RESEARCH ARTICLE

Dysbaric Osteonecrosis in Experienced Dive

Masters and Instructors
Maide Cimsit, Savas Ilgezdi, Cagatay Cimsit, and
Gunalp Uzun

CIMSIT M, ILGEZDI S, CIMSIT C, UZUN G. Dysbaric osteonecrosis in

A Lesions (juxta-articular):
experienced dive masters and instructors. Aviat Space Environ Med
A1. Dense areas with intact articular cortex
2007; 78:11504.
A2. Spherical opacities
Introduction: Dysbaric osteonecrosis (DON) is a type of aseptic
A3. Linear opacities
bone necrosis of long bones such as the humerus, femur, and tibia. It is
A4. Structural failures
observed in workers who perform in high-pressure environments.
a.) Translucent subcortical band
Methods: There were 58 volunteer divers included in this study who had
b.) Collapse of articular cortex
performed at least 500 dives, were working as a dive master or instrucc.) Sequestration of cortex
Delivered
bydid
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Technology to: ?
tor, had never performed industrial and commercial
dives, and
not
A5
degenerative osteoarthritis
have a diagnosis of osteonecrosis. Radiological
evaluation wasOn:
per-Fri, 26 Jun Secondary
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2015 18:07:49
formed according to the guidelines suggested Copyright:
by The BritishAerospace
Research
Medical
Association
B Lesions
(head, neck, and shaft):
Council Decompression Sickness Panel. A total of eight X-rays were
B1. Dense areas
taken per patient. When suspicious lesions were detected, MRI of the reB2. Irregular calcified areas
gion was performed. Results: Of the 58 divers, 2 were eliminated beB3. Translucent and cystic areas
cause of inadequate X-ray studies. A total of 18 DON lesions were
detected in 14 of 56 (25%) divers. Age was the only variable indepenDON lesions may be solitary or multiple. Type A ledently associated with the development of DON (P , 0.05). Discussion:
sions are potentially disabling due to the eventual colThe DON prevalence of 25% in this study is high considering the dive
instructors had thorough diving training and strictly practiced the delapse of the articular surface, while type B lesions are
compression rules. We believe this high prevalence is a result of freusually asymptomatic. Direct radiography is the main
quent and sometimes deep dives for many years. Our findings raise the
screening and diagnostic method. CT scan (13) and MRI
question of whether these divers can be seen as sports divers or should
are also being used for differential diagnosis, especially
be seen as occupational divers. If the latter description is approved,
dive masters and instructors should be kept under periodic screening for
in the early stages of DON. Multiplane imaging and
DON lesions just like professional commercial divers to help reduce the
manipulation of tissue contrast are the advantages of
morbidity associated with this disease.
MRI (4,24).
Keywords: DON, radiology, screening.

YSBARIC osteonecrosis (DON) is a type of aseptic

bone necrosis that results from large ambient pressure changes, such as an abrupt return to normal atmospheric pressure after exposure to hyperbaric pressures.
It is described as an occupational disease and is observed
in divers and Caisson (pressurized tunnel) workers.
DON was first reported in compressed air workers in
1911 and 1913 (3,5). The first case of a diver with osteonecrosis was reported in 1941 by Grutzmacher (11).
DON lesions usually affect the long bones with fatty
marrow, most commonly the proximal third of the humerus, distal third of the femur, and proximal third of
the tibia. The pathophysiology of DON is still in question (12). Lesions are classified according to the sites involved and radiological appearances. Those adjacent to
the articular surface of the hips and shoulders are classified as juxta-articular or type A lesions. Lesions
which are found in the head, neck, and shaft of the
humerus and femur are classified as type B lesions.
Subgroups of type A and B lesions are described as follows (10).

1150

The prevalence of DON varies depending on the

population examined (6,7,13,24,28). It is very rare in
recreational scuba divers, who by definition perform
dives shallower than 50 m and obey decompression
tables (18,19,26). Although Caisson workers, commercial, and navy divers are examined for DON, the risks
are unknown for dive masters and instructors. The
aim of this study was to document the prevalence in
this group.

