Spontaneous repair of asymptomatic osteonecrosis associated with corticosteroid therapy in systemic lupus erythematosus: 10-year minimum follow-up with MRI

Abstract

Systemic lupus erythematosus (SLE) patients are at high risk of developing osteonecrosis. This study utilized MRI to document the long-term natural history of asymptomatic osteonecrosis associated with corticosteroid therapy in SLE patients. Two hundred and one SLE patients treated with high-dose corticosteroids were prospectively observed from 1986 to 1997. The inclusion criterion was that patients had received periodic MRI examinations of all their hip and knee joints for ≥10 years. Joints that were already collapsed and symptomatic at the first examination were excluded. Five hundred and thirty-seven joints (251 hips and 286 knees) were identified in 144 patients, with a mean follow-up period of 13.6 years (range, 10-20 years) and a follow-up rate of 73%. Mean age of SLE onset was 26 years, and the mean highest oral corticosteroid dosage was 57 mg/day. Osteonecrosis developed in 238 (44%) of 537 joints. At final follow-up, 117 (49%) of these 238 joints demonstrated spontaneous repair in the necrotic area. Osteonecrosis completely disappeared in 21 joints. Enlargement of osteonecrosis was noted in 35 joints (15%) following increased steroid dosage because of SLE recurrence. Finally, 52 joints (22%) were collapsed. Spontaneous repair of asymptomatic osteonecrosis was observed, whereas enlargement occurred only after corticosteroid dosage increases.

The natural history of asymptomatic osteonecrosis of the femoral head

“…In this study, no significant relation was found between the factors examined and symptom development, and thus, no guidance was given regarding the need for surgical treatment based on considerations of causative factors. Nakamura et al [16] observed asymptomatic ONFH in systemic lupus erythematosus (SLE) patients administered steroids, and concluded that both duration and degree of steroid use are more related to symptom development and lesion progression. However, in the study, no significant relation was found between symptom development and duration or degree of exposure to steroid.…”

Quantitative T2 mapping of femoral head cartilage in systemic lupus erythematosus patients with noncollapsed osteonecrosis of the femoral head associated with corticosteroid therapy

“…As for other features, Nakamura et al (6) reported that there were no relationships between spontaneous repair of osteonecrosis of the femoral head and lupus nephritis, CNS lupus, osteoporosis, bone protection regimes, antiphospholipid antibody, total cumulative dose of corticosteroid, mean dose of corticosteroid over time, or duration of corticosteroid therapy. Further study is needed about influence of SLE subtypes, osteonecrosis, and steroid use on cartilage degeneration.…”

“…Spontaneous repair of osteonecrotic lesions have been observed during long-term, low-dose corticosteroid therapy in SLE patients with noncollapsed and asymptomatic osteonecrosis of the femoral head (6). Although the osteonecrotic lesion itself is usually asymptomatic initially, once it has progressed to the stage of articular collapse the articular collapse in turn leads to hip pain and deformity of the femoral head that unchecked will result in secondary osteoarthritis (7).…”

“…Articular cartilage degeneration appears to be a secondary effect of mechanical stress following articular collapse in osteonecrosis of the femoral head (9). Since most patients with noncollapsed osteonecrosis are asymptomatic, it has been hypothesized that the femoral head articular cartilage in such patients is in normal condition and that as long as their articular cartilage remains in normal condition, their hip joint eventually will completely recover by a spontaneous repair process in which the osteonecrotic lesion is gradually replaced by viable bone tissue (6). On the other hand, because articular cartilage is thought to be nourished mainly by articular fluid and partly by subchondral bone (10,11), it has been further hypothesized that circulatory disturbance due to subchondral bone necrosis is responsible for cartilage degeneration.…”

Osteonecrosis in Systemic Lupus Erythematosus: An Early, Frequent, and Not Always Symptomatic Complication

“…During the followup in about half of the lesions spontaneous reduction of necrotic areas was observed with complete regression in 9% of the cases. Progression of the osteonecrotic lesions occurred in 14% of the cases, invariably associated with an increase of corticosteroid dosage due to SLE recurrence [53]. …”