|
 
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| CASE SERIES |
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| Year : 2023 | Volume
: 11
| Issue : 1 | Page : 98-101 |
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Avascular necrosis of hip joints in post-COVID-19 patients: A case series
Santosh Karpur1, Nagaraju Baja1, Pruthvi Malikireddy2, Deepthi Pokuri1
1 Department of Radiodiagnosis, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana, India
2 Department of Radiodiagnosis, Malla Reddy Medical College for Women, Hyderabad, Telangana, India
| Date of Submission | 05-Sep-2022 |
| Date of Decision | 03-Nov-2022 |
| Date of Acceptance | 07-Nov-2022 |
| Date of Web Publication | 02-Feb-2023 |
Correspondence Address:
Santosh Karpur
Department of Radiodiagnosis, Malla Reddy Institute of Medical Sciences, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/mjhs.mjhs_97_22
Risk of bone necrosis is increased in patients with COVID-19 due to hypercoagulability. The hypercoagulability is caused by gene encoding for pro-inflammatory proteins which is due to single nucleotide polymorphism. All these mechanisms namely aggregation of leukocytes, hypercoagulability, and inflammation of the vessels can lead to reduced blood supply to the bone. This can ultimately lead to necrosis of the bone. The present case series of 20 cases attempts to study the avascular necrosis (AVN) of hip joint in patients with COVID-19. A history related to AVN was recorded. The patient was screened with plain radiographs of the affected joint. Magnetic resonance imaging (MRI) examination of Hip joint was done on the same day as plain radiograph. The Modified Ficat classification system for MRI was used for staging AVN of the femoral head. The mean interval between the onset of initial symptoms and MRI was 2–4 weeks. Majority of the patients were diagnosed as Stage I (45%). Males were affected more than females, i.e., 70% versus 30%. Fever and hip pain were the most common presenting symptoms. We conclude from the present case series that COVID-19 may be associated with AVN of hip joint as all post-COVID cases had AVN. Hence, all patients who recovered from COVID-19 should be screened for AVN for early diagnosis and prompt treatment.
Keywords: Avascular bone necrosis, consequences, COVID-19, fever, hip joint
How to cite this article:
Karpur S, Baja N, Malikireddy P, Pokuri D. Avascular necrosis of hip joints in post-COVID-19 patients: A case series. MRIMS J Health Sci 2023;11:98-101 |
How to cite this URL:
Karpur S, Baja N, Malikireddy P, Pokuri D. Avascular necrosis of hip joints in post-COVID-19 patients: A case series. MRIMS J Health Sci [serial online] 2023 [cited 2023 Mar 30];11:98-101. Available from: http://www.mrimsjournal.com/text.asp?2023/11/1/98/369047 |
| Introduction | |  |
The recovery rate of patients affected with COVID-19 is getting better over a period of time. However, in some patients, the symptoms continue to persists while some may experience long-term systemic effects.[1] There are many published literature on long-term consequences of COVID-19. They also included long-term effects of COVID-19 on the musculoskeletal system.[2]
The bone effect in patients with COVID-19 may be due to systemic inflammation.[1] COVID-19 induces the formation of the cytokines such as CXCL10, interleukin-17, and tumor necrosis factor-alpha. They cause reduced proliferation of the osteoblasts. There is also a reduction in the differentiation of the osteoblasts.[3]
The risk of bone necrosis is increased in patients with COVID-19 due to hypercoagulability. The hypercoagulability is caused by gene encoding for pro-inflammatory proteins which are due to single-nucleotide polymorphism. All these mechanisms namely aggregation of leucocytes, hypercoagulability, and inflammation of the vessels can lead to reduced blood supply to the bone. This can ultimately lead to necrosis of the bone.[4]
The present case series of 20 cases attempts to study the avascular necrosis (AVN) of hip joint in patients with COVID-19.
| Materials and Methods | | |
The present case series analysis was carried out at the Department of Radiodiagnosis, Malla Reddy Institute of Medical Sciences, Hyderabad, for 12 months from January 2021 to December 2022. A total of 20 patients were studied. Those with polymerase chain reaction indicating positive COVID-19 infection and hip joint pain during the disease were included. Those with prior injury to the affected hip joint, prior treatment with steroids, and severe chronic illnesses such as diabetes and hypertension were excluded from the study.
