Sequential, Multifocal, and Delayed Avascular Necrosis of All Four Major Joints From Hips to Shoulders Following Corticosteroid Therapy

Osteonecrosis is a progressive disorder characterized by compromised bone perfusion leading to structural collapse and joint dysfunction. We describe a 59-year-old male patient who received a tapered regimen of oral methylprednisolone for facial palsy in 2012. Four months after treatment, he developed discomfort in the right hip, and imaging confirmed osteonecrosis of the right femoral head. Conservative management with nonsteroidal anti-inflammatory drugs (NSAIDs) and activity restriction was unsuccessful, leading to core decompression and later total hip arthroplasty (THA). Ten years later, he experienced pain in the contralateral hip, and imaging revealed osteonecrosis of the left femoral head, which was managed by THA. In 2025, the patient presented with pain and limited motion in the right shoulder. Magnetic resonance imaging demonstrated osteonecrotic lesions and marrow edema in the right humeral head, as well as a chronic focal lesion in the left humerus, despite the absence of symptoms. NSAID-based follow-up was selected for the right shoulder, while core decompression was planned for the left. This case illustrates delayed, multifocal, steroid-induced osteonecrosis progressively involving both hips and shoulders over more than a decade. This clinical scenario raises an important consideration: whether patients undergoing corticosteroid therapy should receive routine imaging of major joints to facilitate early detection of osteonecrosis and enable timely interventions, such as core decompression, that may delay or prevent progression to end-stage joint destruction requiring arthroplasty.