Steroid-related osteonecrosis in inflammatory bowel disease

Osteonecrosis is a serious complication of steroid therapy characterized by death of all the cellular elements of bone. We describe a series of patients with steroid-induced osteonecrosis in inflammatory bowel disease. Seven of 161 patients (4.3%) treated with corticosteroids for inflammatory bowel disease over a 10-yr period developed osteonecrosis. The median age at the onset of inflammatory bowel disease was 20 yr and for osteonecrosis the median age was 28 yr. Patients had received steroids for a mean duration of 42 wk with a mean daily dose of 26 mg/day and a mean cumulative lifetime prednisone dose of 7 g. Osteonecrosis occurred within 6 mo of the last administration of steroid in all patients. It presented with joint pain in the hip or knee and was frequently mistaken for the arthralgia of steroid withdrawal or the arthropathy of inflammatory bowel disease. Multiple joints were involved in 6 of the 7 patients. Surgery for the joint disease was required in 4 of the 7 patients. The median duration of follow-up was 2 yr. Five of the 7 patients continued to have significant joint pain and disability that limited their activity. We conclude that inflammatory bowel disease predisposes to steroid-induced osteonecrosis. The age of patients is younger, and the dose and duration are considerably lower than that reported for steroid-induced osteonecrosis in other disease states. Bone scans or magnetic resonance imaging should be performed in patients with joint pain who are receiving or have recently received corticosteroid therapy. Early detection and treatment may prevent the crippling long-term complications of this disease.