Exploring the Association Between COVID-19 and Avascular Necrosis: A Systematic Review

Avascular necrosis (AVN) has emerged as an extrapulmonary complication associated with COVID-19 and corticosteroids. This review aims to evaluate the association between COVID-19 infection, corticosteroid use, and the development of AVN. We conducted a systematic review following the PRISMA guidelines, searching five databases until May 30, 2024. We included cohort and case series studies involving COVID-19 patients who developed AVN. The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). A total of 13 studies, comprising nine case series and four cohort studies, were included. These studies involved 795 patients with a mean age of 46.1 years and a male predominance (66%). The cumulative dose of corticosteroids varied, with an average of 1,462.9 mg. The duration between COVID-19 infection and initial AVN symptoms ranged from 2 to 62 weeks. The most commonly affected bones were the hip and femoral head. The visual analog scale (VAS) score improved with the treatment, and the cases showed improvements. A significant association was found between COVID-19, corticosteroid use, and AVN development. Clinicians should exercise caution when prescribing corticosteroids and monitor for early signs of AVN. Further research is needed to elucidate the pathophysiological mechanisms and explore alternative treatments to mitigate the risk of AVN.