Institutional ethics committee permission was obtained. Written informed consent was taken from the study participants. The study included a group of 20 patients who developed symptoms of joint dysfunction, which were classified as avascular bone necrosis in COVID-19 on magnetic resonance imaging (MRI). History related to AVN was recorded. The patient was screened with plain radiographs of the affected joint. MRI examination of the hip joint was done on the same day as plain radiograph. MRI was performed using a 1.5 T Philips Prodiva CX. Established MRI criteria and staging systems were used for the diagnosis of AVN of the hip joint.
The Modified Ficat classification system[5] for MRI was used for staging AVN of the femoral head. It consists of four stages. In the stage called 0: the plain radiograph and the MRI are normal along with no positive symptoms. In Stage I: Plain radiograph is either normal or shows osteopenia, the MRI shows edema and patient complains of typical groin pain. In Stage II: There is pain and stiffness, MRI shows geographic defect and the plain radiograph shows mixed osteopenia and/or sclerosis and/or subchondral cysts but there is no subchondral lucency. In Stage III: In addition to pain and stiffness, the pain radiates to knee and hip while MRI picture is the same as Stage II and there is crescent sign in plain radiograph. In Stage IV: Plain radiograph shows end-stage with evidence of secondary degenerative change, MRI shows the same picture as plain radiograph and the patient complains of limping with pain.
Data were presented as proportions.
| Results | | |
Majority of the patients were diagnosed as Stage I (45%), i.e., early diagnosis was possible followed by 40% in Stage II. There were no patients with Stages 0 and IV [Table 1].
Males were affected more than females, i.e., 70% versus 30%. Fever and hip pain was the most common presenting symptoms. Forty percent had diabetes and 30% had hypertension [Table 2].
Here, we describe radiological MRI presentation of four cases. In the first case, there was evidence of hyperintensity noted in the right femoral head and neck extending up to inter-trochanteric region and in acetabulum. There was evidence of subtle irregularity of the right femoral head with minimal fluid in the right hip joint. The femoral head and neck was showing normal signal intensity on the left side. There were no signs of subchondral collapse of the femoral head and no signs of intra-capsular effusion on the left side. The peri-articular soft tissue was normal. Thus, there was radiological evidence of AVN of right hip. Second case was of bilateral AVN with FICAT and ARLET Stage II. On the right side, there was hyper-intense signal in femoral head extending to neck with contour abnormality in the head, with geographic areas of sclerosis. Neck of left femur showed focal marrow edema but there was no obvious contour abnormality. Rim sign and double line sign were not seen on the left side but were present on the right side. In the third cases, the diagnosis was Stage III bilateral AVN of hip. There was hyper-intensity, subtle irregularity, and minimal fluid on both sides, but there was no signs of subchondral collapse of head of femur, and peri-articular tissue was normal. Fourth case was also bilateral AVN of hip. Here, both femur heads were showing the geographic defects, signal was hyper-intense, presence of minimal fluid with other features were normal.
Plain radiograph of the right hip is showing subtle irregularity of right femoral head, marginal sclerosis of femoral head, and acetabular rim. No evidence of subluxation or dislocation of the hip joint. No evidence of subchondral cysts.no evidence of subchondral fractures[Figure 1]. | Figure 1: Plain radiograph of right hip showing subtle irregularity of right femoral head and marginal sclerosis of femoral head and acetabular rim
Click here to view |
Coronal T1 image is showing irregularity of femoral head. Linear hypointense lines noted. Adjacent hypointense areas noted, also along the acetabular margin suggest marrow edema. Rest of the femoral head shows normal signal intensity [Figure 2].
