Transient Osteoporosis of Hip Vinod Naneria Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research Centre, Indore
AVN - TOH - BMES• Early diagnosis of AVN may be confused with many conditions classified under Bone Marrow Edema Syndromes and Transient Osteoporosis of Hip.• It is essential to differentiate between these condition for proper and early intervention.• MRI findings of most of these are similar in early stages of diseases.
About this presentation• To highlight conditions similar to AVN.• Many cases may be wrongly treated if not diagnosed properly.• It include – typical findings BMES, TOH, Regional migratory osteoporosis, AVN, Reflex sympathetic osteo-dystrophy syndrome.• Typical history, radiological findings, CT scans, and MRI differentiation.• Many photographs and some text is taken from a review article published in Skeletal Radiol (2009) 38:425–436 by Anastasios V. Korompilias & Apostolos H. Karantanas & Marios G. Lykissas & Alexandros E. Beris
Bone marrow oedema syndrome (BMES)Transient clinical conditions of unknown aetiology,Include conditions – transient osteoporosis of the hip (TOH), – regional migratory osteoporosis (RMO), – reflex sympathetic dystrophy (RSD). BMES is characterized by bone marrow oedema (BME) pattern. Affects the hip, the knee, and the ankle of middle-aged males. Third trimester of pregnancy.
History - Nomenclature• It was in 1959 when Curtiss and Kincaid described a syndrome of transient demineralization of the hip in the third trimester of pregnancy.• Hofmann et al. proposed that such clinical conditions should be included under the general term “Bone Marrow Edema Syndrome”.
Differential Diagnosis - Pathogenesis• The BME on MR imaging can be due to other disorders such as infection, inflammation, neoplasia, injury, stress fracture, myleoproliferative disorders, hemoglobinopathy and osteoarthritis.• Curtiss and Kincaid presented a neurogenic compression theory.• Rosen presented venous obstruction and secondary localized hyperaemia may be the cause of the transitory demineralization of the femoral head.
Radiology & MRI• A BME pattern on MR imaging is characterized by high signal intensity compared with normal bone marrow on fat suppressed T2-w and short-tau inversion recovery (STIR) images and low signal intensity on T1-w images.• Enhancement of the BME area after intravenous• administration of contrast agents is indicative of hypervascularity and increased permeability of the capillary bed.
RadiologyTypically - Focal osteopenia on plain radiographs. a The lateral radiograph of the right hip joint is unremarkable. b The lateral radiograph of the left hip joint shows marked osteopenia of both the femoral head and neck and the acetabulum (arrows). Skeletal Radiol (2009) 38:425–436 Reproduce with permission from Dr. A. V. Korompilias
Radiology• Radiographs of patients who have transient osteoporosis of the femoral head may reveal in later stages complete disappearance of the osseous architecture, known as “phantom” appearance of the femoral head.• The trochanters, the acetabula, and the iliac wings are rarely affected.• On the other hand, in patients with osteonecrosis of the femoral head, plain radiographs show a radiolucent lesion surrounded by a sclerotic rim. In later stages of the disease, when subchondral bone collapse is present, a “crescent” sign may develop.
RadiologyThe lateral radiographs show lysis and sclerosis in both femoral heads (arrows ina and b), suggesting bilateral osteonecrosis.The “crescent” sign in the left femoral head (open arrow) is diagnostic ofadvanced osteonecrosis with subarticular fracture but not articular collapse.Skeletal Radiol (2009) 38:425–436. Reproduce with permission from Dr. A. V. Korompilias
Scintigraphy – Tc 99 Transient osteoporosis:- Avascular necrosis of the left hip:-The bone scan (anterior view) is showing intense The bone scan (posterior view) showsuptake in the femoral head and neck, early in increased uptake only in the femoral headthe course of the disease (arrow). area with a “cold in hot” appearance (arrow). Reproduce with permission from Dr. A. V. Korompilias
C T Scantransient osteoporosis of the left hip. A The plain AP radiograph shows osteopenia of theouter part of the left femoral head (arrow). b The corresponding CT scan obtained onthe same day shows to better advantage the marked osteopenia of the leftfemoral head with mottled or moth-eaten pattern of the trabecularbone (arrows). Skeletal Radiol (2009) 38:425–436. Reproduce with permission from Dr. A. V. Korompilias
MRI• low-signal intensity on T1-w images.• High signal intensity on STIR or fat-suppressed T2- w images.• These changes reflect the increased content in intra- and extracellular fluid of the bone marrow resulting from new bone formation and repair processes. Joint effusion may also be present.• The lack of additional subchondral changes other than BME on both T2-w and contrast enhanced T1-weighted images have positive predictive value for transient lesions up to 100%.
