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Ivković A, Glavčić M, Vuletić F, Janković S. Core Decompression Combined with Intraosseous Autologous Conditioned Plasma Injections Decreases Pain and Improves Function in Patients with Symptomatic Knee Bone Marrow Lesions. Biomedicines 2023; 11:1799. [PMID: 37509439 PMCID: PMC10376709 DOI: 10.3390/biomedicines11071799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
The purpose of this prospective case series was to determine the effectiveness of using a combination of the core decompression and injection of autologous conditioned plasma (ACP) for the treatment of symptomatic knee bone marrow lesions (BML), as well as to report on the preliminary clinical results based on magnetic resonance imaging (MRI) and patient-reported outcomes (PROMs). Patients with OA-related BML who failed to improve on conservative treatment for three months underwent an identical procedure consisting of arthroscopy, core decompression, and the intraosseous injection of ACP and were followed up for 12 months. A statistically significant reduction in pain and an improvement in function, as measured by the Numeric Pain Rating Scale (NPRS) and Knee Injury and Osteoarthritis Outcome Score (KOOS), was observed at one-week follow-up (8.3 ± 0.8 to 1.5 ± 1.0; p ≤ 0.001 and 33.4 ± 10.6 to 53.9 ± 13.6; p ≤ 0.001 respectively). After six weeks, weight-bearing was allowed, but the trend did not change-the NPRS continued to be low (average 1.4 on 12-month follow-up) and the total KOOS increased 44.6 points from the baseline (average 78.0 on 12-month follow-up). The Whole-Organ Magnetic Resonance Imaging Score improved from 66.1 ± 19.4 prior to surgery to 58.0 ± 15.9 (p < 0.001) after 3 months. In our study, there was no control group, randomisation was not performed, and the sample size was relatively small. A combination of core decompression and the intraosseous injection of ACP into the affected subchondral area proved to be a safe and effective procedure that provides rapid pain relief and a significant increase in joint function up to one year postoperatively.
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Affiliation(s)
- Alan Ivković
- Department of Orthopaedics and Trauma Surgery, University Hospital "Sveti Duh", 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Clinical Medicine, University of Applied Health Sciences, 10000 Zagreb, Croatia
| | - Marin Glavčić
- Department of Orthopaedic and Trauma Surgery, University Hospital "Dubrava", 10000 Zagreb, Croatia
| | - Filip Vuletić
- Department of Orthopaedics and Trauma Surgery, University Hospital "Sveti Duh", 10000 Zagreb, Croatia
| | - Saša Janković
- Department of Orthopaedics and Trauma Surgery, University Hospital "Sveti Duh", 10000 Zagreb, Croatia
- Faculty of Kinesiology, University of Zagreb, 10000 Zagreb, Croatia
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Hoenig T, Eissele J, Strahl A, Popp KL, Stürznickel J, Ackerman KE, Hollander K, Warden SJ, Frosch KH, Tenforde AS, Rolvien T. Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis. Br J Sports Med 2023; 57:427-432. [PMID: 36720584 DOI: 10.1136/bjsports-2022-106328] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Bone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Peer-reviewed studies that reported site-specific RTS of BSIs in athletes. RESULTS Seventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft. CONCLUSION This systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS. PROSPERO REGISTRATION NUMBER CRD42021232351.
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Affiliation(s)
- Tim Hoenig
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Eissele
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Strahl
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- TRIA Orthopedic Center, Bloomington, Minnesota, USA
| | - Julian Stürznickel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathryn E Ackerman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Stuart J Warden
- Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, Indiana, USA
- Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, Indiana, USA
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Li S, Yu H, Long S, Li J, He Y, Zheng X, Yang S, Tang Y, Xie Q, Zheng W. Research advances in the treatment of bone marrow edema syndrome. J Clin Densitom 2023; 26:101367. [PMID: 37005106 DOI: 10.1016/j.jocd.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
Bone marrow edema syndrome (BMES) is a relatively uncommon clinical condition. It has been poorly reported in the literature. Hence, doctors are not sufficiently aware of the disease and are prone to misdiagnosis and mistreatment, which can undoubtedly prolong the course of the disease, reduce the quality of life of patients and even affect their function. This paper reviews the literature and summarizes the treatment options for bone marrow edema syndrome, such as symptomatic treatment, extracorporeal shock waves therapy (ESWT), pulsed electromagnetic fields (PEFs), hyperbaric oxygen (HBO), vitamin D, iloprost, bisphosphonates, denosumab, and surgery, etc. This informs clinicians in treating bone marrow edema syndrome, hopefully improving patients' quality of life and shortening the duration of their disease.
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Affiliation(s)
- Shihong Li
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Huimin Yu
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Shiwei Long
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Jian Li
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Yang He
- Chengdu Xindu District Traditional Chinese Medicine Hospital, Chengdu, China
| | - Xiaolong Zheng
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Shuang Yang
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Yingchao Tang
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China
| | - Qingyun Xie
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China.
| | - Wei Zheng
- People's Liberation Army General Hospital of Western Theater Command, Chengdu, China.
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Influence of Vitamin D and C on Bone Marrow Edema Syndrome-A Scoping Review of the Literature. J Clin Med 2022; 11:jcm11226820. [PMID: 36431295 PMCID: PMC9696648 DOI: 10.3390/jcm11226820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Bone marrow edema syndrome (BMES) is a rare disease with a largely unknown etiology. The aim of this scoping review is to systematically evaluate and combine the available evidence about vitamin D and C and BMES. The analysis of the manuscripts was based on country of origin, number of patients, gender, study type, epidemiology, localization, bone mineral density measurements, vitamin status and therapy. Sixty studies were included. The overall number of patients was 823 with a male-to-female ratio of 1.55:1 and a mean age of 40.9 years. Studies were very heterogeneous and of diverging scientific scope with a weak level of evidence. The hip was the most affected joint, followed by the foot and ankle and the knee; 18.3% of patients suffered from multifocal BMES. Sixteen studies reported on vitamin D levels, resulting in a high prevalence of vitamin D deficiency (47%) and insufficiency (17.9%) among BMES patients. Three BME manuscripts were associated with vitamin C deficiency. Current therapeutic interventions include conservative measures (mainly unloading), various osteoactive drugs and iloprost. In summary, data about BMES in association with vitamin status is limited. A causal relationship between vitamin D or vitamin C status, osteopenia, and BMES cannot be determined from the existing literature.
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Costa TMDRL, Borba VZC, Correa RGP, Moreira CA. Stress fractures. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:765-773. [PMID: 36382766 PMCID: PMC10118812 DOI: 10.20945/2359-3997000000562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Stress fractures (SF) represent 10%-20% of all injuries in sport medicine. An SF occurs when abnormal and repetitive loading is applied on normal bone: The body cannot adapt quickly enough, leading to microdamage and fracture. The etiology is multifactorial with numerous risk factors involved. Diagnosis of SF can be achieved by identifying intrinsic and extrinsic factors, obtaining a good history, performing a physical exam, and ordering laboratory and imaging studies (magnetic resonance imaging is the current gold standard). Relative energy deficiency in sport (RED-S) is a known risk factor. In addition, for women, it is very important know the menstrual status to identify long periods of amenorrhea in the past and the present. Early detection is important to improve the chance of symptom resolution with conservative treatment. Common presentation involves complaints of localized pain, with or without swelling, and tenderness on palpation of bony structures that begins earlier in training and progressively worsens with activity over a 2- to 3-week period. Appropriate classification of SF based on type, location, grading, and low or high risk is critical in guiding treatment strategies and influencing the time to return to sport. Stress injuries at low-risk sites are typically managed conservatively. Studies have suggested that calcium and vitamin D supplementation might be helpful. Moreover, other treatment regimens are not well established. Understanding better the pathophysiology of SFs and the potential utility of current and future bone-active therapeutics may well yield approaches that could treat SFs more effectively.
