Images In...

Corticosteroid-associated osteonecrosis of the femoral head: complete resolution on MRI with conservative treatment

Terence Rooney¹, Ronan H Mullan¹, Robert Gibney², Oliver FitzGerald¹

¹ St Vincent’s University Hospital, Department of Rheumatology, Elm Park, Dublin, 4, Ireland
² St Vincent’s University Hospital, Department of Radiology, Elm Park, Dublin, 4, Ireland

Correspondence to:
Terence Rooney, rooneyterence{at}hotmail.com

An elderly man, receiving 10 mg/day oral prednisolone for established polymyalgia rheumatica presented with a 3 month history of left hip pain, especially on weight bearing. Physical examination revealed painful limitation of active and passive motion in all directions. A plain radiograph was normal. An MRI scan (fig 1A–C) showed early osteonecrosis (ON) of the femoral head. Fig 1A shows the subchondral "double-line" sign, distinguishing this condition from transient osteoporosis of the hip.¹ Corticosteroids were withdrawn, and the MRI was repeated after 19 months of protected weight bearing (fig 1D–F), by which time all clinical features had resolved. This scan showed complete resolution of the previous abnormalities.

View this figure (135K): in this window | in a new window | PowerPoint for Teaching   Figure 1 MRI imaging of the left hip joint. (A–C) Baseline coronal T2-weighted, coronal STIR, and sagittal T1-weighted images, respectively. (D–F) Corresponding images, respectively, generated after 19 months of protected weight bearing.

 

ON is a common condition with diverse associations including corticosteroid therapy and inflammatory joint disease, such as systemic lupus erythematosus. Early identification is desirable, as earlier intervention is associated with favourable outcome, with conservative and surgical management.^2,3 This has been greatly facilitated by the development of MRI technology, which can detect ON before plain radiographic features appear. It remains to be established whether conservative therapy or surgical intervention is most appropriate in early, radiographically normal disease.² As surgical intervention may be associated with significant morbidity, it will be important to develop evidence-based selection criteria for choosing between these approaches for individual patients. This case illustrates the utility of MRI in detecting corticosteroid-associated ON of the femoral head, and following its change over time. It serves also to highlight the value of early detection, if disability is to be avoided.

Competing interests: none.

1. Vande Berg, BC, Malghem, JJ, Lecouvet, FE, et al. Idiopathic bone marrow edema lesions of the femoral head: predictive value of MR imaging findings. Radiology 1999; 212: 527–35.[Abstract/Free Full Text]
2. Castro, FP, Jr, & Barrack, RL. Core decompression and conservative treatment for avascular necrosis of the femoral head: a meta-analysis. Am J Orthop 2000; 29: 187–94.[Medline]
3. Yoon, TR, Song, EK, Rowe, SM, et al. Failure after core decompression in osteonecrosis of the femoral head. Int Orthop 2001; 24: 316–8.[CrossRef][Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?