ABSTRACT

Avascular necrosis of the femoral head as post covid sequelae has been reported in recent studies, however with unclear etiology. In the past, we have seen AVN of  femoral head in patients with-  severe acute respiratory syndrome(SARS) similarly in post covid sequelae patients are presenting with AVN. Covid 19 is known to cause multiorgan involvement, which may lead to inflammatory arthritis by triggering autoimmune reactions. A high dose of Steroid intake is one of the major risk factors of AVN. AVN due to high dose corticosteroid usually occurs in a time interval of six months to one year, whereas in post covid sequelae AVN occurs at a shorter interval from the onset of disease.

In the sporadic case reports, only the femoral head was involved (Ficat and Arlet stage 2 disease). We report a case of 30 -year old male with bilateral hip arthritis with accelerated involvement of acetabulum and femoral head. Considering the ambiguity in etiology of arthritis in post covid patients and early acetabular involvement in our patient, there was a diagnostic dilemma among avascular necrosis, inflammatory and infective etiology. This is the first case report about this condition to the best of our knowledge and we present here the clinico radiological, biochemical, and immunological workup for the diagnosis of this rare condition, and the efficacy of combined therapy with immunomodulators and metabolic regulators in the management of this dreadful condition.

KEYWORDS: post covid arthritis hip, early acetabular arthritis, adalimumab.

Introduction

Avascular necrosis(AVN) of femoral head, as post covid sequelae has been reported in recent studies. AVN occurs due to high dose corticosteroid intake over a period of six months to one year, unfortunately in post covid sequelae AVN of femoral head progresses rapidly, probably due to hypercoagulable state in covid 19. Here we present a case of accelerated bilateral hip arthritis in a young adults due to post covid sequelae.

History & Complaints

A 30 year old male presented with complaints of  bilateral hip pain, severe in nature radiating to both knee, unable to weight bear. History of treatment for covid 19 with high dose corticosteroid before three months. Injection methyl prednisolone 1gram given for 10 days followed by oral steroid tablet wysolone for 3 weeks. Patient presented with similar symptoms before two months also, MRI suggestive of bilateral hip joint effusion and myositis, venous doppler shows superficial saphenous thrombus. Hence patient was treated for myositis with NSAIDs, DVT prophylaxis and methylprednisolone. Gentle physiotherapy started.

Local examination

Hip in external rotation, knee extended. The patient was bedridden, severe tenderness in both hips, any movements to the hips causes, severe pain. VAS score 8-9. All range of movements restricted painfully and severe muscle wasting both lower limbs. Distal pulse present.

DISCUSSION

We present a case of bilateral avascular necrosis of femoral head with subchondral sclerosis and cystic changes with accelerated acetabular involvement. From our investigations, there was a diagnostic dilemma. Hence we treated the patient with both metabolic regulators and immuno-modulator. Pathology behind this was not yet understood. After multidisciplinary discussion, patient was started on metabolic regulators and immunomodulator. Patient showed significant symptomatic improvement, with good increase in range of movements. However longer duration of follow-up is needed to assess the final outcome. The patient and family has been clearly counselled regarding the prognosis of the disease and possible need of bilateral total hip replacement if the disease progresses.

LITERATURE REVIEW

1. Powell C, Chang C, Naguwa SM, et al. Steroid induced osteonecrosis: an analysis of steroid dosing risk.
2. Sanjay R Agarwala, Mayank Vijayvargiya, Prashant Pandey. Avascular necrosis as a part of ‘long COVID-19’
3. WHO coronavirus disease (COVID-19) Dashboard.
4. Mirzai R, Chang C, Greenspan A, et al. The pathogenesis of osteonecrosis and the relationships to corticosteroid.

Presenting Author: Dr V Sridaran, Department of Orthopaedics

Primary Author: Dr Aravindan Selvaraj, Chief Orthopaedic Surgeon

Co Authors: Dr K Mukunth, Dr P Keerthivasan, Dr A Vikraman and Dr  A William