Research advances on subchondral insufficiency fracture and osteonecrosis of the knee_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZOU Zhenwei ¹ , ZENG Yirong ² ,  ZENG Jianchun ²

1. The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou Guangdong, 510000, P. R. China;
2. Department of Artificial Joints and Knee Surgery, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou Guangdong, 510000, P. R. China;

Corresponding?author：

ZENG Jianchun, Email: zjccsr2005@126.com

Keywords：

Osteonecrosis of the knee; Subchondral insufficiency fracture of the knee; bone marrow edema; subchondral bone

DOI：

10.7507/1002-1892.202510036

Video：

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Objective To clarify the clinical application of the disease terms “subchondral insufficiency fracture of the knee (SIFK)” and “osteonecrosis of the knee (ONK)”, and to review the research progress on this pathological condition. Methods The research literature in the field of SIFK and ONK both domestically and internationally in recent years was widely reviewed, and the research progress of SIFK and ONK was summarized from the aspects of the current conceptual frameworks, etiological factors and pathogenic mechanisms, clinical and imaging manifestations, therapeutic approaches, and prognostic outcomes. Results The exact etiology of SIFK remains controversial, and its specific pathogenesis has not been fully elucidated. Subchondral fracture has been identified as the primary pathological feature of this disease entity. SIFK predominantly affects the females over 65 years old, presenting with sudden onset of severe and persistent pain. MRI serves as the gold standard for early diagnosis of SIFK. The characteristic MRI findings include bone marrow edema-like signals and a subchondral low-signal line in the affected femoral condyle. Generally, if bone morphology is preserved without subchondral bone collapse, conservative management is typically the first-line treatment approach. Surgical intervention should be considered if there is no clinical or radiographic improvement after 3 to 4 months of conservative therapy. Conclusion Considering the pathological features of bone specimens, adopting the SIFK for the disease classification demonstrates greater appropriateness in diagnosis and management of these disorders. Early diagnosis and management are important for improving the prognosis of SIFK patients.

