Femoral head necrosis

A short review of bone changes during steroid therapy has been published (63 ). Further cases of femoral head necrosis following steroid treatment have been reported... 

Muscle weakness, steroid myopathy, loss of muscle mass, severe arthralgia, vertebral compression fractures, aseptic necrosis of humeral and femoral heads, pathologic fracture of long bones, osteoporosis... 

In 15 men with osteonecrosis of the femoral head after short-term therapy the mean duration of therapy was 21 (range 7-39) days and the mean dose in milligram equivalents of prednisone was 850 (range 290-3300) mg (269). The time from administration of glucocorticoids to hip pain was 17 (range 6-33) months. A new case of bilateral avascular necrosis of the femoral heads after high-dose short-term dexamethasone therapy as an antiemetic in cancer chemotherapy has been reported (270). 

Lausten GS, Lemser T, Jensen PK, Egfjord M. Necrosis of the femoral head after kidney transplantation. Clin Transplant 1998 12(6) 572-4. 

Avascular necrosis of the femoral head and another of slipped capital femoral epiphysis with avascular necrosis have been reported in two children with growth hormone deficiency receiving growth hormone (74). 

This regimen was used by a bodybuilder who went through three cycles each year for 8 years.The subject also reported taking 600 mg of testosterone per week between cycles. This subject ultimately developed avascular necrosis in both femoral heads. 

Petrine KA. Association of anabolic steroids and avascular necrosis of femoral heads. Am J Sports Med. 1991 19 96-98. 

A man with severe hay fever who received at least one depot injection of corticosteroid each year for eleven years developed avascular necrosis of both femoral heads, an uncommon but serious complication of exposure to corticosteroid. Nasser SMS, Ewan P W 2001 British Medical Journal 322 1589. 

Musculoskeletal. Proximal myopathy and tendon rupture may occur. Osteoporosis develops insidiously leading to fractures of vertebrae, ribs, femora and feet. Pain and restriction of movement may occur months in advance of radiographic changes. A biphosphonate, with or without vitamin D, is useful for prevention and treatment. Growth in children is impaired. A vascular necrosis of bone (femoral heads) is a serious complication (at higher doses) it appears to be due to restriction of blood flow through bone capillaries. 

Three patients developed unilateral or bilateral avascular necrosis of the femoral head after 3-54 months of treatment with interferon alfa for chronic myelogenous leukemia (314). One required bilateral hip replacement and two significantly improved after interferon alfa withdrawal. One patient received further interferon alfa without exacerbation. 

Kozuch P, Talpaz M, Faded S, O Brien S, Freireich EJ, Kantarjian H. Avascular necrosis of the femoral head in chronic myeloid leukemia patients treated with interferon-alpha a synergistic correlation Cancer 2000 89(7) 1482-9. 

For this initial design, the femoral head and the shell were press fit into the bone, with the idea that the friction between the bone and the PTFE would prevent relative motion. Unfortunately, the tolerances between the head and shell were such that the articulation tended to occur mainly between the PFTE shell and the acetabulum, resulting in abrasion of the shell and destruction of the underlying bone. Wear also occurred of the PTFE femoral head prosthesis, but more concerning from a clinical standpoint was the concomitant loss of blood supply to the femoral bone inside the PTFE cavity, which lead to necrosis (Charnley 1961). 

Avascular necrosis can potentially complicate any fracture but is thankfully relatively rare in the younger child. In the older teenager with a scaphoid or femoral head fracture, dislocation then avascular necrosis is a more significant risk. 

The most mechanically stable implant is a locked, reamed intra-medullary nail. This is the standard implant utilised in adults. The presence of cross bolts effectively removes any rotational instability. The use of such techniques in children has been controversial, since there have been reports of avascular necrosis (AVN) of the femoral head (Beaty et al. 1994). This has been attributed to damage to the middle circumflex vessels as the nail is introduced into the piriform... 

With a displaced acetabular fracture, open reduction, stable internal fixation and early motion is often indicated. Reduction of a femoral head dislocation should be paramount, as there is a relationship between the occurrence of avascular necrosis and prolonged dislocation (Heeg et al. 1989). Recurrent dislocation may occur from a capsular defect, loose fragments within the joint and remodelling of the joint. 

P450 27C1 was a high-frequency gene in an analysis of factors involved in avascular necrosis of the femoral head [2671]. 

Bouamar R, Koper JW, van Rossum EFC, Weimar W, van Gelder T. Polymorphisms of the glucocorticoid receptor and avascular necrosis of the femoral heads after treatment with corticosteroids. NDT Plus 2009 2 384-6. 

Perthes disease, also known as Legg-Calv -Perthes syndrome after the investigators who independently identified this condition in 1910, is related to an idiopathic avascular necrosis of the proximal femoral epiphysis. It mainly affects children 3-12 years old with a peak incidence at approximately 4-8 years and a definite prevalence (4 1) in males and lower social classes (Guille et al. 1998). The onset of Perthes disease is related to the development of the femoral head vasculature, which includes the ascending cervical arteries (branches from the medial and lateral circumflex arteries), the lateral epiphyseal vessels and... 

Cunliffe et at. (69 ) describe 3 patients with extensive skin disease and liver failure. Two were treated with large amounts of topical steroids and one with a small oral dose of betamethasone. The third patient had constitutional eczema and had taken oral betamethasone 1 mg/day for 6 months. The former two patients developed acute adrenal insuffiency when they failed to apply the steroid for several days. All 3 patients developed a septic necrosis of either the femoral head or the talus. This report emphasizes the fact that the hazards of steroid therapy may be increased in patients with hepatic failure. 

Muscle weakness, loss of muscle mass, tendon rupture, osteoporosis, aseptic necrosis of femoral and humoral heads, spontaneous fractures... 

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