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How can high doses of corticosteroids contribute to osteonecrosis?

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bone disease Defect of tibia, caused by septic osteomyelitis in childhood, with compensatory thickening of the fibula (right). Normal bones are shown at left.

High doses of corticosteroids, such as glucocorticoids, are strongly linked to an increased risk of osteonecrosis, a condition characterized by the death of bone tissue due to a compromised blood supply. While the exact mechanisms are complex, researchers have identified several ways these hormones may contribute to the disease:12

Formation of Fat Emboli: High doses of steroids can lead to hyperlipidemia, or elevated lipid levels in the blood. This may result in the formation of fat emboli that block the small arteries supplying the bone.2
Blood Vessel Changes: Steroids can induce changes in the venous endothelial cells—the cells lining the blood vessels. These changes can cause blood stasis and increase pressure within the bone, eventually leading to tissue death.2
Oxidative Damage: The use of these hormones has also been associated with oxidative damage within the bone tissue itself.2

Patients undergoing prolonged courses of high-dose steroid therapy are at the highest risk, whereas short-term use, such as pulse-dosing or joint injections, rarely leads to this condition.2