Marc Darrow, MD, JD.
I am frequently asked for opinions about COVID-19. One subject that is frequently mentioned is the possible after affects of COVID-19 recovery on joint pain or what is the impact of prolonged steroid or opioid use while waiting for surgery. This is a new field of science, long-term studies are not available yet to give answers beyond the empirical, what is seen in patients, however, the medical research is now coming in abundance. I will cover some of those papers below.
One of the great concerns in the medical community is the impact of COVID-19 on people with significant joint pain or osteoarthritis. Many of the people people have waited, or are still waiting, for an arthroscopic surgery or joint replacement surgery. Some have been managed with opioids prescriptions and cortisone injections that may have caused more joint damage. Some people who had COVID-19 and no demonstrable problem of arthritis have suddenly developed avascular necrosis or joint bone death because of prolonged corticosteroid use to help them breath. The term “Long-Covid” is a term that describes symptoms of COVID-19 that have lasted long after recovery from the acute phrase. Long-Covid can really only describe certain patients who had COVID-19 at a maximum two and one-half years. The majority of recovering people of course can be of much of shorter duration. Therefore the true impact of Long-Covid will not be known for some time.
Long-lasting symptoms of SARS-CoV-2 as the result of an accelerated aging process
There is now research to support the idea that Long-Covid and its degenerative symptoms are a problem of accelerated aging. Covid made you age. Let’s look at research. This paper from the International journal of molecular sciences and was published in January 2022. (1)
“In this review, (the study authors) hypothesize that SARS-CoV-2 contributes to age-related perturbations in endothelial (the cells that line blood vessels) and adipose tissue (fat which is found under the skin, in bone marrow, all over the body), which are known to characterize the early aging process.” (The authors noted) that this would explain the theory of long-lasting symptoms of SARS-CoV-2 as the result of an accelerated aging process.
The authors write: “Connective tissues such as adipose tissue and musculoskeletal tissue are the primary sites of aging. Therefore, current literature was analyzed focusing on the musculoskeletal symptoms in COVID-19 patients (The researchers, based on tissue breakdown, started to look at the musculoskeletal system and advancing osteoarthritis as a clue to the cause of Long-Covid). “Hypovitaminosis D (an insufficiency or deficiency of vitamin D), increased fragility, and calcium deficiency point towards bone aging, while joint and muscle pain are typical for joint and muscle aging, respectively. These characteristics could be classified as early osteoarthritis-like phenotype. Exploration of the impact of SARS-CoV-2 and osteoarthritis on endothelial and adipose tissue, as well as neuronal function, showed similar perturbations. . .(Long-Covid and osteoarthritis and joint breakdown shared many of the same characteristics). This is combined with the current knowledge of musculoskeletal aging to pave the road towards the treatment of long-term COVID-19.”
While Long-Covid is one health concern impacting orthopedic medicine in the years to come and another problem is overuse of cortisone.
It will take years to catch up to the postponed elective orthopedic surgeries there may be a pandemic of avascular necrosis from cortisone usage
In the first study above, the suggestion is made that in Long-Covid, osteoarthritis can be created or accelerated by the carry over symptoms of COVID-19 itself. In this next study, the need to provide patients with cortisone injections while they were waiting for elective procedures is seen as a potent to a possible epidemic of ball and socket joint collapse. Further, Glucocorticoids use to manage acute respiratory disease syndrome may cause avascular necrosis. This is an editorial in the journal Bone and joint research (2).
“From an orthopaedic perspective, elective operations for those suffering with what are often severe, life-limiting conditions were cancelled to allow health services to cope with the successive waves of COVID-19 patients. This has resulted in a staggering increase in waiting lists to levels that will take years to bring back under control. It has also resulted in twice the number of patients who are waiting for total hip or knee arthroplasty experiencing a state of life which can be considered as “worse than death”.”
