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Zandi R, Talebi S, Nodehi S, Ehsani A. Osteonecrosis of acetabulum following total hip arthroplasty: A case report and literature review. Clin Case Rep 2024; 12:e9195. [PMID: 39055088 PMCID: PMC11266430 DOI: 10.1002/ccr3.9195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 06/24/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024] Open
Abstract
Key Clinical Message Despite being rare, we have presented a case of osteonecrosis of acetabulum that followed total hip arthroplasty. It's crucial to act appropriately, as it emulates periprosthetic joint infection. The key point is that the osteonecrosis of acetabulum may necessitate revision and can be classified as aseptic loosening. Abstract Osteonecrosis of the femoral head is well known and managed with total hip arthroplasty (THA). Acetabulum osteonecrosis can be classified as a cause of painful THA and the cemented acetabular component is a feasible option. However, it seems that the osteonecrosis of acetabulum is sparsely alluded in literature. In this case report sustaining of the right hip pain following THA of 35-year-old woman is discussed.
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Affiliation(s)
- Reza Zandi
- Department of Orthopedic Surgery, Taleghani Hospital Research Development Committee, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Shahin Talebi
- Department of Orthopedic Surgery, Taleghani Hospital Research Development Committee, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Saeed Nodehi
- Shahid Beheshti University of Medical ScienceTehranIran
| | - Akbar Ehsani
- Shahid Beheshti University of Medical ScienceTehranIran
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Brochu A, Kairy D, Alos N, Laverdière C, Sinnett D, Sultan S, Curnier D, Miron MC, El-Jalbout R, Fiscaletti M, Hébert LJ. Physical impairments, activity limitations, and participation restrictions of childhood acute lymphoblastic leukemia survivors with and without hip osteonecrosis: a PETALE cohort study. J Cancer Surviv 2024:10.1007/s11764-024-01585-4. [PMID: 38787491 DOI: 10.1007/s11764-024-01585-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 04/02/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE Long-term musculoskeletal complications represent a growing burden for survivors of childhood acute lymphoblastic leukemia (cALL). This study aimed to describe physical impairments, activity limitations, and participation restrictions in a high-risk subgroup of cALL survivors of the PETALE cohort. METHODS This cross-sectional study, using observational data from the PETALE cohort, included a subgroup of survivors who presented high-risk criteria for late effects. Outcomes measures consisted of hip magnetic resonance imaging, maximal isometric muscle strength (MIMS) or torque (MIMT), range of motion (ROM), Near Tandem Balance (NTB), 6-Minute Walk Test (6MWT), Five Time Sit-to-Stand Test (FTSST), and health-related quality of life. Descriptive statistics and regression analyses were performed. RESULTS Survivors (n = 97, 24.2 ± 6.7 years old) showed limited grip strength, FTSST, and NTB performance compared to reference values (p < 0.001). Thirteen participants (14.6%, 18 hips) had hip osteonecrosis (ON) (53.8% male). Higher severity hip ON was found in female survivors (66.7% vs. 22.2%). Survivors with hip ON had reduced hip external rotation ROM compared to those without (p < 0.05). Relationships were found between MIMS and ROM outcomes (r = 0.32, p < 0.01) and with 6MWT (r = 0.39-0.41, p < 0.001). Our multiple linear regression model explained 27.6% of the variance of the 6MWT. CONCLUSIONS Survivors in our subgroup had clinically significant physical impairments and activity limitations, and those with hip ON showed worst hip impairment outcomes. IMPLICATIONS FOR CANCER SURVIVORS These findings emphasize the importance of long-term follow-up including physical therapy assessment to help early identification and management of physical impairments and activity limitations in survivors of cALL.
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Affiliation(s)
- Annie Brochu
- CHU Sainte-Justine, Montréal, Canada.
- Université de Montréal, Montréal, Canada.
| | - Dahlia Kairy
- Université de Montréal, Montréal, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Canada
| | - Nathalie Alos
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Caroline Laverdière
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Daniel Sinnett
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Serge Sultan
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Daniel Curnier
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Marie-Claude Miron
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Ramy El-Jalbout
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Melissa Fiscaletti
- CHU Sainte-Justine, Montréal, Canada
- Université de Montréal, Montréal, Canada
| | - Luc J Hébert
- Université Laval, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Québec, Canada
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Halton JM, Ma J, Babyn P, Matzinger MA, Kaste SC, Scharke M, Fernandez CV, Miettunen P, Ho J, Alos N, Abish S, Barr R, Cairney E, Dix DB, Grant RM, Israels S, Lewis V, Wilson B, Atkinson S, Cabral D, Cummings E, Rodd C, Stein R, Sbrocchi AM, Jaremko JL, Koujok K, Shenouda N, Rauch F, Siminoski K, Ward LM. Reductions in Bone Mineral Density Are Apparent Early in Children With Prevalent Osteonecrosis Lesions Following Leukemia Therapy. J Bone Miner Res 2023; 38:1104-1115. [PMID: 37326443 DOI: 10.1002/jbmr.4870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/16/2023] [Accepted: 06/14/2023] [Indexed: 06/17/2023]
Abstract
Osteonecrosis (ON) is a serious complication of childhood acute lymphoblastic leukemia. We determined the prevalence of osteonecrotic lesions in our patient population by a one-time multisite magnetic resonance imaging (MRI) more than 1 year following leukemia therapy. MRI findings were evaluated in relationship to clinical factors (including longitudinal changes in bone mineral density [BMD]). Eighty-six children enrolled in the Steroid Associated Osteoporosis in the Pediatric Population (STOPP) study were evaluated for ON at 3.1 ± 1.3 years following therapy. Thirty children had a total of 150 confirmed ON lesions (35%). Lumbar spine (LS) BMD Z-scores (mean ± SD) were low at diagnosis and similar between patients with and without ON (-1.09 ± 1.53 versus -1.27 ± 1.25, p = 0.549). LS BMD Z-scores declined from baseline to 12 months in children with ON (-0.31 ± 1.02) but not in those without (0.13 ± 0.82, p = 0.035); the hip BMD Z-scores from baseline to 24 months declined in both groups, but to a greater extent in those with ON (-1.77 ± 1.22) compared to those without (-1.03 ± 1.07, p = 0.045). At the time of the MRI, mean total hip and total body (TB) BMD Z-scores were lower in children with ON (hip -0.98 ± 0.95 versus -0.28 ± 1.06, p = 0.010; TB -1.36 ± 1.10 versus -0.48 ± 1.50, p = 0.018). Pain occurred in 11/30 (37%) with ON versus 20/56 (36%) without, p = 0.841. In multivariable models, older age at diagnosis (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.15-2.13; p = 0.004), and hip BMD Z-score at MRI (OR 2.23; 95% CI, 1.02-4.87; p = 0.046) were independently associated with ON. Overall, one-third of children demonstrated ON after leukemia therapy. Those with ON had greater reductions in spine and hip BMD Z-scores in the first 1 and 2 years of therapy, respectively. Older age and lower hip BMD Z-scores at MRI were significantly associated with prevalent, off-therapy ON. These data assist in identifying children at risk of ON. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
| | - Jinui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paul Babyn
- Department of Medical Imaging, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mary Ann Matzinger
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Sue C Kaste
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Maya Scharke
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Conrad V Fernandez
- Department of Pediatric Hematology and Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paivi Miettunen
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Nathalie Alos
- Département de Pédiatrie, Université de Montréal, Montréal, Quebec, Canada
| | - Sharon Abish
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Ronald Barr
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth Cairney
- Department of Paediatrics, Western University, London, Ontario, Canada
| | - David B Dix
- Department of Pediatrics, University of British Columbia, Vancouver, British of Columbia, Canada
| | - Ronald M Grant
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Sara Israels
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Victor Lewis
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Beverly Wilson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Stephanie Atkinson
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - David Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, British of Columbia, Canada
| | - Elizabeth Cummings
- Department of Pediatric Hematology and Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Celia Rodd
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Stein
- Department of Paediatrics, Western University, London, Ontario, Canada
| | | | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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DeFeo BM, Neel MD, Pui CH, Jeha S, Hankins JS, Kaste SC, Srivastava DK, Ness KK. Functional Outcomes for Children, Adolescents, and Young Adults with Osteonecrosis following Hip Core Decompression. REHABILITATION ONCOLOGY 2022; 40:E46-E53. [PMID: 36876164 PMCID: PMC9979580 DOI: 10.1097/01.reo.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Patients with pediatric leukemia and sickle cell disease are at risk for developing osteonecrosis (ON), a disease that can result in pain, loss of function, and disability. Hip core decompression surgery is an option aimed to prevent femoral head collapse and avoid future arthroplasty. Objective Describe functional outcomes and gait quality among a young population with hip ON before and after hip core decompression. Methods Study included participants with hip ON secondary to treatment for hematologic malignancy or sickle cell disease, between 8 and 29 years old, requiring hip core decompression surgery. At one-year follow-up, 13 participants (9 male, median age 17 years) completed the Functional Mobility Assessment (FMA), range of motion, and GAITRite® testing. Results Participants demonstrated improved mobility and endurance on the FMA at 1-year post-operatively compared to pre-operatively, with higher scores for time on the Timed Up and Go (mean FMA score = 2.92 [SD = 1.32] vs. 2.07 [SD = 1.70]), time on the Timed Up and Down Stairs (3.69 [0.85] vs. 2.92 [1.66]), and 9-Minute Walk Test scores for distance walked (2.69 [0.63] vs. 2.23 [0.93]) and heart rate (4.54 [0.66] vs. 3.31 [1.38]). GAITRite® analysis also showed improvements in many gait parameters at one-year follow-up. Limitations Cancer treatment complications other than ON could have contributed to results, not all eligible participants agreed to participate, and follow-up was only one year. Conclusions Young patients with hip ON demonstrated improvements in functional mobility, endurance, and gait quality one year following hip core decompression.
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Affiliation(s)
- Brian M. DeFeo
- Rehabilitation Services, St. Jude Children’s Research Hospital, Memphis, TN
| | - Michael D. Neel
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN
- Department of St. Jude Global, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Hematological Malignancies Program, St. Jude Children’s Research Hospital, Memphis, TN
| | - Sima Jeha
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN
- Department of St. Jude Global, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jane S. Hankins
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of St. Jude Graduate School of Biomedical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
| | - Sue C. Kaste
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Radiology University of Tennessee Health Science Center
| | | | - Kirsten K. Ness
- Department of St. Jude Graduate School of Biomedical Sciences, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology/Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
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5
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Chen W, Li J, Guo W, Gao S, Wei Q, Li Z, He W. Outcomes of surgical hip dislocation combined with bone graft for adolescents and younger adults with osteonecrosis of the femoral head: a case series and literature review. BMC Musculoskelet Disord 2022; 23:499. [PMID: 35619082 PMCID: PMC9134689 DOI: 10.1186/s12891-022-05456-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background Osteonecrosis of the femoral head (ONFH) may occur in the adolescent and younger adults (AYAs). Total hip arthroplasty (THA) is not the best treatment option for younger patients. Surgical hip dislocation (SHD) combined with bone graft can be used in patients at different stages to reconstruct the bone structure in the head and delay the replacement time. The purpose of this study was to evaluate the effect and potential influencing factors of this surgery for ONFH in AYA patients. Methods We conducted a literature review and a retrospective research of our own cases. The Pubmed, Cochrane Library, EMBASE and CNKI databases were searched from 1 January 2001 to 1 October 2021, for clinical studies. A retrospective case series study of 34 patients (38 hips) treated with SHD combined with bone graft was performed. Results A total of 13 studies were included and the results showed that SHD combined with bone grafts had better clinical results for patients with pre- or early post-collapse. In the case series study, we retrospectively analyzed 34 patients (38 hips), and the mean follow-up time was 40.77 ± 15.87 months. One patient died and three patients were converted to THA finally. The post-collapse degree and post-lesion size were better than those before the operation (P < 0.05). The iHOT-12 at the last follow-up was significantly higher than that before the operation (P < 0.05). There were significant differences in the results of hip Harris score (HHS), visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before the operation, 2 years after the operation and at the last follow-up, but the difference was not related to the follow-up time (P < 0.05). There were no significant differences in the final clinical score and arthritic changes among different Japanese Investigation Committee (JIC) classification, the degree of collapse and the size of the necrotic (P > 0.05). Conclusions In AYA patients, SHD combined with bone grafting is a potentially good option for hip preservation in ONFH. The differences in JIC classification, collapse degree and lesion size did not affect the final clinical function and the risk of osteoarthritis. Even for very severe cases at collapsed stage, good short-term clinical effects can still be achieved by SHD combined with bone graft. Trial registration ChiCTR2100055079.retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05456-w.
