Isopp 2023

The proceedings contain 109 papers. The topics discussed include: dose intensity of palbociclib and initial body weight dosage: implications on progression free survival in 220 patients with ER+/HER2-negative metastatic breast cancer;characteristics of Nirmatrelvir/Ritonavir (Paxlovid) recipients and clinical interventions by oncology pharmacists at a tertiary outpatient cancer center;safe handling of non-carcinogenic drugs in the Ghent University Hospital: development, implementation and communication of hospital-specific guidelines;case series: use of olaparib in uncommon locations in patients with impaired homologous recombination;real-world data evaluation of medicines used in special situations in oncohematology: a retrospective study from a comprehensive cancer institution;Dostarlimab in the treatment of recurrent endometrial cancer: real life experience;medication-related osteonecrosis of the jaws and CDK4/6 inhibitors in breast cancer;and efficacy and safety outcomes of generic imatinib in adults with chronic myeloid leukemia (CML) following the switch from branded imatinib.

AVASCULAR NECROSIS OF THE FEMORAL HEAD – NOT TO BE OVERLOOKED SEQUELA AFTER COVID 19 INFECTION

BackgroundCOVID 19 infection could lead to different sequelae in survivors, known as post-COVID or long COVID 19 syndromes. Some of them are thought to be due to the thrombophylic changes observed in COVID 19 infection, but some are thought to be caused by the administrated (especially high dose) corticosteroid treatment. Avascular necrosis of the femoral head (AVNFH) is a multifactorial disease which leads to compromised vascular supply, ischemia and finally necrosis of the femoral head. As corticosteroids usage and thrombophylic states are among the main known risk factors for the development AVNFH [1], it could be presumed that the frequency of this disease will increase with the COVID 19 pandemic. The exact corticosteroid dose needed for the development of AVNFH is not clear, but it has been stated that a higher daily dose and a larger total cumulative dose increase substantially the risk for the development of osteonecrosis [2].ObjectivesTo describe in detail the characteristics of AVNFH diagnosed in patients after COVID 19 infection.MethodsThe study was done in a tertiary university rheumatological clinic. Data was extracted from the records of patients who have been referred to the clinic because of hip pain between June and December 2022. Inclusion criteria were: - a new onset of uni-or bilateral hip pain that started after a documented COVID 19 infection;and an MRI scan of the hip joints showing osteonecrosis of one or both femoral heads. Exclusion criteria were the presence of hip pain prior to the COVID 19 infection, anamnesis of traumatic injuries of the hips or pelvis, personal history of hypercoagulable states.ResultsNine patients (4 women and 5 men) with an average age 59.1 years (range 38-72) were included in the study. Four patients had been diagnosed with bilateral and five – with unilateral AVNFH, thus 13 hip joints were analysed in total (8 left and 5 right sided). The mean time lap between the COVID 19 infection and the start of the hip pain was 26.2 weeks (range 10-48 weeks). All patients had limited and painful movement in their symptomatic hip(s), especially internal rotation and four of the patients had also elevated CRP levels (mean 11.7 mg/L). The stage of the AVNFH was evaluated according to the Ficat-Arlet classification (0-IV stage). In four hips the AVNFH was stage I, five hips were classified as stage II and the remaining four joints - as stage III. All symptomatic hip joints exhibited effusion/synovitis on both ultrasound examination and the corresponding MRI scan. It should be noted that the presence of hip effusion was found to be related with a worse prognosis in AVNFH [1]. In three patients the amount of the effusion required arthrocentesis and fluid aspiration. The analysis of the joint fluid was consistent with a degenerative disease (i.e., low WBC count with predominant lymphocytes and no crystals). All patients included in our study had received corticosteroids during their COVID19 infection, while 6 of the patients had also been hospitalized due to more severe disease. According to the patients' documentation, the mean cumulative dose of the received corticosteroids was 936.2 mg prednisolone equivalent per patient (range 187-2272 mg).ConclusionAVNFH must not be overlooked in a new onset hip pain after COVID 19 infection. Our results show that corticosteroids administrated during the infection and the presence of hip joint effusion on ultrasound are especially suggestive for the development of osteonecrosis, as they were registered in all of our patients. The presence of these two factors necessitates patient referral for an MRI scan of the hips, in order that AVNFH be detected timely.References[1]Petek D, Hannouche D, Suva D. Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. EFORT Open Rev. 2019 Mar 15;4(3):85-97.[2]Kerachian MA, Séguin C, Harvey EJ. Glucocorticoids in osteonecrosis of the femoral head: a new understanding of the mechanisms of action. J Steroid Biochem Mol Biol. 2009 Apr;114(3-5):121-8.Acknowledgements:NIL.Disclosur of InterestsPLAMEN TODOROV Speakers bureau: speaker at national level for AbbVie, Novartis and UCB, Lily Mekenyan: None declared, Anastas Batalov Speakers bureau: Speaker at national level for AbbVie, Novartis, Pfizer, Stada, Elly Lilly.

