Primary bone marrow oedema syndromes

Bone marrow edema of the knee: a narrative review

Bone marrow edema (BME) is a frequent MRI finding in patients with knee pain. According to the etiology, BME of the knee can be classified into three main categories: ischemic, mechanic, and reactive. The diagnosis may be difficult, because of the specificity of symptoms and the poor radiographic findings. MRI is the gold standard, showing an area of altered signal of the bone with an high signal intensity on fat-suppressed, T2 weighted images, usually in combination with an intermediate or low signal intensity on T1 weighted images. Bone marrow edema tends to be self-limiting and, in most cases, resolves without any consequences in a varying amount of time. However, since it may evolve to complete joint destruction, early diagnosis and correct treatment are crucial to prevent the articular degeneration. Conservative therapy is the first step, with no weight-bearing for 3 to 6 weeks on the affected side, in combination with the administration of anti-inflammatory drugs or painkillers to manage symptoms. In non-responding forms and more advanced stages, minimally invasive preservative surgery can provide significant results, with subchondroplasty and core decompression being the two main procedures available. Knee arthroplasty, both total (TKA) or unicompartmental (UKA), is the only effective option when the degradation of cartilage is diffuse and in patients with subchondral bone collapse.

The terminologies of transient, migratory, or localized osteoporosis, and bone marrow edema syndrome: a scoping review

There is no formally defined terminology for the related entities transient osteoporosis of the hip (TOH), localized or regional migratory osteoporosis (RMO) and bone marrow edema syndrome (BMES). This study aimed to map the diversity and frequency of diagnostic terms and vocabulary utilized in the literature. A comprehensive search of electronic databases and reference lists was conducted. Publications that reported on patients with TOH, RMO, BMES, or related variants were eligible for inclusion. The terminologies were categorized based on the wording of the titles, abstracts, or texts. We included 561 publications, of which 423 were case reports, involving 2921 patients. Overall, TOH was the most commonly used term, occurring in 257 (45.8%). RMO was used in 34 (6.1%) and BMES in 57 (10.2%). The remaining used various combinations of transient, migratory, and regional in conjunction with either osteoporosis or bone marrow edema. Localized osteoporosis was not used. We identified three different terms related to pregnancy. In 76.3% of the publications, the terminology was related to osteoporosis and in 18.2% to bone marrow edema, although terminology did not correspond to actual findings. Bone marrow edema occurred as often as osteoporosis, and osteoporosis was generally ascertained by visual inspection of radiographs, seldom by bone densitometry. Many publications used osteoporosis-related terms without evidence that osteoporosis had been detected. The terminology of these closely related entities is confusing and unstandardized. The lack of formal definitions impedes accurate diagnosis, research on disease mechanisms, and effective treatment.

Case study: Gait assessment of a patient with hallux rigidus before and after plantar modification

INTRODUCTION AND IMPORTANCE

Hallux rigidus (HR) is a degenerative arthritis affecting the first metatarsophalangeal joint (MTP), leading to pain and functional impairment, particularly during the propulsive phase of walking. The prevalence of HR is about 2.5 % in individuals over 50, but younger individuals can also be affected, as demonstrated in this case.

CASE PRESENTATION

We report the case of a 26-year-old patient with a body mass index (BMI) of 20.2, who has been suffering from HR for 5 years. The patient presented with walking difficulties, characterized by a limp and impaired propulsion phase, and pain in the right foot due to HR. A comprehensive gait assessment was conducted using a baropodometric platform and integrated smartphone motion sensors. Following the diagnosis, a non-surgical intervention involving the application of a compressed cotton felt foot orthosis at the MTP plantar area was initiated. This intervention aimed to alleviate pain and improve the functional mobility of the right big toe. Post-treatment assessments showed an increase in the big toe's mobility from 0 degrees to 35 degrees, as measured by a digital goniometer.

CLINICAL DISCUSSION

The application of a soft support, such as compressed cotton felt, at the plantar area of MTP, demonstrated a potential non-surgical therapeutic approach to improve gait and reduce discomfort in HR patients.

CONCLUSION

This case study underscores the potential benefits of plantar modification in the management of HR.

Quantitative MR Analysis of Changes in the Radius Bone Marrow in Osteoporosis

Purpose

This pilot study aimed to explore the feasibility of scanning the human distal radius bone marrow in vivo to detect osteoporosis-related changes using magnetic resonance and evaluate whether the radius may serve as an accessible probing site for osteoporosis. This may lead in the future to the use of affordable means such as low-field MRI scanners for the monitoring of disease progression.

Methods

A clinical trial was performed using a 3T MR scanner, including 26 women assigned into three study groups: healthy-premenopausal (n = 7; mean age 48.6 ± 3.5 years), healthy-postmenopausal (n = 10; mean age 54.5 ± 5.6 years), and osteoporotic-postmenopausal (n = 9; mean age 61.3 ± 5.6 years). Marrow fat composition was evaluated using T2 maps, a two-compartment model of T1, and a Dixon pulse sequence.

Results

The osteoporotic group exhibited higher fat content than the other two groups and lower T2 values than the healthy-premenopausal group.

