A new hypothesis for the bone marrow edema pathogenesis during transient osteoporosis

Transient osteoporosis is an infrequent condition of uncertain etiology with pain, limited range of motion and radiographic evidence of osteoporosis affecting one or more joints. It is self-limited, reversible and can involve only the hip (transient osteoporosis of the hip, TOH) or, less frequently, one or more joints contemporaneously or at different times (regional migratory osteoporosis, RMO). We studied four men with transient osteoporosis, including two with TOH and two with RMO. All patients underwent a standard radiographic work-up of the affected joints, arteriovenous Doppler US, computed tomography, magnetic resonance imaging (MRI) and three-phase bone scanning. In all patients, symptoms were related to bone marrow edema demonstrated at MRI and to a transitory regional arterial hyperflow observed at the early scintigraphic analysis. On the basis of our observations, we hypothesize that regional arterial hyperflow may be the cause of the bone marrow edema and therefore of the transient osteoporosis.     

Transient osteoporosis of the hip: A case report

We report a case of transient osteoporosis of the hip (TOH) in a 59-year-old man including the clinical presentation, diagnostic studies, management and clinical progress. TOH is a rare self-limiting condition that typically affects middle-aged men or, less frequently, women in the third trimester of pregnancy. Affected individuals present clinically with acute hip pain, limping gait, and limited ranges of hip motion. TOH may begin spontaneously or after a minor trauma. Radiographs are typically unremarkable but MR imaging studies yield findings consistent with bone marrow edema. TOH is referred to as regional migratory osteoporosis if it travels to other joints or the contralateral hip. TOH often resembles osteonecrosis but the two conditions must be differentiated due to different prognoses and management approaches. The term TOH is often used interchangeably and synonymously with transient bone marrow edema.     

Three cases of regional migratory osteoporosis

We examined three patients with regional migratory osteoporosis. Radionucleotide bone scanning and MRI was helpful in the diagnosis of this disease, and all patients recovered with conservative treatment. A biopsy of the femoral head, which was performed in one case, demonstrated bone marrow edema without osteonecrosis. A low intensity area of subchondral bone was observed on a T1-weighted image in two cases, as well as a fracture of the subchondral bone, which might be associated with transient osteoporosis. In one case, the affected region migrated from the medial femoral condyle to the lateral femoral condyle in the same knee joint.     

The transitory bone marrow edema syndrome of the hip

AIM OF THE STUDY: Since MRI-studies had begun to establish the diagnosis of transitory bone marrow edema syndrome of the hip orthopedic surgeons have tried to integrate this new syndrome into the internationally accepted system of musculoskeletal diseases. Particularly, the relation to non-traumatic osteonecrosis of the femoral head and the possibilities in therapy were investigated in our clinical trial. METHODS: Our clinical trial encompassed 106 patients suffering from the transitory bone marrow edema syndrome diagnosed in our department between the years 1985 and 2000. In order to confirm this diagnosis we used the patients' histories, their clinical courses, MRI studies, scintigraphic bone scans, intraosseal pressure measurements, phlebographies, laboratory data, and histologic specimens. One half of our collective positive for transient bone marrow edema of the hip underwent core-decompression surgery (50 patients), the other half (56 patients) was treated conservatively by analgesic medication combined with restriction of weight-bearing in the affected extremity. RESULTS: Patients positive for transitory bone marrow edema syndrome of the hip are middle-aged individuals with a male to female predominance of 60 : 40. This group has no or only few risk factors usually associated with osteonecrosis of the femoral head. Thus, the missing alcoholic abuse is striking. All patients suffering from transitory bone marrow edema syndrome of the hip recovered completely independent of the therapy we initiated and none of them showed any signs of osteonecrosis. The one half undergoing surgical decompression of the edema by using a 4.5 mm drill experienced an markedly accelerated relief of their clinical symptoms as well as their signal changes on MRI studies. Conventional X-ray pictures and scintigraphic bone scans are not useful for early differentiation between early stages of osteonecrosis and bone marrow edemas. This also accounts for the historical measurements of intraosseal pressure determinations and phlebographies. In contrast to that, MRI studies are effective in early differentiation between osteonecrosis and bone marrow edema syndrome of the hip, especially when contrast medium (gadolinium) is administrated intravenously and fat-suppressed MRI-sequences find use. Beginning osteonecrosis of the femoral head shows a segmental loss of contrast medium, a "double line sign" interface to the intact bone marrow, and only in a few cases they are associated with a huge symptomatic edema. The histologic examination of specimens obtained from 43 patients with transitory bone marrow edema syndrome of the hip revealed no signs of osteonecrosis. CONCLUSION: MRI studies are useful in differentiation between bone marrow edema syndrome of the hip and non-traumatic osteonecrosis of the femoral head in each stage of these two diseases. The thorough differentiation between these two diseases is of extraordinary importance for the clinical work-up of the patients as well as for scientific reasons. The course of primary bone marrow edema is benign as it results in entire recovery. The core decompression surgery offers the chance to shorten the course of the disease.     

