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A 40-year-old man with 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 )
Source publication
Bone marrow edema syndrome (BMES) refers to transient clinical conditions with unknown pathogenic mechanism, such as transient osteoporosis of the hip (TOH), regional migratory osteoporosis (RMO), and reflex sympathetic dystrophy (RSD). BMES is primarily characterized by bone marrow edema (BME) pattern. The disease mainly affects the hip, the knee,...
Context in source publication
Context 1
... early stages of the disease when plain-film radiographs are reported as normal [15]. CT may be useful in patients with contra- indications to undergo MR imaging study. According to Horiuchi et al. [16], CT findings such as several spotty defects without any cortex participation may be useful for distinguishing BMES from other clinical entities (Fig. ...
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Citations
... Furthermore, the lack of robust comparative research data to date prevents drawing safe conclusions about the optimal therapeutic intervention for patients with transient pregnancy-and lactation-related osteoporosis [31]. Avoiding or discontinuing breastfeeding, avoiding weight lifting, moving with the use of a wheelchair or assistive devices, applying physiotherapy to prevent contractions of the involved hip muscles, and administering mild analgesic drugs such as paracetamol and mild non-steroidal anti-inflammatory drugs are conservative first-line treatment options aimed at relieving pain and preventing microfractures [32]. The subsequent administration of drugs, such as calcitonin, teriparatide, and denosumab, forms the basis of treatment for pregnant women with osteoporosis, as these are among the safest treatment options. ...
... Bone marrow edema syndrome (BMES) BMES is a transient condition with a bone marrow edema pattern, mainly characterized by its self-limited nature which generally affects middle-aged males [12]. It is defined by typical BME features at MRI along with clinical symptoms like pain, decreased joint motion, and increased interstitial fluid without a clear cause and no obvious signs of osteonecrosis, trauma, or infection [13]. ...
Bone marrow edema (BME) is a frequent MRI finding in patients with knee pain. According to the etiology, BME of the knee can be classified into three main categories: ischemic, mechanic, and reactive. The diagnosis may be difficult, because of the specificity of symptoms and the poor radiographic findings. MRI is the gold standard, showing an area of altered signal of the bone with an high signal intensity on fat-suppressed, T2 weighted images, usually in combination with an intermediate or low signal intensity on T1 weighted images. Bone marrow edema tends to be self-limiting and, in most cases, resolves without any consequences in a varying amount of time. However, since it may evolve to complete joint destruction, early diagnosis and correct treatment are crucial to prevent the articular degeneration. Conservative therapy is the first step, with no weight-bearing for 3 to 6 weeks on the affected side, in combination with the administration of anti-inflammatory drugs or painkillers to manage symptoms. In non-responding forms and more advanced stages, minimally invasive preservative surgery can provide significant results, with subchondroplasty and core decompression being the two main procedures available. Knee arthroplasty, both total (TKA) or unicompartmental (UKA), is the only effective option when the degradation of cartilage is diffuse and in patients with subchondral bone collapse.
Supplementary Information
The online version contains supplementary material available at 10.1007/s00402-024-05332-3.
... Similarly, the low bone mass in the region of the hip (the whole hip or neck hip) should be accompanied by imaging control of the hip to exclude a hypometric hip fracture MRI (47)(48), however, apart from being a diagnostic tool, is also suggested for monitoring the progression of the disease. (49) The bone biopsy is not necessary and will show a picture compatible with osteoblastic insufficiency, thus confirming the diagnosis of osteoporosis without an osteomalacia image session (50) (51) (52). ...
Gestational osteoporosis is an existent rare clinical disease presenting with vertebral fractures and is quite often underdiagnosed. Etiology is heterogeneous and risk factors include family history of osteoporosis, low body mass index individuals, women with low physical activity, smoking, failure to achieve maximum bone mass and low level calories nutrition. In our review, we recorded the main hormones and biological markers involved in bone metabolism during pregnancy and breastfeeding period. Regarding imaging methods, ultrasound and magnetic resonance are useful diagnostic tools and MRI can be used as a gold standard when examining hip pain in women who are in the third trimester of pregnancy. Available therapeutic approaches are recorded regarding conservative management and use of medication. The implication of our work is to emphasize the importance of early identification of gestational osteoporosis. Medical specialties dealing with women during pregnancy and postpartum (obstetricians, endocrinologists, orthopedists) should assess the risk factors and be able to make the right diagnosis as early as possible for prognosis optimization.
... [49] TOH blood flow and capillary permeability upsurge triggers a rise in radionuclide uptake, thus, a positive bone scan may be detected in all 3 phases and can carry on for weeks after clinical melioration. [43,50,51] Whilst regional migratory osteoporosis is contiguous with TOH in that it is also ordinarily transient; it is characterized by its asymmetric involvement and movement from proximal to distal, advancing unilaterally from the hip region to knee and ankle. [52] Taking into account that regional migratory osteoporosis is sporadically connected with BMD alterations, serial bone density calculations may denote the evolution of both bone loss and succeeding recovery of impacted regions. ...