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Affiliation(s)
- Wenhuan Chen
- The Third Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Jianxiong Li
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Wenxuan Guo
- The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Shihua Gao
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China
| | - Qiushi Wei
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Afliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ziqi Li
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Afliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wei He
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Afliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China.
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Osteonecrosis in Korean Paediatric and Young Adults with Acute Lymphoblastic Leukaemia or Lymphoblastic Lymphoma: A Nationwide Epidemiological Study. J Clin Med 2022; 11:jcm11092489. [PMID: 35566613 PMCID: PMC9105090 DOI: 10.3390/jcm11092489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 02/04/2023] Open
Abstract
Osteonecrosis (ON) is a serious complication of acute lymphocytic leukaemia (ALL) or lymphoblastic lymphoma (LBL) treatment, and there is little information regarding ON in Korean paediatric and young adult patients. This retrospective cohort study assessed the cumulative incidence of and risk factors for ON using national health insurance claims data from 2008 to 2019 in 4861 ALL/LBL patients. The Kaplan–Meier method was used to estimate the cumulative incidence of ON according to age groups; the Cox proportional hazard regression model was used to identify risk factors related to ON development after diagnosing ALL/LBL. A cause-specific hazard model with time-varying covariates was used to assess the effects of risk factors. Overall, 158 (3.25%) patients were diagnosed with ON, among whom 23 underwent orthopaedic surgeries. Older age, radiotherapy (HR = 2.62, 95% confidence interval (CI) 1.87–3.66), HSCT (HR = 2.40, 95% CI 1.74–3.31), steroid use and anthracycline use (HR = 2.76, CI 1.85–4.14) were related to ON in the univariate analysis. In the multivariate analysis, age and steroid and asparaginase use (HR = 1.99, CI 1.30–3.06) were factors associated with ON. These results suggest that Korean patients with ALL/LBL who used steroids and asparaginase should be closely monitored during follow-up, even among young adult patients.
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Ikemura S, Motomura G, Kawano K, Hamai S, Fujii M, Nakashima Y. The Discrepancy in the Posterior Boundary of Necrotic Lesion Between Axial and Oblique Axial Slices of MRI in Patients with Osteonecrosis of the Femoral Head. J Bone Joint Surg Am 2022; 104:33-39. [PMID: 35108239 DOI: 10.2106/jbjs.20.00493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known concerning differences in assessment of anteroposterior osteonecrotic lesion of the femoral head (ONFH) between the axial plane parallel to the body axis (axial) and the axial plane parallel to the femoral neck axis (oblique axial) using magnetic resonance imaging (MRI). This study aimed to compare the posterior boundary of necrotic lesions between the axial and oblique axial planes on MRI. METHODS This study retrospectively reviewed 120 consecutive hips in 71 patients (47 males and 24 females; mean age, 42 years) with ONFH, for which both axial and oblique axial MRI slices were available. The posterior boundaries of the necrotic lesions were calculated as the ratio of posterior intact circumference to anteroposterior circumference of the femoral head using mid-axial and mid-oblique axial MRI slices. The necrotic angles, calculated using the modified Kerboul method, were compared between cases with progression and nonprogression of collapse. RESULTS The mean posterior intact ratio in the axial slice was 49.2% (range, 8.6 to 85.1%), while that in the oblique axial slice was 33.5% (7.5 to 79.2%). The posterior intact ratio in the oblique axial slice significantly decreased compared to that in the axial slice (p < 0.0001). In cases with progression of collapse, the mean necrotic angle was significantly larger in the oblique axial slice than in the axial slice (p < 0.0001). The sensitivity and specificity of the necrotic angle with regard to the prognosis of the femoral head were both higher when using the oblique axial slice (sensitivity: 88.4%, specificity: 82.3%) than when using the axial slice (sensitivity: 85.1%, specificity: 62.0%). The posterior intact ratio at a mean of 6.8 mm superior to the mid-axial slice corresponded to that of the mid-oblique axial slice. CONCLUSION Our findings suggest that the posterior boundaries of necrotic lesions differ between axial and oblique axial slices, and examination of the oblique axial MRI slice might be more suitable for predicting the prognosis of the femoral head. LEVEL OF EVIDENCE Diagnostic-Investigating a diagnostic test. Level IV (Case series).
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Affiliation(s)
- Satoshi Ikemura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
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Periasamy U, Chilutti M, Kaplan SL, Hickey CP, Hayes K, Pennington JW, Balamuth F, Fitzgerald JC, Weiss SL. Prevalence of and Associations With Avascular Necrosis After Pediatric Sepsis: A Single-Center Retrospective Study. Pediatr Crit Care Med 2022; 23:e153-e161. [PMID: 34991135 PMCID: PMC8897239 DOI: 10.1097/pcc.0000000000002880] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Avascular necrosis (AVN) is a rare, but serious, complication after sepsis in adults. We sought to determine if sepsis is associated with postillness diagnosis of AVN, as well as potential-associated risk factors for AVN in children with sepsis. DESIGN Retrospective observational study. SETTING Single academic children's hospital. PATIENTS Patients less than 18 years treated for sepsis or suspected bacterial infection from 2011 to 2017. Patients who developed AVN within 3 years after sepsis were compared with patients who developed AVN after suspected bacterial infection and with patients with sepsis who did not develop AVN. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS AVN was determined using International Classification of Diseases, 9th Edition/10th Edition codes and confirmed by chart review. The prevalence of AVN after sepsis was 0.73% (21/2,883) and after suspected bacterial infection was 0.43% (53/12,276; risk difference, 0.30; 95% CI, 0.0-0.63; p = 0.05). Compared with 43 sepsis controls without AVN, AVN in the 21 sepsis cases was associated with being older, having sickle cell disease and malignancy, higher body mass index, unknown source of infection, and low platelet count in the first 7 days of sepsis. Half of sepsis patients were treated with corticosteroids, and higher median cumulative dose of steroids was associated with AVN (23.2 vs 5.4 mg/kg; p < 0.01). Older age at infection (odds ratio [OR], 1.3; 95% CI, 1.1-1.4), malignancy (OR, 8.8; 95% CI, 2.6-32.9), unknown site of infection (OR, 12.7; 95% CI, 3.3-48.6), and minimal platelet count less than 100,000/µL in first 7 days of sepsis (OR, 5.0; 95% CI, 1.6-15.4) were identified as potential risk factors for AVN after sepsis following adjustment for multiple comparisons. CONCLUSIONS Although rare, sepsis was associated with a higher risk of subsequent AVN than suspected bacterial infection in children. Older age, malignancy, unknown site of infection, and minimum platelet count were potential risk factors for AVN after sepsis.
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Affiliation(s)
- Uvaraj Periasamy
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston MA, USA
| | - Marianne Chilutti
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Summer L. Kaplan
- Department of Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Christopher P. Hickey
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
| | - Katie Hayes
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
| | - Jeffrey W. Pennington
- Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Fran Balamuth
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
- Department of Pediatrics, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Julie C. Fitzgerald
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
| | - Scott L. Weiss
- The Children’s Hospital of Philadelphia Pediatric Sepsis Program, Philadelphia PA, USA
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA
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Jin H, Li L, Yu W, Fu Y. The efficacy of acupuncture and moxibustion for early and middle-stage osteonecrosis of the femeral head: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e26210. [PMID: 34087895 PMCID: PMC8183785 DOI: 10.1097/md.0000000000026210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 05/17/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Osteonecrosis of the femeral head (ONFH) occurs predominantly in young- and middle-aged people, and the disability rate is high in the late stage of the disease and most patients have to undergo total hip replacement. Clinically, increasing attention is paid to intervening early and middle-stage ONFH so as to delay its progress. Acupuncture and moxibustion (AM) is a unique method for treating ONFH in China. This study aims to summarize the advantages of AM for the treatment of ONFH. METHODS A comprehensive literature search was conducted on the database with languages of English and Chinese. The medical subject titles used are "Osteonecrosis of the femoral head" and "acupuncture and moxibustion." Related words in the title or abstract including but were not limited to "necrosis of the femoral head," "avascular necrosis of the femoral head," "ischemic necrosis of the femoral head," "caput femoris necrosis," "bone paralysis," "bone erosion," and "bone atrophy." RESULTS Nine randomized controlled trials were identified in this meta-analysis that included 630 subjects. Meta-analysis showed that the trial group that treated with conventional therapy combined with AM had a higher effective rate (Z = 2.27 P = 0.02) and excellent and good rate (Z = 4.85 P < 0.00001) and Harris hip function score (HHS) (Z = 2.31 P = 0.02) and lower incidence of related adverse reactions during treatment (Z = 2.82 P = 0.005) compared with the control group that treated with conventional therapy alone. CONCLUSIONS AM for early and middle-stage ONFH is an effective and relatively safe intervention, which can improve the effective rate and excellent and good rate and HHS, and reduce the adverse reaction rate. Clinically, early and middle-stage ONFH can be intervened by combining with AM while taking conventional therapy to improve the efficacy.
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Affiliation(s)
| | - Linhui Li
- Jiangxi University of Traditional Chinese Medicine
| | - Wen Yu
- Jiangxi University of Traditional Chinese Medicine
| | - Yong Fu
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang City, Jiangxi Province, China
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10
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Arakawa Y, Masutani S, Oshima K, Mitani Y, Mori M, Fukuoka K, Moriwaki K, Kato M, Taira K, Tanami Y, Nakazawa A, Koh K. Asian population may have a lower incidence of hip osteonecrosis in childhood acute lymphoblastic leukemia. Int J Hematol 2021; 114:271-279. [PMID: 34008044 DOI: 10.1007/s12185-021-03163-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 11/30/2022]
Abstract
Osteonecrosis (ON), a long-term complication of acute lymphoblastic leukemia (ALL) treatment affects patients' quality of life. Although the incidence of any ON, including asymptomatic, was 21.7% among children with ALL in the U.S., the actual incidence and risk factors in Asia remain unknown. For over 11 years, we performed hip magnetic resonance imaging (MRI) screening to detect asymptomatic ON while initiating maintenance chemotherapy in newly diagnosed children with ALL. Overall, 164 of 175 patients underwent hip MRI screening. The incidence of symptomatic or any ON was 3.0% and 11.6%, respectively. Asymptomatic ON in patients < 10 and ≥ 10 years old was 4.0% and 35.9%, respectively (P < 0.001). In multivariate analysis, age ≥ 10 years was the only significant risk factor. Asymptomatic ON with necrosis of > 30% of the epiphyseal surface of the femoral head was detected in four patients (2.4%). All were ≥ 10 years. Three of them progressed to severe symptomatic ON. The incidence of any ON in Asia may be lower than that seen in the only screening study in the U.S. Future studies should clarify factors affecting such regional differences and develop an effective approach to avoid the progression of ON in children with ALL.
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Affiliation(s)
- Yuki Arakawa
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan. .,Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan.
