Int J Stem Cells.  2017 Nov;10(2):179-183. 10.15283/ijsc17019.

Stem Cell Therapy for Avascular Necrosis of Femoral Head in Sickle Cell Disease: Report of 11 Cases and Review of Literature

• Sadat-Ali
• Azam MQ
• Elshabouri EM
• Tantawy AM
• Acharya S

• KMID: 2400872
• DOI: http://doi.org/10.15283/ijsc17019

Abstract

BACKGROUND AND OBJECTIVE
Sickle cell disease (SCD) is quite common in eastern Saudi Arabia and Avascular necrosis of femoral head (ANFH) occurs in 30% of the young patients leading to early joint arthroplasty. This study was conducted to assess the benefits of injection of osteoblasts in the avascular lesions of the head of femur.
PATIENTS AND METHODS
A preset technique was used, 10 CC of bone marrow aspiration was performed under local anesthesia and aseptic technique. Osteoblasts were separated from the bone marrow cells. The avascular area was drilled and 10 million osteoblasts were transplanted at the lesion site. Patients were seen in the out patient clinic after two weeks for removal of the suture and addressed the questionnaire and examined for the range of movement. The follow up MRI was performed at 4 months.
RESULTS
The average age was 20.2±3.9 years. The mean hemoglobin S was 81.6±4.8 percent. Quality of Life Score for Chronic Hip Disease was assessed and found at 8.6 (1 being the severe limitation and 10 being normal), whereas Harris hip score improved from 41.7±5.1 to 88.93±3.6 (p < 0.001). MRI of pre and post osteoblast implantation showed robust new bone formation and disappearance of the avascular lesions.
CONCLUSIONS
The short term results were good and we believe the injection of osteoblast in the avascular lesion of head of femur is a less invasive procedure devoid of any untoward complications and merits such treatment in large patient group with longer follow up.

Keyword

Sickle cell disease; Avascular necrosis of head of femur; Osteoblasts; Stem cell therapy

MeSH Terms

Anemia, Sickle Cell*
Anesthesia, Local
Arthroplasty
Bone Marrow
Bone Marrow Cells
Femur
Follow-Up Studies
Head*
Hemoglobin, Sickle
Hemoglobins
Hip
Humans
Joints
Magnetic Resonance Imaging
Necrosis*
Osteoblasts
Osteogenesis
Quality of Life
Saudi Arabia
Stem Cells*
Sutures
Hemoglobin, Sickle
Hemoglobins

Figure

• 

  Fig. 1 (A) Pre-injection of Osteoblasts in right head of femur. Arrows showing avascular lesions. (B) Post injection of Osteoblasts at 4 months. The red arrow shows the tract. Through which the osteoblasts were injected.

• 

  Fig. 2 (A) Preoperatively MRI of 22 year old female patient with avascular necrosis of the head of femur. (B) Post injection of osteoblasts MRI after 4 months. New bone formation (blue arrow) and healing of the avascular area is clearly seen. The tract of the injection is highlighted in red Arrow.

• 

  Fig. 3 (A) Pre- injection MRI of 19 year old female with changes in the head and neck of the femur, with avascular areas. (B) Post-Injection showing the remarkable comparative changes to Fig. 3A.

Reference

References

1. El-Hazmi MAF, Warsy AS. Hemoglobinopathies in Arab countries. Teebi AS, Farag TI, editors. Genetic disorders among Arab populations. New York: Oxford University Press;1997. p. 83–110.

2. Sadat-Ali M. Avascular necrosis of the femoral head in sickle cell disease. An integrated classification. Clin Orthop Relat Res. 1993; (290):200–205. PMID: 8472450.

3. Bozic KJ, Zurakowski D, Thornhill TS. Survivorship analysis of hips treated with core decompression for non-traumatic osteonecrosis of the femoral head. J Bone Joint Surg Am. 1999; 81:200–209. DOI: 10.2106/00004623-199902000-00007. PMID: 10073583.

