Avascular necrosis of bone: a common serious complication of

allogeneic bone marrow transplantation.

Enright-H; Haake-R; Weisdorf-D

Am-J-Med. 1990 Dec; 89(6): 733-8

AB: PURPOSE: To describe the incidence, presentation, clinical course,

and management of avascular necrosis of bone following bone marrow

transplantation, and to identify risk factors related to its

development and outcome. PATIENTS AND METHODS: All patients developing

avascular necrosis after transplantation between March 1974 and May

1988 were identified by means of the Minnesota Bone Marrow Transplant

Database and hospital records and included in analysis. Of 902

consecutive patients undergoing bone marrow transplantation, 28

developed avascular necrosis of bone. RESULTS: Twenty-eight of 642

allogeneic transplant recipients (10.4% by product limit estimate)

developed avascular necrosis compared to zero of 260 autologous

transplant recipients. Symptoms developed 1 to 62 months (median 12

months) after transplantation. In the 28 patients a total of 91 joints

were affected (mean 3.3 per patient, range one to eight joints). The

hip joint was most often involved (64% of patients), followed by knee

(61%), ankle (29%), shoulder (21%), and elbow (7%). Initial standard

radiographs were negative in 13 patients, while in nine patients,

technetium-99 scans and/or magnetic resonance imaging demonstrated

changes of osteonecrosis before changes on routine radiographs. Almost

all patients had received steroid prophylaxis and therapy for

graft-versus-host disease (GVHD). We observed a significant correlation

between the total cumulative dose of steroids and number of joints

involved (p less than 0.01). A multivariate analysis (allogeneic

transplant patients only) identified acute or chronic GVHD requiring

steroid therapy (p = 0.003), and increasing age (p = 0.002) as

significant and independent risk factors. Fourteen patients required

surgery, including joint replacement in 11 patients. In six of six

patients, hip core decompression failed to halt disease progression,

and total hip arthroplasty was subsequently required. CONCLUSION:

Avascular necrosis of bone is a frequent late complication of bone

marrow transplantation, causing significant morbidity and often

requiring surgery; diagnosis using conventional imaging techniques may

be difficult and treatment remains inadequate.