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Koichi Oshima
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Yuichi Mitani
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Makiko Mori
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Koichi Moriwaki
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Motohiro Kato
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Katsuaki Taira
- Department of Orthopedics Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Atsuko Nakazawa
- Department of Pathology, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
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11
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Daneshdoost SM, El Abiad JM, Ruble KJ, Jones LC, Crane JL, Morris CD, Levin AS. Bisphosphonate Therapy for Treating Osteonecrosis in Pediatric Leukemia Patients: A Systematic Review. J Pediatr Hematol Oncol 2021; 43:e365-e370. [PMID: 32324697 PMCID: PMC8572516 DOI: 10.1097/mph.0000000000001793] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 03/01/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite improved outcomes in children with leukemia, complications such as osteonecrosis are common. We conducted a systematic review to investigate the role of bisphosphonates in reducing pain, improving mobility, and stabilizing lesions in pediatric leukemia survivors. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched the PubMed, Embase, Cochrane, Web of Science, Scopus, CINAHL, and ClinicalTrials.gov databases. Five of 221 articles retrieved met our inclusion criteria. RESULTS Bisphosphonates, especially when combined with dietary calcium and vitamin D supplements and physical therapy (supplements/PT) were associated with improved pain and mobility in 54% and 50% of patients, respectively. A significantly greater proportion of patients treated with bisphosphonates (83%) reported mild/moderate pain or no pain compared with those with supplements/PT alone (36%) (P<0.001). Sixty-six percent of patients treated with bisphosphonates achieved improved/full mobility compared with 27% of those treated with supplements/PT alone (P=0.02). However, 46% of patients showed progressive joint destruction despite bisphosphonate therapy. No adverse events were reported, except for acute phase reactions to intravenous therapies. CONCLUSIONS Bisphosphonates, when combined with supplements/PT, were associated with less pain and improved mobility, but not prevention of joint destruction in pediatric leukemia patients with osteonecrosis.
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Affiliation(s)
- Shanaz M. Daneshdoost
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
| | - Jad M. El Abiad
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
| | - Kathy J. Ruble
- Department of Pediatrics, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
| | - Lynne C. Jones
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
| | - Janet L. Crane
- Department of Pediatrics, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
| | - Carol D. Morris
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
- Department of Oncology, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
| | - Adam S. Levin
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287
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12
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Total Hip Arthroplasty in Adolescents and Young Adults for Management of Advanced Corticosteroid-Induced Osteonecrosis Secondary to Treatment for Hematologic Malignancies. J Arthroplasty 2021; 36:1352-1360. [PMID: 33281023 DOI: 10.1016/j.arth.2020.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Osteonecrosis of the femoral head (ONFH) is a potentially severe toxicity associated with glucocorticoid treatment for pediatric hematologic malignancy. We examined clinical outcomes of THA in adolescents and young adults treated for hematologic malignancies who developed advanced ONFH. METHODS In a single-institution cohort, we retrospectively reviewed medical records and imaging for perioperative complications, reoperations, functional assessment at last follow-up, and radiological outcomes. Twenty-seven patients (41 hips) underwent THA (bilateral in 14 patients). There were 11 males. Median (interquartile range [IQR]) age at primary diagnosis was 14.9 years [1.8-18.9]. The median (IQR) age at THA was 19.8 years [14.6-30.3]. Mean (range) post-THA follow-up was 111.5 months (65.4-165.8). RESULTS Perioperative complications included one intraoperative calcar fracture that was secured with a cerclage wire and one posterior hip dislocation that occurred 6 days postoperatively, requiring closed reduction. One hip required a revision 21.1 months post-THA due to a fractured ceramic liner. The radiographic review was available for 38 of 41 hips and demonstrated none with loosening, subsidence, or osteolysis; nine developed periacetabular stress shielding. Incidence of stress shielding was associated with increased postoperative pain (P = .0130). There was a significant functional improvement in range of motion (ROM), pain, use of supports, participation in school, work, and sports, and use of pain medication from preoperative to postoperative clinical visits (P < .001). DISCUSSION Total hip arthroplasty in adolescents and young adults offers symptomatic and functional improvement in patients with ONFH. We found it to be safe with low perioperative complication rates even in patients undergoing active treatment for malignancy. LEVEL OF EVIDENCE Level IV, case series study. See Instructions for authors for a complete description of levels of evidence.
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13
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Amin N, Kraft J, Fishlock A, White A, Holton C, Kinsey S, Feltbower R, James B. Surgical management of symptomatic osteonecrosis and utility of core decompression of the femoral head in young people with acute lymphoblastic leukaemia recruited into UKALL 2003. Bone Joint J 2021; 103-B:589-596. [PMID: 33641424 DOI: 10.1302/0301-620x.103b3.bjj-2020-0239.r3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Osteonecrosis (ON) can cause considerable morbidity in young people who undergo treatment for acute lymphoblastic leukaemia (ALL). The aims of this study were to determine the operations undertaken for ON in this population in the UK, along with the timing of these operations and any sequential procedures that are used in different joints. We also explored the outcomes of those patients treated by core decompression (CD), and compared this with conservative management, in both the pre- or post-collapse stages of ON. METHODS UK treatment centres were contacted to obtain details regarding surgical interventions and long-term outcomes for patients who were treated for ALL and who developed ON in UKALL 2003 (the national leukaemia study which recruited patients aged 1 to 24 years at diagnosis of ALL between 2003 and 2011). Imaging of patients with ON affecting the femoral head was requested and was used to score all lesions, with subsequent imaging used to determine the final grade. Kaplan-Meier failure time plots were used to compare the use of CD with non surgical management. RESULTS Detailed information was received for 85 patients who had developed ON during the course of their ALL treatment. A total of 206 joints were affected by ON. Of all joints affected by ON, 21% required arthroplasty, and 43% of all hips affected went on to be replaced. CD was performed in 30% of hips affected by ON. The majority of the hips were grade 4 or 5 at initial diagnosis of ON. There was no significant difference in time to joint collapse between those joints in which CD was performed, compared with no joint-preserving surgical intervention. CONCLUSION There is a high incidence of surgery in young people who have received treatment for ALL and who have developed ON. Our results suggest that CD of the femoral head in this group of patients does not delay or improve the rates of femoral head survival. Cite this article: Bone Joint J 2021;103-B(3):589-596.
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Affiliation(s)
| | | | | | | | | | - Sally Kinsey
- Leeds Children's Hospital, Leeds, UK.,University of Leeds, Leeds, UK
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14
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Inaba H, Varechtchouk O, Neel MD, Ehrhardt MJ, Metzger ML, Karol SE, Ness KK, Ribeiro RC, Pui CH, Relling MV, Sandlund JT, Kaste SC. Whole-joint magnetic resonance imaging to assess osteonecrosis in pediatric patients with acute lymphoblastic lymphoma. Pediatr Blood Cancer 2020; 67:e28336. [PMID: 32472969 PMCID: PMC7391358 DOI: 10.1002/pbc.28336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/04/2020] [Accepted: 03/25/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Osteonecrosis is a debilitating complication in children and adolescents with acute lymphoblastic leukemia or acute lymphoblastic lymphoma (LLy). An objective screening test to identify patients at risk for symptomatic, extensive joint involvement will help manage osteonecrosis. METHODS We performed a prospective, longitudinal pilot study with whole-joint magnetic resonance imaging (MRI) of shoulders, elbows, hips, knees, ankles, and hindfeet to evaluate the incidence and timing of osteonecrosis involving multiple joints in 15 patients with LLy aged 9-21 years at diagnosis. RESULTS Osteonecrosis affecting ≥30% of the epiphysis occurred in eight of 15 patients, with a high prevalence in hips (12 of 26 examined [46%]) and knees (10 of 26 [38%]) post reinduction I and in shoulders (seven of 20 [35%]) post reinduction II. Most osteonecrotic hips and knees with ≥30% epiphyseal involvement became symptomatic and/or underwent surgery (100% and 82%, respectively). All eight patients with ≥30% epiphyseal involvement had multijoint involvement. Seven of these patients had hip or knee osteonecrosis by the end of remission induction, and only these patients developed osteonecrosis that became symptomatic and/or underwent surgery in their hips, knees, shoulders, ankles, and/or feet; all of these joints were associated with epiphyseal abnormalities on post reinduction I imaging. CONCLUSIONS MRI screening in adolescent patients with LLy revealed osteonecrosis in multiple joints. Initial screening with hip and knee MRI at the end of induction may identify susceptible patients who could benefit from referrals to subspecialties, more extensive follow-up imaging of other joints, and early medical and surgical interventions.
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Affiliation(s)
- Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Olga Varechtchouk
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Michael D. Neel
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Matthew J. Ehrhardt
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee,Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Monika L. Metzger
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee,Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Raul C. Ribeiro
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee
| | - John T. Sandlund
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Sue C. Kaste
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee;,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee
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15
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Kaste S, Suliman AY, Li Y, Keerthi D, Kang G, Triplett B, Srinivasan A. Pre- and post-magnetic resonance imaging of hips and knees for detecting osteonecrosis in children and adolescents undergoing hematopoietic cell transplantation. Bone Marrow Transplant 2020; 55:1837-1839. [PMID: 32265502 DOI: 10.1038/s41409-020-0882-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Sue Kaste
- Department of Radiology, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ali Y Suliman
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ying Li
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Dinesh Keerthi
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Brandon Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA. .,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.
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16
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DeFeo BM, Kaste SC, Li Z, Brinkman TM, Neel MD, Srivastava DK, Hudson MM, Robison LL, Karol SE, Ness KK. Long-Term Functional Outcomes Among Childhood Survivors of Cancer Who Have a History of Osteonecrosis. Phys Ther 2020; 100:509-522. [PMID: 32044966 PMCID: PMC7246066 DOI: 10.1093/ptj/pzz176] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/17/2019] [Accepted: 09/19/2019] [Indexed: 11/14/2022]
Abstract
BACKGROUND Glucocorticoids used to treat childhood leukemia and lymphoma can result in osteonecrosis, leading to physical dysfunction and pain. Improving survival rates warrants research into long-term outcomes among this population. OBJECTIVE The objective of this study was to compare the physical function and quality of life (QOL) of survivors of childhood cancer who had an osteonecrosis history with that of survivors who had no osteonecrosis history and with that of people who were healthy (controls). DESIGN This was a cross-sectional study. METHODS This study included St Jude Lifetime Cohort Study participants who were ≥ 10 years from the diagnosis of childhood leukemia or lymphoma and ≥ 18 years old; 135 had osteonecrosis (52.5% men; mean age = 27.7 [SD = 6.08] years) and 1560 had no osteonecrosis history (52.4% men; mean age = 33.3 [SD = 8.54] years). This study also included 272 people who were from the community and who were healthy (community controls) (47.7% men; mean age = 35.1 [SD = 10.46] years). The participants completed functional assessments and questionnaires about QOL. RESULTS Survivors with osteonecrosis scored lower than other survivors and controls for dorsiflexion strength (mean score = 16.50 [SD = 7.91] vs 24.17 [SD = 8.61] N·m/kg) and scored lower than controls for flexibility with the sit-and-reach test (20.61 [SD = 9.70] vs 23.96 [SD = 10.73] cm), function on the Physical Performance Test (mean score = 22.73 [SD = 2.05] vs 23.58 [SD = 0.88]), and mobility on the Timed "Up & Go" Test (5.66 [SD = 2.25] vs 5.12 [SD = 1.28] seconds). Survivors with hip osteonecrosis requiring surgery scored lower than survivors without osteonecrosis for dorsiflexion strength (13.75 [SD = 8.82] vs 18.48 [SD = 9.04] N·m/kg), flexibility (15.79 [SD = 8.93] vs 20.37 [SD = 10.14] cm), and endurance on the 6-minute walk test (523.50 [SD = 103.00] vs 572.10 [SD = 102.40] m). LIMITATIONS Because some eligible survivors declined to participate, possible selection bias was a limitation of this study. CONCLUSIONS Survivors of childhood leukemia and lymphoma with and without osteonecrosis demonstrated impaired physical performance and reported reduced QOL compared with controls, with those requiring surgery for osteonecrosis most at risk for impairments. It may be beneficial to provide strengthening, flexibility, and endurance interventions for patients who have pediatric cancer and osteonecrosis for long-term function.
