Osteonecrosis and Bone Infarction

Part of the Medical Radiology book series (MEDRAD)


Bone ischemia is a relatively common condition, which may be idiopathic or secondary to a variety of clinical situations. Medullary infarction refers to dia-metaphyseal location whereas osteonecrosis to the epiphyseal and sub-articular involvement. In both situations, the lesions may be radiographically occult. Magnetic resonance imaging (MRI) is very sensitive in identifying and characterizing bone ischemia. Newer treatments on femoral head osteonecrosis require early diagnosis, accurate staging, and estimation of prognosis and assessment of treatment. This chapter reviews the current and evolving knowledge on the various faces of bone ischemia with emphasis on the role of MRI on the clinically most important forms of the disease.


Femoral Head Bone Marrow Edema Acute Infarction Osteochondritis Dissecans Proximal Pole 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Ahlbäck S, Bauer GC, Bohne WH (1968) Spontaneous osteonecrosis of the knee. Arthr Rheum 11:705–733CrossRefGoogle Scholar
  2. Arce K, Assael LA, Weissman JL, Markiewitcz MR (2009) Imaging findings in bisphosphonate-related osteonecrosis of jaws. J Oral Maxillofac Surg 67(1):75–84PubMedCrossRefGoogle Scholar
  3. Assouline-Dayan Y, Chang C, Greenspan A et al (2002) Pathogenesis and natural history of osteonecrosis. Semin Arthr Rheum 32:94–124Google Scholar
  4. Barker DJ, Hall AJ (1986) The epidemiology of Perthes’ disease. Clin Orthop Relat Res 209:89–94PubMedGoogle Scholar
  5. Bassounas AE, Karantanas AH, Fotiadis DI, Malizos KN (2007) Femoral head osteonecrosis: volumetric MRI assessment and outcome. Eur J Radiol 63:10–15PubMedCrossRefGoogle Scholar
  6. Baur A, Stäbler A, Arbogast S, Duerr HR, Bartl R, Reiser M (2002) Acute osteoporotic and neoplastic vertebral compression fractures: fluid sign at MR imaging. Radiology 225:730–735PubMedCrossRefGoogle Scholar
  7. Beltran J, Burk JM, Herman LJ et al (1987) Avascular necrosis of the femoral head: early MRI detection and radiological correlation. Magn Reson Imaging 5:431–442PubMedCrossRefGoogle Scholar
  8. Beltran J, Herman LJ, Burk JM et al (1988) Femoral head avascular necrosis: MR imaging with clinical-pathologic and radionuclide correlation. Radiology 166:215–220PubMedGoogle Scholar
  9. Bianchi SD, Scoletta M, Cassione FB et al (2007) Computerized tomographic findings in bisphosphonate-associated osteonecrosis of the jaw in patients with cancer. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104:249–258PubMedCrossRefGoogle Scholar
  10. Chiandussi S, Biasotto M, Dore F et al (2006) Clinical and diagnostic imaging of bisphosphonate-associated osteonecrosis of the jaws. Dentomaxillofac Radiol 35:236–243PubMedCrossRefGoogle Scholar
  11. Coleman B, Kressel H, Dalinka M et al (1988) Radiographically negative avascular necrosis: detection with MR imaging. Radiology 168:525–528PubMedGoogle Scholar
  12. Cooney WP, Dobyns JH, Linscheid RL (1980) Fractures of the scaphoid: a rational approach to management. Clin Orthop 149:90–97PubMedGoogle Scholar
  13. Dailiana ZH, Zachos V, Varitimidis S et al (2004) Scaphoid nonunions treated with vascularised bone grafts: MRI assessment. Eur Radiol 50:217–224CrossRefGoogle Scholar
  14. Dillman JR, Hernandez RJ (2009) MRI of Legg-Calve-Perthes disease. AJR Am J Roentgenol 193:1394–1407PubMedCrossRefGoogle Scholar
  15. Duda SH, Laniado M, Schick F, Claussen CD (1993) The double-line sign of osteonecrosis: evaluation on chemical shift MR images. Eur J Radiol 16:233–238PubMedCrossRefGoogle Scholar
  16. Fordyce M, Solomon L (1993) Early detection of avascular necrosis of the femoral head by MRI. J Bone Jt Surg Br 75:365–367Google Scholar
  17. Fujioka M, Kubo T, Nakamura F et al (2001) Initial changes of non-traumatic osteonecrosis of femoral head in fat suppression images: bone marrow edema was not found before the appearance of band patterns. Magn Reson Imaging 19:985–991PubMedCrossRefGoogle Scholar