... The objective of these treatments is preclusion of microfractures and pain alleviation, however, the natural course of the disease is not modified. [51] Oral and intravenous bisphosphonates along with other antiresorptive agents are not suggested in pregnant and lactating women. [54,55] Bisphosphonates exert influence on fetal skeletal development, causing preterm delivery, fetal growth restriction, neonate transient hypocalcemia and spontaneous abortion. ...
Transient osteoporosis of the hip is indubitably a comparatively infrequent entity affecting both men and women worldwide. Its occurrence in the course of pregnancy, specifically in the third trimester, and lactation are of paramount concernment. The exact association between transient hip osteoporosis and pregnancy is precarious. Etiology and potential pathophysiological mechanisms behind this correlation are still to be utterly defined. Magnetic resonance imaging is highly regarded as the gold standard imaging method for assiduous assessment of this disorder. Physicians of copious medical specialties should practice scrupulous techniques for early and pertinent diagnosis when pregnant women are presented with persistent hip pain, as differential diagnosis with femoral head avascular necrosis can be exceedingly arduous. Treatment is predominantly conservative with protected weight-bearing and analgesic medication in the first line of management. In terms of prognosis, the disease ordinarily resolves spontaneously after a few months. Further research is required in order to elucidate the ambiguity surrounding the establishment of globally approved diagnosis and treatment guidelines for pregnancy-associated transient hip osteoporosis. This paper aims to accentuate the significance of this particular disorder by providing a succinct review of the existing literature, augmenting clinicians’ knowledge about the features of pregnancy-related transient proximal femur osteoporosis.
... Early diagnosis usually requires the performance of an MRI, which may detect BME of the proximal femur already 48 h from the onset of symptoms [47]; it is extremely sensitive for localizing the increased extracellular water content of BME, and to perform the differential diagnosis of associate diseases [4]: BME possesses an intermediate signal on T1-weighted MRI scans and a high signal on T2-weighted scans [48] with increased intensity after the injection of paramagnetic contrast; in transient osteoporosis of the hip, MRI reveals homogenous edema that involves the entire femoral head and neck, often extending to the intertrochanteric region [44]; in AVNH, the edema is less intense, and it is limited to the femoral head or to the subchondral region, commonly not observed in the early stages of the disease. ...
... For individuals at risk for multifocal osteonecrosis, including those undergoing chronic systemic steroids administration or immunosuppressants, a wholebody bone scan may represent a viable option instead of MRI [53]. However, the low specificity of bone scan may require the performance of additional imaging examinations to confirm the diagnosis [48]. ...
Bone marrow edema (BME) of the hip is a radiological-clinical condition with symptoms ranging from asymptomatic to severe, and it is characterized by increased interstitial fluid within the bone marrow, usually at the femur. Depending on the etiology it can be classified as primary or secondary. The primary cause of BME is unknown, while the secondary forms include traumatic, degenerative, inflammatory, vascular, infectious, metabolic, iatrogenic, and neoplastic etiologies. BME could be classified as reversible or progressive. Reversible forms include transient BME syndrome and regional migratory BME syndrome. Progressive forms include avascular necrosis of the femoral head (AVNH), subchondral insufficiency fracture, and hip degenerative arthritis. The diagnosis can be difficult, because at the beginning, the outbreak of hip pain, typically acute and disabling without any prior trauma or exceptional physical activity, is poorly supported by radiographic findings. MRI is the gold standard, and it shows an area of intermediate signal on T1-weighted MRI scans and a high signal on T2-weighted scans, usually lacking sharps margins. In the reversible form, BME is typically self-limiting, and it can be managed conservatively by means of pharmacological and physical therapy. Surgery is generally required for progressive forms in patients who failed non-operative treatment, and it ranges from femoral head and neck core decompression to total hip arthroplasty.
... In most cases, conservative management allows the resolution of symptoms within 6-12 months. 17 The main conservative approaches include restricted weightbearing, anti-resorptive medications and analgesics. 6 This systematic review investigates current management of TBO. ...
Introduction:
Transient bone osteoporosis (TBO) is characterized by persistent pain, loss of function, no history of trauma and magnetic resonance image (MRI) findings of bone marrow edema.
Source of data:
PubMed, Google scholar, EMABSE and Web of Science were accessed in February 2023. No time constrains were used for the search.
Areas of agreement:
TBO is rare and misunderstood, typically affecting women during the third trimester of pregnancy or middle-aged men, leading to functional disability for 4-8 weeks followed by self-resolution of the symptoms.
Areas of controversy:
Given the limited evidence in the current literature, consensus on optimal management is lacking.
Growing points:
This systematic review investigates current management of TBO.
Areas timely for developing research:
A conservative approach leads to the resolution of symptoms and MRI findings at midterm follow-up. Administration of bisphosphonates might alleviate pain and accelerate both clinical and imaging recovery.