"Transient osteoporosis" as a special reversible form of femur head necrosis

There is still controversy whether transient osteoporosis of the hip joint represents a distinct self-limiting disease, or reflects only an early, reversible subtype of non-traumatic osteonecrosis (ON). Transient osteoporosis has several synonyms: algodystrophy of the hip; transient marrow oedema; or bone marrow oedema syndrome--BMOES. Clinical presentation of BMOES shows mechanical hip joint pain, ON risk factors, and a diffuse bone marrow oedema in MR imaging. Histomorphological changes resemble early ON, but with diffuse sufficient repair in BMOES and focal and insufficient repair only at the border of the necrotic lesion in ON. Therefore the clinical course and outcome are significant different, with restitution occurring in BMOES, while progressive destruction of the joint takes place in ON. So far, the preferred treatment strategies are protected weight bearing for BMOES, but operative treatment for ON. In a prospective study of patients with BMOES, the clinical, radiographic, and MRI course of 43 hip joints after core decompression treatment were investigated. All patients showed immediate relief of pain after surgery and the average duration of symptoms with conservative treatment could be dramatically reduced by core decompression from 6 months down to 2 months. There were no perioperative complications. Based on our experience with over 100 BMOES patients, we are convinced that this syndrome represents not a distinct disease but an early reversible subtype of non-traumatic ON. Due to the excellent clinical results of core decompression, we recommend this operative therapeutical concept in patients with painful BMOES.     

8例髋关节暂时性骨质疏松症的临床诊断与治疗

目的探讨髋关节暂时性骨质疏松症（transient osteoporosis of the hip,TOH）的临床表现、诊断、鉴别诊断、治疗及预后。方法2003年8月至2009年8月治疗8例TOH患者,男2例,女6例;年龄22—43岁,平均34．9岁。患者均为单侧发病,左侧5例,右侧3例。患者的患髋均表现有不同程度的突发急性疼痛或渐进性疼痛,同时伴有显著的跛行。患髋内旋轻度受限是主要的体征。症状出现后3—6周,x线片可见股骨头均匀广泛的骨质疏松,MR表现为弥散且一致的等低T1、长T2异常信号,脂肪抑制序列呈高信号。嘱患者在疼痛可忍受的条件下半负重行走,避免出现骨折等并发症;口服二膦酸盐和钙剂;剧烈疼痛时,可口服非甾体类抗炎药物缓解疼痛。结果临床治疗3个月后疼痛明显减轻,10个月后疼痛完全缓解,复查MR示病变完全消失。结论TOH是一种少见的疾病,无原因出现的髋关节疼痛和跛行是主要症状,X线片和MR可分别看到暂时性的骨质疏松和骨髓水肿。此病具有自限性,保守治疗可获得良好的结果,明确诊断是治疗的关键。     

Increased perfusion of the femoral head in transient bone marrow edema syndrome

The pathophysiology of transient bone marrow edema syndrome is not known. Ischemia has been suggested as the pathophysiologic factor, because the histologic findings are similar to those of early stage osteonecrosis. Angiographic studies of osteonecrotic femoral heads have shown arterial interruption and impaired perfusion. The current report describes the angiographic and scintigraphic findings of transient bone marrow edema syndrome of the hip in a 45-year-old man. The nutrient arteries were dilated, and the femoral head perfusion was increased compared with the unaffected contralateral side. These findings suggest that a vasomotor response plays a role in the pathogenesis of transient bone marrow edema syndrome. The disease might be a reversible process after temporary ischemia of the femoral head.     

Magnetic resonance imaging in diagnosis of transient osteoporosis of the hip.

The results of magnetic resonance (MR) imaging in six patients with transient osteoporosis of the hip were reviewed. Short TR/TE (repetition time/echo time) images demonstrated diffusely decreased signal intensity in the femoral head and intracapsular region of the femoral neck. Increased signal intensity was noted with progressive T2 weighting. Bone biopsies were performed in four patients. Histologic findings were nonspecific and included fat necrosis, marrow edema, increased bone resorption, and reactive bone formation. Repeat MR scans in two patients, performed six and eight months after the initial scans, showed an almost complete return to normal marrow signal. All patients became asymptomatic without bony deformity. In the appropriate clinical setting, MR scanning can aid in the diagnosis of transient osteoporosis as the cause of a painful hip.     

Transient osteoporosis of hip in pregnancy.

