Treatment of Osteonecrosis in Children and Adolescents With Acute Lymphoblastic Leukemia

Abstract

Background Cure rates for acute lymphoblastic leukemia (ALL) have improved, but as therapy has intensified, the burden of osteonecrosis (ON) has increased. Limited data exist regarding surgical interventions for pediatric ALL patients with ON. Materials and Methods A multi-center cohort of children with newly diagnosed ALL was established with Pediatric Health Information System (PHIS) data from 43 freestanding children's hospitals from 1999-2011. Patients with ON identified by ICD-9 code were followed for up to 5 years after index ALL admission for the presence of ON-associated orthopedic surgical procedures. Results A cohort of 10,729 ALL patients was assembled, of which 242(2.33%) were identified with an ICD-9 code for ON within 5 years of ALL diagnosis. Fifty-five patients (22.7%) with ON underwent orthopedic surgical intervention aimed at joint preservation (82%) or replacement (18%) with substantial practice variation by hospital in both the rate and type of surgical intervention. The majority of patients had surgical procedures while receiving Maintenance therapy. None of the patients undergoing surgical intervention required ICU-level care within 14 days of surgery, and there was no associated in-hospital mortality. Conclusions No standard of care exists for treatment of ALL-associated ON. While considerable practice variation exists, surgical intervention appears relatively safe.

Bisphosphonate Combination Therapy in the Management of Postchemotherapy Avascular Necrosis of the Femoral Head in Adolescents and Young Adults: A Retrospective Study From India

“…Cure rates for ALL have improved, but as the therapy has intensified, the burden of ON has increased. 3 Osteonecrosis is one of the 14 acute toxic effects that are serious, but too rare to be addressed comprehensively within any single group. 27 …”

“…Heneghan et al 3 conducted a multicenter study to understand the natural history of AVN in patients with ALL. In a cohort of 10,729 patients with ALL, 242 (2.33%) developed AVN within 5 years of diagnosis.…”

“…The incidence of AVN in children and adolescents who undergo chemotherapy for ALL varies from 2.3% to 7.7%. 3 - 6 Median age at diagnosis of AVN was 13.5 years in one study. 7 Median time from diagnosis to the development of AVN after chemotherapy is 1.14 years (range, 0.25 years to 2.12 years).…”

“…Whereas considerable practice variation exists, surgical intervention seems to be relatively safe and is still the treatment of choice. 3 , 13 The only surgical modality that has shown good results is the total hip arthroplasty (THA); however, THA performed at a young age will necessitate at least one revision arthroplasty in the future, as the average life expectancy of the patient exceeds THA survivorship. 14 , 15…”

Musculoskeletal complications following total body irradiation in hematopoietic stem cell transplant patients

“…In asymptomatic patients, routine screening with MRI to search for lesions is not recommended, 24 as many lesions are found incidentally and specific treatment for these lesions is likely not warranted. 63 Conservative treatment regimens include pain management and decreased weight bearing activity. 24 Factors such as the degree of involvement, location (proximity to subchondral bone), age, and patient goals need to be considered to determine whether intervention is indicated.…”