  18. Gardeniers JWM (1993) ARCO Committee on terminology and staging. Report on the committee meeting at Santiago de Compostella. ARCO Newsletter 5:79–82Google Scholar
  19. Genez BM, Wilson MR, Houk RW et al (1988) Early osteonecrosis of the femoral head: detection in high-risk patients with MR imaging. Radiology 168:521–524PubMedGoogle Scholar
  20. Hawkins LG (1970) Fractures of the neck of the talus. J Bone Jt Surg 52A:991–1002Google Scholar
  21. Hadjigeorgiou GM, Karantanas AH, Zibis A et al (2004) Increased frequency of white matter lesions in patients with osteonecrosis (WMLeOn) of the femoral head. Eur J Radiol 50:278–284PubMedCrossRefGoogle Scholar
  22. Hermann G, Singson R, Bromley M et al (2004) Cystic degeneration of medullary bone infarction evaluated with magnetic resonance imaging correlated with pathologic examination. Can Assoc Radiol J 55:321–325PubMedGoogle Scholar
  23. Huang GS, Chan WP, Chang YC et al (2003) MR imaging of bone marrow edema and joint effusion in patients with osteonecrosis of the femoral head: relationship to pain. AJR Am J Roentgenol 181:545–549PubMedGoogle Scholar
  24. Iida S, Harada Y, Shimizu K, Sakamoto M, Ikenoue S, Akita T, Kitahara H, Moriya H (2000) Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis. AJR Am J Roentgenol 174:735–743PubMedGoogle Scholar
  25. Ito H, Matsuno T, Minami A (2006) Relationship between bone marrow edema and development of symptoms in patients with osteonecrosis of the femoral head. AJR Am J Roentgenol 186:1761–1770 CrossRefGoogle Scholar
  26. Karantanas AH (2007) Acute bone marrow edema of the hip: role of MR imaging. Eur Radiol 17:2225–2236PubMedCrossRefGoogle Scholar
  27. Karantanas A, Dailiana Z, Malizos K (2007) The role of MR imaging in scaphoid disorders. Eur Radiol 17:2860–2871PubMedCrossRefGoogle Scholar
  28. Karantanas AH, Drakonaki E, Karachalios T, Korompilias AV, Malizos K (2008) Acute non-traumatic marrow edema syndrome in the knee: MRI findings at presentation, correlation with spinal DEXA and outcome. Eur J Radiol 67:22–33PubMedCrossRefGoogle Scholar
  29. Karantanas AH, Drakonaki EE (2011) The role of MR imaging in avascular necrosis of the femoral head. Semin Musculoskelet Radiol 15:281–300PubMedCrossRefGoogle Scholar
  30. Kattapuram TM, Kattapuram SV (2008) Spontaneous osteonecrosis of the knee. Eur J Radiol 67:42–48PubMedCrossRefGoogle Scholar
  31. Kim YM, Ahn JH, Kang HS, Kim HJ (1998) Estimation of the extent of osteonecrosis of the femoral head using MRI. J Bone Jt Surg Br 80B:954–958CrossRefGoogle Scholar
  32. Kim YM, Oh HC, Kim HJ (2000) The pattern of bone marrow oedema on MRI in osteonecrosis of the femoral head. J Bone Jt Surg Br 82:837–841CrossRefGoogle Scholar
  33. Koo K-H, Kim R (1995) Quantifying the extent of osteonecrosis of the femoral head. A new method using MRI. J Bone Jt Surg Br 77B:875–880Google Scholar
  34. Koo KH, Ahn IO, Kim R et al (1999) Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images. Radiology 213:715–722PubMedGoogle Scholar
  35. Kopecky KK, Braunstein EM, Brandt KD et al (1991) Apparent avascular necrosis of the hip: appearance and spontaneous resolution of MR findings in renal allograft recipients. Radiology 179:523–527PubMedGoogle Scholar
  36. Koren A, Garty I, Katzuni E (1984) Bone infarction in children with sickle cell disease: early diagnosis and differentiation from osteomyelitis. Eur J Pediatr 142:93–97PubMedCrossRefGoogle Scholar
  37. Kubo T, Yamazoe S, Sugano N et al (1997) Initial MRI findings of non-traumatic osteonecrosis of the femoral head in renal allograft recipients. Magn Reson Imaging 15:1017–1023PubMedCrossRefGoogle Scholar
  38. Lamer S, Dorgeret S, Khairouni A et al (2002) Femoral head vascularisation in Legg-Calvé-Perthes disease: comparison of dynamic gadolinium-enhanced subtraction MRI with bone scintigraphy. Pediatr Radiol 32:580–585PubMedCrossRefGoogle Scholar
