Shekar Srinivasan woke up one day with severe pain in the right groin. The 29-year-old had no history of hip pain prior to this.
A few painkillers did not help. On the contrary, he started to develop back pain as well!
On a visit to an orthopaedic doctor, he was asked if he had ever had Covid-19. Shekar revealed that he had had Covid-19, which was severe enough for him to even be hospitalised.
An MRI scan revealed that Shekar had a condition called Avascular Necrosis (AVN), which is also known as bone death.
He was unfortunately in the later stages of this necrosis, with the only option left to him being hip-replacement surgery.
Case numbers increasing
Shekar is one of the several young patients who are presenting with AVN after a severe Covid-19 infection.
While some of them come for treatment at the earlier stages, a majority of them see a doctor only at later stages.
Orthopaedic doctors South First spoke to said such post-Covid-19 cases of bone death are reportedly increasing multifold in various cities across India.
The numbers have increased so much that the All-India Institute of Medical Sciences (AIIMS) recently sought approval from the Indian Council of Medical Research (ICMR) for a multicentric study to probe cases of AVN. There is no data from India on this condition despite its increase.
“Earlier, we used to see around three-four cases in six months and mostly in patients aged 50 and above. Post-Covid-19, and especially now, we are seeing at least 10 cases in the same duration, especially in the 25-35 age group,” said Dr Raghu Nagraj, a senior consultant on orthopaedics and a joint-replacement surgeon at Fortis Hospital in Bengaluru.
What is bone death? What causes it?
Speaking to South First, Dr Krishna Kumar, a consultant orthopaedic joint replacement and arthroscopic surgeon at HOSMAT Hospitals in Bengaluru, explained that avascular necrosis (AVN) or bone death is a condition that leads to the death of the bone due to a sudden blockage of blood supply to the femoral head (ball of the thigh bone) leading to the death of cells and the collapse of the head.
“While the common cause for this condition is idiopathic, where there is no definite reason, certain clotting disorders, alcohol use, and long duration of steroid use can also cause it,” explained Kumar.
“But we are now seeing cases where people are developing AVN following a Covid-19 infection. The cause is probably the same, as there is an increased tendency of clotting of blood seen in Covid-19 patients, as well as steroid use in treatment,” he said.
Speaking to South First from Telangana, Dr Rohith Rathode, an orthopaedic doctor and senior resident at the Government Medical College in the Sangareddy district of Telangana said Covid-19 was a hypercoagulable state that leads to dysfunction of arteries.
Arteries get damaged, their elasticity is lost, and they may even rupture in this hypercoagulable state.
Also, the use of steroids can make the bones soft and the reduced blood supply can cause unnatural bone damage, leading to the death of bones.
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Bone death (AVN) symptoms
Doctors said that the condition may not occur immediately after the Covid-19 infection and treatment.
A few patients presented three months after the recovery from a severe infection of Covid-,19 while a few others came after a year.
Rathode said he has been seeing in his clinical practice at least one in 20 patients who suffered a severe Covid-19 infection come with the condition of AVN.
“Clinically, they complain of pain in the hip joint, difficulty in walking, and difficulty in external and internal rotation of the limb,” he explained.
Some of the symptoms are:
- Persistent pain in the hip
- Pain in the hip joint
- Restriction of movements of hip joints
- Some even develop back pain.
Early diagnosis is important for AVN
Dr Ragu Nagaraj explained that AVN, if presented in the early stages, can be treated with cell therapy, with cells harvested from patients’ bone marrow, grown in the lab, and injected into the dead area to reverse the condition.
However, “at later stages it needs hip replacement as a permanent solution”, he explained.
However, Rathode explained that it is rarely presented in the earlier stages. A normal X-ray may not even detect AVN.
“The death of bones can be detected only at later stages in an X-ray. Unfortunately, the expensive MRI is the only way to detect whether it is a case of bone death,” he explained.
He warned that any kind of hip joint pain after Covid-19, should not be ignored, even if it is experienced after a few months or a year from the infection.
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Treatment options
Dr Krishna Kumar said early detection could help in conserving the femoral head.
At stages 1 and 2, doctors can operate with core decompression and bone marrow injection.
However, for stages three and four Total Hip replacement surgery is the only option and has been a successful procedure that can help the patient to lead a normal life.
However, the drawback of this treatment, according to Rathode, is that it can cost ₹2-3 lakh, and if the patient is young, he or she has to undergo a revision surgery after 10 years.
He explained: “If a patient undergoes hip-replacement surgery at the age of 37, they will have to undergo a revision surgery at the age of 47 years. Similarly, if someone got it done at the age of 27, they have to get a revision surgery at the age of 37 and again at the age of 47, which is a major drawback.”
However, with this surgery, patients can lead a normal life and begin to walk the very next day of the surgery. The recovery time is also faster.
