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Di Martino A, Brunello M, Villari E, Cataldi P, D'Agostino C, Faldini C. Bone marrow edema of the hip: a narrative review. Arch Orthop Trauma Surg 2023; 143:6901-6917. [PMID: 37378892 DOI: 10.1007/s00402-023-04961-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
Bone marrow edema (BME) of the hip is a radiological-clinical condition with symptoms ranging from asymptomatic to severe, and it is characterized by increased interstitial fluid within the bone marrow, usually at the femur. Depending on the etiology it can be classified as primary or secondary. The primary cause of BME is unknown, while the secondary forms include traumatic, degenerative, inflammatory, vascular, infectious, metabolic, iatrogenic, and neoplastic etiologies. BME could be classified as reversible or progressive. Reversible forms include transient BME syndrome and regional migratory BME syndrome. Progressive forms include avascular necrosis of the femoral head (AVNH), subchondral insufficiency fracture, and hip degenerative arthritis. The diagnosis can be difficult, because at the beginning, the outbreak of hip pain, typically acute and disabling without any prior trauma or exceptional physical activity, is poorly supported by radiographic findings. MRI is the gold standard, and it shows an area of intermediate signal on T1-weighted MRI scans and a high signal on T2-weighted scans, usually lacking sharps margins. In the reversible form, BME is typically self-limiting, and it can be managed conservatively by means of pharmacological and physical therapy. Surgery is generally required for progressive forms in patients who failed non-operative treatment, and it ranges from femoral head and neck core decompression to total hip arthroplasty.
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Affiliation(s)
- Alberto Di Martino
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy.
| | - Matteo Brunello
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - Eleonora Villari
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - Piergiorgio Cataldi
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - Claudio D'Agostino
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G.B. Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Ha AS, Chang EY, Bartolotta RJ, Bucknor MD, Chen KC, Ellis HB, Flug J, Leschied JR, Ross AB, Sharma A, Thomas JM, Beaman FD. ACR Appropriateness Criteria® Osteonecrosis: 2022 Update. J Am Coll Radiol 2022; 19:S409-S416. [PMID: 36436966 DOI: 10.1016/j.jacr.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Osteonecrosis is defined as bone death due to inadequate vascular supply. It is sometimes also called "avascular necrosis" and "aseptic necrosis" when involving epiphysis, or "bone infarct" when involving metadiaphysis. Common sites include femoral head, humeral head, tibial metadiaphysis, femoral metadiaphysis, scaphoid, lunate, and talus. Osteonecrosis is thought to be a common condition most commonly affecting adults in third to fifth decades of life. Risk factors for osteonecrosis are numerous and include trauma, corticosteroid therapy, alcohol use, HIV, lymphoma/leukemia, blood dyscrasias, chemotherapy, radiation therapy, Gaucher disease, and Caisson disease. Epiphyseal osteonecrosis can lead to subchondral fracture and secondary osteoarthritis whereas metadiaphyseal cases do not, likely explaining their lack of long-term sequelae. Early diagnosis of osteonecrosis is important: 1) to exclude other causes of patient's pain and 2) to allow for possible early surgical prevention to prevent articular collapse and need for joint replacements. Imaging is also important for preoperative planning. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington.
