AVASCULAR NECROSIS OF BILATERAL KNEES SECONDARY TO CORTICOSTEROID ENEMAS

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.