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.

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.

Transient spontaneous osteonecrosis of the knee (SONK) shortly after SARS-CoV-2 infection: A report of 2 cases.

BACKGROUND: This article describes 2 cases of post-coronavirus disease 2019 (COVID-19) transient spontaneous osteonecrosis of the knee (PCT-SONK) observed in patients who had previously recovered from COVID-19 without corticosteroid administration. OBJECTIVES: The possible pathomechanisms by which a recent SARS-CoV-2 infection may contribute as a causative factor for osteonecrosis are reviewed, and the differential diagnosis and treatment are discussed. MATERIAL AND METHODS: Two patients (males, 45- and 47-year-old) presented with sudden onset knee pain with no trauma history. The pain persisted during rest and at night. On magnetic resonance imaging (MRI), no subchondral bone thickening was observed; bone edema was diffusely distributed in the whole femoral condyle, in contrast to the more focal edema that is typically concentrated mainly around the subchondral region in classic SONK. Both patients were treated nonoperatively with no weight bearing and pharmacological agents, and complete resolution of symptoms was achieved. RESULTS: A follow-up MRI 10 weeks after presentation revealed a near-complete loss of signal in the medial femoral condyle in both patients. CONCLUSION: Orthopedic surgeons should be cautious when sudden knee pain without concurrent trauma or a history of injury occurs shortly after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, even with mild COVID-19 illness. While some studies report the development of post-COVID-19 osteonecrosis after lower doses of corticosteroids and sooner after their administration than in comparable non-COVID-19 cases, our study is the first to report 2 cases with no corticosteroid administration at all. Therefore, the authors believe it adds to the body of knowledge on the potential connections between COVID-19 and PCT-SONK. The transient nature of symptoms and radiological findings suggest that aggressive surgical treatment of non-injury local bone edema occurring shortly after SARS-CoV-2 infection should be avoided.

COVID-Associated Avascular Necrosis of the Maxilla-A Rare, New Side Effect of COVID-19.

PURPOSE: The purpose of this article is to present an interesting, rare case of a patient who experienced avascular necrosis of the maxilla associated with COVID-19 infection. METHODS AND RESULTS: Our team retrospectively evaluated this patient's chart after completion of surgical management. The patient is a 72-year-old male who presented to the University of Texas Health Science Center at Houston for surgical management of his infarcted maxilla, which developed as a sequela of infection with COVID-19. A literature review was completed using PubMed. Twenty-five articles are reviewed and discussed. CONCLUSIONS: Infection with COVID-19 confers a hypercoagulable state in patients, leading to various complications in the head and neck region. In our case report, we present a patient who developed avascular necrosis of the maxilla secondary to infection with COVID-19. Thromboembolic prophylaxis is imperative in COVID-19 patients due to the high rate of potential systemic complications.

Secondary osteonecrosis of the knee as a part of long COVID-19 syndrome: a case series.

COVID-19 infection affects different organ systems with long-term sequelae, which has been termed as long COVID-19 syndrome. To the best of our knowledge, osteonecrosis of the knee as a part of long COVID-19 syndrome has not been documented. Corticosteroids are being used extensively in moderate and severe cases of COVID-19. We report two cases who developed osteonecrosis of the knee after being treated for COVID-19 infection. In our case series, the mean cumulative dose of prednisolone was 1156.5 mg (900-1413 mg), which is less than the cumulative dose reported in literature for osteonecrosis of the knee. In our case series, the patients developed symptomatic osteonecrosis at a mean interval of 73 days after initiation of steroid therapy, with the earliest presenting at 25 days. Early diagnosis of osteonecrosis of the knee on high clinical suspicion by MRI would help in early intervention with bisphosphonate therapy.

Avascular Necrosis Bone Complication after Active COVID-19 Infection: Preliminary Results.

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 large joints and adjacent epiphyses of long bones and the spine, with a background of bone infarctions and 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.

Knee osteonecrosis after COVID-19.

BACKGROUND: COVID-19 is an emergent infection, the long-term complications of which are still under study. While hypercoagulability is a common feature in severe cases, the incidence of ischemic complications such as osteonecrosis remains unknown. Previous studies on SARS-CoV1 found an increase in osteonecrosis 3-36 months after infection, and it is still unclear if this was related to the use of corticosteroids or to the virus itself. METHODS: We introduce a 78-year-old woman who complained of right knee pain and swelling a month after COVID-19 infection onset. Her knee radiography showed no significant changes compared to previous ones. MRI, on the other hand, found osteonecrosis in the internal femoral condyle. No coagulation abnormalities were found in blood tests. RESULTS: While knee replacement should be her main treatment, it will be long delayed due to the pandemic. In the meantime, we increased her tapentadol and salicylic acid doses and gave her home exercises to improve functionality. CONCLUSION: In the follow-up after COVID-19, any muscular or joint pain with unusual characteristics should be carefully examined.