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0CONSERVATIVE TREATMENT OF COVID-RELATED AVASCULAR NEUROSIS OF THE FEMORAL HEAD AT
EARLY STAGES
1Karimov M.Yu., 2Kayumov J.Sh., 3Madrakhimov S.B.
1,2,3Tashkent medical academy, Tashkent, Uzbekistan https://doi.org/10.5281/zenodo.13123072
Abstract. In this study, we provided functional results for the treatment of avascular necrosis of the femoral head associated with COVID-19. The clinical picture ofAVN of the femoral head associated with COVID-19 varied, ranging from asymptomatic cases accidentally detected during imaging studies to severe femoral pain and functional disorders. The diagnosis was made using a combination of clinical assessment, imaging techniques such as magnetic resonance imaging (MRI), and laboratory tests. In conclusion, AVN of the femoral head associated with COVID-19 presents a complex clinical scenario with potential implications for patient management and outcomes.
Keywords: avascular necrosis, femoral head, COVID-19, hip joint.
The appearance of avascular necrosis of the femoral head (AVNFH), a progressive pathological condition[6], characterized by deterioration of bone quality due to blood supply disruption, raised serious concerns in the context of the COVID-19[11] pandemic. AVNFH, especially in the early stages, poses significant problems for both patients and health professionals, requiring timely intervention to preserve hip function and prevent progression of the disease, requiring total hip arthroplasty [15].
In recent years, the relationship between AVNFH and COVID-19 has attracted increasing attention in the orthopedic community. The pathophysiological mechanisms underlying this association are not well understood, but they are believed to involve a complex interaction between viral infection, systemic inflammation, hypercoagulation and vascular damage[5, 18, 21]. Cytokine storm and endothelial dysfunction caused by COVID-19 may also contribute to the development of microvascular thrombosis and ischemic damage to the femoral head, which ultimately speeds up the development of AVNFH[2].
Early diagnosis and intervention are crucial for optimizing outcomes in patients with COVID-19. However, diagnosing AVNFH in the initial stages can be a daunting task, often requiring high alertness index and multimodal imaging techniques such as X-rays, computer tomography (CT) and especially magnetic resonance imaging (MRI) to accurately assess bone vitality [7, 8, 10]. Rapid recognition of avascular necrosis allows timely initiation of appropriate treatment strategies aimed at preserving the function of the hip joint and stopping the progression of the disease.
The purpose of this study is to assess functional outcomes in patients with early stages of AVNFH associated with COVID-19, after conservative treatment.
Materials and methods
Research Design:
In this study, retrospective cohort design was used to study the functional outcomes of patients with early AVNFH associated with COVID-19 after pharmacotherapy and physiotherapy.
Participants:
The study included a total of200 patients diagnosed with AVNFH associated with COVID-19. The patients were identified using medical records from the Multidisciplinary clinic of \ Tashkent medical academy between February 2021 and January 2022.
Inclusion criteria:
1. The diagnosis of AVNFH was confirmed by x-ray imaging (x-ray imaging of the pelvis with grip of both hip joints and MRI).
2. Laboratory confirmed infection COVID-19 (PCR, immunological analysis for IgG and IgM on SARS-CoV-2).
3. Age > 18 years.
4. Early stages of AVNFH (stage I and stage II classification Ficat, 1985).
Exclusion criteria:
1. Started stages of AVNFH (stage III and stage IV classification Ficat).
2. Hip surgery or trauma.
3. Associated musculoskeletal disorders affecting the gait and volume of movement of the hip joint.
4. Incomplete medical records or follow-up.
Treatment protocol:
All patients received standardized treatment protocol consisting of pharmacotherapy and physiotherapy procedures:
Pharmacotherapy: Patients received intravenous infusion of zolendronic acid (Aclasta) to suppress osteoclast activity and stimulate bone remodeling[1]. Anticoagulants (low molecular heparin, rivaroxaban) have been administered to mitigate thrombotic complications associated with COVID-19[14] infection. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been prescribed for pain relief[3] and drugs to improve microcirculation (e.g., pentoxyphylline) have been used to enhance blood flow to the affected femoral head[17].
Physiotherapy: Patients have undergone individual physiotherapy programs aimed at improving the volume of movement of the hip joint, muscle strength and functional mobility. Methods such as passive exercises aimed at increasing the volume of movement, strengthening exercise and gait training were used depending on the patient's specific needs and functional status. [4, 16]
Data collection:
Demographic, clinical, radiological and laboratory data have been extracted from the medical records of the patients. Initial characteristics have been recorded, including age, sex, comorbidity, severity of COVID-19, duration of symptoms, and AVNFH stage. Functional outcomes were evaluated using validated metrics such as the Harris hip joint assessment (Modified HHS, 2000)[9] and the Visual Analog Scale (VAS) to determine pain.
