Dose-Response Meta-Analysis of Corticosteroid Effects in SARS Outbreak: A Model for Risk Stratification and Screening Strategy for Osteonecrosis of Femoral Head Post-Corticosteroid Therapy for COVID-19

Characteristics of osteonecrosis of the femoral head after COVID-19 steroid treatment compared to steroid-associated osteonecrosis

BACKGROUND

Several studies have reported that the steroid dose of osteonecrosis of the femoral head (ONFH) after COVID-19 infection treatment was relatively low. However, the pathogenesis of ONFH after COVID-19 infection was not elucidated. This study aimed to analyze ONFH cases after COVID-19 infection and compare their characteristics with those of steroid-associated ONFH during the same period.

METHODS

This study includes 8 patients diagnosed with ONFH after steroid treatment for COVID-19 infection (COVID-19 group) from January 2020 to December 2023 in our institution and associated institutions. Nine patients diagnosed as steroid-associated ONFH without COVID-19 pneumonia treatment (SA-ONFH group) during same periods. Duration of steroid administration, cumulative dose of prednisolone equivalent, time to the onset of ONFH, history of alcohol and smoking, and blood test results were analyzed. Statistical analysis was performed between both groups using Mann-Whitney U test, Fisher's exact test (p < 0.05).

RESULTS

In COVID-19 group, the mean duration of steroid administration was 31 days, the mean cumulative dose of prednisolone equivalent was 719 mg, the mean time to the onset of ONFH was 9 months, 4 patients had a history of alcohol, 5 patients had a history of smoking. In SA-ONFH group, those were 681 days, 8,720 mg, 23 months, respectively; all patients have no alcohol and smoking history. In COVID-19 group, two patients had no history of alcohol and smoking. The administration duration of steroid in COVID-19 group was significantly shorter than that of SA-ONFH group. In addition, the mean cumulative dose of prednisolone equivalent was significantly lower than that of SA-ONFH group. A systematic inflammatory response and a hypercoagulable status could not be confirmed based on blood test results.

CONCLUSIONS

In our results, the mean cumulative dose in COVID-19 group was 719 mg, less than the diagnostic criteria (2000 mg) and our SA-ONFH group. Even in ONFH patients without history of alcohol and smoking in COVID-19 group, steroid dose were less than the criteria. Therefore COVID-19 infection itself or low-dose of steroid for COVID-19 patients may be a contributing factor to ONFH. Patients after COVID-19 infection treated with steroids should be followed for the possibility of developing ONFH.

Is there an Increase in Total Hip Arthroplasty Due to Osteonecrosis of Femoral Head After Covid-19 Pandemic?: A Retrospective Study Among Patients in Central Karnataka, India

Introduction

Coronavirus disease 2019 (COVID-19) infection or corticosteroid usage during the COVID-19 pandemic as risk factors for avascular necrosis (AVN) of the femoral head (osteonecrosis of the femoral head/femoral head AVN [FHAVN]), as well as its link to clinical and radiological outcomes, are poorly understood. Osteonecrosis, which results from a disruption in vascular supply to the femoral head, is a prevalent cause of hip joint deterioration and one of the most common reasons for total hip arthroplasty (THA)/total hip replacement in India and other Asian countries. This study will aid in understanding the condition's epidemiology and statistically determining the risk of disease related with pandemic exposure.

Materials and Methods

This is a retrospective study of 100 hips diagnosed with osteonecrosis/osteoarthritis of the femoral head that underwent THA at a tertiary care center before and after the COVID-19 pandemic between February 2014 and February 2024.

Results

Late stages of FHAVN, when the diagnosis requiring THA, following the pandemic have increased exponentially. It has also switched from affecting the middle-aged to the younger age groups. Furthermore, the bilaterality necessitating THA has increased considerably. There is a clear shift in the presentation of this disabling illness, as well as the need for THA, which otherwise is rarely carried out on younger people. Furthermore, data on how much corticosteroids were used in the treatment is disturbingly scant, and how it may have contributed to this ailment in India is still questionable.

