title: Treatment of Osteonecrosis in Children and Adolescents With Acute Lymphoblastic Leukemia.
abstract: BACKGROUND
  Cure rates for acute lymphoblastic leukemia (ALL) have improved, but as therapy has intensified, the burden of osteonecrosis (ON) has increased. Limited data exist regarding surgical interventions for pediatric ALL patients with ON.
  
  
  METHODS
  A multi-center cohort of children with newly diagnosed ALL was established with Pediatric Health Information System (PHIS) data from 43 freestanding children's hospitals from 1999 to 2011. Patients with ON identified by International Classification of Diseases, Ninth Revision (ICD-9) code were followed for up to 5 years after index ALL admission for the presence of ON-associated orthopedic surgical procedures.
  
  
  RESULTS
  A cohort of 10,729 ALL patients was assembled, of which 242 (2.33%) were identified with an ICD-9 code for ON within 5 years of ALL diagnosis. Fifty-five patients (22.7%) with ON underwent orthopedic surgical intervention aimed at joint preservation (82%) or replacement (18%) with substantial practice variation by hospital in both the rate and type of surgical intervention. The majority of patients had surgical procedures while receiving maintenance therapy. None of the patients undergoing surgical intervention required intensive care unit-level care within 14 days of surgery, and there was no associated in-hospital mortality.
  
  
  CONCLUSIONS
  No standard of care exists for treatment of ALL-associated ON. While considerable practice variation exists, surgical intervention appears relatively safe.
authors.affiliation: Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA. Electronic address: Heneghanm@email.chop.edu.
authors.forename: Mallorie B
authors.initials: MB
authors.lastname: Heneghan
authors.affiliation: Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Susan R
authors.initials: SR
authors.lastname: Rheingold
authors.affiliation: Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA.
authors.forename: Yimei
authors.initials: Y
authors.lastname: Li
authors.affiliation: Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Alix E
authors.initials: AE
authors.lastname: Seif
authors.affiliation: Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Yuan-Shung
authors.initials: YS
authors.lastname: Huang
authors.affiliation: Pediatric Hospital Medicine, Children's Hospital of Colorado.
authors.forename: Lisa
authors.initials: L
authors.lastname: McLeod
authors.affiliation: Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Wells
authors.affiliation: Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Fisher
authors.affiliation: Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Richard
authors.initials: R
authors.lastname: Aplenc
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D010020:Osteonecrosis / Q000188:drug therapy* / Q000209:etiology*; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000150:complications* / Q000188:drug therapy*; D055815:Young Adult
keywords: Avascular necrosis; Glucocorticoid; Pediatrics