Associated Risk Factors, Pathogenesis, Diagnosis, and Treatment Options for Multifocal Osteonecrosis: A Systematic Review

Abstract

Background: Multifocal osteonecrosis (MFON) is defined as the diagnosis of osteonecrosis in at least three distinct anatomic sites that can occur consecutively or concurrently. It is important for arthroplasty surgeons to be aware of and manage these patients appropriately. There is a paucity of data surrounding the characterization, diagnosis, and treatment of MFON. The purpose of this investigation was to systematically review the literature to identify: (1) clinical presentation/epidemiology, (2) pathophysiology, (3) diagnostic modalities, and (4) treatment guidelines/algorithms of MFON.

Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review across three databases, resulting in a total of 12 articles. Articles met the inclusion criteria if they provided data regarding: (1) clinical presentation/epidemiology, (2) pathophysiology, (3) diagnostic modalities, and (4) treatment guidelines/algorithms of MFON.

Results: There are many etiologies of MFON, though autoimmune diseases such as lupus and prior use of corticosteroids are most commonly implicated in the disease. The femoral head is the most common anatomic site involved, though other joints such as the knee, shoulder, and ankle can be commonly affected. Diagnosis is reserved for standard radiography and whole-body magnetic resonance imaging (MRI) for screening, with regional MRI reserved for additional staging of the disease. Treatment is similar to standard single or oligofocal osteonecrosis and involves joint preservation procedures if the joints are found before collapse and the use of arthroplasty following collapse if nonoperative modalities fail.

Conclusions: Although MFON is a rare clinical condition, it is one that arthroplasty surgeons should be aware of and meticulously screen for in their patients. It is defined as the presence of osteonecrosis in three or more distinct anatomic sites either concurrently or consecutively. Arthroplasty surgeons should be wary of patients who have osteonecrosis and should be meticulous in screening these patients for multiple joint involvement.

Keywords: femoral head; multifocal; osteonecrosis; screening; whole-body MRI.