Identification of vitamin D and other bone metabolism parameters as risk factors for primary bone marrow oedema syndrome

Advantages of cone beam computed tomography for evaluation of subchondral insufficiency fractures of the knee compared to MRI

To determine the diagnostic yield of cone beam computed tomography (CBCT) compared with 3 T magnetic resonance imaging (MRI) for the evaluation of subchondral insufficiency fractures of the knee. Consecutive patients with subchondral insufficiency fractures of the knee examined by 3 T MRI and CBCT of the femoral condyles were reviewed. Two experienced raters graded the lesion severity on 3 T MRI and CBCT images: grade 1: no signs of a subchondral bone lesion; grade 2: subchondral trabecular fracture or cystic changes, but without infraction of the subchondral bone plate; grade 3: collapse of the subchondral bone plate. Ratings were repeated after six weeks to determine reliability. In addition, the bone lesion size was measured as elliptical area (mm2) and compared between CBCT and T1-weighted MRI sequences. Among 30 patients included (43.3% women; mean age: 60.9 ± 12.8 years; body mass index (BMI) 29.0 ± 12.8 kg/m2), the medial femoral condyle was affected in 21/30 patients (70%). The grading of subchondral lesions between MRI and CBCT did not match in 12 cases (40%). Based on MRI images, an underestimation (i.e., undergrading) compared with CBCT was observed in nine cases (30%), whereas overgrading occurred in three cases (10%). Compared to CBCT, routine T1-weighted 3 T sequences significantly overestimated osseus defect zones in sagittal (84.7 ± 68.9 mm2 vs. 35.9 ± 38.2 mm2, p < 0.01, Cohen's d = 1.14) and coronal orientation (53.1 ± 24.0 mm2 vs. 22.0 ± 15.2 mm2, p < 0.01, Cohen's d = 1.23). The reproducibility of the grading determined by intra- and inter-rater agreement was very high in MRI (intra-class correlation coefficient (ICC) 0.78 and 0.90, respectively) and CBCT (ICC 0.96 and 0.96, respectively). In patients with subchondral insufficiency fractures of the knee, the use of CBCT revealed discrepancies in lesion grading compared with MRI. These findings are clinically relevant, as precise determination of subchondral bone plate integrity may influence the decision about conservative or surgical treatment. CBCT represents our imaging modality of choice for grading the lesion and assessing subchondral bone plate integrity. MRI remains the gold standard modality to detect especially early stages.

Considerations Regarding Vitamin D in Foot and Ankle Treatment and Surgery

Although the impact that vitamin D has on bone healing is uncertain in foot and ankle (F&A) surgery, there is support for vitamin D supplementation (2000 IU/day) with calcium (1 g/day) to promote bone healing. Although orthopedic F&A surgeons are frequently the first provider to detect the harbingers of osteoporosis by the occurrence of fragility fractures, this should trigger referral to the appropriate specialist for assessment and treatment. There is circumstantial evidence suggesting a role of hypovitaminosis D in bone marrow edema syndrome and possibly osteochondritis dissecans. There should be a low threshold for assessing vitamin D levels in such patients.

No Significant Differences between Bisphosphonates and Placebo for the Treatment of Bone Marrow Lesions of the Knee: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objectives: The purpose of the present systematic review and meta-analysis is to summarize the current evidence on the role of bisphosphonates in the treatment of knee bone marrow lesions (BMLs), to understand whether they are truly effective in improving symptoms and restoring the subchondral bone status at imaging evaluation. Methods: A literature search was carried out on PubMed, Cochrane, and Google Scholar databases in accordance with the PRISMA guidelines. Potential risk of bias was evaluated using the Cochrane Risk of Bias 2 tool for randomized controlled trials (RCTs) and the ROBINS-I tool for non-randomized studies. Results: A total of 15 studies were included in the present systematic review and meta-analysis. Seven studies were RCTs, two were prospective cohort studies, three were retrospective, and three were case series. Our meta-analysis revealed that bisphosphonates did not significantly improve clinical scores or reduce BML size compared to placebo. Accordingly, the rate of adverse events was also non-significantly higher among bisphosphonate users versus placebo users. Conclusions: The main finding of the present meta-analysis and systematic review is that bisphosphonates show neither significant benefits nor significant adverse events when compared to placebo in the treatment of BMLs of the knee. Level of Evidence: Level IV systematic review of level II-III-IV studies. Level I meta-analysis of level I studies.

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.

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 Primary Bone Marrow Edema of the Knee Associated with Thyroid Disorders? A Retrospective Clinical Study

Primary bone marrow edema (BME) of the knee is still an elusive condition. This retrospective study was undertaken to gain insight into its characteristic features. The records of 48 patients with primary BME of the knee diagnosed by magnetic resonance imaging were reviewed. Demographic data, medical history, current medications, pain type, smoking and drinking habits, allergies, occupation, sports practiced, environmental factors, and life events predating symptom onset were examined. Data analysis demonstrated that 56.3% of patients had experienced a stressful event before BME pain onset and that 50% suffered from thyroid disorders. Standard conservative treatment resulted in pain resolution irrespective of the use of anti-inflammatories. However, most patients reported new persistent symptoms: dysesthesia/hypoesthesia on palpation in the skin area overlying the previous edema and a reduced ipsilateral patellar reflex. To our knowledge, this is the first study characterizing a substantial cohort of patients with BME. We found that middle-aged, sedentary, and slightly overweight women smokers are the typical patients with primary BME of the knee. The appearance and persistence of cutaneous dysesthesia/hypoesthesia at the site of the earlier lesion and ipsilateral patellar hyporeflexia implicate an autonomous nervous system dysfunction in BME pathogenesis and warrant further investigation.