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Evaluating the Impact of High Intensity Interval Training on Axial Psoriatic Arthritis Based on MR Images. Diagnostics (Basel) 2022; 12:diagnostics12061420. [PMID: 35741229 PMCID: PMC9222014 DOI: 10.3390/diagnostics12061420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022] Open
Abstract
High intensity interval training (HIIT) has been shown to benefit patients with psoriatic arthritis (PsA). However, magnetic resonance (MR) imaging has uncovered bone marrow edema (BME) in healthy volunteers after vigorous exercise. The purpose of this study was to investigate MR images of the spine of PsA patients for changes in BME after HIIT. PsA patients went through 11 weeks of HIIT (N = 19, 4 men, median age 52 years) or no change in physical exercise habits (N = 20, 8 men, median age 45 years). We acquired scores for joint affection and pain and short tau inversion recovery (STIR) and T1-weighted MR images of the spine at baseline and after 11 weeks. MR images were evaluated for BME by a trained radiologist, by SpondyloArthritis Research Consortium of Canada (SPARCC) scoring, and by extraction of textural features. No significant changes of BME were detected in MR images of the spine after HIIT. This was consistent for MR image evaluation by a radiologist, by SPARCC, and by texture analysis. Values of textural features were significantly different in BME compared to healthy bone marrow. In conclusion, BME in spine was not changed after HIIT, supporting that HIIT is safe for PsA patients.
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Seefried L, Genest F, Baumann J, Heidemeier A, Meffert R, Jakob F. Efficacy of Zoledronic Acid in the Treatment of Nonmalignant Painful Bone Marrow Lesions: A Triple-Blind, Randomized, Placebo-Controlled Phase III Clinical Trial (ZoMARS). J Bone Miner Res 2022; 37:420-427. [PMID: 34954857 DOI: 10.1002/jbmr.4493] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/27/2021] [Accepted: 12/17/2021] [Indexed: 11/11/2022]
Abstract
Bone marrow lesions (BML) represent areas of deteriorated bone structure and metabolism characterized by pronounced water-equivalent signaling within the trabecular bone on magnetic resonance imaging (MRI). BML are associated with repair mechanisms subsequent to various clinical conditions associated with inflammatory and non-inflammatory injury to the bone. There is no approved treatment for this condition. Bisphosphonates are known to improve bone stability in osteoporosis and other bone disorders and have been used off-label to treat BML. A randomized, triple-blind, placebo-controlled phase III trial was conducted to assess efficacy and safety of single-dose zoledronic acid (ZOL) 5 mg iv with vitamin D 1000 IU/d as opposed to placebo with vitamin D 1000 IU/d in 48 patients (randomized 2:1) with BML. Primary efficacy endpoint was reduction of edema volume 6 weeks after treatment as assessed by MRI. After treatment, mean BML volume decreased by 64.53% (±41.92%) in patients receiving zoledronic acid and increased by 14.43% (±150.46%) in the placebo group (p = 0.007). A decrease in BML volume was observed in 76.5% of patients receiving ZOL and in 50% of the patients receiving placebo. Pain level (visual analogue scale [VAS]) and all categories of the pain disability index (PDI) improved with ZOL versus placebo after 6 weeks but reconciled after 6 additional weeks of follow-up. Six serious adverse events occurred in 5 patients, none of which were classified as related to the study drug. No cases of osteonecrosis or fractures occurred. Therefore, single-dose zoledronic acid 5 mg iv together with vitamin D may enhance resolution of bone marrow lesions over 6 weeks along with reduction of pain compared with vitamin D supplementation only. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Lothar Seefried
- Orthopedic Center for Musculoskeletal Research, Orthopedic Department, University of Wuerzburg, Wuerzburg, Germany
| | - Franca Genest
- Orthopedic Center for Musculoskeletal Research, Orthopedic Department, University of Wuerzburg, Wuerzburg, Germany
| | - Jasmin Baumann
- Orthopedic Center for Musculoskeletal Research, Orthopedic Department, University of Wuerzburg, Wuerzburg, Germany
| | - Anke Heidemeier
- Department of Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Rainer Meffert
- Department of Trauma, Plastic, Reconstructive, and Hand Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Franz Jakob
- Orthopedic Center for Musculoskeletal Research, Orthopedic Department, University of Wuerzburg, Wuerzburg, Germany
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Reviewing Bone Marrow Edema in Athletes: A Difficult Diagnostic and Clinical Approach. Medicina (B Aires) 2021; 57:medicina57111143. [PMID: 34833361 PMCID: PMC8625152 DOI: 10.3390/medicina57111143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/12/2021] [Accepted: 10/18/2021] [Indexed: 01/05/2023] Open
Abstract
Bone marrow edema (BME) is defined as an area of low signal intensity on T1-weighted (T1W) MRI images and associated with intermediate or high signal intensity findings on T2-weighted (T2W) MRI images. BME represents a typical imaging finding that characterizes common stress-related bone injuries of professional and amateur athletes. The etiology of stress-related injuries is influenced by numerous factors, including the initiation of a new sports activity or changes in an existing training protocol. The clinical significance of BME remains unclear. However, a correlation between the imaging pattern of BME, the clinical history of the patient and the type of sports activity practiced is essential for correct diagnosis and adequate therapeutic treatment. It is also important to clarify whether there is a specific threshold beyond which exercise can adversely affect the bone remodeling process, as the clinical picture may degenerate into the presence of BME, pain and, in the most severe cases, bone loss. In our review, we summarize the current knowledge on the etiopathogenesis and treatment options for BME and highlight the main aspects that make it difficult to formulate a correct diagnosis and establish an adequate therapeutic treatment.
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Fredericson M, Kussman A, Misra M, Barrack MT, De Souza MJ, Kraus E, Koltun KJ, Williams NI, Joy E, Nattiv A. The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play. Clin J Sport Med 2021; 31:349-366. [PMID: 34091538 DOI: 10.1097/jsm.0000000000000948] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/23/2021] [Indexed: 02/02/2023]
Abstract
ABSTRACT The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.
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Affiliation(s)
- Michael Fredericson
- Division of Physical Medicine & Rehabiilitation, Stanford University, Stanford, California
| | - Andrea Kussman
- Division of Physical Medicine & Rehabiilitation, Stanford University, Stanford, California
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michelle T Barrack
- Department of Family and Consumer Sciences, California State University, Long Beach, Long Beach, California
| | - Mary Jane De Souza
- Department of Kinesiology and Physiology Penn State University, University Park, Pennsylvania
| | - Emily Kraus
- Division of Physical Medicine & Rehabiilitation, Stanford University, Stanford, California
| | | | - Nancy I Williams
- Department of Kinesiology and Physiology Penn State University, University Park, Pennsylvania
| | | | - Aurelia Nattiv
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, California
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Vasiliadis AV, Zidrou C, Charitoudis G, Beletsiotis A. Single-Dose Therapy of Zoledronic Acid for the Treatment of Primary Bone Marrow Edema Syndrome. Cureus 2021; 13:e13977. [PMID: 33880304 PMCID: PMC8053006 DOI: 10.7759/cureus.13977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective To review the patients diagnosed with bone marrow edema syndrome who had been treated with one single dose of zoledronic acid. Methods The data of 54 patients with bone marrow edema syndrome treated with a single dose of intravenous zoledronic acid and partial weight-bearing were included in the study. The diagnosis was based on clinical examination, the existence of prolonged pain, the presence of bone marrow edema on magnetic resonance imaging, and the patient’s medical history. The efficacy was assessed using changes in symptoms, visual analogue scale, and changes in magnetic resonance imaging. Results Overall, 54 patients (35.2% male) were included with bone marrow edema syndrome, with a mean age of 52.7 ± 9.77 years (range: 35 - 74 years). The most commonly affected joint was the knee in 32 patients (59.2%), followed by the foot/ankle in 13 patients (24.1%), and the hip in nine patients (16.7%). Improved mobility was reported by 29 patients (53.7%) among the total number of the patients at the six-month follow-up visit. The mean visual analogue scale was 6.77 ± 0.83, 7.25 ± 1.19, and 7.46 ± 0.96 at baseline and 5.11 ± 2.14, 4.25 ± 1.84 and 5.15 ± 2.03 at the six-month follow-up for the hip, knee and foot/ankle, respectively (p = 0.098, p < 0.001, p = 0.002). At the six-month follow-up, the MRI showed resolution of the edema in 20 out of 54 patients (approximately 37%). Only 7.4% of the patients reported minor adverse events which were resolved through a single administration of paracetamol. Conclusion Our data show that the combination treatment of a single dose of zoledronic acid and partial weight-bearing for one month improves mobility and reduces edema in patients with bone marrow edema syndrome in the primary weight-bearing joints.
