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The Use of Iloprost in the Treatment of Bone Marrow Edema Syndrome of the Proximal Femur: A Review and Meta-Analysis. J Pers Med 2022; 12:jpm12111757. [PMID: 36573724 PMCID: PMC9695808 DOI: 10.3390/jpm12111757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 11/05/2022] Open
Abstract
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.
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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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Hörterer H, Baumbach SF, Gregersen J, Kriegelstein S, Gottschalk O, Szeimies U, Walther M. Treatment of Bone Marrow Edema of the Foot and Ankle With the Prostacyclin Analog Iloprost. Foot Ankle Int 2018; 39:1183-1191. [PMID: 29862844 DOI: 10.1177/1071100718778557] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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 (BME) of the foot and ankle is challenging to treat. One approach is intravenous Iloprost treatment, which is a vasoactive prostacyclin analog. The aim of this study was to evaluate the early and intermediate outcome of intravenous Iloprost therapy on BME of the foot and ankle and to analyze the influence of its etiology and Association Research Circulation Osseous (ARCO) stage on the outcome. METHODS This was a retrospective study with prospective follow-up. All patients treated by intravenous Iloprost for BME of the foot and ankle (ARCO I-III) at a single orthopedic reference center were included. Demographics, medical history, and MRIs were assessed prior to treatment (t0). MRIs were used to assess the BMEs' etiology (idiopathic/ischemic/metabolic, mechanical/degenerative, traumatic) and severity (ARCO). Complications as well as changes in pain, treatment, and MRI were evaluated after 3 months (t1). The following patient-rated outcome measures (PROMs) were assessed prospectively (t2): 12-Item Short Form Health Survey (SF-12), Visual Analog Scale Foot and Ankle (VAS FA), and the Foot Function Index (FFI) (also at t0). The descriptive outcomes and the influence of the etiology and ARCO on the outcome parameters were evaluated. Out of 70 eligible patients, 42 patients (60%; 47 ± 15 years; 30% female) with a mean follow-up of 28 ± 19 months were included. RESULTS Twelve patients reported minor complications during Iloprost therapy. At t1, pain decreased significantly in 56%, and the amount of BME decreased in 83% of patients. Both parameters correlated moderately (r = -0.463, P = .015). The PROMs at t2 revealed moderate results. The overall FFI improved from 59 ± 21 to 30 ± 22 ( P < .001), the overall VAS FA was 68 ± 20, the SF-12 Physical Component Summary 42 ± 12 and Mental Component Summary 50 ± 9. Subgroup analysis revealed no significant influence of the etiology or ARCO stage on any outcome measure. CONCLUSION Iloprost therapy for BME of the foot and ankle resulted in a 60% pain and 80% edema decrease after 3 months. After 2 years, patient-rated outcome measures showed residual impairment. Neither the etiology nor ARCO stage significantly influenced the outcome. LEVEL OF EVIDENCE Level III, comparative study.
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Affiliation(s)
- Hubert Hörterer
- 1 Schön Klinik München Harlaching, Center for Foot and Ankle Surgery, Munich, Germany.,2 Paracelsus Medical Private University, Salzburg, Austria
| | - Sebastian Felix Baumbach
- 3 University Hospital Munich, Department of General, Trauma, and Reconstructive Surgery, Munich, Germany
| | - Johanne Gregersen
- 1 Schön Klinik München Harlaching, Center for Foot and Ankle Surgery, Munich, Germany.,2 Paracelsus Medical Private University, Salzburg, Austria.,5 Department of Orthopedics and Orthopedic Surgery, Julius-Maximilians-University, Würzburg, Germany
| | - Stefanie Kriegelstein
- 1 Schön Klinik München Harlaching, Center for Foot and Ankle Surgery, Munich, Germany.,2 Paracelsus Medical Private University, Salzburg, Austria
| | - Oliver Gottschalk
- 1 Schön Klinik München Harlaching, Center for Foot and Ankle Surgery, Munich, Germany.,2 Paracelsus Medical Private University, Salzburg, Austria
| | | | - Markus Walther
- 1 Schön Klinik München Harlaching, Center for Foot and Ankle Surgery, Munich, Germany.,2 Paracelsus Medical Private University, Salzburg, Austria.,5 Department of Orthopedics and Orthopedic Surgery, Julius-Maximilians-University, Würzburg, Germany
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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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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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Beckmann J, Roth A, Niethard C, Mauch F, Best R, Maus U. [Bone marrow edema and atraumatic necrosis of the femoral head : Therapy]. DER ORTHOPADE 2016; 44:662-671. [PMID: 26245631 DOI: 10.1007/s00132-015-3146-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND An increase in interstitial bony fluid occurs in bone-marrow edema (BME). The exact pathogenetic processes still remain unknown. BME is an unspecific finding that can occur on its own or accompany multiple diseases and pathologies. GOAL Literature review and presentation of new guidelines. MATERIAL AND METHODS This is a narrative literature review followed by current advice for the therapy of atraumatic osteonecrosis of the hip, based on the recently published S3-guidelines for this disease. RESULTS AND DISCUSSION The differentiation of at least 3 different etiologies is proposed (mechanic, reactive and ischemic). Difficult, but important, is the distinction between the mostly painful, but benign entities (BME syndrome, bone bruise) and the progressive pathologies (osteonecrosis, arthritis, CRPS, tumour). Treatment options are dependent on etiology and clinic and can often be symptomatic. Core decompression is the surgical gold standard, leading to immediate pressure relief and therefore reduction in pain. Recently, it was shown that intravenous administration of Iloprost and bisphosphonates are also effective in achieving a reduction of BME and pain, with considerable improvement in the accompanying symptoms. The combination of core decompression and infusion seems to be another possible optimization ofthe therapy, in particular in the treatment of osteonecrosis.
