Osteonecrosis in Patients with SLE

Abstract

Osteonecrosis is a clinical entity characterized by death of bone marrow and trabecular bone as a result of disruption of blood supply to the bone (1,2). Other aspects of this condition include avascular necrosis, aseptic necrosis, and osseous ischemic necrosis of bones. Osteonecrosis is classified into two main forms; post-traumatic and nontraumatic. The post-traumatic form of osteonecrosis usually develops as a result of traumatic displacement of bone fragments, which leads to impaired blood supply and ischemia to the affected bone. Osteonecrosis of the femoral head is common following fracture of the femoral neck. A variety of systemic diseases and clinical conditions are associated with nontraumatic osteonecrosis. These include autoimmune rheumatic diseases, alcoholism, pregnancy, Gaucher's disease, thrombophilia, corticosteroid therapy, Sickle-cell anemia, pancreatitis, inflammatory bowel diseases, and use of cytotoxic drugs and others. Idiopathic forms of osteonecrosis have also been reported (2-4). Among the rheumatic diseases, osteonecrosis is strongly associated with systemic lupus erythematosus (SLE) (5). However, osteonecrosis has been diagnosed in patients with primary antiphospholipid syndrome (APS) (6), rheumatoid arthritis (7), and systemic vasculitis (8). This article reviews the causes, clinical and epidemiological features, diagnosis, and treatment options for osteonecrosis among patients with SLE.

Systemic Lupus Erythematosus and Osteonecrosis: A Comparison of Patients with Single versus Multiple Joint Involvement

“…Hips remain the most commonly affected joint by osteonecrosis (nonmultifocal or multifocal). The distribution of joint involvement noted in our study is similar to that of other studies with hips being the most commonly affected, followed by knees [17]. Bilateral involvement was common and was noted in 15 patients from Group B. Additionally, all patients in the group with 3 or more joints affected with osteonecrosis had bilateral involvement of at least one joint area.…”

“…Prevalence estimates of osteonecrosis in SLE range from 3-30% [17]. While glucocorticoid use remains a major risk factor for development of this complication, multiple other factors have also been associated with development of osteonecrosis in SLE.…”

Notable Difference between the Development of Vertebral Fracture and Osteonecrosis of the Femoral Head in Patients Treated with High-dose Glucocorticoids for Systemic Rheumatic Diseases

“…(1,3,4,6,7,(26)(27)(28)(29) (15,(32)(33)(34)(35)(36)(37) (Fig. 1) as previously reported (38), probably because the lateral view of DEXA more accurately estimates trabecular bone mass compared with the AP view (39).…”

Endothelial nitric oxide synthase gene polymorphisms and the risk of osteonecrosis of the femoral head in systemic lupus erythematosus

“…In particular, corticosteroid use and excessive alcohol intake are considered to be dominant risk factors, with high dose corticosteroid use (equating to ∼2 g of prednisone within two to three months) the most common risk factor, accounting for between ten and 30 % of osteonecrosis cases [2]. Steroid medications are often used in patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and after renal transplant, all conditions known to be associated with susceptibility to osteonecrosis development [3]. However, only ∼5 % of patients with a history of high dose corticosteroid use, or alcohol abuse, develop osteonecrosis [4], indicating individual differences in sensitivity to these risk factors.…”