Insufficiency Fracture - likely cause - Prednisilone

[Greengarth]

I saw an orthopaedic Fracture surgeon last week following an MRI on my right knee to investigate knee pain. She reported a small meniscus tear and a small piece of detached cartilage. However she also reported an Insufficiency Fracture in the femur which she thinks may have been caused by Prednisolone. She recommend a knee replacement, but is concerned that the prednisone would interfere with the success of the replacement process and has referred me to both a knee surgeon and rheumatology. I wonder if anybody else has experienced this situation? I am male, aged 77 and have been through three cycles of taking Prednisolone over the last six years.

[PMRpro Ambassador]

Plenty of people on the forum who have had hip and/or knee replacements while on pred. Are you currently on pred?

[Greengarth in reply to PMRpro]

As I said n my post, I have been on Prednisolone for six years.

[PMRpro Ambassador in reply to Greengarth]

And so had some of them.

[piglette]

I was told by an orthopaedic surgeon that pred had been ‘eating away’ at my hip cartilage. I had two hip replacements on 5mg of pred. Why are you taking pred?

[Greengarth in reply to piglette]

For PMR.

[piglette in reply to Greengarth]

Did you go through three cycles of pred because PMR came back?

[Greengarth in reply to piglette]

Yes

[piglette in reply to Greengarth]

That is really bad luck, I am so sorry.

[PMRpro Ambassador in reply to piglette]

I wonder if actually it ever went away?

[Greengarth in reply to piglette]

Thank you. We'll get it sorted out.

[Greengarth in reply to piglette]

Yes got down to 1mg and GP told me to try zero. Then went back up to 15 and reduced down from there.

[PMRpro Ambassador in reply to Greengarth]

We'd have suggested 5mg for a short time and back to1mg - 1mg to zero is a big change and even 1/2 mg is enough to keep low level PMR under wraps. You might have been able to stay at 1mg long term doing that.

[Greengarth in reply to PMRpro]

Thanks.

[Sophiestree]

Have you ever had a DEXA to see how your bones are? Do you take anything else other than prednisolone? Vit D?

I think you need this checking to see your overall bone health. As others have said there are many on here who have had that operation.

Do you take prednisolone now? What doses were you on and for how long each time?

I can imagine that was quite alarming for you to hear.

[Greengarth in reply to Sophiestree]

I have been taking daily Vit d for years. The surgeon has ordered a series of tests checking bone health, thyroid, Vit d, calcium etc.

[Sophiestree in reply to Greengarth]

Hopefully a dexa scan has been organised as until you see what the results of that are it is difficult.

[Greengarth in reply to Sophiestree]

Many thanks. Good idea. Will suggest when next see GP

[Sew_And_Sew]

(UK) Whilst on prednisolone you should be taking a number of calcium medications. Pred can cause serious calcium deficiencies so it is vital you are taking these.

I went into hospital for a day procedure in early July and the anaesthetist said I should double my pred dose for three days after surgery. I was on 8mgs at the time.

All went well with no issues around my PMR (Phew!).

It's important to discuss issues around PMR with you GP or rheumatologist so they are fully informed of the procedures you're to have.

Good luck with everything

[Greengarth in reply to Sew_And_Sew]

Thank you. The surgeon has written to rheumatology to ask their advice.

[Sew_And_Sew]

that's excellent. Good luck with everything x

[marionofnorwich]

I also have an insufficiency fracture. I had Covid in April 2022 and soon afterwards experienced a dramatic pain in my right knee. It was eventually xrayed in September 2022 and an insufficiency fracture diagnosed as well as osteo-arthritis and fluid in the bone. I had an MRI in March 2023 and then I booked an appointment with a private orthopaedic surgeon who didn't seem concerned by it specifically but said that my knee is very eroded (osteo-arthritis) but said that it wasn't affecting me enough to recommend a knee replacement at this stage. I now have an NHS appointment in December with an orthopaedic surgeon so will see what he says. My knee has improved over 18 months as I couldn't walk at all for a long time but my walking is still limited - not sure whether PMR, osteo-arthritis, muscle weakness/general fitness or what - I will report back after 6 December to see what the new surgeon says

[Greengarth in reply to marionofnorwich]

Looks like we have similar problems. My orthopaedic surgeon said that the knee could not be replaced whilst I was taking corticosteroids. However, it remains to be seen what the rheumatologist’s view is and indeed the view of the knee specialist surgeon I have been referred to..

Good luck with the next six months. Hope things get resolved.

[Missus835]

Similar. Osteoporosis caused by the Pred. At this time I have 8 vertebral fragility fractures. Two have had vertebroplasties done end of September. Waiting for MRI to determine which ones need the next vertebroplasties. This is where the surgeon injects a cement-like substance into the vertebrae to hopefully rebuild them. So far so good with the procedure. No infection. I'm presuming MRI will inducate how well things are healing. All the best to you.