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Affiliation(s)
- Brian M DeFeo
- DPT, OCS, Rehabilitation Services and Department of Radiological Sciences, Mail Stop 113, St Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis,TN 38105-3678 (USA)
| | - Sue C Kaste
- Department of Radiological Sciences, St Jude Children’s Research Hospital
| | - Zhenghong Li
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital
| | - Tara M Brinkman
- Department of Epidemiology and Cancer Control and Department of Psychology, St Jude Children’s Research Hospital
| | - Michael D Neel
- Department of Surgery, St Jude Children’s Research Hospital
| | - Deo Kumar Srivastava
- Department of Biostatistics and Department of Cancer Prevention and Control, St Jude Children’s Research Hospital
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, Department of Psychology, Department of Cancer Prevention and Control, and Department of Oncology, St Jude Children’s Research Hospital
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, Department of Cancer Prevention and Control, and Comprehensive Cancer Center, St Jude Children’s Research Hospital
| | - Seth E Karol
- Department of Oncology and Comprehensive Cancer Center, St Jude Children’s Research Hospital
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control and Department of Pediatric Medicine, St Jude Children’s Research Hospital
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17
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Kuhlen M, Kunstreich M, Niinimäki R, Dunstheimer D, Lawitschka A, Bardi E, Willasch A, Bader P, Högler W, Peters C, Balduzzi A. Guidance to Bone Morbidity in Children and Adolescents Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:e27-e37. [DOI: 10.1016/j.bbmt.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/12/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022]
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18
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Adesina OO, Gurney JG, Kang G, Villavicencio M, Hodges JR, Chemaitilly W, Kaste SC, Zemel BS, Hankins JS. Height-corrected low bone density associates with severe outcomes in sickle cell disease: SCCRIP cohort study results. Blood Adv 2019; 3:1476-1488. [PMID: 31072833 PMCID: PMC6517655 DOI: 10.1182/bloodadvances.2018026047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 04/01/2019] [Indexed: 11/20/2022] Open
Abstract
Low bone mineral density (BMD) disproportionately affects people with sickle cell disease (SCD). Growth faltering is common in SCD, but most BMD studies in pediatric SCD cohorts fail to adjust for short stature. We examined low BMD prevalence in 6- to 18-year-olds enrolled in the Sickle Cell Clinical Research and Intervention Program (SCCRIP), an ongoing multicenter life span SCD cohort study initiated in 2014. We calculated areal BMD for chronological age and height-adjusted areal BMD (Ht-aBMD) z scores for the SCCRIP cohort, using reference data from healthy African American children and adolescents enrolled in the Bone Mineral Density in Childhood Study. We defined low BMD as Ht-aBMD z scores less than or equal to -2 and evaluated its associations with demographic and clinical characteristics by using logistic regression analyses. Of the 306 children and adolescents in our study cohort (mean age, 12.5 years; 50% female; 64% HbSS/Sβ0-thalassemia genotype; 99% African American), 31% had low areal BMD for chronological age z scores and 18% had low Ht-aBMD z scores. In multivariate analyses, low Ht-aBMD z scores associated with adolescence (odds ratio [OR], 7.7; 95% confidence interval [CI], 1.94-30.20), hip osteonecrosis (OR, 4.0; 95% CI, 1.02-15.63), chronic pain (OR, 10.4; 95% CI, 1.51-71.24), and hemoglobin (OR, 0.74; 95% CI, 0.57-0.96). Despite adjusting for height, nearly 20% of this pediatric SCD cohort still had very low BMD. As the SCCRIP cohort matures, we plan to prospectively evaluate the longitudinal relationship between Ht-aBMD z scores and markers of SCD severity and morbidity.
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Affiliation(s)
- Oyebimpe O Adesina
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - James G Gurney
- School of Public Health, University of Memphis, Memphis, TN
| | | | | | | | | | - Sue C Kaste
- Department of Diagnostic Imaging, and
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA; and
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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19
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Osteonecrosis of the Shoulders in Pediatric Patients Treated for Leukemia or Lymphoma: Single-Institutional Experience. J Pediatr Orthop 2019; 39:104-110. [PMID: 28452860 PMCID: PMC5659977 DOI: 10.1097/bpo.0000000000000900] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteonecrosis of the hips and knees is an often debilitating adverse event in children treated with glucocorticoids for leukemia and lymphoma but the impact of shoulder involvement has been understudied. Thus, we investigated the severity and functional impairment of shoulder osteonecrosis in a well-characterized population of pediatric patients treated for acute lymphoblastic leukemia or lymphoma. METHODS We retrospectively reviewed orthopaedic clinic and physical therapy evaluations to determine range of motion (ROM), pain, and impact of magnetic resonance-defined osteonecrosis (ON) on activities of daily living. Adverse events were classified according to the National Cancer Institute's Common Terminology Criteria for Adverse Events version 4.03. RESULTS We identified 35 patients (22 female), median age at cancer diagnosis 14.2 (range, 4.3 to 19) years; median age at ON diagnosis 16.7 (range, 5.5 to 28) years. Median time to last follow-up from diagnosis of primary malignancy was 6.4 (range, 0 to 12.7) years and from diagnosis of ON was 4.0 (range, 0 to 8.9) years. Twenty-two patients had magnetic resonance evidence of ON; 43 shoulders involved at least 30% of the articular surface of the capital humeral epiphyses.Common Terminology Criteria for Adverse Events mean scores for initial assessments of 55 shoulders (29 patients) showed moderate negative impact of ON on activity of daily living (1.94), decreased ROM limiting athletic activity (0.98), and mild to moderate levels of pain (1.38). Analysis of this group's most recent assessment showed improvement in pain and ON over time, with an average pain grade of 0.58 indicating no pain to mild pain, and 1.37 for ON grade, indicating asymptomatic to mildly symptomatic impact on activities of daily living. We also found minimal worsening average ROM grades (1.11). CONCLUSIONS Shoulder ON is an underappreciated adverse late effect of therapy in children treated for leukemia/lymphoma which can limit quality of life and functionality. In most cases, pain and disability can be improved with treatment. LEVEL OF EVIDENCE Level IV-case series.
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Bruzzi P, Bigi E, Predieri B, Bonvicini F, Cenciarelli V, Felici F, Iughetti L. Long-term effects on growth, development, and metabolism of ALL treatment in childhood. Expert Rev Endocrinol Metab 2019; 14:49-61. [PMID: 30596296 DOI: 10.1080/17446651.2019.1561271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 12/17/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION One aim of the long-term care in survivors from acute lymphoblastic leukemia (ALL) during childhood is to avoid or limit complications caused by aggressive therapeutic strategies. AREAS COVERED ALL survivors are a heterogeneous group according to therapeutic protocols. In the last decades, cranial radiotherapy (cRT) has been largely replaced by intrathecal chemotherapy (CT) with a reduction of endocrine sequelae. Published studies are generally difficult to be interpreted because patients were treated according to different risk-adapted protocols and results are conflicting. We perform this review on endocrine long-term effects in childhood ALL survivors focusing on studies published in the last decades. Articles were selected using the following terms (Mesh terms): 'acute lymphoblastic leukemia' AND 'survivors' AND 'childhood' AND 'growth/puberty/fertility/obesity/metabolic syndrome/bone'. EXPERT COMMENTARY Most childhood ALL survivors treated with CT alone attain normal height and have adequate pubertal development. Despite recent protocols improvements, ALL survivors still develop long-term metabolic complications (overweight, obesity, and cardiovascular disease) especially the female gender and patients with an increased body mass index (BMI) at diagnosis. The aim of this review is to describe the state of the art on these topics. We should be able to anticipate, prevent, and treat endocrine long-term morbidities through a well-established follow-up strategy.
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Affiliation(s)
- Patrizia Bruzzi
- a Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia , Modena , Italy
| | - Elena Bigi
- b Oncology and Hematology Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia , Modena , Italy
| | - Barbara Predieri
- a Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia , Modena , Italy
| | - Federico Bonvicini
- c Post Graduate School of Pediatrics, Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia , Modena , Italy
| | - Valentina Cenciarelli
- c Post Graduate School of Pediatrics, Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia , Modena , Italy
| | - Francesca Felici
- c Post Graduate School of Pediatrics, Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia , Modena , Italy
| | - Lorenzo Iughetti
- c Post Graduate School of Pediatrics, Department of Medical and Surgical Sciences for Mothers, Children and Adults , University of Modena and Reggio Emilia , Modena , Italy
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Cox CL, Zhu L, Kaste SC, Srivastava K, Barnes L, Nathan PC, Wells RJ, Ness KK. Modifying bone mineral density, physical function, and quality of life in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26929. [PMID: 29286560 PMCID: PMC5821547 DOI: 10.1002/pbc.26929] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/09/2017] [Accepted: 11/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The early effects of childhood acute lymphoblastic leukemia (ALL) include decreased physical function, bone mineral density (BMD/g/cm2 ), and health-related quality of life (HRQL). We assessed the capacity of a physical therapy and motivation-based intervention, beginning after diagnosis and continuing through the end of treatment, to positively modify these factors. PROCEDURE A 2.5-year randomized controlled trial of 73 patients aged 4-18.99 years within 10 days of ALL diagnosis assessed BMD at baseline (T0 ) and end of therapy (T3 ), strength, range of motion, endurance, motor skills, and HRQL at baseline (T0 ), 8 (T1 ), 15 (T2 ), and 135 (T3 ) weeks. RESULTS There were no significant changes between groups (intervention, n = 33; usual care, n = 40) in BMD (P = 0.059) at T3 or physical function and HRQL at T0 -T3 . While BMD declined in both the intervention (T0 = -0.21, T3 = -0.55) and usual care (T0 = -0.62, T3 = -0.78) groups, rates of decline did not differ between groups (P = 0.56). Univariate analysis (n = 73) showed associations of higher T3 bone density with body mass index T1 (P = 0.01), T2 (P = <0.0001), T3 (P = 0.01), T3 ankle flexibility/strength (P = 0.001), and T2 parent (P = 0.02)/T0 child (P = 0.03) perceptions of less bodily pain. CONCLUSIONS The intervention delivered during treatment was not successful in modifying BMD, physical function, or HRQL. Physical activity, at the level and intensity required to modify these factors, may not be feasible during early treatment owing to the child's responses to the disease and treatment. Future studies will consider intervention implementation during late maintenance therapy, extending into survivorship.