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Roger J Bartolotta
- Division Chief, Musculoskeletal Imaging, Weill Cornell Medical College, New York, New York
| | - Matthew D Bucknor
- Associate Chair, Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Karen C Chen
- Musculoskeletal Radiology Section Chief, VA San Diego Healthcare System, San Diego, California
| | - Henry B Ellis
- Medical Director, Clinical Research, Texas Scottish Rite Hospital for Children, Dallas, Texas; American Academy of Orthopaedic Surgeons; Board of Directors, Pediatric Research in Sports Medicine; Board of Directors, Texas Orthopaedic Association; Council of Delegates, Texas Representative, AAOS
| | - Jonathan Flug
- Committee Chair, Radiology Quality Oversight, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jessica R Leschied
- Committee on Emergency Radiology-GSER, Henry Ford Health System, Detroit, Michigan
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Akash Sharma
- Chair, Research Committee, Radiology and Chair, PET-MRI Workgroup, Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging
| | - Jonelle M Thomas
- Vice-Chair, Clinical Affairs and Director, Radiology Informatics, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Osteonecrosis of the Femoral Head. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202205000-00002. [PMID: 35511598 PMCID: PMC9076447 DOI: 10.5435/jaaosglobal-d-21-00176] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 01/23/2022] [Indexed: 11/18/2022]
Abstract
Osteonecrosis of the femoral head is a progressive and debilitating condition with a wide variety of etiologies including trauma, steroid use, and alcohol intake. Diagnosis and staging are based on imaging including MRI at any stage and plain radiography in more advanced lesions. The only definitive treatment is total hip arthroplasty, although numerous treatments including disphosphonates and core decompression are used to delay the progression. Lack of satisfactory conservative measures suggests the need for additional research of osteonecrosis including large patient registries to further understand this condition.
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Kaneko K, Chen H, Kaufman M, Sverdlov I, Stein EM, Park‐Min K. Glucocorticoid-induced osteonecrosis in systemic lupus erythematosus patients. Clin Transl Med 2021; 11:e526. [PMID: 34709753 PMCID: PMC8506634 DOI: 10.1002/ctm2.526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 07/21/2021] [Accepted: 07/25/2021] [Indexed: 12/24/2022] Open
Abstract
Osteonecrosis (ON) is a complex and multifactorial complication of systemic lupus erythematosus (SLE). ON is a devastating condition that causes severe pain and compromises the quality of life. The prevalence of ON in SLE patients is variable, ranging from 1.7% to 52%. However, the pathophysiology and risk factors for ON in patients with SLE have not yet been fully determined. Several mechanisms for SLE patients' propensity to develop ON have been proposed. Glucocorticoid is a widely used therapeutic option for SLE patients and high-dose glucocorticoid therapy in SLE patients is strongly associated with the development of ON. Although the hips and knees are the most commonly affected areas, it may be present at multiple anatomical locations. Clinically, ON often remains undetected until patients feel discomfort and pain at specific sites at which point the process of bone death is already advanced. However, strategies for prevention and options for treatment are limited. Here, we review the epidemiology, risk factors, diagnosis, and treatment options for glucocorticoid-induced ON, with a specific focus on patients with SLE.
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Affiliation(s)
- Kaichi Kaneko
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
| | - Hao Chen
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Department of OrthopedicsBeijing Friendship HospitalBeijing100050China
| | - Matthew Kaufman
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Case Western Reserve School of MedicineClevelandOhio44106USA
| | - Isaak Sverdlov
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Tuoro College of Osteopathic Medicine‐New York CampusNew YorkNew York10027USA
| | - Emily M. Stein
- Endocrinology Service, Hospital for Special SurgeryNew YorkNew YorkUSA
- Metabolic Bone Disease Service, Hospital for Special SurgeryNew YorkNew YorkUSA
| | - Kyung‐Hyun Park‐Min
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomics Research CenterHospital for Special SurgeryNew YorkNew York10021USA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNew YorkUSA
- BCMB allied programWeill Cornell Graduate School of Medical SciencesNew YorkNew York10021USA
