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Focused extracorporeal shock wave for osteonecrosis of the femoral head with leukemia after allo-HSCT: a case series

Bone Marrow Transplantation volume 51, pages 1507–1509 (2016)Cite this article

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Osteonecrosis of the femoral head (ONFH) is one of the more common complications following the therapy of leukemia.1 Osteonecrosis is also a common complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT), and the incidence reported in the literature is between 3 and 44%.2, 3 The severity of osteonecrosis can range from asymptomatic to enervating presentations that cause serious pain, reduction in joint mobility and, finally, degenerative changes and progressive joint damage.1, 4 There is no consensus on how ONFH needs to be managed in leukemic patients. Conservative treatments such as non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and protected weight bearing therapy1, 5 are generally unsuccessful. Several studies have described recommended surgical interventions for early-stage ONFH, such as core decompression.1, 6, 7 However, the results of these procedures varied markedly, with lower satisfactory outcomes. In addition, these patients usually required long-term immunosuppression and glucocorticoid (GC) therapy, and appeared physically frail with depressed immune competence. Consequently, these patients are generally at high risk of postoperative infections.8 Thus, we feel a pressing need for an effective and non-invasive alternative approach in the therapy of leukemia-related ONFH. Extracorporeal shockwave therapy (ESWT) enables quicker and more effective responses than surgical procedures like core decompression and non-vascularized bone grafting for early-stage ONFH.9 Recently, a basic study indicated that shock wave therapy produced microfractures, and activated cells to express osteogenic genes that in turn caused new bone formation.19 Therefore, we retrospectively evaluated the effectiveness of focused high-energy shock wave therapy in a series of patients with early stage ONFH after allo-HSCT by assessing clinical and magnetic resonance imaging (MRI) results.

Between January 2012 and September 2014, we recruited 43 patients (that is, 86 hips) with early ONFH in adult survivors presenting with leukemia who received allo-HSCT (Table 1). We included patients with Stage I, II, and III ONFH according to the Association Research Circulation Osseous classification,9, 10 which was mentioned in the literature. We excluded patients with acute infection, other malignancies, coagulation disorders and cardiac arrhythmia that required a pacemaker, pregnancy, skeletal immaturity and poor compliance.9 The cumulative dose of methylprednisolone (MP) from the initial diagnosis of leukemia to the confirmed diagnosis of ONFH after allo-HSCT was calculated, which included GC chemotherapy, GC therapy due to GvHD and GC therapy during blood transfusion. If dexamethasone or prednisone was used in the treatment of leukemia, all GC doses were converted to MP dose equivalents by a dose-conversion relationship. All patients had received intravenous steroids during anti-leukemia therapy. The underlying diagnosis was confirmed by X-ray and MRI analysis. All cases of ONFH at MRI study were bilateral. All ESWT procedures (Dornier Compact DELTA II, Munich, Germany) were performed without general or regional anesthesia by experienced physicians with the patient placed in the supine position on the operating table. Four to six points were located on the hardened layer around the necrotic lesion by C-arm imaging.9 ESWT orthopedic settings were prepared and used according to previously described methods9, 10, 11 as follows: number of levels, 3–4; each spot received a dose of 500–1000 pulses at an energy flux density of >0.44 mJ/mm2 (level 3) and then a dose of 3000–4000 impulses at a frequency of 2−3 Hz. Each patient underwent two consecutive therapy sessions that were spaced one week apart. After ESWT treatment, patients were instructed to walk on crutches with partial weight bearing on the affected leg for 4−6 weeks. Alendronate sodium tablets (at a dose of 70 mg p.o. qw for 12 months) were administered to each patient. An assessment of pain intensity (that is, by visual analog scale (VAS)) and hip function (that is, the Harris hip score (HHS)) was carried out before and after therapy. Radiographic assessment was performed using plain radiographs and MRI analysis. We used MRI findings to evaluate the changes in lesion size, the congruency of the articular surface and bone marrow edema. Radiographs and MRI of the affected hip were performed preoperatively at 6 months, 12 months and once a year thereafter. The primary end points of the study was the need for total hip arthroplasty (THA) during the course of treatment. Secondary end points included improvement in pain and function of the affected hip, and changes on analysis of X-ray and MRI images, which included the size of the lesion and evidence of bone marrow edema. All results were expressed as mean±s.d. for the continuous variables and % for discrete variables. All data analyses were performed using SPSS version 16.0.0 software (SPSS; Chicago, IL, USA). We compared pain and HHSs before and after shock wave treatment using paired Student’s t-tests. The overall clinical outcomes and changes in lesion size were compared statistically by Chi-square test analysis for statistical significance using a 95% confidence interval (P<0.05).

