Osteonecrosis after Childhood Cancer

Osteonecrosis is a problem caused by a short-term or permanent loss of blood supply to the bone. When blood doesn’t get to bones they begin to break down, weaken, and eventually collapse. Osteonecrosis is also called avascular necrosis or “AVN,” “aseptic necrosis, or ischemic bone necrosis.

Am I at Risk?

Survivors who received bone marrow, cord blood, or stem cell transplants, as well as those who received corticosteroids (such as prednisone and dexamethasone) during cancer treatment are at risk for osteonecrosis. 

Risk is even higher if you also had: 

  • high doses of radiation to weight-bearing bones,
  • treatment with radiation prior to 1970,
  • age older than 10 years at treatment,
  • sickle cell disease,
  • radiation to the whole body,
  • transplant from someone other than yourself, or
  • prolonged treatment with corticosteroids for graft-versus-host disease.  

What Are the Symptoms of Osteonecrosis?

Osteonecrosis is most likely to occur during cancer treatment. But it sometimes happens after treatment ends. It can be disabling, depending on what part of the bone is affected, how large an area is involved, and how well the bone rebuilds itself. If it progresses, it can lead to pain and arthritis.&

It can occur in any bone, but most often affects the ends of long bones, such as the thigh bone, causing hip and knee problems. If it occurs near a joint, the joint can collapse. Other common sites are the bones of the upper arms, shoulders, and ankles. It can occur in one bone, but most often occurs in a few at one time. 

People with osteonecrosis may not have any symptoms at first. But as the disorder progresses, most will have some joint pain. The pain may start when you put weight on the bone or joint, but in time it may hurt even at rest. It may become severe enough to limit movement in the affected joint. How long between the first symptoms and loss of joint function varies by person and ranges from months to years. 

How Is Osteonecrosis Diagnosed?

A number of tests can be done to diagnose osteonecrosis.  

  • X-ray is often the first test to help distinguish osteonecrosis from other causes of bone pain, such as fracture. But x-rays may appear normal in the early stages of the condition. X-rays are also used to monitor the course of the condition.
  • MRI can detect osteonecrosis in the earliest stages, when symptoms are not yet present.
  • Bone scans are sometimes used to diagnose osteonecrosis. They are useful because a single scan can show all the areas in the body that are affected. But they can’t detect it at the earliest stages.
  • CT scans provide a 3-D image of bone and can help see the extent of bone damage.  

What If I Have Osteonecrosis?

The goals of treatment for osteonecrosis are to improve use of the affected joint, reduce pain, stop bone damage, and ensure the joint lives. Factors that will affect your treatment include your age, whether the condition is in the early or late stage, the location and amount of bone affected, and the status of your cancer treatment. 

Conservative Treatment 

One or more conservative treatments may be used. They include: 

  • medicine – to reduce pain;
  • reduced weight bearing – to slow the damage and promote healing. Crutches may be used;
  • range of motion exercises – to keep joints flexible, maintain movement, and increase circulation to promote healing and relieve pain; and
  • electrical stimulation – to induce bone growth.  

Surgical Treatment 

Because conservative treatments may not provide lasting improvement, some people need surgery to repair or replace the joint, such as these. 

  • Core decompression – this procedure removes the inner layer of bone to reduce pressure within the bone and create an open area for new blood vessels to grow. It works best in the early stages of osteonecrosis and should help relieve pain and promote healing.
  • Osteotomy – in this surgery bone is taken out so that the tissue without blood supply bears less weight than a nearby healthy area.
  • Joint replacement – the affected bone is taken out and replaced with an artificial joint.  

In addition to conservative and surgical treatment, you can help manage osteonecrosis by following these tips: 

  • Avoid activities that put a lot of stress on your joints, such as running, jumping, football, and soccer. Instead, try sports that are good for joints with osteonecrosis, such as swimming and biking.
  • Be consistent with recommended exercises.
  • Rest your joints when they hurt.
  • Let your health care team know if your symptoms change.
  • Take pain or anti-inflammatory medicine as prescribed.  

Where Can I Find More Information?

You can find more information on osteonecrosis from these organizations: 

 

Childhood Cancer

Medical Information

Research

Coping with Cancer

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