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.

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.

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.

Zoledronic acid is more efficient than ibandronic acid in the treatment of symptomatic bone marrow lesions of the knee

PURPOSE

The purpose of this study was to determine the efficacy and tolerability of different antiresorptive therapeutic regimens for treating symptomatic bone marrow lesions (BML) of the knee.

METHODS

Patient records of 34 patients with radiologically diagnosed, painful BML of the knee treated with either a bisphosphonate (zoledronic, ibandronic, or alendronic acid) or with a human monoclonal antibody (denosumab) were retrospectively evaluated. Response to treatment was assessed, as change in patient-reported pain, by evaluation of BML expansion on MRI using the Whole-Organ Magnetic Resonance Imaging Score (WORMS), and by laboratory analysis of bone turnover markers: C-terminal cross-linking telopeptide (CTx) and procollagen type 1 amino-terminal propeptide (P1NP). Tolerability was evaluated by documentation of adverse reactions.

RESULTS

Zoledronic acid was more or at least equally effective as the other treatment regimens with response to treatment in 11 of 12 patients (92%). The highest rate of adverse events was noted in 4 of 12 patients (33%) treated with zoledronic acid. CTx and WORMS differentiated well between responders and non-responders, whereas P1NP failed to do so. Changes in pain correlated moderately with change in WORMS (r = - 0.32), weakly with change in CTx (r = - 0.07), and not at all with change in P1NP.

CONCLUSION

Zoledronic acid appeared to be more effective than other antiresorptive medications-at the cost of more frequent adverse events. While radiological and laboratory evaluation methods may allow for objective treatment monitoring, they appear to capture different dimensions than patient-reported pain.

LEVEL OF EVIDENCE

III.

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.

Outcome of Teriparatide Treatment on Fracture Healing Complications and Symptomatic Bone Marrow Edema in Four Adult Patients With Hypophosphatasia

The response to teriparatide has been described in very few cases of hypophosphatasia (HPP). In this cross‐sectional study, we report the prevalence of symptomatic bone marrow edema (BME) and fracture healing complications in a large cohort of childhood and adult HPP patients and discuss the results of teriparatide treatment in four cases. From 2016 to 2018, 51 patients with a diagnosis of HPP were seen at our institution. The diagnosis of HPP was established by low serum alkaline phosphatase (ALP), elevated serum pyridoxal‐5‐phosphate (PLP), at least one typical clinical symptom of HPP and supported by ALPL mutation analysis. In this study cohort, 28 (56%) and 14 (27%) patients had a history of fracture or a history of BME, respectively. Four patients, including middle‐aged to elderly women and men who all presented with persistent symptomatic BME or fracture healing complications, were treated with teriparatide. DXA was performed prior to treatment and laboratory values were measured on a regular basis during treatment. Treatment with teriparatide showed variable effects in terms of clinical and biochemical response. Although all four patients displayed a temporary increase in ALP activity, only two patients with a mild form of adult HPP and moderately increased PLP levels showed definite clinical and radiological improvement after teriparatide treatment. In conclusion, fracture healing complications and BME occur frequently in HPP patients. Teriparatide shows variable clinical and biochemical effects depending on the severity of the disease. PLP levels and the number of ALPL alleles might be good parameters to predict treatment outcomes. © 2019 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research

Intra-articular osteoid osteoma accompanied by extensive bone marrow edema. A clinical and micro-morphological analysis

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A series of patients with intra-articular osteoid osteoma (OO) is demonstrated.

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Extensive and persistent bone marrow edema syndrome masked the correct diagnosis.

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No consistent patterns of impaired bone mineral status could be confirmed in these patients.

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Nidus specimens displayed significantly higher mineralization heterogeneity determined by qBEI.

Osteoid osteoma (OO) is a benign bone tumor producing non-mineralized bone matrix (i.e., osteoid). While peritumoral edema is commonly found in OO, extensive bone marrow edema has been reported less frequently. Furthermore, the micro-morphological characteristics of the nidus and its central calcification remain unclear. In this study, a consecutive series of four patients suffering from extensive bone marrow edema triggered by intra-articular osteoid osteoma underwent clinical examination, magnetic resonance imaging (MRI) and computed tomography (CT) as well as dual-energy X-ray absorptiometry (DXA) and laboratory bone turnover analyses. The obtained resection specimens were processed by undecalcified histology and were subsequently analyzed by light microscopy and quantitative backscattered electron imaging (qBEI). We report an entity of intra-articular osteoid osteoma in the knee and foot, in which an extensive and persistent bone marrow edema syndrome masked the correct diagnosis. While metabolic bone diseases were excluded in all cases, the reassessment of the patients’ clinical history including pain characteristics (nocturnal, aspirin sensitivity) led us to perform additional CT, where the tumor was diagnosed. The micro-morphological analysis of the OO biopsies revealed that the nidus was surrounded by hyperosteoidosis, while central mineralization was detected in all cases. This mineralized area showed a significantly higher mineralization heterogeneity than the surrounding trabecular bone and more disorganized collagen fibers detected by qBEI and polarized light microscopy, respectively. Taken together, our results indicate that osteoid osteoma should be considered when persistent and extensive, peri-articular bone marrow edema is diagnosed. The central calcification that is found inside the nidus in conventional imaging was mirrored by bone matrix with a heterogeneous mineralization pattern.

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.