« Previous Article
Next Article »

Original Research (Original Article) 


Abdulhakam Ahmed et al, 2020;4(2):469–472.

International Journal of Medicine in Developing Countries

Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia

Abdulhakam Ahmed1, Asmaa Khalid Hassan Abdelkarim1, Tahani Rajab Ali Alzahrani1, Saeed Faleh Saeed Alshahrani2, Abdulaziz Khalid Saleh Alghamdi1, Abdullah Nasser H. Leslom1

Correspondence to: Abdulhakam Ahmed

*King Fahad Hospital, Al Baha, Saudi Arabia.

Email: x3zx11 [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 30 December 2019 | Accepted: 09 January 2020


ABSTRACT

Background:

Sickle cell disease (SCD) is an autosomal recessive disorder characterized by the production of abnormal hemoglobin S and is associated with high morbidity and mortality. The current study was aimed to determine the incidence of avascular necrosis (AVN) of the head of the femur in SCD patients in Al-Baha region.


Methodology:

A retrospective, descriptive cross-sectional study was conducted in the King Fahad Hospital located in Al-Baha region in the Kindom of Saudi Arabia. The patient’s data collected were the well organized using a computerized system established in 2017.


Results:

The study showed a significant relationship between female gender SCD and developing AVN, 25 (56.8%). Among the total subjects, 44 patients were females, while only 19 patients were male. Furthermore, the study also found a strong statistically significant relationship between the incidence of AVN and recurrence. A total of 44 (24.3%) patients developed recurrence after AVN development. In 12.1% of them, the recurrence was in the left hip, while 9.0% had it on the right hip, followed by 4% on both the hip and only 2% has developed it on the left shoulder. Among the total, 97.7% of the study group were treated from AVN by replacement while 2.3% continued on conservative treatment.


Conclusion:

The incidence of AVN of the head of the femur among 24% of the study patients was considered less than that observed in countries of high incidence including Nigeria with 47% but still this percentage needs attention from health system as the avascular necroses of femur head could affect all aspect of life of the patients and health system economy.


Keywords:

Incidence, avascular necrosis, head of the femur, sickle cell.


Introduction

Sickle cell disease (SCD) is an autosomal recessive disorder characterized by the production of abnormal hemoglobin S and is associated with high morbidity and mortality [1]. Sickle cell anemia is a common genetic disorder in the Al-Baha region in Saudi Arabia and that may relate to the high rates of consanguinity.SCD in Saudi Arabia was first reported in the Eastern province in the1960s [2]. The Saudi Premarital Screening Program estimated the prevalence of the sickle cell gene in the adult population at 4.2% for sickle-cell trait and 0.26% for SCD, with the highest prevalence noted in the Eastern province (approximately 17% for sickle-cell trait and 1.2% for SCD) [3]. King Fahad hospital (KFH), the referral hospital, in the Al-Baha region, we followed the 181 cases of sickle cell anaemia (SCA) come from different parts in Al-Baha from 2016 to 2019 to Estimate the number of cases that developed avascular necrosis (AVN) of the head of the femur. Because AVN of the femoral head is a common complication in patients with SCD [4]. There are many complications and consequences associated with AVN of the head of the femur. One of these complications is depression which affects a wide number of SCA patients with AVN. Advanced stages of Osteonecrosis of the Femoral Head are independent risk factors for both clinical anxiety and clinical depression [5]. AVN can lead to a wide range of life long problems, such as frequent pain and disability, social problems, the catastrophic economic impact on patient beside the psychological problems that we have mentioned it. Many of the patients that we followed has been experienced all the mentioned complications and one patient from the study group had experienced the worst which is death. We followed also the hemoglobin level for each patient at the last attack of AVN and SCA crisis. We also reported the patient with SCA and acute chest syndrome. We followed the patient to estimate the number of patients diagnosed with vascular diseases. Because, it can increase the risk of AVN. Osteonecrosis of the hip is a painful condition that occurs when the blood supply to the head of the femur (thighbone) is disrupted [6]. We followed the patient to estimate the number of patients diagnosed with vascular diseases. Because, it can increase the risk of AVN. Osteonecrosis of the hip is a painful condition that occurs when the blood supply to the head of the femur (thighbone) is disrupted [6]. We followed a wide number of adults male and females from different ages to estimate if males are more affected or females were commonly seen in males compared to females [7]. The management of SCA patients with AVN of the hip is started with conservative treatments and later on, they need to undergo a replacement for the affected part.