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Affiliation(s)
- Angelo V Vasiliadis
- 2nd Orthopaedic Department, General Hospital of Thessaloniki "Papageorgiou", Thessaloniki, GRC
| | - Christianna Zidrou
- 2nd Orthopaedic Department, General Hospital of Thessaloniki "Papageorgiou", Thessaloniki, GRC
| | - George Charitoudis
- 2nd Orthopaedic Department, General Hospital of Thessaloniki "Papageorgiou", Thessaloniki, GRC
| | - Anastasios Beletsiotis
- 2nd Orthopaedic Department, General Hospital of Thessaloniki "Papageorgiou", Thessaloniki, GRC
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Abstract
Bone marrow edema (BME) is a descriptive term used to describe high-signal intensity changes detected on magnetic resonance fluid-sensitive sequences that could be attributed to a number of underlying pathologies. Regardless of the cause, physiologic remodeling of the subchondral bone can be limited because of ongoing joint forces, increased focalization of stress, and reduced healing capacity of the subchondral bone. BME is a known prognostic factor associated with pain, dysfunction, and progressive cartilage damage. This review summarizes the current known causes of BMEs, theories related to histopathological changes, and current treatment options including novel biologic surgical options.
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De Houwer H, Van Beek N, Prinsen S, Van Riet A, De Roeck J, Verfaillie S. Bone marrow oedema syndrome of the foot and ankle in a paediatric population: a retrospective case series with serial MRI evaluation. J Child Orthop 2020; 14:440-450. [PMID: 33204352 PMCID: PMC7666800 DOI: 10.1302/1863-2548.14.190189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE By means of a case series we wanted to describe and correlate the clinical and imaging features of bone marrow oedema syndrome (BMOS) of the foot and ankle in children. METHODS A retrospective data study was performed on patients born on or after 01 January 2001 who underwent multiple MRI scans of the foot and ankle for pain symptoms. Six patients who presented with increased signal intensity on T2-weighted MR imaging without any underlying causes or concomitant pathology were included. RESULTS All patients, three boys and three girls with a mean age of 11 years (8 to 14), displayed patchy areas of increased signal intensity on T2-weighted and turbo inversion recovery magnitude (TIRM) images. On average, six tarsal bones were involved (4 to 8). In all patients, treatment consisted of rest and/or protected weight-bearing. The mean time for symptoms to improve during treatment was 6 months (1 to 16). The mean duration of treatment was nine months (3 to 16). In all patients clinical and imaging symptoms were strongly correlated and regressed in time. CONCLUSION BMOS as a pathological entity should be considered in paediatric patients with foot and ankle pain without a clear underlying cause, and characteristic T2-weighted and TIRM signal intensity increase on MRI images. As BMOS is transient and self-limiting, conservative treatment is advised while the oedema regresses. An early diagnosis of this pathology could prevent unnecessary diagnostic investigations and invasive treatments. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Hannah De Houwer
- Department of Orthopaedic Surgery, AZ Herentals, Herentals, Belgium,Correspondence should be sent to Hannah De Houwer, AZ Herentals - Orthopaedic Surgery, Nederrij 133 Herentals 2200, Belgium. E-mail:
| | | | - Sandra Prinsen
- Department of Pediatric Orthopaedic Surgery, UZ Leuven, Leuven, Belgium
| | - Anne Van Riet
- Department of Orthopaedic Surgery, AZ Herentals, Herentals, Belgium
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[Bone marrow edema syndrome from the perspective of appraisers and insurance clerks]. Unfallchirurg 2020; 123:904-908. [PMID: 32930829 DOI: 10.1007/s00113-020-00867-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
Various diseases or groups of diseases can trigger bone marrow edema (BME). The task of the appraiser is to work out the role of a diagnosed BME in the context of the causality based on liability; however, the inconsistent ICD 10 coding of the BME complex also poses a problem, especially for medically untrained insurance clerks. The coding of the BME as a fracture provided by the coding guidelines poses a problem when assessing reserves for damage settlement. Based on the etiology of BME an algorithm is presented that should make it easier for the expert as well as for the insurance clerk in the case of liability and also for the private accident insurance to classify the diagnosis of BME in the case.
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Baumbach SF, Pfahler V, Bechtold-Dalla Pozza S, Feist-Pagenstert I, Fürmetz J, Baur-Melnyk A, Stumpf UC, Saller MM, Straube A, Schmidmaier R, Leipe J. How We Manage Bone Marrow Edema-An Interdisciplinary Approach. J Clin Med 2020; 9:jcm9020551. [PMID: 32085459 PMCID: PMC7074543 DOI: 10.3390/jcm9020551] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/21/2020] [Accepted: 02/03/2020] [Indexed: 12/11/2022] Open
Abstract
Bone marrow edema (BME) is a descriptive term for a common finding in magnetic resonance imaging (MRI). Although pain is the major symptom, BME differs in terms of its causal mechanisms, underlying disease, as well as treatment and prognosis. This complexity together with the lack of evidence-based guidelines, frequently makes the identification of underlying conditions and its management a major challenge. Unnecessary multiple consultations and delays in diagnosis as well as therapy indicate a need for interdisciplinary clinical recommendations. Therefore, an interdisciplinary task force was set up within our large osteology center consisting of specialists from internal medicine, endocrinology/diabetology, hematology/oncology, orthopedics, pediatrics, physical medicine, radiology, rheumatology, and trauma surgery to develop a consenus paper. After review of literature, review of practical experiences (expert opinion), and determination of consensus findings, an overview and an algorithm were developed with concise summaries of relevant aspects of the respective underlying disease including diagnostic measures, clinical features, differential diagnosis and treatment of BME. Together, our single-center consensus review on the management of BME may help improve the quality of care for these patients.
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Affiliation(s)
- Sebastian F. Baumbach
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Nussbaumstraße 20, 80336 Munich, Germany
| | - Vanessa Pfahler
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of Radiology, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Susanne Bechtold-Dalla Pozza
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of Pediatric Endocrinology and Diabetology, University Hospital, Ludwig-Maximilians-University Munich, Lindwurmstraße 4, 80337 Munich, Germany
| | - Isa Feist-Pagenstert
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Julian Fürmetz
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Nussbaumstraße 20, 80336 Munich, Germany
| | - Andrea Baur-Melnyk
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of Radiology, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Ulla C. Stumpf
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Nussbaumstraße 20, 80336 Munich, Germany
| | - Maximilian M. Saller
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of General, Trauma and Reconstructive Surgery, University Hospital, Ludwig-Maximilians-University Munich, Nussbaumstraße 20, 80336 Munich, Germany
- Experimental Surgery and Regenerative Medicine (ExperiMed), Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-University (LMU), Fraunhoferstraße 20, 82152 Planegg-Martinsried, Germany
| | - Andreas Straube
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department of Neurology, University Hospital, Ludwig-Maximilians-University Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Ralf Schmidmaier
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Department for Endocrinology and Diabetology, Department of Internal Medicine IV, Ludwig-Maximilians-University Munich, Ziemssenstraße 1, 80336 Munich, Germany
- Correspondence: (R.S.); (J.L.); Tel.: +49-89-4400-52101 (R.S.); Fax: +49-89-4400-54410 (R.S.)
| | - Jan Leipe
- Comprehensive Osteology Center Munich, University Hospital, Ludwig-Maximilians-University Munich, 80336 Munich, Germany; (S.F.B.); (V.P.); (S.B.-D.P.); (I.F.-P.); (J.F.); (A.B.-M.); (U.C.S.); (M.M.S.); (A.S.)
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig-Maximilians-University Munich, Ziemssenstraße 1, 80336 Munich, Germany
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Medical Faculty Mannheim of the University Heidelberg, Ludolf-Krehl-Straße 13–17, 68167 Mannheim, Germany
- Correspondence: (R.S.); (J.L.); Tel.: +49-89-4400-52101 (R.S.); Fax: +49-89-4400-54410 (R.S.)
