Managing femoral head osteonecrosis in patients with sickle cell disease

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

BACKGROUND

Avascular necrosis of bone is a frequent and severe complication of sickle cell disease and its treatment is not standardised. This is an update of a previously published Cochrane Review.

OBJECTIVES

To determine the impact of any surgical procedure compared with other surgical interventions or non-surgical procedures, on avascular necrosis of bone in people with sickle cell disease in terms of efficacy and safety.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional trials were sought from both ongoing trial registries and the reference lists of papers identified by the search strategy. Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 17 September 2019.

SELECTION CRITERIA

Randomized clinical trials comparing specific therapies for avascular necrosis of bone in people with sickle cell disease.

DATA COLLECTION AND ANALYSIS

Each author independently extracted data and assessed trial quality. The quality of the evidence was assessed using GRADE. Given only one trial was identified, meta-analyses were not possible.

MAIN RESULTS

One trial (46 participants) was eligible for inclusion. After randomization eight participants were withdrawn, mainly because they declined to participate in the trial. Data were analysed for 38 participants at the end of the trial. After a mean follow-up of three years, hip core decompression and physical therapy did not show clinical improvement when compared with physical therapy alone using the score from the original trial (an improvement of 18.1 points for those treated with intervention therapy versus an improvement of 15.7 points with control therapy). We are very uncertain whether there is any difference between groups regarding major complications (hip pain, risk ratio 0.95 (95% confidence interval 0.56 to 1.60; vaso-occlusive crises, risk ratio 1.14 (95% confidence interval 0.72 to 1.80; very low quality of evidence); and acute chest syndrome, risk ratio 1.06 (95% confidence interval 0.44 to 2.56; very low quality of evidence)). This trial did not report results on mortality or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence that adding hip core decompression to physical therapy achieves clinical improvement in people with sickle cell disease with avascular necrosis of bone compared to physical therapy alone. However, we highlight that our conclusion is based on one trial with high attrition rates. Further randomized controlled trials are necessary to evaluate the role of hip-core depression for this clinical condition. Endpoints should focus on participants' subjective experience (e.g. quality of life and pain) as well as more objective 'time-to-event' measures (e.g. mortality, survival, hip longevity). The availability of participants to allow adequate trial power will be a key consideration for endpoint choice.

Translation, and interobserver and test-retest reliability of the Brazilian Portuguese version of Children's Hospital Oakland Hip Evaluation Scale for patients with sickle cell disease

BACKGROUND

The Children's Hospital Oakland Hip Evaluation Scale is a disease-specific tool for the clinical and functional assessment of the hip in sickle cell disease.

OBJECTIVES

To translate the tool into Brazilian Portuguese and evaluate the interobserver and test-retest reliability.

METHODS

Eighteen patients diagnosed with sickle cell disease and a mean age of 49±11.9 years participated in the study. The scale was applied by two evaluators who did not speak to each other regarding their understanding of the tool and who had no prior training. Interobserver and test-retest reliability of individual items and of the total score were evaluated using the intraclass correlation coefficient and the Bland-Altman method.

RESULTS

When the overall score for each hip was considered, the test-retest intraclass correlation coefficient score for the right hip was 0.95 (0.89-0.98) and for the left hip it was 0.96 (0.91-0.98). Considering all assignments (total score), the score was 0.96 (0.90-0.98). The test-retest intraclass correlation coefficient varied from 0.76 to 1 for 18 of the 27 items (excellent) and from 0.53 to 0.75 for nine items (moderate). When the overall score for each hip was considered, the interobserver intraclass correlation coefficient for both hips was 0.94 (0.86-0.98). Considering all assignments, the total score was 0.94 (0.86-0.98). The interobserver intraclass correlation coefficient varied from 0.48 to 0.75 for 18 out of 27 items (moderate) and varied from 0.77 to 1 for the remaining nine items (excellent).

CONCLUSION

The results demonstrate that the Brazilian version of the Children's Hospital Oakland Hip Evaluation Scale presented adequate interobserver and test-retest reliability and that the version can be used to evaluate clinical function in sickle cell disease patients, producing consistent, standardized and reproducible results.

