Treatment for avascular necrosis of bone in people with sickle cell disease

Bone Disease among Children with Sickle Cell Disease: A Scoping Review of Incidence and Interventions

Background

Children with sickle cell disease (SCD) are more likely to have deficient serum levels of vitamin D for bone metabolism. However, appropriate interventions are essential to prevent its progression and alleviate symptoms.

Purpose

The aim of this study is to determine interventions for managing bone disease in children with SCD.

Methods

This study uses a scoping review. A literature review was conducted using PubMed, CINAHL, ScienceDirect, Scopus, and Google Scholar search engines. The study was eligible for inclusion if it included articles published from 2013 to 2023, full-text, and original study design. Study quality was assessed using the Joanna Briggs Institute (JBI) appraisal tool.

Results

This review identified six studies and 114 children with SCD, including 57 boys (50%) and 57 girls (50%). The majority of SCD types experienced were HbSS (86.84%), HbS-B0 Thal (7.01%), HbSC (5.27%), and the HbSS Arab-Indian haplotype (0.88%). Bone disease problems that often arise in children with SCD include Avascular Necrosis (AVN) (78.08%), Osteonecrosis of the Femoral Head (ONFH) (18.42%), and other bone problems (3.50%). Meanwhile, four types of intervention findings were used in managing bone disease among children with SCD: 1). Surgical procedures 53 (41.09%) included total hip arthroplasty (THA), Osteotomy, and Multiple epiphyseal drilling with Autologous Bone Marrow Implantation (AMBI); 2). Invasive procedures 67 (51.93%) included intravenous bisphosphonates, hydroxyurea (HU), and core decompression (CD) with bone marrow aspirate concentrate injection: 3). Oral pharmacological or Vitamin D3 (cholecalciferol) 4 (3.10%); 4). Non-pharmacology or physical therapy 5 (3.88%).

Conclusion

Our findings highlight that surgical, invasive, pharmacological, and physical therapy interventions positively impact increasing bone mineral density (BMD) and functional improvement of bone disease among children with SCD. The interventions provided excellent functional outcomes with minimal complications and no life-threatening side effects.

Osteonecrosis of the Humeral Head 3 Years Following Fracture Fixation of a 4-Part Proximal Humerus Fracture: A Case Report

Introduction

Osteonecrosis (ON) of the humeral head is defined as "avascular" when the death of bone is due to a disrupted blood supply. It is a known complication following proximal humeral fractures and can lead to poor long-term outcomes and even additional revision surgeries.

Case Report

Patient AP developed symptomatic ON, 3 years following repair of a 4-part valgus impacted proximal humerus fracture. The point of interest in this case is the length of time from injury at which she developed symptomatic ON. Following surgical repair, she was seen at standard intervals, 6 weeks, 3-, 6-, and 12- month follow-ups and demonstrated an excellent recovery. By the 1 year follow-up appointment, she had obtained a range of motion in her left shoulder of 170° forward elevation and 60° in external rotation. At this point, she was able to discontinue physical therapy and was radiographically and clinically healed. However, 2 years after, she began experiencing sudden onset of pain with shoulder ROM and progressive limitation. She was diagnosed with an ON of her proximal humerus. The patient was prescribed a 3-month course of corticosteroid, 3 months following her operation for a gynecological-related issue. However, with strong progress being made 9 months after this prescription, and problems occurring over 2 years after taking the medication, it is unclear whether the ON was related to her fracture pattern or developed as a result of the corticosteroid usage or a combination of the 2 due to a "double hit."

Conclusion

This case review points out the potential need for continued monitoring even after radiographic and clinical healing is achieved in these injuries.

Radiological manifestation of avascular necrosis (AVN) in sickle cell disease (SCD): a review of diagnostic imaging

Symptomatic avascular necrosis (AVN) imposes a higher risk for acute care consumption in adults living with SCD. Symptomatic AVN, have higher rates of visits to the emergency department, higher rates of admissions, and longer lengths of stay in hospitals. Properly timed diagnosis and early interventions can reduce morbidity and enhance the quality of life in these patients. Vaso-occlusion secondary to sickling leads to osteonecrosis of the joint/bone (AVN, dactylitis) and invites infection (osteomyelitis and septic arthritis). Understanding and awareness of the imaging features related to this major morbidity complication are essential for early diagnosis and prompt management. In about half of the patients with SCD, AVN can lead to chronic pain, particularly in the head of the femur and humerus. Humeral and femoral head AVN tend to be linked with each other.  Vertebral bone compression and collapse secondary to AVN have also been reported.  The diagnosis of AVN must be accurate, as the condition is complex requiring specific treatment according to the grade of bone and joint involvement. There are several classifications or staging systems used for grading bone and joint involvement. Knowledge of the image patterns and grade of affection in different joints and bones and the degree of progression of AVN lesions can markedly improve management decisions on AVN-specific surgical versus non-surgical interventions and improve patient outcomes. The aim of this report is to summarize the different imaging techniques and their role in the proper/early diagnosis and follow up of patients with AVN with detailed examples of the common sites involved.

