Risk Factors, Pathogenesis, Diagnosis, and Treatment Options for COVID-Associated Osteonecrosis: A Systematic Review

Osteonecrosis associated with COVID-19 is a relatively rare clinical entity, but with a high incidence during the pandemic. There is a paucity of data regarding the characterization of this group of osteonecrosis patients. The purpose of this investigation was to systematically review the literature to identify: (1) clinical presentation/epidemiology, (2) pathophysiology, (3) diagnostic modalities, and (4) treatment guidelines/algorithms of COVID-19 osteonecrosis.

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review across three databases, resulting in a total of 10 articles. Articles met the inclusion criteria if they provided data regarding: (1) clinical presentation/epidemiology, (2) pathophysiology, (3) diagnostic modalities, and/or (4) treatment guidelines/algorithms of COVID-19 osteonecrosis.

There was considerable variability in duration between COVID-19 infection and osteonecrosis symptoms. The clinical presentation of COVID-associated osteonecrosis is similar to standard symptoms, including joint pain and pain with weight-bearing. Corticosteroids tended to be the most identifiable associated risk factor for COVID-associated osteonecrosis. Diagnosis included radiographs and magnetic resonance imaging for definitive diagnosis. Treatment varied depending on the rapidity of osteonecrosis progression, ranging from bisphosphonates and analgesics to joint-preserving procedures and total joint arthroplasty.

Although COVID-associated osteonecrosis is a rare clinical condition, it is one that orthopaedic surgeons should be aware of and meticulously screen for in their patients. For patients inoculated with the COVID-19 virus, it is important for surgeons to use information regarding clinical presentation, pathophysiology, diagnosis, and treatment of COVID-associated osteonecrosis to screen and manage patients appropriately.