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Explained: Why AIIMS wants a pan-India study on post-Covid cases of Avascular Necrosis

Many patients are being diagnosed with the long post-Covid complications of Avascular Necrosis (AVN), referred to as bone death. What is it, and why are patients developing it? What are the symptoms? Why does AIIMS want to do a multicentric study?

Written by Rupsa Chakraborty , Edited by Explained Desk | Mumbai |
Updated: January 30, 2022 12:58:20 pm
A healthworker collects swab sample for Covid-19 test at Old Delhi Ajmeri Gate  in New Delhi, Thursday.  (Express Photo By Amit Mehra)

The health woes of the patients infected with Covid-19 in the second wave still continues as many are being diagnosed with the long post-Covid complications of Avascular Necrosis (AVN), referred to as bone death. To find a clinical explanation, All India Institute of Medical Sciences (AIIMS) has submitted a proposal to the Indian Council of Medical Research (ICMR) seeking approval for a multicentric study to probe cases of AVN among Covid-19 recovered patients.

What is AVN or bone death?

The AVN is not a new ailment. Before Covid, this case was found due to smoking, alcoholism, and steroid use linked to other conditions. AVN, or Osteonecrosis, is a common cause of painful hips in youngsters. It occurs due to the restricted blood supply to the bone, resulting in loss of its density and weight-bearing capacity. As the bone breaks into small pieces, the patient suffers unbearable pain and loses mobility completely. Hip bones are more prone to this.

Why are the Covid-19 recovered patients developing AVN?

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AIIMS has detected AVN among 50 Covid-19 recovered patients. Of this, five underwent hip replacement surgeries. At Mumbai’s Nanavati Hospital, ten such patients have undergone hip replacements after recovering from Covid-19. Major private hospitals in states like Maharashtra, Delhi, Karnataka and Kerala that recorded a high caseload of Covid-19 last year, have reported an average of 10 such cases so far.

In the second wave, due to the Delta variants, the infection among patients was severe. Patients developed acute pneumonia requiring heavy doses of steroids as a life-saving drug. Excessive and prolonged use of steroids to treat Covid-19 contributes in suppressing immunity when used for patients with low oxygen levels. As seen in AIIMS, out of the 50 patients, 12 didn’t get steroids. So, intravascular blood clots among Covid-19 patients also lead to the death of the femoral head.

“Primarily, there are two causes of AVN among such patients. It could be because of excessive use of steroids during Covid-19 treatment or the inherent ability of Covid-19 to cause blood clots which disrupts the blood flow,”said Dr Pradeep Bhosale, Director – Arthritis and Joint Replacement Surgery at Nanavati Hospital, Mumbai.

As per doctors, if blood supply to the heart decreases, the patient can get a heart attack. An avascularity in the brain can cause a stroke. When this happens to a bone, it becomes soft and collapses. It may also affect the shoulder, knee, hand and foot.

Dr Vijay Mohan, orthopedic and joint replacement surgeon and the present chairman of the academic forum of Kerala Orthopaedic Association, said, “It takes months for Covid recovered patients to develop the symptoms of AVN. Maybe after a year, with more studies, we would get a clinical explanation behind it.”

In May 2021, Hinduja Hospital, Mahim, Mumbai published a research paper— ‘Avascular necrosis as a part of ‘long COVID-19’ with only three case studies. One of the main findings was that patients generally take six months to a year to develop AVN post steroid exposure. But the studied patients were ‘symptomatic and developed early AVN presentation at a mean of 58 days after Covid-19 diagnosis.’

Did steroids administered among patients cause other post-Covid complications?

During the second wave, a large number of Covid-19 patients developed mucormycosis or ‘black fungus’ that causes blindness, organ dysfunction, loss of body tissue, and even death.

Mucormycosis is caused by a group of moulds called mucormycetes which live in the environment. The infection causes death of tissues due to inadequate blood supply to the affected area. Doctors attributed this to the unregulated usage of steroids that compromise immunity, especially among patients with diabetes. AIIMS director Dr Randeep Guleria had advised that overuse of steroids should be controlled since a weakened immune system is a major cause behind the fungal infection.

Why does AIIMS want to do a multicentric study?

Raising the need for a pan-India study on AVN among Covid-19 recovered, Dr Rajesh Malhotra, the head of the orthopaedics department and chief of trauma centre at AIIMS, has submitted a proposal to conduct a multicentric study in India including cases from Delhi, Maharashtra, Karnataka and Kerala that reported high Covid-19 caseload.

“We have to understand if the steroids that were given to these patients were too early or late; duration of their treatment on steroids and the amount of doses that were given. Also, how much is too much for such patients,” said Dr Malhotra. “We need to study the clinical parameters, risk factors and prognostic factors. Region-wise, the data may differ, so we want to conduct a multiple-centric study,” he added.

Dr Malhotra would raise the need for a pan-India-based study during the discussion of their proposal with ICMR. “If ICMR likes our proposal for a grant, they may recruit centres across India as per the protocols to be part of the study,” he said.

However, such a study would be difficult to conduct. “Unlike the western countries, where all the statistics are maintained centrally, in India, such data is not available. For post-Covid complications, patients go to different hospitals, so gathering such data for a wide study would be challenging,” said Dr Narayan Hulse, director, orthopaedic and joint replacement surgery, Fortis Hospital, Bangalore. Dr Hulse treated four such patients, the last one was diagnosed in December, 2021.

What are the symptoms of AVN?

A patient with AVN develops pain around the hip, joints and the movements get restricted. “The patients find it difficult to walk and may start limping. Also, they will exhibit pain around the knee and lower back,” said Dr Hulse.

How can avascular necrosis be diagnosed or treated?

Generally, a Covid-19 recovered patient experiences AVN symptoms after 4-5 months. It can be diagnosed with an MRI.

Not all patients with AVN need to undergo hip replacement surgeries — out of the 50 diagnosed patients in AIIMS, only five of them underwent the surgery. “We always try to preserve the joint and provide treatment if the disease hasn’t progressed,” said Dr Malhotra. When the disease progresses in the first or second stage, core decompression surgeries are conducted. When it reaches the third and fourth stages, then joint replacement surgeries are done.

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