COVID-19 may itself contribute to development of aggressive Post-COVID osteonecrosis in addition to steroids use

COVID-19 infection can cause long-term effects, cumulatively known as long COVID syndrome. One such sequela is osteonecrosis of the femoral head (also called avascular necrosis of the femoral head, or AVNFH). On the basis of 20-year experience in using bisphosphonate therapy in the successful management of osteonecrosis, Sanjay Agarwala et al conducted a study to evaluate the efficacy of the therapy in the management of post-COVID osteonecrosis of the femoral head.

Investigation performed at the Department of Orthopedics, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, India. The study has been published in “JBJS Open Access.”

The authors conducted a retrospective evaluation of 48 patients (88 hips) diagnosed with osteonecrosis of the femoral head at a tertiary care center after COVID-19 infection. Patients received intravenous zoledronic acid (5 mg) at the initiation of therapy and oral alendronate (35 mg) twice weekly, and were followed for a minimum of 6 months. Clinical evaluation was conducted using a visual analog scale (VAS) for pain and the Harris hip score (HHS). Radiographic evaluation was performed to assess the progression of the disease and collapse of the femoral head.

Key findings of the study were:

• At a mean follow-up of 10 months, 84 (95.5%) of the hips showed good clinical outcomes, and only 4 (4.5%) of the hips required surgical intervention.

• Clinical failure necessitating total hip arthroplasty occurred in 2 (3%) of the 66 stage-II hips and in 2 (22%) of the 9 stage-III hips.

• The mean VAS pain score and HHS improved at 6 weeks and steadily improved on subsequent follow-ups.

• In 16 (18%) of the 88 affected hips, radiographic progression was observed.

• The mean dose of corticosteroids administered to the patients to manage COVID-19 infection was 841.3 mg of prednisolone equivalents.

• The mean duration between the commencement of corticosteroid therapy and the development of osteonecrosis was 179 days.

The authors concluded that – “In symptomatic patients, post-COVID osteonecrosis of the hip can be diagnosed early by MRI and treated successfully by medical means, avoiding surgical intervention. Our findings suggest that post-COVID osteonecrosis may have a more aggressive course and presents earlier compared with other etiologies of osteonecrosis reported in the literature. COVID-19 infection and the use of corticosteroids to treat it could contribute to the aggressive nature and presentation of osteonecrosis. The combination of intravenous ZA and oral alendronate provides early pain relief and halts the clinicoradiographic progression of osteonecrosis. The 4 hips in the present study that required surgical management presented very early after COVID infection but progressed rapidly. While the world focuses on the pernicious aspect of this viral infection, we seek to bring relief to the survivors facing its long-term effects in the hip. On the basis of our findings, we believe that the described medical regimen is the best way to treat this debilitating condition of post-COVID osteonecrosis.”

Further reading:

Bisphosphonates for Post-COVID Osteonecrosis of the Femoral Head Medical Management of a Surgical Condition

Sanjay Agarwala, Mayank Vijayvargiya et al

JBJS Open Access 2022:e22.00060

DOI: 10.2106/JBJS.OA.22.00060