Multisite Osteonecrosis to Long-term Corticoid Treatment: A Case Report

Osteonecrosis (ON) refers to the death of bone cells caused by a disruption in blood flow. Multiple-site osteonecrosis (MSON) is a rare condition characterized by concurrent or sequential involvement of three or more separate anatomic sites approximately 3% of ON patients. Avascular necrosis (AVN) is commonly associated with high-dose or long-term corticosteroid use, and several reports suggest that high-dose corticosteroid use is the primary risk factor for developing MSON. The ideal management of ON in a young individual remains a subject of debate. Review of literature supports Core decompression (CD) as an effective treatment option in the pre-collapse stage of ON in small to medium-sized lesions according to Ficat and Arlet Stage I and II. In the advanced stages of the disease (i.e., Stages III and IV), arthroplasty is required when joint preservation is not possible.

A 27-year-old female presented with pain in the right ankle and left shoulder. The patient was on corticosteroids. Suspected MSON by examination was later confirmed using magnetic resonance imaging. CD and bone marrow aspiration concentrate application sequentially in all affected joints in three sessions with a 2-month gap. Alendronate 70 mg once a week was advised. Tensor fascia lata muscle pedicle bone grafting was performed on both hips following two years post-primary surgery due to the continued progression of the disease.

Therefore, young adults experiencing pain or a limited range of motion in their shoulder and ankle joints, particularly if they have a history of steroid use and no other known causes, should be checked for MSON. CD, Bone marrow aspirate concentrate application, and alendronate have decreased the rate of progression of the disease in all joints except in the hips. Tensor fascia lata muscle pedicle grafting decreased progression in the hips.