1.	Gorbachova T, Amber I, Beckmann NM, et al. Nomenclature of subchondral nonneoplastic bone lesions. AJR Am J Roentgenol, 2019, 213(5): 963-982.
2.	Lee DH, Bae BS, Kim SA, et al. Autologous collagen-induced chondrogenesis with high tibial osteotomy for large collapsed steroid-induced osteonecrosis in a patient with systemic lupus erythematosus: a case report and literature review. BMC Musculoskelet Disord, 2025, 26(1): 726. doi: 10.1186/s12891-025-09020-0.
3.	Li D, Shamrock AG, Young JR, et al. Spontaneous osteonecrosis of the knee. Treasure Island: StatPearls Publishing, 2025.
4.	Maraghelli D, Brandi ML, Matucci Cerinic M, et al. Edema-like marrow signal intensity: a narrative review with a pictorial essay. Skeletal Radiol, 2021, 50(4): 645-663.
5.	Ahlb?ck S, Bauer GC, Bohne WH. Spontaneous osteonecrosis of the knee. Arthritis Rheum, 1968, 11(6): 705-733.
6.	Brahme SK, Fox JM, Ferkel RD, et al. Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging. Radiology, 1991, 178(3): 851-853.
7.	Yamamoto T, Bullough PG. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg (Am), 2000, 82(6): 858-866.
8.	Hatanaka H, Yamamoto T, Motomura G, et al. Histopathologic findings of spontaneous osteonecrosis of the knee at an early stage: a case report. Skeletal Radiol, 2016, 45(5): 713-716.
9.	Tanaka Y, Mima H, Yonetani Y, et al. Histological evaluation of spontaneous osteonecrosis of the medial femoral condyle and short-term clinical results of osteochondral autografting: a case series. Knee, 2009, 16(2): 130-135.
10.	Takeda M, Higuchi H, Kimura M, et al. Spontaneous osteonecrosis of the knee: histopathological differences between early and progressive cases. J Bone Joint Surg (Br), 2008, 90(3): 324-329.
11.	Palmer W, Bancroft L, Bonar F, et al. Glossary of terms for musculoskeletal radiology. Skeletal Radiol, 2020, 49(Suppl 1): 1-33.
12.	Malghem J, Lecouvet F, Vande Berg B, et al. Subchondral insufficiency fractures, subchondral insufficiency fractures with osteonecrosis, and other apparently spontaneous subchondral bone lesions of the knee-pathogenesis and diagnosis at imaging. Insights Imaging, 2023, 14(1): 164. doi: 10.1186/s13244-023-01495-6.
13.	Norman A, Baker ND. Spontaneous osteonecrosis of the knee and medial meniscal tears. Radiology, 1978, 129(3): 653-656.
14.	Giannini S, Mazzotti A, Arceri A. Osteonecrosis of the knee: a concise review of the current literature. Int J Bone Frag, 2022, 2(1): 11-15.
15.	Wilmot AS, Ruutiainen AT, Bakhru PT, et al. Subchondral insufficiency fracture of the knee: A recognizable associated soft tissue edema pattern and a similar distribution among men and women. Eur J Radiol, 2016, 85(11): 2096-2103.
16.	Clark SC, Pareek A, Hevesi M, et al. High incidence of medial meniscus root/radial tears and extrusion in 253 patients with subchondral insufficiency fractures of the knee. Knee Surg Sports Traumatol Arthrosc, 2024, 32(11): 2755-2761.
17.	Allaire R, Muriuki M, Gilbertson L, et al. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg (Am), 2008, 90(9): 1922-1931.
18.	Za P, Papalia GF, Ambrosio L, et al. Histopathological examination of post-arthroscopy osteonecrosis of the knee: a scoping review. Knee, 2025, 56: 187-195.
19.	Ntagiopoulos P, Kalinterakis G, Pozzi P, et al. Can knee arthroscopy be considered entirely safe for patients over 50 years old with no risk of osteonecrosis? Case series and literature review on post-artrhoscopy osteonecrosis of the knee (PAONK). Orthop Surg, 2025, 17(5): 1378-1388.
20.	Hussain ZB, Chahla J, Mandelbaum BR, et al. The role of meniscal tears in spontaneous osteonecrosis of the knee: a systematic review of suspected etiology and a call to revisit nomenclature. Am J Sports Med, 2019, 47(2): 501-507.
