Are steroids recommended as a first-line treatment for avascular necrosis?

Steroids Should Not Be Used for Avascular Necrosis Treatment

Steroids should be avoided as a treatment for avascular necrosis (AVN) as they are actually a significant risk factor for causing the condition rather than treating it. 1

Understanding Avascular Necrosis

Avascular necrosis (also called osteonecrosis) is a condition characterized by bone death due to compromised blood supply. It commonly affects the femoral head but can also involve other joints such as the shoulders, knees, and ankles.

Risk Factors for AVN

• Corticosteroid use - a major risk factor 1
• Alcohol abuse
• Trauma
• HIV infection
• Blood dyscrasias
• Chemotherapy
• Radiation therapy
• Gaucher disease
• Caisson disease

Why Steroids Are Contraindicated in AVN

1. Steroids are a primary cause of AVN: Corticosteroids are actually one of the most significant risk factors for developing AVN 1. Higher doses are associated with 1.5-fold greater risk of developing the condition.

2. Mechanism of steroid-induced AVN: Glucocorticoids affect lipid metabolism, resulting in formation of fat emboli and lipoprotein globules that block peripheral vessels, leading to bone ischemia and necrosis 2.

3. Documented risk: The Canadian Association of Gastroenterology specifically warns that corticosteroids, especially repeat courses, should be avoided in patients with a history of avascular necrosis 3.

4. Rapid progression: Even short-term high-dose steroid therapy can cause multifocal avascular necrosis requiring reconstructive surgery within 2.5 years of symptom onset 4.

Recommended Management Approach for AVN

Diagnosis

• MRI is the gold standard for diagnosis, especially in early stages when X-rays appear normal 1
• Imaging both sides is recommended when evaluating hip pain, even if symptoms are unilateral

Treatment Options

1. Early-stage disease:

   • Core decompression as first-line surgical intervention
   • Can be supplemented with autologous bone marrow cells or vascular fibular grafting 1

2. Advanced stages with articular collapse:

   • Total joint replacement is the main treatment 1
   • Resurfacing hemiarthroplasty is an alternative for femoral or humeral head AVN

3. Pain management:

   • Regular paracetamol (acetaminophen)
   • NSAIDs (with caution in elderly or those with renal dysfunction)
   • Advanced pain control may involve opioids for severe pain 1

4. Adjunctive therapies:

   • Bisphosphonates may improve bone density and prevent progression 1
   • Physical therapy and gentle mobilization once acute pain subsides

Risk Mitigation

• Address modifiable risk factors:
  • Reduce or eliminate corticosteroid use when possible
  • Manage hyperlipidemia
  • Reduce alcohol consumption 1
• Consider statin therapy for hypercholesterolemia (with caution regarding drug interactions in HIV patients)

Special Considerations

• HIV-infected patients with symptomatic AVN will ultimately require hip replacement 1
• Patients with sickle cell disease may experience AVN as a common cause of severe chronic pain
• Transplant patients are at particular risk for AVN, with risk factors including duration of dialysis prior to transplantation and glucocorticoid dosage 1

In summary, steroids should be avoided in the management of avascular necrosis as they represent a causative factor rather than a treatment. Management should focus on surgical interventions, pain control, and addressing modifiable risk factors to prevent disease progression.