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Avascular Necrosis in the long-term Multiple Myeloma Survivor

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My point is that there would be more AVN diagnoses if the average five-year survival for Multiple Myeloma patients was more than 51%. 

Hi David. I am an 18 year multiple myeloma survivor. I’ve had 2 autologous stem cell transplants.  The last one I had was 6 years ago. A year ago March I was diagnosed with Avascular Necrosis in both hips.  
The blood flow to the ball joints (femoral head)  has decreased to the point where they are literally dying. No cure for this problem and I will need both hips replaced.

Both my oncologist and orthopedist think my AVN is the result of large doses of dexamethasone  that I was given during my original diagnosis in 2002. Have you heard of any other long-term survivors having the same problem?
I’m trying to find out as much information as I can, thanks for your time. Jack

Hi Jack, 
Thanks for reaching out. While I had heard of AVN in MM survivors previously, l spent my time and blog posts focused on “osteonecrosis of the jaw” (ONJ). My research today indicates the AVN and ONJ are similar but a bit different. 
Here is what the studies linked below indicate. 
  • AVN is a documented adverse event/side effect of high-dose steroid use, both dexamethasone and prednisone. 
  • The study below focusing on survivors most similar to you (MM, induction, ASCT) consider AVN to be a rare side effect occurring in 9% of MM survivors. 
  • Fewer MM survivors experience AVN in both hips but dual hip AVN is documented. 
  • The most common AVN occurrence is in the ball joint aka femoral head. 
As an aside, it bothers me greatly when conventional oncology refers to a serious, painful, expensive side effect as “rare.” I don’t consider 9% to be rare…
The only other MM survivor that I know of, who developed AVN is also a long-term MM survivor. You were diagnosed with AVN at 15 years and I think Jim Bond was diagnosed with AVN after surviving MM for 23-24 years. 
My point is that there would be more AVN diagnoses if the average five-year survival for MM patients was more than 51%. 
  I hope this helps. Let me know if you have any questions. 
David Emerson
MM Survivor
MM Cancer Coach
Director PeopleBeatingCancer

Recommended Reading:

Avascular necrosis

 Avascular necrosis is the death of bone tissue due to a lack of blood supply. Also called osteonecrosis, it can lead to tiny breaks in the bone and the bone’s eventual collapse.

A broken bone or dislocated joint can interrupt the blood flow to a section of bone. Avascular necrosis is also associated with long-term use of high-dose steroid medications and excessive alcohol intake…

Pain can be mild or severe and usually develops gradually. Pain associated with avascular necrosis of the hip might center on the groin, thigh or buttock. Besides the hip, the areas likely to be affected are the shoulder, knee, hand and foot.

Some people develop avascular necrosis on both sides (bilaterally) — such as in both hips or in both knees…

Risk factors

Risk factors for developing avascular necrosis include:

Bisphosphonate use. Long-term use of medications to increase bone density might contribute to developing osteonecrosis of the jaw. This rare complication has occurred in some people treated with high doses of these medications for cancers, such as multiple myeloma and metastatic breast cancer…

Acute vascular necrosis (AVN) is a complication of steroid therapy occurring in up to 40% of patients and accounts for a large percentage of total hip arthroplasties performed at a relatively young age.
Many patients who present with AVN have conditions that increase their baseline risk, including systemic lupus erythematous and renal transplant, making it difficult to determine the exact impact of steroid therapy in the disease pathophysiology.
AVN is associated with high-dose oral or intravenous therapy exceeding 20 mg of prednisone per day for extended periods of time.  There is also a cumulative dose risk that has not yet been clearly defined. 


Avascular necrosis (AVN) of the femoral head, also referred to as osteonecrosis or aseptic necrosis, is a well-recognized and often devastating complication related to glucocorticoid administration.(1) Avascular necrosis occurs in 3 to 40% of patients receiving corticosteroid treatment and occurs most frequently in the femoral head, which is hypothesized to be a result of the limited blood supply to this area.(1-7)  This adverse effect is caused by death of bone tissue in the femoral head, which often leads to pain, impaired mobility, fractures, and in 80% of untreated cases, collapse of the femoral head leading to necessitation of total hip arthroplasty.(2)  Currently, 10,000 to 20,000 cases occur per year in the United States, and steroid-related AVN accounts for 10% of the total hip arthroplasties performed each year. The average age at presentation is 33 years old, with a male to female ratio of 7:3.(1,4,5)

The Details For Those Interested:

Imbalance of Bone Resorption and Rebuilding:

Vascular Impairment:


Apoptosis, or programmed cell death, of osteoblasts and osteocytes is mediated both directly through steroid interactions with the glucocorticoid receptor and indirectly through vascular compromise leading to ischemia and cell compression due to adipogenesis and increased intraosseal pressure.(3-5,10,11)  Death of mature bone cells and their progenitors further drives the imbalance of bone remodeling…”

Evidence suggests a multifactorial process that results from an imbalance in bone resorption and repair, compromise of vasculature, and both direct and indirect bone cell apoptosis.

Avascular necrosis of femoral and/or humeral heads in multiple myeloma: results of a prospective study of patients treated with dexamethasone-based regimens and high-dose chemotherapy
Purpose: To assess the prevalence, time of onset, risk factors, and outcome of avascular necrosis (AVN) of bone in patients with multiple myeloma undergoing antineoplastic therapy
Results: With a median follow-up of 33 months (range, 5 to 114 months), AVN of the femoral head(s) developed in 49 patients (9%). Median time to onset of AVN was 12 months (range, 2 to 41 months). Three risk factors for AVN were identified by multivariate analysis: 
  • cumulative dexamethasone dose 
  • male sex 
  • and younger age 
Conclusion: AVN is a rare and usually asymptomatic complication during myeloma therapy. Cumulative dexamethasone dose, male sex, and younger age, but not thalidomide, increase the risk of AVN…”

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