Transient osteoporosis in pregnancy is a relatively rare disorder characterized by disabling pain in the hip without prior trauma and by striking radiographic evidence of osteopenia that is limited to the hip. Clinical and radiographic findings regress spontaneously within months after pregnancy and without late sequelae. In this study, we report on a case of a 28-yr-old Caucasian woman who suffered from transient osteoporosis during pregnancy. Nine months later, the patient was asymptomatic and there was resolution of the bone marrow edema pattern seen on the initial magnetic resonance imaging scan of her hip. Follow-up bone densitometry at 1 yr revealed a dramatic increase (12.3%) in bone mineral density of the symptomatic hip. We review the literature and discuss possible mechanisms involved in the pathogenesis of transient osteoporosis in pregnancy.     

Regional migratory osteoporosis: a case report

We describe a case of regional migratory osteoporosis (RMO) with clinical images clearly illustrating the migratory behavior of this unusual disorder. RMO is a relatively rare disorder that manifests as rapidly developing, self-limiting, reversible osteoporosis typically seen in the lower limbs of middle-aged men. In our case, the lesion was observed migrating not only from the knee to the ankle within the same limb but also within two compartments of the same knee. To our knowledge, this is the first case showing migration of a lesion both within the same joint and to the adjacent joint. We also present computed tomography images showing characteristic spotty bone defects that are rarely described in the literature, along with magnetic resonance imaging scans revealing bone marrow edema in the affected region. Although little is understood about the etiology or treatment of RMO, knowledge of this disorder is mandatory to avoid its misdiagnosis as some other, more aggressive disease, leading to unnecessary treatment.     

Idiopathic transient osteoporosis of the talus: a cause for unexplained foot and ankle pain

A 53-year-old woman was investigated for several neoplastic, inflammatory, and infective conditions for her left foot, and ankle pain associated with swelling, which she developed unexpectedly without history of trauma or infection. Gross osteopenia in the talus raised the possibilities of several differential diagnoses, but a magnetic resonance imaging scan showed diffuse bone marrow edema in the talus. With negative infective and inflammatory markers, the condition was ultimately labeled as "transient osteoporosis." She was reassured and followed up regularly. At the end of 12 months, she was completely asymptomatic, and her radiograph and magnetic resonance images showed significant improvement, with a normal-appearing talus and ankle joint, and there was complete resolution of bone marrow edema. Although "transient osteoporosis" of the foot is an uncommon condition, clinicians should be aware of this. Unexplained foot pain, with osteopenic bone and diffuse bone marrow edema on magnetic resonance imaging scan, is a feature of this condition. However, the diagnosis is established once other causes are excluded. The condition is self-limiting, and watchful expectancy of a normal recovery is the mainstay of treatment.     

Bone death in transient regional osteoporosis.

A 48-year-old man developed transient regional osteoporosis, with hip and later knee pain. He responded well to lumbar sympathectomy. The femur and tibia adjacent to the painful knee were osteoporotic, while the medial femoral condyle showed increased uptake in a bone scan. In the femoral condyle, bone histology showed areas of dead bone undergoing osteoclastic resorption, and increased bone formation. The tibial bone was histologically normal. The partial bone death in the distal femur suggests that the disorder may be related to both avascular necrosis of bone and reflex sympathetic dystrophy.     

从肝论治甲亢性骨质疏松的相关性探讨

甲亢性骨质疏松是因甲状腺激素过多引起机体骨代谢及骨矿化紊乱而导致的继发性疾病,随着社会的节奏不断加快,其发病率也逐年升高。因其沉默性发病,临床上常常出现漏诊、误诊,耽误了治疗的最佳时机,使病情加重,病程延长,故早诊断、早治疗是治疗此病的关键。对于其治疗,现代医学尚无明确治疗方案和早期干预手段,中医药治疗甲亢性骨质疏松具有充分优势,《黄帝内经》认为"肝藏血主疏泄,调畅气机,以强筋骨",提示气血的运行、筋骨的生长与肝的疏泄功能密切相关。但目前临床治疗多集中在"肾为先天主骨生髓"方面,忽视了"从肝论治"在甲亢性骨质疏松防治中的重要性。本文旨在从中西医角度探讨"从肝论治"甲亢性骨质疏松临床研究的相关性,为甲亢性骨质疏松的防治诊疗提供新思路。     