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Müller F, Appelt KA, Meier C, Suhm N. Zoledronic acid is more efficient than ibandronic acid in the treatment of symptomatic bone marrow lesions of the knee. Knee Surg Sports Traumatol Arthrosc 2020; 28:408-417. [PMID: 31273410 PMCID: PMC6995988 DOI: 10.1007/s00167-019-05598-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/24/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to determine the efficacy and tolerability of different antiresorptive therapeutic regimens for treating symptomatic bone marrow lesions (BML) of the knee. METHODS Patient records of 34 patients with radiologically diagnosed, painful BML of the knee treated with either a bisphosphonate (zoledronic, ibandronic, or alendronic acid) or with a human monoclonal antibody (denosumab) were retrospectively evaluated. Response to treatment was assessed, as change in patient-reported pain, by evaluation of BML expansion on MRI using the Whole-Organ Magnetic Resonance Imaging Score (WORMS), and by laboratory analysis of bone turnover markers: C-terminal cross-linking telopeptide (CTx) and procollagen type 1 amino-terminal propeptide (P1NP). Tolerability was evaluated by documentation of adverse reactions. RESULTS Zoledronic acid was more or at least equally effective as the other treatment regimens with response to treatment in 11 of 12 patients (92%). The highest rate of adverse events was noted in 4 of 12 patients (33%) treated with zoledronic acid. CTx and WORMS differentiated well between responders and non-responders, whereas P1NP failed to do so. Changes in pain correlated moderately with change in WORMS (r = - 0.32), weakly with change in CTx (r = - 0.07), and not at all with change in P1NP. CONCLUSION Zoledronic acid appeared to be more effective than other antiresorptive medications-at the cost of more frequent adverse events. While radiological and laboratory evaluation methods may allow for objective treatment monitoring, they appear to capture different dimensions than patient-reported pain. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Fabio Müller
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Konrad A. Appelt
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Christian Meier
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Basel, Basel, Switzerland ,ENDONET, Basel, Switzerland
| | - Norbert Suhm
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland. .,ENDONET, Basel, Switzerland.
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16
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Pieropan S, Antoniazzi F, Tadiotto E, Caldonazzi F, Maschio M, Aiello G, Melotti G, Cavarzere P, Piacentini G. Bone Marrow Foot Oedema in Adolescents: The Role of Vitamin D. J Bone Metab 2019; 26:241-246. [PMID: 31832389 PMCID: PMC6901693 DOI: 10.11005/jbm.2019.26.4.241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 11/11/2022] Open
Abstract
Background Bone marrow oedema (BMO) in children/adolescents is a rare clinical condition without an etiologic cause. It is associated with typical increased signal intensity on T2-weighted magnetic resonance images (MRI) and an increase in bone turnover in which vitamin D plays a pivotal role. No treatment guidelines for these young patients are to date available. Methods We performed a retrospective study in a pediatric setting of 13 patients with diagnosis of primary BMO of the foot on the basis of clinical and radiological findings. Data collection included sex, age, patient history, symptoms at presentation, clinical examination, laboratory bone turnover markers, vitamin D levels, MRI, treatment, and outcome. Results Vitamin D deficiency or insufficiency was found in 76.9% of cases. All patients were treated with adequate vitamin D daily intake, a short course of analgesic therapy, physical therapy, avoiding detrimental feet and ankle immobilization. All fully recovered in 3-month lag period. Conclusions Our data highlight that environmental factors, such as underestimated articular or bone microtraumatisms, as well as joint hyper mobility, in a bone turnover milieu of vitamin D deficiency could be the cause of this clinical conditions. Adequate vitamin D supplementation, associated with physical and analgesic therapy, is crucial in the management of BMO.
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Affiliation(s)
- Sara Pieropan
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
| | - Franco Antoniazzi
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
| | - Elisa Tadiotto
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
| | | | - Maddalena Maschio
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
| | - Giulia Aiello
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
| | - Giulia Melotti
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
| | - Paolo Cavarzere
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
| | - Giorgio Piacentini
- Pediatric Clinic, Department of Life and Reproduction Sciences, Azienda Ospedaliera Universitaria Integrata, Verona Italy
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17
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González-Martín D, Herrera-Pérez M, Martín-Vélez P, Rendón-Díaz D. Prevalence of bone marrow edema in a study population with foot and/or ankle pain. Foot (Edinb) 2019; 40:76-80. [PMID: 31136917 DOI: 10.1016/j.foot.2019.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/05/2019] [Accepted: 04/12/2019] [Indexed: 02/04/2023]
Abstract
Bone marrow edema (BME) is an imaging diagnosis defined by an abnormal accumulation of intraosseous interstitial fluid within a bone on magnetic resonance imaging (MRI) investigation. The aim of this study was to determine the prevalence of BME in patients with foot and/or ankle pain studied using MRI. This was a retrospective observational work on patient cases and controls studied through MRI of the foot and/or ankle at our Foot and Ankle Unit (FAU). An analytical statistical analysis and a multivariate analysis were performed to eliminate possible confounding factors. 1950 foot and/or ankle MRI cases were reviewed, of which 451 presented bone edema (23% prevalence). The average patient age was 51.8 (range, 7-87); the talus bone was most frequently affected: post-traumatic in 43.5% of cases, degenerative in 34.7% and there was no specific cause identified in 6.3% (these cases were termed 'idiopathic'). With regards to risk factors, in the case of gender, the odds ratio (OR) of men suffering bone oedema was 1.5 times higher than that of women (P = 0.003); for immunosuppression the OR was 3.4 times higher (P = 0.001); while among those with a smoking habit it was 0.59 (P = 0.001), meaning that after ruling smoking out as a possible confounding factor, it was, in fact, revealed to be a protective factor. The prevalence of bone edema in MRI in patients with foot and/or ankle pain was 23%. The average patient was male, aged approximately 50, with traumatic or degenerative origin talus bone oedema. Level of Evidence: Level IV, revision observational study.
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Affiliation(s)
- David González-Martín
- Orthopedic Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain
| | - Mario Herrera-Pérez
- Orthopedic Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain; School of Medicine, Universidad de La Laguna, Tenerife, Spain; Foot and Ankle Unit, Orthopedic Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain.
| | - Pablo Martín-Vélez
- Orthopedic Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain
| | - Diego Rendón-Díaz
- Orthopedic Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain; Foot and Ankle Unit, Orthopedic Department, University Hospital of Canary Islands, La Laguna, Tenerife, Spain
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18
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Schmidt T, Rolvien T, Linke C, Jandl NM, Oheim R, Amling M, Barvencik F. Outcome of Teriparatide Treatment on Fracture Healing Complications and Symptomatic Bone Marrow Edema in Four Adult Patients With Hypophosphatasia. JBMR Plus 2019; 3:e10215. [PMID: 31485555 PMCID: PMC6715780 DOI: 10.1002/jbm4.10215] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/23/2019] [Accepted: 06/24/2019] [Indexed: 12/12/2022] Open
Abstract
The response to teriparatide has been described in very few cases of hypophosphatasia (HPP). In this cross‐sectional study, we report the prevalence of symptomatic bone marrow edema (BME) and fracture healing complications in a large cohort of childhood and adult HPP patients and discuss the results of teriparatide treatment in four cases. From 2016 to 2018, 51 patients with a diagnosis of HPP were seen at our institution. The diagnosis of HPP was established by low serum alkaline phosphatase (ALP), elevated serum pyridoxal‐5‐phosphate (PLP), at least one typical clinical symptom of HPP and supported by ALPL mutation analysis. In this study cohort, 28 (56%) and 14 (27%) patients had a history of fracture or a history of BME, respectively. Four patients, including middle‐aged to elderly women and men who all presented with persistent symptomatic BME or fracture healing complications, were treated with teriparatide. DXA was performed prior to treatment and laboratory values were measured on a regular basis during treatment. Treatment with teriparatide showed variable effects in terms of clinical and biochemical response. Although all four patients displayed a temporary increase in ALP activity, only two patients with a mild form of adult HPP and moderately increased PLP levels showed definite clinical and radiological improvement after teriparatide treatment. In conclusion, fracture healing complications and BME occur frequently in HPP patients. Teriparatide shows variable clinical and biochemical effects depending on the severity of the disease. PLP levels and the number of ALPL alleles might be good parameters to predict treatment outcomes. © 2019 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research
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Affiliation(s)
- Tobias Schmidt
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Tim Rolvien
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany.,Department of Orthopedics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Carolin Linke
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Nico Maximilian Jandl
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany.,Department of Orthopedics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Michael Amling
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics University Medical Center Hamburg-Eppendorf Hamburg Germany
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19
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Rolvien T, Krause M, Zustin J, Yastrebov O, Oheim R, Barvencik F, Frosch KH, Amling M. Intra-articular osteoid osteoma accompanied by extensive bone marrow edema. A clinical and micro-morphological analysis. J Bone Oncol 2019; 18:100256. [PMID: 31497501 PMCID: PMC6722254 DOI: 10.1016/j.jbo.2019.100256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 12/18/2022] Open
Abstract
A series of patients with intra-articular osteoid osteoma (OO) is demonstrated. Extensive and persistent bone marrow edema syndrome masked the correct diagnosis. No consistent patterns of impaired bone mineral status could be confirmed in these patients. Nidus specimens displayed significantly higher mineralization heterogeneity determined by qBEI.