Coronal STIR images showing hyperintensity in the right femoral head and neck extending up to intertrochanteric region and acetabulum suggestive of marrow edema. No significant marginal irregularity seen. Minimal hip joint effusion noted. No evidence of subchondral collapse [Figure 3]. | Figure 3: Coronal STIR images showing hyperintensity in right femoral head and neck extending up to intertrochanteric region and acetabulum suggestive of marrow edema
Click here to view |
Coronal STIR images show minimal fluid in the right hip joint. Marrow edema was noted in the femoral head and acetabulum. Slightly irregular margins of femoral head noted. No collapse of femoral head seen [Figure 4].
Plain radiograph of both hip joints show sclerosis along the margins of both femoral heads and acetabulum. congruity of both acetabulum and femoral head maintained. Rest of the femoral bone and acetabulum appear normal represents FICAT and ARLET Stage II. Axial T1 images show geographic defects in the form of hypointense lines in both femoral heads. Few patchy hypointense areas noted represent marrow edema. Congruity of both acetabulum and femoral head maintained. Rest of the femoral bone and acetabulum appear normal represents FICAT and ARLET Stage II [Figure 5]. | Figure 5: (a and b) Plain radiography and MRI of the patient showing signal intensity changes in both femoral heads in geographical pattern, no collapse of femoral heads and congruity of both hip joints maintained, suggestive of FICAT and ARLET stage II osteonecrosis of both femoral heads. MRI: Magnetic resonance imaging
Click here to view |
| Discussion | | |
In the present case series, we found that the majority of the patients were diagnosed as stage I (45%), i.e., early diagnosis was possible followed by 40% in Stage II. There were no patients with stages 0 and IV. Males were affected more than females, i.e., 70% versus 30%. Fever and hip pain was the most common presenting symptoms. Forty percent had diabetes and 30% had hypertension.
Sulewski et al.[6] observed that there was a clear relation between COVID-19 and the joint changes. There were no other risk factors for AVN. The study group patients were free from any degenerative or autoimmune diseases. The authors found that response to the steroid treatment was positive with reduction in the joint pains. We also found that all cases of COVID-19 had AVN in the present case series.
Namiranian et al.[7] in their review of few cases of AVN post-COVID-19 concluded that all cases of joint pains recovering from COVID-19 should be taken seriously and should be evaluated for the AVN.
Agarwala et al.[8] in their case series of three cases, found that all cases developed femoral head AVN on an average of 58 days after the diagnosis of COVID-19. They were treated with prednisolone. They noted that this AVN was post-COVID as the steroid-induced AVN takes 6 months–1 year to develop.
Hong and Du.[9] studied 28 cases with AVN those who recovered from SARS infection. It took 119 days on an average for these cases to develop AVN. Three patients in their series had very early bilateral AVN of the femoral head. Four cases had unilateral femoral head. Five cases had bilateral knee and hip AVN. They concluded that SARS patients can develop AVN. Steroid use is also associated with the AVN. They stated that more studies are required in this regard.
| Conclusion | | |
We conclude from the present case series that COVID-19 may be associated with AVN of hip joint as all post-COVID cases had AVN. Hence, all patients recovered from COVID-19 should be screened for AVN for early diagnosis and prompt treatment. However, more robust epidemiological studies are required to comment on this association.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 4. | Griffith JF. Musculoskeletal complications of severe acute respiratory syndrome. Semin Musculoskelet Radiol 2011;15:554-60. |
| 5. | Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br 1985;67:3-9. |
| 6. | Sulewski A, Sieroń D, Szyluk K, Dąbrowski M, Kubaszewski Ł, Lukoszek D, et al. Avascular necrosis bone complication after active COVID-19 infection: Preliminary results. Medicina (Kaunas) 2021;57:1311. |
| 7. | Namiranian P, Razavi SZ, Karimi M, Ayati MH. Avascular necrosis in patients recovering from COVID-19. Am J Med Sci 2021;362:331-2. |
| 8. | Agarwala SR, Vijayvargiya M, Pandey P. Avascular necrosis as a part of 'long COVID-19'. BMJ Case Rep 2021;14:e242101. |
| 9. | Hong N, Du XK. Avascular necrosis of bone in severe acute respiratory syndrome. Clin Radiol 2004;59:602-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]
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