... Clinical presentation of TBMES includes a sudden-onset hip pain, effecting mostly males between the 4 th and 6 th decade of life and rarely females in the 3 rd trimester of pregnancy [18]. The treatment approach mostly includes partial weight-bearing and administration of analgesics and anti-inflammatory agents [18,19]. In line with this information, we thought that all the reversible BMLs in our study were TBMES. ...
ABSTRACT
Purpose
Contrary to self-limiting nature of reversible bone marrow lesions, irreversible bone marrow lesions require early surgical intervention in order to prevent further morbidity. Thus, early discrimination of irreversible pathology is necessitated. Purpose of this study is to evaluate efficacy of radiomics and machine learning regarding this topic.
Material and methods
Database was scanned for patients who had undergone MRI of hip for differential diagnosis of bone marrow lesions and had follow up images acquired within 8 weeks after first imaging. Images that showed resolution of edema were included in the reversible group. Remainders that showed progression into characteristic signs of osteonecrosis were included in irreversible group. Radiomics was performed on first MR images, calculating first and second order parameters. Support Vector Machine and Random Forest Classifiers were performed using these parameters.
Results
Thirty-seven patients (seventeen osteonecrosis) were included. A total number of 185 ROIs were segmented. Forty-seven parameters were accepted as classifiers with an Area Under the Curve value ranging from 0,586 to 0,718. Support Vector Machine yielded a sensitivity of 91.3%, a specificity of 85.1%. Random Forest Classifier yielded a sensitivity of 84.8% and a specificity of 76.7%. Area Under the Curves were 0.921 for Support Vector Machine and 0.892 for Random Forest Classifier.
Conclusions
Radiomics analysis could prove useful for discrimination of reversible and irreversible bone marrow lesions before the irreversible changes occurred, which could prevent morbidities of osteonecrosis by guiding decision-making process for management.
... El edema óseo per se no presenta hallazgos característicos en las pruebas de imagen de radiología simple, ni en tomografía axial computarizada, pero pueden ser útiles en el diagnóstico de la causa etiológica. La RM es la prueba de imagen de elección para su diagnóstico, en la cual se muestra como una lesión de bordes mal definidos, que sobrepasa las cicatrices fisarias y que puede extenderse a las partes blandas adyacentes, con se-ñal hipointensa en las secuencias potenciadas en T1 e hiperintensa en las secuencias T2, con supresión grasa y STIR (short tau inversion recovery) (6) . Además, la imagen de RM puede revelar la presencia de fracturas trabeculares por impactación del hueso subcondral y hundimiento del cartílago suprayacente, que se presentan como líneas hipointensas en T2, paralelas a la superficie articular. ...
... Infection, avascular necrosis, malignancies, and degenerative and inflammatory arthropathies can cause irreversible edema. The self-limiting feature of transitory osteoporosis distinguishes it from other reversible causes of bone marrow edema [8]. For better patient care, it is critical to distinguish TOOH from other illnesses that have long-term consequences, such as AVN of the femoral head and destructive diseases of joints caused by inflammation and malignancy. ...
Transient osteoporosis of the hip (TOOH) is a rare disorder of unknown etiology without any antecedent history of trauma. There is a sudden onset of acute severe pain and temporary osteopenia in the joint involved with associated radiological findings of bone loss and marrow edema. Magnetic Resonance Imaging (MRI) is the gold standard imaging modality for diagnosis and disease monitoring. The major goal of this case presentation is to emphasize the necessity to add TOOH as an important differential of sudden hip pain and to review the literature on this entity.
... BMES primarily may affect the hip, knee, and ankle joints. Many hypotheses have been proposed to explain the disorder's pathogenesis, but the etiology of BMES remains unknown [10] . ...
We describe a case of bone marrow edema (BME) shifting within one ankle joint in a 35-year-old - male patient. He presented with increasing pain and no history of trauma. Clinically no local swelling was found and laboratory findings and plain x-ray studies were normal. He did not improve on non-steroidal anti-inflammatory drugs for 2 weeks. A Gadolinium enhanced magnetic resonance imaging showed no evidence of synovitis, but BME was observed in the talus and transient regional osteoporosis was diagnosed. The patient was treated conservatively by protective partial weight bearing of the affected joint and he showed partial improvement after 6 months of daily treatment with Calcitonin Salmon nasal spray. A magnetic resonance imaging after 6 months showed that the BME had shifted anteriorly with complete resolution at the initial site. Transient regional osteoporosis is a rare self-limiting syndrome characterized by sudden onset of joint pain, functional limitations and spontaneous recovery, without preceding trauma. The condition may present as one episode affecting only one joint or recurrent episode that may affect multiple joints. BME between different compartments of the same joint can occur and has been reported only in a few case reports in the knee joint. The case is discussed and the literature is reviewed.