Conclusions

Osteoporosis-related changes in the composition of the distal radius bone marrow may be detected in vivo using MRI protocols. The scanning protocols chosen here can later be repeated using low-field MRI scanners, thus offering the potential for early detection and treatment monitoring, using an accessible, affordable means that may be applied in small clinics. This trial is registered with MOH_2018-05-23_002247, NCT03742362.

Evaluation of the effect of vitamin D level on greater tuberosity primary bone marrow edema

INTRODUCTION

The anabolic effects of vitamin D on bone tissue have been demonstrated in experimental studies. The aim of this study was to evaluate the relationship between greater tuberosity primary bone marrow edema (GTPBMO) and vitamin D levels.

MATERIALS AND METHODS

Thirty-nine patients (22 females and 17 males; mean age 49.02 ± 13.08 years) with isolated GTPBMO between March 2016 and March 2018 were included in the study. Sixty patients (34 females and 26 males; mean age 43.45 ± 12.61 years) who did not have any shoulder complaints and fulfilled the study criteria were selected as the control group. Both groups were compared in terms of vitamin D levels.

RESULTS

The mean vitamin D level was 13.43 ± 9.02 ng/mL in the GTPBMO group. In contrast, mean vitamin D level was 21.54 ± 8.03 ng/mL in the control group (p < 0.001). In the GTPBMO group, vitamin D deficiency was detected in 31 (79.5%) patients, vitamin D insufficiency was detected in 5 (12.8%) patients, and vitamin D levels were normal in 3 (7.7%) patients. In the control group, vitamin D deficiency was detected in 29 (48.3%) patients, vitamin D insufficiency was detected in 16 (26.7%) patients, and vitamin D levels were normal in 15 (25%) patients.

CONCLUSION

The etiology of GTPBMO has not yet been fully understood, but the results obtained in this study show that vitamin D levels were significantly lower in patients with GTPBMO. The findings suggest that low vitamin D levels may be one of the contributing factors in the etiology of GTPBMO.

Bone marrow edema of the hip: a narrative review

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.

Wrist Injuries in Climbers

BACKGROUND

Acute and chronic injuries to the wrist are among the most common sport-related complaints of climbing athletes but have not been extensively evaluated in this population. Therefore, it is important to categorize climbing injuries to the wrist, analyze risk factors, and assess treatment outcomes.

PURPOSE

To evaluate the distribution, outcomes, and influencing factors of wrist injuries in climbers.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Climbing athletes with wrist injuries who presented to our specialized sports medical center over the course of 4 years (2017-2020) were selected. All had prospectively completed questionnaires including their climbing-specific background (years of training, climbing level, training methods, etc). Injuries were analyzed (International Climbing and Mountaineering Federation [UIAA] grade and diagnosis), and treatment methods and outcomes were retrospectively assessed with a minimum follow-up of 2 years. Parameters included the climbing score, visual analog scale for pain score, Patient-Rated Wrist Evaluation (PRWE) score, and shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score including the sport component (DASH-Sport) score before and after treatment as well as time to return to climbing.

RESULTS

A total of 69 patients (25 female, 44 male) with 78 wrist injuries were identified and analyzed. Of these, 7 injuries were bilateral, occurring at the same time, and 2 injuries were independent reinjuries to either the same or the contralateral side. In addition, 24 injuries (30.8%) were acute, while 54 (69.2%) were chronic. Overall, 2 injuries had a UIAA grade of 3; all others had a UIAA grade of 2. The most frequent injuries were synovitis of the ulnocarpal recess, ulnar impaction, bone marrow edema of the lunate, wrist sprains (joint capsular pain with stress, with no pathological finding on magnetic resonance imaging), and wrist ganglion cysts. Nonoperative treatment was performed for 61 of the injuries, while 17 were treated surgically. In 51 cases (65.4%), injuries healed without consequences; in 27 cases (34.6%), discomfort remained. The visual analog scale pain score decreased from 4.8 ± 1.9 before treatment to 0.7 ± 1.0 after treatment (P < .001), the PRWE score decreased from 53.6 ± 24.9 to 10.3 ± 13.1 (P < .001), the QuickDASH score improved from 53.0 ± 16.6 to 20.0 ± 20.2 (P < .001), and the DASH-Sport score improved from 82.0 ± 16.1 to 38.1 ± 23.5 (P < .001). The climbing score improved from 2.5 ± 1.1 to 4.3 ± 1.0 points (P < .001). The patient-reported number of days with pain was negatively correlated with changes in the PRWE score (r = -0.351; P < .001), QuickDASH score (r = -0.316; P = .007), and climbing score (r = -0.264; P = .025) as well as the number of days without climbing (r = -0.266; P = .025). The number of days without climbing was positively correlated with changes in the PRWE score (r = 0.369; P < .001).

CONCLUSION

Wrist injuries in climbers constituted a diverse set of diagnoses. Ulnar-sided injuries were most common, and many patients had >1 diagnosis. Outcomes for all treatment methods (surgery and nonoperative care) were favorable, but approximately one-third of climbers had persistent wrist discomfort after treatment, underscoring the need for accurate diagnoses and acute and expert care.

