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Murugesan L, Sivakumar N, Ramamoorthy L, Farooq U. COVID-19-Associated Bilateral Avascular Necrosis of Femoral Head in a Young Male Without Corticosteroid Exposure: A Case Report. Cureus 2024; 16:e57525. [PMID: 38707109 PMCID: PMC11067823 DOI: 10.7759/cureus.57525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/07/2024] Open
Abstract
Avascular necrosis (AVN), also known as osteonecrosis, ischemic bone necrosis, or aseptic necrosis, is a progressive bone disease marked by the deterioration of bone tissue due to compromised blood flow in the subchondral region. AVN is typically caused by disruptions in vascular supply, intravascular blockages, or pressure on blood vessels, leading to diminished circulation. This condition predominantly affects the long-bone epiphysis in weight-bearing joints, particularly impacting the femoral head. The ongoing global health challenge posed by the novel coronavirus disease (COVID-19) has raised awareness of its diverse clinical manifestations. While pulmonary dysfunction remains a hallmark, reports of AVN of the hip have emerged in association with COVID-19 infection. Despite existing literature documenting cases of unilateral and bilateral femoral head necrosis associated with COVID-19 infection, it is noteworthy that corticosteroid use has been identified as a significant contributing factor to the development of this condition. Here, we present a case of bilateral AVN of the femoral head in a young individual linked solely to COVID-19 infection. Existing case records show only a handful of instances where COVID-19 has led to avascular necrosis, all involving either older individuals or those with notable risk factors. What sets our case apart is that the patient is young and lacks any significant risk factors. This report aims to propose a credible connection between COVID-19 infection and femoral head osteonecrosis in young patients not exposed to steroid treatment.
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Affiliation(s)
| | | | | | - Umar Farooq
- Internal Medicine, Knights Medical Associates, Bensalem, USA
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Hassan AAA, Khalifa AA. Femoral head avascular necrosis in COVID-19 survivors: a systematic review. Rheumatol Int 2023; 43:1583-1595. [PMID: 37338665 PMCID: PMC10348993 DOI: 10.1007/s00296-023-05373-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023]
Abstract
The current systematic review aimed to document published cases of femoral head avascular necrosis (FHAVN) post-COVID-19, to report the COVID-19 disease characteristics and management patients received, and to evaluate how the FHAVN were diagnosed and treated among various reports. A systematic literature review was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines through a comprehensive English literature search on January 2023 through four databases (Embase, PubMed, Cochrane Library, and Scopus), including studies reporting on FHAVN post-COVID-19. Fourteen articles were included, ten (71.4%) were case reports, and four (28.6%) case series reported on 104 patients having a mean age of 42.2 ± 11.7 (14:74) years, in which 182 hip joints were affected. In 13 reports, corticosteroids were used during the COVID-19 management plan for a mean of 24.8 ± 11 (7:42) days, with a mean prednisolone equivalent dose of 1238.5 ± 492.8 (100:3520) mg. A mean of 142.1 ± 107.6 (7:459) days passed between COVID-19 diagnosis and FHAVN detection, and most of the hips were stage II (70.1%), and concomitant septic arthritis was present in eight (4.4%) hips. Most hips (147, 80.8%) were treated non-surgically, of which 143 (78.6%) hips received medical treatment, while 35 (19.2%) hips were surgically managed, 16 (8.8%) core decompression, 13 (7.1%) primary THA, five (2.7%) staged THA and three (1.6%) had first stage THA (debridement and application of antibiotic-loaded cement spacer). The outcomes were acceptable as regards hip function and pain relief. Femoral head avascular necrosis post-COVID-19 infection is a real concern, primarily attributed to corticosteroid usage, besides other factors. Early suspicion and detection are mandatory, as conservative management lines are effective during early stages with acceptable outcomes. However, surgical intervention was required for progressive collapse or patients presented in the late stage.
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Affiliation(s)
| | - Ahmed A. Khalifa
- Orthopedic Department, Qena Faculty of Medicine, South Valley University, Kilo 6 Qena-Safaga Highway, Qena, Egypt
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Sinha PR, Mallick N, Sahu RL. Avascular Necrosis of the Hip after the COVID-19 Pandemic. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2023; 15:S661-S664. [PMID: 37654323 PMCID: PMC10466589 DOI: 10.4103/jpbs.jpbs_87_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 09/02/2023] Open
Abstract
Background and Objectives It is clear that COVID-19 can have a wide range of effects on the body, and the musculoskeletal system is no exception. Studies are ongoing to better understand how the virus may impact the hip bone and joint tissue. However, it is known that COVID-19 can cause inflammation and damage to various parts of the body, including the bones and joints, which could lead to pain, stiffness, and other symptoms. Materials and Methods A retrospective analysis is done with ten patients admitted to the hospital due to COVID-19 and later complained of hip pain. Magnetic resonance imaging (MRI) was performed on the patients, and it was found that they had degenerative changes characterized by avascular necrosis (AVN) of the head of the femur. One of the patients had a history of previous surgery on the femur with a plate and screws and was doing well but developed AVN after contracting COVID-19. Results Observation among these groups shows a strong association between the history of COVID-19, high levels of IgG antibodies, the presence of joint abnormalities, and moderately severe symptoms. There is no evidence of identifying autoimmune, degenerative, or AVN diseases. This set of patients responded positively to supportive therapy and anti-inflammatory drugs used in empirical treatment, which subsided joint pain and acute inflammatory symptoms. Conclusions It has been determined that there are significant musculoskeletal complications in COVID-19 patients, including AVN, which may be caused by the high use of steroids and microembolism leading to bone necrosis. Therefore, further studies and long-term follow-up are recommended.
