Original articleIntravenous pamidronate in the treatment of transient osteoporosis of the hip
Introduction
Transient osteoporosis of the hip (TOH), also referred as bone marrow edema syndrome (BMES), describes a clinical entity of unknown etiology characterized by disabling hip pain that typically affects middle-aged men and women in the third trimester of pregnancy. The clinical course is usually characterized by an abrupt or gradual onset of pain, with functional disability increasing to a maximum within 4–8 weeks. This is followed by a period of some weeks or months during which the level of pain remains stable before a regression phase in which the pain gradually subsides. As described by Lequesne,22 the patients show a typical disproportionate functional disability in relation to a minimal restriction of movement, with pain only being elicited at the extremes of motion. A focal loss of radiodensity involving the femoral head and neck, and sometimes the trochanter, becomes apparent on plain radiographs 4–8 weeks after the clinical onset; however, bone scintigraphy radiotracer uptake and bone marrow edema, as displayed by magnetic resonance imaging (MRI), are seen earlier and appear just a few days after appearance of symptoms.
Since the first description of the disease by Curtiss and Kincaid,9 the clinical, roentgenographic,20, 23, 31, 32 scintigraphic,14 and MRI features6, 39 of TOH have been extensively reported in the literature under various names (e.g., transitory demineralization, migratory osteolysis, algodystrophy of the hip), and all investigators have described it as self-limiting with spontaneous resolution 6–24 months after a conservative approach, such as restricted weight-bearing and symptomatic treatment.
Various therapeutic approaches have been adopted in an attempt to shorten the clinical course, but there is no general agreement about their efficacy, because validated methods of objectively assessing clinical improvement have rarely been used. It has been reported that an invasive procedure, such as core decompression, will significantly reduce pain within a few weeks,16 but some investigators consider operative intervention unnecessarily aggressive and dangerous.15, 41
Over the last 10 years, a number of studies have reported positive results after the treatment of reflex sympathetic dystrophy (RSD) with bisphosphonates. Clodronate,38 pamidronate,8, 11, 24 and alendronate1 have all proved to be efficacious in the management of RSD, which has many scintigraphic, histopathological, and MRI similarities with TOH.
We assessed the therapeutic efficacy of a short intravenous pamidronate course in patients with TOH by means of clinically validated methods and X-ray absorptiometry, which proved to be helpful in the follow-up of the disease, and allowed a quantitative evaluation of the bone involvement.37
Section snippets
Patients
Between February 1995 and March 2000, 16 consecutive patients with TOH (13 men and 3 women, mean age 38.3 years, range 30–49) were recruited after having been referred to our Rheumatology Day Hospital by the Orthopedic and Rheumatological Outpatient Services and the Emergency Department. All patients complained of pain in the hip on weight-bearing; four reported pain at rest (sitting and lying in bed) and two had nocturnal pain. None reported recent trauma or illness or any other risk factors
Results
Fifteen patients completed the study: one patient refused to undergo the second MRI scan 3 months after the end of treatment, but regularly underwent BMD measurements and answered when interviewed by phone. Assuming that the onset of the disease occurred when the pain began, the mean duration of disease at entry was 8 ± 3.8 weeks (median 7). As a predisposing factor other than pregnancy, a history of unusual activity before onset of the symptoms23 was reported by two patients (a long walk and a
Discussion
Because of its rarity and the difficulty in making an early diagnosis (radiographs in the first weeks after clinical onset are often unrevealing), TOH is not widely recognized and therefore possibly underdiagnosed. As we found, no laboratory test, including bone markers, provides any useful diagnostic clues.20 About 300 cases have so far been reported in the literature, but there is still controversy about the etiology, pathophysiology, and outcome of the disease, and there is disagreement as
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Pathological femoral neck fracture in a male patient due to non-simultaneous bilateral transient hip osteoporosis: A case report: Statements and Declarations
2023, Journal of Clinical Orthopaedics and TraumaResearch Advances in the Treatment of Bone Marrow Edema Syndrome
2023, Journal of Clinical DensitometryOsteonecrosis of the Knee: Not all Bone Edema is the Same
2022, Orthopedic Clinics of North AmericaCitation Excerpt :Nonweight-bearing is not recommended because disuse osteopenia may worsen demineralization. Use of bisphosphonates has been proposed, and there are limited studies suggesting that they provide improvement or shorten the disease cycle.16,89,90,92 With the increasing utilization of MRI, orthopedic surgeons will likely be seeing many more patients present with a diagnosis of some form of bone marrow edema about the knee.
The efficacy and safety of bisphosphonates in patients with bone marrow edema syndrome/transient osteoporosis: A systematic literature review
2020, Journal of OrthopaedicsCitation Excerpt :Of the 42 patients that achieved regression of BME on MRI, mean time was 3.85 months with ranges from 3 to 12 months.12–15 36 patients had complete resolution of BME after 3 months,13–15 3 patients after 6 months,13 3 had complete resolution after 12 months,12 30 patients had near complete resolution in 6 months,18 while the remaining 5 patients had less response12,14 and 1 was non-responder.12 VAS scores were available in 5/9 studies.12,13,15,17,18
Transient osteoporosis: Clinical spectrum in adults and associated risk factors
2019, Endocrine PracticeCitation Excerpt :These findings suggest that TO is usually a self-resolving condition which can be managed conservatively in the majority of patients. Although bisphosphonates have offered potential improvement in other metabolic bone disorders associated with pain (9), the mechanism by which they may offer benefit in TO is unclear. All patients with TO reported by Trevisan et al (1) were treated with bisphosphonates and unloading; hence, it is difficult to ascertain a specific benefit from bisphosphonates from that study.