Avascular necrosis of the femoral head after single steroid intra-articular injection

  • Ali A. Al-OmariEmail author
  • Abdelwahab J. Aleshawi
  • Omar A. Marei
  • Hamza M. Bani Younes
  • Khaled Z. Alawneh
  • Esra’a ALQuran
  • Ziyad M. Mohaidat
General Review • HIP - ARTHROPLASTY


Femoral head avascular bone necrosis (AVN) is the loss of blood supply to the bone tissue of femoral head that results in cellular death. This condition causes a significant limitation in patient daily life activities and has a poor functional outcome. Long-term steroid intake was established as a cause of AVN. However, few cases reported femoral head AVN post-single steroid intra-articular injection. We review all cases of AVN that results from single intra-articular steroid injection and present a case of femoral head AVN developed in a 78-year-old male. The patient, who was not known to have any medical illness, presented complaining of mild left hip pain for 4 months with long distant ambulation and weight standing. He was diagnosed to have left hip joint osteoarthritis for which he received intra-articular steroid injection 2 months prior visiting our orthopedics center. MRI of the pelvis revealed AVN of the femoral head. He underwent total hip arthroplasty. The pathological examination confirmed the diagnosis of AVN. To best of our knowledge, this is the fifth case of AVN of femoral head AVN after single intra-articular steroid injection. We reviewed all cases of AVN of femoral head after single steroid injection. Intra-articular steroid injection can cause femoral head AVN, and the patient receiving these injections should be aware about this rare but significant complication that results in poor functional outcome and significant morbidity.


Arthroplasty Avascular Intra-articular Steroids 



This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interests

This article has not been published or presented elsewhere in part or in entirely and is not under consideration by another journal. All authors have approved the manuscript and agreed with submission to your esteemed journal. The authors declare that they have no competing interests.


