Femoral Head Destruction in Rheumatoid Arthritis and Osteo-Arthritis

Since 1951, intra-articular hydrocortisone has been used in the treatment of arthritis, particularly rheumatoid arthritis of the larger joints (Hollander, Brown, Jessar, and Brown, 1957). Most patients derive subjective improvement lasting a few days up to weeks, and, as this is frequently of value in the treatment programme, it has been used extensively. Only recently has the suggestion been made that this treatment may not be free from serious risk. Occasional transitory exacerbations of symptoms in injected joints has been seen by all physicians using intra-articular corticosteroids, both hydrocortisone acetate and hydrocortisone tertiarybutylacetate, and the risk of introduction of pathogenic organisms has been recognized as ever-present, though with aseptic precautions it has rarely been experienced. Less commonly, thrombophlebitis has been reported (Chandler, Wright, and Hartfall, 1958). The more recent warnings have been prompted by the observation of apparently accelerated radiological deterioration in treated joints. Thus, Chandler and Wright (1958) noted that thirteen of 25 steroid-treated knee joints showed such changes over a 48-week treatment period, despite symptomatic improvement in most cases. In their view the major reason for this was the encouragement of a damaging level of performance by steroid interference with a normal locally protective mechanism. The patients in this trial were all cases of rheumatoid arthritis whose principal disability arose from knee involvement. A similar treatment trial (Wright, Chandler, Morison, and Hartfall, 1960) of 25 patients with osteo-arthritis of the knees did not show this radiological change and the clinical response was only transient. Further reports have appeared from Chandler, Jones, Wright, and Hartfall (1959) at Leeds, and from workers at the London Hospital (Sweetnam, Mason, and Murray, 1960; Sweetnam, 1960). Some of the cited examples occurred in patients who received steroids only by mouth and in every case the weight-bearing joints-that is the hips or kneeswere implicated. These authors have suggested that rapid destruction of such joints has been brought about by the administration of the steroids, and they state that this change is not seen to occur rapidly in arthritic patients who have not received steroids (Sweetnam and others, 1960). In any unit using oral or intra-articular steroids it is of great importance to know the frequency and predisposing factors, even though only a minority of steroid-treated patients may show this type of arthropathy. The case material at Queen Elizabeth Hospital, the New Zealand national hospital for rheumatic diseases, has therefore been examined with particular reference to the hip joint, and all cases showing femoral head destruction have been reviewed and the findings analysed.