For many patients diagnosed with avascular necrosis, the treatment pathway begins with a troubling reality. The disease is often discovered after damage has already started.
Blood supply to the bone becomes compromised. Bone tissue begins to die. Over time, the joint weakens, collapses and, for many patients, eventually requires replacement. The conversation that follows is frequently less about preserving the joint than preparing for its eventual failure.
Daniel Wiznia, MD, associate professor of orthopedics and rehabilitation at New Haven Conn.-based Yale School of Medicine and co-director of Yale’s Avascular Necrosis & Osteonecrosis Program, believes that paradigm has persisted for far too long.
“It’s a neglected disease,” Dr. Wiznia told Becker’s. “I don’t think we teach residents enough about AVN, and I don’t think we teach specialists enough about AVN.”
For years, many patients diagnosed with avascular necrosis were told some version of the same thing: wait. Wait until symptoms become severe enough. Wait until the bone collapses. Wait until a joint replacement becomes unavoidable.
“When I first started treating avascular necrosis, patients were often told, ‘You’re going to need a hip replacement eventually, so come back when your hip collapses,'” Dr. Wiznia said.
At Yale, the goal is fundamentally different. The program was built around a question that has historically received far less attention: How can physicians preserve a patient’s native joint before collapse occurs?
The question many patients never get answered
One of the first surprises Dr. Wiznia encountered while building Yale’s AVN program had little to do with surgery. It was how often patients arrived without a clear understanding of why they developed the disease in the first place.
Avascular necrosis can be linked to a wide range of underlying conditions, including sickle cell disease, autoimmune disorders, cancer treatments, steroid exposure, coagulation abnormalities and metabolic disease. Yet many patients spend years navigating orthopedic care without a comprehensive evaluation of the root cause.
For Dr. Wiznia, that represents a missed opportunity. Rather than treating AVN solely as an orthopedic problem, Yale built a program that brings together specialists across hematology, rheumatology, endocrinology, oncology and hyperbaric medicine. The approach reflects a reality he says becomes obvious once physicians begin caring for large numbers of AVN patients.
“One thing that struck me as we developed the program is the medical complexity of these patients,” Dr. Wiznia said. “I’ve become great friends with hematology, rheumatology, oncology and endocrinology because these patients are complex patients.”
Understanding why the disease developed matters because it influences what happens next. The future of joint preservation, he believes, depends as much on understanding the biology behind the disease as treating the damage it leaves behind.
The experience has also challenged the traditional boundaries of orthopedic care. Rather than functioning as a standalone orthopedic program, Yale’s AVN initiative increasingly operates as a multidisciplinary disease-management program, bringing together specialists who historically may not have been involved in the same patient’s care.
Reengineering a decades-old operation
When surgery is necessary, Yale is also rethinking how one of the field’s most established procedures is performed. Core decompression has been used for decades as a way to relieve pressure inside the bone and slow progression of AVN. Traditionally, surgeons rely on fluoroscopic images to guide instruments toward the affected area.
The challenge is that the diseased bone cannot always be visualized precisely. Rather than accepting the limitations of a decades-old procedure, he viewed it as an engineering problem. If surgeons could see the lesion more clearly, model it in three dimensions and personalize the approach for each patient, he believed the procedure could become more precise and less disruptive.
“We’re planning the surgery in 3D and customizing it for each patient,” Dr. Wiznia said. “We’re able to maximize removal of the necrotic bone while minimizing injury to healthy bone.”
The engineering principles behind the procedure are sophisticated. The patient experience is remarkably simple. Historically, patients undergoing core decompression often spent months on crutches after surgery. Today, many patients treated through Yale’s navigated approach are walking the same day.
“Traditionally, most patients were told they couldn’t walk for two or three months,” Dr. Wiznia said. For patients trying to preserve their joints and maintain their quality of life, the difference can be substantial.
The treatment that doesn’t involve surgery
Not every innovation emerging from the program involves an operating room. One of Yale’s most distinctive efforts centers on hyperbaric oxygen therapy, a treatment that remains relatively underutilized in orthopedic care despite what Dr. Wiznia believes is a compelling biologic rationale.
AVN is fundamentally a disease of impaired blood supply and oxygen delivery. Hyperbaric oxygen therapy seeks to address that problem directly. “The underlying pathophysiology of AVN is a perfect fit for hyperbaric oxygen therapy,” Dr. Wiznia said.
Patients spend approximately two hours per day inside a hyperbaric chamber, five days a week, for several weeks. The commitment can be significant. So can the potential reward.
“If I told you I had a very low-risk therapy that could drastically reduce the risk of your hip collapsing, you’d be very interested in that,” he said. The treatment has become particularly valuable for patients with disease affecting multiple joints simultaneously, where preserving as much native anatomy as possible becomes even more important.
Unlike surgery, hyperbaric oxygen offers a nonoperative strategy for intervening before structural collapse occurs. For Dr. Wiznia, it represents another example of how AVN treatment is shifting away from simply reacting to damage and toward preserving joints earlier in the disease process.
“I’ve seen patients have fantastic results,” Dr. Wiznia said.
The future may not be replacement
The common thread across Yale’s work is that every intervention, whether navigation, hyperbaric oxygen therapy, biologics or multidisciplinary care, is designed around the same objective: extending the life of a patient’s native joint.
For decades, AVN has often been viewed through the lens of joint replacement. The disease progresses. The joint collapses. Replacement becomes necessary.
Dr. Wiznia believes that framework is beginning to change. Not because one technology will solve the problem. Not because one procedure will replace another. But because physicians are becoming better at identifying the disease earlier, understanding its causes more completely and tailoring treatment to individual patients.
“We know the causes of AVN are quite diverse,” he said. “You may not treat someone who has avascular necrosis from sickle cell disease the same way you treat someone who developed it from steroid use.”
That philosophy is driving the next generation of research at Yale, where engineers, physicians and scientists are collaborating on new imaging technologies, personalized instrumentation, biologic therapies and joint-preservation strategies.
For Dr. Wiznia, that partnership represents something larger than innovation. It represents a shift in how the field thinks about the disease itself.
Historically, the central question in avascular necrosis was when a patient would need a joint replacement. At Yale, researchers are increasingly asking a different question: Can we prevent them from needing one at all?
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