Osteoid osteoma (OO) is a benign bone tumor producing non-mineralized bone matrix (i.e., osteoid). While peritumoral edema is commonly found in OO, extensive bone marrow edema has been reported less frequently. Furthermore, the micro-morphological characteristics of the nidus and its central calcification remain unclear. In this study, a consecutive series of four patients suffering from extensive bone marrow edema triggered by intra-articular osteoid osteoma underwent clinical examination, magnetic resonance imaging (MRI) and computed tomography (CT) as well as dual-energy X-ray absorptiometry (DXA) and laboratory bone turnover analyses. The obtained resection specimens were processed by undecalcified histology and were subsequently analyzed by light microscopy and quantitative backscattered electron imaging (qBEI). We report an entity of intra-articular osteoid osteoma in the knee and foot, in which an extensive and persistent bone marrow edema syndrome masked the correct diagnosis. While metabolic bone diseases were excluded in all cases, the reassessment of the patients’ clinical history including pain characteristics (nocturnal, aspirin sensitivity) led us to perform additional CT, where the tumor was diagnosed. The micro-morphological analysis of the OO biopsies revealed that the nidus was surrounded by hyperosteoidosis, while central mineralization was detected in all cases. This mineralized area showed a significantly higher mineralization heterogeneity than the surrounding trabecular bone and more disorganized collagen fibers detected by qBEI and polarized light microscopy, respectively. Taken together, our results indicate that osteoid osteoma should be considered when persistent and extensive, peri-articular bone marrow edema is diagnosed. The central calcification that is found inside the nidus in conventional imaging was mirrored by bone matrix with a heterogeneous mineralization pattern.
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Affiliation(s)
- Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Corresponding author at: Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany.
| | - Matthias Krause
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jozef Zustin
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Pathologisch-Anatomisches Institut Regensburg, Regensburg, Germany
| | - Oleg Yastrebov
- Department of Foot Surgery, Agaplesion Diakonieklinikum, Hamburg, Germany
| | - Ralf Oheim
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Corresponding author.
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20
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Bone Marrow Edema: A Case of Regional Migratory Osteoporosis. Am J Phys Med Rehabil 2019; 99:e60-e63. [PMID: 31045875 DOI: 10.1097/phm.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bone marrow edema represents a typical pattern on magnetic resonance imaging consisting of an area of abnormal bone signal with low to intermediate intensity on T1-weighted images and a high intensity on fat-suppressed T2-weighted images. Bone marrow edema syndromes are a group of entities characterized by idiopathic bone marrow edema and osteoporosis. Regional migratory osteoporosis is a bone marrow edema syndrome characterized by a self-limited migrating arthralgia of the lower limbs not related to trauma or other events. Its clinical presentation is variable and may include a less frequent form of migration of the bone marrow edema within the same joint, illustrated here by means of a case report. Conservative treatment is the preferred approach to this condition, and usually, it resolves completely and with no sequelae. Physicians should be made aware of this condition to avoid unnecessary and costly diagnostic and therapeutic measures.
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21
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Zaldibar Barinaga MB, Reoyo Díez JI. [Idiopathic bone marrow oedema: Outcome of 3 cases treated with denosumab]. Rehabilitacion (Madr) 2019; 53:126-130. [PMID: 31186095 DOI: 10.1016/j.rh.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/03/2018] [Accepted: 01/06/2019] [Indexed: 06/09/2023]
Abstract
Idiopathic bone marrow oedema is considered an unclarified pathophysiological entity of multifactorial origin affecting middle-aged persons; it is characterised by pain and functional limitation of the lower extremities. Characteristic findings on magnetic resonance imaging are hypointense T1 and hyperintense T2 images in the affected joints. We present 3clinical cases of BMO in men (age: 45-64 years), involving 2knees and one hip. Onset occurred with intense pain (VAS ≥ 5), with no clear cause and functional limitation with characteristic images on magnetic resonance imaging. Treatment consisted of vitamin D 20,000 IU/week orally and a single subcutaneous dose of denosumab 60mg (off label use). The patients avoided weight bearing on affected joints and conducted self-assisted exercises to maintain range of movement. Outcome was favourable with clinical and bone oedema resolution, with no notable complications. This report demonstrates that denosumab is a treatment option for the clinical/radiological resolution of bone marrow oedema and seems to shorten the clinical course of the process.
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Affiliation(s)
| | - J I Reoyo Díez
- Servicio de Rehabilitación, Hospital de Santa Marina, Bilbao (Vizcaya), España
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22
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Ghasemi RA, Sadeghi S, Rahimee N, Tahmasebi M. Technologies in the Treatment of Bone Marrow Edema Syndrome. Orthop Clin North Am 2019; 50:131-138. [PMID: 30477703 DOI: 10.1016/j.ocl.2018.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bone marrow edema syndrome is a rare and self-limited syndrome with an unknown cause. The natural time course for improvement of clinical symptoms and normalization in MRI lasts from 3 to 18 months. This entity must be distinguished from other causes of marrow abnormality, such as stress fractures and osteonecrosis, for the best treatment options. Various treatments from conservative to surgical have been made to provide pain relief and accelerate the natural course of the disease. This article reviews bone marrow edema syndrome with a focus on treatment in the foot and ankle.
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Affiliation(s)
- Reza A Ghasemi
- Tehran University of Medical Science, Number 21, Dameshgh Street, Vali-e Asr Avenue, Tehran 1416753955, Iran.
| | - Saleh Sadeghi
- Tehran University of Medical Science, Number 21, Dameshgh Street, Vali-e Asr Avenue, Tehran 1416753955, Iran
| | - Narges Rahimee
- Tehran University of Medical Science, Number 21, Dameshgh Street, Vali-e Asr Avenue, Tehran 1416753955, Iran
| | - Mohamadnaghi Tahmasebi
- Tehran University of Medical Science, Number 21, Dameshgh Street, Vali-e Asr Avenue, Tehran 1416753955, Iran
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23
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Oehler N, Mussawy H, Schmidt T, Rolvien T, Barvencik F. Identification of vitamin D and other bone metabolism parameters as risk factors for primary bone marrow oedema syndrome. BMC Musculoskelet Disord 2018; 19:451. [PMID: 30579337 PMCID: PMC6303903 DOI: 10.1186/s12891-018-2379-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/11/2018] [Indexed: 01/29/2023] Open
Abstract
Background The aetiology and pathogenesis of primary bone marrow oedema syndrome (BMES) remain unclear. This retrospective cross-sectional study in a large cohort of patients with BMES was performed to characterise the overall skeletal status and turnover in patients with BMES, with the aim of identifying risk factors for this disease. Methods Patients who were diagnosed with BMES on the basis of clinical and radiological (magnetic resonance imaging) findings in our outpatient clinic were identified retrospectively. Patient history, co-existing metabolic disorders, bone metabolism parameters (serum calcium, phosphate, 25-OH-D3, bone-specific alkaline phosphatase, parathyroid hormone, and osteocalcin, and urinary deoxypyridinoline) and bone mineral density (as measured by dual-energy X-ray absorptiometry) were extracted from the medical records. Patients with secondary causes for BMES were excluded from the study. Results Of the 171 patients, 65 were identified without secondary cause for BMES. Of the 65 patients, 61.5% were female. The mean age was 49.5 ± 16.7 years, and age-related BMES prevalence showed two peaks, one in adolescence (11–20 years) and one at an older age (51–70 years). BMES predominantly affected the weight-bearing joints, namely, the ankle/foot (55.1%), knee (22.4%) and proximal femur (16.3%). Thyroid disorders and secondary hyperparathyroidism were highly prevalent (21.5 and 21.4%, respectively). On average, the cohort had elevated deoxypyridinoline levels and low 25-OH-D3 levels (19.0 ± 7.5 μg/l in patients without vitamin D supplementation). Osteopenia and osteoporosis were diagnosed in 47.4 and 17.5% of patients, respectively. Conclusions BMES is associated with high bone turnover. Patients who are diagnosed with BMES should be screened carefully for bone metabolism disorders and their potential risk factors. Electronic supplementary material The online version of this article (10.1186/s12891-018-2379-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola Oehler
- Department of Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Haider Mussawy
- Department of Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany. .,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany.