(a )The coronal T1-w TSE MR image shows low signal intensity in the right femoral head.(b) &(c) The transverse fat-suppressed T2-w TSE and the coronal STIR MR imagesdemonstrate the same area with high signal intensity in keeping with bone marrowedema. A moderate joint effusion is also evident. Reproduce with permission from Dr. A. V. Korompilias
Transient Osteoporosis (TOH)• Transient demineralization of the hip usually involves healthy middle-aged men and rarely women, almost exclusively during the third trimester of pregnancy or the immediate postpartum period .• The syndrome is characterized by acute disabling pain in the hip and functional disability without a history of previous trauma.• Histological examination reveals focal areas of thin and disconnected bone trabeculae covered by osteoid and active osteoblasts, active osteocytes in the lacunae.
Transient Osteoporosis (TOH)• Clinical course is relatively short and may last up to 6–8 months, with rapid aggravation of pain and functional restriction of the hip during the first month after the onset. Radiological findings of osteopenia of the femoral head and/or the femoral neck may be present in 3–6 weeks after the onset of the symptoms. Spontaneous clinical and radiological recovery is the rule. Recurrence in the same joint or migration of the disease to the contra lateral femoral head may be seen.
Regional migratory osteoporosis• Sequential polyarticular arthralgia of the weight-bearing joints associated with severe focal osteoporosis.• Lower appendicular skeleton is mainly affected, there are several reports in the recent literature describing combined axial skeleton involvement.• Regional osteoporosis is a distinctive feature of the disease.
Regional migratory osteoporosis• RMO was first described by Duncan et al.• Migration occurs in 5–41%.• Migration may occur in different or the same joint in an unpredictable time interval after the onset of the first symptoms.• The joint nearest the diseased one is the next to be involved.
Regional migratory osteoporosis Reproduce with permission from Dr. A. V. Korompilias
Reflex sympathetic dystrophy• The terms RSD, algodystrophy, chronic regional pain syndrome, and Sudeck syndrome have been used in the literature in order to describe the same clinical entity.• RSD is characterized by three distinct stages: acute, dystrophy, and atrophy.• The history of trauma and the presence of secondary changes such as skin atrophy, sensomotor alterations, and contractures may be helpful to distinguish from the other types of BMES.
Osteonecrosis• Usually presented as acute or chronic hip pain.• History of Cortisone / Alcohol / Tobacco.• Collagen disorders – RA, SLE• Hemoglobainopathy - sickle and thallacaemia• Any young male with anterior hip pain is AVN till proved otherwise.
Typical findings of a serpentine band-like sign and the “doubleline” sign are shown on the coronal T1-w (a) and the axial T2-w (b) TSE MR images (arrows). c The oblique axial fat-suppressed contrast enhanced T1-w MR image of the righthip shows only the osteonecrotic lesions (arrows) with nomarrow edema.
d The sagittal T2-gradient-recalled echo MR image of the lefthip shows subarticular collapse with contour deformity(white arrows). There is also anterior labrum degeneration(open arrow). e The oblique axial fat suppressed contrast-enhanced T1-wMR image of the left hip shows diffuse enhancementsecondary to the articular collapse.
Acknowledgement REVIEW ARTICLE: Bone marrow edema syndrome • Anastasios V. Korompilias & Apostolos H. Karantanas & Marios G. Lykissas & Alexandros E. Beris • Published online: 16 July 2008. • Skeletal Radiol (2009) 38:425–436 • DOI 10.1007/s00256-008-0529-1A. V. Korompilias (*) : M. G. Lykissas : A. E. Beris, Department of Orthopaedic Surgery, School ofMedicine, University of Ioannina, 45110 Ioannina, Greecee-mail: email@example.comA. H. Karantanas, Department of Radiology, University of Crete School of Medicine,Heraklion, Greece
Case reports• Cases of TOH seen and Follow up at Choithram Hospital & Research centre, Indore, India and at private clinics of the authors.• All AVN when diagnosed early may not have typical “double line sign”.• In these cases TOH is a strong diagnosis.• Management & prognosis of both differs.
