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.