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Healthy living after treatment of childhood, adolescent, and young adult cancer

Osteonecrosis after Cancer Treatment
What is osteonecrosis?
Osteonecrosis is a disorder resulting from a temporary or permanent loss of blood supply to the bone. Blood carries
essential nutrients and oxygen to the bones. When the blood supply is disrupted, the bone tissues (osteo) begin to break
down (necrosis). This can weaken the bone and eventually result in its collapse. If this occurs near a joint, it can leadto the collapse of the joint surface, resulting in pain and inflammation (arthritis). Osteonecrosis is also referred to as
avascular necrosis or “AVN,” “aseptic necrosis,” and “ischemic bone necrosis.”
Osteonecrosis can occur in any bone, but most commonly affects the ends (epiphysis) of long bones such as the thighbone (femur), causing hip and knee problems. Other common sites include the bones of the upper arms, shoulders, andankles. Osteonecrosis can occur in a single bone, but more commonly occurs in several bones at one time (multifocalosteonecrosis).
Osteonecrosis can sometimes be disabling, depending on what part of the bone is affected, how large an area isinvolved, and how well the bone rebuilds itself. Normal bone continuously breaks down and rebuilds itself. This process
keeps the bones strong. Osteonecrosis is the result of bone tissues breaking down faster than the body can repair them.
If the disorder progresses, it can lead to pain and arthritis.
What causes osteonecrosis?
Osteonecrosis is caused by interruption of the blood supply to the bone. If blood vessels are blocked with fat, become
too thick or too small, or get too weak, they may not be able to provide the amount of blood necessary for the bone
tissue to survive.
What are the risk factors for osteonecrosis?
Corticosteroids (such as prednisone and dexamethasone) given during cancer treatment can affect the bone andblood vessels, resulting in osteonecrosis. People who have undergone hematopoietic cell transplant (bone marrow,cord blood, or stem cell transplant) are also at risk for developing osteonecrosis. Other factors that increase the risk ofosteonecrosis in people who received corticosteroid therapy or hematopoietic cell transplant (HCT) include treatment
with high doses of radiation to weight bearing bones, treatment with older radiation approaches (before 1970), being
pubertal or post-pubertal at the time of treatment, having sickle cell disease, receiving total body irradiation (TBI),undergoing an allogeneic transplant (from a donor) and having prolonged treatment with corticosteroids for chronic
graft-versus-host disease following HCT. Osteonecrosis is most likely to occur during the time that cancer is being
treated, but it can also sometimes happen after completion of cancer therapy.
Steroids and osteonecrosis
Corticosteroids (such as prednisone and dexamethasone) are commonly used for treatment of many cancers, such as
leukemia and lymphoma. Dexamethasone is also sometimes used for treatment of nausea and vomiting associatedwith chemotherapy and to control brain swelling. There is no clear explanation as to how corticosteroids cause
osteonecrosis, but it is believed that they may interfere with the body’s ability to break down fatty substances. These
substances can clog the blood vessels, causing them to narrow. This reduces the amount of blood that gets into thebone.

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What are the symptoms of osteonecrosis?
People in the early stages of osteonecrosis may not have any symptoms. For some individuals, the first symptoms may
be mild joint pain either with movement or at rest and, when caught early, may heal with conservative treatment. Moresevere osteonecrosis can result in significant pain and impaired mobility.
How is osteonecrosis diagnosed?
If you or your child develops joint pain concerning for osteonecrosis, your provider may recommend images of the joint.
This can include an X-Ray, MRI, CT or bone scan.
How is osteonecrosis treated?
The goals of treatment for osteonecrosis are pain control, maintaining joint function and preventing further damage.
Treatment can be conservative or surgical. To decide the best treatment, the following factors are considered:• The person’s age• The stage of the disorder (early or late)• The location and the amount of bone affected (small or large)• The status of cancer and cancer treatment
Conservative treatment• Medication—to reduce pain
• Reduced weight bearing—to slow the damage and promote natural healing. Crutches may be recommended tolimit weight or pressure on the affected joint• Range of motion exercises—to keep the joints flexible. This is also important to maintain movement and increase
circulation in the joints. This can promote healing and may relieve pain. Physical therapists can teach the correct
exercises•

Electrical stimulation—to induce bone growthConservative treatments may be used alone or in combination, but they may not provide lasting improvement. Somepeople may require surgery to permanently repair or replace the joint.
Surgical Treatment• Core decompression—is a surgery that removes the inner layer of bone. This may reduce pressure within thebone and create an open area for new blood vessels to grow. Sometimes a piece of healthy bone with good bloodvessels (bone graft) is put in this area to speed up the process. This procedure works best in the early stages ofosteonecrosis and should help relieve pain and promote healing.
• Osteotomy—is a surgery that involves taking out a piece of bone, usually a wedge, to reposition the bone so thatthe tissue lacking blood supply (avascular area) bears less weight than nearby healthy bone.
• Arthroplasty—is also referred to as joint replacement. The affected bone is removed and replaced with anartificial joint. This treatment may be needed in the late stages of osteonecrosis and when a joint is destroyed.
Health Promoting Behaviors/Interventions• Avoid activities that put a lot of stress on your joints. Activities that stress the joints include running, jumping,football, soccer, volleyball, basketball, and similar sports. Low impact activities, such as swimming and bicycling,
can be good for joint health.
• Be consistent with recommended exercises.
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Healthy living after treatment of childhood, adolescent, and young adult cancer•Rest joints when they hurt.

•Let your healthcare provider or physical therapist know if there are any changes in your symptoms.

•Take pain or anti-inflammatory medications as prescribed.

•MInd-body therapies such as massage, acupuncture, biofeedback, and relaxation techniques may improve pain
control, increase blood flow and reduce stress.

Resources•

National Institute of Arthritis and Musculoskeletal and Skin Diseases
National Institutes of Health, 1 AMS Circle, Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-226-4267 (toll free), TTY: 301-565-2966
Fax: 301-718-6366. Web: https://www.niams.nih.gov/health-topics/osteonecrosis•American Academy of Orthopaedic Surgeons
9400 West Higgins Road, Rosemont, IL 60018
Phone: 847-823-7186 (toll free). Web: www.aaos.org

Adapted by Katherine Myint-Hpu, MSN, MPH, PNP, National Institutes of Health Clinical Center, Washington, DC, from “HealthTopics: Questions and Answers about Avascular Necrosis” by the National Institute of Arthritis and Musculoskeletal andSkin Diseases, January 2001, and “Avascular Necrosis – Do You Know” by St. Jude Children’s Research Hospital, used withpermission.
Reviewed by Leeann Carmichael, DNP, APN, FNP-BC; Kayla L. Foster, MD, MPH; and Melissa Acquazzino MD, MS.

Additional health information for childhood cancer survivors is available atwww.survivorshipguidelines.org
Note: Throughout this Health Links series, the term “childhood cancer” is used to designate pediatric cancers that may occur during childhood, adolescence, or young adulthood.
Health Links are designed to provide health information for survivors of pediatric cancer, regardless of whether the cancer occurred during childhood, adolescence, or youngadulthood.
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