The correlation between transient osteoporosis of the hip and pregnancy: A review

Transient osteoporosis of the hip is indubitably a comparatively infrequent entity affecting both men and women worldwide. Its occurrence in the course of pregnancy, specifically in the third trimester, and lactation are of paramount concernment. The exact association between transient hip osteoporosis and pregnancy is precarious. Etiology and potential pathophysiological mechanisms behind this correlation are still to be utterly defined. Magnetic resonance imaging is highly regarded as the gold standard imaging method for assiduous assessment of this disorder. Physicians of copious medical specialties should practice scrupulous techniques for early and pertinent diagnosis when pregnant women are presented with persistent hip pain, as differential diagnosis with femoral head avascular necrosis can be exceedingly arduous. Treatment is predominantly conservative with protected weight-bearing and analgesic medication in the first line of management. In terms of prognosis, the disease ordinarily resolves spontaneously after a few months. Further research is required in order to elucidate the ambiguity surrounding the establishment of globally approved diagnosis and treatment guidelines for pregnancy-associated transient hip osteoporosis. This paper aims to accentuate the significance of this particular disorder by providing a succinct review of the existing literature, augmenting clinicians' knowledge about the features of pregnancy-related transient proximal femur osteoporosis.

Subchondral insufficiency fractures, subchondral insufficiency fractures with osteonecrosis, and other apparently spontaneous subchondral bone lesions of the knee-pathogenesis and diagnosis at imaging

Subchondral insufficiency fractures (SIFs) and SIFs with osteonecrosis (SIF-ONs) of the knee (previously misnamed spontaneous osteonecrosis of the knee (SONK)) are bone lesions that appear without prior traumatic, tumoral, or inflammatory event.Both conditions are characterized in the early stages by epiphyseal bone marrow edema (BME)-like signal at MRI. However, while SIFs usually heal spontaneously, they can also evolve to osteonecrosis (i.e., SIF-ON), which may progress to an irreversible collapse of the articular surface. Careful analysis of other MRI signs may help differentiate the two conditions in the early phase. In SIFs, the BME edema-like signal extends to the area immediately adjacent to the subchondral plate, while in SIF-ONs, this subchondral area shows low signal intensity on fluid-sensitive MR images due to altered bone marrow. The thickness and length of subchondral areas with low fluid-sensitive signal intensity are important factors that determine the prognosis of SIF-ONs. If they are thicker than 4 mm or longer than 14 mm, the prognosis is poor. The differential diagnosis of SIFs and SIF-ONs include bone lesions associated with the "complex regional pain syndrome" (CRPS), epiphyseal osteonecrosis of systemic origin, and those related to cartilage pathology.Clinical relevance statement Imaging plays an essential role in diagnosing subchondral insufficiency fractures (SIFs) from subchondral insufficiency fractures with osteonecrosis (SIF-ONs) and collapse, as well as in distinguishing them from other spontaneous knee subchondral bone lesions presenting with bone marrow edema-like signal.Key points• Subchondral insufficiency fractures may affect the knee, especially in older adults.• Subchondral insufficiency fractures usually heal spontaneously.• Sometimes, subchondral osteonecrosis and collapse may complicate subchondral insufficiency fractures.• Bone marrow-like edema is an aspecific sign seen in all these lesions.• Degraded marrow in osteonecrosis complicating fractures is hypointense on fluid-sensitive sequences.

Management of transient bone osteoporosis: a systematic review

INTRODUCTION

Transient bone osteoporosis (TBO) is characterized by persistent pain, loss of function, no history of trauma and magnetic resonance image (MRI) findings of bone marrow edema.

SOURCE OF DATA

PubMed, Google scholar, EMABSE and Web of Science were accessed in February 2023. No time constrains were used for the search.

AREAS OF AGREEMENT

TBO is rare and misunderstood, typically affecting women during the third trimester of pregnancy or middle-aged men, leading to functional disability for 4-8 weeks followed by self-resolution of the symptoms.

AREAS OF CONTROVERSY

Given the limited evidence in the current literature, consensus on optimal management is lacking.

GROWING POINTS

This systematic review investigates current management of TBO.

AREAS TIMELY FOR DEVELOPING RESEARCH

A conservative approach leads to the resolution of symptoms and MRI findings at midterm follow-up. Administration of bisphosphonates might alleviate pain and accelerate both clinical and imaging recovery.

Pathological femoral neck fracture in a male patient due to non-simultaneous bilateral transient hip osteoporosis: A case report: Statements and Declarations

We report a case of a 31-year-old man who developed a non-simultaneous bilateral transient hip osteoporosis (THO) complicated with an atraumatic undisplaced pathological femoral neck fracture (FNF) of his left hip. He was successfully treated with internal fixation on the left hip, and a follow-up Magnetic Resonance Imaging evidenced satisfactory resolution on the right side. Diagnosis and management of THO are usually challenging as symptoms before pathological FNFs might be misdiagnosed. This case highlights the importance of suspecting pathological FNFs when pain persists despite conservative treatment. Finally, surgical treatment is strongly recommended if a pathological FNF is confirmed.

Level of evidence

Level IV.

Subchondral stress fracture of the femoral head (SSFFH) in young and healthy military recruits: clinical recommendations and fracture configurations on MRI

PURPOSE

This study aimed to evaluate the clinical and radiologic characteristics of the fatigue-type of SSFFH in healthy military recruits.

