Subcutaneous Atrophy following Methylprednisolone Injection in ...

Copyright 1979 by The Journal of Bone and Joint Surgery. Incorporated
Subcutaneous Atrophy following Methylprednisolone Injection
in Osgood-Schlatter Epiphysitis
BY P. K. M. ROSTRON, M.CH.ORTH., F.R.C.S.*, WIGAN, AND R. F. CALVER, M.CH.ORTH.,
Subcutaneous atrophy has been reported following
local application of various steroid preparations, whether
applied 5 I I 1 or injected intralesionally, in-
tradermally, or subcutaneously l.45.13#{149} In most cases the
steroid involved was triamcinolone2413. Only occasional
cases have been reported in which methylprednisolone
(Depo-Medrone) caused the atrophy
Observations
Fifty-four patients (seventy knees) with Osgood-
Schlatter disease were studied, and followed for a minimum
of six months and a maximum of twenty-one months
(mean, fifteen months). There were forty-two boys and
twelve girls. All of the girls were less than twelve years
old. All of the patients were referred to a general chil-
dren’s orthopaedic clinic with the typical symptoms and
signs of tibial epiphysitis, and only those who received at
least one injection of corticosteroid locally were included
in the study group.
All of the patients had had a local injection of one
milliliter of methylprednisolone (forty milligrams per mil-
liliter) mixed with two to four milliliters of 1 per cent
lidocaine hydrochloride solution, and injected with full
aseptic technique into the tender area at the growth carti-
lage of the tibial tubercle. No attempt was made to limit
the spread of the mixture.
In eight knees we subsequently noted a significant
degree of subcutaneous atrophy with formation of striae in
the skin around the tibial tubercle. In one knee there was
striae formation only.
The subcutaneous atrophy occurred in five of the
fifty-six involved knees in the boys and in four of fourteen
* Centre for Hip Surgery, Wrightington Hospital, Wigan WN6
9EP, England.
1- Warrington Infirmary, Warrington, England.
WARRINGTON, ENGLAND
References
in the girls. This complication usually was noted between
two and ten months after an injection. No patient received
more than two injections. One patient also had an injection
of hydrocortisone. In the relatively short follow-up period
(six to twenty-one months), the eight patients with the
complication had no symptoms relative to the tibial
epiphysitis, but no change was noted in the atrophy or
dermal striae.
Comment
Of all the steroids, triamcinolone is the one that
causes the most disturbing cutaneous and subcutaneous
side effects :t, I 2 Intradermal and subcutaneous injections
of triamcinolone have caused an atrophic process in the
skin with poikiloderma, pigmentary change, telangiec-
tasia, and alopecia I3 These changes rarely occur after
methylprednisolone or hydrocortisone acetate injection .
The skin atrophy and depigmentation may be reversible
after a number of years2, but full restitution of the fat may
not occur and the striae usually are permanent1. In our se-
ries methylprednisolone was injected with local anesthetic
admixed, and we found a surprisingly high incidence ( 12.9
per cent) of subcutaneous atrophy following this therapy.
The physician treating patients with Osgood-Schlatter
disease should be aware of the complications of steroid in-
jection as therapy. Subcutaneous atrophy has followed in-
jections of steroids in other and other complica-
tions, local and systemic, are also on record’7’”. Changes
in pigmentation, atrophy, and striae are the important local
complications that produce permanent disfigurement as re-
gards the skin, but other local complications have been re-
ported, such as panniculitis, hypersensitivity reaction.
secondary infection , and moderate pain and discomfort .
Nois: The authors would like to thank Mr. G. L. Shatwell and Mr. R. Owen for permission
to examine and report their cases.
1 . BEARDWELL. ANN: Subcutaneous Atrophy after Local Corticosteroid Injection. British Med. J. . 3: 600, 1967.
2. CASSIDY, J. T., and BOLE, G. G.: Cutaneous Atrophy Secondary to Intra-articular Corticosteroid Administration. Ann. mt. Med. . 65: 1008-
1018. 1966.