Other unforeseen consequences may well be found as a result of the drug treatments used to combat the effects of the disease. “Glucocorticoids have been used to manage acute respiratory disease syndrome (ARDS) in COVID-19 patients, and have shown to be beneficial in reducing 28-day mortality and the need for mechanical ventilation. . . Ostensibly effective in the treatment of ARDS, the widespread use of such treatment may be a double-edged sword. The detrimental effects of steroids are well documented, and the link between these drugs and the occurrence of femoral head avascular necrosis (bone death common in advanced hip and talus osteoarthritis) is increasingly recognized. . . If the rates of avascular necrosis reach the heights of those reported following (COVID-19), then orthopedic services may be subject to a pandemic of avascular necrosis, and result in a significant increase in the burden of musculoskeletal disease in the community.”
“Patients were symptomatic and developed early avascular necrosis presentation at an average of 58 days after COVID-19 diagnosis as compared with the literature which shows that it generally takes 6 months to 1 year to develop avascular necrosis post steroid exposure.”
A July 2021 study documented the same concerns: (3)
“‘Long COVID-19’ can affect different body systems. At present, avascular necrosis as a consequence of ‘long COVID-19’ has yet not been documented. By large-scale use of life-saving corticosteroids in COVID-19 cases, we anticipate that there will be a resurgence of avascular necrosis cases. We report a series of three cases in which patients developed avascular necrosis of the femoral head after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 758 mg (400-1250 mg), which is less than the mean cumulative dose of around 2000 mg steroid, documented in the literature as causative for avascular necrosis. Patients were symptomatic and developed early avascular necrosis presentation at an average of 58 days after COVID-19 diagnosis as compared with the literature which shows that it generally takes 6 months to 1 year to develop avascular necrosis post steroid exposure.”
The problem of opioids
There was already an vast and extensive opioid problem before COVID-19 came along. Researchers are suggesting COVID-19 will make it worse. A September 2021 paper (4) had researchers assessing the impact COVID-19 had on access to hip and knee replacement surgery, specifically the impact on preoperative opioid prescribing rates for those awaiting surgery. They found evidence of potential for an emerging opioid problem associated with the influence of COVID-19 on elective arthroplasty services. Viable alternatives to opioid analgesia for those with end-stage arthritis should be explored, and prolonged waiting times for surgery ought to be avoided in the recovery from COVID-19 to prevent more widespread opioid use.
Longer wait until joint replacement lead to worsening joint conditions.
An August 2021 paper (5) that suggested once patients could get a knee replacement or hip replacement they had to stay in the hospital longer. These are the researchers’ observations:
“Elective orthopaedic services have had to adapt to significant system-wide pressures since the emergence of COVID-19 in December 2019. Length of stay is often recognized as a key marker of quality of care in patients undergoing arthroplasty. Expeditious discharge is key in establishing early rehabilitation and in reducing infection risk, both procedure-related and from COVID-19. . . Time to surgery and length of hospital stay were significantly higher following recommencement of elective orthopedic services in the latter part of 2020 (during COVID) in comparison to a similar patient cohort from the year before (Pre-COVID). Longer waiting times may have contributed to the clinical and radiological deterioration of arthritis and general musculoskeletal conditioning, which may in turn have affected immediate postoperative rehabilitation and mobilization, as well as increasing hospital stay.”
Patient’s concerns over COVID-19 prevented many from getting surgery
An October 2021 study in the journal Arthroplasty today (6) displayed patient concerns about surgery once elective surgeries were allowed to resume in California. “Over 3 months, the level of concern in arthroplasty (joint replacement) patients regarding the COVID-19 pandemic closely mirrored daily COVID-19 incidence and deaths within the state (California). No decrease in patient concern was identified during the study period, a troubling finding that persisted 3 months after the resumption of elective surgery. However, most patients undergoing joint arthroplasty did not believe that the COVID-19 pandemic would negatively affect the safety or outcome of their surgery. Despite this, approximately one-third of patients were hesitant to proceed with surgery because of the COVID-19 pandemic. The most cited safety practices that relieved concern were preoperative COVID-19 testing, mandatory Personal protective equipment (masks) usage by hospital staff, and surgeon reassurance. Our analysis found that female sex, greater age, and Asian race were independently associated with greater concern regarding the COVID-19 pandemic.”
