Transient Bone Marrow Edema Syndrome Research Articles

Transient Primary Bone Marrow Edema Syndrome - A Synthesis

A complex and often confusing nomenclature is currently used for relatively rare syndromes characterized by sudden onset of joint pain in the lower limbs, absence of trauma, bone marrow edema and its resolution, both confirmed by the MRI, as well as a self-limiting course. These include transient osteoporosis of the hip (TOH), of the knee (TOK), of the foot and ankle and transient bone marrow edema syndrome. Our purpose was to review the literature in order to substantiate the hypothesis that these apparently different conditions may be synthesized into a single disease entity, termed transient primary bone marrow edema syndrome (TPBMES). Of a total of 546 patients scrutinized, 342 had TOH, 105 had TOH of pregnancy, and 49, mainly females, showed transient foot-and-ankle osteoporosis. TPBMES occurred also with systemic osteoporosis or in a migratory pattern. The six proposed subsets of TPBMES have in common a MRI-based diagnosis and remission, as well as a self-limiting course. Thus, the hypothesis of a single disease entity is sustainable. We conclude that the education of the medical profession regarding this rare disease should expand. The causes of the prolonged symptoms seen in the systemic osteoporosis and migratory subsets warrant further studies. The efficiency of our suggested modality of management should be validated in a large cohort.

Letter to Editor A Clinical 'PIC- Perspectives, issues & Concerns" on Idiopathic Transient Osteoporosis during Pregnancy with alarm bells on its Idiopathic nature - Response.

Dear Editor, At the outset, I would like to congratulate the authors of the article published in your journal in the current issue entitled- Idiopathic Transient Osteoporosis during Pregnancy – Report of a Clinical Case JOCR November – December 2019 Volume 9 Issue 6 Page 54-57. However, I regret to mention that the workup mentioned in this article needs to be improved, before one can come to definitive diagnosis of Idiopathic Transient Osteoporosis during Pregnancy. I would like to highlight various perspectives, issues & concerns, the knowledge of which are must for the readers of this journal pertaining to this disorder. It is pertinent to mention no doubt the increasing utilization of magnetic resonance imaging (MRI) has allowed physicians to investigate edematous changes in bone marrow, a clinically important entity which was previously undetected on conventional radiographs. The first use of the term “bone marrow edema” was by Wilson et al in 1988, and the term “bone marrow edema syndrome” was described in 1993 after the investigation of histological specimens [1]. Later on, importantly Hayes et al. advocated that the term “transient bone marrow edema syndrome” should be used for patients in whom the bone marrow edema pattern was not accompanied by radiographic evidence of osteopenia [2]. And thus separating the two entities i.e. “the transient bone marrow edema syndrome” and “Transient Osteoporosis” Occurrence of hip pain during pregnancy is quite common, although transient osteoporosis as a condition causing this symptom is uncommonly seen. Clinicians should also be aware of intra-articular disorders such as loose bodies, and labral tears; peri-articular pathology such as tendinitis and bursitis; or extra-articular conditions such as referred pain from the lumbar spine, the sacroiliac joint, and or from nerve entrapment syndromes. So, a detailed history and physical examination is helpful to narrow the differential diagnoses, which, in turn, dictate the modal

Transient Primary Bone Marrow Edema Syndrome - A Synthesis

A complex and often confusing nomenclature is currently used for relatively rare syndromes characterized by sudden onset of joint pain in the lower limbs, absence of trauma, bone marrow edema and its resolution, both confirmed by the MRI, as well as a self-limiting course. These include transient osteoporosis of the hip (TOH), of the knee (TOK), of the foot and ankle and transient bone marrow edema syndrome. Our purpose was to review the literature in order to substantiate the hypothesis that these apparently different conditions may be synthesized into a single disease entity, termed transient primary bone marrow edema syndrome (TPBMES). Of a total of 546 patients scrutinized, 342 had TOH, 105 had TOH of pregnancy, and 49, mainly females, showed transient foot-and-ankle osteoporosis. TPBMES occurred also with systemic osteoporosis or in a migratory pattern. The six proposed subsets of TPBMES have in common a MRI-based diagnosis and remission, as well as a self-limiting course. Thus, the hypothesis of a single disease entity is sustainable. We conclude that the education of the medical profession regarding this rare disease should expand. The causes of the prolonged symptoms seen in the systemic osteoporosis and migratory subsets warrant further studies. The efficiency of our suggested modality of management should be validated in a large cohort.

