A Stage-Based, Multidisciplinary Approach to Therapy-Associated Osteonecrosis in Pediatric Oncology Patients

Therapy-associated osteonecrosis (ON) is a debilitating musculoskeletal complication of pediatric cancer treatment and can lead to progressive joint destruction, chronic pain, and long-term functional impairment. As survival among children with cancer continues to improve, orthopaedic surgeons are increasingly involved in evaluating and managing these patients. Unlike idiopathic ON, therapy-associated ON poses unique challenges because of skeletal immaturity, multifocal disease, ongoing oncologic therapy, and the need to preserve native joint function over decades of survivorship. Despite its clinical significance, management remains heterogeneous, and no standardized treatment algorithm currently exists. This current concept ​review summarizes current evidence on the epidemiology, risk factors, clinical presentation, imaging, staging, and orthopaedic management of therapy-associated ON in pediatric oncology patients. Particular emphasis is placed on early recognition, magnetic resonance imaging-based diagnosis, Association Research Circulation Osseous staging, and stage-specific treatment strategies aimed at preserving the native joint whenever possible. Both nonoperative and operative treatment options are reviewed in the context of disease severity and patient-specific factors, highlighting the importance of multidisciplinary collaboration among pediatric oncology, orthopaedic surgery, radiology, endocrinology, rehabilitation, and pain management specialists. To address the lack of standardized clinical guidance, we propose a practical, stage-based, multidisciplinary management algorithm that integrates risk stratification, imaging, disease staging, and evidence-informed treatment principles into a unified clinical framework. By emphasizing timely diagnosis, individualized treatment, and coordinated multidisciplinary care, this review offers a practical approach to evaluating and managing therapy-associated ON and identifies key areas for future prospective investigation.

(1)Therapy-associated osteonecrosis is a common and potentially debilitating musculoskeletal complication of pediatric cancer treatment that requires early recognition to preserve native joint function.(2)Risk stratification based on patient characteristics, cancer therapy, and clinical presentation should guide surveillance and prompt magnetic resonance imaging (MRI) evaluation for symptomatic or high-risk patients.(3)MRI remains the gold standard for diagnosis and Association Research Circulation Osseous staging, enabling identification of precollapse disease, when joint-preserving interventions are most effective.(4)Management should adopt a multidisciplinary, stage-based approach that integrates disease severity, skeletal maturity, oncologic treatment status, and patient goals.