The impact of Hydroxyurea on the rates of Vaso-occlusive crises in patients with sickle cell disease in Saudi Arabia: a single-center study

BACKGROUND

Vaso-occlusive crises (VOCs) are acute and common painful complication of sickle cell disease (SCD), and are the main reason behind the frequent emergency department visits among SCD patients. Hydroxyurea (HU) is an old and commonly used medication that demonstrated its effectiveness in reducing the risk of VOCs and the incidence of hospitalization. Although multiple studies have examined the impact of HU on the rates of VOCs, few have explored its effectiveness among SCD patients in Saudi Arabia.

METHODS

This was a single-center retrospective cohort study in which the electronic medical records of patients with SCD who have not had any previous exposure to HU prior to the initiation of HU treatment for ≥12 months were recruited. Paired t-test was conducted to examine the difference in the rates of VOCs, and levels of hemoglobin (Hgb), hematocrit (HCT), and platelet counts (PLT Ct) prior to the initiation of HU therapy and 12 months later. Multiple linear regression was conducted to examine whether age, gender, use of opioid analgesics, Hgb, HCT, and PLT Ct levels predict higher or lower rates of VOCs.

RESULTS

One hundred and fifty-six patients met the inclusion criteria and were included in the analysis. About 51% of the patients were males, and their mean age was 12.69 years. The mean HU dosage was 16.52 mg/kg/day, and the mean reduction in the rate of VOCs was 1.36 events per patient per year (95% CI [1.03-1.70], p < 0.0001) after the initiation of HU. Females were more likely to have greater reduction in the rates of VOCs in comparison to their male counterparts (β-estimate = 12.85, 95% CI [0.759-24.93], p = 0.0374).

CONCLUSION

The use of HU results in a significant reduction in the rates of VOCs and emergency department visits. Future studies with robust research designs should be conducted to further examine the impact of HU on VOCs, hospitalization, and length of stay as well as compare HU to other newly approved medications for SCD, such as crizanlizumab.

Bone Infarcts and Tumorigenesis—Is There a Connection? A Mini-Mapping Review

(1) Background: Avascular necrosis (AVN) may affect every part of the bone. Epiphyseal infarcts are likely to be treated early because most are symptomatic. However, meta- and diaphyseal infarcts are silent and are diagnosed incidentally. Sarcomas developing in the necrotic bone are extremely rare, but they have been reported in the literature. (2) Methods: We conducted a mapping review of recent evidence regarding these malignancies. Methods: A mapping review using a systematic search strategy was conducted to answer research questions. We limited our research to the last ten years (2012–2022). (3) Results: A total of 11 papers were identified, including 9 case reports and 3 case series. The pathomechanism of carcinogenesis in AVN was not investigated to date. Histologically, most tumors were malignant fibrous histiocytoma. The prognosis is relatively poor, especially for patients with metastases, but adjuvant chemotherapy may increase short- and long-term survival. (4) Conclusions: Since AVN-related malignancies are sporadic, no prospective studies have been conducted. The majority of evidence comes from small case series. More research is needed to identify the risk factors that would justify follow-up of patients after bone infarcts at higher risk of developing a malignancy.

Sickle Cell Disease: A Review

IMPORTANCE

Sickle cell disease (SCD) is an inherited disorder of hemoglobin, characterized by formation of long chains of hemoglobin when deoxygenated within capillary beds, resulting in sickle-shaped red blood cells, progressive multiorgan damage, and increased mortality. An estimated 300 000 infants are born annually worldwide with SCD. Most individuals with SCD live in sub-Saharan Africa, India, the Mediterranean, and Middle East; approximately 100 000 individuals with SCD live in the US.

OBSERVATIONS

SCD is diagnosed through newborn screening programs, where available, or when patients present with unexplained severe atraumatic pain or normocytic anemia. In SCD, sickling and hemolysis of red blood cells result in vaso-occlusion with associated ischemia. SCD is characterized by repeated episodes of severe acute pain and acute chest syndrome, and by other complications including stroke, chronic pain, nephropathy, retinopathy, avascular necrosis, priapism, and leg ulcers. In the US, nearly all children with SCD survive to adulthood, but average life expectancy remains 20 years less than the general population, with higher mortality as individuals transition from pediatric to adult-focused health care systems. Until 2017, hydroxyurea, which increases fetal hemoglobin and reduces red blood cell sickling, was the only disease-modifying therapy available for SCD and remains first-line therapy for most individuals with SCD. Three additional therapies, L-glutamine, crizanlizumab, and voxelotor, have been approved as adjunctive or second-line agents. In clinical trials, L-glutamine reduced hospitalization rates by 33% and mean length of stay from 11 to 7 days compared with placebo. Crizanlizumab reduced pain crises from 2.98 to 1.63 per year compared with placebo. Voxelotor increased hemoglobin by at least 1 g/dL, significantly more than placebo (51% vs 7%). Hematopoietic stem cell transplant is the only curative therapy, but it is limited by donor availability, with best results seen in children with a matched sibling donor. While SCD is characterized by acute and chronic pain, patients are not more likely to develop addiction to pain medications than the general population.