Transient Bone Marrow Edema Syndrome versus Osteonecrosis: Perfusion Patterns at Dynamic Contrast-enhanced MR Imaging with High Temporal Resolution Can Allow Differentiation.

Purpose To prospectively evaluate the perfusion patterns at quantitative dynamic contrast material-enhanced (DCE) magnetic resonance (MR) imaging of transient bone marrow edema syndrome (TBMES) and avascular osteonecrosis. Materials and Methods Institutional review board approval and written informed consent were obtained. Thirty-two patients (21 men, 11 women; mean age, 48 years; 26 hips, 10 knees) underwent conventional MR imaging and a dynamic contrast-enhanced three-dimensional spoiled gradient-echo sequence at 3 T. Parameter maps for mean transit time (MTT) and plasma flow (PF) were evaluated qualitatively and quantitatively. Differences in perfusion patterns were analyzed by using the Fisher exact test. Regions of interest were drawn in areas of high PF and long MTT on each parametric map. Mean, median, standard deviation, minimum, and maximum values were determined. TBMES and osteonecrosis were compared statistically by using the Mann-Whitney U and Wilcoxon signed-rank tests, with a P value of less than .05 considered indicative of a significant difference. Results Nineteen joints with TBMES and 17 joints with osteonecrosis were evaluated. TBMES joints showed a subchondral elongated area of high PF and low MTT that was surrounded by an area of long MTT and low PF. Osteonecrosis joints showed a subchondral area with low or no detectable PF and MTT adjacent to the joint surface, which was surrounded by a rim of high PF and intermediate MTT. Patterns for TBMES and osteonecrosis did not overlap. A significant difference (P < .001) in PF in the immediate subchondral area was found between TBMES and osteonecrosis; in joints with osteonecrosis, this was comparable to background noise, and therefore, could not be quantified. In the circumscribed rim of high PF and intermediate MTT, which was only found in joints with osteonecrosis, mean ± standard deviation PF was 18.9 mL/100 mL per minute ± 11.0 and mean MTT was 213.3 seconds ± 56.8. No significant difference between TBMES and osteonecrosis was found for MTT (P = .09) and PF (P = .75) in the surrounding area. Conclusion Parameter maps derived at dynamic contrast-enhanced MR imaging with high temporal resolution can allow differentiation of osteonecrosis from TBMES in hip and knee joints. © RSNA, 2016 Online supplemental material is available for this article.

Bone marrow lesions and subchondral bone pathology of the knee.

Bone marrow lesions (BMLs) around the knee are a common magnetic resonance imaging (MRI) finding. However, despite the growing interest on BMLs in multiple pathological conditions, they remain controversial not only for the still unknown role in the etiopathological processes, but also in terms of clinical impact and treatment. The differential diagnosis includes a wide range of conditions: traumatic contusion and fractures, cyst formation and erosions, hematopoietic and infiltrated marrow, developmental chondroses, disuse and overuse, transient bone marrow oedema syndrome and, lastly, subchondral insufficiency fractures and true osteonecrosis. Regardless the heterogeneous spectrum of these pathologies, a key factor for patient management is the distinction between reversible and irreversible conditions. To this regard, MRI plays a major role, leading to the correct diagnosis based on recognizable typical patterns that have to be considered together with coexistent abnormalities, age, and clinical history. Several treatment options have been proposed, from conservative to surgical approaches. In this manuscript the main lesion patterns and their management have been analysed to provide the most updated evidence for the differential diagnosis and the most effective treatment.

Bilateral Transient Osteoporosis of the Hip: A Case Report.

