Osteonecrosis and bone health in children, teenagers and young people with leukaemia

Following a review of the literature describing the bone health of children, teenagers and young people with leukaemia, this thesis is comprised of two main parts. The first part describes a retrospective review of patients with acute lymphoblastic leukaemia (ALL) who were recruited into the national study, UKALL 2003. This reports upon the UK prevalence of symptomatic osteonecrosis (ON) in young people with ALL, assessing the chronology of development of symptoms and subsequent diagnosis. This study also evaluated risk factors for the development of ON, and determined the joints most commonly affected. The surgical and medical management of patients is described, with a review of long-term outcomes of patients. This is the largest single UK study reporting symptomatic ON in childhood ALL, providing long term follow up data of patients. The overall prevalence of symptomatic ON was calculated to be 5.5%. Age at diagnosis of ALL significantly affected risk of development of ON, with the highest risk in those aged between 10 and 20 years at diagnosis of ALL. Affected patients had a high rate of surgical intervention, with hip replacements in 26% of patients. Core decompression was performed in 30% of hips affected by ON but we found no significant difference in femoral head survival between those patients who had core decompression compared with conservative management The second part of this thesis describes the establishment and interim findings of the British OsteoNEcrosis Study, a prospective longitudinal cohort study of patients aged 10-25 years diagnosed with ALL or lymphoblastic lymphoma. This is the first multi-centre prospective study using MRI imaging for assessment of asymptomatic ON in the UK, and combines physiotherapy assessment with imaging and biochemical results. The results suggest osteonecrotic lesions develop between induction and start of maintenance chemotherapy, with the majority of patients developing multiple asymptomatic osteonecrotic lesions by the start of maintenance chemotherapy.