Corticosteroid induced avascular necrosis and COVID-19: The drug dilemma

Using Computed Tomography-Based Three-dimensional Modeling and Computer Navigation for Minimally Invasive Core Decompression and Adjuvant Orthobiologic Therapy of Femoral Head Avascular Necrosis

Avascular necrosis of the femoral head is a debilitating condition that can lead to femoral head collapse. Core decompression with adjuvant cellular therapies, such as bone marrow aspirate concentrate, delays disease progression and improves outcomes. However, inconsistent results in the literature may be due to limitations in surgical technique and difficulty in targeting the necrotic lesions. Here, we present a surgical technique utilizing computed tomography-based three-dimensional modeling and instrument tracking to guide the therapy to the center of the lesion. This method minimizes the number of attempts to reach the lesion and confirms the three-dimensional positioning of the instrumentation within the lesion. Our technique may improve the outcomes of core decompression and adjuvant therapy and prevent or delay hip collapse in patients with femoral head avascular necrosis.

Bilateral pericapsular end nerve blocks for steroid-induced avascular necrosis following COVID-19 infection requiring bilateral total hip replacement

BACKGROUND

Osteonecrosis or avascular necrosis (AVN) of the hip was one of the dreaded complications of coronavirus disease 2019 (COVID-19), which emerged in patients who received steroid therapy. Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients. Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous (IV) or oral dexamethasone, methylprednisolone or hydrocortisone. The use of such high doses of corticosteroids has shown very positive results and has been lifesaving in many cases. Still, long-term consequences were drug-induced diabetes, osteoporosis, Cushing syndrome, muscle wasting, peripheral fat mobilization, AVN, hirsutism, sleep disturbances and poor wound healing. A significant number of young patients were admitted for bilateral total hip replacements (THR) secondary to AVN following steroid use for COVID-19 treatment.

AIM

To assess the efficacy of bilateral pericapsular end nerve group (PENG) blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery.

METHODS

This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals, Hyderabad, India. Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months. All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia.

RESULTS

The duration of surgery was 2.5 h on average. Seventeen out of twenty patients (85%) had a Visual Analog Score (VAS) of less than 2 and did not require any supplementation. One patient was removed from the study, as he required re-exploration. The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug. Fifteen out of seventeen patients (88.2%) could be mobilized 12 h after the procedure.

CONCLUSION

Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19, which surfaced in patients who received steroid therapy requiring surgical intervention. Bilateral PENG block is an effective technique to provide post-operative analgesia resulting in early mobilization and enhanced recovery after surgery.

A Rare Case of Pulmonary Embolism, Deep Vein Thrombosis, Bilateral Avascular Necrosis of the Femoral Head, and Miscarriage following COVID-19 in a Patient with Multiple Genetic Coagulation Factor Deficiency-A Case Report

The coronavirus disease (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The most common symptoms of COVID-19 are respiratory symptoms, but some patients develop severe thrombotic complications. Studies have looked into the association between the disease severity in COVID-19 patients and polymorphisms in the genes encoding prothrombotic and cardiovascular risk factors. The presented rare case describes inflammatory and acute thrombotic complications with musculoskeletal involvement in a patient with combined coagulation genetic defects. A 37-year-old woman was hospitalized with a respiratory infection of coronavirus etiology complicated by pneumonia and pulmonary embolism and confirmed using computed tomography and elevated D-dimer. Sixteen days after discharge, she developed deep vein thrombosis after discontinuation of antiplatelet and anticoagulant therapy due to bleeding. Four months after infection, we found bilateral avascular necrosis of the femoral head. The patient had a miscarriage with considerable blood loss and was given genetic testing, which confirmed the presence of a combined defect with a risk of both thrombosis and bleeding-heterozygous for the Leiden G1691A mutation, homozygous for the 677C>T mutation (MTHFR), heterozygous for the Val34Leu (factor XIII) mutation, and 4G/5G polymorphism in the promoter of the plasminogen activator inhibitor 1 (PAI-1) genes. The described rare clinical case poses a serious challenge regarding the anticoagulant and antiplatelet therapy, especially in the presence of thrombotic complications in COVID-19 and the underlying genetic defect associated with a risk of bleeding, including life-threatening intracranial bleeding. More research is needed to better understand the major medical concern about antithrombotic treatment in COVID-19 patients with bleeding risk in the context of genetic coagulation disorders. The case raises the vigilance of clinicians to search for a genetic predisposition to the development of severe thrombotic events in COVID-19 patients with no other known underlying diseases.

Avascular Necrosis as a Sequela of COVID-19: A Case Series

Avascular necrosis (AVN) is a degenerative bone condition characterized by cellular death and bone collapse from compromised subchondral blood circulation. AVN begins with vascular interruption, hypertension, intravascular occlusion, or extravascular compression which reduces bone circulation. Although corticosteroids are frequently used to treat acute COVID-19 infections, patients are prone to its side effects, particularly AVN. Furthermore, COVID-19 produces coagulopathies, specifically hypercoagulability, that may contribute to venous thrombosis, which may serve as the impetus of AVN. While the literature discussing COVID-19, AVN, and corticosteroid use is not conclusive, patients being treated with corticosteroids for COVID-19 are at an increased risk for AVN possibly due to the combination of COVID-19 infection and corticosteroid use, or the use of high-dose steroids alone. The purpose of this case series is to elucidate AVN as a long-term sequalae of COVID-19, describe our management of COVID-19 and steroid-induced AVN, and discuss the current literature regarding AVN and COVID-19. Three patients hospitalized for COVID-19 infections were treated with corticosteroids and subsequently developed AVN. All patients, but one, had multiple sites of infarction and were treated with core decompression in the hip where there was no collapse of the subchondral bone. One of these patients had multiple infarcts in bilateral femoral heads, femoral shafts, and knees. This patient had a history of end-stage renal disease, and, therefore, total knee replacement was postponed until medical clearance. Core decompression was performed on the femoral head that showed no collapse to delay osteoarthritis of the hip. Multiple articles in the current literature support the idea that the combination of COVID-19 and corticosteroid use increases the risk of AVN and reduces the onset of COVID-19-related respiratory symptoms. The patient cases discussed in this case series suggest a possible association between COVID-19, corticosteroid use, and AVN.

The Art of the Editorial

Many traditional scientific journals carry an editorial at the start of each issue or perhaps in most issues.  The more recently established online journals seemed to have discontinued this tradition, for example there is no editorial in Sociological Research Online or many of the online journals in the BMC stable, such as BMC Pregnancy & Childbirth or BMC Public Health. Over the past two decades we have published close to fifty editorials between us.  We would like to highlight some of their specific features to offer advice and encouragement to would-be editorial writers, and, more generally, promote the writing and publishing of editorials.  This paper includes an overview of the eight most recent editorials, all focusing on the hot topic of COVID-19, published in this scientific journal.