Idiopathic transient osteoporosis of the hip

We have reviewed 11 patients with idiopathic transient osteoporosis of the hip; the six who were women all developed the condition during pregnancy. Both simultaneous and sequential bilateral involvement were seen, but biochemical studies were consistently normal and one synovial biopsy showed only non-specific inflammation. Radioisotope bone scans and CT scans were useful to aid diagnosis. Treatment by limiting weight-bearing relieved symptoms, and spontaneous resolution was paralleled by radiographic remineralisation, usually within a few months. One patient developed a stress fracture of the hip and other areas of transient osteoporosis. A hip involved by the condition should be protected from overloading until bone density has recovered.     

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。     

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.     

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

We report four cases of transient hip osteoporosis studied between 1995 and 1997. All patients were men. The diagnosis was based on clinical symptoms, absence of abnormal laboratory tests, increased uptake in the femoral head and neck on Tc-99 bone scans and magnetic resonance imaging showing Oedema of the bone marrow. In three patients radiographs showed osteopenia of the head and neck of the involved femur, whereas no major radiographic changes were seen in the fourth patient. The clinical symptoms lasted 7 months and there was no recurrence after 8-24 months' follow-up.     

Transient osteoporosis of the hip in pregnancy: a report of three cases

Transient osteoporosis of the hip is a rare disease of unknown etiology. It is usually seen in middle-aged men and women in the third trimester of pregnancy and is associated with hip pain. It typically runs a benign course with eventual resolution of symptoms. We report three patients who presented with unilateral hip pain that started in the third trimester of pregnancy. Diagnosis of transient osteoporosis of the hip was made with the help of clinical and radiologic studies. Treatment was comprised of pain control therapy with diclofenac sodium (100 mg/day) for three months, bed rest for a month followed by mobilization with a walking aid. The follow-up period was at least 24 months. Clinical improvement occurred in the third month in one patient, and at the end of six months in the remaining patients. Complete radiologic improvement was seen at the end of 12 months.     

"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.     

Clinical utility of spine bone density in elderly women.

It is common clinical practice to obtain a bone density measurement at both the hip and spine to evaluate osteoporosis. With aging, degenerative changes in the lumbar spine may elevate the bone mineral density (BMD) results giving false assurances that the fracture risk at the spine is low. We examined the association of spine osteoarthritis and bone mineral density in 1082 community-dwelling ambulatory older women aged 50-96 years who participated in a 1992-1996 osteoporosis research clinic visit. The BMD was measured at the hip and posteroanterior (PA) and lateral lumbar spine using dual energy X-ray absorptiometry (DXA). Spine osteoarthritis was identified on the PA lumbar spine DXA images by a musculoskeletal radiologist. Forty percent of women had evidence of spine osteoarthritis (OA). Women with spine OA had a mean age of 77.4 yr (95% confidence interval [CI]: 76.5-78.2), were significantly older than women without spine OA (mean age, 66.8 yr; 95% CI: 65.9-67.7), and were more likely to have prevalent radiographic fractures (14.2% vs. 9.5%; p<0.05). Age-adjusted BMD at the femoral neck, total hip, PA spine, and lateral spine was significantly higher in women with spine OA. Women with spine OA were more likely to have osteoporosis by the World Health Organization classification at the femoral neck and total hip than those without spine OA, but less likely based on the PA spine (14.4% vs. 24.5%). Despite higher BMD levels, women with OA of the lumbar spine had higher prevalence of osteoporosis at the hip and more radiographic vertebral fractures. In elderly women 65 yr and older who are likely to have spine OA, the DXA measurement of the spine may not be useful in assessing fracture risk, and DXA of the hip is recommended for identification of osteoporosis.     

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 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.     

Transient demineralization of the hip--case report]

Transient osteoporosis of the hip is an uncommon disorder of unclear etiology. It is often confused with other diagnosis including osteonecrosis of the femoral head. Authors describe a case of transient osteoporosis of the hip of 32 years woman. The symptoms occurred in third trimester of pregnancy. The primary symptoms were right hip pain and decreased range of motion of the right hip. In diagnostic process helpful were clinical examination, X-ray, ultrasonography, MRI and microscopic examination. As a treatment authors used walking on crutches, calcitonin and calcium preparate. After a few months remission of symptoms and normalization in accessory investigations were obtained.     

