A 52-year-old Caucasian woman presents to the office for the evaluation of a constant left groin pain. The pain started spontaneously about a week ago and is gradually progressive. It is worse with walking and weight bearing. She has a past medical history of systemic lupus erythematosus, chronic renal insufficiency, and hypertension. She has been maintained on 20 mg/day of prednisone for eight months. Attempts to decrease the dose of prednisone in the past have caused a flare of lupus activity. She does not smoke or drink alcohol. On physical examination, she walks with a limp. There is marked discomfort and limitation of the range of motion on the left side. The radiologic imaging reveals that the patient has stage 4 osteonecrosis of the femoral head. She has considerable pain on weight bearing, and this is affecting her daily activities. Which of the following is the most appropriate next step in the management of this patient?

Question

A 52-year-old Caucasian woman presents to the office for the evaluation of a constant left groin pain.  The pain started spontaneously about a week ago and is gradually progressive.  It is worse with walking and weight bearing.  She has a past medical history of systemic lupus erythematosus, chronic renal insufficiency, and hypertension.  She has been maintained on 20 mg/day of prednisone for eight months.  Attempts to decrease the dose of prednisone in the past have caused a flare of lupus activity.  She does not smoke or drink alcohol.  On physical examination, she walks with a limp.  There is marked discomfort and limitation of the range of motion on the left side. The radiologic imaging reveals that the patient has stage 4 osteonecrosis of the femoral head.  She has considerable pain on weight bearing, and this is affecting her daily activities.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The goal of therapy of osteonecrosis is to preserve the native joint for as long as possible. The main modalities of treatment include conservative therapy, core decompression, osteotomy, and joint replacement. Total hip replacement is the therapy of choice for stage 4 disease of the femoral head (flattening of the femoral head with joint space narrowing). (Choice A) Conservative therapy with bed rest, partial weight bearing, and analgesics is usually ineffective in halting the progress of the disease. It is not recommended for advanced disease. (Choice B) Core decompression offers a chance to preserve the native joint in the early stage 1 or 2 disease (positive radiographs without femoral head collapse). It can provide significant pain relief compared to the conservative treatment. (Choice D) Discontinuing prednisone does not halt the progress of the disease. It may lead to more complications in the form of lupus flare and adrenal insufficiency. (Choice E) Aggressive physical therapy will lead to more patient discomfort and further progression of the disease. Partial weight bearing with or without crutches can be attempted, but this does not halt disease progression. Educational objective: Total hip replacement is the treatment of choice for advanced osteonecrosis of the femoral head. Conservative therapy is usually ineffective in halting the progression of the disease.

A 52-Year-Old Caucasian Woman Presents to the Office for the Evaluation