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Krez A, Lane J, Heilbronner A, Park-Min KH, Kaneko K, Pannellini T, Mintz D, Hansen D, McMahon DJ, Kirou KA, Roboz G, Desai P, Bockman RS, Stein EM. Risk factors for multi-joint disease in patients with glucocorticoid-induced osteonecrosis. Osteoporos Int 2021; 32:2095-2103. [PMID: 33877383 PMCID: PMC8056829 DOI: 10.1007/s00198-021-05947-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/01/2021] [Indexed: 12/24/2022]
Abstract
UNLABELLED This study investigated risk factors for osteonecrosis involving multiple joints (MJON) among glucocorticoid-treated patients. The best predictor of MJON was cumulative oral glucocorticoid dose. Risk of MJON was 12-fold higher in patients who had a second risk factor for osteonecrosis. Further research is needed into strategies for prevention of MJON. INTRODUCTION Osteonecrosis (ON) is a debilitating musculoskeletal condition in which bone cell death can lead to mechanical failure. When multiple joints are affected, pain and disability are compounded. Glucocorticoid treatment is one of the most common predisposing factors for ON. This study investigated risk factors for ON involving multiple joints (MJON) among glucocorticoid-treated patients. METHODS Fifty-five adults with glucocorticoid-induced ON were prospectively enrolled. MJON was defined as ON in ≥ three joints. Route, dose, duration, and timing of glucocorticoid treatment were assessed. RESULTS Mean age of enrolled subjects was 44 years, 58% were women. Half had underlying conditions associated with increased ON risk: systemic lupus erythematosus (29%), acute lymphoblastic leukemia (11%), HIV (9%), and alcohol use (4%). Mean daily oral dose of glucocorticoids was 29 mg. Average cumulative oral dose was 30 g over 5 years. The best predictor of MJON was cumulative oral glucocorticoid dose. For each increase of 1,000 mg, risk of MJON increased by 3.2% (95% CI 1.03, 1.67). Glucocorticoid exposure in the first 6 months of therapy, peak dose (oral or IV), and mean daily dose did not independently increase risk of MJON. The risk of MJON was 12-fold in patients who had a second risk factor (95% CI 3.2, 44.4). CONCLUSIONS Among patients with glucocorticoid-induced ON, cumulative oral dose was the best predictor of multi-joint disease; initial doses of IV and oral glucocorticoids did not independently increase risk. Further research is needed to better define optimal strategies for prevention and treatment of MJON.
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Affiliation(s)
- A Krez
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - J Lane
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - A Heilbronner
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - K-H Park-Min
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomic Research Center, Hospital for Special Surgery, New York, NY, USA
| | - K Kaneko
- Arthritis and Tissue Degeneration Program, David Z. Rosensweig Genomic Research Center, Hospital for Special Surgery, New York, NY, USA
| | - T Pannellini
- Research Division, Hospital for Special Surgery, New York, NY, USA
| | - D Mintz
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - D Hansen
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - D J McMahon
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - K A Kirou
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - G Roboz
- Department of Hematology and Oncology, Weill Cornell Medical Center, New York, NY, USA
| | - P Desai
- Department of Hematology and Oncology, Weill Cornell Medical Center, New York, NY, USA
| | - R S Bockman
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA
| | - E M Stein
- Endocrinology Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, USA.
- Metabolic Bone Disease Service, Hospital for Special Surgery, New York, NY, 10021, USA.
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Cajiao K, Setoain FJ, Peris P. Multifocal Osteonecrosis: The Usefulness of Bone Scintigraphy. J Clin Rheumatol 2021; 27:e196-e197. [PMID: 32251061 DOI: 10.1097/rhu.0000000000001364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yokota S, Sakamoto K, Shimizu Y, Asano T, Takahashi D, Kudo K, Iwasaki N, Shimizu T. Evaluation of whole-body modalities for diagnosis of multifocal osteonecrosis-a pilot study. Arthritis Res Ther 2021; 23:83. [PMID: 33706802 PMCID: PMC7947377 DOI: 10.1186/s13075-021-02473-3] [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] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/04/2021] [Indexed: 08/26/2023] Open
Abstract
