Search

Aseptic osteonecrosis is observed in 25% of cases after renal transplantation. This etiological variety of osteonecrosis is unusual in that it is frequently bilateral and has multiple localisations. Apart from the classical radiological signs, attention in attracted by isolated images of osteocondensation in the metaphyses and/or the diaphyses suggesting massive bony infarction and the appearances of fatigue fractures observed frequently (14%). In 43% of cases, the obvious necrosis was proceeded by early bone pain, around the 7 th day, during massive administration of corticosteroids in the prevention or cure of graft resection. This finding suggested to us that the best time to observe ischemia of the bone or marrow is very early and led us to undertake an experimental study in the rabbit. Two series of New Zealand White rabbits were treated with massive doses of corticosteroid and sacrificed between the 3rd and the 21st day. The treated animals presented an early peak of hyperlipemia from the 7th day onwards, and diffuse lesions of hepatic and renal steatosis. Fat emboli associated with appearances of parietal thrombosis were observed in most cases. In the same animals, there were also appearances of stage I or stage II necrosis. Referring to the description of bone marrow necrosis in stages by Arlet and Ficat, there was observed in all the series, a frequency of marrow lesions of all stages much higher in treated animals (16 out of 20) than in controls. Only one lesion of stage I was observed in controls; the difference was highly significant. (0,000001p0,00001). If one only considers necroses of stage II and III (10/20 in the treated group nil in controls) the frequency was still significant p0.001. The preliminary results of the fixation of tetracycline are reported.

The authors report 30 cases of aseptic osteonecrosis in 65 different bones, including 37 hips, 13 knees, 5 taluses, 1 cuboid, 8 shoulders, 1 humeral condyle, following renal transplantation. One patient had osteonecrosis in six different bones. In 24 cases, the necrosis occurred before the end of the 18th month following the graftmin 21 cases, radiodiagnosis of the first localisation was made before the end of the first month following the first clinical sign. The usual presenting symptom of osteonecrosis is a clear, sub-chondral crescent. In 2/3rds of cases of osteonecrosis of the femoral neck, there is a rapidly destructive form often well tolerated clinically. In 1/3rd of cases, the course was slow with mainly osteocondensation. The course is particularly destructive when, following failure of the graft, the transplanted patient is submitted to periodic hemodialysis. In 8 cases, the femoral condyles were involved, and in 4, the tibial condylesm the appearance may be that of osteochondritis dissecans, but more often the course resembles the destructive form of aseptic necrosis of the femoral head. Shoulder involvement leads to a radiological picture identical with that of the hips. One transplanted patient out of 5, has a chance to develop osteonecrosis within two years following the graft.

Over a period of observation of 14 years, one or more aspetic osteonecroses (AON) were discovered in 29 patients who had undergone renal transplantation. Altogether 64 AON were discovered. In patients who had survived at least 1 year, the frequency of this lesion was 18 percent. These transplantation necroses were often bilateral (16 cases out of 21 AON of the femoral head) or multiple (6 patients presenting AON in more than 3 sites) ; necroses were sometimes found in unusual sites (shoulder, ankle, upper end of the tibia, scaphoid, condyle of the humerus). The AONs of the lower limbs were remarkable because of their extent and because of the rapid evolution of the radiological signs. This is in contrast to the moderate nature of the pain. Latent types of necrosis are also found (3 cases of AON of the femoral head). During a search for factors favouring the development of AON, the authors noted that the average duration of haemodialysis was longer in the patients with AON than in a control group of transplant patients. The average daily dose of corticoids for the first six months after transplantation was not significantly different in the two groups studied. However, the 15 patients with transplants who were not given corticoids did not develop AON.