  39. Libicher M, Appelt A, Berger I et al (2007) The intravertebral vacuum phenomen as specific sign of osteonecrosis in vertebral compression fractures: results from a radiological and histological study. Eur Radiol 17:2248–2252PubMedCrossRefGoogle Scholar
  40. Malizos KN, Siafakas MS, Fotiadis DI, Karachalios TS, Soucacos PN (2001) An MRI-based semiautomated volumetric quantification of hip osteonecrosis. Skeletal Radiol 30:686–693PubMedCrossRefGoogle Scholar
  41. Malizos KN, Zibis AH, Dailiana Z, Hantes M, Karachalios T, Karantanas AH (2004) MR imaging findings in transient osteoporosis of the hip. Eur J Radiol 50:238–244PubMedCrossRefGoogle Scholar
  42. Malizos KN, Karantanas AH, Varitimidis SE et al (2007a) Osteonecrosis of the femoral head: etiology, imaging and treatment. Eur J Radiol 63:16–28PubMedCrossRefGoogle Scholar
  43. Malizos KN, Zachos V, Dailiana ZH, Zalavras C, Varitimidis S, Hantes M, Karantanas A (2007b) Scaphoid nonunions: management with vascularized bone grafts from the distal radius: a clinical and functional outcome study. Plast Reconstr Surg 119:1513–1525PubMedCrossRefGoogle Scholar
  44. Matsuno T, Kaneda K, Takeda N (1996) Development of angiosarcoma at the site of a bone infarct. Clin Orthop Relat Res 327:259–263PubMedCrossRefGoogle Scholar
  45. McKiernan F, Faciszewski T (2003) Intravertebral clefts in osteoporotic vertebral compression fractures. Arthr Rheum 48:14149CrossRefGoogle Scholar
  46. Merlini L, Combescure C, De Rosa V, Anooshiravani M, Hanquinet S (2010) Diffusion-weighted imaging findings in Perthes disease with dynamic gadolinium-enhanced subtracted (DGS) MR correlation: a preliminary study. Pediatr Radiol 40:318–325PubMedCrossRefGoogle Scholar
  47. Min BW, Song KS, Cho CH, Lee SM, Lee KJ (2008) Untreated asymptomatic hips in patients with osteonecrosis of the femoral head. Clin Orthop Relat Res 466:1087–1092PubMedCrossRefGoogle Scholar
  48. Mirra MJ, Gold RH, Marafiote R (1977) Malignant (fibrous) histiocytoma arising in association with a bone infarct in sickle cell disease: coincidence or cause-and -effect? Cancer 39:186–194PubMedCrossRefGoogle Scholar
  49. Mitchell DG, Rao VM, Dalinka MK et al (1987) Femoral head avascular necrosis: correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings. Radiology 162:709–715PubMedGoogle Scholar
  50. Mont MA, Hungerford DS (1995) Non-traumatic avascular necrosis of the femoral head. J Bone Jt Surg Am 77:459–474Google Scholar
  51. Morag Y, Morag-Hezroni M, Jamadar DA et al (2009) Bisphospnonate-related osteonecrosis of the jaw: a pictorial review. Radiographics 29:1971–1986PubMedCrossRefGoogle Scholar
  52. Norman A, Steiner GC (1983) Radiographic and morphological features of cyst formation in idiopathic bone infarction. Radiology 146:335–338PubMedGoogle Scholar
  53. Ohzono K, Saito M, Sugano N et al (1992) The fate of nontraumatic avascular necrosis of the femoral head: a radiologic classification to formulate prognosis. Clin Orthop Relat Res 277:73–78PubMedGoogle Scholar
  54. Pape D, Seil R, Anagnostakos K, Kohn D (2007) Postarthroscopic osteonecrosis of the knee. Arthroscopy 23:428–438PubMedCrossRefGoogle Scholar
  55. Pearce DH, Mongiardi CN, Fornasier VL, Daniels TR (2005) Avascular necrosis of the talus: a pictorial essay. Radiographics 25:399–410PubMedCrossRefGoogle Scholar
  56. Radke S, Kirschner S, Seipel V, Rader C, Eulert J (2004) Magnetic resonance imaging criteria of successful core decompression in avascular necrosis of the hip. Skeletal Radiol 33:519–523PubMedCrossRefGoogle Scholar
  57. Rao VM, Fishman M, Mitchell DG et al (1986) Painful sickle cell crisis: bone marrow patterns observed with MR imaging. Radiology 161:211–215PubMedGoogle Scholar
  58. Sagar P, Shailam R, Nimkin K (2010) Avascular necrosis of the metacarpal head: a report of two cases and review of literature. Pediatr Radiol 40:1895–1901PubMedCrossRefGoogle Scholar
  59. Saini A, Saifuddin A (2004) MRI of osteonecrosis. Clin Radiol 59:1079–1093PubMedCrossRefGoogle Scholar
