Osteonecrosis in sickle cell disease: Contemporary orthopaedic practice and outcomes across African healthcare settings

Background: Osteonecrosis is a disabling complication of sickle cell disease (SCD), with a disproportionate burden in Africa, where healthcare resources are limited. Despite this, the region remains underrepresented in the literature on SCD-related osteonecrosis. This scoping review synthesises current evidence on the epidemiology, management practices, and outcomes of SCD-related osteonecrosis in African healthcare settings. Methods: Following PRISMA-ScR guidelines, we systematically searched MEDLINE, Embase, Web of Science, Google Scholar, and African Journals Online through February 2025. Eligible studies reported clinical features, management, or outcomes of osteonecrosis in SCD patients in Africa. Data on demographics, staging, imaging, treatment modalities, and outcomes were narratively synthesised. Results: Thirty-two studies involving 779 patients met the inclusion criteria. Most were small, descriptive case series. Patients typically presented late: 85% at Ficat stage III–IV, with delays exceeding 20 years in some cases. The femoral head was affected in 98% of cases. Diagnosis relied almost exclusively on radiographs, with MRI reported in only 6% of studies. Conservative management, mainly traction and immobilisation, showed benefit in paediatric early-stage cases but was largely ineffective in adults. Joint-preserving surgeries were rarely reported but included core decompression and vascularised grafting with variable success. Arthroplasty predominated, yielding functional improvement but was technically demanding and prone to complications, particularly in SS genotype patients. Conclusion: Late presentation, diagnostic limitations, and reliance on salvage arthroplasty mark SCD-related osteonecrosis in Africa. Strengthening early detection, expanding capacity for joint-preserving interventions, and generating robust regionally relevant evidence are critical to improving outcomes in this high-burden, resource-constrained setting.