MATERIALS AND METHOD

We retrospectively analyzed 39 hips from 32 patients who were treated for SSFFH between 2014 and 2018. Clinical variables were analyzed. We devised a categorization system that divided SSFFH into five types (A-E) according to the extent of the fracture line MRI axial view. The femoral head was divided into three parts for the categorization: the anterior third, middle third, and posterior third.

RESULTS

The included patients were 39 hips from 32 patients with the mean age 22.3 years. Almost all patients with SSFFH (96.9%) complained of hip pain with limping at the time of diagnosis. The mean time to the onset of the hip pain from the beginning of military training was 24.8 days. There were seven patients (21.9%) with concomitant stress fractures on whole-body bone scan. Six hips (15.4%) developed osteoarthritis and required surgery. Almost all the cases (94.9%) involved the anterior compartment of the femoral head.

CONCLUSIONS

Military recruits with the hip pain and limping within one month of military training should undergo detailed evaluation. A whole-body bone scan with SPECT is useful for identifying other concomitant stress fractures. Majority of SSFFH involved the anterior compartment of the femoral head.

Influence of Vitamin D and C on Bone Marrow Edema Syndrome-A Scoping Review of the Literature

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.

Is bone marrow oedema in patients with labral tear an indicator of hip pain?

Background

Hip labral tear (LT) causes various degrees of hip pain, for which there are few objective measures. Bone marrow oedema (BME), characterized by a diffuse, widely spreading change in the bone marrow, is observed in some patients with LT. However, its pathological role has not been fully understood. The purpose of this study was to investigate the prevalence of BME on hip magnetic resonance imaging (MRI) in patients with LT and to determine whether BME was an objective indicator of hip pain.

Methods

In total, 84 patients with LT who underwent MRI scanning under the same conditions were included. We determined the presence or absence of BME and its size on MRI and evaluated the relationships between BME and sex, age, and pain and total scores on the modified Harris hip score (MHHS). In addition, we collected data on surgical treatments such as hip arthroscopy within a one-year follow-up period and examined whether the presence of BME affected the course of therapy.

Results

BME was found in 34.5% of patients. MHHS pain and total scores were significantly lower in patients with BME (MHHS pain score: non-BME vs. BME ≤ 1 cm: p = 0.022, non-BME vs. BME > 1 cm: p < 0.001; MHHS total score: non-BME vs. BME ≤ 1 cm: p = 0.131, non-BME vs. BME > 1 cm: p = 0.027). The presence of BME did not differ between patients who did and did not undergo surgery during follow-up (p = 0.563).

Conclusion

BME on MRI in patients with LT might be an indicator of hip pain and hip joint dysfunction.

Beyond the Hip Labrum: A Pictorial Review

Magnetic resonance arthrography and 3T magnetic resonance imaging of the hip are a technique commonly performed in young, physically active patients presenting with pain relating to the hip, with the focus on assessing for the presence of labral tears and femoroacetabular impingement. Abnormal signal within the labrum can be misleading, however, as labral tears are a frequent incidental finding and have been identified in a large proportion of the asymptomatic population. A range of extralabral conditions can cause hip-related pain in young patients, including pathology related to the bones, joints, and periarticular soft tissues. It is vital that the radiologist is aware for these pathologies and examines for them even in the presence of a confirmed labral tear. In this article, we review a range of common extralabral pathologies responsible for hip pain and highlight review areas that aid in their diagnosis.

Neridronate for transient osteoporosis of the hip in a child

Transient osteoporosis of the hip (TOH) is usually reported in middle-aged men or during pregnancy as a benign self-limiting condition. Nevertheless, its impact on quality of life in terms of pain and disability is considerable. Also, it can lead to insufficiency fractures or, more rarely, evolve into osteonecrosis. This condition is anecdotally described in the pediatric age and very little is known about how it may affect the growing bone. We herein describe a case of TOH in a 10-year-old child treated at our pediatric rheumatology service and summarize the pediatric cases of TOH previously reported in literature. There are two points of interest in our case report, the first one being the unusual complication of TOH with a femoral physis fracture and the second the complete recovery after the off-label therapy with bisphosphonates. We suggest that interventional medical treatment could be considered in selected cases of juvenile TOH, to prevent any possible irreversible damage on the femoral physis. As far as we know, this is the first report of neridronate employment in children affected by TOH.

"Pregnancy and Lactation Associated Osteoporosis"

Pregnancy-associated osteoporosis (PAO) is a rare condition of skeletal fragility affecting women in pregnancy or the postpartum period. During normal pregnancy and lactation, substantial changes in calcium metabolism and skeletal physiology occur in order to meet the demands of the developing foetus. Whilst these adaptations are reversible and generally of no clinical consequence for the mother, a small number of women will develop osteoporosis and suffer fragility fractures. Vertebral fractures occur most commonly in PAO and are often multiple. Due to the rarity of PAO, systematic study to date has been limited. Aetiology is poorly understood, but traditional osteoporosis risk factors and genetic factors are likely to play a role. A small number of cases may be due to an underlying metabolic bone disorder or monogenic condition. Management of PAO is challenging, due both to a poor evidence base and the fact that spontaneous improvement in BMD is known to occur once pregnancy and lactation are complete. Bisphosphonates, denosumab and teriparatide have all been used in individual patients, but the data supporting their use are currently limited.

