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The second wave of Covid-19 took a huge toll on the country. We all are preparing for the third wave of this deadly disease now. However, some patients recovered with Covid but still have to deal with this dark chapter of their lives. People are experiencing some long term symptoms or diseases associated with Covid-19. One such disease is something known as bone death. Bone Death, also known as Avascular Necrosis (AVN) was reported in Mumbai earlier in July. The doctors have expressed a cause of concern over the disease that is now being reported in various parts if the country.

To know more about this post-Covid complication, Medically Speaking spoke to several specialists: Padma Shree Dr. Yash Gulati, Ortho Surgeon and Senior Consultant, Spine Surgery and Joint Replacement, Indraprastha Apollo Hospitals; Dr. Nikunj Agarwal, Ortho Surgeon and Senior Consultant, Orthopaedics and Joint Replacement, Max Hospital; Dr. Siddharth Shah, Consultant, Knee and Hip Replacement Surgeon, SL Raheja Hospital.

Question: Dr Gulati, what is bone death? Is it possible to prevent it?

Dr Yash Gulati: The term bone death has been coined recently because of the increased cases of what doctors call Avascular necrosis (AVN). This commonly happens in the upper part of the thigh bone. The thigh bone or the femur bone has a ball that rotates in a socket. This ball has a very peculiar way of getting blood supply. If the blood supply gets damaged, a part of the head of that ball can get damaged and can cause the bone to collapse. This can happen in various other joints like the shoulder joint, knee bone etc. There are several causes of this disease. Steroids, fractures, prolonged alcohol consumption are some common causes. If the disease is detected early, it requires smaller procedures to treat it. If it is detected in the end stage, it requires joint replacement.

Question: Dr Agrawal, how will a layman realise that they need to get checked for AVN? What are the symptoms? What should one watch out for in their recovery stage?

Dr Nikunj Agrawal: Corticosteroid intake is the most common cause of AVN. If the patient has a history of prolonged steroid intake, there is a possibility that they could be developing AVN. In the early stages, the patient starts developing hip pain. In the later stages, they experience stiffness and restriction in the movement of the hip joint.

Question: Dr Shah, tell us a little about your experience with the patients of AVN.

Dr Siddharth Shah: Cases of patients with AVN after Covid-19 are increasing gradually. Patients usually experience symptoms like groin pain, buttock pain or sometimes pain in the upper part of the thigh. Some patients are unable to take weight on that leg and eventually start limping. Most of the patients of AVN include men. Data also shows that it is eight times more common in males than females. It happens most commonly between the age group of 20-55 years of age. All these patients were administered steroids during their treatment for Covid.

Question: Dr Gulati, why do people need to be wary of steroids? Are they required at all in mild Covid cases?

Dr Yash Gulati: Steroid is a wonder drug. It is excellent when it is used and very bad when it is abused. Unfortunately, during the pandemic, steroids were abused. A study by WHO showed that steroids were not appropriate in about 60% of the cases. The problem is that there was no standardisation of steroids at that time. The right amount of steroids need to be given to the patients, at the right time by the right people.

Question: You said that patients should consult doctors if they have hip pain or joint pain after a prolonged intake of steroids. What about the patients who do not have a history of steroid intake at all?

Dr Nikunj Agrawal: There was a lot of misinformation regarding the use of steroids. Most of my patients were from tier two and tier three cities who had been given steroids right from day one of Covid to 21 days. Such patients with a background of hip pain and joint pain could be suffering from AVN or bone death.

Question: Dr Shah, did your patients also have a history of steroid intake?

Dr Siddharth Shah: All my patients had a history of steroid intake during their recovery from Covid-19. There was no sign of steroid abuse in my patients. It is known that the total cumulative dose of steroids increases the risk of steroids. The lowest dose for the shortest period is most likely to reduce the risk of AVN.

Question: Dr Gulati, is there anything we can do to prevent it? Is it unpreventable? Because there were reports that 20% of people were at risk of AVN especially in the second wave of Covid.