Subjects and Method

Retrospective, descriptive cross-sectional study that was conducted in KFH which is located in Al-Baha region in the Kindom of Saudi Arabia, this region is of high altitude around 2,000 m above sea level. It is included in the area of the highest rate for both SCD was observed in the Eastern and Southern regions, KFH serving around 200,000 population. Patients data collected from the well organized and computerized system established in 2017. The sample of this study was all patients originally from Al-Baha region and of regular follow-up and treatment in KFH with complete data. Those who are not from Al-Baha region were excluded. Data collected by authors of this study from the hospital database system for patients, after proper permission from the hospital administration and ethical committee. Data was double entered to ensure accuracy and analyzed using SPSS version 16.1. For data analysis, multiple statistical methods have been used, descriptive analysis was done for all data, including frequencies and crosstable analysis to describe and compare among all respondents.


Results

The results of patients (total of181 patients) were available for analysis. Patients’ ages SD (7.25), mean (26.23) 4:6. All the patients included in the research were known to have SCA, the result showed 44 patients (24.3%) of the studied group is having AVN (table1).

The study showed a significant relationship between female gender sicker and developing AVN, 25 (56.8%) from 44 patients were females, while only 19 patients (43.2) were males (Table 2).

The study showed 35 (19.3%) patients are suffering from acute chest syndrome. Other medical problems which strongly associated with the sick cell patient with AVN is a disability that has been proved in the study in Table 3, the result reflects it that 51(28.2%) patients out of 181 total study group disabled.

There was no remarkable relation between AVN in sickle cell patient and vascular diseases only 15 (8%) out of 181 (100%) were suffering from vascular diseases. There was no strong relation between the AVN in sickle cell patient and chronic illnesses for which 1 (0.6) have AF, 1 (0.6) have asthma, 2 (1.20), epilepsy (0.6), G6PD 1 (0.6), Hashimoto 1 (0.6), HTN 3 (1.7), hepatitis C 1 (0.6), cardiac disease 1 (0.6), lymphoma 1 (0.6), Parkinson disease 1 (0.6) (Figure 1).

Table 1. Incidence of AVN among the studied group.

AVN Frequency Percent
No 137 75.7
Yes 44 24.3
Total 181 100.0

Table 2. Relation between the incidence of AVN and sex.

Sex AVN Total
No Yes
No. % No. % No. %
Male 86 62.8 19 43.2 105 58.0
Female 51 37.2 25 56.8 76 42.0
Total 137 100.0 44 100.0 181 100.0
X2
p
5.248
0.018*

Table 3. Relation between the incidence of AVN and disable.

Disable AVN Total
No Yes
No. % No. % No. %
No 118 86.1 12 27.3 130 71.8
Yes 19 13.9 32 72.7 51 28.2
Total 137 100.0 44 100.0 181 100.0
X2
p
57.011
0.0001*

97.7% of the study group were treated from AVN by replacement, while only 2.3% were on conservative treatment only. There was a highly statistically significant relationship between the incidence of AVN and recurrence. 44 (24.3%) patients were developed recurrence after AVN takes place. In 12.1% of them, the recurrence was in the left hip, while (9.0%) were in the right hip, followed by (4%) in the patient who suffers from both hip AVN recurrence and only (2%) has developed left shoulder AVN (Table 4).