Efficacy of Zoledronic Acid in the Treatment of Nonmalignant Painful Bone Marrow Lesions: A Triple-Blind, Randomized, Placebo-Controlled Phase III Clinical Trial (ZoMARS)

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).

Bone Marrow Edema: Overview of Etiology and Treatment Strategies

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Bone marrow edema (BME) is a nonspecific but relevant finding, usually indicating the presence of an underlying pathology.

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The gold standard technique for detecting BME is magnetic resonance imaging (MRI), as it allows for a correct diagnosis to be made, which is extremely important given the heterogeneity of BME-related diseases.

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Depending on the severity of painful symptomatology and the MRI evidence, different treatment strategies can be followed: physical modalities, pharmacological options, and surgical therapy.

A novel mutation in collagen gene COL1A2 associated with transient regional osteoporosis

A young man was diagnosed with transient regional osteoporosis (TRO). The genetic analysis revealed a novel de novo likely pathogenic variant in COL1A2 gene. Our hypothesis is that TRO may be a possible clinical manifestation of osteogenesis imperfecta due to a reduced bone mass and an impaired trabecular mechanical competence.

INTRODUCTION

Transient regional osteoporosis (TRO) is a disease characterized by episodes of pain in the lower limbs involving the hip, knee, ankle or foot. Here, we present a clinical case of a Caucasian 25-year-old man exhibiting TRO. Based on few mild clinical findings suggestive of osteogenesis imperfecta (OI), but without a history of fragility fractures, we performed a genetic assessment to investigate this hypothesis.

METHODS

Medical history was obtained from the patient and family members, including biochemical, RMI and DXA assessments. Next-generation sequencing of COL1A1, COL1A2, COL2A1, CASR, CYP19A1, CUL7, CRTAP, KAL1, LEPRE1, LRP5, PPIB and SLC9A3R1, genes involved in juvenile osteoporosis, was performed.

RESULTS

We identified a novel de novo heterozygous missense variant, c.488G > A, in exon 11 of the COL1A2 gene (NM_000089.3), resulting in the putative p.Gly163Asp substitution in the N-terminal part of the helical domain of type I collagen. The variant was predicted to be damaging by the in silico prediction tools and the mutation was therefore classified as likely pathogenic. This mutation can affect skeletal health impairing bone mass and trabecular mechanical competence, inducing a disease whose features strictly evoke a TRO.

CONCLUSION

The present study describes a novel de novo heterozygous missense variant in COL1A2 gene, possibly inducing a propensity to trabecular microfractures. The recurrent symptomatic bone marrow oedema episodes could be the clinical picture consistent with the hypothesis of an inherited connective tissue disorder giving bone fragility.

Evolutionary course of the femoral head osteonecrosis: Histopathological - radiologic characteristics and clinical staging systems

Osteonecrosis of the femoral head (ONFH) is a recalcitrant ischemic disorder, which could be classified into two major categories: traumatic and nontraumatic. Regardless of different risk factors, it has been testified that ONFH results from primitive vascular problems, leading to temporary or permanent loss of blood supply to bone tissue. Histopathological and microarchitectural alterations ensues, which is a gradual evolutionary process involving bone marrow and osteocyte necrosis, progressive destruction of subchondral bone, unsuccessful reparative process, and eventual articular collapse and degenerative arthritis. Based on the imaging features of ONFH, different classification systems have been developed to evaluate the severity and prognosis of the disease, which is pivotal for implementation of treatment strategy, especially the joint-preserving surgery. However, patients classified with the same severity stage, especially in the peri-collapse stage, sometimes responded differently after similar joint-preserving surgery. The unusual phenomenon may be attributed to the limitation of the current imaging classification systems, which might underestimate the disease severity, especially when referring to the early stages. In this review, we briefly summarize the etiology and pathogenesis of ONFH. The imaging features and staging classification systems of ONFH are also described. More importantly, we focus on histopathological and microstructural alterations of the femoral head, and provide an overview of their essential contribution to ONFH progression. Given the observation of discordance between imaging characteristics and histopathological alterations, a substantial amount of research on the relationship between imaging and histopathological features is required to further modify and revise the current wide-accepted classification systems.

Pathogenesis of Axial Spondyloarthritis - Sources and Current State of Knowledge

Scientific breakthroughs have culminated in the development of the spondyloarthritis (SpA) concept as a family of rheumatic diseases, distinct from rheumatoid arthritis. The demonstration of inflammatory lesions in the sacroiliac joints and spine of patients with axial symptoms of SpA who lacked radiographic features of ankylosing spondylitis (AS) helped refine the SpA concept. Axial SpA includes patients with AS and patients with axial symptoms previously categorized as undifferentiated SpA. This review examines the sources of knowledge that inform axial SpA pathogenesis, highlighting current limitations, and a basic working model of axial SpA pathogenesis.

