Double Trouble—COVID-19 and the Widespread Use of Corticosteroids: Are We Staring at an Osteonecrosis Epidemic?

Abstract

Background A combination of immune-mediated vascular damage and routine use of systemic corticosteroid (CS) therapy in COVID-19 may significantly increase the risk and burden of osteonecrosis (ON) after COVID-19. This narrative review explores the pathogenesis, risk factors, and possible preventive and early treatment measures for ON in COVID-19. Methods For this narrative review, an extensive literature search was performed using the PubMed, Medline, and Science Direct databases from January 2000 to August 2021 for relevant articles on etiopathogenesis, epidemiology, clinical manifestations, and treatment of severe acute respiratory syndrome coronavirus (SARS-CoV) infection and steroid-induced ON (SION). Results Pathogenesis of COVID-19, utility of corticosteroids in the treatment of COVID-19, pathogenesis of SION vis-a-vis SARS-CoV infection, associated risk factors, and early diagnosis and treatment of ON following CS therapy of SARS-CoV infection were discussed. Conclusion Preliminary data of COVID-19 and similar trends from the SARS 2003 epidemic indicate that the “angiocentric” pathogenesis of SARS-CoV-2 and treatment with high-dose CS may increase the risk of ON in COVID-19 patients. Risk stratification based on CS intake during COVID-19 treatment can help identify subjects at moderate to high-risk for ON where early preventive and follow-up plans can be initiated.

Femoral Head Osteonecrosis Post-Covid-19 Infection, A prophecy Coming True. A Report of Seven Hips

“…Although the occurrence of ONFH post-COVID-19 infection seems to be multifactorial, most authors stressed on the judicious use of Corticosteroids to guard against the development of severe complications of its prolonged and cumulative use, especially in high doses [3,26,4]. As all of the affected patients in the current report are considered young contradictory to the report by…”

“…The evidence showed a strong correlation between Corticosteroids use and ONFH development [3,18,19,10]; however, the pathophysiology of such correlation is still unclear, which could be multifactorial, including possible fat emboli formation, increased intraosseous pressure caused by fat cell hypertrophy, hyperlipidemia, and endothelial dysfunction, all of these possible factors could contribute to bone marrow ischemia and subsequent necrosis [20].…”

“…At the start of the COVID-19 pandemic, it was commonly known for being a discrete respiratory infection; however, later on, it affected almost all body systems, including the musculoskeletal system, which presented in various forms and severity starting from just myalgia and arthralgia up to rhabdomyolysis and joints osteonecrosis [1,2]. These effects could appear during the acute disease stage, but sometimes it occurs as a late consequence of the disease or as a side effect of the medications used during management [1,3].…”

“…In the past few months, there was a plethora of publications discussing nearly one theme: the fear of bone marrow osteonecrosis after the widespread use of Corticosteroids in patients suffering from COVID-19 [4,3,5,6]. Most of the authors based their fears on what occurred after the SARS Epidemic in 2003, as high rates of osteonecrosis of the femoral head (ONFH) (up to 23%) were reported in patients recovering from the condition who had received corticosteroid treatment [7,3,8]. Some authors reported cases who suffered from bone marrow osteonecrosis in the hip, knee, shoulder, and vertebrae as direct or indirect consequences of COVID-19 infection and management [9][10][11][12]2].…”

Avascular necrosis of the epiphyses of bones in patients who have had SARS-CoV-2 infection: Clinical observations and a narrative review of literature data

“…К настоящему времени выделены факторы риска развития АН после COVID-19. К ним относятся: высокие кумулятивные дозы ГК (>5 г в эквиваленте метилпреднизолона); прием ГК >10 дней; тяжелая пневмония; ОРДС; госпитализация в отделение интенсивной терапии; ИВЛ; повышение в сыворотке крови уровня следующих маркеров: ИЛ-6 ≥40 пг/мл, ферритина ≥300 нг/мл, триглицеридов ≥300 мг/л, D-димера ≥1000 нг/мл [39]. Следовательно, тяжелое и среднетяжелое течение COVID-19 -факторы риска развития АН, и все больные, перенесшие заболевание в данной форме, должны быть информированы о необходимости выполнения магнитно-резонансной томографии (МРТ) при появлении боли в каком-либо суставе в период до 12 месяцев после выписки из стационара для своевременной диагностики АН.…”