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Our adult daughter has developed the start of a collapsed hip from taking steroids for her lupus. They call this condition osteonecrosis. It's not really hurting her right now. But she's only 35 years old, so we are concerned that she might end up crippled before she's 40. What do you advise?

Some surgeons advocate what is referred to as careful neglect. This is a watch-wait-and-see approach. But there are just as many orthopedic surgeons who say head it off at the pass. In other words, treat it early and prevent the problem from getting much worse. The voice of reason and experience comes through loud and clear on this one: study patients who have this problem and see if there are any predictive factors of disease progression. Those patients who have significant risk factors for progression of disease without treatment should be teated early in the course of their disease development. It is possible that the question of how (and when) it's best to treat asymptomatic (no pain, no symptoms) osteonecrosis of the femoral head has already been answered but lies buried in the medical literature. That's why a group of surgeons from the Center for Joint Preservation and Replacement at Sinai Hospital in Baltimore, Maryland reviewed all of the articles they could find published on this topic up to the middle of 2008. This type of study is called a systematic review. Information collected from the studies that were high enough quality to be part of the review included patient age, how long they were followed, location and size of the bone lesion, and use of certain medications (e.g., steroids) or excessive alcohol. They also looked at personal medical history of lupus, sickle cell disease, kidney disease, kidney transplantation, and human immunodeficiency virus (HIV). By combining all the hips studied into one group, they found that 394 of the total 664 hips developed symptoms and eventual collapse. That's a percentage rate of about 59 per cent (more than half, almost two-thirds). The destruction took place over a period of time from as little as two months and as long as 20 years. There were some telltale factors to help predict who might go on to a symptomatic phase. The size of the lesion was the main risk factor. The larger the lesion at the time of diagnosis, the more likely destruction and collapse were to occur in time. Patients with sickle cell disease were also at great risk of disease progresion. Patients with lupus were much less likely to progress to collapse unless they were taking steroids over a long period of time. The authors concluded that based on the systematic review there is enough evidence to support a more aggressive approach to treating asymptomatic hip osteonecrosis. Large lesions are likely to get worse, so don't wait. A wait-and-see approach may be okay for smaller areas of bone death but the patient should be followed closely. Any sign of progression should be addressed right away.

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