Histological appearance of the intra-osseous vessels of the femoral head in aseptic osteonecrosis of the hip, with or without antiphospholipid antibodies

Orthopaedic manifestations of the antiphospholipid (Hughes) syndrome

The antiphospholipid (Hughes) syndrome (APS), is characterized by arterial and/or venous thrombosis and pregnancy morbidity in association with antiphospholipid antibodies (aPL). Since its classical description 21 years ago, the clinical spectrum of Hughes syndrome has embraced the realms of obstetrics, nephrology, cardiology, neurology, gastroenterology and now, possibly orthopaedics. This is not surprising, given that this disease can affect virtually any organ system and blood vessel of any size and nature. Just as venous thrombosis may affect limbs and internal organs, arterial thrombosis has been shown to affect organs such as the brain, eye, heart, kidney, liver and may also involve the skeleton. In this review, the skeletal aspects of Hughes syndrome, postulated pathogenesis and possible implications of anticoagulation will be discussed. Finally, the approach to APS patients undergoing orthopaedic surgery shall also be outlined.

Musculoskeletal manifestations of the antiphospholipid syndrome

The scope of clinical and laboratory manifestations of the antiphospholipid syndrome (APS) has increased dramatically since its discovery in 1983, where any organ system can be involved. Musculoskeletal complications are consistently reported in APS patients, not only causing morbidity and mortality, but also affecting their quality of life. We reviewed all English papers on APS involvement in the musculoskeletal system using Google Scholar and Pubmed; all reports are summarized in a table in this review. The spectrum of manifestations includes arthralgia/arthritis, avascular necrosis of bone, bone marrow necrosis, complex regional pain syndrome type-1, muscle infarction, non-traumatic fractures, and osteoporosis. Some of these manifestations were reported in good quality studies, some of which showed an association between aPL-positivity and the occurrence of these manifestations, while others were merely described in case reports.

Multifocal avascular necrosis after liver transplantation: an unusual presentation of the antiphospholipid syndrome

We describe the case of a 31-year-old man who presented with an antiphospholipid syndrome (APS), which manifested as multifocal avascular necrosis (AVN) one year after orthotopic liver transplantation. The patient developed multiple AVN affecting hips, left knee, humerus and tarsal bones just after withdrawal of corticosteroid therapy. Three years later when lupus anticoagulant was detected, he began anticoagulant treatment and no further AVN episodes were observed. It is important to be aware of this clinical manifestation of APS, especially in these cases where it can be easily overlooked because of corticosteroid therapy.

[Orthopedic manifestations of the antiphospholipid syndrome]

PURPOSE

The antiphospholipid syndrome (APS) is characterized by arterial and/or venous thrombosis, and pregnancy morbidity in association with antiphospholipid antibodies. Since its classical description 22 years ago, the clinical spectrum of APS has embraced the realms of obstetrics, nephrology, cardiology, neurology, gastroenterology, angiology and now, possibly orthopaedics. This is not surprising given that this disease can affect virtually any organ system and blood vessel of any size and nature. Just as venous thrombosis may affect limbs and internal organs, arterial thrombosis has been shown to affect organs such as the brain, eye, heart, kidney, liver and may also involve the skeleton.

CURRENT KNOWLEDGE AND KEY POINTS

In this review, we describe the orthopedic aspects of APS recently reported, bone metatarsal fractures, osteonecrosis and more exceptional complications, ie algodystrophy and bone marrow necrosis. We briefly discuss postulated pathogenesis and possible implications of anticoagulation.

FUTURE PROSPECTS AND PROJECTS

This data need further confirmation. They may suggest complementary physiopathologic and therapeutic implications.

Multiple avascular necrosis of bone and polyarticular septic arthritis in patients with systemic lupus erythematosus

OBJECTIVE

Avascular necrosis of bone (AVN) and osteoarticular infection share similar risk factors in systemic lupus erythematosus (SLE) patients. However, their coincidental development in SLE has rarely been described. We describe four cases of AVN complicated by Staphylococcus aureus infection in SLE.

METHODS

Patients were identified by retrospectively reviewing an SLE cohort followed between 1979 and 2003. A review of the literature from 1960 until 2003 was also done.

RESULTS

Among 315 SLE patients, four developed joint infection by S. aureus following or coincidentally with AVN. All presented multifocal disease with severe or relapsing course, resulting in severe incapacity. The clinical course suggests that AVN developed first in active SLE patients with positive antiphospholipid (aPL) antibodies treated with high-dose corticosteroids (CS), and subsequent bone infarcts favor infection. Our patients often required prolonged antibiotic therapy and surgical treatment.

CONCLUSIONS

Active SLE patients with aPL antibodies on high-dose CS seem at high risk of developing multiple AVN complicated by infection. Avascular necrosis and bone or joint infection by S. aureus in these patients is a major complication that leads to severe joint destruction and disability.

Risk factors for avascular necrosis of bone in patients with systemic lupus erythematosus: is there a role for antiphospholipid antibodies?

BACKGROUND

Avascular necrosis of bone (AVN) is a well known complication in patients with systemic lupus erythematosus (SLE).

OBJECTIVE

To investigate the role of antiphospholipid antibody status (IgM and IgG anticardiolipin antibodies and lupus anticoagulant) with adjustment for corticosteroid use as risk factors for the development of AVN.

METHODS

A cohort of 265 patients receiving long term follow up in our SLE clinic from 1978 to 1998 was analysed. Patients with AVN complications were detected and then matched for age, sex, ethnicity, duration of disease, and organ disease with two other patients with SLE. A further 31 patients were chosen at random for the analysis.

RESULTS

Eleven patients had AVN, giving a point prevalence of 4%. There were no significant differences demonstrable in the presence of individual antiphospholipid antibodies (aPL) or their combination between the group with AVN or the two control groups.

CONCLUSION

Incorporating an adjustment for corticosteroid use we were unable to show a link between the presence of aPL and the development of AVN in patients with SLE.