Did the COVID-19 Pandemic Coincide With an Increase in Osteonecrosis as Indication for Total Hip Arthroplasty in Older Patients?

BACKGROUND: Osteonecrosis of the femoral head is a common indication for total hip arthroplasty (THA). It is unclear to what extent the COVID-19 pandemic has impacted its incidence. Theoretically, the combination of microvascular thromboses and corticosteroid use in patients who have COVID-19 may increase the risk of osteonecrosis. We aimed to (1) assess recent osteonecrosis trends and (2) investigate if a history of COVID-19 diagnosis is associated with osteonecrosis. METHODS: This retrospective cohort study utilized a large national database between 2016 and 2021. Osteonecrosis incidence in 2016 to 2019 was compared to 2020 to 2021. Secondly, utilizing a cohort from April 2020 through December 2021, we investigated whether a prior COVID-19 diagnosis was associated with osteonecrosis. For both comparisons, Chi-square tests were applied. RESULTS: Among 1,127,796 THAs performed between 2016 and 2021, we found an osteonecrosis incidence of 1.6% (n = 5,812) in 2020 to 2021 compared to 1.4% (n = 10,974) in 2016 to 2019; P < .0001. Furthermore, using April 2020 to December 2021 data from 248,183 THAs, we found that osteonecrosis was more common among those who had a history of COVID-19 (3.9%; 130 of 3,313) compared to patients who had no COVID-19 history (3.0%; 7,266 of 244,870); P = .001). CONCLUSION: Osteonecrosis incidence was higher in 2020 to 2021 compared to previous years and a previous COVID-19 diagnosis was associated with a greater likelihood of osteonecrosis. These findings suggest a role of the COVID-19 pandemic on an increased osteonecrosis incidence. Continued monitoring is necessary to fully understand the impact of the COVID-19 pandemic on THA care and outcomes.

Is post-COVID osteonecrosis of jaw (PCONJ) Masquerading as osteomyelitis ? A largest unicentric report of 13 cases

Objective The purpose of this study was to ascertain the correlation between COVID-19 infection and jaw osteonecrosis, along with the identification of risk factors that could be associated with the development of the condition. Another aim of our study is to establish whether maxillofacial osteonecrosis is an early or late complication seen in COVID-19 patients. Material and method This was a retrospective study conducted over a period of two years. Case records of patients with a history of severe COVID and steroid treatment who later developed jaw osteonecrosis were evaluated. Result 13 patients with an age range from 8 years to 70 years were identified. Osteonecrosis was seen as late as 21 months after COVID-19. The majority of the cases involved maxilla, one case was of bi-jaw involvement, and one case presented with isolated mandibular involvement. 6 patients were diabetic and 11 patients gave a history of provocative dental treatment like extraction. Conclusion A triad of post-COVID coagulopathy, steroid administration, and a provocative dental treatment may contribute to jaw osteonecrosis which may be seen in patients without pre-existing systemic illness and may present as late as 21 months after COVID-19.

Rare localization of avascular necrosis during treatment of COVID-19 with glucocorticosteroids

The development of bony avascular necrosis induced by glucocorticoid treatment of COVID-19 is a common adverse effect, with femoral head being the most commonly affected. Timely detection of avascular necrosis is important in the prevention of osteoarthrosis and other complications. We present a clinical case of a 54-year-old patient hospitalized for novel coronavirus infection with complaints of severe pain in both knees 2 weeks after the disease onset. Magnetic resonance imaging revealed pronounced changes in both knees, corresponding to avascular necrosis. The results of conservative therapy, including non-steroidal anti-inflammatory drugs and bisphosphonate bone resorption inhibitors, produced a pronounced positive result. At follow-up examination 3 months later, there was no pain, but the knee joints still had slight restrictions of movement. Magnetic resonance imaging showed a significant decrease in the previously detected changes. The side effects of glucocorticoids (impaired glucose tolerance, increased blood pressure, tachycardia, gastrointestinal erosive ulcers, sleep disorders, etc.) are widely known, but knee osteonecrosis caused by steroid intake rarely comes to the attention of clinicians. This clinical case emphasizes the complex nature of osteonecrosis pathogenesis and demonstrates a wide range of complications in corticosteroid therapy. © 2022, Eco-Vector LLC. All rights reserved.