Transient osteoporosis of the hip (TOH) is a rare disorder of unknown etiology that is characterized by pain and limited mobility of the hip. The entity was first reported by Curtiss and Kincaid in 19591. Their original report described unilateral regional osteoporosis of the hip occurring in women during the third trimester of pregnancy. The nomenclature of this disorder is complicated, and some physicians prefer the term “transient bone marrow edema syndrome” to describe the imaging findings characteristic of TOH. Wilson et al. introduced the term transient bone marrow edema syndrome in 19882. They used it to describe ten patients with clinical presentations and magnetic resonance imaging (MRI) findings that were identical to transient osteoporosis or regional migratory osteoporosis when radiographic evidence of osteoporosis was lacking 2-4. We prefer the term TOH and believe that it more accurately describes the features described in our case report. TOH is now known to affect both men and women; the typical patient is a man between the age of forty and sixty years5. The prevalence of this disorder has not been established since only approximately 200 cases have been reported in the literature6. While the etiology of TOH is not known, the pathophysiology of the condition is thought to involve cellular death of fatty and hematopoietic bone marrow elements7-9. In clinical correlation, patients present with acute hip pain that has not been precipitated by an infection, trauma, or an underlying bone disorder10. The pain worsens over the ensuing weeks. Patients often develop an antalgic gait and restricted joint motion. Radiographic findings lag behind the clinical presentation and may not appear for up to two months after the initial presentation11. The majority of the previously …

Transient osteoporosis of the hip, complete resolution after treatment with alendronate as observed by MRI description of eight cases and review of the literature

Transient osteoporosis of the hip (TOH), also referred to as transient bone marrow edema syndrome, is most common in middle-aged men and often after trivial trauma or sport-related injuries. Diagnosis is usually made by eliminating other possible causes of hip pain. Magnetic resonance imaging (MRI) plays an important role in diagnosis and demonstrates a typical pattern of bone marrow edema (BME) in the form of diffuse low signal on T1-weighted images and high signal on T2 fat-suppressed or short T1 inversion recovery images. No consensus exists about the management of TOH, as it may progress to avascular necrosis. We describe eight cases of TOH treated with alendronate resulting in improvement of pain and function and complete resolution of BME on MRI. The literature is reviewed regarding TOH and the relationship with bone marrow edema syndrome, avascular necrosis of the hip, and regional migratory osteoporosis. To our knowledge, this is the first report describing the improvement of this condition after of alendronate with documented radiological improvement on follow-up MRI.

Transient bone marrow oedema syndrome in an HIV-infected patient on highly active antiretroviral therapy

Bone marrow oedema syndrome (BMES, also known as transient osteoporosis) is an uncommon, self-limiting condition characterized by disabling pain, reversible osteopaenia on X-rays and by bone marrow oedema pattern on magnetic resonance imaging (MRI). Here we describe the first reported case of BMES in an HIV-positive patient on highly active antiretroviral therapy.

Hyperbaric Oxygen Therapy for Transient Bone Marrow Oedema Syndrome of the Hip

Transient bone marrow oedema syndrome of the proximal femur is characterized by acute, progressive pain in the hip that is increased by weight-bearing. Treatment includes restricted weight-bearing and analgesic medication. A prospective, randomized study was performed to compare two groups of patients affected by bone marrow oedema syndrome of the femoral head. 20 patients received pharmacological and hyperbaric oxygen therapy, and a control group of 21 patients received pharmacological therapy alone. The overall average WOMAC score at 3 months was significantly higher (p<0.001) for the hyperbaric oxygen group (70.8 points) compared with the control group (56.4 points). Magnetic Resonance Imaging at 3 months showed resolution of bone marrow oedema in 55.0% of the patients treated with hyperbaric oxygen compared with 28% in the control group. Hyperbaric oxygen therapy appears to be effective in treating transient bone marrow oedema syndrome, resulting in an accelerated recovery of hip function compared to pharmacological therapy alone.

Transient Bone Marrow Oedema Syndrome: A Report of Two Cases

Transient bone marrow edema syndrome (TBMES) is a disorder with unknown etiology and must be included in the differential diagnosis of hip pain. TBMES generally has a good prognosis but, it can be result in avascular necrosis (AVN). We present two cases diagnosed with TBMES, one of whom experienced full remission and the other who developed AVN.

Dolore acuto non traumatico del ginocchio nell’adulto: ruolo della risonanza magnetica

Acute nontraumatic pain in the adult knee can be seen in many settings, such as transient bone marrow oedema syndrome (TBMOS), regional migratory osteoporosis (RMO), spontaneous osteonecrosis (SONK) and insufficiency fractures. Early differentiation among them is crucial to avoid unnecessary treatment. TBMOS and RMO are considered to be self-limiting conditions without longterm sequelae. On the other hand, the clinical course of SONK is thought to be dependent on the size of osteonecrosis. Recent data suggest the term SONK is misleading one and should be replaced. Insufficiency fractures may demonstrate a similar clinical syndrome without a history of a single traumatic injury. The imaging pathway for knee pain has evolved considerably with the advent of magnetic resonance (MR) imaging, which is very sensitive in the early depiction of bone marrow oedema. Therefore, in patients with acute nontraumatic knee pain whose radiographs are negative or inconclusive, MR imaging is the method of choice for further evaluation. This article discusses the potential aetiologies and reviews MR imaging findings of the most common disorders afflicting the subchondral knee-joint area.

