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Osteonecrosis of the femoral head (ONFH) is increasingly recognized as a major post-COVID-19 complication, yet most studies are limited to case reports and small series. This study aimed to evaluate COVID-19-related factors potentially contributing to ONFH development in post-COVID-19 patients.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods<\/jats:title>\n            <jats:p>A retrospective analysis was conducted on 84 patients with ONFH and a confirmed history of COVID-19. Baseline characteristics were collected, and patients were categorized into the following groups for comparative analysis: (1) vaccinated vs. unvaccinated, (2) unilateral vs. bilateral ONFH, (3) dexamethasone (DEX) and methylprednisolone (MPS) vs. DEX therapy, and (4) Association Research Circulation Osseus (ARCO) stage 2 vs. stage 3. Group differences and associations were analyzed.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>The DEX and MPS-treated group had a greater extent of COVID-19 lung involvement compared to the DEX-treated group (60% vs. 30%, <jats:italic>p<\/jats:italic>\u2009=\u20090.002), as well as longer hospital stays in both general ward (14.2 days vs. 10.6 days, <jats:italic>p<\/jats:italic>\u2009=\u20090.018) and ICU (5.5 days vs. 2 days, <jats:italic>p<\/jats:italic>\u2009=\u20090.020). The DEX and MPS-treated group also had a longer duration of steroid therapy (19.3 days vs. 12.3 days, <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001) and received higher DEX-equivalent cumulative steroid doses (380\u00a0mg vs. 125 mg, <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001). Notably, ONFH symptoms developed earlier in the DEX and MPS-treated group compared to the DEX-treated group (7.5 months vs. 12 months, <jats:italic>p<\/jats:italic>\u2009=\u20090.004). Multivariable logistic regression analysis identified cumulative steroid dose as the sole predictor of ONFH severity (OR: 1.015, 95% CI: 1.001\u20131.028, <jats:italic>p<\/jats:italic>\u2009=\u20090.032), with ARCO stage 3 patients receiving higher cumulative steroid doses than stage 2 patients (240\u00a0mg vs. 126 mg, <jats:italic>p<\/jats:italic>\u2009=\u20090.018).<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions<\/jats:title>\n            <jats:p>Our study demonstrated that cumulative steroid dose is the primary determinant of ONFH severity in post-COVID-19 patients. Additionally, combined use of corticosteroids may accelerate the onset of ONFH, highlighting the need for cautious steroid management in COVID-19 patients.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1186\/s13018-025-05657-8","type":"journal-article","created":{"date-parts":[[2025,4,10]],"date-time":"2025-04-10T00:16:43Z","timestamp":1744244203000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Osteonecrosis of the femoral head in post-COVID-19 patients: a retrospective comparative study"],"prefix":"10.1186","volume":"20","author":[{"given":"Jichang","family":"Seong","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abduaziz","family":"Babakulov","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Saodat","family":"Asilova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Babamukhamedova","family":"Shakhnoza","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Makhmudova","family":"Nodira","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akbarjon","family":"Mirzayev","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,4,10]]},"reference":[{"issue":"1","key":"5657_CR1","doi-asserted-by":"publisher","first-page":"157","DOI":"10.23750\/abm.v91i1.9397","volume":"91","author":"D Cucinotta","year":"2020","unstructured":"Cucinotta D, Vanelli M. 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