Bilateral avascular necrosis of the femoral head due to the use of heroin: A case report.

INTRODUCTION: Femoral head avascular necrosis is caused by disruption of the blood supply of the femoral head, which finally results in hip dysfunction. Non traumatic osteonecrosis may related with corticosteroid use, alcohol abuse, SLE, hemoglobinopathies or exposure to cytotoxic agents. But avascular necrosis of the femoral head (ANFH) due to heroin use is a rare condition. We report a patient with bilateral ANFH due to heroin use treated by simultaneous bilateral hip arthroplasty. PRESENTATION OF CASE: 37 year-old male patient presented with bilateral hip pain that had been occurring for four years. The patient had no history of smoking, excessive drinking, using corticosteroid and the other drugs or trauma but used heroin for 10 years. In clinic and radiologic examination indicated advanced degenerative changes on both hip due to femoral head avascular necrosis. The patient was treated with simultaneous bilateral total hip arthroplasty. After 6 months postoperatively the active hip range of motion was painless. DISCUSSION: Avascular femoral head necrosis caused by the using of heroin is rare. Ultimately, osteonecrosis of the femoral head occurs through one final common pathway, which is decreased blood flow to the femoral head that leads bone ischemia and death. But it is still unknown that heroin's systemic effects. Intravenous drug use more as a serious problem for today. There is a need for comprehensive studies to demonstrate effects of heroin on bone and vascularity metabolism.
CONCLUSION: Heroin use will be important problem for population. That's why is crucial to understand the effect of heroin.

Introduction

Femoral head avascular necrosis is caused by disruption of the blood supply of the femoral head, which finally results in hip dysfunction [1], [2]. Osteonecrosis progresses traumatically or non- traumatically. Nontraumatic osteonecrosis is usually associated with corticosteroid use, alcohol abuse, systemic lupus erythematosus, hemoglobinopathies including sickle cell anemia, Legg-Calve Perthes disease and exposure to radiation or cytotoxic agents [3], [4], [5]. Less common associations include Gaucher’s disease, dysbarisms, HIV, hyperlipidemia, pancreatitis and gout [2]. The treatment is challenging and based on the stage of the necrosis. Advanced stage avascular necrosis needs total hip arthroplasty [6].

Avascular necrosis of the femoral head (ANFH) due to heroin use is a rare condition. There are few reports of heroin injection to the femoral veins resulted with thomboflebitis and subsequently ANFH [7]. However, osteonecrosis of femoral head caused by heroin without injection to the femoral veins is not reported. In this case, we report a patient with bilateral ANFH due to heroin use treated by simultaneous bilateral total hip arthroplasty.

Case report

A 37 year-old male patient presented with bilateral hip pain that had been occurring for four years. When we deepen the patient’s history learned that, he is a history teacher and using IV heroin for 10 years. The patient had no history of smoking, excessive drinking, using corticosteroid and the other drugs or trauma but use heroin for 10 years. 2 years ago he applied psychiatrist for treatment and had seen pharmacotherapy 2 months, psychotherapy 6 months. Buprenorphine/naloxone (suboxone 8 mg) treatment was applied for 2 months. He completely stopped heroin use during six months, but then he left follow-up and started using drug again. There is no family history for ANFH. Patient redirected by psychiatrist when hip pain increased dramatically. There is no other predispose factors can related with osteonecrosis. Routine blood test results of liver and kidney electrolytes, hemoglobinopathies and coagulopathies were normal. Clinic examination of both hip revealed generalized tenderness in the groin with limited range of motion. Hip flexion was restricted to 90°, hip extension to 10° with minimal abduction and fixed in external rotation. Initial radiographs showed severe ischemic necrosis which lead to arthrosis and collapse in bilateral hip joints (Fig. 1). Magnetic resonance imaging of the bilateral hip joints indicated advanced degenerative changes on both sides (Fig. 2).

Fig. 1

Preoperative X-ray imaging.

Fig. 2

Preoperative MRI imaging.

The patient was treated with simultaneous bilateral total hip arthroplasty. After 6 months postoperatively the active hip range of motion was painless. There was no flexion or abduction contracture at both hip joints. Harris hip score raised from 52 to 89. Being treated to leave the drug last year. Blood and urine tests for heroin is clean out for the last 6 months. The control radiographs there is no evidence for loosening and infection for arthroplasty (Fig. 3).

Fig. 3

Postoperative X-ray imaging.

Discussion

Avascular femoral head necrosis caused by the using of heroin is rare. Ultimately, osteonecrosis of the femoral head occurs through one final common pathway, which is decreased blood flow to he femoral head that leads bone ischemia and death. Vascular occlusion can be caused by local thrombi, fat emboli, nitrogen bubbles, or abnormally shaped red cells [8]. The blood vessels in the femoral head may be directly damaged by vasculitis, irradiation, or chemical toxicity [9], [10]. Most common factors like alcohol and corticosteroids occurs osteonecrosis with abnormality of lipid metabolism and fat emboli [2]. Also hypercoagulopathy and genetic alterations like factor V Leiden mutation can cause of avascular necrosis [11]. In this case our patient have no risk factor for osteonecrosis other than using heroin. It is complicated that how heroin occurs osteonecrosis of femoral head [12], [13], [14]. Wu et al. show osteonecrosis of femoral head in the patient who injected heroin to femoral vein [7]. They explain process with thrombophlebitis resulting from the intravenous injection. But it is still unknown that heroin’s systemic effects. There are some studies about miscrovascular damage and apopitosis caused by intravenous opioid using [15], [16]. Intravenous drug use more as a serious problem for today. There is a need for comprehensive studies to demonstrate effects of heroin on bone and vascularity metabolism. We fixed late stage of necrosis on this patient and had to do arthroplasty for treatment. In the future it is crucial that the reveal etiology for the more cost effective and more functional therapies.

Conflicts of interest

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Funding

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Ethical approval

None.

Consent

This is a statement that the patient had given informed consent for the case report to be published.

Author contribution

OO, corresponding author of the case, did the literature search,manuscript writing, worked in data collection (follow-up data).

FD had attended the surgery and also worked in data collecting (follow-up data). KS did the literature search and helped the manuscript writing.

FI performed the surgery, made study design and helped in manuscript editing.

MS made the initial study design, joined the surgery and made the general supervision of the case report.

All authors read and approved the final manuscript.

Research studies

None.

Guarantor

Okan Ozkunt.