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    Musculoskeletal Imaging

    Osteonecrosis of Hip and Knee in Patients with Severe Acute Respiratory Syndrome Treated with Steroids

    Published Online:Apr 1 2005https://doi.org/10.1148/radiol.2351040100

    Abstract

    PURPOSE: To evaluate whether there is a relationship between steroid treatment and risk for osteonecrosis of the hip and knee in patients with severe acute respiratory syndrome (SARS).

    MATERIALS AND METHODS: The hospital ethics committee approved the study, and all patients provided written informed consent. A total of 254 patients with confirmed SARS treated with steroids underwent evaluation with magnetic resonance (MR) imaging for osteonecrosis. Clinical profiles, joint symptoms, relevant past medical and drug history, steroid dose, and radiographic and MR imaging evidence of osteonecrosis and other bone abnormalities were evaluated. Mann-Whitney, Kruskal-Wallis, and Pearson exact χ2 tests were performed, and univariate and multivariate logistic regression analyses were applied.

    RESULTS: One hundred thirty-four (53%) of 254 patients had recent onset of large joint pain, but 211 (80%) of 264 painful joints were not associated with abnormality on MR images. MR images in 12 (5%) of 254 patients showed evidence of subchondral osteonecrosis in the proximal femur (n = 9), distal femur (n = 2), and proximal and distal femora and proximal tibiae (n = 1). Additional nonspecific subchondral and intramedullary bone marrow abnormalities were present in 77 (30%) of 254 patients. Results of multiple logistic regression analysis confirmed cumulative prednisolone-equivalent dose to be the most important risk factor for osteonecrosis. The risk of osteonecrosis was 0.6% for patients receiving less than 3 g and 13% for patients receiving more than 3 g prednisolone-equivalent dose. No relationship was found between additional nonspecific bone marrow abnormalities and steroid dose.

    CONCLUSION: An appreciable dose-related risk was found for osteonecrosis in patients receiving steroid therapy for SARS. Additional nonspecific bone marrow abnormalities were frequent. Joint pain was common after SARS infection and was not a useful clinical indicator of osteonecrosis.

