Osteonecrosis is more common in adolescents than in children, with the highest risk among those who are older than 10 years.[51,60,61] Osteonecrosis also occurs much more frequently in whites than in blacks.[51,64] Studies evaluating the influence of gender on the risk of osteonecrosis have yielded conflicting results, with some suggesting a higher incidence in females [51,54] that has not been confirmed by others.[53,54,61] Genetic factors influencing antifolate and glucocorticoid metabolism have also been linked to excess risk of osteonecrosis among survivors. St. Jude Children's Research Hospital investigators observed an almost sixfold (odds ratio = 5.6; 95% confidence interval [CI], 2.7-11.3) risk of osteonecrosis among survivors with polymorphism of the ACP1 gene, which regulates lipid levels and osteoblast differentiation.
Approximately 5% of children undergoing myeloablative stem cell transplantation will develop osteochondroma (OC), a benign bone tumor that most commonly presents in the metaphyseal regions of long bones. OC generally occurs as a single lesion, however multiple lesions may develop in the context of hereditary multiple osteochondromatosis. A large Italian study reported a 6.1% cumulative risk of developing OC at 15 years posttransplant, with increased risk associated with younger age at transplant (?3 yrs) and use of TBI. Growth hormone therapy may influence the onset and pace of growth of OCs.[23,67] Because malignant degeneration of these lesions is exceptionally rare, clinical rather than radiological follow-up is most appropriate, and surgery for biopsy or resection is generally unnecessary.
Table 8. Bone and Joint Late Effects
CT = computed tomography; DXA = dual-energy x-ray absorptiometry; GVHD = graft-versus-host disease; HSCT = hematopoietic stem cell transplantation.
|Predisposing Therapy||Musculoskeletal Effects||Health Screening|
|Radiation impacting musculoskeletal system ||Hypoplasia; fibrosis; reduced/uneven growth (scoliosis, kyphosis); limb length discrepancy||Exam: bones and soft tissues in radiation fields |
|Radiation impacting head and neck ||Craniofacial abnormalities||History: psychosocial assessment, with attention to: educational and/or vocational progress, depression, anxiety, post-traumatic stress, social withdrawal |
|Head and neck exam|
|Radiation impacting musculoskeletal system ||Radiation-induced fracture||Exam of affected bone|
|Methotrexate; corticosteroids (dexamethasone, prednisone); radiation impacting skeletal structures; HSCT||Reduced bone mineral density||Bone mineral density test (DXA or quantitative CT) |
|Corticosteroids (dexamethasone, prednisone) ||Osteonecrosis||History: joint pain, swelling, immobility, limited range of motion |
|Radiation with impact to oral cavity ||Osteoradionecrosis||History/oral exam: impaired or delayed healing following dental work, persistent jaw pain or swelling, trismus|
|HSCT with any history of chronic GVHD ||Joint contracture||Musculoskeletal exam|
|Amputation ||Amputation-related complications (impaired cosmesis, functional/activity limitations, residual limb integrity, chronic pain, increased energy expenditure)||History: pain, functional/activity limitations|
| Exam: residual limb integrity |
|Limb-sparing surgery ||Limb-sparing surgical complications (functional/activity limitations, fibrosis, contractures, chronic infection, chronic pain, limb length discrepancy, increased energy expenditure, prosthetic malfunction [loosening, non-union, fracture]) ||History: pain, functional/activity limitations |
|Exam: residual limb integrity|
|Radiograph of affected limb|
|Orthopedic evaluation |