Osteonecrosis of the Knee

Knee pain has many causes. A relatively common cause of knee pain in older women occurs when a segment of bone loses its blood supply and begins to die. This condition is called osteonecrosis, which literally means "bone death." In the knee, the knobby portion of the thigh bone on the inside of the knee is most often affected. However, osteonecrosis of the knee may also occur on the outside of the knee or on the flat top of the lower leg bone.

Osteonecrosis of the knee develops through four stages, which can be identified by symptoms and X-rays:

  • Stage I: Symptoms are most intense in the earliest stage and may continue for six to eight weeks before subsiding. Because X-rays are normal, a positive bone scan is needed to make the diagnosis. Treatment at this point is non-operative and conservative, focusing on pain relief and protected weight-bearing.
  • Stage II: It may take several months for the disease to progress to Stage II. At this point, X-rays will show that the rounded edge of the thighbone is starting to flatten out. An MRI or bone scan can be used to diagnose the disease. A CT scan may also be used to measure the affected area of bone area.
  • Stage III: By the time the disease reaches stage III (three to six months after onset), it is clearly visible on X-rays, and no other diagnostic tests are needed. The articular cartilage covering the bone begins to loosen as the bone itself begins to die. Operative treatments may be considered at this point.
  • Stage IV: At this point, the bone begins to collapse. The articular cartilage is destroyed, the joint space narrows, and bone spurs may form. Severe osteoarthritis results and joint replacement surgery may be necessary.


The exact cause of the disease is not yet known. One theory is that a stress fracture, combined with a specific activity or trauma, results in an altered blood supply to the bone. Another theory supposes that a buildup of fluid within the bone puts pressure on blood vessels and diminishes circulation. More than three times as many women as men are affected; most are over 60 years of age.

Osteonecrosis of the knee is also associated with certain conditions and treatments, such as obesity, sickle cell anemia, lupus, kidney transplants, and steroid therapy. Steroid-induced osteonecrosis frequently affects multiple joints and is usually seen in young patients. Regardless of the cause, if the disease is not identified and treated early, it can develop into severe osteoarthritis.


  • Sudden pain on the inside of the knee, perhaps triggered by a specific activity or minor injury.
  • Increased pain at night and with activity.
  • Swelling over the front and inside of the knee.
  • Heightened sensitivity to touch in the area.
  • Limited motion due to pain.


In the early stages of the disease, treatment is non-operative. If the affected area is small, this treatment may be all that is needed. Options include:

  • Medications to reduce the pain
  • A brace to relieve pressure on the joint surface.
  • A conditioning program with exercises to increase the strength of the muscles in your thighs.
  • Activity modifications to reduce knee pain.

If more than half of the bone surface is affected, you may need surgical treatment. Several different procedures may be used to treat osteonecrosis of the knee. Among the surgical options are:

  • Arthroscopic cleansing (debridement) of the joint.
  • Drilling to reduce pressure on the bone surface.
  • Procedures to shift weight-bearing away from the affected area.
  • Replacement of one or both joint surfaces.

Your orthopedic surgeon will discuss the options with you and make a recommendation based on your individual situation.

Reproduced with permission Fischer S., (interim ed): Your Orthopaedic Connection. Rosemont, Illinois. Copyright American Academy of Orthopaedic Surgeons.