    © RSNA, 2005

    References

    • 1 World Health Organization. Cumulative number of reported probable cases of SARS, 1 Nov 2002 to 31 July 2003. Available at: www.who.int/csr/sars/country/table2003_09_23/en. Accessed January 9 2004.
      Google Scholar
    • 2 Wing PC, Nance P, Connell DG, Gagnon F. Risk of avascular necrosis following short term megadose methylprednisolone treatment. Spinal Cord 1998; 36:633-636.
      MedlineGoogle Scholar
    • 3 Cook AM, Dzik-Jurasz AS, Padhani AR, Norman A, Huddart RA. The prevalence of avascular necrosis in patients treated with chemotherapy for testicular tumours. Br J Cancer 2001; 85:1624-1626.
      MedlineGoogle Scholar
    • 4 Zizic TM, Marcoux C, Hungerford DS, Dansereau JV, Stevens MB. Corticosteroid therapy associated with ischemic necrosis of bone in systemic lupus erythematosus. Am J Med 1985; 79:596-604.
      MedlineGoogle Scholar
    • 5 World Health Organization. Alert, verification and public health management of SARS in the post outbreak period. Available at: www.who.int/csr/sars/postoutbreak/en/print.html. Accessed January 9 2004.
      Google Scholar
    • 6 Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003; 348:1986-1994.
      MedlineGoogle Scholar
    • 7 Wong KT, Antonio GE, Hui DS, et al. Severe acute respiratory syndrome: radiographic appearances and pattern of progression in 138 patients. Radiology 2003; 228:401-406.
      Google Scholar
    • 8 Khanna AJ, Yoon TR, Mont MA, Hungerford DS, Bluemke DA. Femoral head osteonecrosis: detection and grading by using a rapid MR imaging protocol. Radiology 2000; 217:188-192.
      Google Scholar
    • 9 Lecouvet FE, Vande Berg BC, Maldague BE, et al. Early irreversible osteonecrosis versus transient lesions of the femoral condyles: prognostic value of subchondral bone and marrow changes on MR imaging. AJR Am J Roentgenol 1998; 170:71-77.
      MedlineGoogle Scholar
    • 10 Zanetti M, Bruder E, Romero J, Hodler J. Bone marrow edema pattern in osteoarthritic knees: correlation between MR imaging and histologic findings. Radiology 2000; 215:835-840.
      Google Scholar
    • 11 Goffin E, Vande Berg B, Devogelaer JP, et al. Post-renal transplant syndrome of transient lower limb joint pain: description under a tacrolimus-based immunosuppression. Clin Nephrol 2003; 59:98-105.
      MedlineGoogle Scholar
    • 12 Vande Berg BC, Malghem J, Goffin EJ, Duprez TP, Maldague BE. Transient epiphyseal lesions in renal transplant recipients: presumed insufficiency stress fractures. Radiology 1994; 191:403-407.
      Google Scholar
    • 13 Steinberg ME, Bands RE, Parry S, Hoffman E, Chan T, Hartman KM. Does lesion size affect the outcome in avascular necrosis? Clin Orthop 1999; 367:262-271.
      MedlineGoogle Scholar
    • 14 Tsang KW, Lam WK. Management of severe acute respiratory syndrome: the Hong Kong University experience. Am J Respir Crit Care Med 2003; 168:417-424.
      MedlineGoogle Scholar
    • 15 Zhong NS, Zeng GQ. Our strategies for fighting severe acute respiratory syndrome (SARS). Am J Respir Crit Care Med 2003; 168:7-9.
      MedlineGoogle Scholar
    • 16 Wang H, Ding Y, Li X, Yang L, Zhang W, Kang W. Fatal aspergillosis in a patient with SARS who was treated with corticosteroids. N Engl J Med 2003; 349:507-508.
      MedlineGoogle Scholar
    • 17 Boss JH, Misselevich I. Osteonecrosis of the femoral head of laboratory animals: the lessons learned from a comparative study of osteonecrosis in man and experimental animals. Vet Pathol 2003; 40:345-354.
      MedlineGoogle Scholar
    • 18 Wang GJ, Cui Q, Balian G. The Nicolas Andry award. The pathogenesis and prevention of steroid-induced osteonecrosis. Clin Orthop 2000; 370:295-310.
      Google Scholar
    • 19 Oinuma K, Harada Y, Nawata Y, et al. Osteonecrosis in patients with systemic lupus erythematosus develops very early after starting high dose corticosteroid treatment. Ann Rheum Dis 2001; 60:1145-1148.
      MedlineGoogle Scholar
    • 20 Stevens K, Tao C, Lee SU, et al. Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol 2003; 180:363-368.
      MedlineGoogle Scholar
    • 21 Beltran J, Knight CT, Zuelzer WA, et al. Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging. Radiology 1990; 175:533-536.
      Google Scholar
    • 22 Fukuta S, Masaki K, Korai F. Prevalence of abnormal findings in magnetic resonance images of asymptomatic knees. J Orthop Sci 2002; 7:287-291.
      MedlineGoogle Scholar
    • 23 Goffin E, Vande Berg B, Pirson Y, Malghem J, Maldague B, van Ypersele de Strihou C. Epiphyseal impaction as a cause of severe osteoarticular pain of lower limbs after renal transplantation. Kidney Int 1993; 44:98-106.
      MedlineGoogle Scholar
    • 24 Jagose JT, Bailey RR, Hughes TH. Acute bone-marrow oedema in cyclosporin-treated renal transplant recipients. QJM 1997; 90:359-366.
      MedlineGoogle Scholar
    • 25 Coates PT, Tie M, Russ GR, Mathew TH. Transient bone marrow edema in renal transplantation: a distinct post-transplantation syndrome with a characteristic MRI appearance. Am J Transplant 2002; 2:467-470.
      MedlineGoogle Scholar
    • 26 Sakai T, Sugano N, Ohzono K, Matsui M, Hiroshima K, Ochi T. MRI evaluation of steroid- or alcohol-related osteonecrosis of the femoral condyle. Acta Orthop Scand 1998; 69:598-602.
      MedlineGoogle Scholar
    • 27 Baumgarten KM, Mont MA, Rifai A, Hungerford DS. Atraumatic osteonecrosis of the patella. Clin Orthop 2001; 383:191-196.
      MedlineGoogle Scholar
    • 28 Pollack MS, Dalinka MK, Kressel HY, Lotke PA, Spritzer CE. Magnetic resonance imaging in the evaluation of suspected osteonecrosis of the knee. Skeletal Radiol 1987; 16:121-127.
      MedlineGoogle Scholar
    • 29 Havel PE, Ebraheim NA, Jackson WT. Steroid-induced bilateral avascular necrosis of the lateral femoral condyles: a case report. Clin Orthop 1989; 243:166-168.
      MedlineGoogle Scholar
    • 30 Masuko-Hongo K, Kato T, Nishioka K. Virus-associated arthritis. Best Pract Res Clin Rheumatol 2003; 17:309-318.
      MedlineGoogle Scholar
    • 31 Nicholls JM, Poon LL, Lee KC, et al. Lung pathology of fatal severe acute respiratory syndrome. Lancet 2003; 361:1773-1778.
      MedlineGoogle Scholar

    Article History

    Published in print: Apr 2005