Background This study aimed to investigate the ability of whole-body bone scintigraphy (WB-BS) in the detection of multifocal osteonecrosis (ON) compared to whole-body magnetic resonance imaging (WB-MRI) and to clarify the characteristics of patients with multifocal ON among those with ON of the femoral head (ONFH) using WB-MRI. Methods Forty-six patients who had symptomatic ONFH and underwent surgery in our hospital from April 2019 to October 2020 were included in the study. Data on patient demographics, including age, sex, body mass index (BMI), history of corticosteroid intake, alcohol abuse, smoking, and symptomatic joints, were collected from their medical records. All patients underwent WB-MRI and WB-BS before surgery. Results The agreement in the detection of ON by WB-MRI vs the uptake lesions by WB-BS in the hip joints was moderate (κ = 0.584), while that in other joints was low (κ < 0.40). Among the 152 joints with ON detected by WB-MRI, 92 joints (60.5%) were symptomatic, and 60 joints (39.5%) were asymptomatic. Twelve out of the 46 (26.0%) patients had multifocal (three or more distinct anatomical sites) ON. Nonetheless, while WB-BS detected symptomatic ON detected by WB-MRI as uptake lesions in 82.6% (76/92) of the joints, asymptomatic ON detected by WB-MRI was detected as uptake lesions in 21.7% (13/60) of the joints. All patients with multifocal ON had a history of steroid therapy, which was significantly higher than that in patients with oligofocal ON (P = 0.035). The patients with a hematologic disease had multifocal ON at a higher rate (P = 0.015). Conclusions It might be difficult for WB-BS to detect the asymptomatic ON detected by WB-MRI compared to symptomatic ON. Considering the cost, examination time, and radiation exposure, WB-MRI might be useful for evaluating multifocal ON. Larger longitudinal studies evaluating the benefits of WB-MRI for detecting the risk factors for multifocal ON are required.
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Affiliation(s)
- Shunichi Yokota
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Keita Sakamoto
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yukie Shimizu
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.,Department of advanced diagnostic imaging development, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tsuyoshi Asano
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Daisuke Takahashi
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Tomohiro Shimizu
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
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Boontanapibul K, Steere JT, Amanatullah DF, Huddleston JI, Maloney WJ, Goodman SB. Initial Presentation and Progression of Secondary Osteonecrosis of the Knee. J Arthroplasty 2020; 35:2798-2806. [PMID: 32527695 DOI: 10.1016/j.arth.2020.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/24/2020] [Accepted: 05/11/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Early detection and intervention are critical to maintaining the native articular cartilage before collapse in secondary osteonecrosis of the knee (SOK). We conducted a retrospective study documenting the initial stage of presentation and the progression of SOK. METHODS Our database was reviewed for patients younger than 65 years of age diagnosed with atraumatic SOK between 2002 and 2018. Demographic data, plain radiographs as well as MRI at initial evaluation, and initial treatment were classified and analyzed. RESULTS One hundred four patients with 164 knees were identified. Mean age was 39 ± 16 years. Females (64%) with bilateral disease (58%) predominated. Seventy-five percent of patients had a history of corticosteroid use, of which 41% were diagnosed with hematologic malignancy and lupus. Fifteen percent of patients had a history of ethanol abuse. At initial presentation, 55% of patients were diagnosed with Ficat-Arlet stage I/II, while 45% were diagnosed with Ficat-Arlet stage III/IV. We found a significant difference in the mean age of patients at early stage of SOK with corticosteroid use (31 ± 12 years of age) when compared to ethanol use (43 ± 13 years of age, P = .02). Treatments included observation (57%), joint preservation surgery (20%), and total knee arthroplasty (23%). CONCLUSION Nearly half of patients presented at late stage compromising the potential for joint preservation. The difference in age of referral by over a decade, based on etiology of SOK, suggests a strong provider-based referral or screening bias may be present. Hence, a multidisciplinary approach to earlier detection and referral may be a more effective strategy for preventing the progression of SOK.
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Affiliation(s)
- Krit Boontanapibul
- Stanford University Medical Center Outpatient Center, Redwood City, CA; Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Joshua T Steere
- Stanford University Medical Center Outpatient Center, Redwood City, CA
| | | | | | - William J Maloney
- Stanford University Medical Center Outpatient Center, Redwood City, CA
| | - Stuart B Goodman
- Stanford University Medical Center Outpatient Center, Redwood City, CA
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