21.	Pruès-Latour V, Bonvin JC, Fritschy D. Nine cases of osteonecrosis in elderly patients following arthroscopic meniscectomy. Knee Surg Sports Traumatol Arthrosc, 1998, 6(3): 142-147.
22.	Reddy AS, Frederick RW. Evaluation of the intraosseous and extraosseous blood supply to the distal femoral condyles. Am J Sports Med, 1998, 26(3): 415-419.
23.	Muscolo DL, Costa-Paz M, Makino A, et al. Osteonecrosis of the knee following arthroscopic meniscectomy in patients over 50-years old. Arthroscopy, 1996, 12(3): 273-279.
24.	Yokota S, Ishizu H, Miyazaki T, et al. Osteoporosis, osteoarthritis, and subchondral insufficiency fracture: recent insights. Biomedicines, 2024, 12(4): 843. doi: 10.3390/biomedicines12040843.
25.	Koshino T, Okamoto R, Takamura K, et al. Arthroscopy in spontaneous osteonecrosis of the knee. Orthop Clin North Am, 1979, 10(3): 609-618.
26.	Aglietti P, Insall JN, Buzzi R, et al. Idiopathic osteonecrosis of the knee. Aetiology, prognosis and treatment. J Bone Joint Surg (Br), 1983, 65(5): 588-597.
27.	Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg (Br), 1985, 67(1): 3-9.
28.	Ochi J, Nozaki T, Nimura A, et al. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. Jpn J Radiol, 2022, 40(5): 443-457.
29.	Lecouvet FE, van de Berg BC, Maldague BE, et al. Early irreversible osteonecrosis versus transient lesions of the femoral condyles: prognostic value of subchondral bone and marrow changes on MR imaging. AJR Am J Roentgenol, 1998, 170(1): 71-77.
30.	Ramnath RR, Kattapuram SV. MR appearance of SONK-like subchondral abnormalities in the adult knee: SONK redefined. Skeletal Radiol, 2004, 33(10): 575-581.
31.	Higuchi H, Kobayashi Y, Kobayashi A, et al. Histologic analysis of postmeniscectomy osteonecrosis. Am J Orthop (Belle Mead NJ), 2013, 42(5): 220-222.
32.	Gorbachova T, Melenevsky Y, Cohen M, et al. Osteochondral lesions of the knee: differentiating the most common entities at MRI. Radiographics, 2018, 38(5): 1478-1495.
33.	Plett SK, Hackney LA, Heilmeier U, et al. Femoral condyle insufficiency fractures: associated clinical and morphological findings and impact on outcome. Skeletal Radiol, 2015, 44(12): 1785-1794.
34.	Lecouvet FE, Malghem J, Maldague BE, et al. MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies. Radiol Clin North Am, 2005, 43(4): 655-672.
35.	Lotke PA, Abend JA, Ecker ML. The treatment of osteonecrosis of the medial femoral condyle. Clin Orthop Relat Res, 1982(171): 109-116.
36.	Sayyid S, Younan Y, Sharma G, et al. Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome. Skeletal Radiol, 2019, 48(12): 1961-1974.
37.	Aman ZS, DePhillipo NN, Lind DRG, et al. The role of bisphosphonates and prostaglandins for the treatment of subchondral insufficiency fractures of the knee: an evidenced-based opinion. J Orthop Exper Innov, 2022, 3(2): 34672. doi: 10.60118/001c.34672.
38.	Jiang Y, Zhao JJ, Mitlak BH, et al. Recombinant human parathyroid hormone (1-34) [teriparatide] improves both cortical and cancellous bone structure. J Bone Miner Res, 2003, 18(11): 1932-1941.
39.	Horikawa A, Miyakoshi N, Hongo M, et al. Treatment of spontaneous osteonecrosis of the knee by daily teriparatide: A report of 3 cases. Medicine (Baltimore), 2020, 99(5): e18989. doi: 10.1097/MD.0000000000018989.
40.	Yates PJ, Calder JD, Stranks GJ, et al. Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. Knee, 2007, 14(2): 112-116.
41.	Choi HG, Kim JS, Yoo HJ, et al. The fate of bone marrow lesions after open wedge high tibial osteotomy: a comparison between knees with primary osteoarthritis and subchondral insufficiency fractures. Am J Sports Med, 2021, 49(6): 1551-1560.
42.	Mont MA, Marker DR, Zywiel MG, et al. Osteonecrosis of the knee and related conditions. J Am Acad Orthop Surg, 2011, 19(8): 482-494.