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Affiliation(s)
| | - Liang Zhu
- The University of Texas Health Science Center at Houston, TX
| | - Sue C. Kaste
- St. Jude Children's Research Hospital, Memphis, TN
- The University of Tennessee Health Science Center, Memphis, TN
| | | | - Linda Barnes
- St. Jude Children's Research Hospital, Memphis, TN
| | - Paul C. Nathan
- The Hospital for Sick Children, University of Toronto, Toronto, CA
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Theruvath AJ, Ilivitzki A, Muehe A, Theruvath J, Gulaka P, Kim C, Luna-Fineman S, Sakamoto KM, Yeom KW, Yang P, Moseley M, Chan F, Daldrup-Link HE. A PET/MR Imaging Approach for the Integrated Assessment of Chemotherapy-induced Brain, Heart, and Bone Injuries in Pediatric Cancer Survivors: A Pilot Study. Radiology 2017; 285:971-979. [PMID: 28777701 DOI: 10.1148/radiol.2017170073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose To develop a positron emission tomography (PET)/magnetic resonance (MR) imaging protocol for evaluation of the brain, heart, and joints of pediatric cancer survivors for chemotherapy-induced injuries in one session. Materials and Methods Three teams of experts in neuroimaging, cardiac imaging, and bone imaging were tasked to develop a 20-30-minute PET/MR imaging protocol for detection of chemotherapy-induced tissue injuries of the brain, heart, and bone. In an institutional review board-approved, HIPAA-compliant, prospective study from April to July 2016, 10 pediatric cancer survivors who completed chemotherapy underwent imaging of the brain, heart, and bone with a 3-T PET/MR imager. Cumulative chemotherapy doses and clinical symptoms were correlated with the severity of MR imaging abnormalities by using linear regression analyses. MR imaging measures of brain perfusion and metabolism were compared among eight patients who were treated with methotrexate and eight untreated age-matched control subjects by using Wilcoxon rank-sum tests. Results Combined brain, heart, and bone examinations were completed within 90 minutes. Eight of 10 cancer survivors had abnormal findings on brain, heart, and bone images, including six patients with and two patients without clinical symptoms. Cumulative chemotherapy doses correlated significantly with MR imaging measures of left ventricular ejection fraction and end-systolic volume, but not with the severity of brain or bone abnormalities. Methotrexate-treated cancer survivors had significantly lower cerebral blood flow and metabolic activity in key brain areas compared with control subjects. Conclusion The feasibility of a single examination for assessment of chemotherapy-induced injuries of the brain, heart, and joints was shown. Earlier detection of tissue injuries may enable initiation of timely interventions and help to preserve long-term health of pediatric cancer survivors. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Ashok J Theruvath
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Anat Ilivitzki
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Anne Muehe
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Johanna Theruvath
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Praveen Gulaka
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Christine Kim
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Sandra Luna-Fineman
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Kathleen M Sakamoto
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Kristen W Yeom
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Phillip Yang
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Michael Moseley
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Frandics Chan
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
| | - Heike E Daldrup-Link
- From the Department of Radiology and the Molecular Imaging Program (A.J.T., A.I., A.M., J.T., P.G., C.K., K.W.Y., M.M., F.C., H.E.D.L.), Department of Pediatrics, Division of Pediatric Hematology/Oncology (S.L.F., K.M.S., H.E.D.L.), and Department of Medicine, Division of Cardiology (P.Y.), Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Rd, Stanford, CA 94305-5654
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Newman JM, George J, North WT, Navale SM, Klika AK, Barsoum WK, Higuera CA. Hematologic Malignancies Are Associated With Adverse Perioperative Outcomes After Total Hip Arthroplasty. J Arthroplasty 2017; 32:2436-2443.e1. [PMID: 28372919 DOI: 10.1016/j.arth.2017.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/14/2017] [Accepted: 03/03/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Advancements in treating hematologic malignancies have improved survival, and these patients may be part of the growing population undergoing total hip arthroplasty (THA). Therefore, the purpose of this study was to evaluate the perioperative outcomes of THA in patients with hematologic malignancies. METHODS The Nationwide Inpatient Sample identified patients who underwent THA from 2000 to 2011 (n = 2,864,412). Patients diagnosed with any hematologic malignancy (n = 18,012) were further stratified into Hodgkin disease (n = 786), non-Hodgkin lymphoma (n = 5062), plasma cell dyscrasias (n = 2067), leukemia (n = 5644), myeloproliferative neoplasms (n = 3552), and myelodysplastic syndromes (n = 1082). Propensity matching for demographics, hospital characteristics, and comorbidities identified 17,810 patients with any hematologic malignancy and 17,888 controls; additional matching was performed to compare hematologic malignancy subtypes with controls. Multivariate regression was used to analyze surgical and medical complications, length of stay (LOS), and costs. RESULTS Compared to controls, hematologic malignancies increased the risk of any surgery-related complication (odds ratio [OR], 1.4; P < .0001) and any general medical complication (OR, 1.47; P < .0001). Additionally, hematologic malignancies were associated with an increase in LOS (0.16 days; P = .004) and increased costs ($1,101; P < .0001). CONCLUSION Patients with hematologic malignancies undergoing THA have an increased risk of perioperative complications, longer LOS, and higher costs. The risk quantification for adverse perioperative outcomes in association with increased cost may help to design different risk stratification and reimbursement methods in such populations.
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Affiliation(s)
- Jared M Newman
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - W Trevor North
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Suparna M Navale
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Portera MV, Karol SE, Smith C, Yang W, Cheng C, Neel MD, Pui CH, Relling MV, Kaste SC. Osteonecrosis is unrelated to hip anatomy in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26407. [PMID: 28035753 PMCID: PMC5596390 DOI: 10.1002/pbc.26407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 12/31/2022]
Abstract
Osteonecrosis is a debilitating toxicity associated with acute lymphoblastic leukemia (ALL) treatment. A recent report associated interindividual differences in hip anatomy with the development of idiopathic osteonecrosis in adults. To evaluate the impact of hip anatomy on the development of therapy-related osteonecrosis, we retrospectively evaluated the femoral neck-shaft angle, femoral neck offset, and lateral center-edge angle using x-rays of 18 osteonecrosis cases and 46 control children treated for newly diagnosed ALL on a single protocol. Despite adequate statistical power, we found no association between hip anatomy and osteonecrosis. Investigation of other factors contributing to ALL-associated osteonecrosis is warranted.
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Affiliation(s)
- Mary V. Portera
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Seth E. Karol
- Department of Comprehensive Cancer Center, St. Jude Children’s Research Hospital, Memphis, TN, USA,Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Colton Smith
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Wenjian Yang
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Michael D. Neel
- Department of Orthopaedics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Sue C. Kaste
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN, USA
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Kuhlen M, Kunstreich M, Krull K, Meisel R, Borkhardt A. Osteonecrosis in children and adolescents with acute lymphoblastic leukemia: a therapeutic challenge. Blood Adv 2017; 1:981-994. [PMID: 29296741 PMCID: PMC5737600 DOI: 10.1182/bloodadvances.2017007286] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/18/2017] [Indexed: 01/19/2023] Open
Abstract
Osteonecrosis (ON) represents one of the most common and debilitating sequelae of antileukemic treatment in children and adolescents with acute lymphoblastic leukemia (ALL). Systematic screening strategies can focus on early detection and intervention to prevent ON from progressing to stages associated with pain and functional impairment. These strategies hold promise for reducing ON-associated morbidity without the risk of impairing leukemia control. Herein, we critically reviewed clinical data on pharmacological, nonpharmacological/nonsurgical, and surgical (including cellular) treatment options for ON, which are covered in the literature and/or are conceivable based on the supposed underlying ON pathophysiology. Prevention of ON progression is of paramount importance, and attempts seem to be more effective in early (precollapse) disease status than in late-stage (collapse) ON. Based on the results of ongoing prospective magnetic resonance imaging screening studies, which will hopefully identify those patients with a high risk of ON progression and debilitating sequelae, prospective interventional studies are urgently needed. Although there is still a lack of high-quality studies, based on currently available data, core decompression surgery combined with cellular therapies (eg, employing mesenchymal stem cells) appears most promising for preventing joint infraction in children at high risk of developing late-stage ON.
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Affiliation(s)
- Michaela Kuhlen
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Marina Kunstreich
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Kathinka Krull
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Roland Meisel
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Arndt Borkhardt
- Department of Pediatric Oncology, Hematology, and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
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Abstract
Younger patients are affected more often by osteonecrosis than by osteoarthritis, and osteonecrosis has significantly greater long-term morbidity. Corticosteroids are the most common cause of nontraumatic osteonecrosis. The femoral head is the most common site of osteonecrosis. In rare instances, osteonecrosis of the jaw has been associated with bisphosphonate exposure. This phenomenon is more common with repeated intravenous infusions of bisphosphonates. Case reports of osteonecrosis of the jaw in association with other medications, such as denosumab, have been reported. The final common pathway in the pathogenesis of osteonecrosis is disruption of blood supply to a segment of bone. Abnormalities in lipid metabolism, bone homeostasis, regulation of apoptosis, coagulopathies, innate immunity, and oxidative stress may play a role in the pathogenesis of osteonecrosis. Epigenetics may alter the predisposition to develop osteonecrosis. MRI is currently the optimal test for early diagnosis and identification of the extent of osteonecrosis. Nonsurgical treatment of osteonecrosis does not change the natural history of the disease. Although surgical treatment of femoral head osteonecrosis has many variations, most symptomatic patients eventually require total hip arthroplasty. Knowledge of risk factors and early detection are crucial to the successful management of osteonecrosis. Because of the lack of successful treatment options, new modes of management focus on the prevention of osteonecrosis.
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Ippolito D, Masetto A, Talei Franzesi C, Bonaffini PA, Casiraghi A, Sironi S. Relative volume measured with magnetic resonance imaging is an articular collapse predictor in hematological pediatric patients with femoral head osteonecrosis. World J Radiol 2016; 8:750-756. [PMID: 27648169 PMCID: PMC5002506 DOI: 10.4329/wjr.v8.i8.750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/10/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the potential value of femoral head (FH) volume measurements to predict joint collapse, as compared to articular surface involvement, in post-treatment osteonecrosis (ON) in pediatric patients affected by lymphoproliferative diseases.
METHODS Considering 114 young patients with lymphoproliferative diseases undergone a lower-limbs magnetic resonance imaging (MRI) examination between November 2006 and August 2012 for a suspected post-treatment ON, we finally considered a total of 13 cases (7 males, mean age 15.2 ± 4.8 years), which developed a FH ON lesions (n = 23). The MRI protocol included coronal short tau inversion recovery and T1-weighted sequences, from the hips to the ankles. During the follow-up (elapsed time: 9.2 ± 2 mo), 13/23 FH articular surface (FHS) developed articular deformity. The first MRI studies with diagnosis of ON were retrospectively analyzed, measuring FH volume (FHV), FHS, ON volume (ONV) and the articular surface involved by ON (ONS). The relative involvement of FHS, in terms of volume [relative volume (RV): ONV/FHV] and articular surface [relative surface (RS): ONS/FHS], was then calculated.
RESULTS By using receiver operating characteristic curve analysis (threshold of 23% of volume involvement), RV predicted articular deformity in 13/13 FHS [sensitivity 100%, specificity 90%, accuracy 95%, positive predictive value (PPV) 93%, negative predictive value (NPV) 100%]. Considering a threshold of 50% of articular involvement, RS predicted articular deformity in 10/13 femoral heads (sensitivity 77%, specificity 100%, accuracy 87%, PPV 100%, NPV 77%).
CONCLUSION RV might be a more reliable parameter than RS in predicting FH deformity and could represent a potential complementary diagnostic tool in the follow-up of femoral heads ON lesions.
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Osteonecrosis detected by whole body magnetic resonance in patients with Hodgkin Lymphoma treated by BEACOPP. Eur Radiol 2016; 27:2129-2136. [PMID: 27519911 DOI: 10.1007/s00330-016-4535-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 07/09/2016] [Accepted: 07/27/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The purpose of our retrospective review of prospectively acquired Whole Body Magnetic Resonance (WB-MRI) scans was to assess the incidence of osteonecrosis in patients who received different chemotherapies. METHODS We evaluated the WB-MRI scans performed on 42 patients with Hodgkin Lymphoma treated by three chemotherapy regimens (6ABVD, 2ABVD + 4BEACOPP, 2ABVD + 8BEACOPP), excluding patients with the main risk factors for osteonecrosis. RESULTS Six out of seven patients (86 %) who received eight BEACOPP and one out of five patients (20 %) treated by four BEACOPP presented osteonecrosis, with a statistically significant difference of frequency between the two groups of patients (p < 0.05); no injury has been reported in patients treated by only ABVD. Among a total of 48 osteonecrotic lesions observed, 48 % were detected in the knee; multifocal osteonecrosis were detected in six out of seven patients (86 %). CONCLUSIONS The development of osteonecrosis is strictly related to the chemotherapy protocol adopted and the number of cycles received, with a strong correlation between the dose of corticosteroids included in the BEACOPP scheme and this complication. WB-MRI can be considered as a helpful tool that allows detecting earlier osteonecrotic lesions in patients treated with corticosteroids. KEY POINTS • Osteonecrosis is a possible complication of patients with Lymphoma treated by chemotherapy. • Osteonecrosis is related to the corticosteroids included within the BEACOPP protocol. • WB-MRI allows detecting osteonecrotic lesions in patients treated with corticosteroids.