MULTIFOCAL OSTEONECROSIS AS A CONSEQUENCE OF A NEW CORONAVIRUS INFECTION.

The impact of the transferred coronavirus infection on the musculoskeletal system still remains an urgent problem. Arthralgia, myalgia, arthritis, autoimmune disorders and also osteonecrosis are may be development of the post-COVID period. This article discusses the case of the debut of multifocal osteonecrosis after a coronavirus infection.Copyright © 2023 Ima-Press Publishing House. All rights reserved.

Mucormycosis of the bones of the facial skull, nasal cavity and paranasal sinuses in patients with COVID-19.

Currently, the relevance of the issues of diagnosis and treatment of invasive fungal diseases has increased significantly due to the pandemic of a new coronavirus infection COVID-19 and the massive use of corticosteroids for the treatment. The key success factors in the outcome of invasive fungal diseases are early diagnosis and treatment, including the applying of an adequate systemic antifungal therapy and surgical treatment. Extensive areas of mycotic lesions of the facial bones and paranasal sinuses are life-threatening conditions due to anatomical proximity to brain structures and a high risk of dissemination of I invasive fungal diseases with a fatal outcome. The objective of this work was to study the risk factors, possible pathogenesis, diagnosis and treatment strategy of invasive fungal diseases of the orofacial region in convalescents of COVID-19. We present case-series data on six patients in the clinics of maxillofacial surgery and otorhinolaryngology of the Pavlov First Saint Petersburg State Medical University over the period of 2021-2022. Predisposing factors, clinical and radiological symptoms, features of diagnosis, therapy and surgical strategy were analyzed. The presented observations confirm the relevance and danger of complications after a COVID-19 in the form of the development of invasive fungal diseases with damage to the maxillofacial region caused by mucormycetes and Aspergillus spp., as well as importance of early diagnosis and treatment.Copyright © 2021, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

AVASCULAR NECROSIS OF HIP AFTER ACTIVE COVID-19 INFECTION

Background and objectives: The course of SARS-CoV-2 (COVID-19) is still under analysis. The majority of complications arising from the infection are related to the respiratory system. The adverse effect of the viral infection on bone and joint tissue has also been observed. Materials and Methods: We present a group of 10 patients with degeneration of hip, with a background of avascular necrosis (AVN) immediately after infection with the COVID-19 virus. In MR imaging, changes in the characteristics of AVN were documented. Results: Observation of this group showed a clear correlation among the history of COVID-19 disease in the patients, moderately severe symptoms, high levels of IgG antibodies, and the time of occurrence of joint changes. No other clinically significant complications were observed following COVID-19 infection in the study group. No other risk factors for AVN or autoimmune or degenerative diseases were found in the study group. The group of patients responded well to empirical treatment with steroids, which normalized acute inflammatory symptoms and pain in the joints. Conclusions: During coronavirus (COVID-19) infection, there are complications in the locomotor system, such as microembolism and the formation of AVN;hence, more research is needed. [ FROM AUTHOR] Copyright of Journal of Cardiovascular Disease Research (Journal of Cardiovascular Disease Research) is the property of Journal of Cardiovascular Disease Research and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

POSTCOVID NECROSIS OF THE MAXILLOFACIAL REGION

The analysis of a clinical case with osteonecrosis of the maxillofacial region, which was a manifestation of a complication of a COVID-19 coronavirus infection, to show the diagnostic capabilities of computed tomography followed by multiplanar and 3D reconstructions. Materials and methods. Clinical observation of patient R. 53 years old is presented, with complaints of pain, painful swelling of the soft tissues of the right suborbital area, painfulness during chewing, which appeared in the early period after COVID-19. The patient was referred to the Department of Oral and Maxillofacial Surgery where she underwent comprehensive radiological examination to determine the nature of the changes and comprehensive treatment. Results. The diagnosis of osteonecrosis with the progression to the soft tissue suppuration and upper jaw destruction was verified by CT scan and confirmed by surgical intervention. Detection and detailed diagnosis of these changes was facilitated by multispiral computed tomography and 3D reconstructions during the follow-up. Discussion. COVID-19 coronavirus infection can be complicated by necrosis of the skeletal bones, including the jaw, which can be diagnosed with radiology methods. Various radiological methods can be used to diagnose this pathology, but CT scan of the maxillofacial region is the most informative. Conclusion. CT of the skull bones and facial skeleton in patients with osteonecrosis of the maxillofacial region provides complete diagnostic information about the localization and distribution of the lesion, which determines the further tactics of patient management taking into account the detected changes. As a result, timely initiated adequate treatment helped to cope with the progressing protracted pathological process of the maxillofacial region, which was a manifestation of a complication of the recent COVID-19 coronavirus infection. © 2022 Russian Electronic Journal of Radiology. All rights reserved.