1. Gorbachova T, Amber I, Beckmann NM, et al. Nomenclature of subchondral nonneoplastic bone lesions. AJR Am J Roentgenol, 2019, 213(5): 963-982.
2. Lee DH, Bae BS, Kim SA, et al. Autologous collagen-induced chondrogenesis with high tibial osteotomy for large collapsed steroid-induced osteonecrosis in a patient with systemic lupus erythematosus: a case report and literature review. BMC Musculoskelet Disord, 2025, 26(1): 726. doi: 10.1186/s12891-025-09020-0.
3. Li D, Shamrock AG, Young JR, et al. Spontaneous osteonecrosis of the knee. Treasure Island: StatPearls Publishing, 2025.
4. Maraghelli D, Brandi ML, Matucci Cerinic M, et al. Edema-like marrow signal intensity: a narrative review with a pictorial essay. Skeletal Radiol, 2021, 50(4): 645-663.
5. Ahlb?ck S, Bauer GC, Bohne WH. Spontaneous osteonecrosis of the knee. Arthritis Rheum, 1968, 11(6): 705-733.
6. Brahme SK, Fox JM, Ferkel RD, et al. Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging. Radiology, 1991, 178(3): 851-853.
7. Yamamoto T, Bullough PG. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg (Am), 2000, 82(6): 858-866.
8. Hatanaka H, Yamamoto T, Motomura G, et al. Histopathologic findings of spontaneous osteonecrosis of the knee at an early stage: a case report. Skeletal Radiol, 2016, 45(5): 713-716.
9. Tanaka Y, Mima H, Yonetani Y, et al. Histological evaluation of spontaneous osteonecrosis of the medial femoral condyle and short-term clinical results of osteochondral autografting: a case series. Knee, 2009, 16(2): 130-135.
10. Takeda M, Higuchi H, Kimura M, et al. Spontaneous osteonecrosis of the knee: histopathological differences between early and progressive cases. J Bone Joint Surg (Br), 2008, 90(3): 324-329.
11. Palmer W, Bancroft L, Bonar F, et al. Glossary of terms for musculoskeletal radiology. Skeletal Radiol, 2020, 49(Suppl 1): 1-33.
12. Malghem J, Lecouvet F, Vande Berg B, et al. Subchondral insufficiency fractures, subchondral insufficiency fractures with osteonecrosis, and other apparently spontaneous subchondral bone lesions of the knee-pathogenesis and diagnosis at imaging. Insights Imaging, 2023, 14(1): 164. doi: 10.1186/s13244-023-01495-6.
13. Norman A, Baker ND. Spontaneous osteonecrosis of the knee and medial meniscal tears. Radiology, 1978, 129(3): 653-656.
14. Giannini S, Mazzotti A, Arceri A. Osteonecrosis of the knee: a concise review of the current literature. Int J Bone Frag, 2022, 2(1): 11-15.
15. Wilmot AS, Ruutiainen AT, Bakhru PT, et al. Subchondral insufficiency fracture of the knee: A recognizable associated soft tissue edema pattern and a similar distribution among men and women. Eur J Radiol, 2016, 85(11): 2096-2103.
16. Clark SC, Pareek A, Hevesi M, et al. High incidence of medial meniscus root/radial tears and extrusion in 253 patients with subchondral insufficiency fractures of the knee. Knee Surg Sports Traumatol Arthrosc, 2024, 32(11): 2755-2761.
17. Allaire R, Muriuki M, Gilbertson L, et al. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Similar to total meniscectomy. J Bone Joint Surg (Am), 2008, 90(9): 1922-1931.
18. Za P, Papalia GF, Ambrosio L, et al. Histopathological examination of post-arthroscopy osteonecrosis of the knee: a scoping review. Knee, 2025, 56: 187-195.
19. Ntagiopoulos P, Kalinterakis G, Pozzi P, et al. Can knee arthroscopy be considered entirely safe for patients over 50 years old with no risk of osteonecrosis? Case series and literature review on post-artrhoscopy osteonecrosis of the knee (PAONK). Orthop Surg, 2025, 17(5): 1378-1388.
20. Hussain ZB, Chahla J, Mandelbaum BR, et al. The role of meniscal tears in spontaneous osteonecrosis of the knee: a systematic review of suspected etiology and a call to revisit nomenclature. Am J Sports Med, 2019, 47(2): 501-507.
21. Pruès-Latour V, Bonvin JC, Fritschy D. Nine cases of osteonecrosis in elderly patients following arthroscopic meniscectomy. Knee Surg Sports Traumatol Arthrosc, 1998, 6(3): 142-147.
