Clinically occult avascular necrosis of the hip in systemic lupus erythematosus

Objective. To study the natural history of clinically occult avascular necrosis (AVN) of the hip in patients with systemic lupus erythematosus (SLE). Methods. Sixty-six patients with SLE (without symptoms referable to the hip) receiving at least 5 mg/day prednisone for greater than or equal to 6 months were screened by magnetic resonance imaging (MRI) for AVN of the hip. A complete MRI evaluating class and percentage of femoral head involvement, AP and lateral radiographs of the hips, bone scant and physical examination were performed for patients with positive MRI. Medical records were reviewed for serologic and clinical variables that might predict AVN. Repeat MRI were obtained at 3, 6, and 12, months to assess possible progression or resolution of the lesion. Patients with negative screening MRI underwent repeat screening after one year to assess the one year incidence rate. Results. Eleven asymptomatic hips (8%) in 8 patients (12%) had MRI documented AVN. The percentage of femoral head involvement ranged from 1 to 46%. One lesion was MRI class B, the remaining lesions were class A. The radiographic stage of 10 hips was stage 1, the MRI class B hip was stage 2. Risk factors for clinically occult AVN included Afro-American origin, Raynaud's phenomenon, migraine headaches, and a maximal corticosteroid dose of at least 30 mg/day. After 12 months, 43 of 58 patients with an initially negative MRI underwent repeat screening examinations; no new lesions were observed. Conclusion. Clinically occult AVN of the hip is common in patients with SLE. The short term natural history of these lesions appears stable without spontaneous healing or clinical or radiographic progression. Risk factors for these asymptomatic lesions ore similar to the risks for symptomatic AVN and surgical intervention appears not to be indicated in these patients.