APPRAISAL OF LONG BONE RADIOLOGY AS SCREENING

MODALITY FOR DYSBARIC OSTEONECROSIS

Review Article
Surg Capt G Varghese*, Col R Ravi Kumar+, Surg Lt Cdr Rohit Verma#, Surg Lt Cdr LVV Rao#
Word Count: 1714

Citation:
Verghese G, Ravi Kumar R, Verma R, Rao LVV. Long Bone Radiology and
Screening for Dysbaric Osteonecrosis. Journal of Marine Medicine Society 2010; 12 (2): 78
80.

Senior Advisor (Marine Medicine) and Head of Department, Department of Undersea Medicine, INHS Asvini,
Colaba, Mumbai 400005
+ Senior Advisor (Radiodiagnosis and Interventional Radiology) INHS Asvini, Colaba, Mumbai 400005
# Resident (Marine Medicine), Department of Undersea Medicine, INHS Asvini, Colaba, Mumbai 400005
Email: v_rohit@yahoo.com

Abstract
Dysbaric osteonecrosis (DON) is a disabling illness of professional divers. Long bone
radiology has been used as screening modality for detecting DON. There are various
advantages and disadvantages inherent with the modality. The recommendations on the
basis of extensive review of literature is to reinforce the current practice of screening with 5
yearly long bone radiology with MRI screening at 3 year intervals for those at increased
risk.

Key Words: Dysbaric osteonecrosis, long bone radiology, screening

Introduction
Dysbaric Osteonecrosis (DON) is the ischemic death of cellular constituents of both bone
and bone marrow caused by an occupational hazard of exposure to pressurized environment [1].
It is seen mostly in professional divers who dive deeper than 30 metres, use mixed gas or
perform dives longer than 4 hours [1]. Divers with increased age [4], obesity, alcoholism,
cigarette smoking, fatty liver, hyperlipidemia [1] and impaired fibrinolysis with increased
Prothrombin Activator Inhibitor (PAI-1) [1] may have greater susceptibility for developing
DON. It affects mainly, lower end of femur (40%), humeral head (29%), femoral head (16%)
and upper tibia (15%). Its incidence ranges from 2.5 % in US Navy divers [1] to 50.5% in
Japanese shellfish divers [1]. It is generally considered to be a disease of professional divers and
caisson workers [4] although its incidence has occasionally been reported among recreational
SCUBA divers and dive masters as well [1]. However, its incidence is negligible among aviators
[4] and hyperbaric chamber attendants [1]. It manifests as progressive, persistent radiating pain
and restricted joint movements usually affecting the hip or shoulder joint precipitated by lifting
of heavy weights. The pain develops insidiously over months to years and is preceded by a long
asymptomatic period [4]. Secondary degenerative osteoarthritis follows collapse of the articular
cartilage, further reducing joint movements.
The exact etiology is not known though it is thought to be a long term effect of
inadequate decompression. However, it is known to occur after a single exposure to pressure.
Also not all divers who develop DON have a history of sustaining decompression sickness
(DCS); neither do all divers who suffer from DCS develop DON [4]. It is postulated that

inappropriate decompression may lead to fat emboli which may obstruct end arteries in rigid
haversian canals of bone, leading to osteonecrosis. These fat emboli may originate from fatty
liver, coalescence of plasma proteins or disruption of the bone marrow [4]. Another hypothesis is
that fat in the bone marrow takes up large amount of nitrogen during longer pressure exposures
which expands during decompression phase. This leads to increase in the intramedullary pressure
which consequently compromises blood flow within non compliant bone cavities. This leads to
ischaemia and progress to necrosis after a critical period [1].
The area of necrosis is much widespread than is evident radiologically. Revascularization
of the necrotic bone from the viable bone occurs. This leads to formation of a zone of thickened
trabeculae separated from the necrotic bone by a line of dead collagen which is the first sign seen
radiologically. The necrotic trabeculae, not strengthened by the revascularization process
eventually collapse under a load. The clinical symptoms manifest at this stage and are not
necessarily related to a recent hyperbaric exposure [4].
Various screening modalities have been employed to detect DON at a stage where further
damage can be prevented. Long bone plain radiology, computerized tomography (CT scan),
Magnetic Resonance Imaging (MRI), 99m technetium labeled bone scan and Single Photon
Emission Computed Tomography (SPECT) have been utilized with varying results for screening
and diagnosis of this illness. No modality has been found to be ideal or foolproof. Each modality
has its consequent inherent advantages, disadvantages and side effects. Also, they have varying
cost and availability issues. This paper examines the relative merits and demerits of long bone
radiology as a modality for screening for DON.

