Steroid induced osteonecrosis: An analysis of steroid dosing risk

Abstract

Osteonecrosis is a serious condition involving bone destruction that frequently requires surgical treatment to rebuild the joint. While there is an abundance of literature documenting corticosteroid related osteonecrosis, there is no consensus as to the relative risk of osteonecrosis after administration of steroids via parenteral, oral, topical, inhaled and other routes. This risk is an important prognostic indicator because identification and conservative intervention can potentially reduce morbidity associated with aggressive surgical treatment of osteonecrosis. This paper provides insight into establishing guidelines related to the risk of developing osteonecrosis as a result of corticosteroid use. Case studies, retrospective studies and prospective studies in humans on different corticosteroids and varied dosages were assessed. Most cases of osteonecrosis are secondary to systemically administered corticosteroids and/or high dose daily therapy, particularly in patients with underlying comorbidities including connective tissue diseases, hyperlipidemia, or previous trauma. Previous case reports of osteonecrosis related to inhaled or topical use of steroids are complicated by the fact that in the great majority of cases, the patients are also treated with systemic steroids prior to the development of osteonecrosis. Based on the literature, a set of recommendations regarding the risk of osteonecrosis in patients on steroids was formulated.

What Are Risk Factors for 30-day Morbidity and Transfusion in Total Shoulder Arthroplasty? A Review of 1922 Cases

“…Although we were unable to quantify the complexity of TSA cases in our study, we suggest that surgical complexity may be closely reflected by increased operative time and report that operative time [ 2 hours is an independent risk factor for any complication. Known deleterious side effects of corticosteroid use include delayed wound healing, infection, and osteonecrosis [21,25,26,35]. We found that steroid use was an independent risk factor with a threefold increase for experiencing any complication after undergoing TSA (OR, 3).…”

Unilateral Femoral Head Osteonecrosis Caused by Low-Dose Oral Corticosteroid Used for Secondary Adrenal Insufficiency From Idiopathic Hypopituitarism

“…There is no dose cutoff for the occurrence of AVN after steroid use. Powell et al [8] reviewed 66 cases of steroidinduced AVN and found that the most commonly associated administered route included intravenous steroids followed by oral and rarely intramuscular, intra-articular injections and inhaled steroids. Karkoulias et al [9] reported aseptic femoral head necrosis in a patient receiving long courses of inhaled and intranasal corticosteroids.…”

Multifocal osteonecrosis and osteomyelitis in a liver transplant recipient

“…The most commonly affected sites of ON in patients on steroid therapy are femoral and humeral heads. [8] In addition, knee joints, talus, lunate and scaphoid bones are susceptible to ischemic necrosis because of their geometry, nutritional characteristics and hemodynamic features. Also is not clear whether the risk of ON is related to cumulative steroid dosage or not dose dependent.…”