What is avascular necrosis, a post-Covid-19 complication that has ‘astounded the medical community’?

What causes avascular necrosis?

While one of the reasons is loss of blood supply, others are mostly due to steroids, alcohol, and sickle cell disease. “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. AVN can also be caused by traumatic events such as a fracture, dislocation of joints, or during cancer treatment due to exposure to radiation. Although the exact reason is still unknown, there is a possible chance that medicines taken during Covid-19 treatment could have reduced blood flow in the body,” Dr Kapoor told indianexpress.com.

The patient will complain of pain around the hip or the groin region (Source: Getty Images/Thinkstock)

Risk factors for avascular necrosis

– Severe trauma-induced bone damage
– Fractures
– Blood vessels have been harmed
– Long-term corticosteroid usage
– Sickle cell disease
– Pancreatitis or inflammation of the pancreas
– Both radiation and chemotherapy
– Autoimmune conditions
– HIV
– Hyperlipidaemia or high cholesterol where there is an excess of lipids or fats in the blood

Identifying avascular necrosis with symptoms

The patient will complain of pain around the hip or the groin region. It could make it very difficult to walk which could lead to limping, Dr Kapoor mentioned.

Steroid-induced AVN can start occurring anytime from three weeks to three months, said Dr Laxman Jessani, consultant, infectious disease, Apollo Hospitals Navi Mumbai. Dr Deshpande mentioned that while only a few cases of bone mortality have been documented in India so far, “physicians are worried that this number may increase given that it can take between three months and a year for patients recuperating from coronavirus to develop AVN”.

A 2021- BMJ case report also noted that “post Covid-19, there is a greater propensity to develop AVN, mainly if the patient has been on steroids”. “The literature suggests the mean dose of steroid in prednisone equivalents of 2000 mg is required to cause AVN, but we feel that due to the Covid-19 virus, the sensitivity to develop AVN is higher and to a smaller cumulative dose of steroids,” it reads.

Diagnosis and treatment of avascular necrosis

Prompt diagnosis ensures timely treatment. “Hence, periodic MRI scans for possible AVN of the hip in patients with long covid are advised,” Dr Jessani told indianexpress.com.

The diagnosis is made on clinical examination, and finally on an MRI basis by knowing the extent of AVN. Commonly used FICAT And ARLET classifications are the ones used to classify the disease.

“If you diagnose AVN early, it can be treated but if it is diagnosed at a later stage, the person may have to undergo joint replacement surgery. Hence, MRI is very important to identify the disease,” Dr Kapoor said. Agreed Dr Jessani and said that if AVN is left untreated, the hip would be permanently damaged as the disorder is irreversible and would require surgical intervention.

Doctors, when dealing with patients who have long-lasting Covid symptoms, in particular, will advise taking medicine and engaging in physiotherapy for at least six weeks to ease the pain, Dr Deshpande noted. “Patients may need to take anti-inflammatory medications such as statins if they have excessive cholesterol levels and fatty deposits blocking their blood vessels, and blood thinners,” he said.

The sole alternative in cases of the advanced stage is surgery. Core decompression of the bone, bone contouring, bone transplantation, and joint replacement are surgical possibilities. According to Dr Kapoor, the management may involve core decompression to muscle pedicle or hip replacement. Even one contouring and bone transplantation are other surgical possibilities, Dr Deshpande said.

Prevention of avascular necrosis

AVN can be prevented by avoiding spurious medications wherein the probability of steroids mixing is high, Dr Jessani said.

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