CONCLUSIONS AND RELEVANCE

In the US, approximately 100 000 people have SCD, which is characterized by hemolytic anemia, acute and chronic pain, acute chest syndrome; increased incidence of stroke, nephropathy, and retinopathy; and a life span that is 20 years shorter than the general population. While hydroxyurea is first-line therapy for SCD, L-glutamine, crizanlizumab, and voxelotor have been approved in the US since 2017 as adjunctive or second-line treatments, and hematopoietic stem cell transplant with a matched sibling donor is now standard care for severe disease.

Severe Pain Profiles and Associated Sociodemographic and Clinical Characteristics in Individuals With Sickle Cell Disease

OBJECTIVE

The aim of this study was to identify classes of individuals with sickle cell disease (SCD) who share distinct severe pain profiles and evaluate differences in demographic, clinical, and psychosocial characteristics between classes.

METHODS

This exploratory, cross-sectional study used data collected for the SCD Implementation Consortium Research Registry at Duke University. Using Adult Sickle Cell Quality of Life-Measurement System pain-item data from 291 adults with SCD, latent class analysis was used to determine classes of individuals sharing distinct severe pain profiles. Bivariate analyses and logistic regression models were used to assess the relationships between pain profile classes and demographic, clinical, and psychosocial characteristics.

RESULTS

Three classes sharing distinct severe pain profiles were identified: Low Frequency and Impact class (n=73), Moderate Frequency and Impact class (n=94), and High Frequency and Impact class (n=124). When compared with the Low Frequency and Impact class and controlling for age and sex, individuals in the Moderate Frequency and Impact class were more likely to: be female (P=0.031) and unemployed (P=0.013); report worse sleep (P=0.005) and social functioning (P=0.005); have less emotional distress (P=0.004); describe pain as "sore" (P=0.002); and have previous SCD-related lung complications (P=0.016). When compared with the Low Frequency and Impact class, individuals in the High Frequency and Impact class: had worse social functioning (P<0.001) and previous SCD-related lung complications (P=0.006); described pain as "sore" (P<0.001); and were taking pain medication daily for SCD (P=0.001).

DISCUSSION

Severe pain experiences in SCD are complex; however, there are subgroups of people who report similar experiences of severe pain.

The Risk of Developing Osteoporosis in Hemolytic Anemia-What Aggravates the Bone Loss?

Hemolytic anemia (HA) renders erythropoietic stress on the bone marrow and has been linked to osteoporosis. In this nationwide retrospective cohort study, we examined this correlation by utilizing the Taiwan National Health Insurance Research Database (NHIRD). We identified two cohorts, matching population with and without HA in a 1:4 ratio. A total of 2242 HA patients and 8968 non-HA patients were enrolled. Patients with HA had a significantly higher cumulative incidence (log-rank test p = 0.0073), higher incidence density (5.11 vs. 3.76 per 1000 persons-years), and a 1.31-fold risk of developing osteoporosis than non-HA patients (aHR = 1.31, 95% C.I. 1.04-1.63, p = 0.01). After adjusting for age, sex, and comorbidities, patients with factors including female (aHR = 2.57, 95% C.I. 2.05-3.22, p < 0.001), age > 65 (aHR = 9.25, 95% C.I. 7.46-11.50, p < 0.001), diagnosis of cholelithiasis (aHR = 1.76, 95% C.I. 1.20-2.58, p = 0.003) and peptic ulcer disease (aHR = 1.87, 95% C.I. 1.52-2.29, p < 0.001) had significantly higher risk of osteoporosis. We propose that this correlation may be related to increased hematopoietic stress, increased consumption of nitric oxide (NO) by hemolysis, and the inhibitory effects of iron supplements on osteogenesis through the receptor activator of nuclear factor κB ligand (RANKL)/Osteoprotegerin pathway and the Runt-related transcription factor 2 (RUNX2) factor. Our findings suggest that patients with hemolytic anemia are at a higher risk of developing osteoporosis, and it would be in the patient's best interest for physicians to be aware of this potential complication and offer preventative measures.

Considerations for Cannabis Use to Treat Pain in Sickle Cell Disease

Pain in Sickle Cell Disease (SCD) is a major comorbidity and unique with acute pain due to recurrent and episodic vaso-occlusive crises as well as chronic pain, which can span an individual's entire life. Opioids are the mainstay treatment for pain in SCD. Due to recent health crises raised by adverse effects including deaths from opioid use, pain management in SCD is adversely affected. Cannabis and its products are most widely used for pain in multiple conditions and also by patients with SCD on their own. With the availability of "Medical Cannabis" and approval to use cannabis as medicine across majority of States in the United States as well as over-the-counter preparations, cannabis products are being used increasingly for SCD. The reliability of many of these products remains questionable, which poses a major health risk to the vulnerable individuals seeking pain relief. Therefore, this review provides up to date insights into available categories of cannabis-based treatment strategies, their mechanism of action and pre-clinical and clinical outcomes in SCD. It provides evidence for the benefits and risks of cannabis use in SCD and cautions about the unreliable and unvalidated products that may be adulterated with life-threatening non-cannabis compounds.