Dl. Braverman et al., AVASCULAR NECROSIS OF BILATERAL KNEES SECONDARY TO CORTICOSTEROID ENEMAS, Archives of physical medicine and rehabilitation, 79(4), 1998, pp. 449-452
Avascular necrosis (AVN) is a devastating adverse effect of corticoste
roid therapy rarely reported in the setting of inflammatory bowel dise
ase. We describe a 48-year-old woman with 6 weeks of progressive bilat
eral knee pain resulting in the inability to ambulate. Her symptoms de
veloped suddenly, 9 months after treatment with hydrocortisone enemas
for ulcerative proctitis. On physical examination, the patient had kne
e tenderness, decreased range of motion, and flexion contractures. Mag
netic resonance imaging showed multiple bony infarcts in bilateral dis
tal femora and proximal tibias, consistent with advanced AVN. Initial
therapy included pain management, serial casting, gentle flexibility a
nd strengthening, and limited mobility training. The rehabilitation ef
forts led to functional improvement. Ultimately, bilateral total knee
arthroplasties were recommended to treat her advanced AVN. This is the
first reported case of AVN secondary to hydrocortisone enemas. We rev
iew the literature and discuss the pathophysiology and management of c
orticosteroid-induced AVN. (C) 1998 by the American Congress of Rehabi
litation Medicine and the American Academy of Physical Medicine and Re
habilitation.