  60. Saito S, Ohzono K, Ono K (1988) Minimal osteonecrosis as a segmental infarct within the femoral head. Clin Orthop Relat Res 231:35–50PubMedGoogle Scholar
  61. Schmidt GP, Reiser MF, Baur-Melnyk A (2009) Whole-body imaging of bone marrow. Semin Musculoskelet Radiol 13:120–133PubMedCrossRefGoogle Scholar
  62. Schmitt R, Heinze A, Fellner F et al (1997) Imaging and staging of avascular osteonecroses at the wrist and hand. Eur J Radiol 25:92–103PubMedCrossRefGoogle Scholar
  63. Schmitt R, Christopoulos G, Wagner M et al (2011a) Avascular necrosis (AVN) of the proximal fragment in scaphoid nonunion: Is intravenous contrast agent necessary in MRI? Eur J Radiol 77:222–227PubMedCrossRefGoogle Scholar
  64. Schmitt R, Frohner S, van Schoonhovenb J et al (2011b) Idiopathic osteonecrosis of the scaphoid (Preiser’s disease)—MRI gives new insights into etiology and pathology. Eur J Radiol 77:228–234PubMedCrossRefGoogle Scholar
  65. States LJ (2001) Imaging of metabolic bone disease and marrow disorders in children. Radiol Clin North Am 39:749–772PubMedCrossRefGoogle Scholar
  66. Steinberg ME, Brighton CT, Hayken GD, Tooze SE, Steinberg DR (1984) Early results in the treatment of avascular necrosis of the femoral head with electrical stimulation. Orthop Clin North Am 15:163–175PubMedGoogle Scholar
  67. Steinberg ME, Bands RE, Parry S, Hoffman E, Chan T, Hartman KM (1999) Does lesion size affect the outcome in avascular necrosis? Clin Orthop Relat Res 367:262–271PubMedCrossRefGoogle Scholar
  68. Steinberg ME, Steinberg DR (2004) Classification systems for osteonecrosis: an overview. Orthop Clin North Am 35:273–283 vii–viiiPubMedCrossRefGoogle Scholar
  69. Steinberg ME, Hayken GD, Steinberg DR (1995) A quantitative system for staging avascular necrosis. J Bone Jt Surg Am 77B:34–41Google Scholar
  70. Steiner RM, Mitchell DG, Rao VM et al (1990) Magnetic resonance imaging of bone marrow: diagnostic value in diffuse hematologic disorders. Magn Reson Q 6:17–34PubMedGoogle Scholar
  71. Stevens K, Tao C, Lee SU et al (2003) Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol 180:363–368PubMedGoogle Scholar
  72. Sugimoto H, Okubo RS, Ohsawa T (1992) Chemical shift and the double-line sign in MRI of early femoral avascular necrosis. J Comput Assist Tomogr 16:727–730PubMedCrossRefGoogle Scholar
  73. Theodorou DJ, Theodorou SJ, Haghighi P, Resnick D (2002) Distinct focal lesions of the femoral head: imaging features suggesting an atypical and minimal form of bone necrosis. Skeletal Radiol 31:435–444PubMedCrossRefGoogle Scholar
  74. Torres FX, Kyriakos M (1992) Bone infarct-associated osteosarcoma. Cancer 70:2418–2430PubMedCrossRefGoogle Scholar
  75. Tosun B, Al F, Tosun A (2011) Spontaneous osteonecrosis of the tarsal navicular in an adult: Mueller-Weiss syndrome. J Foot Ankle Surg 50:221–224PubMedCrossRefGoogle Scholar
  76. Turner DA, Templeton AC, Selzer PM, Rosenberg AG, Petasnick JP (1989) Femoral capital osteonecrosis: MR finding of diffuse marrow abnormalities without focal lesions. Radiology 171:135–140PubMedGoogle Scholar
  77. Umans H, Haramati N, Flusser G (2000) The diagnostic role of gadolinium enhanced MRI in distinguishing between acute medullary bone infarct and osteomyelitis. Magn Reson Imaging 18:255–262PubMedCrossRefGoogle Scholar
  78. Yamamoto T, Bullough PG (2000) Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Jt Surg Am 82:858–866CrossRefGoogle Scholar
  79. Zhao FC, Li ZR, Zhang NF et al (2010) Lesion size changes in osteonecrosis of the femoral head: a long-term prospective study using MRI. Int Orthop 34:799–804PubMedCrossRefGoogle Scholar
  80. Zibis AH, Karantanas AH, Roidis NT et al (2007) The role of MR imaging in staging femoral head osteonecrosis. Eur J Radiol 63:3–9PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Department of RadiologyHinchingbrooke HospitalHuntingdon, CambridgeshireUK
  2. 2.Department of Medical ImagingUniversity Hospital, University of CreteHeraklionGreece

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