Dysbaric Osteonecrosis - A Reassessment and Hypothesis

Abstract

Bone death or osteonecrosis is a concept which Hippocrates put forward in antiquity(1), but it was not until 1794 that James Russell of Edinburgh wrote the first modern-day descriptions; in these cases infection was the predominant etiology(1, 2). In 1888 Konig described necrosis of the adult femoral head without infection(3) (aseptic necrosis of bone) and in the same year Twynam reported a case of osteonecrosis in a caisson worker(4) in which however there was still a significant infective component In 1911 Bornstein and Plate, followed later and independently by Bassoe in 1913, presented radiological confirmation of aseptic necrosis of bone in compressed air workers(5). The first report of aseptic necrosis in an underwater diver subsequently appeared in 1936(6). The condition of aseptic necrosis of bone in association with exposure to raised ambient pressure (previously referred to as caisson disease, pressure induced osteoarthropathy [7], ‘bone rot’ [8] and other synonyms [6]) is now generally known as dysbaric osteonecrosis(6). Despite detailed examination of this problem by many authorities, dysbaric osteonecrosis still remains a significant occupational hazard with serious medico-legal consequences (5-13). This suggests that preventative measures are being based upon an incomplete understanding of the pathophysiology of the disease, and that other etiological factors are perhaps being overlooked. Dysbaric Osteonecrosis Dysbaric Osteonecrosis, Gas Bubbles and Decompression Sickness The Blood Supply of Bone The Rhizomelic Joints A Hypothesis Conclusion References