Avascular necrosis of the first metatarsal head in a young female adult: A case report and review of literature

BACKGROUND

This case study describes an atypical presentation of avascular necrosis (AVN) of the first metatarsal head, which is largely unfounded in the literature.

CASE SUMMARY

A healthy 24-year-old female initially presented with pain at the first metatarsophalangeal joint (MTPJ) and was diagnosed with AVN by physical examination and magnetic resonance imaging. The patient demonstrated atypically poor progress in recovery, despite being in otherwise good health and being of young age, with no history of corticosteroid or alcohol use. The patient also did not have any history or clinical features of autoimmune disease or vasculitis, such as systemic lupus erythematosus. The patient was managed with conservative treatment for 18 mo, which allowed for gradual return of full range of motion of the first MTPJ and subsiding pain, permitting the patient to return to high-intensity sports training and full weight-bearing. Throughout her recovery, many differential diagnoses were ruled out through specific investigations leading to further reinforcement of the diagnosis of AVN of the 1^st metatarsal head.

CONCLUSION

Atypical AVN may occur with no predisposing risk factors. Treatment is mainly conservative, with unclear guidelines in literature on management.

Similarity in Sequential Bilateral Transient Osteoporosis of the Hip: A Report of 3 Cases

CASE

Three middle-aged men with habitual drinking developed unilateral hip pain and were referred for osteonecrosis of the femoral head (ONFH). Radiographs showed osteopenia, and magnetic resonance imaging (MRI) showed diffuse bone marrow edema (BME). After several months, the patients' symptoms resolved and radiographic images normalized. More than 6 months later, the contralateral side showed the same clinical course.

CONCLUSION

Transient osteoporosis of the hip (TOH) resembles ONFH but heals spontaneously. We report 3 rare cases of sequential TOH, similar in that they occurred in middle-aged male habitual drinkers at risk for ONFH, characterized by diffuse BME on MRI and radiographic resolution.

Bone Marrow Edema Syndrome of the Foot Treated with Extracorporeal Shock Wave Therapy: A Retrospective Case Series

To determine the validity and safety of extracorporeal shock wave therapy (ESWT) in the treatment of bone marrow edema syndrome (BMES) of the foot. Twenty patients diagnosed as foot BMES in our Center were followed and treated by ESWT for 1 to 2 courses. The target of the ESWT treatment was the most obvious foot tenderness, or the most obvious part of bone edema on magnetic resonance imaging (MRI). One course of ESWT was 1 time/week, 5 times in total, with the shock wave energy flow density 0.18 mJ/mm². The visual analog scale (VAS) and the American Orthopedic Foot and Ankle Society (AOFAS) scores of the foot were recorded before treatment, at 3 months after treatment and the last follow-up; the areas of BME before treatment and at the last follow-up were measured by the fat suppression MRI. Complications during treatment were also recorded. Twenty follow-up patients were obtained. Compared with the pretreatment, the patients had significant improvement in various indicators at 3 months after treatment (p < 0.01). The sagittal MRI at the last follow-up showed that the BME area decreased significantly (p < 0.01). Two patients developed transient erythema on their skin after treatment and alleviated after 2 days of rest. No serious complications were found during treatment. Our findings show that for patients with foot BMES, the use of ESWT treatment can effectively relieve local pain, improve the motor function of the foot and ankle. Two courses of treatment may be required for some patients.

Is bone marrow edema syndrome a precursor of hip or knee osteonecrosis? Results of 49 patients and review of the literature

PURPOSE

Diagnosis of bone marrow edema syndrome (BMES) can be challenging. There is sometimes uncertainty about the correct diagnosis of BMES on morphologic magnetic resonance imaging (MRI), since subchondral findings like lines and spots can be misinterpreted as "beginning" or "possible" avascular osteonecrosis (AVN). The aim of our study was to systematically assess the temporal course of BMES from first diagnosis on MRI until the end of clinical symptoms and the full disappearance of bone marrow edema (BME) to determine whether subchondral lines and spots detected in these patients can develop into osteonecrosis.

METHODS

In a combined retrospective and prospective study, we retrieved serial MRI scans of hips and knees with BME from the hospital database. According to clinical and imaging data, all patients with degenerative, infectious/inflammatory, rheumatic, neoplastic conditions and those showing typical osteonecrosis were excluded. We collected all available MRI examinations from first detection of BME until its disappearance. In case edema had not fully resolved in the last available MRI scan, we performed an MRI with an additional dynamic contrast-enhanced (DCE-MRI) sequence. For each MRI scan, we recorded the severity of edema, the presence of subchondral hypointense lines and the presence of subchondral focal hypointense zones on T1-weighted images by two independent readers. The DCE-MRI scans were used to calculate parameter maps to assess the perfusion characteristics.

RESULTS

The study comprised 49 patients aged 22-71 years. In total, 171 morphologic and 5 DCE-MRI scans were evaluated. In 44 patients (89.8%), the BMES completely healed without remnants. In 18 of 49 patients (36.7%), a subchondral line was present in the first MRI exam. Nine patients (18.4%) developed a subchondral line within 1-5 months after the first MRI. In total, 27 out of 49 patients (55.1%) had subchondral lines (12 knees, 15 hips) during the timeframe of the study. All subchondral lines disappeared in the timeframe of the study. Subchondral focal hypointense zones were present in 14 out of 49 patients (28.6%): in 9 cases, subchondral focal hypointense zones disappeared after a median of 5.5 months (range, 1-85 months), while in 5 cases, subchondral focal lesions persisted until the end of the study (up to more than 85 months) without edema in the surrounding bone. All persisting subchondral focal lesions were hyperperfused. These 5 patients had associated meniscal lesions.