Migrating transient osteoporosis of the hip in a 30-year-old man

Transient osteoporosis of hip is a condition of unknown etiology, presenting as painful limping, and characterized by osteopenia of the involved joint without preexisting disease or immobilization. Most of the cases were reported in middle-aged men, and one-third of the cases develop in women in the third trimester of pregnancy. The hypothesis that this condition leads to avascular necrosis of the hip has been disproved by various reports and hence does not warrant any surgical interference. This is a self limiting condition, which needs regular follow-up. The authors report a case of migrating transient osteoporosis of the hip in a 30-year-old man successfully treated with antiresorptive treatment.     

Late presentation of a displaced subcapital fracture of the hip in transient osteoporosis of pregnancy

Transient osteoporosis of the hip is rare and has two demographic peaks, one during the third trimester of pregnancy and the other around the fifth to sixth decade of life. During pregnancy, osteoporosis presents with insidious onset of hip pain and antalgic limp with no antecedent infection or trauma. Radiographs show pronounced osteopenia of the femoral head and neck with preservation of the joint space. 1 Bone scan and magnetic resonance imaging are sensitive but not specific for diagnosis, and laboratory studies are typically normal. 2 We present the case of a patient with a displaced, grossly unstable subcapital hip fracture who presented 5 months postpartum and describe successful treatment by open reduction and internal fixation with a muscle-pedicle bone graft.     

Correlation of plain radiographic indices of the hip with quantitative bone mineral density

SUMMARY: Radiographic parameters of the hip can be useful as an indication of bone mineral density at the femoral neck. Measurements available from routine hip radiographs were correlated with DXA values. Although radiographs are not a test for osteoporosis, measurements of cortical thickness provide information useful for referral for osteoporosis assessment. INTRODUCTION: Plain hip radiographs are widely used for evaluation of hip pathology in osteoarthritis. A purpose of this study was to determine whether there are relationships between radiographic parameters of bone structure and bone mineral density T-scores, as assessed by dual energy x-ray absorptiometry (DXA). METHODS: Pre-operative radiographs of 32 postmenopausal, osteoarthritic women undergoing hip arthroplasty were evaluated. Radiographic parameters including the Singh index, Dorr classification, canal-to-calcar ratio, and cortical thickness indices (CTI) were measured and compared with T-score, serum 25 hydroxyvitamin D levels, body mass index (BMI), and body weight. RESULTS: The T-score at the femoral neck for type C bone was significantly lower than that of type A (p = 0.041). The CTIs were correlated positively with T-scores for anteroposterior radiographs (r = 0.5814, p = 0.0005), and for lateral radiographs (r = 0.571, p = 0.0006). A threshold for lateral CTI set at a value of < or =0.40 results in sensitivity of 0.85 and specificity of 0.79 to segregate the osteoporotic and non-osteoporotic patients. CONCLUSION: Femurs with small radiographic cortical thickness indices had lower T-scores. Finding a radiographic hip cortical thickness index (LAT) with a value of < or =0.40 should be an alert for referral for osteoporosis evaluation and bone mineral density testing.     

Total hip arthroplasty after renal transplantation. Long-term follow-up study and assessment of metabolic bone status

Twenty-two patients had 36 total hip arthroplasties for painful osteonecrosis of the femoral head. At a mean of 86 months after operation, a complete follow-up evaluation, including physical examination, was obtained in 24 hips in 15 patients. An additional 12 hips in seven patients were followed by telephone interview and radiographic evaluation. Although most patients experienced improved hip function and symptomatic relief from pain as a result of the operation, 10 hips developed heterotopic bone, 5 hips dislocated after operation, 6 hips failed due to aseptic loosening, and 1 hip developed a deep infection, and one patient died due to pulmonary embolism. Neither sex, preoperative steroid dose, nor postoperative mean alternate-day steroid dose could be related to aseptic loosening. However, histologic examination of transilial bone biopsy specimens (7 patients, 13 hips) revealed steroid-induced osteoporosis, by the presence of hyperosteoidosis (increased unmineralized osteoid) and increased bone resorption. Bilateral hip involvement, osteoporosis, and high turnover skeletal remodelling at the cement-bone interface potentially contributed to a failure rate that was higher in this group than that reported for primary hip arthroplasty for other diagnoses. The existence of steroid-induced metabolic bone disease and preexisting renal osteodystrophy may pose a significant threat to the long-term survival of a total hip implant.     