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Affiliation(s)
- Priti R. Sinha
- Department of Orthopaedics, GS Medical College and Hospital, Pilkhuwa, Hapur, Uttar Pradesh, India
| | - Nitin Mallick
- Department of Orthopaedics, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
| | - Ramjee L. Sahu
- Department of Orthopaedics, Saraswati Institute of Medical Sciences, Pilkhuwa, Hapur, Uttar Pradesh, India
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Sidiropoulos K, Christofilos SI, Tsikopoulos K, Kitridis D, Drago L, Meroni G, Romanò CL, Kavarthapu V. Viral infections in orthopedics: A systematic review and classification proposal. World J Orthop 2022; 13:1015-1028. [PMID: 36439372 PMCID: PMC9685635 DOI: 10.5312/wjo.v13.i11.1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/01/2021] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although the impact of microbial infections on orthopedic clinical outcomes is well recognized, the influence of viral infections on the musculoskeletal system might have been underestimated.
AIM To systematically review the available evidence on risk factors and musculoskeletal manifestations following viral infections and to propose a pertinent classification scheme.
METHODS We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), the Reference Citation Analysis (RCA), and Scopus for completed studies published before January 30, 2021, to evaluate risk factors and bone and joint manifestations of viral infection in animal models and patient registries. Quality assessment was performed using SYRCLE's risk of bias tool for animal studies, Moga score for case series, Wylde score for registry studies, and Newcastle-Ottawa Scale for case-control studies.
RESULTS Six human and four animal studies were eligible for inclusion in the qualitative synthesis. Hepatitis C virus was implicated in several peri- and post-operative complications in patients without cirrhosis after major orthopedic surgery. Herpes virus may affect the integrity of lumbar discs, whereas Ross River and Chikungunya viruses provoke viral arthritis and bone loss.
CONCLUSION Evidence of moderate strength suggested that viruses can cause moderate to severe arthritis and osteitis. Risk factors such as pre-existing rheumatologic disease contributed to higher disease severity and duration of symptoms. Therefore, based on our literature search, the proposed clinical and pathogenetic classification scheme is as follows: (1) Viral infections of bone or joint; (2) Active bone and joint inflammatory diseases secondary to viral infections in other organs or tissues; and (3) Viral infection as a risk factor for post-surgical bacterial infection.
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Affiliation(s)
| | - Savvas Ilias Christofilos
- Department of Genetics, Evolution and Environment, University College London, London WC1E 6BT, United Kingdom
| | | | - Dimitrios Kitridis
- the First Department of Orthopaedics, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Lorenzo Drago
- Department of Biomedical Sciences for Health and Microbiome, University of Milan, Milan 20133, Italy
| | - Gabriele Meroni
- Department of Biomedical, Surgical, and Dental Sciences, One Health Unit, University of Milan, Milan 20133, Italy
| | - Carlo Luca Romanò
- Gruppo di Studio SIOT Infezioni-Clinica San Gaudenzio-Novara-Gruppo Policlinico di Monza, University of Milan, Milan 20100, Italy
| | - Venu Kavarthapu
- Trauma, and Orthopaedics, Kings College Hospital London, Denmark Hill, London SE59RS, United Kingdom
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Shetty GM. Double Trouble-COVID-19 and the Widespread Use of Corticosteroids: Are We Staring at an Osteonecrosis Epidemic? Indian J Orthop 2022; 56:226-236. [PMID: 34720174 PMCID: PMC8547122 DOI: 10.1007/s43465-021-00546-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/10/2021] [Indexed: 02/04/2023]
Abstract
Background A combination of immune-mediated vascular damage and routine use of systemic corticosteroid (CS) therapy in COVID-19 may significantly increase the risk and burden of osteonecrosis (ON) after COVID-19. This narrative review explores the pathogenesis, risk factors, and possible preventive and early treatment measures for ON in COVID-19. Methods For this narrative review, an extensive literature search was performed using the PubMed, Medline, and Science Direct databases from January 2000 to August 2021 for relevant articles on etiopathogenesis, epidemiology, clinical manifestations, and treatment of severe acute respiratory syndrome coronavirus (SARS-CoV) infection and steroid-induced ON (SION). Results Pathogenesis of COVID-19, utility of corticosteroids in the treatment of COVID-19, pathogenesis of SION vis-a-vis SARS-CoV infection, associated risk factors, and early diagnosis and treatment of ON following CS therapy of SARS-CoV infection were discussed. Conclusion Preliminary data of COVID-19 and similar trends from the SARS 2003 epidemic indicate that the "angiocentric" pathogenesis of SARS-CoV-2 and treatment with high-dose CS may increase the risk of ON in COVID-19 patients. Risk stratification based on CS intake during COVID-19 treatment can help identify subjects at moderate to high-risk for ON where early preventive and follow-up plans can be initiated.
