transient osteoporosis of hip

Transient Osteoporosis of Hip

Vinod Naneria

Girish Yeotikar

Arjun Wadhwani

Choithram Hospital & Research Centre, Indore

India

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.

Normal

AVN

TOH

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.

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

Radiology

Typically - Focal osteopenia on plain radiographs.

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.

The lateral radiographs show lysis and sclerosis in both femoral heads (arrows in a and b), suggesting bilateral osteonecrosis. The “crescent” sign in the left femoral head (open arrow) is diagnostic of advanced osteonecrosis with subarticular fracture but not articular collapse. Skeletal Radiol (2009) 38:425–436.

Radiology

Reproduce with permission from Dr. A. V. Korompilias

Transient osteoporosis:- The bone scan (anterior view) is showing intense uptake in the femoral head and neck, early in the course of the disease (arrow).

Avascular necrosis of the left hip:- The bone scan (posterior view) shows increased uptake only in the femoral head area with a “cold in hot” appearance (arrow).

Scintigraphy – Tc 99

Reproduce with permission from Dr. A. V. Korompilias

C T Scan

transient osteoporosis of the left hip. A The plain AP radiograph shows osteopenia of the outer part of the left femoral head (arrow). b The corresponding CT scan obtained on the same day shows to better advantage the marked osteopenia of the left femoral head with mottled or moth-eaten pattern of the trabecular bone (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 images demonstrate the same area with high signal intensity in keeping with bone marrow edema. 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 “double line” 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 right hip shows only the osteonecrotic lesions (arrows) with no marrow edema.

d The sagittal T2-gradient-recalled echo MR image of the left hip 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-w MR image of the left hip shows diffuse enhancement secondary 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/s00256-008-0529-1

A. V. Korompilias (*) : M. G. Lykissas : A. E. Beris, Department of Orthopaedic Surgery, School of Medicine, University of Ioannina, 45110 Ioannina, Greece e-mail: koroban@otenet.gr

A. 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.

6/5/2011

6/5/2011

Follow up on 18/7/2011 – compare with old MRI of 7/5/2011 – persistent but significantly regression of joint effusion noted. Complete regression of marrow edema of supero- lateral quadrant of left femoral head.

MRI – Findings 18/07/2011

18/7/2011

Follow up 28/10/2011. Nearly complete regression of marrow edema of right femoral head neck noted with no effusion in the joint. No evidence of AVN.

MRI findings on 28/10/2011

Complete regression

Complete Regression

Complete Regression

Complete Regression

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.

Left femoral head , neck and trochanteric regions show altered marrow signal intensity appearing hypointense on T1 sequences while appear hyperintense on STIR sequences suggesting marrow edema. No effusion. Acetabulum, right femoral head and SI joints are normal. Joint spaces are normal. Diagnosis : Marrow edema involving left femoral head , neck, and trochanteric regions - ? Early AVN , post traumatic oedema?

MRI findings on march 2008

March 2008

March 2008

MRI findings on 31/7/2008: Follow up The study reveals subtle T1 / T2 hypo intensity in the left femoral head. ? Sclerosis. No abnormal sign noted over the fat sat sequences. Right femoral head show normal size, contour, intact cortical margins and normal bone marrow signal intensity. Acetabular cartilages are normal. Compare with the previous MRI dated 7/3/2008, the edema involving the left femoral head, neck and upper shaft are not seen now.

31/7/2008

31/7/2008

Complete Regression

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.

A suspicious small area of subchondral erosion in the anterio-superior aspect of left femoral head & an ill defined marrow edema in the rest of the femoral & neck with left hip joint effusion & synovial distention. The differential diagnostic possibilities include ? Transient osteoporosis of hip / early Avascular necrosis (stage 2A), Non-specific infective.

MRI findings on June 2009

June 2009

June 2009

June 2009

Follow up MRI: Complete disappearance of the marrow edema in the left femoral head & neck, Disappearance of joint fluid as compare to previous MRI dated 14/5/2008 with no residual cortical erosion or necrosis. Right hip joint is normal.

MRI findings on Sept 2009

June 2009

Sept. 2009

Sept. 2009

Complete Regression

Sept. Sept. 2009

Complete Regression

Sept. 2009

Complete Regression

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.

A suspicious small area of subchondral erosion in the antero – superior aspect of left femoral head & an ill-defined marrow edema in the left femoral head & the neck with joint effusion and synovial distension. D/D include; Transient osteoporosis of hip, Early Avascular necrosis (stage 2 A), Non-specific Infective pathology.

MRI – reported on 14 / 5 / 2008

14/5/2008

14/5/2008

14/5/2008

Follow up Impression:- Complete disappearance of the marrow edema in the left head & neck. Complete disappearance of joint effusion in the left hip. No residual cortical erosion or sclerosis or any new abnormality as compare to MRI done on 14/5/2008.

MRI findings on 18/8/2008

18/8/2008

Complete Regression

18/8/2008

Complete Regression

18/8/2008

Complete Regression

• Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 32 years. • It is intended for use only by the students of orthopaedic surgery. • Views and opinion expressed in this presentation are personal. • Depending upon the x-rays and clinical presentations viewers can make their own opinion. • For any confusion please contact the sole author for clarification. • Every body is allowed to copy or download and use the material best suited to him. Authors are not responsible for any controversies arise out of this presentation. • For any correction or suggestion please contact:

naneria@yahoo.com

DISCLAIMER