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Transient Osteoporosis of the Hip
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Contents
Other Names
- Transient osteoporosis of the hip (TOH)
- Primary bone marrow edema syndrome (BMES)
- Primary TOH
- Secondary TOH
- Transitory Demineralization of the Hip
- Transient Marrow Edema Syndrome
- Bone Marrow Edema (BME)
- Transient Regional Osteoporosis
- Regional Osteoporosis
- Algodystrophy
- Regional migratory osteoporosis
Background
- This page describes Transient osteoporosis of the hip (TOH), an idiopathic and temporary clinical condition that affects the femoral head
- Overall this phenomenon is poorly described in the literature and there is a paucity of data surrounding it
History
- First described by Curtiss in 1958[1]
- Termed transient osteoporosis of the hip by Hunder and Kelly in 1967[2]
Epidemiology
- More common in men than women (need citation)
- Mean age is 40 years of age (range 20 to 80)[3]
Pathophysiology
- General
- Typically considered to be benign and self limiting
- In women, typically seen in the last trimester of pregnancy
- Some type of insult initiates the process, typically idiopathic
- Leads to leading to an increase in bone turnover, venous hypertension, and/or microfracture causing edema[4]
- 3 stage hypothesis[5]
- Stage 1: acute onset hip pain is due to edema (insult often unknown)
- Stage 2: involves increased resorption and demineralization of the bone
- Stage 3: resolution of the process clinically and by radiograph
- The cause of hip pain is not always clear, proposed etiologies include[4]
- Increased intraosseous pressure
- Venous hypertension
- Increased focal bone turnover
- Microfracture
- Periosteal irritation
- Uncommon, can progress to ischemic injury to the femoral head and Avascular Necrosis
- Distinguishing between TOH and early AVN is challenging clinically and radiographically
- Also unclear if TOH represents early AVN or is a separate clinical entity
- Some authors suggest TOH represents an abortive syndrome of the AVN pathway[6]
Etiology
- Most commonly idiopathic
- May be primary vs secondary, challenging to distinguish
- Proposed insults leading to TOH include trauma, infection, inflammation, degenerative process, ischemic injury, neoplasia, surgery, drugs, metabolic, and neurologic disorders
- Compression of the Obturator Nerve
Associated Conditions
Risk Factors
- Pregnancy, particularly 3rd trimester
- Note that estrogen is elevated in pregnancy
- Alcohol use
- Tobacco Use Disorder
- History of corticosteroid use
- Abnormal vascularity
- Drug use
- Inflammation
- Metabolic derangement
- Mechanical injury
- Neurologic deficit
- Osteogenesis Imperfecta[7]
- Osteoporosis
- Not entirely clear if this is truely a risk factor
- Hypothyroidism[8]
- Hypophosphotemia[9]
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Pain of TOH usually starts spontaneously
- Pain presentation may vary from insidious vague pain with antalgic gait
- Less commonly, may result in more severe progressive pain leading to immobility and hospitalization
- Physical Exam: Physical Exam Hip
- Special Tests
Evaluation
Radiographs
- Standard Radiographs Hip
- Screening tool
- Early Findings (first 3-6 weeks from symptom onset)
- Typically normal
- Later findings (after the first 3-6 weeks)
- Eventually will see diffuse osteopenia of the femoral head, sometimes bilateral
- Periarticular demineralization
- Absence of subchondral changes
MRI
- Preferred imaging modality for suspected TOH
- Sensitive enough to detect TOH up to 48 hours after onset[10]
- Findings
- Intermediate signal sequences on T1-weighted image
- High signal intensity on T2-weighted images
- Hyper intensity on contrast enhanced images
- Delayed peak enhancement of edematous marrow is particularly characteristic of TOH
- Characteristic of TOH[11]
- Homogenous pattern of enhancement with no clear border
- Diffuse pattern of edema with no focal defect, typically located at femoral head, sometimes neck
- The presence of an irregular band of low signal intensity due to stress fracture
- Absence of subchondral changes
- Findings are often accompanied by joint effusion
Bone Scintography
- Radionucleotide uptake occurs in all 3 phases of TOH
- Lasts for up to 4 weeks after resolution of symptoms[12]
Classification
- N/A
Management
Prognosis