Long Bone Radiology

Long bone plain radiology has been recommended as a screening modality by various
diving organizations and studies [1, 2, 3]. It involves plain radiology of bilateral shoulder, hip
and knee joints by using special projections. These radiology films are taken serially at fixed
frequencies depending upon the risk stratification of the diver. Early diagnosis is based on minor
alterations in the trabecular pattern of the bone resulting in abnormal densities or lucencies. Early
detection of asymptomatic lesions may only be verified by serial radiological examinations,
showing the progression of the lesion [4].
The lesions have been classified according to the site where they appear as either Juxta
articular lesion (JA lesion or A lesion) or head, neck and shaft lesion (HNS lesion or B lesion) by
the Medical Research Council (MRC) of UK [1]. The JA lesions are potentially disabling and
have been used as a screening finding to disqualify professional divers from further diving.
However, the problem of what to do when confronted with an asymptomatic HNS lesion is not
yet solved. If these are thought to be provoked by non adherence to established diving tables,
the diving tables should clearly be followed in the future [4]. Some [2] suggest the following
restrictions in those detected with asymptomatic HNS lesions:
(a) No decompression diving
(b) Limited maximum depth (18m) and slower ascent rates
(c) Use of standard air or helium - oxygen tables only
(d) No saturation or experimental diving

A considerable skill is required in the assessment of radiographs, as these lesions need to

be differentiated from similar lesions of bone islands, enchondroma, normal variants and
osteoarthritis. Solitary lesions require careful assessment, whereas multiple lesions make
diagnosis easier. The radiological changes are relatively late manifestations. The first
radiological sign may be noted not earlier than three months and may take upto an year, perhaps
even longer [4].
The radiation hazard associated with radiographic examination must be kept to an
acceptable level. The mean effective dose equivalent associated with a divers long-bone survey
is between 1-2 milli Sieverts (mSv) [1]. The probability of developing a fatal malignancy after
a single radiologic long bone survey is 8 x 10-5 or 1 in 12500 exposures [1]. These levels of
radiation are equivalent to receiving about 6 days natural background radiation [1] which is
considerable lesser than some common radiological procedures such as CT scan abdomen which
delivers radiation equivalent to 3 years worth of natural background radiation [14]. Attempts to
further reduce the radiation hazard to a minimum include omitting the knee radiographs as the
lesions in this region rarely, if ever, cause symptoms and restricting the radiography to those
divers only who dive deeper than 30 metres. The gonads of the diver must be protected from
ionizing radiation by use of a lead shield during the procedure.
The frequency of conducting long bone radiology depends on the type and frequency of
diving undertaken by the diver. The baseline x ray should be taken of all divers who intend to
dive deeper than 30 metres, for duration more than 4 hours or breath mixtures. Repeat studies
must be done according to the divers experience over the preceding 3 years. Divers who dive
more than 4 hours, dive deeper than 50 metres, saturation divers or those who have suffered
symptomatic DCS, should undergo yearly follow-ups whereas those who dive shallower than 50

meters but deeper than 30 meters not lasting more than 4 hours are recommended to be followed
up radiologically every 3 years [2]. Other guidelines [8] recommend screening only for divers
with more than 20 hours per week under water. Some [9] recommend individualization of the
frequency according to the clinical assessment. The records including the films should be
retrievable and stored for the lifetime of the diver [8].

Comparison of Long Bone radiology with other modalities

99m technetium labeled bone scan has higher rate of picking up silent lesions [4] and
earlier than long bone plain radiology. However, these have a considerably higher false positive
rate and also increased radiation hazard apart from being expensive and being less easily
available. The same is true for CT scan. There have been attempts to utilize MRI scan [13],
which have better sensitivity and early diagnosis apart from having no radiation hazard.
However, it is more expensive and also has higher false positive rate.

Advantages of Long Bone radiology in screening of DON

1.

It is a highly sensitive modality (~100%) [15] for detection of DON.

2.

Long bone radiology has been implicated as one of the causes of decreasing incidence of

Don in Japanese professional divers [2].

3.

It has vetted by various professional diving organizations and navies as a useful method

of screening of DON [2, 8, 9, 10]

4.

It is a non invasive modality.

5.

It is inexpensive.

6.

It is easily available.

Disadvantages of Long bone radiology in screening of DON

1.

It has low specificity (~30%) for detection of DON [15].

2.

It exposes the individual to harmful radiation.

3.

Considerable skill and experience is required in assessment of the radiological findings.

4.

It has poor temporal relationship with the development of the illness.

5.

It does poor demarcation of the lesion.

6.

The course of action in case of HNS lesions is uncertain as the prognostic value of the

finding is not known.

Conclusion

The ideal screening modality for Dysbaric osteonecrosis remains to be enunciated. In the
absence of such a modality, Long bone plain radiology remains a cost effective method of
screening for those divers who are at increased risk of developing DON. Hence, baseline long
bone radiology should be done for every diver at entry. The frequency of conducting the follow
up radiological studies should be dictated by the risk profile of the diver. In case of a diver who
does not dive deeper than 50 metres, and the duration of each individual dive is less than 4 hours
and cumulative for a week is less than 20 hours, the radiological study may be conducted once in
5 years. For divers, who dive deeper than 50 metres, do saturation or experimental diving or who
have received recompression therapy for any decompression illness, the follow up should be

done using MRI at 3 year intervals. Further those divers who are at increased risk of developing
DON as a consequence of being obese, alcoholic, having hyperlipidemia, those who smoke
cigarettes and have increased PAI-1 levels should also undergo more frequent screening in the
form of MRI of long bones every 3 years. On detection of JA lesions, the diver should be
withheld from all further professional diving activity. On detection of a HNS lesion, the diver
should be cautioned to perform only no-decompression dives. The methodology of conducting
the long bone radiology should be thoroughly reviewed and proper positioning of the diver
during the procedure should be made obligatory. The radiological assessments should be done by
experts who have considerable skill and experience in detection of the relevant lesions. Further,
the radiologists should be sensitized the requisites, so that false positive and negative cases may
be minimized.

Conflicts of Interests

None Identified

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