Distinguishing Transient Bone Marrow Edema Syndrome of the Hip from Femoral Head Osteonecrosis

In this review, femoral head osteonecrosis and transient bone marrow edema syndrome are discriminated. In order to reach a proper differential diagnosis, clinical findings, corresponding or divergent imaging patterns and possible pathophysiologies of the two diseases are described.

MRI Findings in the Subchondral Bone Marrow: A Discussion of Conditions Including Transient Osteoporosis, Transient Bone Marrow Edema Syndrome, SONK, and Shifting Bone Marrow Edema of the Knee

Bone marrow edema signal can be seen in many settings ranging from trauma and arthritis to less common conditions including transient osteoporosis, transient bone marrow edema syndrome, true osteonecrosis, spontaneous osteonecrosis, and shifting bone marrow edema. Terms such as spontaneous osteonecrosis of the knee (SONK) appear frequently in the radiology and orthopedics literature but are rarely described on true, histologic basis. This article reviews the less frequently encountered and less well understood entities and explores their potential pathophysiologies and significance.

Transient Bone Marrow Edema Syndrome of the Knee: Clinical and Magnetic Resonance Imaging Results at 5 Years After Core Decompression

We report on 24 cases of transient bone marrow edema syndrome in 18 patients who underwent core decompression of the knee. Diagnosis was made with the use of radiographs, magnetic resonance imaging (MRI), and core biopsy testing. Arthroscopic surgery and core decompression were carried out in all patients, and MRI was performed again, 5 years after surgery was performed. Medial and lateral femoral condyles were affected in 15 and 7 knees, respectively. In all, 6 patients presented with bilateral involvement of the knees (migrating transient bone marrow edema syndrome). Two of these patients had affections of the medial and lateral compartments within the same knee at different times, consistent with intra-articular regional bone marrow edema syndrome. Core biopsy specimens showed areas of bone marrow edema and vital trabeculae covered by osteoblasts and osteoid seams. Resolution of symptoms and normalization of MRI findings occurred in all patients within 12 weeks after surgery. Migrating bone marrow edema was found in a high percentage (33%) of patients at 5-year follow-up; however, all patients were clinically asymptomatic, and signal alterations on MRI had resolved completely. The high incidence of migrating bone marrow edema, the lack of osteonecrotic regions in our specimens, and the fact that none of these cases progressed to spontaneous osteonecrosis seem to further support the contention that bone marrow edema syndrome of the knee is a distinct entity. Level II, diagnostic study; development of diagnostic criteria on the basis of consecutive patients and with universally applied reference gold standard.

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

54-Year-Old Man With Hip Pain

Fatty marrow conversion of the proximal femoral metaphysis in transient bone marrow edema syndrome

In the proximal femoral metaphysis, hematopoietic marrow is predominant during the adult stage of life. The conversion of hematopoietic marrow to fatty marrow in the proximal femoral metaphysis has been suggested as an etiologic factor of ischemia in the pathogenesis of femoral head osteonecrosis. To determine whether the chronology of fatty marrow conversion of the proximal femoral metaphysis is related to transient bone marrow edema syndrome of the hip, a case control study was conducted on 10 patients with the disease. There were 8 men and 2 women with a mean age of 33 years (range 19-45 years). The 10 patients were matched with 20 controls for gender and age (5-year range). T1-weighted MRI scans of their hips were reviewed. Marrow of the greater trochanter becomes fatty before puberty, and thus, the greater trochanter can be used as a built-in control. The signal intensity of the proximal femoral metaphysis was compared to that of the greater trochanter. In all patients, the signal intensity of the proximal femoral metaphysis was isointense (fatty marrow) relative to that of the greater trochanter. In control subjects, the signal intensity was isointense in 8 (40%) and hypointense (hematopoietic marrow) in 12 (60%) (p < 0.05). The current study shows that the proximal femoral metaphysis is predominantly fatty in transient bone marrow edema syndrome. The conversion of hematopoietic to fatty marrow is known to correlate with decreases in intramedullary blood flow. Thus, the current study suggests that an ischemia of the proximal femur secondary to fatty marrow conversion of the proximal femoral metaphysis might be a cause of transient bone marrow edema syndrome of the hip.

