Avascular necrosis after chemotherapy for haematological malignancy in childhood

K. H. Salem, A-K. Brockert, R. Mertens, W. Drescher


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.


  • Dr K. H. Salem and A-K. Brockert contributed equally as first authors to this work.

    Data were presented in part in the ASCO Meeting 2009, Orlando, Florida, in the NCI, NIH/ORDR and COG Osteonecrosis Workshop 2010, Bethesda, Maryland and in the 33rd SICOT Orthopaedic World Conference, Dubai 2012.

    The authors certify that their institution has approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

    No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

    This article was primary edited by A. Ross and first-proof edited by G. Scott.

  • Received August 15, 2012.
  • Accepted July 27, 2013.
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