Post-COVID Steroid AVN of the Hip in Young Adults

One of the clinical challenges with AVN is that early-stage disease is often subtle. The symptoms in stages 1 and 2 — when joint preservation is still feasible — may be easily attributed to other causes, leading to delays in the right investigation.

Typical early symptoms

• Groin pain — dull, aching discomfort in the groin or upper inner thigh, often on one side (though bilateral disease is common with steroid-related AVN). May be worse on walking or after activity and ease with rest.
• Hip stiffness — reduced range of motion, particularly internal rotation of the hip, is an early clinical sign. Patients sometimes describe difficulty crossing their legs or putting on shoes.
• Pain on loading — pain that worsens when bearing weight on the affected side, or a subtle change in gait.
• Night pain — aching at rest or at night can occur, though it is more typical of later stages.

Importantly, the severity of symptoms does not reliably indicate the stage of AVN. Some patients with stage 2 disease have significant pain; others with early collapse (stage 3) are still relatively functional. The stage is determined by imaging, not by how much it hurts.

Why X-ray misses early AVN — and why this matters

X-rays show bone changes only after structural loss is already significant. In stages 1 and 2 of AVN, the femoral head remains round and intact — the necrosis is happening inside the bone, and plain films appear normal. A patient presenting with groin pain after COVID steroid treatment who has a normal X-ray should not be reassured.

MRI is the investigation of choice for suspected early AVN. It can detect marrow changes and the necrotic lesion before any collapse has occurred. This matters because stage 1 and stage 2 AVN — the stages detectable only on MRI — are the stages where joint-preserving intervention may still be an option. Once the femoral head collapses (stage 3 onward), that window closes.

The most common and emotionally significant question a young adult with post-COVID AVN asks is: "Do I need a hip replacement?" The honest answer is: it depends on the stage at diagnosis.

Joint-preserving approaches (stages 1–2)

When the femoral head has not yet collapsed, preserving the joint is the goal. Joint-preserving options that may be considered include:

• Core decompression — drilling into the necrotic zone to reduce intraosseous pressure and stimulate revascularisation. The appropriateness depends on lesion size and location; outcomes are better for smaller, earlier lesions.
• Osteotomy — repositioning the femoral head so that the necrotic zone is moved out of the load-bearing area of the joint. Used in selected younger patients with a lesion geometry that makes this mechanically feasible.
• Protected weight-bearing — reducing load on the affected hip during the vulnerable period. Rarely used as a standalone treatment; typically part of a broader management plan.

Not every early-stage case is a candidate for every procedure. The necrotic lesion's size, location, and the patient's overall health, activity demands and bilateral involvement all inform what is realistic. A careful assessment — not a protocol — determines the plan.

Hip replacement (stages 3–4)

When significant collapse has occurred, the joint surface is permanently damaged and joint-preserving procedures are unlikely to succeed. Total hip replacement (THR) removes the collapsed femoral head and damaged socket and replaces them with durable implants, restoring pain-free movement.

In a patient in their 30s or 40s, the implant's longevity and the possibility of revision surgery in later decades are discussed explicitly. This makes the decision more complex than for an older patient — which is another reason why catching AVN early matters so much.

For more on hip replacement, see: Hip Replacement in Surat. For the general AVN overview, see: AVN Hip Treatment in Surat.

Post-COVID and steroid-related AVN in young adults is not a condition that benefits from watchful waiting. The treatment options available depend critically on the stage at which the patient is assessed — and that stage is only determinable with an MRI.

Dr. Aman Khanna holds an M.S. in Orthopaedics from Government Medical College, Surat and has been in orthopaedic practice since 2016. His fellowship in Sports Medicine, Hip & Knee at Lyon Croix-Rousse University Hospital, France (2021) provided specific exposure to hip preservation and reconstruction in a high-volume setting, including the range of joint-preserving procedures considered in younger patients with AVN. His IOA Clinical Fellowship in Arthroscopy (2024) broadens the joint-level assessment he applies to complex hip cases.

When a patient presents with possible post-COVID AVN, the assessment includes a full history of steroid exposure, alcohol use, trauma and haematological conditions; review of any existing imaging; and MRI if not already done. Both hips are evaluated, given the frequency of bilateral involvement with steroid-related AVN. The treatment plan is individualised based on staging and lesion characteristics — joint-preserving options are explored before replacement is recommended where the stage permits.

Full credentials are listed on the About page. The full range of hip procedures is described on the Services page.