Biochemical markers of bone metabolism in bone marrow edema syndrome of the hip

The aim of this study was to evaluate bone metabolism in patients with bone marrow edema syndrome of the hip. In 37 consecutive patients undergoing core decompression of the femoral head, biochemical markers of bone metabolism were measured in aspirates from cancellous bone and in samples obtained simultaneously from peripheral blood. The diagnosis was made by means of radiographs, magnetic resonance imaging (MRI), and core biopsy specimens. Undecalcified microtome section were available for histopathological evaluation. Bone specific alkaline phosphatase (bone ALP), osteocalcin (OC), procollagen Type I N-terminal propeptide (PINP), and C-terminal cross-linking telopeptide (ICTP) were studied. Mean serum levels of analytes were 13.1 ng/mL (OC), 11.2 ng/mL (bone ALP), 4.7 ng/mL (ICTP), and 38.8 ng/mL (PINP). In samples obtained from cancellous bone, mean concentrations of all markers were elevated significantly. The mean bone to serum ratios for bone ALP and OC were 14.1 ( P = 0.005) and 4.1 ( P = 0.002), respectively. For collagen Type I metabolites, bone to serum ratios averaged 16.3 ( P = 0.001) for ICTP and 9.6 ( P = 0.001) for PINP. Markers of bone formation correlated with each other in serum as well as in aspirates from cancellous bone. Elevation of all markers in aspirates from cancellous bone pointed at increased bone turnover, which correlated with histopathological findings of irregularly woven bone, osteoid seams, and lining cells. Mean serum concentrations of all markers, however, were not different from healthy individuals and thus did not provide any useful clue in the diagnosis of this disease. The lack of osteonecrotic regions in our specimens, the marked increase of bone turnover in samples obtained from edematous lesions, and the fact that none of the patients developed osteonecrosis of the femoral head so far seem to further support the contention that transient bone marrow edema syndrome of the hip is a distinct clinical entity.

Elevated Levels of Lipoprotein(a) in Familial Bone Marrow Edema Syndrome of the Hip

There is controversy whether bone marrow edema syndrome represents a distinct transient disease or reflects an early reversible phase of spontaneous osteonecrosis of the hip. Hypofibrinolysis on the basis of elevated plasma levels of plasminogen activator inhibitor or lipoprotein(a) or both has been reported to favor the development of bone marrow edema syndrome and nontraumatic avascular necrosis. The current authors report on the familial occurrence of transient bone marrow edema syndrome of the hip in three female family members. Plasma concentrations of lipoprotein(a) were elevated in all three patients, whereas serum levels of plasminogen activator inhibitor were within normal ranges. This first familial description of transient bone marrow edema syndrome of the hip strongly suggests that a genetically determined elevation of lipoprotein(a) may be an important predisposing factor in these patients.

MR imaging of bone marrow edema pattern: transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis.

The bone marrow edema (BME) pattern of signal intensity changes on magnetic resonance (MR) images (decreased on T1-weighted and increased on T2-weighted) is a nonspecific finding encountered with several entities, including transient osteoporosis of the hip, transient BME syndrome, osteonecrosis, trauma, infection, and infiltrative neoplasm. Transient osteoporosis, an unusual but distinct syndrome characterized by self-limited pain and radiographically evident osteopenia, can be distinguished from other causes of the BME pattern, particularly osteonecrosis, on the basis of clinical findings and the development of radiographically evident focal osteopenia within 8 weeks after the onset of pain. This is an important distinction, since all patients with transient osteoporosis recover completely, without intervention. The term transient BME syndrome can be used to describe any patient in whom a reversible BME pattern is seen on MR images. Although the transient BME syndrome is also self-limited and quite likely related to transient osteoporosis, the authors believe that to avoid confusion, this nonspecific term should be reserved only for patients who do not develop radiographically evident osteopenia.