Dr Yash Gulati: We take so many drugs that have side effects. Avoid the intake of steroids when not required. Alcohol abuse over a while is also a very important cause of AVN. To prevent AVN, we should avoid the intake of things that can cause it. Major damage can be prevented if AVN is detected early.

Question: Dr Agrawal, do you agree that early detection is key? What happens if it is diagnosed at a later stage?

Dr Nikunj Agrawal: Early detection is the key to the successful treatment of AVN. If it is detected early, the patient can be treated with minimally invasive techniques like drilling or smaller surgeries to decompress the ball. In the late stages, we have to change the joints or go for a total hip replacement surgery.

Question: What was your experience with the patients of AVN?

Dr Siddharth Shah: I would like to reiterate that early diagnosis is key. Secondly, as doctors, we should also have a very low threshold for investigations like MRI. In early cases, the X-rays of patients are going to be normal. MRI picks it up early. This will help us make a diagnosis in time. If the diagnosis is early, we would be able to treat the patients with medicines or surgeries which are less invasive. Nearly half of the patients who came to me had advanced disease so there was no treatment option other than hip replacement. I could treat the other patients with the help of certain special drugs, antiresorptive drugs like bisphosphonates. Apart from that, the patients were advised to take rest and not to put weight on the affected leg.

Question: Dr Gulati, are X-rays not enough for the detection of AVN? Should the people go for an MRI or a CT Scan right away?

Dr Yash Gulati: If it is visible on an X-ray then it is already quite late. It has to be diagnosed much earlier than that. There is nothing to panic about. If there is a symptom, go and see a doctor.

Question: Dr Shah, did you recommend MRI to your patients? Did they have any apprehensions about it?

Dr Siddharth Shah: I had recommended MRI to my patients. I explained to them their condition. Once we explain them, they do not have any apprehensions.

Question: Dr Agrawal, is there an age group that could be more susceptible to AVN post-Covid recovery?

Dr Nikunj Agrawal: AVN most commonly affects the younger age group. 30-55 years is the main age group that will get affected with AVN.

Question: Dr Gulati, who are the patients who would require a replacement surgery altogether? What would be the stage in which the surgery would be needed? What are the types of treatments a person can get?

Dr Yash Gulati: I would like to add something before that. MRI is not like a CT scan. MRI does not have radiations. Except in the first trimester of pregnancy, MRI is quite safe. So people should not be apprehensive about it. The treatment of AVN depends on the stage. In the early stage, practices like offloading, weight-bearing, bone marrow insertion, giving antiresorptive drugs can give good results. Joint replacement is done at the last stage. The decision of joint replacement is more of the patient than that of the doctor. Every joint replacement has a life of its own. We try to avoid joint replacement in younger people. However, if the disability is high, we have no other option. Pain and disability are the indications for joint replacement surgery.

Question: Were your patients mostly elderly or the younger generation who were recovering from Covid?

Dr Siddharth Shah: The patients who were recommended hip replacement were about 45 or 50 years of age. Hip replacement has a finite life. It may have to be changed after a certain period. Timely diagnosis can help prevent the progression of AVN to a severe stage where hip replacement becomes inevitable.

Question: What would be your last word for the people who are watching this?

Dr Nikunj Agrawal: Have a high index of suspicion if you have joint pain or hip pain and a history of steroid intake during Covid-19 recovery. Such patients should visit the doctors as early as possible so that they get treated at the right stage with minimally invasive techniques.

Dr Yash Gulati: Don’t panic. A very small percentage of people who take steroids during Covid will get affected with AVN. If you have symptoms, visit the doctor, get diagnosed early. As far as the steroids are concerned, make sure you get a judicious dose. Discuss it with your doctor. Be very wary of the drugs that you are getting.

Dr Siddharth Shah: One must not panic. Take treatment under medical supervision. Timely diagnosis is key. If there is an onset of any symptoms related to the hip joint, seek a specialist orthopaedic surgeon’s opinion for further treatment.