| | - Tobias Schmidt
- Department of Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Tim Rolvien
- Department of Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestraße 59, 22529, Hamburg, Germany
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Shaner AC, Spiker AM, Goolsby MA, Kelly BT, Helfet DL. Case report: ischial stress fracture non-union in a college football player. J Hip Preserv Surg 2018; 5:312-318. [PMID: 30393560 PMCID: PMC6206699 DOI: 10.1093/jhps/hny019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/19/2018] [Indexed: 12/31/2022] Open
Abstract
Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.
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Affiliation(s)
- Adam C Shaner
- Department of Orthopaedic Surgery, Trauma Surgery, Westchester Medical Center, New York Medical College, NY, USA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, Sports Medicine and Hip Preservation, University of Wisconsin – Madison, Madison, WI, USA
| | | | - Bryan T Kelly
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David L Helfet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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25
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Kang S, Gao F, Han J, Mao T, Sun W, Wang B, Guo W, Cheng L, Li Z. Extracorporeal shock wave treatment can normalize painful bone marrow edema in knee osteoarthritis: A comparative historical cohort study. Medicine (Baltimore) 2018; 97:e9796. [PMID: 29384878 PMCID: PMC5805450 DOI: 10.1097/md.0000000000009796] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Bone marrow edema (BME) represents a reversible but highly painful finding in magnetic resonance imaging (MRI) of patients with knee osteoarthritis. The aim of this retrospective study was to evaluate the efficacy of extracorporeal shock wave treatment (ESWT) on painful BME in osteoarthritis of the knee.This study focuses on people who had early-to-mid stage osteoarthritis with knee pain and MRI findings of BME. Patients who underwent ESWT treatment or prescribed alendronate treatment in our department were analyzed. Knee pain and function were measured using the visual analog scale (VAS) for pain and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), respectively. The degree of BME was measured with MRI scans.A total of 126 patients who received ESWT treatment (Group A, n = 82) or alendronate treatment (Group B, n = 44) were included. All patients were followed up clinically and radiographically for a minimum of 12 months. The mean follow-up was 23.5 months (range, 12-38 months). The VAS and WOMAC score decreased more significantly after treatment in Group A than that in Group B (P <.01) within 3 months. In 6-month MRI follow-ups, there was higher incidence of distinct reduction and complete regression of BME of the affected knee in Group A than that in Group B (P <.01).ESWT is an effective, reliable, and noninvasive treatment in patients with painful BME in osteoarthritis of the knee followed by a rapid normalization of the MRI appearance. It has the potential to shorten the natural course of this disease.
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Affiliation(s)
| | - Fuqiang Gao
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Jun Han
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Tianli Mao
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Wei Sun
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Bailiang Wang
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Wanshou Guo
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Liming Cheng
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
| | - Zirong Li
- Department of Orthopedics, China-Japan Friendship Hospital, National Health and Family Planning Commission of the People's Republic of China, Peking Union Medical College, Beijing, China
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Pountos I, Giannoudis PV. The role of Iloprost on bone edema and osteonecrosis: Safety and clinical results. Expert Opin Drug Saf 2018; 17:225-233. [PMID: 29315006 DOI: 10.1080/14740338.2018.1424828] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Iloprost is a commercially available prostaglandin I2 (PGI2) analogue that is shown to have antithrombotic, vasodilatative and antiproliferative effects. A number of clinical studies have shown that Iloprost can be effective in the management of bone marrow oedema and the treatment of avascular necrosis. The aim of this manuscript is to present our current understanding on the effect of Iloprost on the treatment of these conditions. AREAS COVERED The authors offer a comprehensive review of the existing literature on the experimental and clinical studies analysing the effect of Iloprost on bone, bone marrow oedema and avascular necrosis. EXPERT OPINION The available data from the clinical studies suggest that Iloprost has limited effect in advanced stages of avascular necrosis. However, literature suggests that Iloprost administration can be a viable option in the management of bone marrow oedema and early stages of osteonecrosis. Despite these promising results its effect on bone homeostasis needs further elucidation. Moreover, further data on its safety, dosage and efficiency through randomized multicenter studies are desirable in order to reach final conclusions.
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Affiliation(s)
- Ippokratis Pountos
- a Academic Department of Trauma & Orthopaedics, School of Medicine , University of Leeds , Leeds , United Kingdom
| | - Peter V Giannoudis
- a Academic Department of Trauma & Orthopaedics, School of Medicine , University of Leeds , Leeds , United Kingdom
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27
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Stress and Insufficiency Fractures. Clin Rev Bone Miner Metab 2017. [DOI: 10.1007/s12018-017-9239-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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28
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Rolvien T, Schmidt T, Barvencik F, Amling M. Denosumab in bone marrow oedema syndrome. Response to Letter to the Editor of Injury. Injury 2017; 48:2368. [PMID: 28784253 DOI: 10.1016/j.injury.2017.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/28/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Tim Rolvien
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany
| | - Tobias Schmidt
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany
| | - Florian Barvencik
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany
| | - Michael Amling
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Lottestr. 59, 22529 Hamburg, Germany.
