Introduction: Osteonecrosis or avascular necrosis is a debilitating disease that can affect various joints such as the shoulder and knee, but it is most common in the hip. These cases may be challenging, and it is important that orthopaedic residents receive adequate training concerning the associated risk factors, diagnosis, and treatment modalities commonly used in treating this disease. Current scientific publications are often recommended as one of the main sources of information for surgeons in training. The purpose of the present study was to characterize the osteonecrosis information provided in the peer-reviewed literature, and to analyze the osteonecrosis related knowledge frequently tested on the Orthopaedic In-Training Examination (OITE). In addition, we assessed the relevance of recent literature as a tool for young physicians who are learning more about osteonecrosis as they prepare for their board examinations.

Methods: A systematic review was conducted using the Medline bibliographic databases of all literature from 5 years (2001–2005) in 4 high-impact orthopaedic journals (a total of 6750 articles): The Journal of Bone and Joint Surgery American (JBJS), Clinical Orthopaedics and Related Research (CORR), Journal of Arthroplasty (JOA), and Journal of Orthopaedic Research (JOR). For each year, the total number of articles and the number of articles related to “osteonecrosis” or “avascular necrosis” were determined. All articles were screened by two reviewers and grouped as having either a primary or secondary focus on osteonecrosis. The primary focus articles were stratified according to four subject areas including: etiology/associated risk factors, pathology/pathophysiology, diagnosis/classification, and treatment. Articles related to the treatment of osteonecrosis were further stratified according to non-invasive (such as pharmacological treatment and shock wave), core decompressions and nonvascularized graftings, revascularization techniques, osteotomies, and replacement surgeries (such as total hip arthroplasty and hemi- and total hip resurfacing). Next, the OITE was reviewed for each of the five years that followed the published literature (2002–2006). The questions were stratified in a similar manner as the literature. The overall proportions and the percentages in each category were compared between the OITE questions and the literature.

Results: Overall, 136 (2.0%) articles had an osteonecrosis primary focus, and 115 (1.7%) had a secondary focus. There were 30 primary focus articles every year except for 2002 when there were 16. Out of the four journals reviewed, CORR had the highest percentage of etiology and risk factor related articles (25%), whereas JOR was the most concentrated in pathology (33%) and diagnosis/classification (33%). JOA articles were mostly focused on treatment (83%). The percentage of OITE questions (0.6%) that had a primary osteonecrosis focus was statistically lower than the overall percentage of osteonecrosis articles (p < 0.001). The percentage of articles in each category was also different. Grouped by treatment, etiology/risk factors, pathology, and diagnosis/classification, there were 55%, 22%, 12%, and 11% for the articles and 25%, 25%, 0%, and 50% for the OITE questions. Additionally, the treatment questions in the OITE only focused on THA, but more than half of the articles discussing treatment reported other modalities such as vascularized bone grafting and the use of pharmacological agents.

Conclusions: Knowledge of the content and type of articles in literature can guide residents as they continue their education and learn more about osteonecrosis. All of the journals reviewed in this study provide an overall greater percentage of articles that are focused on osteonecrosis than the proportion of OITE questions. The results of this study suggest that students preparing for the OITE would benefit most by studying those articles that are related to the diagnosis/classification of osteonecrosis. Conversely, the OITE could more accurately reflect the literature by providing future questions concerning the pathology and the different treatment modalities frequently used depending on the stage and progression of this disease.