From the Department of Underwater and Hyperbaric Medicine,

Faculty of Medicine, Istanbul University, Istanbul, Turkey (M. Cimsit,
S. Ilgezdi); the Department of Radiology, Faculty of Medicine,
Marmara University, Istanbul, Turkey (C. Cimsit); and the Department
of Underwater and Hyperbaric Medicine, Gulhane Military Medical
Academy, Hayderpasa Teaching Hospital, Istanbul, Turkey (G. Uzun).
This manuscript was received for review in April 2007. It was
accepted for publication in September 2007.
Address reprint requests to: Cagatay Cimsit, M.D., Department of
Radiology, Faculty of Medicine, Marmara University, Bodrum Kati,
Istanbul, Altunizade 34660, Turkey; cagataycimsit@yahoo.com.
Reprint & Copyright by Aerospace Medical Association, Alexandria, VA.
DOI: 10.3357/ASEM.2109.2007

Aviation, Space, and Environmental Medicine x Vol. 78, No. 12 x December 2007

DON IN DIVE MASTERS & INSTRUCTORSCIMSIT ET AL.

METHODS

All statistical analyses were carried out with the SPSS

software package (version 10.0, SPSS, Chicago, IL). Statistical significance was set at P , 0.05.

The study was performed at the Department of

Underwater and Hyperbaric Medicine, Istanbul Faculty
of Medicine. Divers were invited to the Department by
RESULTS
invitation letters or by telephone and the aim and the
Of the 58 divers, 2 were eliminated because of inadetechnical details of the study were explained. Informed
quate
X-ray studies. Radiological evaluations were
consents were taken from each subject who decided to
made on 56 divers. Of these, 7 were women and 49 were
be involved. The study was approved by the local ethimen. Mean age was 37.4 yr (6 9.9), mean diving experical committee.
ence was 13.2 yr (6 7.9), mean maximum dive depth
There were 58 volunteer divers who had performed at
was 70.8 m (6 14.1), and average depth of dive was
least 500 dives, were working as a dive instructor or a
24.7 m (6 6.7). Daily number of dives was 46.
dive guide, had never performed industrial and comExcept the two divers who were using U.S. Navy demercial dives, were asymptomatic at the time of enrolcompression
tables, all were using diving computers
ment and examination, and did not have a diagnosis of
based
on
Buhlmann
decompression tables. All divers
osteonecrosis, who were included in this study. A quesstated
a
strict
practice
of decompression rules. Seven
tionnaire was filled in for each diver to get information
divers
(12.5%)
stated
no
alcohol usage. Eight of the reabout the diver profiles and medical histories, such as
maining
group
(16.3%
of
total)
consumed high amounts
diving experiences and habits, years of diving, decomof alcohol (57.9 6 3 cl z wk21). With the exception of
pression sickness (DCS) history, alcohol intake, past and
these eight divers, no causes of aseptic necrosis other
current diseases, and possible causes of aseptic bone
than hyperbaric exposure were found in the divers. Six
necrosis. Laboratory analysis consisted of complete
(10.7%)to:
had
blood counts, ESR, serum cholesterol,
triglyceride,
Delivered
by Publishingdivers
Technology
? a history of type I DCS.
A
total
of
448
X-rays were obtained from 56 divers.
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On: Fri, 26 Jun 2015 18:07:49
HDL, SGOT, SGPT, uric acid, glucose
levels, and urine
Radiographic
evaluation
revealed a total of 18 DON leCopyright:
Aerospace
Medical
Association
analysis.
sions
in
14
divers.
The
prevalence
of DON was 25%. Of
The radiographs of the divers were taken according to
the
lesions,
17
were
type
B,
and
1
was
type A1. We could
the technique recommended by The British Research
not
be
certain
about
the
three
juxta-articular
radiological
Council Decompression Sickness Panel (5). A total of
images
in
two
divers,
but
MRI
screening
showed
no evieight X-rays were obtained from each subject, with imdence
of
DON.
Six
of
the
lesions,
including
the
type
A1
ages including both shoulders, hips, knee joints anterolesion,
were
localized
in
the
humerus,
six
were
in
the
posteriorly, and knee joints laterally. When suspicious
proximal femur, two were in the distal femur, and four
lesions were detected, MRI examination of the suspected
were in the upper tibia. The distribution of the lesions is
site was performed. MRI consisted of T1 weighted impresented in Table I.
ages in the axial and sagittal planes, and T2 weighted
Results of univariate logistic regression analyses are
images in the axial and coronal planes. Examinations
presented in Table II. We did not find a significant relawere performed on 1.5 Tesla MR units.
tionship between DON and sex, alcohol consumption,
Radiological evaluation was performed according to
history of DCS, diving experience, total number of dives,
the method recommended by The British Research
maximum diving depth, or frequent diving depth. The
Council Decompression Sickness Panel (5). We made
only variable associated with the development of DON
three independent interpretations at different times for
was divers age (P 5 0.001). Age, maximum diving
all subjects. The radiographs which did not show any
depth, and frequent diving depth were included in
DON lesions were eliminated in the first evaluation. The
the multiple logistic regression analyses to identify the
second evaluation was made by one of the investigators
independent predictors of DON (Table III). Age was
who had experience in DON lesions, the third by the rafound to be the only variable independently associated
diologist member of the authors. The final evaluation
with the development of DON (P 5 0.006). Divers
and MR interpretations were made by the author who is
a radiologist. Investigators were blinded to the details of
the individual divers at all times.
TABLE I. DYSBARIC OSTEONECROSIS LESIONS ACCORDING TO
The data are expressed as percentages for categorical
LOCALIZATION AND TYPE.
variables and as mean (6 SD) for continuous variables.
Femur 1/3 Femur 2/3 Tibia 1/3
Optimal cutoff levels for continuous variables were deHumerus
Proximal
Distal
Proximal Total
%
termined by using receiver operating characteristic
A1
1
1
5.5
curves. Binary logistic regression analysis was used in
B1
2
2
2
1
7
38.8
univariate modeling to identify variables associated
B2
1
3
4
22.2
with the development of DON. In order to know
B3
2
4
6
33.3
Total
6
6
2
4
18
100
the independent predictors of DON, variables with
%
33.3
33.3
11.1
22.2
100
P , 0.20 in the univariate analyses were entered into
final analysis using a backward stepwise logistic reA lesions: Juxta-articular lesionsA1: dense areas with intact articular
gression model. Correlations between continuous varicortex. B lesions: Head, neck, and shaft lesionsB1: dense areas; B2:
irregular calcified areas; B3: translucent and cystic areas.
ables were analyzed with the Pearson correlation test.
Aviation, Space, and Environmental Medicine x Vol. 78, No. 12 x December 2007

