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AVN Management in SLE — SCE Rheumatology MCQ

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ModerateMusculoskeletal ImagingAVN Management in SLESCE Rheumatology

A 40-year-old woman with SLE develops avascular necrosis of both femoral heads while on Prednisolone 25 mg daily. She has bilateral groin pain worse on weight-bearing. MRI shows bilateral femoral head AVN Ficat stage II (MRI changes without femoral head collapse). What management should be considered?

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Correct answer: B — Urgent orthopaedic referral for consideration of core decompression to prevent femoral head collapse and glucocorticoid dose reduction

Early AVN (Ficat stage I-II before femoral head collapse) may benefit from core decompression which aims to reduce intraosseous pressure promote revascularisation and prevent progression to femoral head collapse. Once collapse occurs (Ficat III-IV) joint replacement becomes necessary. Glucocorticoid dose reduction is essential to remove the ongoing risk factor. EULAR 2023 SLE recommendations emphasise minimising glucocorticoid exposure partly to prevent AVN. MRI is the most sensitive investigation for early AVN detection. Bilateral involvement is common in steroid-associated AVN (up to 80%).

Reference: EULAR 2023 SLE recommendations; Mont MA et al 2006 AVN management