Prednisolone/unspecified steroid

Abstract

Osteonecrosis of the humeral head stage III: case report A 53-year-old woman developed osteonecrosis of the humeral head stage III during treatment with prednisolone and an unspecified steroid for systemic lupus erythematosus (SLE). The woman presented to the orthopaedic hospital with a chief complaint of pain and limited active elevation of the right shoulder. Her medical history was significant for lupus nephritis and SLE. She had been receiving treatment with an unspecified steroid pulse therapy followed by oral prednisolone [dosage not stated] for 17 years. Ten years prior to the presentation, she had been diagnosed with osteonecrosis of the medial femoral condyle in her right knee joint. Therefore, she underwent mosaicplasty. Three months prior to the current presentation, she experienced shoulder pain without any history of injury or trauma. Therefore, she visited another clinic. At that time, she had been diagnosed with osteoarthritis of the glenohumeral joint. Therefore, she was treated with nonsteroidal anti-inflammatories for pain relief. However, the pain in her right shoulder persisted even during daily activities. Therefore, she presented to the orthopaedic hospital. On presentation, physical examination revealed active range of motion (ROM) of the right shoulder as 40° in external rotation at the side, 100° in forward flexion, 60° in abduction and T12 in internal rotation behind the back. All directions of active ROM were restricted owing to shoulder pain. The pre-operative American shoulder and elbow surgeons and the Japanese orthopaedic association functional scores were found to be 53.3 and 69.0 points, respectively. The plain radiograph showed a subchondral lucency with a sclerotic rim and normal articular congruity of the glenoid. Additionally, mild inferior osteophyte formation was observed in the humeral head (stage I osteoarthritis). The CT scan showed focal subchondral bone collapse with an articular incongruity of the humeral head. The size of the affected area was 126 mm2. Additionally, MRI findings showed low signal intensity on both T1 and T2-weighted images. Based on these findings, a clinical diagnosis of steroidinduced osteonecrosis of the humeral head stage III was made. The woman underwent osteochondral autograft transplantation to preserve the native joint. Subsequently, the right shoulder was immobilised using an abduction sling for 4 week postsurgery. She then started passive and active-assisted exercises after the immobilisation period. Eight weeks after the surgery, she started to perform exercises to strengthen the rotator cuff and the scapula stabilisers, and she was able to return to her work 2 months post-surgery. Her ability to perform daily activities fully recovered, which was impaired previously. CT scan revealed graft union at 6 months after the surgery. At 2 years after the surgery, the glenohumeral joint space was maintained, although the size of the inferior osteophyte was increased as compared to the pre-operative examination. MRI revealed complete graft integration. Two years after the surgery, osteonecrosis of the humeral head recovered completely. She was found to be asymptomatic and active ROM in the right shoulder improved to 70° in external rotation at the side, 170° in forward flexion, 170° in abduction and T10 in internal rotation behind the back. The post-operative American shoulder and elbow surgeons and the Japanese orthopaedic association scores improved to 95.0 and 100 points, respectively. Two-years postsurgery, the Lysholm score of the left knee from which the osteochondral graft had been harvested, was found to be 95 points.