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

BACKGROUND

Avascular necrosis of bone is a frequent and severe complication of sickle cell disease and its treatment is not standardised. This is an update of a previously published Cochrane Review.

OBJECTIVES

To determine the impact of any surgical procedure compared with other surgical interventions or non-surgical procedures, on avascular necrosis of bone in people with sickle cell disease in terms of efficacy and safety.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional trials were sought from the reference lists of papers identified by the search strategy.Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 27 May 2016.

SELECTION CRITERIA

Randomized clinical trials comparing specific therapies for avascular necrosis of bone in people with sickle cell disease.

DATA COLLECTION AND ANALYSIS

Each author independently extracted data and assessed trial quality. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

One trial (46 participants) was eligible for inclusion. After randomization eight participants were withdrawn, mainly because they declined to participate in the trial. Data were analysed for 38 participants at the end of the trial. After a mean follow up of three years, hip core decompression and physical therapy did not show clinical improvement when compared with physical therapy alone using the score from the original trial (an improvement of 18.1 points for those treated with intervention therapy versus an improvement of 15.7 points with control therapy). There was no significant statistical difference between groups regarding major complications (hip pain, risk ratio 0.95 (95% confidence interval 0.56 to 1.60; vaso-occlusive crises, risk ratio 1.14 (95% confidence interval 0.72 to 1.80; very low quality of evidence); and acute chest syndrome, risk ratio 1.06 (95% confidence interval 0.44 to 2.56; very low quality of evidence)). This trial did not report results on mortality or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence that adding hip core decompression to physical therapy achieves clinical improvement in people with sickle cell disease with avascular necrosis of bone compared to physical therapy alone. However, we highlight that our conclusion is based on one trial with high attrition rates. Further randomized controlled trials are necessary to evaluate the role of hip-core depression for this clinical condition. Endpoints should focus on participants' subjective experience (e.g. quality of life and pain) as well as more objective 'time-to-event' measures (e.g. mortality, survival, hip longevity). The availability of participants to allow adequate trial power will be a key consideration for endpoint choice.

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

BACKGROUND

Avascular necrosis of bone is a frequent and severe complication of sickle cell disease and its treatment is not standardised.

OBJECTIVES

To determine the impact of any surgical procedure compared with other surgical interventions or non-surgical procedures, on avascular necrosis of bone in people with sickle cell disease in terms of efficacy and safety.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional trials were sought from the reference lists of papers identified by the search strategy.Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 17 March 2014.

SELECTION CRITERIA

Randomised clinical trials comparing specific therapies for avascular necrosis of bone in people with sickle cell disease.

DATA COLLECTION AND ANALYSIS

Each author independently extracted data and assessed trial quality. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

One trial (46 participants) was eligible for inclusion. After randomisation eight participants were withdrawn, mainly because they declined to participate in the trial. Data were analysed for 38 participants at the end of the trial. After a mean follow up of three years, hip core decompression and physical therapy did not show clinical improvement when compared with physical therapy alone using the score from the original trial (an improvement of 18.1 points for those treated with intervention therapy versus an improvement of 15.7 points with control therapy). There was no significant statistical difference between groups regarding major complications (hip pain, relative risk (RR) 0.95 (95% confidence interval (CI) 0.56 to 1.60; vaso-occlusive crises, RR 1.14 (95% CI 0.72 to 1.80; very low quality of evidence); and acute chest syndrome, RR 1.06 (95% CI 0.44 to 2.56; very low quality of evidence)). This trial did not report results on mortality or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence that adding hip core decompression to physical therapy achieves clinical improvement in people with sickle cell disease with avascular necrosis of bone compared to physical therapy alone. However, we highlight that our conclusion is based on one trial with high attrition rates. Further randomised controlled trials are necessary to evaluate the role of hip-core depression for this clinical condition. Endpoints should focus on participants' subjective experience (e.g. quality of life and pain) as well as more objective 'time-to-event' measures (e.g. mortality, survival, hip longevity). The availability of participants to allow adequate trial power will be a key consideration for endpoint choice.

An update on the recent literature on sickle cell bone disease

PURPOSE OF REVIEW

To summarize the findings of the recent publications on sickle cell bone disease (SBD).