22. Reddy AS, Frederick RW. Evaluation of the intraosseous and extraosseous blood supply to the distal femoral condyles. Am J Sports Med, 1998, 26(3): 415-419.
23. Muscolo DL, Costa-Paz M, Makino A, et al. Osteonecrosis of the knee following arthroscopic meniscectomy in patients over 50-years old. Arthroscopy, 1996, 12(3): 273-279.
24. Yokota S, Ishizu H, Miyazaki T, et al. Osteoporosis, osteoarthritis, and subchondral insufficiency fracture: recent insights. Biomedicines, 2024, 12(4): 843. doi: 10.3390/biomedicines12040843.
25. Koshino T, Okamoto R, Takamura K, et al. Arthroscopy in spontaneous osteonecrosis of the knee. Orthop Clin North Am, 1979, 10(3): 609-618.
26. Aglietti P, Insall JN, Buzzi R, et al. Idiopathic osteonecrosis of the knee. Aetiology, prognosis and treatment. J Bone Joint Surg (Br), 1983, 65(5): 588-597.
27. Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg (Br), 1985, 67(1): 3-9.
28. Ochi J, Nozaki T, Nimura A, et al. Subchondral insufficiency fracture of the knee: review of current concepts and radiological differential diagnoses. Jpn J Radiol, 2022, 40(5): 443-457.
29. Lecouvet FE, van de Berg BC, Maldague BE, et al. Early irreversible osteonecrosis versus transient lesions of the femoral condyles: prognostic value of subchondral bone and marrow changes on MR imaging. AJR Am J Roentgenol, 1998, 170(1): 71-77.
30. Ramnath RR, Kattapuram SV. MR appearance of SONK-like subchondral abnormalities in the adult knee: SONK redefined. Skeletal Radiol, 2004, 33(10): 575-581.
31. Higuchi H, Kobayashi Y, Kobayashi A, et al. Histologic analysis of postmeniscectomy osteonecrosis. Am J Orthop (Belle Mead NJ), 2013, 42(5): 220-222.
32. Gorbachova T, Melenevsky Y, Cohen M, et al. Osteochondral lesions of the knee: differentiating the most common entities at MRI. Radiographics, 2018, 38(5): 1478-1495.
33. Plett SK, Hackney LA, Heilmeier U, et al. Femoral condyle insufficiency fractures: associated clinical and morphological findings and impact on outcome. Skeletal Radiol, 2015, 44(12): 1785-1794.
34. Lecouvet FE, Malghem J, Maldague BE, et al. MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies. Radiol Clin North Am, 2005, 43(4): 655-672.
35. Lotke PA, Abend JA, Ecker ML. The treatment of osteonecrosis of the medial femoral condyle. Clin Orthop Relat Res, 1982(171): 109-116.
36. Sayyid S, Younan Y, Sharma G, et al. Subchondral insufficiency fracture of the knee: grading, risk factors, and outcome. Skeletal Radiol, 2019, 48(12): 1961-1974.
37. Aman ZS, DePhillipo NN, Lind DRG, et al. The role of bisphosphonates and prostaglandins for the treatment of subchondral insufficiency fractures of the knee: an evidenced-based opinion. J Orthop Exper Innov, 2022, 3(2): 34672. doi: 10.60118/001c.34672.
38. Jiang Y, Zhao JJ, Mitlak BH, et al. Recombinant human parathyroid hormone (1-34) [teriparatide] improves both cortical and cancellous bone structure. J Bone Miner Res, 2003, 18(11): 1932-1941.
39. Horikawa A, Miyakoshi N, Hongo M, et al. Treatment of spontaneous osteonecrosis of the knee by daily teriparatide: A report of 3 cases. Medicine (Baltimore), 2020, 99(5): e18989. doi: 10.1097/MD.0000000000018989.
40. Yates PJ, Calder JD, Stranks GJ, et al. Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. Knee, 2007, 14(2): 112-116.
41. Choi HG, Kim JS, Yoo HJ, et al. The fate of bone marrow lesions after open wedge high tibial osteotomy: a comparison between knees with primary osteoarthritis and subchondral insufficiency fractures. Am J Sports Med, 2021, 49(6): 1551-1560.
42. Mont MA, Marker DR, Zywiel MG, et al. Osteonecrosis of the knee and related conditions. J Am Acad Orthop Surg, 2011, 19(8): 482-494.

Chinese Journal of Reparative and Reconstructive Surgery

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