Who is the convict; COVID-19 or corticosteroid? Late onset avascular necrosis of hips after COVID-19. A case report with literature review.

AIM: Avascular necrosis (AVN) or osteonecrosis is characterized by death of bone tissue due to endothelial damage and vascular abnormality. Coronavirus can induce endothelial damage and abnormal blood clotting, so that COVID-19 is known as a vascular disease. We aim to evaluate the relationship between AVN and COVID-19. CASE: Here we present a 39-year old man with severe COVID-19 and corticosteroid consumption who developed late onset AVN of both hips 20 month after COVID-19. CONCLUSION: An awareness of the possible osteonecrosis for all physicians dealing with patients with musculoskeletal problems following COVID-19 is necessary.

Dose-Response Meta-Analysis of Corticosteroid Effects in SARS Outbreak: A Model for Risk Stratification and Screening Strategy for Osteonecrosis of Femoral Head Post-Corticosteroid Therapy for COVID-19.

Corticosteroids (CS) have been used in the management regimens for COVID-19 disease to mitigate the cytokine storm and ill effects of the pulmonary inflammatory cascade. With the rampant use of CS, clinicians started reporting the occurrence of osteonecrosis of the femoral head (OFH). In this systematic review, we aim to analyze the literature and identify the definitive cumulative dose and duration of CS needed for the development of OFH based on the SARS model and generate a risk-based screening recommendation for OFH in convalescent COVID-19 patients to facilitate early identification and management. An electronic database search was conducted until December 2022 in PubMed, Web of Science, Embase, and CNKI (China Knowledge Resource Integrated Database). Studies involving CS therapy and osteonecrosis data in SARS patients were included. Three authors independently extracted the data from the included studies and a dose-response meta-analysis was performed for various doses and duration of CS utilized in the included studies. We selected 12 articles with 1728 patients in the analysis. The mean age was 33.41 (±4.93) years. The mean dosage of CS administered was 4.64 (±4.7) g which was administered for a mean duration of 29.91 (±12.3) days. The risk of osteonecrosis increases at pooled OR of 1.16 (95% CI 1.09-1.23, p < 0.001) per 2.0 g increase in the cumulative dose of CS usage. Similarly, the risk increases at pooled OR of 1.02 (95% CI 1.01-1.03, p < 0.001) per 5 days of increase in the cumulative duration of CS usage. A cumulative dosage of 4 g and a duration of 15 days were determined as the critical cut-off for the non-linear dose-response relationship observed. Appropriate and frequent screening of these individuals at regular intervals would help in the identification of the disease at an early stage in order to treat them appropriately.

Dimethyloxalylglycine Attenuates Steroid-Associated Endothelial Progenitor Cell Impairment and Osteonecrosis of the Femoral Head by Regulating the HIF-1α Signaling Pathway.

Endothelial impairment and dysfunction are closely related to the pathogenesis of steroid-associated osteonecrosis of the femoral head (SONFH). Recent studies have showed that hypoxia inducible factor-1α (HIF-1α) plays a crucial role in endothelial homeostasis maintenance. Dimethyloxalylglycine (DMOG) could suppress HIF-1 degradation and result in nucleus stabilization by repressing prolyl hydroxylase domain (PHD) enzymatic activity. Our results showed that methylprednisolone (MPS) remarkably undermined biological function of endothelial progenitor cells (EPC) by inhibiting colony formation, migration, angiogenesis, and stimulating senescence of EPCs, while DMOG treatment alleviated these effects by promoting HIF-1α signaling pathway, as evidenced by senescence-associated ß-galactosidase (SA-ß-Gal) staining, colony-forming unit, matrigel tube formation, and transwell assays. The levels of proteins related to angiogenesis were determined by ELISA and Western blotting. In addition, active HIF-1α bolstered the targeting and homing of endogenous EPCs to the injured endothelium in the femoral head. Histopathologically, our in vivo study showed that DMOG not only alleviated glucocorticoid-induced osteonecrosis but also promoted angiogenesis and osteogenesis in the femoral head as detected by microcomputed tomography (Micro-CT) analysis and histological staining of OCN, TRAP, and Factor Ⅷ. However, all of these effects were impaired by an HIF-1α inhibitor. These findings demonstrate that targeting HIF-1α in EPCs may constitute a novel therapeutic approach for the treatment of SONFH.