[PMRpro Ambassador in reply to Missus835]

Had you had a dexascan before the pred? Unless you did, you cannot be sure the osteoporosis is entirely due to pred. Some people develop it anyway - which is why a baseline dexascan is important,

[Missus835 in reply to PMRpro]

No Pro, nothing done prior to Pred with the exception of bloodwork and highly elevated markers. Osteoporosis is not genetic for me, however and no signs of it prior either. BDX done 2 weeks ago is not much change from a year ago (about 8 months after PMR diagnosis at which time rheumy said osteopenia) and then changed her tune and said osteoporosis when I spoke with her this August. Nothing "baseline".

[PMRpro Ambassador in reply to Missus835]

Then it may not have been the pred - there are no signs in advance usually, except maybe loss of height.

[Missus835 in reply to PMRpro]

I have lost 6 cm between scans. This is what the technician told me. It could be a combination of Rabeprazole and Pred. I've been on Rab for a few years and prior to that other -prazoles...or maybe it's "just osteoporosis" and of an older age. In some skewed sense it would be nice if it wasn't the Pred. Thanks Pro.

[Greengarth in reply to PMRpro]

I think the GP thought it was just a torn meniscus.

[PMRpro Ambassador in reply to Greengarth]

That's why they have relatively easy access to walk-in x-rays services. But they won't use them. A GP nearly killed my husband by not suggesting a chest x-ray.

[Greengarth in reply to Missus835]

Don’t recall being warned of this dramatic effect of corticosteroids on bone. Yes was told to ,and did take, alendronic acid and vitamin d supplements and extra dairy products, but assumed that if I did this I would be OK. How else would I have known what was happening to my femur?

[Missus835 in reply to Greengarth]

I do/did all those things as well Greengarth. Still on Pred. About your femur...I do not know. You're doing all the right things. I wasn't aware of my vertebral issues either until the back pain started last May and they finally did a CT scan in July and then another Oct. 13. My stomach does not tolerate AA so I had a zolendronate infusion about 2 weeks ago. Hopefully this will start to build my bones up.

[Greengarth in reply to Missus835]

Many thanks.Good to here there is a way forward.

[1951grumpa]

Greengarth, I’ve had PMR since 2011. In 2016 I had a left knee replacement in 2017 a right knee scope for some torn meniscus in 2019 a microdisectomy and in 2021 a gall bladder removed. All with general anesthesia and I was on 4-5 mg prednisone. Neither my rheumatologist or surgeons we’re concerned with me taking steroids.

[Greengarth in reply to 1951grumpa]

That’s very interesting, I’ll raise that when the surgeon/rheumatologist get back to me. May solve the problem. Many thanks.

[Bella59]

I have been on pred since 2019,like yourself i came off them in 2021 it was just under two years.My pain returned in a matter of weeks.I saw my consultant a few months later and was back on 20 mgs pred i was back to square one.I had to reduce to zero in about eight weeks as i had my first hip replacement.My surgeon did not want to operate while i was on steroids.My next hip was replaced six months later but he allowed me to stay on 5mgs.So now i am on 3.5 mgs and pray i will manage to come off pred this time and be fine.My surgeon let me stay on 5mgs as my first op went well and no infections.It is really down to your surgeon.

[PMRpro Ambassador in reply to Bella59]

I wonder if you were classified as being off pred in 2 years and then relapsing since it took time to see the consultant? Instead of being down to a very low disease activity in 2 years but requiring an ongoing low dose.

Had you not come off the pred, you would probably have been at 1mg for the op and any surgeon who complained at that compared with a reasonably fit patient in a position to do the recovery rehab needs a reality check.

[Bella59 in reply to PMRpro]

I agree but surgeon conferred with Rheumatology consultant and he wanted me off pred for first op.I also had to stop meds for RA for couple weeks which is normal practice.Hindsight is a great thing,if i knew then what i know now thanks to this forum i would have questioned why.After first op i went back up on steroids to aid recovery.Second op i stayed on 5mgs same surgeon.I have been reducing really slowly now on 3.5mgs when i get down to 3mgs to get cortisol tested by gp.I was told if it is under 300 to get gp to let Rheumatology know they would arrange further testing at the hospital.Thank goodness for this forum especially you and Dorset L.I am also on thyroid and Nrsa forums again i have gained so much information. Thanks.

[PMRpro Ambassador in reply to Bella59]

Keeps us from wearying!

[Greengarth in reply to Bella59]

That’s very interesting. There seems to be a good deal of latitude as to the dosage of prednisone that surgeons will operate with. Your history is good news for me and hopefully my surgeon may be equally flexible. Thanks for your help.

[Greengarth in reply to Bella59]

Hope my surgeon will be flexible about my dose of prednisilone.

[Bella59]

I hope so for you ,by the way i had spinal ana on both hips also two knee replacements.Wish u well.

[Greengarth in reply to Bella59]

Thanks