Bilateral Femur and Humerus Avascular Necrosis Associated With Corticosteroids: A Rare Case Presentation

Abstract

Avascular necrosis of the bone is a pathology characterized by compromised blood circulation, leading to necrosis due to insufficient vascular nourishment. Within the realm of orthopedics and traumatology, instances of avascular necrosis are steadily increasing. Notably, the escalating use of corticosteroids in managing inflammatory diseases and acute respiratory distress syndrome associated with the COVID-19 pandemic has resulted in a surge of outpatient referrals concerning cases of glucocorticoid-associated avascular necrosis. This study aims to elucidate the management of avascular necrosis following oral corticosteroid use in a young and otherwise healthy male patient, impacting both humeral and femoral heads bilaterally. A 26-year-old adult male, devoid of chronic health conditions, received a diagnosis of bilateral avascular necrosis in humeral and femoral heads within two years following a one-month course of oral corticosteroids. The patient underwent a comprehensive treatment regimen, encompassing hyperbaric oxygen therapy, oral antiplatelet therapy, a tailored physical therapy and rehabilitation program, and bilateral core decompression surgery for both hip joints. During the three-year follow-up, the patient exhibited a favorable response to treatment, demonstrating a complete and painless range of motion in both shoulder and hip joints. This case serves to underscore a crucial point: femoral head avascular necrosis may not invariably manifest as the initial bone affected, and a substantial time lapse may transpire between corticosteroid use and the onset of clinical symptoms. We emphasize the critical importance of not dismissing complaints pertaining to other bones in patients with a confirmed diagnosis and stress the significance of prompt detection in avascular necrosis. Furthermore, this study highlights the necessity for heightened vigilance in instances of orthopedic grievances among individuals with a history of corticosteroid use, particularly those related to the pandemic and inflammatory diseases, to facilitate early diagnosis and intervention for avascular necrosis.

Keywords: avascular necrosis of the femoral head; avascular necrosis of the humeral head; bilateral femoral heads; bilateral humeral heads; core decompression; corticosteroid-associated avascular necrosis; covid-19; multifocal involvement; osteonecrosis.

Figure 1. T1 and T2 sequence magnetic resonance images depicting avascular necrosis involvement of bilateral humeral heads.

T1 sequence in the proximal right humerus (a) and in the proximal left humerus (b); T2 sequence in the proximal right humerus (c) and in the proximal left humerus (d). The lesions are marked with a red ellipse.

Figure 2. Bilateral hip magnetic resonance images of the patient.

T1 (a) and T2 (b) sequence magnetic resonance images illustrating avascular necrosis involvement of bilateral femoral heads. The lesions are marked with green ellipses.