Regional Migratory Osteoporosis of the Hip and Talus

Shahverdi, Mohammad Hasan; Salariye, Mostafa; Shokri, Hosein

doi:10.17795/soj-4098

Volume 3, Issue 1 (2-2016) JROS 2016, 3(1): 0-0 | Back to browse issues page

‎ 10.17795/soj-4098

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Shahverdi M H, Salariye M, Shokri H. Regional Migratory Osteoporosis of the Hip and Talus. JROS 2016; 3 (1)
URL: http://jros.iums.ac.ir/article-1-169-en.html

Regional Migratory Osteoporosis of the Hip and Talus

Mohammad Hasan Shahverdi

¹, Mostafa Salariye¹

, Hosein Shokri¹

1- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran

Keywords: Regional Migratory Osteoporosis, Recurrence, Hip, Talus

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Abstract

Conclusions: It is important to consider TOH in the differential diagnosis of middle-aged males and young females with hip pain. It should be included in the differential diagnosis of patients with acute foot and ankle pain. The importance of recognizing this condition lies in its self-limiting nature, with spontaneous resolution in less than a year in the majority of cases. Consequently, invasive investigations may often be avoided in these patients.

Copyright © 2016, Iran University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

2. Case Presentation

The patient is a 60-year-old male who complained of a gradually increasing pain in his left hip joint, when he was walking, without a history of any preceding trauma. The pain decreased over night and with rest and had worsened over the blast two months, therefore, his walking became painful. The patient did not have any significant risk factors.

Hip joint tenderness and slightly reduced passive range of motion of the joint at terminal were found on physical examination. The plain radiography and blood tests were normal (Figure 1). Bone scintigraphy showed increased uptake of radioisotope in the left femoral head and neck (Figure 2). Resting, non-NSAIDs (nonsteroidal anti-inflammatory drugs) analgesia and protected weight bearing were recommended. The patient’s hip pain improved completely after ten months and his walking was normal.

Figure 1. Transient Osteoporosis of the Left Hip

A, Pelvic radiograph obtained in a 60-year-old male with hip pain shows normal findings; B, MR images showed a BME pattern in the left femoral head and neck; C, MR T2-coronal image revealed diffuse and homogeneous high signal intensity throughout the left femoral head and neck.

Figure 2. Anterior and posterior whole-body bone scan demonstrated obviously increased uptake in the left femoral head and neck.

Five months after his full recovery, the patient represented with acute pain in his right ankle joint. He expressed that the pain was more severe than the previous hip joint involvement, and denied any history of precipitating event or trauma. The plain radiography and blood tests were normal. Magnetic resonance imaging (MRI) of his ankle joint demonstrated moderate joint effusion and severe deep soft tissue edema around the ankle with increased signal intensity on T2-weighted images and decreased signal intensity on T1-weighted images (Figure 3). The Findings were consistent with bone marrow edema syndrome. The patient received the same medications and recovered after six months.

Figure 3. A, Lateral T2-weighted MRI showing increased signal intensity; B, lateral T2-weighted MRI showing decreased signal intensity in the talus. Bone marrow edema syndrome consistent with these findings.

3. Discussion

Transient osteoporosis first explained by Curtiss and Kincaid in 1959 as transient demineralization of the hip in pregnant females (1) and was named “Transient osteoporosis of the hip” nine-years later by Lequesne (5) as an uncommon condition without proved etiology and pathology. It is indicated as regional migratory osteoporosis (RMO) when another involved adjacent joint with similar clinical and radiological features appears (6).

RMO manifestations include acute pain, most frequently in weight-bearing joints with local soft tissue swelling that progress rapidly and increase by weight bearing which make walking painful and influence the patient gait. It usually involves lower limb joints and few reports of upper limb involvement are published. Disease spreads through proximal to distal and hip is the most commonly joint involvement as primary following by the knee, ankle and foot (4). Symptoms subside over a nine-month period and then RMO involves another region. The knee, ankle and the hip respectively, are the joints which RMO usually involves in the first recurrence (4). RMO demineralization radiography manifestations may not be observable in plain radiography at first but computed tomography scan can show bone osteoporosis at this stage. Enhanced radioisotope uptake is observed in bone scintigraphy. Magnetic resonance imaging shows bone marrow edema features that increase signal intensity in T2-weighted sequences and decrease signal intensity in T1-weighted sequences. Dietary of low calcium intake and smoking were recommended as RMO risk factors (7). Differential diagnoses such as avascular necrosis (AVN), reflex sympathetic dystrophy (RSD), osteomyelitis and septic arthritis should be considered. RMO and AVN might have the same radiological appearances at first, but they have typically different risk factors (7). RSD can be ruled out by its skin change features, muscle atrophy, history of injury and more involvement of upper limb (8, 9). Normal blood tests are indicators to exclude some causes such as septic arthritis and osteomyelitis.

RMO is a self-limited disease with a spontaneous resolution, therefore, conservative treatment and following-up the patients are the best therapeutic strategies. Recommendations such as protected and limited weight-bearing and use of analgesics can result in complete resolution. Bisphosphonate (alendronate) and iloprost are helpful medications (10, 11). Surgical decompression for conservative therapy resistant cases can be a good choice (12). It seems that corticosteroids do not change the duration of the disease (13).

When a middle-aged male or a pregnant female especially in the third trimester of pregnancy presented with a history of acute weight-bearing joint pain in the clinic, without any trauma and probably with a history of smoking who has normal plain radiography and blood tests, one of the conditions that should be considered is transient osteoporosis and most of the times it is under-diagnosed or mislabeled. It is important to consider migratory osteoporosis as a differential diagnosis in such patients since RMO is a self-limited, reversible and good prognosis condition that can emulate some irreversible conditions such as avascular necrosis and bone neoplasm which need invasive investigations and costly therapeutic strategies. Also the patient should be oriented about recurrence nature of the disease in the same or another weight-bearing joint.

References

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Subject: Knee surgery
Received: 2019/09/9 | Accepted: 2016/02/15 | Published: 2016/02/15

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