Figure 1. Relation between the incidence of AVN and chronic illness.

in this study, there was a relation between the incidence of AVN and psychiatric illnesses 11 (6.1%) patients were diagnosed with psychiatric illnesses after they developed AVN (Table 5).

95% of the patients in the study group were on folic acid, and 98.9% of them were on hydroxyurea. That reflects almost all the sickle cell patient in Al-Baha region is in the regular course of treatment.

Table 4. Relation between the incidence of AVN and recurrence.

Recurrence AVN Total
No Yes
No. % No. % No. %
No 137 100.0 33 75.0 170 93.9
Both.Hip 0 0.0 2 4.5 2 1.1
LT. Hip 0 0.0 4 12.1 4 2.35
LT / She 0 0.0 1 2.3 1 0.6
R.Hip 0 0.0 4 9.1 4 2.2
Total 137 100.0 44 100.0 181 100.0
X2
p
36.466
0.0001*

Table 5. Relation between the incidence of AVN and psychiatric.

Psychiatric AVN Total
No Yes
No. % No. % No. %
No 133 97.1 37 84.1 170 93.9
Yes 4 2.9 7 15.9 11 6.1
Total 137 100.0 44 100.0 181 100.0
X2
p
9.844
0.005*

Discussion

In this study, we found the incidence of AVN in the AL-Baha region among sickle cell disease patients is 24% while in another study that’s done in Nigeria. Of the 416 patients with sickle cell disease, 340 (81.7%) had hemoglobin SS genotype, while 76 (18.3%) had SC genotype. Sixty-six (15.9%) patients 35 males (53%) and 31 females (47%) had clinical and radiologic features of AVN of the femoral head [8]. We found in this study there was a statistically significant relationship between incidence of AVN and gender p < 0.05 where is female gender sickler and developing AVN, 25 (56.8%) from 44 patients were females, while only 19 patient (43.2) were males. This study found out there was no relation between AVN and acute chest syndrome. In our study, there was 98.9% of samples were on hydroxyurea, There was no statistically significant relationship between the incidence of AVN and hydroxyurea but in another study in KFH in al-Madinah increase of an incidence in the exposed group, they considered hydroxyurea as a confirmed risk factor for developing AVN [9]. There was no statistically significant relationship between incidence of AVN and age but in another study in Bahiana School of Medicine and Public Health showed AVN in sickle cell anemia has a direct relationship with age and is prevalent in 8.7% to 12.4% by age 21, and progressing to values higher than 50% in population over 35 years old [10]. 6%–95% of the patients in our study group were on folic acid, there was no statistically significant relationship between the incidence of AVN and folic acid, there was study in Melaka-Manipal Medical College that showed no statistically significant relationship between incidence of AVN or any effect in SCD patients and using of folic acid supplementation [11]. There was a highly statistically significant relationship between the incidence of AVN and recurrence. 44 (24.3%) patients were developed recurrence after AVN takes place. In 12.1% of them, the recurrence was in the left hip, while 9.0% wherein the right hip, followed by (4%) in the patient who suffers from both hip AVN recurrence and only (2%) has developed left shoulder AVN. There study in OMAN showed: AVN of the femoral head is a common complication in patients with SCD, and the collapse of the femoral head occurs in 90% of the patients within five years of the diagnosis of osteonecrosis [12]. In our study, there was a statistically significant relationship between incidence of AVN and psychiatric illness p < 0.05, in another study done in Tianjin Medical University General Hospital, was overall incidences of depression and AVN was 30.6% (196 of 641) [13]. In this study, we found that there was a highly significant relationship between the incidence of AVN and disability p < 0.05. Also, found in this study, there was no relation between the incidence of AVN and chronic illness, vascular disease. The following limitations of the present investigation are to be kept in mind when interpreting the results. The effect of the AVN of the head of a femur on the patient`s work is not mentioned because of the lake of data. Medication history of the patients of some deficiency especially in regarding narcotics and status of dependency on some medications like morphine and tramadol


Conclusion

The incidence of AVN of the head of the femur of 24% of the patients is considered less than some countries of high incidence like Nigeria which is 47% but this percentage considered significant and needs more attention from health system because of the effect of the avascular necroses of femur head in all aspect of life of the patients and health system economy.