4. Iorio R, Healy WL, Abramowitz AJ, Pfeifer BA. Clinical outcome and survivorship analysis of core decompression for early osteonecrosis of the femoral head. J Arthroplasty. 1998; 13:34–41. DOI: 10.1016/S0883-5403(98)90073-0. PMID: 9493536.

5. Hungerford DS. Pathogenesis of ischemic necrosis of the femoral head. Instr Course Lect. 1983; 32:252–260. PMID: 6546072.

6. Luo RB, Lin T, Zhong HM, Yan SG, Wang JA. Evidence for using alendronate to treat adult avascular necrosis of the femoral head: a systematic review. Med Sci Monit. 2014; 20:2439–2447. DOI: 10.12659/MSM.891123. PMID: 25424061. PMCID: 4257480.

7. Hernigou P, Bernaudin F, Reinert P, Kuentz M, Vernant JP. Bone-marrow transplantation in sickle-cell disease. Effect on osteonecrosis: a case report with a four-year follow-up. J Bone Joint Surg Am. 1997; 79:1726–1730. DOI: 10.2106/00004623-199711000-00015. PMID: 9384433.

8. Yoshioka T, Mishima H, Akaogi H, Sakai S, Li M, Ochiai N. Concentrated autologous bone marrow aspirate transplantation treatment for corticosteroid-induced osteonecrosis of the femoral head in systemic lupus erythematosus. Int Orthop. 2011; 35:823–829. DOI: 10.1007/s00264-010-1048-y. PMCID: 3103953.

9. Lee HS, Huang GT, Chiang H, Chiou LL, Chen MH, Hsieh CH, Jiang CC. Multipotential mesenchymal stem cells from femoral bone marrow near the site of osteonecrosis. Stem Cells. 2003; 21:190–199. DOI: 10.1634/stemcells.21-2-190. PMID: 12634415.

10. Li ZH, Liao W, Cui XL, Zhao Q, Liu M, Chen YH, Liu TS, Liu NL, Wang F, Yi Y, Shao NS. Intravenous transplantation of allogeneic bone marrow mesenchymal stem cells and its directional migration to the necrotic femoral head. Int J Med Sci. 2011; 8:74–83. DOI: 10.7150/ijms.8.74. PMID: 21234272. PMCID: 3020395.

11. Sen RK, Tripathy SK, Aggarwal S, Marwaha N, Sharma RR, Khandelwal N. Early results of core decompression and autologous bone marrow mononuclear cells instillation in femoral head osteonecrosis: a randomized control study. J Arthroplasty. 2012; 27:679–686. DOI: 10.1016/j.arth.2011.08.008.

12. Axelrod DA, Hayward R. Nonrandomized interventional study designs (Quasi-experimental designs). Penson DF, Wei JT, editors. Clinical research methods for surgeons. New York: Humana Press Inc;2006. p. 63–76.

13. Azam MQ, Sadat-Ali M. Early cementless total hip arthroplasty in young sickle cell patients: 4–12 year follow up. J Arthoplasty. 2016; 31:2536–2541. DOI: 10.1016/j.arth.2016.04.025.

14. Daltro GC, Fortuna VA, Salvino de Araújo MA, Lessa PIF, Sobrinho UAB, Borojevic R. Femoral head necrosis treatment with autologous stem cells in sickle cell disease. Acta Ortop Bras. 2008; 16:23–27. DOI: 10.1590/S1413-78522008000100004.

15. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clin Orthop Relat Res. 2002; (405):14–23. DOI: 10.1097/00003086-200212000-00003. PMID: 12461352.

16. Gangji V, De Maertelaer V, Hauzeur JP. Autologous bone marrow cell implantation in the treatment of non-traumatic osteonecrosis of the femoral head: five year follow-up of a prospective controlled study. Bone. 2011; 49:1005–1009. DOI: 10.1016/j.bone.2011.07.032. PMID: 21821156.

17. Wong RSY. Mesenchymal stem cells: angels or demons? J Biomed Biotechnol. 2011; DOI: 10.1155/2011/459510.