Bone marrow edema syndrome of the third metatarsal bone: a rare cause of metatarsalgia treated with Iloprost

The Use of Iloprost in the Treatment of Bone Marrow Edema Syndrome of the Proximal Femur: A Review and Meta-Analysis

Objective: The aim of this meta-analysis was to investigate the impact of intravenous iloprost therapy on pain, function, edema changes, and follow-up surgery in bone marrow edema syndrome of the proximal femur. Methods: A systematic literature search up to May 2022 was performed to find relevant papers that made a statement about the outcome of intravenous iloprost therapy alone. Factors such as the Visual Analog Scale (VAS), Harris Hip Score (HHS), edema reduction, and follow-up interventions were considered. These were compared using Forest plots. Results: In 11 studies, 190 proximal femora with bone marrow edema syndrome that received intravenous iloprost therapy without further therapeutic intravenous or surgical intervention such as core decompression were studied. There was a significant mean improvement in VAS by 3.3 cm (2.07−4.5 cm) (p < 0.001) and HHS by 24.36 points (18.23−30.49) (p < 0.001) 3−6 months after receiving iloprost therapy. Only in 9.3% of cases (1.1−24.3%) did no clinical or radiological improvement occur. Conclusions: It could be shown that the existing publications support intravenous therapy with iloprost in patients with bone marrow edema syndrome and result in good clinical outcomes.

Technologies in the Treatment of Bone Marrow Edema Syndrome

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.

The role of Iloprost on bone edema and osteonecrosis: Safety and clinical results

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.

Bone Marrow Edema Syndrome in the Foot and Ankle

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.