List of Abbreviations

AVN Avascular Necrosis
HTN Hypertension
G6PD Glucose 6 phosphate dehydrogenase deficiency
HB Hemoglobin
KFH King Fahad Hospital
SCA Sickle cell Anaemia
SCD Sickle cell disease
SCTH Sickle Cell Thalassemia
SPSS Statistical Package for Social Science

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

This study was approved by the IRB of the Ministry of Health on 15/5/2018. Provide a reference number.


Author details

Abdulhakam Ahmed1, Asmaa Khalid Hassan Abdelkarim1, Tahani Rajab Ali Alzahrani1, Saeed Faleh Saeed Alshahrani2, Abdulaziz Khalid Saleh Alghamdi1, Abdullah Nasser H Leslom1

  1. King Fahad Hospital, Al Baha, Saudi Arabia
  2. Ministry of Health, Al Baha, Saudi Arabia

References

  1. Jastaniah W. Epidemiology of sickle cell disease in Saudi Arabia. Ann Saudi Med. 2011;31(3):289–93. https://doi.org/10.4103/0256-4947.81540
  2. Creary M, Williamson D, Kulkarni R. Sickle cell disease: current activities, public health implications, and future directions. J Women’s Health. 2007;16(5):575–82. https://doi.org/10.1089/jwh.2007.CDC4
  3. Makani J, Williams TN, Marsh K. Sickle cell disease in Africa: burden and research priorities. Ann Trop Med Parasitol. 2007;101(1):3–14. https://doi.org/10.1179/136485907X154638
  4. Wali Y, Almaskari S. Avascular Necrosis of the Hip in Sickle Cell Disease in Oman: Is it serious enough to warrant bone marrow transplantation? Sultan Qaboos Univ Med J. 2011;11(1):127.
  5. Chen SB, Hu H, Gao YS, He HY, Jin DX, Zhang CQ. Prevalence of clinical anxiety, clinical depression and associated risk factors in chinese young and middle-aged patients with osteonecrosis of the femoral head. PLoS One. 2015;10(3):e0120234. https://doi.org/10.1371/journal.pone.0120234
  6. Hsu H, Nallamothu SV. Hip Osteonecrosis. InStatPearls [Internet] 2019 May 7. Treasure Island, FL:StatPearls Publishing.
  7. Wu D, Song D, Ni J, Dai R. Avascular necrosis of the femoral head due to the bilateral injection of heroin into the femoral vein: a case report. Exp Ther Med. 2013;6(4):1041–3. https://doi.org/10.3892/etm.2013.1236
  8. Elmaghraby SA, Balelah SH, Almahdi HA, Habib HM, Al-loqmani DD, Tharwat RJ. The prevalence of avascular necrosis in adults with sickle cell disease in king fahad hospital. International Journal of Advanced Research (IJAR); 2017. https://doi.org/10.21474/IJAR01/6031
  9. Almeida-Matos M, Carrasco J, Lisle L, Castelar M. Avascular necrosis of the femoral head in sickle cell disease in pediatric patients suffering from hip dysfunction. Rev Salud Pública. 2016;18:986–95. https://doi.org/10.15446/rsap.v18n6.50069
  10. Dixit R, Nettem S, Madan SS, Soe HH, Abas AB, Vance LD, Stover PJ. Folate supplementation in people with sickle cell disease. Cochr Database Syst Rev. 2018(3). https://doi.org/10.1002/14651858.CD011130.pub3
  11. Wali Y, Almaskari S. Avascular Necrosis of the Hip in Sickle Cell Disease in Oman: is it serious enough to warrant bone marrow transplantation? Sultan Qaboos Univ Med J. 2011;11(1):127.
  12. He D, Xue Y, Li Z, Tang Y, Ding H, Yang Z, ZHang C, ZHou H, ZHao Y, Zong Y. Effect of depression on femoral head avascular necrosis from femoral neck fracture in patients younger than 60 years. Orthopedics. 2014;37(3):e244–51. https://doi.org/10.3928/01477447-20140225-56
  13. He D, Xue Y, Li Z, Tang Y, Ding H, Yang Z, ZHang C, ZHou H, ZHao Y, Zong Y. Effect of depression on femoral head avascular necrosis from femoral neck fracture in patients younger than 60 years. Orthopedics. 2014 Mar 1;37(3):e244–51.


