in which the disease was in an early
stage. Total knee arthroplasty was successful in only 71 percent
of the knees.
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