Conclusion

The COVID-19 pandemic could be the most serious threat, causing late-stages FHAVN (stages 3 and 4 of the Ficat and Arlet classification), in an accelerated manner, necessitating THA and overburdening existing medical care.

The Lachnospiraceae-butyric acid axis and its role in glucocorticoid-associated osteonecrosis

Glucocorticoids (GCs) are key inducers of osteonecrosis, yet not all patients treated with GCs develop glucocorticoid-associated osteonecrosis (GAON). The factors mediating this relationship are unclear. Studies have shown that gut microbiota and their metabolites influence bone metabolism, but their role in GAON is unclear. This study aimed to explore the connection between GAON and gut microbiota. Through bidirectional Mendelian randomization analysis, we identified 14 gut microbial taxa, including Lachnospiraceae (IVW, P = 0.011), associated with GAON. RNA-seq analysis revealed that GAON differentially expressed genes (DEGs) were enriched for intestinal inflammatory response mechanisms. We then compared patients who developed GAON (17 cases), those who did not (GAnON, 15 cases), and those untreated with GCs (Blank, 15 cases) for gut microbiota composition, short-chain fatty acids (SCFAs), and serum inflammatory factors. Our findings indicated a decrease in Lachnospiraceae abundance (GAON 17.13%, GAnON 12.51%, Blank 24.52%) in GC-treated patients. Serum inflammatory factors (IL-17 A, IL-33, and TNF-α) associated with GAON (59.603 ± 12.147, 89.337 ± 20.714, 42.584 ± 9.185) showed significant differences between Blank (1.446 ± 0.683, 11.534 ± 4.705, 4.682 ± 1.48) and GAnON (25.353 ± 8.181, 32.527 ± 7.352, 12.49 ± 3.217) groups, with a negative correlation between these factors and Lachnospiraceae levels. Butyric acid levels in SCFAs varied among groups (P<0.01) and correlated with Lachnospiraceae and inflammatory factors. Controlled experiments in GAON rats demonstrated butyric acid's osteoprotective role in GAON development (P<0.01). In conclusion, our study suggests that reduced Lachnospiraceae and butyric acid levels, along with increased inflammation due to GCs use, contribute to GAON. Butyric acid may mediate the effects of Lachnospiraceae and inflammation. Butyrate supplementation could potentially reduce GAON incidence, offering a novel approach for its clinical management.

Osteonecrosis of the Femoral Head: Another Legacy of COVID-19?

Background. Recovery from COVID-19 does not always proceed without complications, especially in patients who have suffered severe forms of the disease. Most researchers confirm a significant increase in the incidence of osteonecrosis of the femoral head (ONFH) after COVID-19. However, there is no clear opinion on the individual aspects of the development and course of the disease. This is an extremely important issue that allows us to identify the main risk groups for the development of post-COVID-19 osteonecrosis and, consequently, to perform the earliest possible screening of this complication. Aims of the study: 1) To evaluate the impact of the past COVID-19 on epidemiologic parameters and clinical course of osteonecrosis of the femoral head in patients; 2) to study the causes of its development. Methods. We have analyzed the data of medical histories of 674 patients diagnosed with osteonecrosis of the femoral head who sought medical care in 2018 and in 2022. Patients were divided into 4 groups according to the presumed causes of development of the disease. The first group enrolled 183 patients who underwent COVID-19 and received steroid therapy (ST). The second group included 78 patients who underwent COVID-19 without ST therapy. The third group consisted of 103 patients with ONFH that manifested in 2022 without COVID-19 in the previous medical history. The comparison group was made up of 310 patients who developed ONFH in 2018 before the appearance of the SARS-CoV-2 virus. Results. The sample of patients with COVID-19-associated osteonecrosis differed significantly from patients without COVID-19, in terms of gender, age, time of disease onset, extent of the femoral head damage, and disease progression rate (p0.001). The level of early ONFH diagnosis was extremely low, not differing from that in the pre-pandemic period. Conclusion. The COVID-19 pandemic has increased the incidence of ONFH, significantly modifying both its epidemiology and clinical picture. Nevertheless, the vigilance of practitioners remains extremely low, which affects the timely diagnosis of the disease.