- Typically resolves in 6 months (range 2-12 months) with conservative therapy[13]
- Core decompression therapy vs conservative therapy
- Does not appear to improve outcomes compared to medical therapy[3]
- Note that data is limited to case reports
- Progression to Avascular Necrosis of the Hip
- Limited data does makes prognostication challenging
Nonoperative
- First line treatment
- Goal: Prevent microfractures, relieve pain
- Minimizing weight-bearing activities and relative rest
- Using Crutches or Wheelchair if needed
- Hot packs
- Ultrasound therapy
- Bisphosphonates
- IV pamidronate showed an average clinical recovery of 2 months, compared to a historical control recovery of 6 months[14]
- However, alendronate oral therapy in 8 cases shows an average clinical recovery of 6 months
- Calcitonin
- In 6 cases shows a shortened mean clinical recovery of 4.7 months
- Teriparatide
- Case reports of benefit[15]
- Combination therapy
- Corticosteroids including Prednisolone, Deflazacort have been used
- Special Population: Pregnant women
Operative
- Indications
- Progression to AVN
- Technique
- Core Decompression +/- bone grafting
- Total Hip Arthroplasty
- Rotational Osteotomy
- Curettage and Bone Grafting
- Vascularized Free-fibula Transfer
- Total Hip Resurfacing
- Hip Arthrodesis
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- Hip Fracture
- In particular, Subchondral, femoral neck, and subcapital fractures
- Progression to Avascular Necrosis of the Hip
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Curtiss PH Jr, Kincaid WE (1959) Transitory demineralization of the hip in pregnancy. A report of three cases. Am J Orthop 41-A: 1327–1333
- ↑ Hunder GG, Kelly PJ. Transient osteoporosis of the hip: a clinical syndrome? Arthritis Rheum 1967; 10: 285.
- ↑ 3.0 3.1 Asadipooya, K., L. Graves, and L. W. Greene. "Transient osteoporosis of the hip: review of the literature." Osteoporosis International 28.6 (2017): 1805-1816.
- ↑ 4.0 4.1 Patel S (2014) Primary bone marrow oedema syndromes. Rheumatology (Oxford) 53(5):785–792
- ↑ Cano-Marquina A, Tarín JJ, García-Pérez MÁ, Cano A (2014) Transient regional osteoporosis. Maturitas 77(4):324–329
- ↑ Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Bone marrow edema syndrome. Skeletal Radiol 2009; 38: 425-36.
- ↑ Young SD 3rd, Nelson CL, Steinberg ME (2008) Transient osteoporosis of the hip in association with osteogenesis imperfecta: two cases, one complicated by a femoral neck fracture. Am J Orthop (Belle Mead NJ) 37(2):88–91
- ↑ Mepani JB, Findling JW (2009) Reversible bone marrow edema of the hip due to severe hypothyroidism. J Clin EndocrinolMetab 94(4):1068
- ↑ Whyte MP, Wenkert D, McAlister WH, Mughal MZ, Freemont AJ, Whitehouse R, Baildam EM, Coburn SP, Ryan LM,Mumm S (2009) Chronic recurrent multifocal osteomyelitis mimicked in childhood hypophosphatasia. J Bone Miner Res 24(8):1493–1505
- ↑ Szwedowski D, Nitek Z,Walecki J (2014) Evaluation of transient osteoporosis of the hip in magnetic resonance imaging. Pol J Radiol 79:36–38
- ↑ Malizos KN, Zibis AH, Dailiana Z, Hantes M, Karachalios T, Karantanas AH (2004) MR imaging findings in transient osteoporosis of the hip. Eur J Radiol 50(3):238–244
- ↑ Korompilias AV, Karantanas AH, Lykissas MG, Beris AE (2009) Bone marrow edema syndrome. Skelet Radiol 38(5):425–436
- ↑ Bijl M, van Leeuwen MA, van Rijswijk MH. Transient osteoporosis of the hip: presentation of (a)typical cases and a review of the literature. Clin Exp Rheumatol 1999; 17: 601-4.
- ↑ Varenna M, Zucchi F, Binelli L, Failoni S, Gallazzi M, Sinigaglia L (2002) Intravenous pamidronate in the treatment of transient osteoporosis of the hip. Bone 31(1):96–101
- ↑ Fabbriciani, Gianluigi, et al. "Transient osteoporosis of the hip: successful treatment with teriparatide." Rheumatology international 32.5 (2012): 1367-1370.
- ↑ Fabbriciani G, Pirro M, Manfredelli MR, Bianchi M, Sivolella S, Scarponi AM, Mannarino E (2012) Transient osteoporosis of the hip: successful treatment with teriparatide. Rheumatol Int 32(5): 1367–1370
- ↑ Seok H, Kim YT, Kim SH, Cha JG (2011) Treatment of transient osteoporosis of the hip with intravenous zoledronate—a case report. Ann Rehabil Med 35(3):432–435
Created by:
John Kiel on 21 September 2020 11:25:27
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Last edited:
5 October 2022 13:06:20
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