Rare Case Of Avascular Necrosis In A Dodgeball Player

Abstract

HISTORY: A 27-year-old male presented with left anteromedial hip/groin pain for 2 weeks. He competes in a dodgeball league and plays occasional racquetball as well. After a dodgeball game, he noted onset of hip and groin pain, which became progressively severe, and went to a local Emergency Department. He had x-rays and were told they were normal, however he had significant pain even with weightbearing at this point. No past history of hip dysplasia, dislocation, hip surgery. PHYSICAL EXAMINATION: Hip flexion was 110°, internal rotation 20°, external rotation 60°, abduction 45°; significant pain with flexion, adduction, and internal rotation, and positive FABER. He was able to ambulate without assistance. DIFFERENTIAL DIAGNOSIS: • Labral tear • Femoroacetabular impingement • Femoral neck stress fracture • Loose body • Chondral defect • Athletic pubalgia TESTS AND RESULTS: X-rays were obtained and suggested minimal left femoral head collapse, and did suggest mild right femoral head sclerosis; an MRI showed large areas of grade 2 avascular necrosis bilaterally. The left had a joint effusion, edema in addition to necrotic fatty signal in the femoral head compatible with early collapse. FINAL/WORKING DIAGNOSIS: Bilateral hip avascular necrosis with early left collapse. TREATMENT/OUTCOME: - Internal Medicine and Rheumatology referral for serological work up. - Referred to Orthopedic Surgeon; recommended toe-touch weightbearing, counseled on risk of progression. Alendronate was considered as with precollapse Ficat stages 0-II. - At 8 months, left hip pain was progressing, and noted onset of right hip pain. X-rays showed visible left AVN on the entire weightbearing surface with collapse and flattening of the superior articular surface; right hip now showed subtle sclerosis. - His only pertinent history included a brief course of oral corticosteroids when he got his wisdom teeth removed, which he did not initially disclose. This case reports an unusual etiology of an avascular necrosis after taking a short-term dose of corticosteroids. Case raises awareness to counsel health providers about collaborating to provide patients with optimal care and avoid potential serious side effects.