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Affiliation(s)
- J Beckmann
- Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Deutschland.
| | - A Roth
- Bereich Endoprothetik/Orthopädie, Klinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universität Leipzig AöR, Leipzig, Deutschland
| | - C Niethard
- Orthopädische Gemeinschaftspraxis, Heinsberg, Deutschland
| | - F Mauch
- Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Deutschland
| | - R Best
- Sportklinik Stuttgart, Taubenheimstr. 8, 70372, Stuttgart, Deutschland
| | - U Maus
- Universitätsklinik für Orthopädie und Unfallchirurgie, Klinik für Orthopädie und spezielle orthopädische Chirurgie, Pius-Hospital Oldenburg, Oldenburg, Deutschland
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Claßen T, Becker A, Landgraeber S, Haversath M, Li X, Zilkens C, Krauspe R, Jäger M. Long-term Clinical Results after Iloprost Treatment for Bone Marrow Edema and Avascular Necrosis. Orthop Rev (Pavia) 2016; 8:6150. [PMID: 27114807 PMCID: PMC4821225 DOI: 10.4081/or.2016.6150] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 02/12/2016] [Accepted: 02/12/2016] [Indexed: 11/22/2022] Open
Abstract
The treatments of avascular osteonecrosis (AVN) include both conservative and surgical methods which are dependent on the stage and progression of the disease. The vasoactive-prostaglandin-analogue iloprost (PGI2) has been utilized in several areas of medicine and recently has been used for the treatment of AVN. A total of 108 patients with 136 osteonecrosis of different joints, etiology and severity were treated with iloprost. The mean follow-up was 49.71 months: range 15-96 months, and outcome measurements recorded regarding subjective complaints, visual analog scale (pain), function and survival. The outcome scores used include the Harris Hip Score, Knee Society score, Foot and Ankle Survey, visual analogue scale (VAS) and a separate questionnaire. The location and etiology of AVN in our study demonstrated the typical pattern. All of the observed side effects of the therapy were minor and completely reversible. Most of patients (74.8%) showed a significant improvement of subjective complaints and decrease in VAS pain scores after the treatment with iloprost. However, 20% of the treated joints with the stadium Association for Research on Osseous Circulation (ARCO) grade 2, 71% with ARCO 3 and 100% with ARCO 4 underwent subsequent total joint replacement. The medical treatment of bone marrow edema or avascular osteonecrosis by Iloprost provides an safe and effective alternative strategy in the management of AVN presenting in the early stages (ARCO 1 or 2). For more advanced stages (ARCO 3 or 4), surgical intervention should be prioritized.
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Affiliation(s)
- Tim Claßen
- Department of Orthopedics, University of Duisburg-Essen , Essen, Germany
| | - Antonia Becker
- Department of Orthopedics, University of Duisburg-Essen , Essen, Germany
| | - Stefan Landgraeber
- Department of Orthopedics, University of Duisburg-Essen , Essen, Germany
| | - Marcel Haversath
- Department of Orthopedics, University of Duisburg-Essen , Essen, Germany
| | - Xinning Li
- Department of Orthopedic Surgery, Boston University School of Medicine, Sports Medicine and Shoulder Surgery , Boston, MA, USA
| | - Christoph Zilkens
- Department of Orthopedics, Heinrich-Heine University , Düsseldorf, Germany
| | - Rüdiger Krauspe
- Department of Orthopedics, Heinrich-Heine University , Düsseldorf, Germany
| | - Marcus Jäger
- Department of Orthopedics, University of Duisburg-Essen , Essen, Germany
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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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Proposal of early retreatment with iloprost in partially responsive patients with bone marrow edema syndrome: a case report. ITALIAN JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.itjm.2012.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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