The Stages of Osteonecrosis

April 06, 2013

A post about stages of osteonecrosis (a complication of lupus), needs an introductory explanation of WHAT osteonecrosis-or avascular necrosis-is. Basically, osteonecrosis is the condition that results when the blood supply to bones is cut off, often by a tiny blood clot caused by lupus. Lupus can cause tiny blood clots to  form, and therefore, this is a complication of this autoimmune disease.


“Stages of Osteonecrosis (Avascular Necrosis)

Osteonecrosis (Avascular Necrosis) is classified in stages referring to how far the disease has progressed. There are the Ficat and the Steinberg Classification systems. Most orthopedic doctors use the Ficat classification system to determine at what stage your disease is. The stages are as follows:

Stage I: 

  • X-Ray: ON (AVN) is not detectable.
  • MRI: there might appear slight bone marrow edema or joint effusion. Joint effusion most commonly appears in the knees.
  • Bone Scan: evidence of increased uptake. Increased uptake is mainly due to increased activity of osteoblasts (cells responsible for bone formation) associated with new bone formation, and to a lesser degree by increased blood flow to bone. Increased uptake is an indication that there might be a tumor, fracture or infection.

Stage II:

  • X-Ray: mixed osteopenia, a condition where bone mineral density is lower than normal, or evidence of sclerosis.
  • MRI: evidence of lesion; an abnormality in bone tissue.
  • Bone Scan: increased uptake (see note above).

Stage III:

  • X-ray & MRI: bone collapse of joint appears imminent.

Stage IV:

  • X-ray & MRI: collapse of joint.
Image taken from the Journal of the American Academy of Orthopaedic Surgeons

To learn more click here: Ficat Classification and Steinberg Classification

A lot of websites, talking about Ficat Classification, refer to the level of pain at each stage of the disease. One indication of early ON (AVN) in the hips is pain in the groin. However, it appears to me that the pain differs from one ON (AVN) sufferer to another. My ON (AVN) is in my distal femurs and the first time I felt pain was in my knee caps.  As the disease worsened the pain ran like hot rods up and down my thighs.Take into account that every body is different.”

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5 thoughts on “The Stages of Osteonecrosis

  1. My wife has had lupus for several years. She developed AVN in both her hips and both shoulders, all of which have been replaced. She has been told by her doctors that the AVN was caused by PREDNISONE, a steroid, which was prescribed for her to combat the lupus. I have not previously heard any professional medical opinion to the effect that AVN was a side-effect of–or was caused by–lupus. I have, however, heard that asthma patients, who also are prescribed Prednisone, have also developed AVN in joints. I question whether AVN is “caused” by lupus or is a result of having lupus. I would recommend that ANYONE who is prescribed Prednisone should question their doctor on this issue.

  2. Gary, lupus can cause clots to form, often in a condition called antiphospholipid syndrome. It often disrupts pregnancies, causing miscarriages because of the clots it forms. There are a lot of blood disorders that can cause clots, one of which is Factor V Leiden (I think) , but I do know antiphospholipd syndrome (APS) does. I have APS and am on lifetime coumadin. It is thought (or at least surmised) that the way steroids (used for asthma and often in the treatment of lupus or Crohn’s) cause AVN is because they disturpt fat metabolism and cause fatty clots, but ANYTHING that causes blood to clot or any kind of a clot (divers who get the ‘bends’ have nitrogen clots and they can develop AVN. It is a ROTTEN disease, and you can’t always know the cause because there are so many causes of AVN. I hope Robin is ok; you seem to be so invested in her care and she’s lucky! There’s a whole organization, THe Antiphosolipid Syndrome Association of America (APA) that exists. I think their website is Annie


  4. Why don't docs inform patients of abnormalities to tell their PCP about? They should. They should educate or someone in their office should make sure that the patient knows what was found by a doc the PCP referred a patient to. Something is wrong when that piece of the puzzle doesn't get put into place. That's like sending a patient to a rheumatologist for his/her expert opinion but the rheumatologist never sending back notes or a letter of WHAT he found. Not good medical practice and I don't know the laws governing physicians, but that is more than a courtesy. To me, it borders on medical malpractice.

    But, the patient should always know what he sees a specialist for and what the outcome of that visit was. For too long, we were coddled by Marcus Welby kinds of docs. Well, that's not the way healthcare is going anymore and healthcare is becoming more consumer driven. With a more consumer-driven system, though, come more responsibilities of the consumer (patient). To make sure that he/she gets those results if the specialist isn't going to get them to the PCP.

  5. I don’t have Lupus, but I know how painful and devastating this disease can be for people. A really good friend of mine suffered from Lupus. The drugs she took cause her to have excessive hair growth on her face and chest. It was very said because she was really young (early twenties) and wanted desperately to have a family. Because of the disease she wasn’t able conceive for years. She finally tried some different drug to help prevent blood clots and help increase her fertility. She did finally get pregnant and had a healthy baby girl. About a year later without the help of drugs she got pregnant again and had another girl. They are her life now and she feels so blessed.

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