Statistical analysis:
Descriptive statistics were used to summarize the initial characteristics and functional results. The continuous variables were represented as an average standard deviation or median with an interquartile range, while the categorical variables were represented as frequencies and percentages. Changes in performance before and after treatment were analysed using paired t-tests or, as appropriate, Wilcoxon rank tests. The value p < 0.05 was considered statistically significant.
The study was conducted in accordance with the principles set out in the Helsinki Declaration and approved by the Institutional ethical committee of Tashkent medical academy. Informed consent was obtained from all participants or their legal guardians prior to inclusion in the study. Patient confidentiality and anonymity were strictly observed throughout the study.
Results and discussion
Initial characteristics:
Table 1 summarizes the initial characteristics of the studied population. The cohort included 200 patients with an average age of 38.7 years (SD ± 8.3), with a sufficient male prevalence (80%). Most patients had co-morbidity, most commonly arterial hypertension (34%) and diabetes mellitus (12%). The average duration of symptoms of COVID-19 was 19 days (IQR: 7-28), and the distribution of Ficat by AVNFH stage was I (33%) and II stage (67%).
Table 1. Initial characteristics of the study group
Characterization Significance
Age (years), average ± SD 38.7 ± 8.3
Sex, n (%) Men: 160 (80%) Women: 40 (20%)
Associated diseases, n (%) Hypertension: 68 (34%) Diabetes mellitus: 24 (12%) Others: 30 (15%)
Duration of symptoms COVID-19 (days), median (IQR) 10 (7-14)
Ficat stages, n (%) Stage I: 66 (33%) Stage II: 134 (67%)
Note: SD - standard deviation (standard deviation), IQR - Interquartile range
The demographic profile of the study participants reflects a typical population of patients affected by AVNFH associated with COVID-19.
The average age of 38.7 suggests that AVNFH can affect young and middle-aged people, which is inconsistent with previous literature indicating a higher prevalence of AVNFH among the middle-aged and above.
The predominance of males in this cohort is also consistent with existing epidemiological data for AVNFH [15], which often show higher prevalence among males than females.
Related diseases such as hypertension and diabetes mellitus are common risk factors for development of AVNFH [12, 19] as they can violate the vascular perfusion of the femoral head, predisposing people to ischemic injury and subsequent necrosis.
The average duration of symptoms of COVID-19, at 19 days, indicates an acute phase of viral disease during which AVNFH may develop as a complication.
Functional outcomes:
After treatment with pharmacotherapy and physiotherapy, patients demonstrated a significant improvement in functional performance compared to the baseline.
The average Harris score on the hip joint (modified HHS) increased from 62.4 (SD ± 8.9) to 83.7 (SD ± 6.7) after treatment, indicating a significant improvement in hip joint function. Similarly, the Visual Analog Pain Assessment Scale (VAS) has declined significantly from an average of 7.2 (SD ± 1.5) to 2.9 (SD ± 1.2), reflecting a marked reduction in pain severity (Table 2).
Table 2. Functional results before and after treatment
Outcome indicator Before treatment (Medium ± SD) After treatment (medium ± SD) p
Modified Harris Hip Score 62.4 ± 8.9 83.7 ± 6.7 <0.05
VAS 7.2 ± 1.5 2.9 ± 1.2 <0.05
Note: SD - standard deviation, IQR - Interquartile range (Interquartile scale), VAS -visual analog pain scale, p - confidence level less than 0.05
The improvement in functional outcomes observed in this study highlights the effectiveness of a combined treatment approach, including pharmacotherapy and physiotherapy, in the early stages of AVNFH associated with COVID-19[4]. The significant increase in the modified HHS after treatment indicates a significant improvement in hip joint function, which is crucial for maintaining patient mobility and quality of life. Lower VAS rates mean a marked reduction in the severity of pain after treatment, which is important for improving patient comfort and overall well-being. These results indicate that the proposed treatment regimen effectively addresses both functional disorders and pain associated with AVNFH, resulting in a significant improvement in patient outcomes. [16]
Complications and undesirable phenomena:
The incidence of complications and undesirable events related to the treatment regimen was low. A small proportion of patients (8%) reported transient gastrointestinal symptoms such as nausea and dyspepsia after ingestion of NSAIDs. There was no progression of osteonecrosis to late stages during the study period (6 months), but 12% (24 patients) showed clear radiological signs of progression of AVNFH over a 12-month period. Thromboembolic complications associated with treatment and/or COVID-19 were not found.