Avascular osteonecrosis in a young patient with a novel coronavirus infection

COVID19 continues demonstrating possible complications after recovery. One of these complications is avascular osteonecrosis, which can lead to bone destruction and patient disability. Cases of the development of osteonecrosis associated with coronavirus infection were widely reported during and after the SARS epidemic in 2003. They also appear to be common in COVID19 infection. All patients who have recovered from COVID19 infection, especially who received glucocorticoids, are threaten of osteonecrosis development. We describe a case of bone necrosis in a healthy young woman without additional risk factors with a mild course of COVID, who received a short course of glucocorticoids. This is the first described case of COVIDinduced osteonecrosis in our country, although due to the largescale use of glucocorticoids, there are probably more such cases. Early diagnosis is important to prevent disease progression. Therefore, clinical alertness is necessary in all patients with COVID19. © 2022 by the Author(s).

POSTCOVID NECROSIS OF THE MAXILLOFACIAL REGION.

The analysis of a clinical case with osteonecrosis of the maxillofacial region, which was a manifestation of a complication of a COVID-19 coronavirus infection, to show the diagnostic capabilities of computed tomography followed by multiplanar and 3D reconstructions. Materials and methods. Clinical observation of patient R. 53 years old is presented, with complaints of pain, painful swelling of the soft tissues of the right suborbital area, painfulness during chewing, which appeared in the early period after COVID-19. The patient was referred to the Department of Oral and Maxillofacial Surgery where she underwent comprehensive radiological examination to determine the nature of the changes and comprehensive treatment. Results. The diagnosis of osteonecrosis with the progression to the soft tissue suppuration and upper jaw destruction was verified by CT scan and confirmed by surgical intervention. Detection and detailed diagnosis of these changes was facilitated by multispiral computed tomography and 3D reconstructions during the follow-up. Discussion. COVID-19 coronavirus infection can be complicated by necrosis of the skeletal bones, including the jaw, which can be diagnosed with radiology methods. Various radiological methods can be used to diagnose this pathology, but CT scan of the maxillofacial region is the most informative. Conclusion. CT of the skull bones and facial skeleton in patients with osteonecrosis of the maxillofacial region provides complete diagnostic information about the localization and distribution of the lesion, which determines the further tactics of patient management taking into account the detected changes. As a result, timely initiated adequate treatment helped to cope with the progressing protracted pathological process of the maxillofacial region, which was a manifestation of a complication of the recent COVID-19 coronavirus infection.Copyright © 2022 Russian Electronic Journal of Radiology. All rights reserved.

Incidental osteonecrosis in the distal left femur in a case of beta-thalassemia with COVID-19: Role of [99mTc]Tc-MDP whole-body bone scan.

Secondary anemia in hemoglobinopathies like thalassemia can cause expansion of the bone marrow cavities because of compensatory marrow hyperplasia. This case demonstrates spontaneous osteonecrosis of the distal left femur in a patient with ß-thalassemia that may be secondary to ischemic infarction secondary to occlusion of the microvasculature within the expanded cancellous bone. This subject was referred to Hazrat Rasool Akram Hospital because of fever, cough, and bone pain. In the CT scan she had scattered peripheral CGO in both lungs due to COVID-19 with two paravertebral masses due to extramedullary hematopoiesis. The patient had also generalized bone pain so the physician asked for a whole-body bone scan and incidentally, we found a cold lesion with a rim of increased uptake in the distal left femur that with bone biopsy it was consistent with osteonecrosis. This case illustrates the importance of performing a whole-body bone scan in ß-thalassemia for the management of patients and diagnosis of occult osteonecrosis.

[COVID-induced facial bones necrosis]. / COVID-indutsirovannyi nekroz chelyustnykh kostei.

The article focuses on the clinical manifestation of inflammatory and destructive lesions of the bones of the midface, nose and paranasal sinuses as a long-term complication of COVID-19 with clinical examples provided.

