Bilateral Osteonecrosis of the Femoral Head and Proximal Femur After Corticosteroid Injections: A Case Report

Abstract

Atraumatic bilateral osteonecrosis of the femoral head (ONFH) is a rare phenomenon whose etiology is not fully understood. In this report, we describe the case of a 75-year-old female patient who developed rapidly onset bilateral ONFH after intra-articular corticosteroid injections. She was treated with staged bilateral total hip arthroplasty. Several months post-operatively, she developed aseptic loosening of the left femoral implant and requiring revision of her femoral implant. The severity and distal extent of her osteonecrosis was not fully appreciated upon initial surgical management, likely increasing her risk of failure of femoral implant osseous integration. This case demonstrates that intra-articular corticosteroid injections can cause severe ONFH with extension into the proximal femur and fixation failure. Thus, the extent of osteonecrosis in the proximal femur may influence stem choice.

Figure 1

Anteroposterior radiograph of the pelvis demonstrating bilateral trochanteric bursitis and early bilateral hip osteoarthritis.

Figure 2

Anteroposterior radiograph of the pelvis demonstrating evidence of bilateral osteonecrosis of the femoral head with prominent bone loss of her right femoral head and complete collapse of her left femoral head.

Figure 3

T2-weighted MRI scans of the left hip and femur demonstrating flattening of the left femoral head and a large effusion.

Figure 4

Six-week post-operative right total hip arthroplasty and 3-month post-operative left total hip arthroplasty anterior-posterior radiograph of the pelvis demonstrating satisfactory alignments of both implants without evidence of subsidence.

Figure 5

Ten-month post-operative anterior-posterior radiograph of the left hip and femur demonstrating medial periosteal reaction and failure of left femoral implant fixation with subsidence of the femoral stem.

Figure 6

T2-weighted (A) coronal and (B) axial MRI scans of the left hip and femur demonstrating extensive bone infarction involving the greater trochanter and proximal intramedullary femur.

Figure 7

One-year post-operative anterior-posterior radiograph of the left hip joint demonstrating no evidence of subsidence or failure of fixation.