Nontraumatic Osteonecrosis of the Distal Tibia: A Case Presentation and Review of the Literature

Abstract

Osteonecrosis, although commonly occurring in the hip, can also affect the leg and foot. In the foot, it most commonly occurs in the talus. The incidence of osteonecrosis occurring in the tibia is relatively rare. We report a case of a woman who presented to our clinic with ankle pain that was idiopathic in nature. Subsequent magnetic resonance imaging showed findings consistent with osteonecrosis of the bilateral distal tibias and several other lesions located in the shoulder, hip, and calcaneus. The present report also serves as a review of both etiology and treatment of osteonecrosis as it relates to the lower extremity.

Osteonecrosis of the distal tibia in systemic lupus erythematosus: A rare case report

“…Binding of glucocorticoids to these receptors has been shown to induce an anti-inflammatory response through apoptotic pathways within the immunogenic cells. Thus, osteoclasts and osteoblasts can undergo apoptosis after prolonged treatment with glucocorticoids [ 2 ]. Apoptosis of the osteoblasts and osteoclasts, a decreased bone turnover and a decreased survival of osteocytes appear to be important mechanisms for inducing ON [ 1 ].…”

“…The conservative management of ON included pharmacological treatment, modification of activity with restricted weight bearing, and the used of ultrasound or electric signals to stimulates repair. Medications that have been investigated in several studies and have been used in patients with ON included bisphosphonates (inhibition of osteoclast activity), statins (pro-osteoblastic and anti-adipogenic effects on bone marrow stromal cells), heparin (stabilization the balance between the fibrinolytic and thrombotic cascades), antimalarials (antithrombotic and lipid-lowering properties) and supplementation with folic acid (reduce homocysteine levels) [ 2 , 10 ].…”

“…The exact mechanism of ON is still unclear, some mechanisms involved include ischaemia, vascular occlusion, intraosseous microcirculation coagulation, and mechanical stress [ 1 ]. There are multiple risk factors and medical condition associated with ON, including trauma, alcohol abuse, smoking, vascular disease, renal disease, coagulation disorders, and rheumatic diseases, especially in systemic lupus erythematosus (SLE) [ 1 , 2 ].…”

“…The term multifocal osteonecrosis is used to describe the presence of osteonecrotic lesions in three or more anatomical sites [ 1 ]. Few case reports have described ON affecting the ankle, and the talus is the more common site of injury than the distal tibia [ 2 ]. Very few cases of nontraumatic ON in distal tibia have been reported in the literature.…”

Third tarsal bone osteonecrosis associated with chronic recurrent cellulitis in an adult horse

“…In human patients, the predilection sites for osteonecrosis include the femoral head and tarsus (McLeod et al . ); a tenuous blood supply and limited collateral circulation at these locations have been implicated as predisposing factors. Although not a feature of this case, laminitis has been documented in cellulitis‐affected equine limbs and vascular compromise due to limb swelling suggested as the cause (Markel et al .…”