PATHOLOGICAL CHANGES IN THE OSTEOARTICULAR SYSTEM DURING COVID-19 DRUG THERAPY (REVIEW OF LITERATURE)

The recommended drugs for the treatment of COVID-19 are, on the one hand, experimental in nature, but at the same time, they have many side effects that cause long-term complications in organs and systems, including osteoarticular. Based on the analysis of modern domestic and foreign literature, to determine the effect of not only the new coronavirus infection COVID-19, but also the drugs used to treat it, on the human osteoarticular system. In the course of the study, a scientific search was made for publications in the electronic databases PubMed, MedLine and e-Library for the period from January 2000 to October 2021 for the main keywords. Due to successive "waves” of the COVID-19 pandemic, the number of patients receiving non-specific therapy, including corticosteroids, will increase in the coming years. Preliminary data on COVID-19 and similar trends during the Sars-COV-1 epidemic of 2003 show that the pathogenesis of Sars-Cov-2 and its treatment with high doses of corticosteroids may increase the risk of osteonercosis in patients, which will inevitably lead to an increase in orthopedic diseases in patients not only the middle age group, but also young patients in the near future. Currently, studies are required aimed at risk stratification, studying the pathogenesis of damage to the musculoskeletal system after COVID-19 and the effectiveness of preventive and therapeutic measures in such patients. © 2022 by the Author(s).

Post Mucormycosis Frontal Bone Osteonecrosis: "A Road Less Traveled During the Pandemic".

BACKGROUND: Osteonecrosis in mucormycosis is a rare phenomenon and has been reported usually following trauma or in immunocompromised individuals. Osteonecrosis of skull as a complication of mucormycosis is a rare presentation, which makes the study ever so rare and interesting. METHODS: Within 6 months, a total of 114 patients presented with mucormycosis as COVID-19 sequel, 60 of whom underwent form of endoscopic sinus debridement. Six of these 60 patients presented with frontal bone osteonecrosis and were included in the study. All 6 patients presented within a time period of 2-4 months' post FESS. RESULTS: One of the 6 patients succumbed to her illness. Another patient presented with local recurrence after 3 months, for which she underwent resurgery and debridement. The other 4 patients showed gradual recovery and are without symptoms or radiologic progression at 6-month follow-up. CONCLUSIONS: Osteonecrosis in mucormycosis is a rare phenomenon, and the 2 entities have rarely been reported together. The disease usually limits itself to the frontal bone only, and pathogenesis for spread is due to a vicious cycle of infection and ischemia. Prompt diagnosis via imaging, aggressive surgical debridement with a good antifungal cover, good patient compliance, and regular follow-up form the mainstay of treatment.

FEMORAL HEAD OSTEONECROSIS POST-COVID-19 INFECTION, A PROPHECY COMING TRUE. A REPORT OF SEVEN HIPS

Musculoskeletal complications following COVID-19 infection or because of its medications had been reported in the literature. Here, we report on seven hips in four patients who presented with osteonecrosis of the femoral head (ONFH) after having COVID-19 infection, and their treatment regimen included glucocorticoid. Four patients presented to us complaining of hip pain (bilateral in three patients and unilateral in one), all reported being diagnosed as having COVID-19 infection, and their line of management included corticosteroid intake for various durations. The diagnosis was confirmed by plain hip radiographs and magnetic resonance imaging. The disease was in the early stages in all patients without femoral head collapse. Thus, all hips were treated by core decompression. ONFH is a real concern in patients who have COVID-19 infection, especially when corticosteroids are administered as part of their management. A follow-up and screening strategy should be established for patients who had COVID-19 infection to detect the early development of hip osteonecrosis. [ FROM AUTHOR]

Hyperbaric oxygen therapy in stage III C Kienböck disease: Time is bone.

Kienböck disease, also known as lunatomalacia, is a rare condition which can lead to progressive wrist pain and abnormal carpal motion. We present the case of a 30-year-old patient with Down syndrome who came to our observation for treatment of stage III C Kienböck disease. In September 2019, the patient reported wrist pain with limitation in movements and initially underwent conservative treatment without benefit. In October 2020, pain symptoms and difficult movements with reduced strength worsened and surgical treatment was proposed, but the patient and his family declined. Thereby the patient underwent conservative treatment with hyperbaric oxygen therapy (HBOT) 60 sessions, 100% oxygen at 2.5 absolute atmospheres (ATA), oxygen total time 60 min, once daily, five times per week. After 6 months, a positive clinical and radiological evolution were observed, with an improvement in the patterns of pain, motion, and strength and an almost complete involution of the process of aseptic necrosis of the semilunar. To the best of our knowledge, this is the first report of stage III C Kienböck's disease in Down's syndrome patient treated with HBOT.