股骨上端骨髓水肿综合征的MRI表现特点

目的：分析股骨上端骨髓水肿综合征的MRI表现特点以提高对该病的认识。方法;回顾性分析10例股骨上端骨髓水肿综合征患者的MRI表现,男6例,女4例;年龄36～57岁,平均41．5岁;病史1周～3个月。临床表现为突然发作的髋部疼痛9例,行走能力及髋关节活动受限7例;全部病例无明显外伤史,女性患者未在孕期。随访3～12个月,症状消失3个月复查MRI后结束随访。结果：MRI主要表现为弥漫性骨髓水肿,累及股骨头、颈、粗隆间,10例13髋中骨髓水肿1级6髋,2级5髋,3级2髋。合并髋关节积液9髋,I级积液6髋,Ⅱ级1髋,III级2髋。治疗3-12个月后患者髋部疼痛症状消失,股骨内MRI信号恢复正常。     

老年髋部骨折的手术治疗

目的 报告老年人髋部骨折临床治疗效果,分析老年人髋部骨折特点及诊治注意事项。方法 对55岁以上老年髋部骨折193例的临床资料进行总结分析。结果 随访135例,时间6～22个月。术后下肢静脉栓塞2例,股骨头缺血性坏死1例,内固定物松动1例,116例(85.9％)恢复行走功能。结论 老年人髋部骨折以女性多见,65岁以后,老年髋部骨折发生率明显上升。说明随着年龄的增加,骨折的发生率明显增高,骨折危险性增加。老年人髋部骨折属于骨质疏松性骨折,一般都有明显外伤史。老年人多伴有心血管系统或呼吸系统疾病,骨折后长期卧床具有致命的危险,因此若无禁忌证应争取早期手术。在治疗骨折的同时,应注意对骨质疏松症的治疗。应重视骨折后下肢深静脉血栓形成的预防。     

Das Knochenmarködemsyndrom (KMÖS)

Bone marrow edema (BME) syndrome represents a pathologic accumulation of interstitial fluid in bone – with a traumatic BME being differentiated from a non-traumatic, often ischemic, and a reactive as well as a mechanical BME. Atraumatic/ischemic BME is inconsistently described as a separate entity or as a reversible preliminary stage of osteonecrosis (ON). However, there is always the risk of transformation of BME into ON and subsequent joint destruction. The most common sites of BME are the hip, knee, and ankle. Magnetic resonance imaging is the diagnostic gold standard. Differential diagnoses of the transient BME as osteonecrosis, osteochondrosis dissecans, and a reflex dystrophy should be considered. Conservative or surgical treatment is considered, depending on the etiology of BME. BME syndrome is generally treated conservatively. Infusion of prostacycline or bisphosphonates is a promising option. Ischemic BME and early stages of ON can be successfully treated by core decompression. A combination of both treatment options may also offer advantages.     

Migrating bone marrow edema syndrome: a cause of recurring knee pain

Bone marrow edema syndrome is a condition of unknown etiology, presenting with painful limping. It is characterized by normal radiographs, but magnetic resonance imaging findings change with bone marrow edema. When there is osteopenia in the radiographs, the condition is called transient osteoporosis. The term migratory bone marrow edema syndrome is used when there is involvement of another joint, or another compartment in the same joint, which typically occurs within 6 months of onset of primary symptoms. Here, a case of migratory bone marrow edema syndrome in a 47-year-old male patient, which was conservatively managed, is reported.     

Transient Peripartum Osteoporosis of the Femoral Head in First and Third Pregnancy

The aim of this article was to present transient peripartum femoral head osteoporosis. This very rare condition occurred twice in our patient—a woman in her 30s. The cases described in the literature were mostly unilateral, with bilateral hip involvement noted much less frequently. In our patient, transient osteoporosis occurred in the third trimester of her first pregnancy in the right hip, her second pregnancy was uncomplicated, and in the third trimester of the patient's third pregnancy, osteoporotic changes were noted in the left hip joint. The patient breastfed her first and third babies only 3 wk each. She breastfed her second baby for 4 mo. The diagnostic workup was based on the clinical examination and radiographic/magnetic resonance imaging, which revealed bone marrow edema, and the dual-energy X-ray absorptiometry scans. The treatment consisted in core decompression of the femoral head (foragé), unloading of the hip using crutches as well as administration of calcitonin and calcium supplements. Complete recovery of the femoral heads was achieved. The follow-up time was 7 yr.     

股骨头骨髓水肿综合征的诊治及其与股骨头缺血性坏死的鉴别诊断

目的：通过对股骨头骨髓水肿综合征诊治的观察,分析其疾病特点及其与股骨头缺血性坏死的异同。方法：自2004年1月,股骨头骨髓水肿综合征患者19例,男12例,女7例;平均年龄（46．7±10．36）岁。给予药物及物理治疗,治疗前后按照髋关节Harris评分系统进行评分。结果：治疗前平均（43．17±12．62）分,治疗后平均（86．73±14．29）分,治疗前、后评分差异有统计学意义（P〈0．05）。结论：股骨头骨髓水肿综合征疾病特点不同于股骨头缺血性坏死,是一类独立的疾病。