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Mah W, Sonkusare SK, Wang T, Azeddine B, Pupavac M, Carrot-Zhang J, Hong K, Majewski J, Harvey EJ, Russell L, Chalk C, Rosenblatt DS, Nelson MT, Séguin C. Gain-of-function mutation in TRPV4 identified in patients with osteonecrosis of the femoral head. J Med Genet 2016; 53:705-9. [PMID: 27330106 PMCID: PMC5035228 DOI: 10.1136/jmedgenet-2016-103829] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Background Osteonecrosis of the femoral head is a debilitating disease that involves impaired blood supply to the femoral head and leads to femoral head collapse. Methods We use whole-exome sequencing and Sanger sequencing to analyse a family with inherited osteonecrosis of the femoral head and fluorescent Ca2+ imaging to functionally characterise the variant protein. Results We report a family with four siblings affected with inherited osteonecrosis of the femoral head and the identification of a c.2480_2483delCCCG frameshift deletion followed by a c.2486T>A substitution in one allele of the transient receptor potential vanilloid 4 (TRPV4) gene. TRPV4 encodes a Ca2+-permeable cation channel known to play a role in vasoregulation and osteoclast differentiation. While pathogenic TRPV4 mutations affect the skeletal or nervous systems, association with osteonecrosis of the femoral head is novel. Functional measurements of Ca2+ influx through mutant TRPV4 channels in HEK293 cells and patient-derived dermal fibroblasts identified a TRPV4 gain of function. Analysis of channel open times, determined indirectly from measurement of TRPV4 activity within a cluster of TRPV4 channels, revealed that the TRPV4 gain of function was caused by longer channel openings. Conclusions These findings identify a novel TRPV4 mutation implicating TRPV4 and altered calcium homeostasis in the pathogenesis of osteonecrosis while reinforcing the importance of TRPV4 in bone diseases and vascular endothelium.
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Affiliation(s)
- Wayne Mah
- Division of Hematology and Oncology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Swapnil K Sonkusare
- Department of Pharmacology, University of Vermont, Burlington, Vermont, USA Department of Molecular Physiology and Biological Physics, University of Virginia, Charlottesville, Virginia, USA
| | - Tracy Wang
- Division of Hematology and Oncology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bouziane Azeddine
- Division of Hematology and Oncology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mihaela Pupavac
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Jian Carrot-Zhang
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada Department of Human Genetics, McGill University and Genome Québec Innovation Centre, Montreal, Quebec, Canada
| | - Kwangseok Hong
- Department of Molecular Physiology and Biological Physics, University of Virginia, Charlottesville, Virginia, USA
| | - Jacek Majewski
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada Department of Human Genetics, McGill University and Genome Québec Innovation Centre, Montreal, Quebec, Canada
| | - Edward J Harvey
- Department of Surgery, Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Laura Russell
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Colin Chalk
- Department of Neurology & Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - David S Rosenblatt
- Department of Human Genetics, McGill University, Montreal, Quebec, Canada
| | - Mark T Nelson
- Department of Pharmacology, University of Vermont, Burlington, Vermont, USA Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Chantal Séguin
- Division of Hematology and Oncology, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Niinimäki TT, Ohtonen P, Harila-Saari AH, Niinimäki RA. Young patients with hematologic and lymphatic malignancies have an increased risk of hip and knee arthroplasty. Acta Oncol 2016; 55:567-71. [PMID: 26967713 DOI: 10.3109/0284186x.2015.1119884] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Skeletal complications such as osteonecrosis (ON) are potential adverse events in patients treated for cancer, especially in those treated for hematologic and lymphatic malignancies (HLMs). ON may damage the hip or knee joints and may lead to arthrosis requiring total joint arthroplasty (TJA). The aim of this study was to address the risk of TJA in patients with cancer, especially those treated for HLM, in a nationwide population-based setting. Material and methods All patients who had undergone TJA after cancer diagnosis between the years 2000 and 2012 were identified by linking the Arthroplasty Register and the Cancer Registry. Standardized incidence ratios (SIRs) of TJAs were calculated to assess whether patients with any cancer, but especially HLM, have increased risk for TJA when compared with the general population. Results In patients with HLM or other cancer, the overall SIRs were similar compared with the general population. However, in HLM patients under 50 years of age, the SIR was 7.6, and in patients under 35 years of age, it was 45.5. The corresponding SIRs in patients with other cancers were 3.6 and 6.6, respectively. The highest SIRs, including all age groups, were among patients with acute lymphoblastic leukemia (SIR = 4.5) and acute myeloid leukemia (SIR = 1.9). Discussion HLMs imply an increased risk for TJA compared with the general population. The risk is especially high in patients younger than 50 years, regardless of the type of HLM. Young patients with HLM, as well as their healthcare providers, should be aware of the highly increased risk of skeletal complications requiring TJA.
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Affiliation(s)
- Tuukka T. Niinimäki
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Pasi Ohtonen
- Division of Operative Care and Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Arja H. Harila-Saari
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Riitta A. Niinimäki
- Department of Children and Adolescents, Oulu University Hospital and University of Oulu, Oulu, Finland
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Niinimäki T, Niinimäki J, Halonen J, Hänninen P, Harila-Saari A, Niinimäki R. The classification of osteonecrosis in patients with cancer: validation of a new radiological classification system. Clin Radiol 2015; 70:1439-44. [PMID: 26453406 DOI: 10.1016/j.crad.2015.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/01/2015] [Accepted: 08/07/2015] [Indexed: 11/24/2022]
Abstract
AIM To validate a new, non-joint-specific radiological classification system that is suitable regardless of the site of the osteonecrosis (ON) in patients with cancer. MATERIAL AND METHODS Critical deficiencies in the existing ON classification systems were identified and a new, non-joint-specific radiological classification system was developed. Seventy-two magnetic resonance imaging (MRI) images of patients with cancer and ON lesions were graded, and the validation of the new system was performed by assessing inter- and intra-observer reliability. RESULTS Intra-observer reliability of ON grading was good or very good, with kappa values of 0.79-0.86. Interobserver agreement was lower but still good, with kappa values of 0.62-0.77. Ninety-eight percent of all intra- or interobserver differences were within one grade. Interobserver reliability of assessing the location of ON was very good, with kappa values of 0.93-0.98. CONCLUSION All the available radiological ON classification systems are joint specific. This limitation has spurred the development of multiple systems, which has led to the insufficient use of classifications in ON studies among patients with cancer. The introduced radiological classification system overcomes the problem of joint-specificity, was found to be reliable, and can be used to classify all ON lesions regardless of the affected site.
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Affiliation(s)
- T Niinimäki
- Department of Surgery, Oulu University Hospital and Oulu University, Oulu, Finland.
| | - J Niinimäki
- Department of Radiology, Oulu University Hospital, Oulu, Finland; Oulu University, Oulu, Finland
| | - J Halonen
- Department of Radiology, Oulu University Hospital, Oulu, Finland
| | - P Hänninen
- Department of Surgery, Oulu University Hospital and Oulu University, Oulu, Finland
| | - A Harila-Saari
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - R Niinimäki
- Department of Children and Adolescents, Oulu University Hospital and Oulu University, Oulu, Finland
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Abstract
Osteonecrosis, also known as avascular necrosis or AVN, is characterized by a stereotypical pattern of cell death and a complex repair process of bone resorption and formation. It is not the necrosis itself but rather the resorptive component of the repair process that results in loss of structural integrity and subchondral fracture. Most likely, a common pathophysiological pathway exists involving compromised subchondral microcirculation. Decreased femoral head blood flow can occur through three mechanisms: vascular interruption by fractures or dislocation, intravascular occlusion from thrombi or embolic fat, or intraosseous extravascular compression from lipocyte hypertrophy or Gaucher cells. In this review, we emphasize etiologic relationships derived mostly from longitudinal cohort studies or meta-analyses whose causal relationships to osteonecrosis can be estimated with confidence. Understanding risk factors and pathophysiology has therapeutic implications since several treatment regimens are available to optimize femoral head circulation, interrupt bone resorption, and preserve the subchondral bone.
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Te Winkel ML, Pieters R, Wind EJD, Bessems JHJMG, van den Heuvel-Eibrink MM. Management and treatment of osteonecrosis in children and adolescents with acute lymphoblastic leukemia. Haematologica 2015; 99:430-6. [PMID: 24598854 DOI: 10.3324/haematol.2013.095562] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
There is no consensus regarding how to manage osteonecrosis in pediatric acute lymphoblastic leukemia patients. Therefore, we performed a quality assessment of the literature with the result of a search strategy using the MESH terms osteonecrosis, children, childhood cancer, surgery, bisphosphonates, 6 hydroxymethyl-glutaryl CoA reductase inhibitors, anticoagulants and hyperbaric oxygen, and terms related to these MESH terms. A randomized controlled trial showed that osteonecrosis can be prevented by intermittent, instead of continuous, corticosteroid administration. The studies on interventions after onset of osteonecrosis were of low-quality evidence. Seven pediatric acute lymphoblastic leukemia studies described non-surgical interventions; bisphosphonates (n=5), hyperbaric oxygen therapy (n=1), or prostacyclin analogs (n=1). Safety and efficacy studies are lacking. Five studies focused on surgical interventions; none was of sufficient quality to draw definite conclusions. In conclusion, preventing osteonecrosis is feasible in a proportion of the pediatric acute lymphoblastic leukemia patients by discontinuous, instead of continuous, steroid scheduling. The questions as to how to treat childhood acute lymphoblastic leukemia patients with osteonecrosis cannot be answered as good-quality studies are lacking.
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Niinimäki T, Harila-Saari A, Niinimäki R. The diagnosis and classification of osteonecrosis in patients with childhood leukemia. Pediatr Blood Cancer 2015; 62:198-203. [PMID: 25359608 DOI: 10.1002/pbc.25295] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/11/2014] [Indexed: 11/11/2022]
Abstract
Osteonecrosis is a well-recognized complication in patients with childhood leukemia. Its clinical relevance is highly dependent on the size and location of the lesion. Therefore, the diagnosis, description of the affected site and the classification of the disease, must be precise. We conducted an extensive literature review to assess the quality of studies reporting the incidence of osteonecrosis in patients with childhood leukemia. Of the 31 included studies, one-third (32% [n = 10]) did not describe the diagnostic method that was used to assess osteonecrosis. In almost two-third (61% [n = 19]) of the studies, the osteonecrosis classification system was not used. We conclude that the quality of most published studies on the incidence of osteonecrosis in patients with childhood leukemia is relatively poor because many studies did not describe the radiological method used to diagnose osteonecrosis and/or did not use a validated osteonecrosis classification system. To compare the incidence of osteonecrosis, and to assess the severity and clinical consequences of osteonecrosis in patients with childhood leukemia, there is a need for a robust and widely recognized classification system to grade all cases of osteonecrosis despite the site of lesion. Pediatr Blood Cancer 2015;62:198-203. © 2014 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Riitta Niinimäki
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
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Abstract
Treatment for childhood cancer with chemotherapy, radiation and/or hematopoietic cell transplant can result in adverse sequelae that may not become evident for many years. A clear understanding of the association between therapeutic exposures and specific long-term complications, and an understanding of the magnitude of the burden of morbidity borne by childhood cancer survivors, has led to the development of guidelines to support lifelong risk-based follow up for this population. It is important to develop interventions to reduce the impact of treatment-related late effects on morbidity and mortality and to continue research regarding the etiopathogenesis of therapy-related cancers and other late effects.