CONCLUSION

Our study shows that subchondral lines and spots found in patients with BMES do not develop into AVN. Subchondral lines, which resemble subchondral insufficiency fractures, are associated with BMES. Subchondral focal T1-hypointense zones do not represent AVN; most probably these areas represent reparative processes within the subchondral bone, where tensile and shear force overload is present due to altered biomechanics.

Edema-like marrow signal intensity: a narrative review with a pictorial essay

The term edema-like marrow signal intensity (ELMSI) represents a general term describing an area of abnormal signal intensity at MRI. Its appearance includes absence of clear margins and the possibility of exceeding well-defined anatomical borders (for example, physeal scars). We can define "ELMSI with unknown cause" an entity where the characteristic MR appearance is associated with the absence of specific signs of an underlying condition. However, it is more often an important finding indicating the presence of an underlying disease, and we describe this case as "ELMSI with known cause." It presents a dynamic behavior and its evolution can largely vary. It initially corresponds to an acute inflammatory response with edema, before being variably replaced by more permanent marrow remodeling changes such as fibrosis or myxomatous connective tissue that can occur over time. It is important to study ELMSI variations over time in order to evaluate the activity state and therapeutic response of an inflammatory chronic joint disease, the resolution of a trauma, and the severity of an osteoarthritis. We propose a narrative review of the literature dealing with various subjects about this challenging topic that is imaging, temporal evolution, etiology, differential diagnoses, and possible organization, together with a pictorial essay.

Single-Dose Therapy of Zoledronic Acid for the Treatment of Primary Bone Marrow Edema Syndrome

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.

The Effect of Type and Daily Doses of Insulin to Treatment Success in Type 2 Diabetes Patients who are Receiving Basal-bolus Insulin Therapy

Objectives

The present study aims to compare different types of insulin concerning treatment success and insulin dose requirement in type 2 diabetes patients who were receiving basal-bolus insulin therapy and to evaluate the causes of treatment failure despite high doses of insulin.

Methods

In our retrospective study, 198 type 2 diabetes patients who were receiving basal-bolus insulin therapy included. Patients were divided into three groups according to the insulin types (Group 1: short and long-acting analogue insulin users (n=83), Group 2: short and long-acting human regular insulin users (n=58), Group 3: human regular insulin + long-acting analogue insulin users (57)). Demographic data and daily insulin doses were recorded from the patient follow-up files. These data and the rates of achievement of the target HbA1c levels were also compared between groups. In addition, insulin doses of the patients whose glycemic targets could and could not be achieved were compared.

Results

In this study, 123 (62.1%) of the 198 patients were female and 65 (47.9 %) were male. The mean age of the three groups was 55.81±8.1, 58.3±8.9, 58.3±8.8, respectively. HbA1C values were 8.72±1.65% in group 1, 9.0±1.98% in group 2 and 9.05±2.24% in group 3. The rates of achievement HbA1c value below 7% were 27.7% in analogue insulin group, 25.9% human regular insulin group and 31.6% in regular + analogue insulin group (p >0.05). There were no significant differences in daily basal and bolus insulin doses, total daily and per kg insulin doses and basal-bolus rates between groups. Higher total daily insulin doses were determined in patients who could not achieve target glycemic values than achieved it in group 1 and 2. Higher basal insulin doses were determined in patients who could not achieve target glycemic values than could achieved it in group 3.

Conclusion

In our study, in which we did not find any significant difference in the dose analysis between analogue and regular insulin, the findings showed that high insulin doses might not be sufficient for glycemic control. The underlying causes should be investigated and correctible reasons should be eliminated in these patients.

Transient Osteoporosis of the Hip: A Case Report

Transient osteoporosis of the hip, idiopathic, is a table, beginning with hip pain without a history of trauma, usually self-limiting and seen in middle-aged men and pregnant women. In this case report, a male patient who was admitted because of hip pain and detected transient osteoporosis go the hip was discussed. The purpose of the case presentation is to emphasize the necessity of transient osteoporosis of the hip in the differential diagnosis of sudden onset of hip pain and to review the literature on this subject.

Loss and gain of bone in spondyloarthritis: what drives these opposing clinical features?

The breadth of bone lesion types seen in spondyloarthritis is unprecedented in medicine and includes increased bone turnover, bone loss and fragility, osteitis, osteolysis and erosion, osteosclerosis, osteoproliferation of soft tissues adjacent to bone and spinal skeletal structure weakness. Remarkably, these effects can be present simultaneously in the same patient. The search for a potential unifying cause of effects on the skeleton necessarily focuses on inflammation arising from the dysregulation of immune response to microorganisms, particularly dysregulation of T_H17 lymphocytes, and the dysbiosis of established gut and other microbiota. The compelling notion that a common antecedent pathological mechanism affects existing bone and tissues with bone-forming potential (entheses), simultaneously with variable effect in the former but bone-forming in the latter, drives basic research forward and focuses our awareness on the effects on these bone mechanisms of the increasing portfolio of targeted immunotherapies used in the clinic.