The low incidence of complications and undesirable events observed in this study indicates a relatively high safety profile of the proposed COVID-19 treatment protocol. The transient gastrointestinal symptoms reported by a group of post-NSAIDs are consistent with known side effects of these drugs and are generally moderate and self-restraining. [20] It is important to note that 24 cases of progression have been identified, suggesting that the therapeutic benefits of conservative interventions outweigh the risks involved. These results confirm the feasibility and safety of introducing the proposed treatment approach to clinical practice for AVNFH in patients with COVID-19.
Radiological assessment:
An X-ray evaluation of the hip joints found favorable outcomes in terms of bone remodeling and joint architecture. Subsequent MRI showed regression of areas of avascular necrosis in 21% of patients, lack of progression of osteonecrosis at the identified stage in 47% of patients, elimination of bone edema and restoration of trabecular bone structure indicating healing.
X-rays are objective evidence of regression and bone healing after COVID-19 treatment. Resolution of sites of avascular necrosis on MRI images (Fig.1) suggests that combined pharmacotherapy and physiotherapy regime effectively contribute to the restoration of bone tissue, resulting in the restoration of normal bone architecture. The absence of bone edema and restoration of the structure of the trabecular bone structure also indicate a reversal of ischemic injury and an adequate blood supply to the affected femoral head. [13] These X-ray improvements confirm the
functional results observed in this study and highlight the efficacy of the treatment protocol in promoting joint resolution and preservation in patients with COVID-19-related AVNFH.
Figure 1. Patient M. 38 years old. STIR and T1 weighted MRI regimens showing significant reduction of bone edema and stopping progression of avascular femoral head necrosis The analysis of subgroups based on the Ficat stages of AVNFH showed similar improvements in the functional results of both the AVNFH stage I and stage II groups. There were no significant differences in HHS or VAS between the two groups after treatment (p > 0.05). (Table 3.)
Table 3. Analysis of subgroups of functional results by A VNFH stages
Outcome indicator Stage 1 (n=66) Stage 2 (n=134) p
Harris Hip Score 84.1 ± 6.5 82.3 ± 7.2 0.182
VAS 2.8 ± 1.3 3.1 ± 1.1 0.317
Note: VAS - visua analog pain scale, p - confidence level less than 0.05
Subgroup analysis provides valuable insight into the effectiveness of the COVID-19 approach to treating the early stages of AVNFH. Comparable improvements in functional outcomes observed in both AVNFH stage I and stage II suggest that the proposed intervention is equally useful regardless of the severity of the disease at the time of occurrence. These findings underline the importance of early detection and intervention with AVNFH, as the rapid initiation of treatment can lead to beneficial outcomes even in cases with a more advanced disease. In addition, the absence of significant differences in functional outcomes between the two stages of osteonecrosis highlights the potential for successful disease management and functional recovery through the proposed treatment protocol, regardless of the severity of the disease.
The results of this study show that combined treatment with pharmacotherapy and physiotherapy results in beneficial functional outcomes in patients with early stages of AVNFH associated with COVID-19. After treatment, there was a significant improvement in hip joint function and pain relief at low incidence of side effects. These findings highlight the importance of early intervention and interdisciplinary management to optimize outcomes in COVID-19 patients. The positive results observed in this study confirm the effectiveness of the proposed treatment protocol and provide valuable information for the management of this category of patients. Further research is needed to confirm these results and to explore additional therapeutic techniques to improve the results in this patient population. In addition, long-term follow-up studies are needed to assess the persistence of treatment effects and potential relapse in COVID-19 patients with AVNFH. Overall, the study contributes to a growing body of literature on the treatment of COVID-19 skeletal muscle manifestations and emphasizes the importance of a comprehensive approach to patient care in the treatment of the various clinical consequences of the disease.
Conclusion
Conservative treatment of avascular femoral head necrosis associated with COVID-19 is a complex clinical challenge that requires an interdisciplinary approach to optimize patient outcomes. The study examined functional results after the treatment of the early stages of AVNFH, and stressed the importance of conservative treatments to accelerate bone healing and functional recovery.
In conclusion, early detection and intervention, combined with a comprehensive approach to treatment that includes pharmacotherapy and physiotherapy, are necessary to achieve beneficial functional results in patients with AVNFH associated with COVID-19. Further studies with a control group are needed to confirm these results and explore additional therapeutic techniques to improve the results in this population of patients.
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