Potential risk factors for osteonecrosis: Several possible risk factors for osteonecrosis were independently evaluated. These are schematically shown in Figure 1. Risk factors in­cluded use of corticosteroids, use of parenteral nutrition (all administered solutions included lipid emulsions), or con­comitant corticosteroid and parenteral nutrition. In addi­tion, because nutrient absorption may be a factor in the pathogenesis of bone disease in Crohn’s disease, the fre­quency of small bowel resection in this group of 877 patients was also considered.

A total of 483 patients with Crohn’s disease (55.1%) were treated with some form of corticosteroid during their man­agement, usually oral prednisone, for at least one treatment course, most often as part of their pharmacological manage­ment. For men with Crohn’s disease, 187 of 385 (48.6%) re­ceived at least one course of corticosteroids. For prednisone, the usual initial dose given was 20 to 40 mg daily, and this dose was tapered over a period of four to 10 weeks. Occasion­ally, patients required longer periods of lower doses of 5 to 10 mg daily before the oral prednisone could be discontin­ued. Hospitalized patients treated with intravenous cortico- steroids usually received hydrocortisone 200 mg daily (equivalent to about 40 mg of prednisone).

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Osteonecrosis rates: The records of 877 patients with Crohn’s disease seen during a 20-year period were retrospec­tively analyzed to determine the frequency of osteonecrosis and possible factors that might have influenced its develop­ment. This represented the entire clinical experience of a sole gastroenterologist in a tertiary care university teaching hospital. Of these 877 patients, 492 (56.1%) were fe­male and 385 (43.9%) were male. Therefore, the overall os- teonecrosis rate in this series of Crohn’s disease patients was four in 877 (approximately 0.5%). All patients with os- teonecrosis were male, so the actual rate of osteonecrosis in men was four in 385 (about 1%). No women were detected with osteonecrosis.

Characteristics of Crohn’s disease: Table 1 shows the clini­cal characteristics of the four male patients with osteonecrosis detected in this group of 877 patients with Crohn’s disease. All patients had a diagnosis of Crohn’s disease estab­lished before age 40 years. All patients had at least colonic involvement, and three also had ileal inflammatory changes. The clinical behaviour of the Crohn’s disease was classified as penetrating in two, but no patient had stricturing or stenosing disease. Of these four patients, three had a central spondyloarthropathy, a peripheral arthropathy or both. Other extraintestinal features associated with Crohn’s dis­ease were not observed. One patient died with a metastatic colorectal cancer. Follow-up data were available on all 877 patients with a mean of 7.8 years.

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Case 3: A 36-year-old man presented with an ischiorectal abscess that required incision and drainage in 1989. Because of diarrhea and a weight loss of 20 kg, further investigations were done. Fecal cultures and studies for parasites were nega­tive. Colonoscopy showed superficial and deep serpentine ulcers, mucosal swelling, erythema, friability and pseudopol- yps in the transverse and descending colon, with a normal ascending colon and rectum. The ileum was erythematous but not ulcerated. Multiple ileal and colonic mucosal biop­sies showed severe but patchy inflammatory changes, but no granulomas. Upper gastrointestinal endoscopy and biopsies revealed focal gastritis (without Helicobacter species) and nonspecific duodenitis; no granulomas were found. Barium radiographs of the upper gastrointestinal tract were normal, but a barium enema showed changes of Crohn’s disease.

The patient had a four-year history of right hip pain that worsened with walking and was associated with morning stiffness. Slight tenderness of the right hip was noted during his initial evaluation in 1989; his right leg was externally ro­tated, with a restricted range of motion in both legs, more on the right side. Radiographs of both hips in July 1989 revealed changes typical of avascular necrosis in the left hip and gross destruction of the right hip. In addition, there was radio- graphic evidence of sacroiliitis and early ankylosing spondy- litis.

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Case 2: A 29-year-old man first developed diarrhea, up to 10 watery movements daily, in 1983. Colonoscopic evaluation in a community hospital showed colitis with deep ulcera- tions, thought to be consistent with Crohn’s colitis. He was treated with sulphasalazine 2 g daily and corticosteroid ene­mas. His symptoms improved, but he had occasional epi­sodes of bloody diarrhea. In 1986, his bloody diarrhea became more severe, up to 20 times per day. Progressive weight loss, estimated to be about 15 kg, developed. He was admitted to hospital and treated with 5-aminosalicylic acid 1600 mg (Asacol) and intravenous hydrocortisone 400 mg daily. Colonoscopic changes were extensive with cecal and rectal sparing. Biopsies showed inflammatory changes only, with no granulomas. He was transferred to another hospital for parenteral nutrition (including lipid emulsion). His weight increased by 10 kg, and his diarrhea improved with a frequency of about 10 movements/day. Surgical treatment was declined.

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Clinical records of 877 patients with Crohn’s disease were retrospectively reviewed by the authors. Four patients with osteonecrosis were found, including two who were previ­ously reported elsewhere. Follow-up data were available, with a mean for the entire patient group of 7.8 years. Osteonecrosis was diagnosed on the basis of routine radio- graphic studies and nuclear scanning, as well as modern imaging methods, including MRI, which has been available at the University of British Columbia Hospital, Vancouver, British Columbia since 1981. Statistical evaluation of the steroid and nonsteroid population included the Fisher’s ex­act test.

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