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Transient Osteoporosis of Hip MRI Findings
1. Transient Osteoporosis of Hip
Vinod Naneria
Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research Centre,
Indore
2. 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.
4. 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
5. 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.
6. 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”.
7. 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.
8. 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.
9. Radiology
Typically - Focal osteopenia on plain radiographs.
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
Reproduce with permission from Dr. A. V. Korompilias
10. 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.
11. Radiology
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.
Reproduce with permission from Dr. A. V. Korompilias
12. Scintigraphy – Tc 99
Transient osteoporosis:- Avascular necrosis of the left hip:-
The bone scan (anterior view) is showing intense The bone scan (posterior view) shows
uptake in the femoral head and neck, early in increased uptake only in the femoral head
the course of the disease (arrow). area with a “cold in hot” appearance
(arrow).
Reproduce with permission from Dr. A. V. Korompilias
13. 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
14. 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%.
15. (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
16. 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.
17. 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.
18. 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.
19. 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.
21. 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.
22. 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.
23. 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.
24. 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.
25. 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
26. 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.
27. 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.
28. 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.
31. MRI – Findings 18/07/2011
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.
33. MRI findings on 28/10/2011
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.
39. 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.
40. MRI findings on march 2008
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?
43. 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.
46. 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.
47. MRI findings on June 2009
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.
51. MRI findings on Sept 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.
56. 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.
57. MRI – reported on 14 / 5 / 2008
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.
61. MRI findings on 18/8/2008
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.
65. DISCLAIMER
• 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