Orthopaedics-Traumatology Unit, Pointe-à-Pitre University Hospital Center (UHC), CHU de Pointe-à-Pitre, 97159 Guadeloupe, France.
Orthop Traumatol Surg Res. 2009 Nov;95(7):498-504. doi: 10.1016/j.otsr.2009.07.009. Epub 2009 Oct 3.
The young age of patients, total arthroplasties complications risks, and implant costs justify evaluation of the results of core decompression in the treatment of sickle-cell disease avascular necrosis of the femoral head (ONFH).
In sickle-cell disease necrosis, core decompression offers good relief from pain and delays the use of total arthroplasty in comparison to a conservatively treated control group by a simple non-weight bearing protocol.
From 1994 to 2008, among 215 drepanocytic adults, 42 patients (22 genotype SS, 20 genotype SC; 15 men, 27 women) presented symptomatic ONFH. We report the data from a prospective study of two patients' groups: a non-operated group (16 patients aged 36.5+/-6.5 years, 23 hips) and an operated group (26 patients aged 30.3+/-2.8 years, 42 hips). The results were considered on the basis of change in clinical status according to the numeric evaluation of pain scale, the functional score of Merle d'Aubigné-Postel (MAP), the radiological progression of lesions, and the time delay to total arthroplasty.
Twenty-three hips were conservatively treated by discharge (a pair of canes). After a follow-up period of 13.4+/-0.5 years, no pain improvement was noted (p=0.76), and MAP score was unchanged (p=0.27). Out of 23 hips managed by discharge, 9 stage IV hips (degenerative arthritis, 39.1%) underwent arthroplasty after an average delay of 2.6+/-2.4 years. Forty-two hips were treated by core decompression. The duration of follow-up was 11.3+/-1.8 years. Postoperatively, pain reduction and MAP score improvement were significant in 39 out of 42 hips (93%, p<0.0001). Twenty-nine out of these 42 hips had a favorable evolution. Ten hips (23.8%) progressed to total arthroplasty, after a period of 7.4+/-2.7 years, longer than the one of the non-operated group (p=0.0007). By comparing the two groups (operated and non-operated), the benefit of core decompression appeared very significant (p<0.0001). In addition to allocating patients osteonecrosis stages, the Koo and Kim Index estimated the severity and evolution of necrotic lesions in both groups. It indicated decline in the non-operated group (p=0.002) and improvement for operated patients (p=0.0002).
Core decompression had a favorable clinical and radiological outcome superior to surgical abstention. Stages I and II ONFH remained stable after drilling, necessitating no arthroplasty (considered as a failure of drilling). The Koo and Kim Index above 30 degrees in the non-operated group was a significant indicator of lesions degradation (p=0.002). In addition to the indolence obtained by core decompression, the benefit of drilling was manifested by the prolonging the adjournment before arthroplasty end-point. It was respectively 7.4+/-2.7 years in the operated group versus 2.6+/-2.4 years in the non-operated group (difference of 4.8 years, p<0.01).
The technique of core decompression remains a valid option place in the treatment sickle-cell disease avascular necrosis of the femoral head (ONFH). It may be especially recommended in under-equipped regions where drepanocytosis and its osteo-articular complications are frequent.
Level III case-control therapeutic study.
患者年龄较轻、全髋关节置换术并发症风险高以及植入物成本等因素，都使得评估核心减压术治疗镰状细胞病股骨头坏死（ONFH）的效果具有重要意义。
与保守治疗的对照组相比，在镰状细胞病性坏死中，核心减压术通过简单的非负重方案提供了良好的疼痛缓解效果，并延迟了全髋关节置换术的使用。
1994 年至 2008 年，在 215 例镰状细胞病成年患者中，42 例患者（22 例基因型 SS，20 例基因型 SC；15 名男性，27 名女性）出现了症状性 ONFH。我们报告了来自两组前瞻性研究的数据：一组未手术组（16 例患者，年龄 36.5+/-6.5 岁，23 髋）和一组手术组（26 例患者，年龄 30.3+/-2.8 岁，42 髋）。根据疼痛量表的数值评估、Merle d'Aubigné-Postel（MAP）功能评分、病变进展的放射学以及全髋关节置换术的延迟时间，来评估临床状况的变化。
23 髋采用保守治疗（一对拐杖）出院。随访 13.4+/-0.5 年后，没有疼痛改善（p=0.76），MAP 评分也没有变化（p=0.27）。在出院管理的 23 髋中，9 髋（退行性关节炎，39.1%）在平均 2.6+/-2.4 年后进展为 IV 期，接受了关节置换术。42 髋接受了核心减压术治疗。随访时间为 11.3+/-1.8 年。术后 39 髋（93%，p<0.0001）疼痛减轻，MAP 评分改善。在这 42 髋中，29 髋有良好的演变。10 髋（23.8%）在 7.4+/-2.7 年后进展为全髋关节置换术，比未手术组的时间更长（p=0.0007）。通过比较两组（手术组和未手术组），核心减压术的效果非常显著（p<0.0001）。除了分配患者的骨坏死分期外，Koo 和 Kim 指数还估计了两组患者坏死病变的严重程度和演变。它表明未手术组下降（p=0.002），而手术组改善（p=0.0002）。
核心减压术的临床和放射学结果优于手术回避。钻孔后 I 期和 II 期 ONFH 保持稳定，无需关节置换（被认为是钻孔失败）。非手术组的 Koo 和 Kim 指数大于 30 度是病变恶化的显著指标（p=0.002）。除了通过核心减压术获得的缓解外，钻孔的益处还表现为在关节置换术终点之前延迟的时间延长。手术组分别为 7.4+/-2.7 年，未手术组为 2.6+/-2.4 年（差异为 4.8 年，p<0.01）。
核心减压术仍然是治疗镰状细胞病股骨头坏死（ONFH）的有效方法。在镰状细胞病及其骨关节炎并发症频繁发生的欠发达地区，它可能特别推荐使用。
III 级病例对照治疗研究。
