Peter G. Bullough

A 57-year-old woman suffered rapid destruction of both hip joints over a 10 months period. At the first visit, her radiographs demonstrated slight joint space narrowing and acetabular cyst formation in both hips. Five months later, joint space narrowing had further progressed, and intra-articular injection of steroid was given in both hips. However, the hip pain gradually became worse. Five months later, both joint spaces had totally disappeared and both femoral heads had undergone massive collapse. At gross examination, both resected femoral heads showed extensive opaque yellow areas consistent with osteonecrosis. Microscopic examination of these areas revealed evidence of both extensive fracture and callus formation, as well as necrosis throughout, indicating that the osteonecrosis observed in this case was a secondary phenomenon superimposed on pre-existing osteoarthritis and subchondral fracture. There were many pseudogranulomatous lesions in the marrow space and necrotic area, where tiny fragments of bone and articular cartilage, surrounded by histiocytes and giant cells, were embedded, such as are typically seen in rapidly destructive arthrosis. No radiologic or morphologic evidence of primary osteonecrosis was noted. This case indicates that at least some cases of rapidly destructive arthritis are the result of subchondral fracture with superimposed secondary osteonecrosis.

A 93-year-old man presented with a one-month history of persistent left hip pain of sudden onset. At first visit, radiographs revealed a fracture line at the medial portion of the acetabulum with no displacement. Magnetic resonance imaging revealed bone marrow edema in the corresponding medial portion of the acetabulum. Radiographs obtained 2 months later showed rapid acetabular osteolysis with associated prominent migration of the femoral head into the acetabulum. Histology obtained from the hip joint was consistent with a subchondral insufficiency fracture with no evidence of massive chondrolysis. Our case was considered as a subchondral insufficiency fracture of the left acetabulum resulting in rapid acetabular osteolysis (protrusio acetabuli).

We describe a 50-year-old woman who had a 10-year history of left groin pain. She experienced rapid collapse of the femoral head during a 3-month period after a single injection of corticosteroid into the hip joint, in which osteonecrosis was histologically observed.

A 55 year old woman had a 32 year history of SLE, which had been treated with corticosteroids (8 mg/day). She had a history of hypothyroidism, arthritis in both shoulders, skin rash, pericarditis, and pleuritis, but had no history of smoking or drinking. The body mass index indicated she was overweight (27.4 kg/m²).