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Affiliation(s)
- Wendy Landier
- Department of Population Sciences, City of Hope, 1500 E. Duarte Rd., DPS-173, Duarte, CA 91010, USA
| | - Saro Armenian
- Department of Population Sciences, City of Hope, 1500 E. Duarte Rd., DPS-173, Duarte, CA 91010, USA
| | - Smita Bhatia
- Department of Population Sciences, City of Hope, 1500 E. Duarte Rd., DPS-173, Duarte, CA 91010, USA.
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Kaste SC, Pei D, Cheng C, Neel MD, Bowman WP, Ribeiro RC, Metzger ML, Bhojwani D, Inaba H, Campbell P, Rubnitz JE, Jeha S, Sandlund JT, Downing JR, Relling MV, Pui CH, Howard SC. Utility of early screening magnetic resonance imaging for extensive hip osteonecrosis in pediatric patients treated with glucocorticoids. J Clin Oncol 2015; 33:610-5. [PMID: 25605853 DOI: 10.1200/jco.2014.57.5480] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hip osteonecrosis frequently complicates treatment with glucocorticoids. When extensive (affecting ≥ 30% of the epiphyseal surface), 80% of joints collapse within 2 years, so interventions are needed to prevent this outcome. PATIENTS AND METHODS This prospective cohort magnetic resonance imaging (MRI) screening study included all consecutive children treated for acute lymphoblastic leukemia on a single protocol. Hip MRI was performed at 6.5 and 9 months from diagnosis (early screening) and at completion of chemotherapy (final evaluation) to determine whether screening could identify extensive hip osteonecrosis before symptom development. RESULTS Of 498 patients, 462 underwent screening MRI. Extensive asymptomatic osteonecrosis was identified by early screening in 26 patients (41 hips); another four patients (seven hips) were detected after the screening period, such that screening sensitivity was 84.1% and specificity was 99.4%. The number of joints screened to detect one lesion was 20.1 joints for all patients, 4.4 joints for patients older than 10 years, and 198 joints for patients ≤ 10 years old (P < .001). Of the 40 extensive lesions in patients older than 10 years, 19 required total hip arthroplasty and none improved. Of eight extensive lesions in younger patients, none required arthroplasty and four improved. CONCLUSION In patients age 10 years old or younger who require prolonged glucocorticoid therapy, screening for extensive hip osteonecrosis is unnecessary because their risk is low and lesions tend to heal. In children older than 10 years, early screening successfully identifies extensive asymptomatic lesions in patients who would be eligible for studies of interventions to prevent or delay joint collapse.
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Affiliation(s)
- Sue C Kaste
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX.
| | - Deqing Pei
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Cheng Cheng
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Michael D Neel
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - W Paul Bowman
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Raul C Ribeiro
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Monika L Metzger
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Deepa Bhojwani
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Hiroto Inaba
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Patrick Campbell
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Jeffrey E Rubnitz
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Sima Jeha
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - John T Sandlund
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - James R Downing
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Mary V Relling
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Ching-Hon Pui
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
| | - Scott C Howard
- Sue C. Kaste, Deqing Pei, Cheng Cheng, Michael D. Neel, Raul C. Ribeiro, Monika L. Metzger, Deepa Bhojwani, Hiroto Inaba, Patrick Campbell, Jeffrey E. Rubnitz, Sima Jeha, John T. Sandlund, James R. Downing, Mary V. Relling, Ching-Hon Pui, and Scott C. Howard, St Jude Children's Research Hospital; Sue C. Kaste, University of Tennessee Health Sciences Center, Memphis, TN; and W. Paul Bowman, Cook Children's Medical Center, Fort Worth, TX
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Abstract
Skeletal abnormalities are commonly seen in children and adolescents with leukemia. The spectrum ranges from mild pain to debilitating osteonecrosis (ON) and fractures. In this review, we summarize the skeletal manifestations, provide an update on therapeutic strategies for prevention and treatment, and discuss the most recent advances in musculoskeletal research. Early recognition of skeletal abnormalities and strategies to optimize bone health are essential to prevent long-term skeletal sequelae and diminished quality of life observed in children and adolescents with leukemia.
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Affiliation(s)
- Sogol Mostoufi-Moab
- Department of Pediatrics, The Children’s Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Jacqueline Halton
- Department of Pediatrics, The Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario Canada K1H8L1
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Salem KH, Brockert AK, Mertens R, Drescher W. Avascular necrosis after chemotherapy for haematological malignancy in childhood. Bone Joint J 2013; 95-B:1708-13. [PMID: 24293604 DOI: 10.1302/0301-620x.95b12.30688] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Avascular necrosis (AVN) is a serious complication of high-dose chemotherapy for haematological malignancy in childhood. In order to describe its incidence and main risk factors and to evaluate the current treatment options, we reviewed 105 children with a mean age of 8.25 years (1 to 17.8) who had acute lymphoblastic or acute myeloid leukaemia, or a non-Hodgkin’s lymphoma. Overall, eight children (7.6%) developed AVN after a mean of 16.8 months (8 to 49). There were four boys and four girls with a mean age of 14.4 years (9.8 to 16.8) and a total of 18 involved sites, 12 of which were in the femoral head. All these children were aged > nine years (p < 0.001). All had received steroid treatment with a mean cumulative dose of prednisone of 5967 mg (4425 to 9599) compared with a mean of 3943 mg (0 to 18 585) for patients without AVN (p = 0.005). No difference existed between genders and no thrombophilic disorders were identified. Their initial treatment included 11 core decompressions and two bipolar hip replacements. Later, two salvage osteotomies were done and three patients (four hips) eventually needed a total joint replacement. We conclude that AVN mostly affects the weight-bearing epiphyses. Its risk increases with age and higher steroid doses. These high-risk patients may benefit from early screening for AVN. Cite this article: Bone Joint J 2013;95-B:1708–13.
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Affiliation(s)
- K. H. Salem
- Cairo University, Kasr
Al-Aini Str., 11562 CairoEgypt
| | - A-K. Brockert
- RWTH Aachen University, Department
of Orthopaedic Surgery, Pauwelsstr. 30, D-52074
Aachen, Germany
| | - R. Mertens
- RWTH Aachen University, Department
of Pediatric Oncology, Pauwelsstr. 30, D-52074 Aachen, Germany
| | - W. Drescher
- RWTH Aachen University, Department
of Orthopaedic Surgery, Pauwelsstr. 30, D-52074
Aachen, Germany
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Kaste SC, Kaufman RA, Gajjar A, Broniscer A. Magnetic resonance imaging is the preferred method to assess treatment-related skeletal changes in children with brain tumors. Pediatr Blood Cancer 2013; 60:1552-6. [PMID: 23526749 PMCID: PMC4309017 DOI: 10.1002/pbc.24536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 02/21/2013] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the growing skeleton for potential altered skeletalgenesis associated with antiangiogenesis therapy. PATIENTS AND METHODS Knee radiographs and magnetic resonance imaging (MRI) were prospectively obtained on patients enrolled on two consecutive clinical trials using vandetanib, a potent oral (VEGF receptor 2) VEGFR-2 inhibitor alone or combined with dasatinib, a multiple tyrosine kinase inhibitor, in children with newly diagnosed diffuse intrinsic pontine glioma (DIPG). RESULTS Fifty-nine patients (32 females) underwent 119 MRIs; 51 patients underwent 89 radiographs of the knees. The median age at enrollment was 6.2 years (range, 2.4-17.6 years). The dose of vandetanib ranged from 50 to 145 mg/m(2) /day. The median treatment duration was 205 days. Only two patients have not experienced disease progression after 18 and 60 months from diagnosis. MRI identified clinically significant premature physeal fusion in both knees of one patient, focal physeal thickening in one, osteonecrosis in eight patients (present at enrollment in one), and bony spicules crossing the physis in two patients (bilateral in one). MRI follow-up period averaged 5.3 months (range, 0-25.5 months; median, 3.5 months). Radiographs delineated normally fused physes in two patients but no cases of premature physeal fusion, osteonecrosis or bony spicules. CONCLUSIONS As MRI provided greater information than radiographs, and thus would be a more sensitive test to assess skeletalgenesis in pediatric patients.
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Affiliation(s)
- Sue C. Kaste
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MSN #220, Memphis, Tennessee 38105,Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee,Correspondence to: Sue C. Kaste, Department of Radiological Sciences, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MSN #220, Memphis, TN 38105.
| | - Robert A. Kaufman
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, MSN #220, Memphis, Tennessee 38105,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Amar Gajjar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Alberto Broniscer
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
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Padhye B, Dalla-Pozza L, Little DG, Munns CF. Use of zoledronic acid for treatment of chemotherapy related osteonecrosis in children and adolescents: a retrospective analysis. Pediatr Blood Cancer 2013; 60:1539-45. [PMID: 23625773 DOI: 10.1002/pbc.24563] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 03/21/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Osteonecrosis (ON) is a disabling complication of chemotherapy, especially steroids in children and adolescents. There are few reports in the literature of non-surgical management of ON. Patients with chemotherapy related ON, treated with zoledronic acid (ZA) were analyzed for clinical and radiological outcome. METHODS Retrospective chart review. Serial joint radiographs were performed to assess response and graded according to Association Research Circulation Osseous (ARCO) system. All patients were evaluated for bone turnover and bone mineral density (BMD) at set intervals. RESULTS Twenty children with ON were treated with ZA for median duration of 13 months (range 5-25) with median number of doses being 6 (2, 8). Five (25%) patients were pain free at the end of treatment and had minimal joint destruction on X-ray (ARCO score II); 5 (25%) underwent arthroplasty due to severe joint destruction and pain limiting activity (ARCO score III/IV); 10 (50%) reported ongoing pain with activity, none on regular analgesia. BMD analysis showed increase in lumbosacral BMD after 1 year of treatment. Compared to patients with ON of the knees, majority of patients with ON of the hips had radiological progression. CONCLUSION ZA was well tolerated and improved joint pain in the majority of patients. Despite treatment with ZA, most patients with ON of hips had progressive joint destruction requiring arthroplasty. Patients with ON of the knees appeared to have radiological stabilization. Novel treatment strategies should be considered to prevent this debilitating complication in survivors of childhood cancer.
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Affiliation(s)
- Bhavna Padhye
- Department of Oncology, The Children's Hospital at Westmead, Sydney, Australia.
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Girard P, Auquier P, Barlogis V, Contet A, Poiree M, Demeocq F, Berbis J, Herrmann I, Villes V, Sirvent N, Kanold J, Chastagner P, Chambost H, Plantaz D, Michel G. Symptomatic osteonecrosis in childhood leukemia survivors: prevalence, risk factors and impact on quality of life in adulthood. Haematologica 2013; 98:1089-97. [PMID: 23645686 DOI: 10.3324/haematol.2012.081265] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Corticosteroid can induce osteonecrosis in children with leukemia. Few studies have been designed to assess the influence of a wide range of cumulative steroid dose on this side effect. Prevalence, risk factors of symptomatic osteonecrosis and its impact on adults' Quality of Life were assessed in 943 patients enrolled in the French "Leucémies de l'Enfant et de l'Adolescent" (LEA) cohort of childhood leukemia survivors. During each medical visit, data on previous osteonecrosis diagnosis were retrospectively collected. Patients without a history but with suggestive symptoms were investigated with magnetic resonance imaging. The total steroid dose in equivalent of prednisone was calculated for each patient and its effect on osteonecrosis occurrence was studied in multivariate models. Cumulative incidence was 1.4% after chemotherapy alone versus 6.8% after transplantation (P<0.001). A higher cumulative steroid dose, age over ten years at diagnosis, and treatment with transplantation significantly increased the risk of osteonecrosis. A higher post-transplant steroid dose and age over ten years at time of transplantation were significant factors in the transplanted group. With patients grouped according to steroid dose quartile, cumulative incidence of osteonecrosis reached 3.8% in the chemotherapy group for a dose beyond 5835 mg/m(2) and 23.8% after transplantation for a post-transplant dose higher than 2055 mg/m(2). Mean physical composite score of Quality of Life was 44.3 in patients with osteonecrosis versus 54.8% in patients without (P<0.001). We conclude that total and post-transplant cumulative steroid dose may predict the risk of osteonecrosis, a rare late effect with a strong negative impact on physical domains of Quality of Life.
