Post-COVID-19 avascular necrosis of the femoral head in Southeastern Europe    

Abstract
Aim: While acute outcomes of COVID-19 pandemic have been extensively documented, attention has recently shifted toward long‑term sequelae, including musculoskeletal complications such as avascular necrosis (AVN) of the femoral head. Our aim was to analyze the burden of musculoskeletal disorders in Southeastern European (SEE) countries, with emphasis on the “other musculoskeletal disorders” category that encompasses AVN, and to contextualize these findings against COVID-19 mortality and disability trends.
Methods: We carried out a comparative analysis across Albania, Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia, Serbia, and Slovenia using Global Burden of Disease (GBD) estimates. Age‑standardized mortality rates and disability‑adjusted life years (DALYs) were extracted for COVID‑19 (for the period 2020-2023) and musculoskeletal disorders (for 2020 and 2023).
Results: COVID‑19 mortality and DALYs peaked in 2021 across all SEE countries, followed by sharp declines in 2022 and 2023. Montenegro and North Macedonia consistently reported the highest values, whereas Croatia and Slovenia had comparatively lower burdens. In contrast, musculoskeletal disorders exhibited stable mortality and DALY rates between 2020 and 2023, with “other musculoskeletal disorders” contributing modest but persistent morbidity. AVN accounts for 8%-12% of primary hip arthroplasties in Europe, predominantly affecting adults aged 30-50 years, with case reports also from SEE region linking post‑COVID corticosteroid use to AVN onset.
Conclusion: Musculoskeletal disorders remain a substantial contributor to morbidity in SEE countries. AVN, though relatively rare, carries disproportionate disability and surgical burden. Pandemic‑related exposures may have amplified AVN risk in the SEE region, underscoring the need for improved surveillance, early diagnosis, and cautious corticosteroid management.
Keywords: avascular necrosis (AVN), avascular necrosis of femoral head, musculoskeletal disorders, orthopedy, other musculoskeletal disorders, post COVID-19, Southeastern Europe.