Corticosteroid-induced osteonecrosis of the femoral head: about one case (Ain Assel village, Tangier Morocco)

Patient is a 20-year-old married woman with one child.

Two years ago, following an auto palpation, she discovered a lump in her left breast.

She consults with a gynecologist and a breast ultrasound was done on 26/09/2019 which notes: “a galactophoritis of the left breast, BIRADS 3.

on 04/12/2019, the patient will undergo a biopsy of the left breast and the result is: “Granulomatous mastitis”.

Corticosteroid therapy with Cortancyl 20 mg was started on 04/12/2019, the dose was 3 tablets per day for several weeks according to the patient.

The pain in the right groin crease began in March 2020, first the pain when walking then pain at rest, to become sleepless at night, the pain made the patient wake up when she wanted to turn over in bed.

The patient stopped seeing her first gynecologist to see another doctor, who reduced the dose of Cortancyl.

Seeing that the pain did not stop but worsened, the patient decided to stop corticosteroids by herself and to go to a third doctor.

On 04/11/2020, the latter prescribes an X-ray of the pelvis, showing: “heterogeneous aspect of the bone web of the right femoral epiphysis making suspect an osteonecrosis of the right femoral head”.

An MRI of the pelvis was performed on 11/11/2020 and confirmed the existence of aseptic osteonecrosis of the right femoral head with dissection under chondral stage 3 of Ficat.

On 20/11/2020, the patient came to my medical office because she was offered surgery and she wanted to confirm if it was the right and only solution to her pain.

the patient came with two young girls from her family without the presence of the husband. the patient is smiling but slightly stressed. Examination of the left breast indeed notes the existence of a small lump at the level of the internal median dial without pain on palpation without local signs of inflammation, the small mass is mobile and not fixed. no galactorrhea. examination of the right breast is normal. the supraclavicular and axillary ganglion areas are free

the patient was sitting on a chair during the questioning, on getting up she was in pain and started to limp on her way to the examination bed.

Examination of the two lower limbs in supine position does not note any shortening or vicious attitude. the flexion-extension of the two lower limbs is not painful. no inflammatory signs in the right groin crease, hernial orifices are free. The abduction movement of the right lower limb and an external rotation of the right foot awaken exquisite pain in the right groin crease. The right knee is free, not painful.

Finally I convinced the patient to trust and fallow the advices of her orthopedist, that she must be accompanied by her husband next time so that the orthopedist answer all their questions about the surgery and after the surgery , (duration of the physiotherapy…..)

Conclusion:

Doctors should be more aware of risk factors and side effects when prescribing corticosteroid therapy. The awareness of risk factors and earlier definitive diagnosis are essential for the success of joint preservation. When following up a patient with osteonecrosis, treatments are determined by lesion characteristics, patient factors, and preference of doctors. Surgical treatment showed better results than conservative therapy in earlier-stage ONFH, and there should be a trend in minimizing the surgical injury and evaluation of treatment for preserving the femoral head with normal function throughout a patient’s life.(1)

References:

1: Corticosteroid-induced Osteonecrosis of the Femoral Head: Detection, Diagnosis, and Treatment in Earlier Stages

Li-Hua Liu, Qing-Yu Zhang, Wei Sun, Zi-Rong Li, and Fu-Qiang Gao

Chin Med J (Engl). 2017 Nov 5; 130(21): 2601–2607.doi: 10.4103/0366-6999.217094

Image’s Credit: https://www.geco-medical.org/geco2008/21janvierFUTURA/classification_physiopathologie_onaf.pdf

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