Background/Purpose: Osteonecrosis has emerged as debilitating complication of acute pediatric lymphoblastic leukemia (pALL), with severe pain and poor functional outcome. Patients with ON of weight bearing joints with > 50% surface involvement may eventually need surgery. Intravenous Pamidronate (IV-PAM) has been reported to be beneficial in some cases of idiopathic ON.
Objective: To study if IV-PAM was effective in 1) preventing joint ON progression and need for surgical intervention and in 2) reducing ON related pain in pALL.
Methods: All consecutive pALL patients (0-18 years) who developed bone pain were assessed for ON with a whole body MRI (WB-MRI). Patients with confirmed ON received two 9-month courses of once/monthly IV-PAM (first dose 0.5 mg/kg; all others 1 mg/kg/dose, maximum dose 60 mg/dose). Visual analogue score for pain (VAS), with “0” being “no-pain” and “10” being “the worst possible pain” was administered at baseline, 3, 6 and 12 months and yearly. The radiologic outcome was assessed by serial WB-MRIs.
Results: Out of 40 pALL patients with bone pain, all had osteoporosis and 24/40 had ON (9F:15M). Ten patients had ON lesions in upper and 20/24 in lower extremities; with ON affecting 26 large joints (shoulders [10], hips [4] and knees [12]). Four hip joints had >50% femoral head surface involvement, and 4 knee joints had >50 % surface involvement by ON.
The mean duration of follow-up was 7 (range 3-15) years. None of the large joint ON required surgery: two femoral heads developed minor collapse, while other ON lesions remained stable or resolved.
The mean pain VAS pre-pamidronate was 8.5/10 (range 8-10/10; 0.1/10 (range 0-1/10) at 6 months, and unchanged at 0. 08/10 (range 0-1/10) at 12 months and at final follow-up.
Conclusion: Our results suggest that IV-PAM is effective in controlling ON related pain and may prevent joint ON progression and orthopedic surgery.
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