RECENT FINDINGS

Individuals with sickle cell disease (SCD) are living longer and develop progressive organ damage including SBD with age. Recent studies suggest alternative radiological diagnostics such as ultrasound and scintigraphy can detect and differentiate between different forms of SBD. MRI with or without diffusion-weighted sequences remains the gold standard. Case reports of cranio-orofacial SBD highlight the rarity of this presentation. Vitamin D deficiency is highly prevalent at all ages, but may not be an independent risk factor for avascular necrosis (AVN). Gene polymorphisms of the Annexin A gene may predict AVN in SCD. A recent study demonstrated reduced days with pain and improved physical activity quality of life following high-dose vitamin D therapy. The high rates of osteopenia and osteoporosis in SCD support the need for research addressing this rising public health problem. Lastly, results of total hip arthroplasty for AVN in SCD has improved significantly over time with the use of cementless prosthetic material and improved supportive care.

SUMMARY

SBD remains poorly studied. Prospective randomized studies targeting predictors, diagnostics, prevention, and treatment options for SBD are sorely needed.

The pathogenesis of nontraumatic osteonecrosis

Nontraumatic osteonecrosis continues to be a challenging problem causing debilitating major joint diseases. The etiology is multifactorial, but steroid- and alcohol-induced osteonecrosis contribute to more than two thirds of all cases with genetic risk factors playing an important role in many other cases, especially when they contribute to hypercoagulable states. While the exact mechanisms remain elusive, many new insights have emerged from research in the last decade that have given us a clearer picture of the pathogenesis of nontraumatic osteonecrosis of the femoral head. Progression to end stage osteonecrosis of the femoral head appears to be related to four main factors: interactions involving the differentiation pathway of osteoprogenitor cells that promote adipogenesis, decreased angiogenesis, direct suppression of osteogenic gene expression and proliferation of bone marrow stem cells, and genetic anomalies or other diseases that promote hypercoagulable states.

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

BACKGROUND

Avascular necrosis of bone is a frequent and severe complication of sickle cell disease and its treatment is not standardised.

OBJECTIVES

To determine the impact of any surgical procedure compared with other surgical interventions or non-surgical procedures, on avascular necrosis of bone in people with sickle cell disease in terms of efficacy and safety.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional trials were sought from the reference lists of papers identified by the search strategy.Date of the most recent search of the Group's Haemoglobinopathies Trials Register: 21 February 2012.

SELECTION CRITERIA

Randomised clinical trials comparing specific therapies for avascular necrosis of bone in people with sickle cell disease.

DATA COLLECTION AND ANALYSIS

Each author independently extracted data and assessed trial quality. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

One trial (46 participants) was eligible for inclusion. After randomisation eight participants were withdrawn, mainly because they declined to participate in the trial. Data were analysed for 38 participants at the end of the trial. After a mean follow up of three years, hip core decompression and physical therapy did not show clinical improvement when compared with physical therapy alone using the score from the original trial (an improvement of 18.1 points for those treated with intervention therapy versus an improvement of 15.7 points with control therapy). There was no significant statistical difference between groups regarding major complications (hip pain, relative risk (RR) 0.95 (95% confidence interval (CI) 0.56 to 1.60; vaso-occlusive crises, RR 1.14 (95% CI 0.72 to 1.80); and acute chest syndrome, RR 1.06 (95% CI 0.44 to 2.56)). This trial did not report results on mortality or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence that adding hip core decompression to physical therapy achieves clinical improvement in people with sickle cell disease with avascular necrosis of bone compared to physical therapy alone. However, we highlight that our conclusion is based on one trial with high attrition rates. Further randomised controlled trials are necessary to evaluate the role of hip-core depression for this clinical condition. Endpoints should focus on participants' subjective experience (e.g. quality of life and pain) as well as more objective 'time-to-event' measures (e.g. mortality, survival, hip longevity). The availability of participants to allow adequate trial power will be a key consideration for endpoint choice.