1151

DON IN DIVE MASTERS & INSTRUCTORSCIMSIT ET AL.

TABLE II. UNIVARIATE LOGISTIC REGRESSION ANALYSES TO IDENTIFY FACTORS ASSOCIATED WITH DYSBARIC OSTEONECROSIS.
Cut-Off Level

DON ! (N $ 42)

DON ~ (N $ 14)

Regression Coefficient

Odds Ratio (95% C.I.)

Age (yr)

45

2.289

0.393

0.954

Alcohol

1.000

0.000

History of DCS

0.620

0.460

Diving experience (yr)

15

8/14
(57.1%)
13/14
(92.9%)
2/14
(14.2%)
2/14
(14.3%)
6/14
(42.9%)
11/14
(78.6%)
9/14
(64.3%)
11/14
(78.6%)

0.001

Sex (Male)

5/42
(11.9%)
35/42
(83.3%)
6/42
(14.2%)
4/42
(9.5%)
12/42
(28.6%)
31/42
(73.6%)
18/42
(42.9%)
21/42
(50.0%)

0.325

0.629

0.722

0.263

0.171

0.875

0.071

1.299

9.9
(2.4-40.5)
2.6
(0.3-23.2)
1.0
(0.2-5.6)
1.6
(0.3-9.7)
1.9
(0.5-6.6)
1.3
(0.3-5.5)
2.4
(0.7-8.4)
3.7
(0.9-15.1)

Total number of dives (n)

675

Maximum diving depth (m)

70

Frequent diving depth (m)

24

DON 2 5 subjects without dysbaric osteonecrosis; DON 1 5 subjects with dysbaric osteonecrosis; DCS 5 decompression sickness.

