Retrospective cohort study assessing radiological outcomes and risk factors for progression of femoral head osteonecrosis in children with sickle cell disease, following bisphosphonate therapy, CD-BMAC and proximal femoral reorientation osteotomy.

AIM: To evaluate the radiological outcomes of femoral head osteonecrosis (FHO) in children with sickle cell disease (SCD), comparing non-operative treatment (bisphosphonates) and head-preserving surgical interventions-core decompression with bone marrow aspirate concentrate (CD-BMAC) and proximal femur reorientation osteotomy (PFRO)-by analyzing changes in Steinberg stage before treatment to final follow-up.

METHODS

Retrospective review of 28 hips from 17 pediatric SCD patients treated between 2010 and 2024, analyzed patient demographics, disease stage, treatment modalities, disease progression, and follow-up duration; and compared pre-collapse and post-collapse stages.

RESULTS

Among 75 hips with FHO in 51 children, 61 (81%) were non-traumatic. Of the 28 hips (13 pre-collapse, 15 post-collapse) in 17 children (mean age 11.6 years; 58.8% male), the average interval from SCD diagnosis to FHO onset was 78.8 months (Standard deviation-36.6). Treatments included bisphosphonates (11 hips), CD-BMAC (5), and PFRO (6). After excluding salvage procedures and lost follow-up, 20 hips were available for the final outcome analysis. At final follow-up (mean 30.7 months), FHO improved or remained stable in 15 hips (75%), while it progressed by at least 1 Steinberg stage in 5 hips (25%). In pre-collapse hips, no further disease progression was seen. In post-collapse cases, progression was noted in three of five bisphosphonate-treated hips and two CD-BMAC-treated hips; PFRO-treated hips showed no progression. Two hips developed arthritis.

CONCLUSION

Bisphosphonates, CD-BMAC, and PFRO prevent disease progression in pre-collapse hips. In post-collapse hips, PFRO showed no further progression, while CD-BMAC and bisphosphonates showed mixed results.

SIGNIFICANCE OF STUDY: Early radiological screening and intervention before femoral head collapse is critical to preserving joint anatomy.

LEVEL OF EVIDENCE: Level IV.