Risk factors and impact of orthopaedic monitoring on the outcome of avascular necrosis of the femoral head in adults with sickle cell disease: 215 patients case study with control group

INTRODUCTION

Sickle cell disease is a public health problem. The WHO has recommended that global management be implemented to reduce mortality and morbidity. Since no comprehensive care programme for bone and joint complications exists, the Caribbean Sickle Cell Disease Center added orthopaedic consultation to screen for and monitor these complications in 1992.

HYPOTHESIS

Comprehensive medical and surgical care of patients with sickle cell disease will reduce the complications and disability associated with this disease.

POPULATIONS AND METHODS

Two populations were compared to evaluate the impact of comprehensive disease management on the occurrence of avascular necrosis (AVN) of the femoral head (femoral head AVN). The case-control series, [E-1994], included 115 patients (58 SS and 57 S) without orthopaedic monitoring and was evaluated retrospectively. The other patient series, [E-2008], included 215 patients (94 SS and 121 SC) with systematic orthopaedic care and was followed prospectively. Age, gender, duration of follow-up, haemoglobin levels, genotype, pain before treatment, associated humerus AVN and leg ulcers were analysed.

RESULTS

Femoral head AVN occurred in young adult patients (35.3 ± 4 years for [E-1994] and 29 ± 3.4 years for [E-2008]). Only elevated haemoglobin levels were associated with the occurrence of femoral head AVN, which suggests that increased blood viscosity contributes to the condition ([E-1994], P<0.0001; [E-2008], P=0.001). Treatment in [E-2008] patients reduced the number of femoral head AVN cases from 36.5% in [E-1994] to 14.4% in [E-2008] (P<0.0001).

DISCUSSION

The prevention and management of femoral head AVN must include medical treatment of the disease to reduce the occurrence of painful vaso-occlusive crises, which are known to trigger femoral head AVN. The effectiveness of this programme hinged on identifying risk factors and using simple approaches (hydration, pain medication, rest and crutches) to manage painful joint crises before femoral head AVN appeared. These approaches could be implemented in disadvantaged countries where sickle cell disease is prevalent.

CONCLUSION

By knowing the risk factors, symptomatic patients who are at risk for femoral head AVN can be identified and additional evaluations can be performed early on in cases of hip pain.

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

BACKGROUND

Avascular necrosis of bone is a frequent and severe complication of sickle cell disease (SCD) and its treatment is not standardised.

OBJECTIVES

To determine the impact of any surgical procedure compared with other surgical interventions or non-surgical procedures, on avascular necrosis of bone in people with SCD in terms of efficacy and safety.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Haemoglobinopathies Trials Register, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Additional trials were sought from the reference lists of papers identified by the search strategy.Most recent search: 27 March 2009.

SELECTION CRITERIA

Randomised clinical trials comparing specific therapies for avascular necrosis of bone in people with SCD.

DATA COLLECTION AND ANALYSIS

Each author independently extracted data and assessed trial quality. Since only one trial was identified, meta-analysis was not possible.

MAIN RESULTS

One trial (46 participants) was eligible for inclusion. After randomisation eight participants were withdrawn, mainly because they declined to participate in the trial. Data were analysed for 38 participants at the end of the trial. After a mean follow up of three years, hip core decompression and physical therapy did not show clinical improvement when compared with physical therapy alone using the score from the original trial (an improvement of 18.1 points for those treated with intervention therapy versus an improvement of 15.7 points with control therapy). There was no significant statistical difference between groups regarding major complications (hip pain, relative risk (RR) 0.95 (95% confidence interval (CI) 0.56 to 1.60; vaso-occlusive crises, RR 1.14 (95% CI 0.72 to 1.80); and acute chest syndrome, RR 1.06 (95% CI 0.44 to 2.56)). This trial did not report results on mortality or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence that adding hip core decompression to physical therapy achieves clinical improvement in people with SCD with avascular necrosis of bone compared to physical therapy alone. However, we highlight that our conclusion is based on one trial with high attrition rates. Further randomised controlled trials are necessary to evaluate the role of hip-core depression for this clinical condition. Endpoints should focus on participants' subjective experience (e.g. quality of life and pain) as well as more objective 'time-to-event' measures (e.g. mortality, survival, hip longevity). The availability of participants to allow adequate trial power will be a key consideration for endpoint choice.