The Natural Progression of Shoulder Osteonecrosis Related to Corticosteroid Treatment

Abstract

Background Little is known about the rate and factors of progression of shoulder osteonecrosis (ON) related to corticosteroids. Purpose We retrospectively evaluated 125 patients (215 shoulders) with humeral head ON diagnosed by MRI to determine the delay between corticosteroid treatment and the different stages and factors influencing the progression of the disease. Methods Seventy-four of the shoulders had asymptomatic Stage I ON, 58 had asymptomatic Stage II ON, 46 had symptomatic Stage I ON, and 37 had symptomatic Stage II ON. The minimum followup was 10 years (average, 14 years; range, 10-20 years). The delay between the beginning of the corticosteroid treatment and the diagnosis of ON of the humeral head averaged 15 months (range, 6-24 months). Results We observed partial or total regression on MRI only in patients with asymptomatic Stage I ON. At last followup, pain had developed in 98 (74%) and collapse had occurred in 71 (54%) of the 132 previously asymptomatic shoulders. Of the 83 symptomatic shoulders, 68 (82%) had collapsed at the final followup. The time between diagnosis and collapse averaged 10 years for patients with symptomatic Stage I ON and 3 years for patients with symptomatic Stage II ON. Conclusions Stage at initial visit, occurrence of pain, and continuation of peak doses of corticosteroids predicted progression of disease in asymptomatic shoulders, whereas in the symptomatic shoulders, extent and location of the lesion were the main risk factors for progression.

The Natural Progression of Adult Elbow Osteonecrosis Related To Corticosteroid Treatment

“…Spontaneous resolution was observed in early asymptomatic disease (Stage I) under only three conditions: when there was only one lesion on the elbow, when it was situated on the area of the trochlea, and when the patient no longer had peak doses of corticosteroids. Our results in the elbow are consistent with the results of others, suggesting some early hip [9], knee [17], or shoulder [8] lesions may have spontaneous complete or incomplete regression. This situation was a rarity in this series of patients with elbow ON related to high doses of corticosteroids and underlying diseases as compared with the incidence of regression (41%) observed for the knee [17].…”

“…This conforms to prospective studies using MRI showing the area of the femoral head ON never enlarges during repetitive MRI [9,16]. The same has been observed for the knee [17] and shoulder [8]. However, we observed new lesions when peak doses with increased levels were received by the patient during the first 2 years after the diagnosis.…”

“…Spontaneous total regression was only detected within 4 years after the beginning of the corticoid treatment and is consistent with observations for the hip, knee, or shoulder with corticosteroid-induced ON [2,7,8,17]. However, these series (and our series) concern only a small number of patients and larger series with different doses of corticosteroids are necessary to know the exact incidence of spontaneous regression of steroid-related ON in the different joints.…”

“…Larger series are necessary to elucidate the exact incidence of expansion of steroid-related ON of the elbow. The rate of progression of ON to collapse in the elbow of our patients appeared lower than in the hip and shoulder when compared with the data of another study [8] specific to rate of progression of ON in various joints, at least if we accept hip, shoulder, and elbow ON occurred at the same time in the same patients. As reported with other series of hip, knee, or shoulder ON related to corticosteroids [6,7,[13][14][15], the rate of disease progression was quicker in symptomatic than in asymptomatic elbows and quicker in elbows with Stage II ON than in elbows with Stage I ON.…”

“…We determined the delay between the beginning of the corticosteroid treatment and the different stages of ON and which factors influenced disease progression. We analyzed our hypothesis that stage, occurrence of pain, continuation of peak doses of corticosteroids, number of lesions, and location of the lesion would influence the clinical or radiographic disease progression in the elbow, as has been observed in hip [7] and shoulder [8] ON.…”