Case one• M. a 40 yrs, Female – acute onset pain rt hip.• Clinically – anterior hip tenderness with limitation of movements.• Routine x-rays and investigations negative.• MRI finding are noted below each photo with date and follow up status.
MRI findings – 06 / 05/ 2011• Marrow oedema noted involving the Rt. Femoral head and neck up to intertrochanteric line.• Linear –T2 hypo intensity noted in neck of rt. Femur.• Joint effusion ++• Minimal subchondral marrow oedema noted in the left femoral head.
Case two• M.A. – 37 male, acute onset pain left hip of 2 weeks duration.• Clinically anterior hip tenderness with limitation of movements of left hip.• Radiology and routine investigations were normal.• MRI findings with dates and follow up presented here.
MRI findings on march 2008Left femoral head , neck and trochanteric regionsshow altered marrow signal intensity appearinghypointense on T1 sequences while appearhyperintense on STIR sequences suggesting marrowedema.No effusion.Acetabulum, right femoral head and SI joints arenormal.Joint spaces are normal.Diagnosis : Marrow edema involving left femoralhead , neck, and trochanteric regions - ? Early AVN ,post traumatic oedema?
MRI findings on 31/7/2008:Follow upThe study reveals subtle T1 / T2 hypo intensity in theleft femoral head. ? Sclerosis.No abnormal sign noted over the fat sat sequences.Right femoral head show normal size, contour, intactcortical margins and normal bone marrow signalintensity.Acetabular cartilages are normal.Compare with the previous MRI dated 7/3/2008, theedema involving the left femoral head, neck andupper shaft are not seen now.
Case Three• V. B. a 30 years, female with H/o acute left hip pain of a week’s duration.• Clinically anterior hip tenderness with limitation of hip movements.• Radiology and routine investigations were normal.• MRI findings with follow up images are presented here.
MRI findings on June 2009A suspicious small area of subchondralerosion in the anterio-superior aspect of leftfemoral head & an ill defined marrowedema in the rest of the femoral & neckwith left hip joint effusion & synovialdistention.The differential diagnostic possibilitiesinclude ? Transient osteoporosis of hip /early Avascular necrosis (stage 2A), Non-specific infective.
MRI findings on Sept 2009Follow up MRI:Complete disappearance of the marrowedema in the left femoral head & neck,Disappearance of joint fluid as compare toprevious MRI dated 14/5/2008 with noresidual cortical erosion or necrosis.Right hip joint is normal.
Case five• Mr. A.T. a 36 yrs, male acute pain in the left hip of a weeks’s duration.• Clinically he had anterior hip tenderness with limitation of hip movements.• Radiology and routine investigations were normal.• MRI finding with follow up MRI are presented here.
MRI – reported on 14 / 5 / 2008A suspicious small area of subchondral erosion inthe antero – superior aspect of left femoralhead & an ill-defined marrow edema in the leftfemoral head & the neck with joint effusion andsynovial distension.D/D include;Transient osteoporosis of hip,Early Avascular necrosis (stage 2 A),Non-specific Infective pathology.
MRI findings on 18/8/2008Follow upImpression:-Complete disappearance of the marrowedema in the left head & neck.Complete disappearance of jointeffusion in the left hip.No residual cortical erosion or sclerosisor any new abnormality as compare toMRI done on 14/5/2008.
DISCLAIMER• Information contained and transmitted by this presentation isbased on personal experience and collection of cases at ChoithramHospital & Research centre, Indore, India, during last 32 years.• It is intended for use only by the students of orthopaedicsurgery.• Views and opinion expressed in this presentation are personal.• Depending upon the x-rays and clinical presentations viewers canmake their own opinion.• For any confusion please contact the sole author for clarification.• Every body is allowed to copy or download and use the materialbest suited to him. Authors are not responsible for anycontroversies arise out of this presentation.• For any correction or suggestion please contact:firstname.lastname@example.org