An evolving understanding
There are many factors that can contribute to accelerated joint breakdown and avascular necrosis. Research is showing us that people who recovered from COVID-19 may be at risk for premature joint breakdown, people who received corticosteroids to treat respiratory disorders may be at risk for bone destruction in weight bearing joints, such as the hip. People who may have never had COVID-19 may be at risk for joint destruction because as they waited for surgery they were given more corticosteroids to combat pain and inflammation. Or, they were prescribed opioids. Some people delayed surgery or treatment for fear of going to the doctors. Rapidly advancing joint destruction appears to be an after affect of the pandemic.
A March 2022 study (7) also suggested the problems of oxidative stress (premature aging, reduced immunity, compromised healing) share characteristics between orthopedic conditions and also in COVID-19. The paper authors write: “Their (oxidative stress, orthopedic conditions, COVID-19) separate connections to antibiotic resistant bacteria have also been examined. Several studies have reported higher risks of infections and severe outcomes in patients with rheumatoid arthritis, osteoarthritis, bone fractures and bone replacement surgeries. The major risk factor identified in all of the mentioned disorders is type 2 diabetes and obesity. . . . As mentioned by several authors, antibiotic resistance (a concern in infection following joint replacement) might become an even bigger problem, by prolonging itself in the post-pandemic era, and by becoming even more difficult to counteract.”
Our treatment options
As outlined above, numerous factors over the last two years have caused what many predict will be a joint replacement epidemic. Regardless of what caused the accelerated joint destruction, regenerative injection can help with joint degeneration.
In my practice, I use regenerative injection treatments to reduce or eliminate patients’ pain involving the musculoskeletal system, including but not limited to joints, tendons, ligaments, and muscles from head to toe. Generally about 80–90% of patients see improvement with this treatment protocol. Bone Marrow Aspirate stem cell therapy is the injection of a damaged area of the body with stem cells that have been drawn from the patient’s own bone marrow. Stem cells are “de-differentiated pluripotent” cells, which means that they continue to divide to create more stem cells; these eventually “morph” into the tissue needing repair—for our purposes, collagen, bone, and cartilage.
1 Lauwers M, Au M, Yuan S, Wen C. COVID-19 in Joint Ageing and Osteoarthritis: Current Status and Perspectives. International Journal of Molecular Sciences. 2022 Jan;23(2):720.
2 Snowden GT, Clement ND, Zhang S, Xue Q, Simpson AH. Orthopaedic long COVID-the unknown unknowns: are we facing a pandemic of avascular necrosis following COVID-19?. Bone & Joint Research. 2022 Jan 14;11(1):10-1.
3 Agarwala SR, Vijayvargiya M, Pandey P. Avascular necrosis as a part of ‘long COVID-19’. BMJ Case Reports CP. 2021 Jul 1;14(7):e242101.
4 Green G, Abbott S, Vyrides Y, Afzal I, Kader D, Radha S. The impact of the COVID-19 pandemic on the length of stay following total hip and knee arthroplasty in a high volume elective orthopaedic unit. Bone & Joint Open. 2021 Aug 2;2(8):655-60.
5 Farrow L, Gardner WT, Tang CC, Low R, Forget P, Ashcroft GP. Impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty: a retrospective cohort study. BMJ Quality & Safety. 2021 Sep 12.
6 Chen XT, Chung BC, Jones IA, Christ AB, Oakes DA, Gilbert PK, Longjohn DB, Lieberman JR, Heckmann ND. Patient Perception Regarding the Safety of Elective Joint Arthroplasty Surgery During the COVID-19 Pandemic. Arthroplasty Today. 2021 Oct 1;11:113-21.
7 Huzum B, Curpan AS, Puha B, Serban DN, Veliceasa B, Necoara RM, Alexa O, Serban IL. Connections between orthopedic conditions and oxidative stress: current perspective and the possible relevance of other factors, such as metabolic implications, antibiotic resistance, and COVID-19. Medicina. 2022 Mar 17;58(3):439.
February 23, 2023