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ACR Appropriateness Criteria® Osteonecrosis: 2022 Update.

  • Ha, Alice S1
  • Chang, Eric Y2
  • Bartolotta, Roger J3
  • Bucknor, Matthew D4
  • Chen, Karen C5
  • Ellis, Henry B Jr6
  • Flug, Jonathan7
  • Leschied, Jessica R8
  • Ross, Andrew B9
  • Sharma, Akash10
  • Thomas, Jonelle M11
  • Beaman, Francesca D12
  • 1 Panel Vice-Chair, University of Washington, Seattle, Washington. Electronic address: [email protected].
  • 2 Panel Chair, VA San Diego Healthcare System, San Diego, California.
  • 3 Division Chief, Musculoskeletal Imaging, Weill Cornell Medical College, New York, New York.
  • 4 Associate Chair, Department of Radiology, University of California, San Francisco, San Francisco, California.
  • 5 Musculoskeletal Radiology Section Chief, VA San Diego Healthcare System, San Diego, California.
  • 6 Medical Director, Clinical Research, Texas Scottish Rite Hospital for Children, Dallas, Texas; American Academy of Orthopaedic Surgeons; Board of Directors, Pediatric Research in Sports Medicine; Board of Directors, Texas Orthopaedic Association; Council of Delegates, Texas Representative, AAOS.
  • 7 Committee Chair, Radiology Quality Oversight, Mayo Clinic Arizona, Phoenix, Arizona.
  • 8 Committee on Emergency Radiology-GSER, Henry Ford Health System, Detroit, Michigan.
  • 9 University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin.
  • 10 Chair, Research Committee, Radiology and Chair, PET-MRI Workgroup, Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging.
  • 11 Vice-Chair, Clinical Affairs and Director, Radiology Informatics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
  • 12 Specialty Chair, University of Kentucky, Lexington, Kentucky.
Published Article
Journal of the American College of Radiology : JACR
Publication Date
Nov 01, 2022
DOI: 10.1016/j.jacr.2022.09.009
PMID: 36436966


Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation. Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.

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