  1. 1.
    Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME (2002) Pathogenesis and natural history of osteonecrosis. Semin Arthr Rheum 32:94–124CrossRefGoogle Scholar
  2. 2.
    Weinstein RS (2012) Glucocorticoid-induced osteonecrosis. Endocrine 41:183–190CrossRefPubMedGoogle Scholar
  3. 3.
    Wang Y, Li Y, Mao K, Li J, Cui Q, Wang GY (2003) Alcohol-induced adipogenesis in bone and marrow: a possible mechanism for osteonecrosis. Clin Orthop Relat Res 410:213–224CrossRefGoogle Scholar
  4. 4.
    Shigemura T, Nakamura J, Kishida S, Harada Y, Takeshita M, Takazawa M, Takahashi K (2012) The incidence of alcohol-associated osteonecrosis of the knee is lower than the incidence of steroid-associated osteonecrosis of the knee: an MRI study. Rheumatology (Oxford) 51:701–706CrossRefGoogle Scholar
  5. 5.
    MacNicol MF, Ludlam CA (1999) Does avascular necrosis cause collapse of the dome of the talus in severe hemophilia? Haemophilia 5:139–142CrossRefPubMedGoogle Scholar
  6. 6.
    Poignard A, Flouzat-Lachaniette CH, Amzallag J, Galacteros F, Hernigou P (2012) The natural progression of symptomatic humeral head osteonecrosis in adults with sickle cell disease. J Bone Joint Surg Am 94:156–162CrossRefPubMedGoogle Scholar
  7. 7.
    Moskal JT, Topping RE, Franklin LL (1997) Hypercholesterolemia: an association with osteonecrosis of the femoral head. Am J Orthop 26:609–612PubMedGoogle Scholar
  8. 8.
    Mok CC, Lau CS, Wong RW (1998) Risk factors for avascular bone necrosis in systemic lupus erythematosus. Br J Rheumatol 37:895–900CrossRefPubMedGoogle Scholar
  9. 9.
    Gregosiewicz A, Wosko I (1988) Risk factors of avascular necrosis in the treatment of congenital dislocation of the hip. J Pediatr Orthop 8:17–19CrossRefPubMedGoogle Scholar
  10. 10.
    Michael AM, David H (1995) Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am 77:459–474CrossRefGoogle Scholar
  11. 11.
    Yamamoto T, Schneider R, Iwamoto Y, Bullough P (2006) Rapid destruction of the femoral head after a single intraarticular injection of corticosteroid into the hip joint. J Rheumatol 33:1701–1704PubMedGoogle Scholar
  12. 12.
    Kassam AM (2010) Accelerated avascular necrosis after single intra-articular injection of corticosteroid into the hip joint. Case Rep bcr1020092405Google Scholar
  13. 13.
    Vanushkina M, Bauernfeind M, Morrison E, Paul J (2018) 200—Avascular necrosis following ultrasound-guided intra-articular corticosteroid hip injection: a case report.−02#/Poster-info-612717. Accessed 15th Feb 2018
  14. 14.
    Thompson AR, Ensrud ER (2019) Rapid onset of femoral head osteonecrosis after a single intraarticular hip joint injection of corticosteroid—a case report. Am J Phys Med Rehabil. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Laroche M, Arlet J, Mazieres B (1990) Osteonecrosis of the femoral and humeral heads after Intraarticular corticosteroid injections. J Rheumatol 17:549–551PubMedGoogle Scholar
  16. 16.
    Mont MA, Pivec R, Banerjee S, Issa K, Elmallah RK, Jones LC (2015) High-dose corticosteroid use and risk of hip osteonecrosis: meta-analysis and systematic literature review. J Arthroplasty 30:1506–1512.e5CrossRefPubMedGoogle Scholar
  17. 17.
    Chandler GN, Wright V (1958) Deleterious effect of intra-articular hydrocortisone. Lancet 27(2):661–663CrossRefGoogle Scholar
  18. 18.
    Laroche M, Arlet J, Mazieres B (1990) Osteonecrosis of the femoral and humeral heads after intraarticular corticosteroid injections. J Rheumatol 17:549–551PubMedGoogle Scholar
  19. 19.
    Fisher DE, Bickel WH (1971) Corticosteroid-induced avascular necrosis. J Bone Jt Surg Am 53:859–873CrossRefGoogle Scholar
  20. 20.
    Drescher W, Schlieper G, Floege J, Eitner F (2010) Steroid-related osteonecrosis— an update. Nephrol Dial Transplant 26:2728–2731CrossRefGoogle Scholar
  21. 21.
    Habib GS, Saliba W, Nashashibi M (2010) Local effects of intraarticular corticosteroids. Clin Rheumatol 29:347–356CrossRefPubMedGoogle Scholar
  22. 22.
    Batra S, Batra M, McMurtrie A, Sinha AK (2008) Rapidly destructive osteoarthritis of the hip joint: a case series. J Orthop Surg Res 3:3CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Goker B, Doughan AM, Schnitzer TJ, Block JA (2000) Quantification of progressive joint space narrowing in osteoarthritis of the hip: longitudinal analysis of the contralateral hip after total hip arthroplasty. Arthritis Rheum 43:988–994CrossRefPubMedGoogle Scholar
  24. 24.
    Pivec R, Johnson AJ, Harwin SF, Mont MA (2013) Differentiation, diagnosis, and treatment of osteoarthritis, osteonecrosis, and rapidly progressive osteoarthritis. Orthopedics 36:118–125CrossRefPubMedGoogle Scholar
  25. 25.
    Weinstein RS (2012) Glucocorticoid-induced osteonecrosis. Endocrine 41:183–190CrossRefPubMedGoogle Scholar
  26. 26.
    Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM (2005) The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. J Bone Jt Surg Am 87:2155–2159CrossRefGoogle Scholar
  27. 27.
    Song Q, Ni J, Jiang H, Shi Z (2017) Sildenafil improves blood perfusion in steroid-induced avascular necrosis of femoral head in rabbits via a protein kinase G-dependent mechanism. Acta Orthop Traumatol Turc 51:398–403CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Special Surgery, Division of Orthopedics, Faculty of MedicineJordan University of Science and TechnologyIrbidJordan
  2. 2.King Abdullah University Hospital JordanUniversity of Science and TechnologyIrbidJordan
  3. 3.Department of Diagnostic Radiology and Nuclear Medicine, Faculty of MedicineJordan University of Science and TechnologyIrbidJordan
  4. 4.Department of Pathology, Faculty of MedicineJordan University of Science and TechnologyIrbidJordan

Personalised recommendations