The Natural Progression of Adult Elbow Osteonecrosis Related To Corticosteroid Treatment

Background In patients with corticosteroid treatment, the elbow is a rare site of osteonecrosis; there is little information about the rate and risk factors of disease progression in symptomatic and asymptomatic elbows. Question/Purposes We determined the delay between the beginning of corticosteroid treatment and different stages of osteonecrosis and which stage and dose of steroids influenced disease progression. Methods Osteonecrosis related to corticosteroids was diagnosed by MRI in 50 elbows of 35 adult patients. Thirty elbows were asymptomatic at initial evaluation (19 with Stage I, 11 with Stage II osteonecrosis). Among the 20 elbows symptomatic at initial evaluation, 13 had radiographic evidence of osteonecrosis without collapse (Stage II) and seven had lesions evident only on MRI (Stage I). Results At latest followup (average, 17 years; range, 10–25 years), of the 30 previously asymptomatic elbows, pain developed in 24 and collapse occurred in 14; of the 20 previously symptomatic elbows, 15 showed collapse (seven initially with Stage I, eight with Stage II osteonecrosis). The average time between diagnosis and collapse was 8 and 5 years, respectively, for symptomatic elbows with Stages I and II osteonecrosis. Stage at initial visit, development of pain, and continuation of peak doses of corticosteroids were risk factors for disease progression in asymptomatic elbows. In symptomatic elbows, the extent in contact with the articular surface and lesion location were the main risk factors for disease progression. Conclusions Untreated asymptomatic and symptomatic elbow osteonecrosis related to corticosteroids has a moderate likelihood of elbow collapse, with decrease in ROM, but none of the patients in this case series followed for 10 to 20 years had elbow arthroplasty. Level of Evidence Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.