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Rise in Avascular Necrosis cases among people who had Covid, say Pune doctors
Increased use of steroids among patients to reduce the severity of infection as life-saving measures is likely to be the reason behind the trend
Many doctors treated multiple complications in recovered patients during the Covid-19 pandemic, including mucormycosis, blood clots, chronic fatigue and new-onset diabetes, among others. However, city doctors now report an increase in Avascular necrosis (AVN) or osteonecrosis cases.
Increased use of steroids among patients to reduce the severity of infection as life-saving measures is likely to be the reason behind the trend, said city doctors.
AVN of the femoral head or AVN hip joint is one of the important aetiologies of arthritis of the hip. Avascular necrosis is the death of bone tissue due to a lack of blood supply and it most commonly affects the femur (thigh bone) and damages one of the most important weight-bearing joints in the body. This condition is described as the death of the bone tissue when the blood supply doesn’t reach the hip joint. AVN can be caused by traumatic events such as a fracture, dislocation of joints or during cancer treatment due to radiation exposure. Alcohol or steroid abuse is also a major risk factor.
Shankar Jadhav, 52-year-old, who was infected with Covid in January last year, developed pain in the back and groin areas after four months. “I took the issue lightly and took some temporary medicines but it didn’t work. The pain aggravated and by the time the actual problem was diagnosed, it was late. When I went to the hospital during the MRI test the doctors revealed AVN. The problem was severe so I underwent a hip replacement earlier this year,” he said.
According to Dr Neeraj Adkar, robotic orthopaedic surgeon, Sai Shree Hospital, during the last six months around 150 to 170 people have undergone hip replacement at his hospital due to AVN and out of them a significant number of patients were earlier infected with Covid.
“We don’t recommend hip replacement and try to manage patients with medical management. But if the patient comes late and it is a delayed presentation in such a situation the AVN is already in grade IV. The blood supply to the femoral head is cut off in individuals on steroids and this leads to the death of cells causing AVN. In early stages like grade I, grade II or grade III the disease can be managed with the help of medicines and adjuvant therapy,” said, Dr Adkar.
In grades I and II we do core decompression, a surgical procedure that involves surgical drilling into the area of dead bone near the joint, according to Adkar. “This reduces pressure, allows increased blood flow, and slows or stops bone or joint destruction,” he added.
Other orthopaedic surgeons and experts informed that Covid-19 patients’ post-recovery are facing this problem, and have warned against excessive use of steroids. Another reason is that since the clotting tendency of the body generally increases due to Covid, the blood supply to some areas stops in some patients who have also taken steroids. Not all patients on steroids will develop AVN as it occurs in only those who are sensitive to certain steroids or those who have a predilection for developing AVN.
Dr Kailash Patil, arthroscopy and joint replacement surgeon at Sancheti Hospital, stated there is a significant rise in the number of patients coming with AVN, majorly the surge is due to steroids used during their treatment in the pandemic.
“The steroids were given as a life-saving drug but unfortunately this led to AVN in them. The patients with existing stage I or stage II AVN are coming with stage III and stage IV AVN. Along with this, there are new patients of AVN coming with a history of Covid-19. The patient will complain of pain around the hip or the groin region. Many claim their condition to be difficult, unable to walk and start limping due to the diseases,” Patil said.
According to Patil, in the earlier stage I and II the patient is managed on medicines and in the later stage surgery is the option depending on the presentation of the patient.
Vatsala Dandge, 48-year another recovered Covid-19 patient maintained that she suddenly developed pain in the left hip joint in August last year. “Initially I thought that it was a simple joint pain but it did not subside even after a couple of months. When contacted an orthopaedic surgeon I was advised an X-Ray test. As there was nothing in the X-Ray, I was given medications, pain killers and muscle relaxers. Even after two months, it was of no help. Finally, an MRI was done post and I was diagnosed with bone death. Doctors said it was too late and I had to undergo hip replacement,” she said.
Dr Shrikrushna Joshi, medical director of Lokmanya Group of Hospitals, said during Covid-19, patients were administered steroids along with other medicines during treatment and this has led to a spike in the number of AVN cases.
“In the past six months at our hospitals, we have done hip replacement of 400 to 500 patients. Almost all of them had Covid-19 history. This was due to the use of steroids they developed AVN. We have even got patients of age between 30 to 35 years with AVN grade III,” he said.
Dr Joshi, further, said in almost 80% of the cases the patients come with a condition wherein they require hip replacement. “The pain develops in grade III and surgery is required in grade IV. The condition is progressing and the condition of the patient continues to worsen with increased symptoms and pain. One can require surgery in grade III if the movement is compromised and the hip ball is damaged,” he said.