Table 1 Patient demographic characteristics in leukemia-related ONFH after allo-HSCT
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References

  1. te Winkel ML, Pieters R, Wind EJ, Bessems JH, van den Heuvel-Eibrink MM . Management and treatment of osteonecrosis in children and adolescents with acute lymphoblastic leukemia. Haematologica 2014; 99: 430–436.

    Article  Google Scholar 

  2. Kaste SC, Shidler TJ, Tong X, Srivastava DK, Rochester R, Hudson MM et al. Bone mineral density and osteonecrosis in survivors of childhood allogeneic bone marrow transplantation. Bone Marrow Transplant 2004; 33: 435–441.

    Article  CAS  Google Scholar 

  3. Torii Y, Hasegawa Y, Kubo T, Kodera Y, Minami S, Morishita Y et al. Osteonecrosis of the femoral head after allogeneic bone marrow transplantation. Clin Orthop Relat Res 2001; 382: 124–132.

    Article  Google Scholar 

  4. te Winkel ML, Pieters R, Hop WC, de Groot-Kruseman HA, Lequin MH, van der Sluis IM et al. Prospective study on incidence, risk factors, and long-term outcome of osteonecrosis in pediatric acute lymphoblastic leukemia. J Clin Oncol 2011; 29: 4143–4150.

    Article  Google Scholar 

  5. Sala A, Mattano LA Jr, Barr RD . Osteonecrosis in children and adolescents with cancer - an adverse effect of systemic therapy. Eur J Cancer 2007; 43: 683–689.

    Article  Google Scholar 

  6. Mont MA, Cherian JJ, Sierra RJ, Jones LC, Lieberman JR . Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update. J Bone Joint Surg Am 2015; 97: 1604–1627.

    Article  Google Scholar 

  7. Müller I, Vaegler M, Holzwarth C, Tzaribatchev N, Pfister SM, Schütt B et al. Secretion of angiogenic proteins by human multipotent mesenchymal stromal cells and their clinical potential in the treatment of avascular osteonecrosis. Leukemia 2008; 22: 2054–2061.

    Article  Google Scholar 

  8. Pagano L, Caira M . Risks for infection in patients with myelodysplasia and acute leukemia. Curr Opin Infect Dis 2012; 25: 612–618.

    Article  Google Scholar 

  9. Wang CJ, Wang FS, Huang CC, Yang KD, Weng LH, Huang HY . Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting. J Bone Joint Surg Am 2005; 87: 2380–2387.

    Article  Google Scholar 

  10. Gao F, Sun W, Li Z, Guo W, Wang W, Cheng L et al. High-Energy Extracorporeal Shock Wave for Early Stage Osteonecrosis of the Femoral Head: A Single-Center Case Series. Evid Based Complement Alternat Med 2015; 2015: 468090.

    PubMed  PubMed Central  Google Scholar 

  11. Ioppolo F, Rompe JD, Furia JP, Cacchio A . Clinical application of shock wave therapy (SWT) in musculoskeletal disorders. Eur J Phys Rehabil Med 2014; 50: 217–230.

    CAS  PubMed  Google Scholar 

  12. Tauchmanovà L, De Rosa G, Serio B, Fazioli F, Mainolfi C, Lombardi G et al. Avascular necrosis in long-term survivors after allogeneic or autologous stem cell transplantation: a single center experience and a review. Cancer 2003; 97: 2453–2461.

    Article  Google Scholar 

  13. Koo KH, Ahn IO, Kim R, Song HR, Jeong ST, Na JB et al. Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images. Radiology 1999; 213: 715–722.

    Article  CAS  Google Scholar 

  14. Babaei S, Stewart DJ . Overexpression of endothelial NO synthase induces angiogenesis in a co-culture model. Cardiovasc Res 2002; 55: 190–200.

    Article  CAS  Google Scholar 

  15. Wang CJ, Wang FS, Yang KD, Weng LH, Hsu CC, Huang CS et al. Shock wave therapy induces neovascularization at the tendon bone junction. J Orthop Res 2003; 21: 984.

    Article  Google Scholar 

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Acknowledgements

This study was supported by the National Natural Science Foundation of China (81372013) and the Research Fund of China-Japan Friendship Hospital (2014-4-QN-29). China-Japan Friendship Hospital Youth Science and technology excellence project (2014-QNYC-A-06). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

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  1. W Sun and F Gao: Joint first authors.

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  1. Department of Orthopedic Surgery, Centre for Osteonecrosis and Joint-Preserving & Reconstruction, Beijing Key Laboratory of Arthritic and Rheumatic Diseases, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Beijing, China

    W Sun, F Gao, W Guo, B Wang, Z Li, L Cheng & W Wang

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Correspondence to W Sun.

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Sun, W., Gao, F., Guo, W. et al. Focused extracorporeal shock wave for osteonecrosis of the femoral head with leukemia after allo-HSCT: a case series. Bone Marrow Transplant 51, 1507–1509 (2016). https://doi.org/10.1038/bmt.2016.155

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