CONSERVATIVE SURGICAL TREATMENT OF OSETONECROSIS OF THE FEMORAL HEAD IN SICKLE CELL ANAEMIA PATIENTS: OUTCOME AT TWO TO TEN YEARS IN 21 PATIENTS TREATED WITH DRILL-BIOPSY AND THREE TREATED WITH FEMORAL OSTEOTOMY

Abstract

Purpose: Patients with sickle-cell anaemia tolerate surgery poorly. They are susceptible to infections and results of orthopaedic treatment are uncertain. Mechanical and infectious complications of total hip arthroplasty encountered in adults have led us to conduct systematic screening and early conservative surgical treatment for osteonecrosis of the femoral head (ONFH). Two surgical techniques have been retained in sickle-cell anaemia patients: simple drilling and femoral osteotomy.

Material and methods: Between 1993 and 1999, among 248 sickle-cell anaemia patients examined in our study, 69 had active or quiescent ONFH: stage I=1, stage II=42, stage III=16, stage IV=10. We retained for analysis 16 patients (7 SS and 8 SC, 1 S-betathal), seven men and nine women, age range 15–44 years. These patients had 24 hips with active disease. Simple drilling-biopsy was indicated for osteochondrosis of the hip joint (n=1), stage I ONFH (n=1), stage II ONFH (n=13, early stage III ONFH (n=3) and advanced stage III ONFH (n=3). These three patients with advanced stage III disease underwent drilling for two particular indications: poor general status and disabling pain. Flexion femoral osteotomy was performed for the last three patients with stage III ONFH with localised polar weakening. In all, we performed three femoral osteotomies and 21 simple drilling procedures. Mean postoperative follow-up was six years (2–10).

Results: Clinical results were assessed with the Postel-Merle-d’Aubligné score. Among the 24 hips, 20 had a favourable outcome (83%).

Discussion: ONFH in sickle-cell anaemia patients requires surgical cure when the femoral heads display recent changes of the bony network (osteolysis, defects) and associated cephalic remodelling with or without pain. After drilling and osteotomy, the disease course shows that the femoral head’s spherical shape is preserved when the lesions are treated early by drilling in stage I, II, and III disease. Bipolar weakening remains an indication for femoral osteotomy. This conservative approach can prevent osteoarthritic degradation. It has enabled us to postpone total hip arthroplasty in young subjects with sickle-cell anaemia.