Bone marrow oedema syndrome of the foot and ankle in a paediatric population: a retrospective case series with serial MRI evaluation

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.

Transient osteoporosis of the hip and subclinical hypothyroidism: an unusual dangerous duet? Case report and pathogenetic hypothesis

BACKGROUND

Transient osteoporosis of the hip (TOH) is a rare and temporary clinical condition characterised by bone marrow edema (BME), severe pain, and functional limitation. It commonly occurs in middle-aged men or in women in the last trimester of pregnancy. TOH usually resolves with conservative therapy but may predispose to hip fracture or progression to avascular necrosis (AVN). Etiology is still unclear, although several pathophysiological mechanisms underpinning this condition has been proposed. We describe the management of an unusual case of TOH occurred in a patient with subclinical hypothyroidism.

CASE PRESENTATION

A clinical case of a 46-year-old man with severe pain in the left anterior thigh is presented. After a comprehensive clinical and radiological approach, a TOH was diagnosed. Moreover, biochemical assessment suggested the presence of subclinical hypothyroidism. After 3 months of treatment with clodronate, physical therapy and hormone replacement therapy (HRT) a significant improvement of clinical and radiological outcomes was observed.

CONCLUSION

Several pathological conditions have been related to development of TOH. In our case, we suggested for the first time a role of subclinical hypothyroidism as novel contributory factor for the onset of this condition, providing pathophysiological mechanisms and a scientific rationale for pharmacological treatment.

Guidelines for clinical diagnosis and treatment of osteonecrosis of the femoral head in adults (2019 version)

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies.

TRANSLATIONAL POTENTIAL OF THIS ARTICLE

New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life.

How We Manage Bone Marrow Edema-An Interdisciplinary Approach

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.

Individualized Treatment of Bone Marrow Edema of the Knee With the Aid of Classical Homeopathy: A Report of 2 Cases

BACKGROUND

Bone marrow edema lesions around the knee are a common magnetic resonance image finding. They constitute a central component of a wide variety of inflammatory and noninflammatory conditions affecting the knee joint. Those lesions are not only a significant source of pain, but are also connected to many musculoskeletal pathologies.

CASE REPORT

We describe 2 cases of bone marrow edema of the knee joint treated with the aid of Classical Homeopathy. In both of the cases, Arnica montana was the chosen homeopathic remedy.

CONCLUSIONS

The results of the treatment are promising, encouraging for more research on this area.

Transient Osteoporosis of the Hip: Risk and Therapy

Objective

The aim of this study was to investigate the impact of occupation in patients with transient osteoporosis of the hip (TOH). The study also compares two different types of management for this condition: conservative treatment and surgical drilling.

Methods

This was a retrospective case series study. The medical records for patients diagnosed with TOH at our institution within the period 2012–2017 were retrieved. General demographic data, clinical features, and diagnostic modalities were obtained. In addition, management procedures and their associated prognostic factors were acquired. The effectiveness of these procedures was assessed by the number of days of sick leave, the time needed for full recovery and the number of recurrences of TOH. Also, pain responses at 24 hrs, 48 hrs, and at 1 week were estimated subjectively through a “pain score” out of 10, and objectively through the degree of improvement in daily activity. The patients had a regular follow-up at 4- to 6-week intervals.

Results

In total, 15 cases of TOH, 14 men and one woman, were enrolled in the study. The mean age of the patients was 41 years (range 26–59 years). Out of the 15 cases, nine were healthcare professionals (eight physicians and one nurse). Ten patients underwent hip drilling for core decompression and five patients were treated conservatively. The time needed for full recovery was 5.8 weeks for those who underwent drilling, and 48.3 weeks for three patients receiving conservative treatment. The other two patients who were treated conservatively had not achieved full or near-full recovery at the time of reporting this study.

Conclusion

Physicians may be at increased risk of developing TOH. Further studies should be conducted to examine the role of this occupation as a risk factor. In addition, hip drilling should be considered as an effective treatment modality, especially in those patients who seek a faster recovery.

Bone Marrow Foot Oedema in Adolescents: The Role of Vitamin D

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.

Prevalence of bone marrow edema in a study population with foot and/or ankle pain

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.

Asymptomatic Bone Marrow Edema Detected by 67Ga Scintigraphy

A 46-year-old woman presented with a complaint of fever. CRP was 2.1 mL/L in blood, white blood cell count was 20-29/hpf, and bacterial count was 3418/μL in a urinalysis. Ga scan revealed accumulation of Ga in the left distal femur, although she had no symptoms around the site. MRI demonstrated diffuse high signal intensity on T2-weighted STIR images. Osteomyelitis was suspected, and biopsy was performed. Bacterial culture of the bone marrow was negative, and histological examination showed no infiltration of inflammatory cells. Two months after the biopsy, disappearance of altered signal intensity of MRI was observed.

Bone Marrow Edema: A Case of Regional Migratory Osteoporosis

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.