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Horas K, Fraissler L, Maier G, Jakob F, Seefried L, Konrads C, Rudert M, Walcher M. High Prevalence of Vitamin D Deficiency in Patients With Bone Marrow Edema Syndrome of the Foot and Ankle. Foot Ankle Int 2017; 38:760-766. [PMID: 28340550 DOI: 10.1177/1071100717697427] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bone marrow edema syndrome (BMOS) is a phenomenon primarily affecting the lower extremity. It is characterized by a sudden onset of pain and an ill-defined osseous hyperintense signal in magnetic resonance imaging. The main cause of BMOS is still largely unknown. Its pathophysiology is presumably multifactorial and it has recently been demonstrated that it usually involves an increase in bone turnover and alterations within the bone microenvironment. Vitamin D plays a pivotal role in maintaining a healthy and well-balanced bone microenvironment. However, to date only limited information has been reported on vitamin D status in patients with BMOS. Moreover, it is still uncertain whether hypovitaminosis D is associated with the etiology and course of the disease. For this reason, the aim of this study was to determine serum vitamin D levels (25(OH)D) of patients diagnosed with BMOS of the foot and ankle. METHODS Patients were identified and laboratory results collected by retrospective review of the medical records between year 2011 and 2015. Diagnosis was based on clinical examination, the existence of prolonged foot pain, the presence of abnormal bone marrow signal intensity in T1- and T2-weighted magnetic resonance imaging, and the patient's medical history. All patients who demonstrated other concomitant diagnoses were excluded from the study. RESULTS Overall, 31 patients were affected by BMOS with a mean age of 44.4 (range, 18-76) years. Notably, 84% of patients (26/31) had low vitamin D levels with a mean 25(OH)D level of 19.03 ng/mL. Specifically, 61% of patients (19/31) were vitamin D deficient, 23% (7/31) vitamin D insufficient, and only 5 patients (16%) had sufficient vitamin D levels. Statistical analysis showed no significant difference comparing vitamin D levels with patient age, sex, and time of diagnosis. Moreover, there was no correlation between vitamin D status and the number of bony foci or location of BMOS. CONCLUSION We found a widespread rate of vitamin D deficiency in patients presenting with BMOS of the foot and ankle. Comparing these data to the vitamin D status of the general population in Germany and to patients living in comparable latitudes, this raises the possibility that BMOS might be associated with low vitamin D status. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Konstantin Horas
- 1 Department of Orthopedics, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Lukas Fraissler
- 1 Department of Orthopedics, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Gerrit Maier
- 2 Department of Orthopedic Surgery, Pius-Hospital, Carl-von-Ossietzky-University, Oldenburg, Germany
| | - Franz Jakob
- 3 Orthopedic Center for Musculoskeletal Research, University of Wuerzburg, Wuerzburg, Germany
| | - Lothar Seefried
- 1 Department of Orthopedics, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Christian Konrads
- 1 Department of Orthopedics, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Maximilian Rudert
- 1 Department of Orthopedics, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
| | - Matthias Walcher
- 1 Department of Orthopedics, Koenig-Ludwig-Haus, University of Wuerzburg, Wuerzburg, Germany
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30
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Zhu Z, Otahal P, Wang B, Jin X, Laslett LL, Wluka AE, Antony B, Han W, Wang X, Winzenberg T, Cicuttini F, Jones G, Ding C. Cross-sectional and longitudinal associations between serum inflammatory cytokines and knee bone marrow lesions in patients with knee osteoarthritis. Osteoarthritis Cartilage 2017; 25:499-505. [PMID: 27836676 DOI: 10.1016/j.joca.2016.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe cross-sectional and longitudinal associations between serum levels of interleukin (IL) - 6, IL-17A, IL-17F, IL-23 and knee bone marrow lesions (BMLs) in patients with knee osteoarthritis (OA). DESIGN Patients (n = 192) with symptomatic knee OA (mean 63 years, range 50-79, female 53%) were assessed at baseline and after 24 months. At each time point, serum IL-6, IL-17A, IL-17F and IL-23 were measured using Bio-Plex® Multiplex Immunoassays with Luminex xMAP technology. Knee BMLs were scored using the modified whole organ MRI score (WORMS) from T2 weighted fat-suppressed fast spin echo magnetic resonance imaging (MRI). Multivariable linear regression and log binominal regression were used to determine the associations between cytokines and BMLs. RESULTS Baseline IL-6 (quarters) were significantly associated with total knee BMLs (P < 0.01 for the trend) as well as associated with an increase in BML score (P = 0.05 for the trend), after adjustment for confounders. Baseline IL-17F and IL-23 (highest quarters vs others) was associated with an increase in BML score in females (P = 0.04 for IL-17F; P = 0.01 for IL-23), but not in males, in multivariable analyses. In contrast, IL-17A was not significantly associated with BMLs in either females or males. CONCLUSION IL-6 is associated with increased knee BMLs in both females and males with OA. Serum IL-17F and IL-23 predicted increased knee BML scores in females only, suggesting that inflammation is involved in BML pathogenesis in knee OA, especially in women. TRAIL REGISTRATION ClinicalTrials.gov identifier: NCT01176344; Australian New Zealand Clinical Trials Registry: ACTRN12610000495022.
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Affiliation(s)
- Z Zhu
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Arthritis Research Institute, 1(st) Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - P Otahal
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - B Wang
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - X Jin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - L L Laslett
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - A E Wluka
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - B Antony
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - W Han
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - X Wang
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Arthritis Research Institute, 1(st) Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - T Winzenberg
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - F Cicuttini
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - G Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - C Ding
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Arthritis Research Institute, 1(st) Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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31
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Denosumab is effective in the treatment of bone marrow oedema syndrome. Injury 2017; 48:874-879. [PMID: 28242067 DOI: 10.1016/j.injury.2017.02.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/30/2017] [Accepted: 02/21/2017] [Indexed: 02/02/2023]
Abstract
Bone marrow oedema (BMO) syndrome describes a painful condition with increase of interstitial fluid within bone and is often lately diagnosed due to unspecific symptoms. The underlying causes are diverse while it is widely assumed that in cases of BMO local bone resorption is increased. Denosumab, a human monoclonal antibody that binds to the receptor activator of nuclear factor kappa-B ligand (RANKL) inhibits osteoclastic bone resorption and is commonly administered in the treatment of osteoporosis. Besides one previous case report, its clinical effectiveness in the treatment of bone marrow oedema has not been elucidated. We treated 14 patients with primary (idiopathic) bone marrow oedema of the lower extremity with single dose denosumab application. Mean time between onset of pain and therapy was 155days. MRI scans were performed for initial diagnosis, and 6-12 weeks after denosumab injection. Vitamin D and calcium homeostasis were strived to be balanced before initiation of therapy. Furthermore bone status was analysed using Dual-energy X-ray absorptiometry (DXA) and extended bone turnover serum markers. After 6-12 weeks, BMO dissolved partly or completely in 93%, while a complete recovery was observed in 50% of the individuals. Visual analogue scale (VAS) evaluation revealed a significant decrease in pain level. Furthermore, bone turnover decreased significantly after treatment. No adverse reactions were reported. In conclusion, our retrospective analysis shows that denosumab is highly effective in the treatment of bone marrow oedema and therefore represents an alternative treatment option.
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Abstract
Football is currently the most popular sporting activity in the world. Multiple reports have shown that a high incidence of osteoarthritis is found in football players. Evidence clearly shows that traumatic injury significantly predisposes players for such pathophysiology. Injuries are frequent in amateur as well as professional football players, with knee and ankle accounting for the most severe injuries. Many professional athletes lose playing time due to injuries and many are forced into early retirement. Posttraumatic osteoarthritis is a common finding among ex-football players with numbers well above the normal population. Today's surgical techniques are advanced and capable of restoring the joint to a certain extent. However, a restitution ad integrum is reached only in very rare cases. Professional football players that return to play after serious injuries perform their extremely strenuous activity on morphologically compromised joints. Incomplete rehabilitation and pressure to return to play after an injurious event clearly put the athlete at an even higher risk for joint degeneration. Prevention strategies, improved surgical management, strict rehabilitation, as well as future aspects such as early suppression of inflammation, personalized medicine, and predictive genomics DNA profiling are needed to reduce incidence and improve the health perspectives of football players.
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Affiliation(s)
- Gian M. Salzmann
- Musculoskeletal Centre, Orthopaedics Lower Extremities, Schulthess Clinic, Zurich, Switzerland,Gian M. Salzmann, Schulthess Klinik, Lengghalde 2, 8008 Zurich, Switzerland.
