SAN FRANCISCO, California—Steroid-induced osteonecrosis in patients with systemic lupus erythematosus (SLE) has a high rate of resolution so long as the lupus remains under control, but both asymptomatic and symptomatic shoulder damage in patients with steroid-induced hip osteonecrosis is likely to cause eventual shoulder collapse unless treated, experts reported at the American Academy of Orthopedic Surgeons 2008 annual meeting.

“Spontaneous reduction of osteonecrosis occurred when SLE remained under control, allowing corticosteroid dosage decreases in due course, whereas new lesions occurrence only after SLE recurrence.”—Junichi Nakamura, MD.
Junichi Nakamura, MD, and colleagues from Chiba, Japan, analyzed medical records of 235 SLE patients treated with high-dose corticosteorids who had received periodic magnetic resonance imaging of their hip and knee joints for at least 10 years.1 The investigators excluded joints that had already collapsed at the first examination. They reported data for 443 joints (212 hips, 231 knees) in 117 patients with follow-up of 10 to 20 years (mean 13 years) and oral steroid doses up to 57 mg/day. They found that osteonecrosis developed in 183 of 443 joints (41%).

“At the final follow-up of these 183 joints, 105 joints (57%) comprising 41 hips and 64 knees, evidenced a spontaneous reduction in the necrotic area. Osteonecrosis completely vanished in 17 joints, comprising 7 hips and 10 knees,” Dr. Nakamura said. Most of the joints remained normal, but new osteonecrotic lesions developed in 2% following SLE flares that required increases in corticosteroid dosages.

“Spontaneous reduction of osteonecrosis occurred when SLE remained under control, allowing corticosteroid dosage decreases in due course, whereas new lesions occurred only after SLE recurred,” Dr. Nakamura said.

In related work, Philippe Hernigou, PhD, of Creteil, France, described the natural history of shoulders with corticosteroid-induced osteonecrosis.2 That study of 250 shoulders in 125 consecutive patients with bilateral hip osteonecrosis related to high-dose steroids was meant to determine the natural history, rate of disease progression, and outcome of patients’ shoulders. Subjects were followed with no therapeutic intervention or attempt at modifying the disease by conservative surgical treatment for shoulders without collapse. Mean follow-up was 15 years.

“Untreated asymptomatic and symptomatic shoulder osteonecrosis related to corticosteroids has a high likelihood of shoulder collapse, and the natural evolution...after 15 years resulted…in glenohumeral osteoarthritis [in most patients], with the risk of shoulder arthroplasty in the future,” Dr. Hernigou said. He continued that if diagnosed early, surgery would only be needed in a few patients.

References
1. Nakamura J. MRI of steroid-induced osteonecrosis in systemic lupus erythematosus: 10-year minimum follow-up. Presented at: AAOS 2008 meeting; March 5, 2008; San Francisco, Calif. Presentation 112.
2. Hernigou P. The natural history of shoulders with corticosteroid-induced osteonecrosis. Presented at: AAOS 2008 meeting; March 5, 2008; San Francisco, Calif. Presentation 015.