髋部暂时性骨质疏松症的诊断与保守治疗

目的 探讨暂时性骨质疏松症的诊断方法及保守治疗疗效.方法 回顾性分析2006年10月至2009年7月收治的10例暂时性骨质疏松症患者的临床资料,对其临床表现、体格检查及影像学特征进行归纳.男4例,女6例;年龄22～43岁,平均35岁.所有女性患者均不在妊娠期内.2例髋关节正侧位X线片表现正常,8例表现为股骨头不同程度的骨质疏松,骨小梁模糊.MRI均表现为广泛均匀的信号改变,累及股骨头和股骨颈,其中7例病变同时出现在股骨转子周围.T1加权像表现为低信号,T2加权像表现为高信号.治疗方法包括避免重体力劳动、过量运动、长距离行走及采用药物治疗,药物包括非甾体抗炎镇痛药和二膦酸盐类药物.采用四点口述分级疼痛评分和Harris髋关节评分对治疗结果进行评价.结果 10例均获得随访,随访时间1.0～3.5年,平均2.5年.治疗1天后临床症状开始改善,治疗前疼痛评分为3级8例、4级2例,治疗6个月后为1级6例、2级3例、3级1例.治疗前Harris髋关节评分65～85分,平均74.5分;治疗6个月后84～100分,平均96分.治疗6个月后,X线片及MRI影像均基本恢复正常.结论 暂时性骨质疏松症是一种一过性、自限性疾病,有独特的临床及影像学特征.保守和支持疗法对暂时性骨质疏松症有效.     

Bilateral fracture of the femoral neck following transient osteoporosis in pregnancy

During pregnancy changes of the bone metabolism can occur. Femoral neck fractures are known as a very rare consequence of transient osteoporosis in pregnancy. In a case report we present the clinical, radiological and histological features of a bilateral fracture of the femoral neck. A 29-year-old woman presented with pain in the right hip, which occurred in the 34 (th) week of pregnancy. The symptoms were initially interpreted as a sacroiliac joint affection and consequently a conservative treatment was initiated. Five days after a Caesarean section a dislocated fracture of the femoral neck was diagnosed on the left side. On the contralateral side the fracture was not dislocated. For therapy this patient underwent a total hip replacement on the left hand side and an internal fixation on the other side. Especially during pregnancy changes of the bone are diagnosed late due to the side effects of radiation. This case report indicates that MR imaging and other non-ionising techniques should be considered if such symptoms persist in spite of therapy.     

Transient osteoporosis

Transient osteoporosis is characterized primarily by bone marrow edema. The disease most commonly affects the hip, knee, and ankle in middle-aged men. Its cause remains unknown. The hallmark that separates transient osteoporosis from other conditions presenting with a bone marrow edema pattern is its self-limited nature. Laboratory tests usually do not contribute to the diagnosis. Plain radiographs may reveal regional osseous demineralization. Magnetic resonance imaging is used primarily for early diagnosis and monitoring disease progression. Early differentiation from more aggressive conditions with long-term sequelae is essential to avoid unnecessary treatment. Clinical entities such as transient osteoporosis of the hip and regional migratory osteoporosis are spontaneously resolving conditions. However, early differential diagnosis and surgical treatment are crucial for the patient with osteonecrosis of the hip or knee.     

Insufficiency subchondral fracture of the femoral head: report of 4 cases and review of the literature

Insufficiency subchondral fractures are nontraumatic flattened lesions in the superolateral area of the femoral head, occurring in healthy adults. These lesions were recently described and are an infrequent cause of acute hip pain. We report on 4 patients who were diagnosed with an insufficiency subchondral fracture. All the patients showed radiographic progression of the lesion after 4 months, and 3 patients required a total hip arthroplasty. The etiology and the natural history of these rare lesions remain to be elucidated. These lesions should be differentiated from osteonecrosis and transient osteoporosis, because treatment and prognosis may differ.     

Transient osteoporosis

Six hips in four patients with hip pain, limited range of motion, no antecedent trauma, and normal laboratory studies demonstrated roentgenographic evidence of periarticular osteoporosis. The subchondral cortex was attenuated. There was little or no cartilage loss. The preliminary diagnosis was transient osteoporosis (migratory osteolysis, regional osteoporosis). This problem is most frequently seen in the hip joint in two population groups: men near 40 and women in the third trimester of pregnancy. Other joints may be involved and the process may regress in one joint but recur in another. Diagnosis is based on typical clinical and roentgenographic observations including an aspiration of sterile joint fluid. Radioisotope scanning may be helpful. Bone or synovial biopsy sampling is not necessary. Proper management requires accurate diagnosis and conservative treatment of a cooperative patient. Pain may persist for six months or longer. Treatment consists of analgesics, protection against stress fractures, and physical therapy for prevention of contractures.