How to Cite this Article
Pubmed Style

Ahmed A, Abdelkarim AKH, Alzahrani TRA, Alshahrani SFS, Alghamdi AKS, Leslom ANH. Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia. IJMDC. 2020; 4(2): 469-472. doi:10.24911/IJMDC.51-1577695480


Web Style

Ahmed A, Abdelkarim AKH, Alzahrani TRA, Alshahrani SFS, Alghamdi AKS, Leslom ANH. Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia. https://www.ijmdc.com/?mno=79926 [Access: January 28, 2022]. doi:10.24911/IJMDC.51-1577695480


AMA (American Medical Association) Style

Ahmed A, Abdelkarim AKH, Alzahrani TRA, Alshahrani SFS, Alghamdi AKS, Leslom ANH. Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia. IJMDC. 2020; 4(2): 469-472. doi:10.24911/IJMDC.51-1577695480



Vancouver/ICMJE Style

Ahmed A, Abdelkarim AKH, Alzahrani TRA, Alshahrani SFS, Alghamdi AKS, Leslom ANH. Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia. IJMDC. (2020), [cited January 28, 2022]; 4(2): 469-472. doi:10.24911/IJMDC.51-1577695480



Harvard Style

Ahmed, A., Abdelkarim, . A. K. H., Alzahrani, T. R. A., Alshahrani, . S. F. S., Alghamdi, . A. K. S. & Leslom, . A. N. H. (2020) Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia. IJMDC, 4 (2), 469-472. doi:10.24911/IJMDC.51-1577695480



Turabian Style

Ahmed, Abdulhakam, Asmaa Khalid Hassan Abdelkarim, Tahani Rajab Ali Alzahrani, Saeed Faleh Saeed Alshahrani, Abdulaziz Khalid Saleh Alghamdi, and Abdullah Nasser H Leslom. 2020. Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (2), 469-472. doi:10.24911/IJMDC.51-1577695480



Chicago Style

Ahmed, Abdulhakam, Asmaa Khalid Hassan Abdelkarim, Tahani Rajab Ali Alzahrani, Saeed Faleh Saeed Alshahrani, Abdulaziz Khalid Saleh Alghamdi, and Abdullah Nasser H Leslom. "Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia." International Journal of Medicine in Developing Countries 4 (2020), 469-472. doi:10.24911/IJMDC.51-1577695480



MLA (The Modern Language Association) Style

Ahmed, Abdulhakam, Asmaa Khalid Hassan Abdelkarim, Tahani Rajab Ali Alzahrani, Saeed Faleh Saeed Alshahrani, Abdulaziz Khalid Saleh Alghamdi, and Abdullah Nasser H Leslom. "Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia." International Journal of Medicine in Developing Countries 4.2 (2020), 469-472. Print. doi:10.24911/IJMDC.51-1577695480



APA (American Psychological Association) Style

Ahmed, A., Abdelkarim, . A. K. H., Alzahrani, T. R. A., Alshahrani, . S. F. S., Alghamdi, . A. K. S. & Leslom, . A. N. H. (2020) Incidence of avascular necrosis of the head of the femur among sickle cell patients in Albaha region, Kingdom of Saudi Arabia. International Journal of Medicine in Developing Countries, 4 (2), 469-472. doi:10.24911/IJMDC.51-1577695480