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Affiliation(s)
- Pauline Girard
- Department of Pediatric Hematology-Oncology, APHM, La Timone Hospital, Aix-Marseille University, France
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Leblicq C, Laverdière C, Décarie JC, Delisle JF, Isler MH, Moghrabi A, Chabot G, Alos N. Effectiveness of pamidronate as treatment of symptomatic osteonecrosis occurring in children treated for acute lymphoblastic leukemia. Pediatr Blood Cancer 2013; 60:741-7. [PMID: 23002054 DOI: 10.1002/pbc.24313] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 08/14/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Osteonecrosis (ON) is a severe complication of acute lymphoblastic leukemia (ALL) treatments. Recent studies suggest that bisphosphonates might reduce pain and loss of motor function in patients with ON. We assessed the effects of pamidronate compared to standard care in patients with symptomatic ON (sON) and studied whether steroids might be continued after diagnosis of ON in some patients. METHODS We evaluated 17 patients with sON as complication of primary ALL treatment between 2000 and 2008. Fourteen patients were treated with pamidronate. Mobility and pain control were monitored in all patients. Affected joints were classified by magnetic resonance imaging (MRI) at ON diagnosis and after 6-72 months. RESULTS Out of 220 patients with ALL, 17 (7.7%) patients developed sON. The median age at ALL diagnosis was 11 years (range: 2.7-16.6 years) and sON occurred a median of 13.4 months (range: 2.5-34 months) after ALL diagnosis. Affected joints were hip, knee and ankle. MRI scans showed 7 severe, 4 moderate, and 6 mild ON lesions. Fourteen patients showed improvement in pain (77% of patients) and motor function (59% of patients), even though corticoids were reintroduced in 4 patients. MRI demonstrated improvement, stability or worsening in 6, 3, and 5 cases, respectively. CONCLUSIONS Pamidronate seems to be effective in the management of pain and motor function recovery in sON. Further studies are needed to provide evidence as to whether bisphosphonates can be recommended for the treatment or the prevention of ON in childhood ALL patients.
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Affiliation(s)
- Coralie Leblicq
- Endocrinology Service and Research Center, CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
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Mayer SW, Mayer BK, Mack Aldridge J, Urbaniak JR, Fitch RD, Lark RK. Osteonecrosis of the femoral head in childhood malignancy. J Child Orthop 2013; 7:111-6. [PMID: 24432068 PMCID: PMC3593023 DOI: 10.1007/s11832-012-0471-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 12/03/2012] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Children undergoing chemotherapeutic treatment of malignancies have up to a 9 % incidence of osteonecrosis. The purpose of this article is to determine the time from initiation of chemotherapy to the onset of symptoms and the diagnosis of osteonecrosis of the femoral head in this patient population. METHODS A retrospective review of the records of 18 patients (29 hips) under 21 years of age with both a diagnosis of osteonecrosis of the femoral head and childhood onset malignancy was undertaken to determine the time from initiation of chemotherapy to the onset of symptoms and diagnosis of osteonecrosis of the femoral head. RESULTS Mean time from initiation of chemotherapy to the onset of pain was 18.8 months (8.0-49.1). The mean time from development of pain to diagnosis of osteonecrosis was 3.9 months (-13.1 to 25). The mean overall time from initiation of chemotherapy to diagnosis of osteonecrosis was 22.7 months (9.0-54.1). 11/18 patients had bilateral disease. 16/18 patients (21/29 hips) had already progressed to stage 4 osteonecrosis at the time of diagnosis. CONCLUSIONS There was a high incidence of stage 4 or greater osteonecrosis at the time of diagnosis. Providers caring for these patients should be aware of the potential for osteonecrosis, and the need for prompt diagnosis and referral to an orthopedic surgeon. Screening with advanced imaging studies may be warranted for children undergoing chemotherapeutic regimens for childhood malignancy to prevent delay in the diagnosis and management of this process so that joint preservation therapies remain an option.
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Affiliation(s)
- Stephanie W. Mayer
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, 200 Trent Drive, Room 5309, Duke Clinic Building, Durham, NC 27710 USA
| | - Braden K. Mayer
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, 200 Trent Drive, Room 5309, Duke Clinic Building, Durham, NC 27710 USA
| | - J. Mack Aldridge
- />Triangle Orthopaedic Associates, 120 William Penn Plaza, Independence Park, Durham, NC 27704 USA
| | - James R. Urbaniak
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, 200 Trent Drive, Room 5309, Duke Clinic Building, Durham, NC 27710 USA
| | - Robert D. Fitch
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, 200 Trent Drive, Room 5309, Duke Clinic Building, Durham, NC 27710 USA
| | - Robert K. Lark
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 2923, 200 Trent Drive, Room 5309, Duke Clinic Building, Durham, NC 27710 USA
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Abstract
Osteonecrosis affects younger patients more often than osteoarthritis and has significantly greater long-term morbidity. Corticosteroids constitute the most common cause of nontraumatic osteonecrosis. The femoral head is the most common site of osteonecrosis. Bisphosphonate use is associated with osteonecrosis of the jaw. The final common pathway in the pathogenesis of osteonecrosis is disruption of blood supply to a segment of bone. Abnormalities in lipid metabolism, bone homeostasis, regulation of apoptosis, coagulopathies, and oxidative stress may play a role in the pathogenesis of osteonecrosis. Magnetic resonance imaging is currently the optimal test for early diagnosis and identification of the extent of osteonecrosis. Nonsurgical treatment of osteonecrosis does not change the natural history of the disease. Although there are many variations on surgical treatment of femoral head osteonecrosis, most patients eventually require total hip arthroplasty. Knowledge of risk factors and early detection are crucial to the successful management of osteonecrosis. Due to the lack of successful treatment options, new modes focus on prevention of osteonecrosis.
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Miettunen PM, Lafay-Cousin L, Guilcher GMT, Nettel-Aguirre A, Moorjani V. Widespread osteonecrosis in children with leukemia revealed by whole-body MRI. Clin Orthop Relat Res 2012; 470:3587-95. [PMID: 23008023 PMCID: PMC3492614 DOI: 10.1007/s11999-012-2579-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 08/21/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Confirmation of early long-bone epiphyseal osteonecrosis in pediatric patients with leukemia allows for medical and surgical intervention before articular surface collapse. MRI detects early osteonecrosis, but multiple focused MR images are required to capture all lesions. QUESTIONS/PURPOSES We determined whether whole-body MRI (WB-MRI) could (1) assist in diagnosing long-bone epiphyseal and other osteonecroses, (2) characterize articular surface involvement, and (3) detect preferential sites for osteonecrosis. PATIENTS AND METHODS We retrospectively reviewed prospectively collected data on all 11 pediatric patients newly diagnosed with leukemia who had musculoskeletal pain develop that persisted 4 weeks or more during leukemia treatment. All were screened for osteonecrosis by WB-MRI, which consisted of a one-time scan of the entire body. Osteonecrosis was defined as circumscribed lesions with a distinct rim of low signal intensity in the normally high-intensity marrow on T1-weighted images and high signal intensity in the normally low-intensity marrow on short-tau inversion recovery images. RESULTS WB-MRI confirmed osteonecrosis in nine of 11 patients. All patients had multisite lesions; eight had long-bone epiphyseal lesions, which comprised 66 of 129 (51%) of all lesions. Osteonecrosis involving greater than 50% of the epiphyseal surface was present in 57% of distal femoral and proximal tibial lesions. All humeral and femoral head lesions involved more than 1/3 of the medial surface volume but were asymptomatic. No articular collapse was present. All osteonecrotic lesions were more common in the lower extremities. CONCLUSIONS WB-MRI confirmed early epiphyseal osteonecrosis, with quantification of articular surface involvement. Lower limbs were preferentially affected, but asymptomatic humeral head osteonecrosis was present in five of nine patients. LEVEL OF EVIDENCE Level IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Paivi Maria Miettunen
- Division of Pediatric Rheumatology, Department of Pediatrics, Alberta Children’s Hospital and University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8 Canada
| | - Lucie Lafay-Cousin
- Division of Pediatric Oncology, Department of Pediatrics, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
| | - Gregory M. T. Guilcher
- Division of Pediatric Oncology, Department of Pediatrics, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
| | - Alberto Nettel-Aguirre
- Departments of Pediatrics and Community Health Sciences, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
| | - Vijay Moorjani
- Department of Diagnostic Imaging, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
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Heid A, Dickschas J, Schoeffl V. Cortison-induzierte Humeruskopfnekrose bei akuter myeloischer Leukämie. Unfallchirurg 2012; 116:180-4. [DOI: 10.1007/s00113-012-2243-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ilizarov hip reconstruction for the management of advanced osteonecrosis in an adolescent with leukemia. J Pediatr Orthop B 2012; 21:252-9. [PMID: 21753739 DOI: 10.1097/bpb.0b013e328348aac4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With advances in chemotherapy, long-term survival for childhood leukemia is improving. However, chemotherapy-induced osteonecrosis of the proximal femur remains a challenging problem. We present a case of an adolescent female with advanced osteonecrosis of the proximal femur after chemotherapy for acute lymphoblastic leukemia. She underwent an Ilizarov hip reconstruction with a subtrochanteric valgus extension osteotomy and distal femoral lengthening with varus angulation using an external fixator. At a 3-year follow-up, her symptoms and gait had markedly improved. On the basis of this preliminary report, Ilizarov hip reconstruction is a viable alternative for advanced osteonecrosis of the proximal femur in an adolescent.
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Norambuena GA, Khoury M, Jorgensen C. Mesenchymal stem cells in osteoarticular pediatric diseases: an update. Pediatr Res 2012; 71:452-8. [PMID: 22430381 DOI: 10.1038/pr.2011.68] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cellular therapy has gained an increasing popularity in recent years. Mesenchymal stem cells (MSCs) have the potential to differentiate into bone, cartilage, or fat tissue. In recent studies, these cells have also shown healing capability by improving angiogenesis and preventing fibrosis, which could have a role in tissue repair and tissue regeneration. Preclinical and clinical orthopedic studies conducted in the adult population support the use of MSCs for bone-healing problems, early stages of osteonecrosis, and local bone defects. Only a few published studies support the use of MSCs in pediatric osteoarticular disorders, probably due to the unknown long-term results of cellular therapy. The purpose of this review is to explain the mechanism by which MSCs could exhibit a therapeutic role in pediatric osteoarticular disorders.
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Brandwein JM. Treatment of acute lymphoblastic leukemia in adolescents and young adults. Curr Oncol Rep 2012; 13:371-8. [PMID: 21744057 DOI: 10.1007/s11912-011-0185-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment approaches for adolescents and young adults with acute lymphoblastic leukemia (ALL) have evolved considerably in the past 5-7 years. One of the major changes has been the widespread adoption of pediatric-based protocols, which appears to have significantly improved survival and probably renders allogeneic hematopoietic stem cell transplantation (HSCT) unnecessary in most standard-risk patients. However, high-risk patients, such as those with BCR-ABL or MLL rearrangements or high white count presentations, should still be referred for HSCT in CR-1. Minimal residual disease positivity has also been identified as a high-risk feature. Patients with BCR-ABL-positive ALL should receive combined therapy with a tyrosine kinase inhibitor and chemotherapy prior to HSCT. The adoption of pediatric-based regimens has been associated with significant additional toxicities, including venous thromboembolism, osteonecrosis, other steroid-related changes, and neuropathy, which can potentially have a major adverse impact on the quality of life of these young ALL patients.
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Affiliation(s)
- Joseph M Brandwein
- Department of Medical Oncology and Hematology, Princess Margaret Hospital, University of Toronto, Ontario, Canada.
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