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Affiliation(s)
- Gautam M. Shetty
- Knee and Orthopaedic Clinic, 407B, Galleria, Hiranandani Gardens, Powai, Mumbai, 400076 India
- AIMD Research, Mumbai, India
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Comment on "Decreases in pediatric fractures during the COVID‑19 pandemic-a nationwide epidemiological cohort study". Eur J Pediatr 2022; 181:3987-3988. [PMID: 36006467 PMCID: PMC9406269 DOI: 10.1007/s00431-022-04597-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 04/24/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022]
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Sulewski A, Sieroń D, Szyluk K, Dąbrowski M, Kubaszewski Ł, Lukoszek D, Christe A. Avascular Necrosis Bone Complication after Active COVID-19 Infection: Preliminary Results. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121311. [PMID: 34946256 PMCID: PMC8709043 DOI: 10.3390/medicina57121311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/16/2021] [Accepted: 11/26/2021] [Indexed: 12/22/2022]
Abstract
Background and objectives: The course of SARS-CoV-2 (COVID-19) is still under analysis. The majority of complications arising from the infection are related to the respiratory system. The adverse effect of the viral infection on bone and joint tissue has also been observed. Materials and Methods: We present a group of 10 patients with degeneration of large joints and adjacent epiphyses of long bones and the spine, with a background of bone infarctions and avascular necrosis (AVN) immediately after infection with the COVID-19 virus. In MR imaging, changes in the characteristics of AVN were documented. Results: Observation of this group showed a clear correlation among the history of COVID-19 disease in the patients, moderately severe symptoms, high levels of IgG antibodies, and the time of occurrence of joint changes. No other clinically significant complications were observed following COVID-19 infection in the study group. No other risk factors for AVN or autoimmune or degenerative diseases were found in the study group. The group of patients responded well to empirical treatment with steroids, which normalized acute inflammatory symptoms and pain in the joints. Conclusions: During coronavirus (COVID-19) infection, there are complications in the locomotor system, such as microembolism and the formation of AVN; hence, more research is needed.
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Affiliation(s)
- Adam Sulewski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61545 Poznan, Poland; (M.D.); (Ł.K.)
- Correspondence:
| | - Dominik Sieroń
- Division of Magnetic Resonance Imaging, Silesian Center for Heart Diseases, 41800 Zabrze, Poland;
| | - Karol Szyluk
- Department of Physiotherapy, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40752 Katowice, Poland;
- I Department of Orthopaedic and Trauma Surgery, District Hospital of Orthopaedics and Trauma Surgery, Bytomska 62 Str., 41940 Piekary Śląskie, Poland
| | - Mikołaj Dąbrowski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61545 Poznan, Poland; (M.D.); (Ł.K.)
| | - Łukasz Kubaszewski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61545 Poznan, Poland; (M.D.); (Ł.K.)
| | - Dawid Lukoszek
- Dawid Lukoszek Physiotherapy Osteopathy, 42690 Hanusek, Poland;
| | - Andreas Christe
- Department of Radiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland;
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Hasan LK, Deadwiler B, Haratian A, Bolia IK, Weber AE, Petrigliano FA. Effects of COVID-19 on the Musculoskeletal System: Clinician's Guide. Orthop Res Rev 2021; 13:141-150. [PMID: 34584465 PMCID: PMC8464590 DOI: 10.2147/orr.s321884] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/06/2021] [Indexed: 12/13/2022] Open
Abstract
The global pandemic caused by SARS-CoV-2, or COVID-19, continues to impact all facets of daily life. Clinical manifestations of COVID-19 commonly include musculoskeletal symptoms such as myalgias, arthralgias, and neuropathies/myopathies. The inflammatory response and its impact on the respiratory system have been the focus of most studies. However, the literature is more limited regarding the inflammatory response and its implications for other organ systems, specifically the musculoskeletal system. Previous studies have described how systemic inflammation may play a role in bone and joint pathology. Furthermore, it is important to understand the effects current therapeutics used in the treatment of COVID-19 may have on the musculoskeletal system. In this study, we will review the current understanding of the effect COVID-19 has on the musculoskeletal system, provide an overview of musculoskeletal symptoms of patients infected with the virus, and address key issues for clinicians to address during the care of COVID-19 patients.
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Affiliation(s)
- Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Brittney Deadwiler
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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