CASE
An 82-year-old female with arthritis in her glenohumeral joints had been receiving cortisone injections biannually
in our clinic with good success. Her medical history included mild hypertension and Guillain-Barré syndrome that had responded to high-dose corticosteroids without residual effects. Surgical history included bilateral total knee replacement and a cholecystectomy. She did not smoke or use alcohol. Overall, she was healthy and ambulatory, and she remained active and independent.
On March 1, she began having right lateral hip pain but no groin or thigh pain. She denied recent travel or tick exposure and reported no recent fevers or illnesses. No other joints were inflamed. Examination showed normal range of motion (ROM) in the right hip with no reproduction of pain. The area over the greater trochanter was exquisitely tender. A cortisone injection was administered directly into the trochanteric bursa.
Six weeks later, the patient returned for follow-up and reported no relief
of symptoms. Her complaint was
now predominantly groin pain. A radiograph of the hip showed very mild degenerative changes (Figure 1).
Examination revealed decreasing ROM and significant synovitis and pain with hip motion. Aspiration of the joint produced 10 cc of clear, inflammatory-type fluid; the findings for Gram stain, cultures, and cell counts were negative for infection. Cortisone was injected directly into the femoral-acetabular joint to decrease the inflammation.
Over the next 5 weeks, the patient's pain worsened, and her condition declined rapidly to the point that she was unable to bear weight on her right lower extremity. An MRI showed mild degeneration in the hip joint and normal morphology of the femoral head. There were no signs of infection, avascular necrosis (AVN), or lytic-type lesions.
When the patient returned to the office 2 weeks later, she was unable to bear any weight, was in severe pain with any attempt at movement, and had become confined to a wheelchair. Repeat radiography showed complete collapse of the femoral head and destruction of the morphology of her hip joint. Once again, joint aspiration showed no evidence of organisms. Her ESR and C-reactive protein levels were within normal limits.
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