3. DUKES, M. N. G. Ieditorj: Meyler’s Side Effects of Drugs. Vol. 8, 1972-1975. Amsterdam, Excerpta Medica. 1975.
4. FISHERMAN, E. W.; FEINBERG, A. R-; and FEINBERG, S. M.: Local Subcutaneous Atrophy. J. Am, Med. Assn., 179: 971-972, 1962.
5. GoLDMAN, LEON: Reactions following Intralesional and Sublesional Injections of Corticosteroids. J. Am. Med. Assn., 182: 613-616. 1962.
6. GRICE, K.: Tinea of the Hand and Forearm. Betamethasone Valerate Atrophy. Proc. Roy. Soc. Med., 59: 254, 1966.
7. HOLLANDER. J. L.: BROWN, E. M., JR.; JESSAR, R. A.; and BROWN, C. Y.: Hydrocortisone and Cortisone Injected into Arthritic Joints. (‘omparative
Effects of and Use of Hydrocortisone as a Local Antiarthritic Agent. J. Am. Med. Assn., 147: 1629-1635, 1951.
8. JANSEN, L. H.: Nevenwerkingen van lokaal geappliceerde corticosteroIden. Nederlands Tijdschr. Geneesk.. 116: 1497-1503. 1972.
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628 P. K. M. ROSTRON AND R. F. CALVER
9. KENDALL, P. H.: Untoward Effects following Local Hydrocortisone Injection. Ann. Phys. Med., 4: 170-175, 1958.
10. MEARA, R. H.: Atrophic Striae following Topical Fluocinolone Therapy. British J. Dermatol. , 76: 481-482, 1964.
11. MUNRO, D. D,: Corticosteroids in Skin Diseases. Prescrib. J., 17: 84-89, 1977.
12. RooK, A. [editorl: Recent Advances in Dermatology. Edinburgh, Churchill Livingstone, 1976.
13. SCHETMAN, DONALD; HAMBRICK, G . W., JR.; and WILSON, C. E.: Cutaneous Changes following Local Injection of Triamcinolone. Arch. Dermatol.,
88: 820-828, 1963.
Copy nght 979 h I/se Joititail ci II O?l( ,,al Jo:,,t St vti t . I, au’ psitel
Resection of the Proximal Third of the Femur for
Chondrosarcoma in a Child:
Replacement with a Metallic Prosthesis
CASE REPORT
BY EARNEST B. CARPENTER, M.D.*, RICHMOND, VIRGINIA
From the Department of Orthopaedie Surgery. Medical College of Virginia. Crippled Children’s Hospital. Richmond
Radical resection of a malignant bone tumor in an ex- Case Report
tremity, particularly chondrosarcoma, is an acceptable This eight-year-old boy was first seen in August 1970 because of a
treatment if ablation of the involved extremity is not ac- limp of three to four months’ duration. Physical examination at that time
ceptable . Reconstruction of the resected area of bone has revealed marked limitation of internal and external rotation of the right
FIG. I
Anteroposterior roentgenogram of pelvis and proximal part of femur, showing lesion arising from lesser trochanter.
been accomplished by massive cortical bone grafts or by
metallic prostheses I-ti and many patients have been re-
ported who have survived following that treatment. The
case to be described is that of an eight-year-old boy who,
for eight years, used a custom-made Vitallium pros-
thesis, fabricated to match the proximal third of the femur
resected for chondrosarcoma. The patient was in excellent
general health at the time of writing and could participate
in all non-contact sports.
* Virginia Orthopaedic Associates, Inc. , 4315 Grove Avenue,
Richmond, Virginia 23221.
hip and roentgenograms (Fig. 1) showed a lesion arising from the lesser
trochanter. A biopsy was done and the specimen revealed a large lesion
with a soft cartilaginous cap and a broad base, arising from the lesser
trochanter.
Multiple histological sections revealed a well differentiated
chondrosarcoma that had many atypical chondroblasts with numerous
pyknotic and double nuclei . The initial biopsy-specimen slides and subsequent
gross specimen were reviewed by Dr. Lent C. Johnson who concurred
in the diagnosis.
The parents of the child refused the recommendation of disarticula-
tion of the hip but agreed to resection of the proximal third of the femur
with replacement by a prosthesis . Three days after the biopsy , the resec-
tion was carried out through an anterolateral incision and the proximal
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