age was correlated with diving experience (r50.690;

navy divers. Bolte et al. (4) reported a 3.2% prevalence of
P , 0.001), but not with total number of dives (r 5 0.207;
DON using MRI examination. Previously, in Jones and
P 5 0.126). However, diving experience was significantly
Neumanns chapter on DON (15), Elliott and Harrison
by Publishing
Technology
correlated with the total number ofDelivered
dives performed
reported
DONto:
in?4% of 350 British Royal Navy divers,
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(r 5 0.409; P 5 0.002).
and Sphar
et al. found only 16 men (1.7%) with DON
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among 934 U.S. Navy divers. Since navy divers go
DISCUSSION
through a well-disciplined diving training and strictly
follow the decompression schemes, one can argue that
Prevalence results for DON studies vary between 0%
DON prevalence is correlated to the dive profile.
and 85.7% (6,19,28). The lower prevalences are seen
The 25% DON prevalence in our study is higher than
among Navy divers, and higher numbers are seen
expected since the instructors and dive masters are supamong Caisson workers and professional divers. The
posed to have proper training, good knowledge about
populations with high prevalences are commercial divsafe diving rules, and practice accordingly. The possible
ers using conventional and empirical techniques in
lack of diving discipline or the events occurring during
Japan (1,2,17,20,21), Hawaii (25), and Turkey (6,8,24).
a dive that cause wrong practice and the relatively high
Kawashima et al. studied 905 Japanese shellfish divers
numbers of daily dives may be responsible for the high
and reported that 52% of these divers had DON (17).
prevalence of DON in this cohort.
Miyanashi et al. (20) found lesions in 31 of the 56 divers
The localizations of lesions were most frequent in the
(55%), and Shinoda et al. detected DON lesions in all 23
humerus and proximal femur. This finding was consisscuba diving fishermen using MRI scans (22). Wade and
tent with the data present in the literature (1,6,8,10,21).
his colleagues reported a 65% incidence rate among
Dawson et al. detected humeral head lesions in 23% of
Hawaiian diving fishermen using standard radiographs
Philippino diving fishermen (9), and Jones et al. reported
(25). In 1985, Cimsit et al. reported DON in 85% of 21
that 10 lesions (33.3%) out of a total of 30 were in the husponge divers (6). In 1998, radiographic evidence of
meral heads (16). The only juxta-articular lesion (5.55%)
DON was discovered in 70% of 51 sponge/shellfish divin this study was also in the humerus. This low prevaers from Turkey (8).
lence of type A lesions were in contrast with some other
In contrast to the above, DON is very rare among
previously reported findings: Wade et al. found 15
Navy divers (4,23,28). Spinnen and Ahovuo (23), and
juxta-articular shoulder lesions (34%) among a total of
Yildiz et al. (28) found no evidence of DON lesions in
43 lesions in Hawaiian divers (25).
It is unclear if there is any correlation between DON
and DCS. Bornstein and Plate stated that in the 3 DON
TABLE III. MULTIPLE LOGISTIC REGRESSION ANALYSIS TO
cases out of 500 Caisson workers they studied, there was
IDENTIFY INDEPENDENT PREDICTORS OF DYSBARIC
at least 1 episode of DCS (5). The report published by
OSTEONECROSIS.
the Decompression Sickness Central Registry and RaCut-Off
Regression
Odds Ratio
diological Panel states the prevalence of DON as 4.5%
Level
Coefficient
(95% C.I.)
P
and DCS as 31.2% among commercial divers in England
Age (yr)
45
2.129
8.4 (1.9-38.1)
0.006
(10). Ohta et al. reported DON prevalence as 69.3% and
Maximum diving
70
0.015
1.0 (0.2-4.6)
0.984
DCS as 83.5% (21). In a study performed with 171 divers
depth (m)
Yangsheng et al. found that 33 out of 90 divers with DCS
Frequent diving
24
1.002
2.7 (0.6-13.2)
0.216
also had DON, and the correlation was significant (27).
depth (m)
The same study indicates the correlation between DON
1152

Aviation, Space, and Environmental Medicine x Vol. 78, No. 12 x December 2007

DON IN DIVE MASTERS & INSTRUCTORSCIMSIT ET AL.

screening for DON lesions just like professional comand dive depth and work time. In the study performed
mercial divers.
by Toklu and Cimsit (24), the prevalences of DON and
DCS were 70.6% and 74.5%, respectively. When the divREFERENCES
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