0:00

<v ->Now, there're many, many causes of marrow ischemia.

0:05

And I've given in this slide a short list

0:07

of some of them, emphasizing one

0:09

of the ones that I think is most interesting,

0:12

and that is vasculitis,

0:14

particularly that in systemic lupus erythematosus

0:18

because if I look back on my career

0:21

and think of all the cases

0:22

in which I've seen osteonecrosis and bone infarcts,

0:27

in those cases where the osteonecrosis and infarcts

0:30

were most widespread,

0:33

the disease typically was systemic lupus erythematosus.

0:37

It's a rather common complication in SLE,

0:41

and typically involves multiple sites

0:44

of involvement, including the small bones

0:47

at the periphery of the extremity.

0:50

Now, I mention that

0:52

because that is not a common site

0:54

for osteonecrosis related to other causes.

0:58

It appears that a major risk factor

1:00

is the steroid therapy

1:02

and it depends upon how much the cumulative dose,

1:06

as well as how long you have been giving

1:09

the corticosteroid therapy.

1:12

Here is a patient

1:14

who unfortunately became a cadaver with osteonecrosis

1:18

related to lupus.

1:20

Look at all this extensive involvement

1:23

of the bones around the ankle and midfoot.

1:26

The specimen is the sagittal section

1:28

of the Taylor showing you involvement in that bone.

1:33

Here's another one.

1:34

Vasculitis in a patient

1:36

with systemic lupus erythematosus.

1:39

Note on the T1 that there's fat in the middle of this.

1:43

This is the reaction around it,

1:46

this serpentine-like border.

1:48

And you can see the involvement of the small bones,

1:50

even out toward the terminal phalanges.

1:53

Typical of vasculitis and lupus-induced osteonecrosis.

2:00

Now, steroids in general

2:01

are well-known to cause osteonecrosis.

2:05

We know osteonecrosis with steroids

2:08

is most commonly seen in the area

2:10

of the femoral heads,

2:12

humeral heads are fairly common, and then the knee.

2:16

In the knee, the typical site is the femoral condyle

2:19

and tibial plateau.

2:21

An uncommon site is the patella.

2:23

A rare site, excuse me, is the fibula.

2:28

Here's an example of steroid-induced osteonecrosis,

2:31

involving the superior aspect of the patella.

2:34

And by the way, it is usually the superior aspect

2:37

that is involved.

2:39

If you look at this case without a history,

2:41

you might consider this is a osteochondral fracture.