| | - Stefan Preiss
- Musculoskeletal Centre, Orthopaedics Lower Extremities, Schulthess Clinic, Zurich, Switzerland
| | - Marcy Zenobi-Wong
- Department of Health Sciences and Technology, Cartilage Engineering and Regeneration Laboratory, ETH Zurich, Switzerland
| | - Laurent P. Harder
- Musculoskeletal Centre, Orthopaedics Lower Extremities, Schulthess Clinic, Zurich, Switzerland
| | - Dirk Maier
- Department for Orthopedic Surgery and Traumatology, Freiburg University Hospital, Freiburg, Germany
| | - Jirí Dvorák
- Musculoskeletal Centre, Orthopaedics Lower Extremities, Schulthess Clinic, Zurich, Switzerland,FIFA Medical Assessment and Research Centre (F-MARC), FIFA, Zurich, Switzerland
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Flores-Robles BJ, Sanz-Sanz J, Sanabria-Sanchinel AA, Huntley-Pascual D, Andréu Sánchez JL, Campos Esteban J, Blanco R, Merino-Argumanez C, Espinosa-Malpartida M, Ramos-Giráldez MC, Godoy-Tundidor H, Jiménez-Palop MM, Barbadillo Mateos C, Villa-Alcázar LF, Isasi CM, Mulero JB. Zoledronic Acid Treatment in Primary Bone Marrow Edema Syndrome. J Pain Palliat Care Pharmacother 2017; 31:52-56. [PMID: 28287351 DOI: 10.1080/15360288.2016.1276993] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary bone marrow edema syndrome (BMES) is characterized by the combination of joint pain and distinctive magnetic resonance imaging changes. It has been suggested that the use of bisphosphonate drugs reduce symptom severity. Our objective was to review cases of patients diagnosed with BMES in the last 7 years who had been treated with zoledronic acid. Access to a pharmaceutical database was gained in order to obtain a list of zoledronic acid prescriptions. Based on clinical and MRI criteria for BMES, patients were selected. Baseline pain intensity was evaluated on a scale of 0 to 3 and was also assessed after 3 and 12 months. Functional recovery was evaluated by noting if a patient had returned to carrying out his or her normal daily activities. Out of 633 patients, 17 cases of BMES were identified (8 men), with a median age of 54 ± 14.1 years. The most frequently affected joint was the ankle (9), followed by the hip. Sixteen patients presented with moderate to severe pain initially. Of those patients, 13 had no pain after 12 months. Zoledronic acid is a option in the management of BMES, since 75% of patients treated with it presented with a complete response.
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34
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Mirghasemi SA, Trepman E, Sadeghi MS, Rahimi N, Rashidinia S. Bone Marrow Edema Syndrome in the Foot and Ankle. Foot Ankle Int 2016; 37:1364-1373. [PMID: 27587374 DOI: 10.1177/1071100716664783] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED Bone marrow edema syndrome (BMES) is an uncommon and self-limited syndrome characterized by extremity pain of unknown etiology. Symptoms may include sudden or gradual onset of swelling and pain at rest or during activity, usually at night. This syndrome mostly affects middle-aged men and younger women who have pain in the lower extremities. The most common sites involved with BMES, in decreasing order of frequency, are the bones about the hip, knee, ankle, and foot. The diagnosis of BMES is confirmed with magnetic resonance imaging to exclude other causes of bone marrow edema. The correct diagnosis in the foot and ankle often is delayed because of the low prevalence and nonspecific signs. This delay may intensify bone pain and impair patient function and quality of life. The goal of BMES treatment is to relieve pain and shorten disease duration. Treatment options are limited and may include symptomatic treatment, pharmacologic treatment, and surgery. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
| | - Elly Trepman
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Narges Rahimi
- Department of Physical Medicine & Rehabilitation, AJA Medical Science University, Tehran, Iran
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35
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Abstract
Tibial stress fractures are common in the athlete. There are various causes of these fractures, the most common being a sudden increase in training intensity. Most of these injuries are treated conservatively; however, some may require operative intervention. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. The physician must understand the nature of the fracture and the likelihood for it to heal in a timely manner in order to best treat these fractures in this patient subset.
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Affiliation(s)
- John J Feldman
- Department of Orthopaedics, University of Tennessee-Campbell Clinic, 49 South 4th Street, Apartment 208, Memphis, TN 38103, USA.
| | - Eric N Bowman
- Department of Orthopaedics, University of Tennessee-Campbell Clinic, 170 Alexander Street, Memphis, TN 38111, USA
| | - Barry B Phillips
- Department of Orthopaedics, Campbell Clinic Orthopaedics, University of Tennesee-Campbell Clinic, 1400 South Germantown Road, Germantown, TN 38138, USA
| | - John C Weinlein
- Department of Orthopaedics, University of Tennessee-Campbell Clinic, 145 Greenbriar Drive, Memphis, TN 38117, USA
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36
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Nie H, Cui Y, Wu S, Ding Y, Li Y. 1,25-Dihydroxyvitamin D Enhances Alveolar Fluid Clearance by Upregulating the Expression of Epithelial Sodium Channels. J Pharm Sci 2016; 105:333-8. [PMID: 26852863 DOI: 10.1016/j.xphs.2015.11.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/28/2015] [Accepted: 11/11/2015] [Indexed: 02/06/2023]
Abstract
Vitamin D is implicated in the pathogenesis of asthma, acute lung injury, and other respiratory diseases. 1,25-Dihydroxyvitamin D (1,25(OH)2D3), the hormonal form of vitamin D, has been shown to reduce vascular permeability and ameliorate lung edema. Therefore, we speculate that 1,25(OH)2D3 may regulate alveolar Na(+) transport via targeting epithelial Na(+) channels (ENaC), a crucial pathway for alveolar fluid clearance. In vivo total alveolar fluid clearance was 39.4 ± 3.8% in 1,25(OH)2D3-treated mice, significantly greater than vehicle-treated controls (24.7 ± 1.9 %, n = 10, p < 0.05). 1,25(OH)2D3 increased amiloride-sensitive short-circuit currents in H441 monolayers, and whole-cell patch-clamp data confirmed that ENaC currents in single H441 cell were enhanced in 1,25(OH)2D3-treated cells. Western blot showed that the expression of α-ENaC was significantly elevated in 1,25(OH)2D3-treated mouse lungs and 1,25(OH)2D3-treated H441 cells. These observations suggest that vitamin D augments transalveolar fluid clearance, and vitamin D therapy may potentially be used to ameliorate pulmonary edema.
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Affiliation(s)
- Hongguang Nie
- Institute of Metabolic Disease Research and Drug Development, China Medical University, Shenyang, Liaoning 110122, China.
| | - Yong Cui
- Department of Anesthesiology, First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110122, China
| | - Sihui Wu
- Institute of Metabolic Disease Research and Drug Development, China Medical University, Shenyang, Liaoning 110122, China
| | - Yan Ding
- Institute of Metabolic Disease Research and Drug Development, China Medical University, Shenyang, Liaoning 110122, China
| | - Yanchun Li
- Institute of Metabolic Disease Research and Drug Development, China Medical University, Shenyang, Liaoning 110122, China; Department of Medicine, Division of Biological Sciences, University of Chicago, Chicago, Illinois 60637
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Eriksen EF. Treatment of bone marrow lesions (bone marrow edema). BONEKEY REPORTS 2015; 4:755. [PMID: 26644910 PMCID: PMC4662576 DOI: 10.1038/bonekey.2015.124] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/07/2015] [Indexed: 11/09/2022]
Abstract
Bone marrow lesions (BMLs) or using older terminology 'Bone marrow edema' is characterised by excessive water signals in the marrow space on magnetic resonance imaging or ultrasound; BMLs constitute a central component of a wide variety of inflammatory and non-inflammatory rheumatologic conditions affecting the musculoskeletal system: BMLs are not only considered significant sources of pain but also linked to increased disease activity in many musculoskeletal conditions (for example, osteoarthritis, rheumatoid arthritis). The purpose of this review is to summarise current knowledge about the treatment of BMLs, with an emphasis on the clinical and histological features of this entity in inflammatory and non-inflammatory disease. We also try to pair this hypothesis with the apparent beneficial effects of various treatment regimens, mainly within the group of bone antiresorptive drugs (calcitonin, bisphosphonates) on symptoms associated with BMLs.
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Affiliation(s)
- Erik F Eriksen
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
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Abstract
BACKGROUND The development of bone marrow edema in body regions adjacent to joints can have many causes and a differentiation is not possible using magnetic resonance imaging (MRI). DEFINITION Bone marrow edema is not necessarily an indication for microfractures. The definition of bone marrow edema is a purely radiological description. There is no uniform classification of bone marrow edema. The clinical significance, therapy and course are heterogeneous; therefore, there are no uniform recommendations for therapy. DIAGNOSTICS A bone marrow edema visible in MRI does not always lead to certain inferences regarding the pathogenesis. In order to be able to detect fractures it is necessary to carry out a biopsy and a histological examination. CONCLUSION The interpretation of MRI results and the derivation of a therapy in every case need a balanced assessment of the MRI results, medical history, clinical investigations and clinical symptoms.
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Affiliation(s)
- C Rangger
- Klinik für Orthopädie und Unfallchirurgie, Krankenhaus Nord West, Steinbacher Hohl 2-26, 60488, Frankfurt, Deutschland,
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