The Journal of Bone and Joint Surgery (American). 2006;88:2573-2582.
doi:10.2106/JBJS.E.01454
© 2006 The Journal of Bone and Joint Surgery, Inc.
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Physical Therapy Alone Compared with Core Decompression and Physical Therapy for Femoral Head Osteonecrosis in Sickle Cell Disease

Results of a Multicenter Study at a Mean of Three Years After Treatment

Lynne D. Neumayr, MD1, Christine Aguilar, MD1, Ann N. Earles, PNP2, Harry E. Jergesen, MD3, Charles M. Haberkern, MD, MPH4, Bamidele F. Kammen, MD1, Paul A. Nancarrow, MD1, Eric Padua, MD1, Meredith Milet, MPH5, Bernard N. Stulberg, MD6, Roger A. Williams, MD1, Eugene P. Orringer, MD7, Nora Graber, MS8, Shanda M. Robertson, BS1, Elliott P. Vichinsky, MD1 the National Osteonecrosis Trial in Sickle Cell Anemia Study Group

1 Departments of Hematology (L.D.N., C.A., S.M.R., and E.P.V.), Pediatric Rehabilitation (C.A.), Radiology (B.F.K., P.A.N., and E.P.), and Pathology (R.A.W.), Children's Hospital and Research Center, 747 52nd Street, Oakland, CA 94609. E-mail address for L.D. Neumayr: lneumayr{at}mail.cho.org
2 68-1979 Lina Poepoe Street, Waikoloa, HI 96738
3 Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU-320W, San Francisco, CA 94143
4 Department of Anesthesiology, Children's Hospital and Regional Medical Center, 4800 Sand Point Way N.E., Seattle, WA 98112
5 Environmental Health Investigations Branch, California Department of Health Services, 850 Marina Bay Parkway, Building P, 3rd Floor, Richmond, CA 94804
6 Cleveland Center for Joint Reconstruction, 1730 West 25th Street, Cleveland, OH 44113
7 University of North Carolina School of Medicine, 125 MacNider Building, CB 700, Chapel Hill, NC 27599
8 Rho Federal Systems, Inc., 6330 Quadrangle Drive, Suite 500, Chapel Hill, NC 27517

Investigation performed at the Children's Hospital and Research Center, Oakland, California, and fourteen other centers from the National Osteonecrosis in Sickle Cell Disease Network

In support of their research for or preparation of this manuscript, one or more of the authors received National Institutes of Health Grants 5-P60-HL20985 and M01-RR00046. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Osteonecrosis of the femoral head is a common complication in patients with sickle cell disease, and collapse of the femoral head occurs in 90% of patients within five years after the diagnosis of the osteonecrosis. However, the efficacy of hip core decompression to prevent the progression of osteonecrosis in these patients is still controversial.

Methods: In a prospective multicenter study, we evaluated the safety of hip core decompression and compared the results of decompression and physical therapy with those of physical therapy alone for the treatment of osteonecrosis of the femoral head in patients with sickle cell disease. Forty-six patients (forty-six hips) with sickle cell disease and Steinberg Stage-I, II, or III osteonecrosis of the femoral head were randomized to one of two treatment arms: (1) hip core decompression followed by a physical therapy program or (2) a physical therapy program alone. Eight patients withdrew from the study, leaving thirty-eight who participated.

Results: Seventeen patients (seventeen hips) underwent decompression combined with physical therapy, and no intraoperative or immediate postoperative complications occurred. Twenty-one patients (twenty-one hips) were treated with physical therapy alone. After a mean of three years, the hip survival rate was 82% in the group treated with decompression and physical therapy and 86% in the group treated with physical therapy alone. According to a modification of the Harris hip score, the mean clinical improvement was 18.1 points for the patients treated with hip core decompression and physical therapy compared with 15.7 points for those treated with physical therapy alone. With the numbers studied, the differences were not significant.

Conclusions: In this randomized prospective study, physical therapy alone appeared to be as effective as hip core decompression followed by physical therapy in improving hip function and postponing the need for additional surgical intervention at a mean of three years after treatment.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.


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