Outcome of painful bone marrow edema of the femoral head following treatment with parenteral iloprost

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

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

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.

Effectiveness of Iloprost in the Treatment of Bone Marrow Edema

Background and objective

Bone marrow edema (BME) is a rare condition caused by insufficient osseous blood supply and may result in severe pain that has adverse effects on patients’ life. To date, various conservative treatments have been recommended for the treatment of BME, including analgesics, immobilization of the affected extremity, and iloprost infusion. The aim of this retrospective study was to investigate the effectiveness of parenteral iloprost therapy in the treatment of BME detected in different skeletal locations.

Materials and methods

This retrospective study included 23 patients (17 men and six women) with BME who were classified as stage I-III according to the Association Research Circulation Osseous (ARCO) classification. BME was localized to the proximal femur in 13 (56.5%), the distal femur in four (17.4%), tarsal bone in four (17.4%), and tibial plateau in two (8.7%) patients. The mean age of the patients was 46.7 years and all the patients were evaluated with the Visual Analog scale (VAS), Functional Mobility Scale (FMS), and MRI.

Results

A significant improvement was observed in the post-treatment VAS and FMS scores of all patients compared to their pre-treatment scores. Moreover, the edema regressed completely in 60.9% of the patients at three months of MRI control. No serious side effects were observed during the treatment in any of the patients. However, transient side effects including headache, arrhythmia, and flushing were observed in five patients.

Conclusion

The present study indicated that iloprost therapy is an effective and safe option in the treatment of BME patients, particularly in the reduction of severe pain that has adverse effects on patients’ social life, regardless of ARCO staging. Moreover, this therapy could be particularly useful in reducing pain, improving functional recovery, and achieving complete regression of the edema on MRI in ARCO stage I-II patients.

Single Dose Therapy of Zoledronic Acid for the Treatment of Transient Osteoporosis of Hip

Objective

To shorten the natural course of transient osteoporosis of hip (TOH), which is a self-limiting idiopathic condition and requires 6–12 months for the resolution of symptoms, various therapies including treatment with bisphosphonates have been attempted. There exist fewer case reports evaluating the effect of bisphosphonates in TOH and most of them lack radiographic evidence of resolution of disease. The present study was carried out with an aim to evaluate the clinical and radiological outcomes of TOH patients subsequent to treatment with a single dose of zoledronic acid.

Methods

Data of 19 adult male and non-pregnant female patients with TOH treated with zoledronic acid were included in the study. Efficacy was assessed using changes in clinical signs and symptoms, visual analogue scale pain score, and changes in bone marrow edema (BME) in magnetic resonance imaging (MRI).

Results

Mean age of the patients was 42.1 years, 17 being males. The mean time of onset of symptom was 4 weeks. Subsequent to treatment, the patients were pain-free and had no limp within an average of 2.8 weeks (range, 2–5 weeks) and remained asymptomatic at a mean follow-up of 35 months (range, 6–54 months). The post-treatment MRI showed resolution of BME in approximately 84% (16/19) of patients at 3 months. No major adverse events were reported. None of the patients progressed to avascular necrosis at their last follow-up.

Conclusion

Intravenous single dose administration of zoledronic acid provides early pain relief and complete reversal of TOH. Consequently, zoledronic acid is proposed as a new paradigm in the management of TOH.

Comparison of histological and morphometrical changes underlying subchondral bone abnormalities in inflammatory and degenerative musculoskeletal disorders: a systematic review

OBJECTIVE

Subchondral bone abnormalities (SBAs) on magnetic resonance imaging (MRI) are observed frequently and associated with disease course in various musculoskeletal disorders. This review aims to map the existing knowledge of their underlying histological features, and to identify needs for future research.

DESIGN

We conducted a systematic review following PRISMA guidelines until September 2017, including all studies correlating histological features to on MRI defined SBAs in patients with osteoarthritis (OA), rheumatoid arthritis (RA), spondyloarthritis (SpA) and degenerative disc disease (DDD). Two authors independently retrieved articles and assessed study quality.

RESULTS

A total of 21 studies (466 patients) correlated histological features to SBAs in OA (n = 13), RA (n = 3), ankylosing spondylitis (AS) (n = 1) and DDD (n = 4). Reported changes in OA were substitution of normal subchondral bone with fibrosis and necrosis, and increased bone remodeling. In contrast, in RA, AS or DDD fibrosis was not reported and SBAs correlated to an increase in inflammatory cell number. In DDD necrosis was observed. Similar to OA, increased bone remodeling was shown in RA and DDD. The risk of bias assessment showed a lack in described patient criteria, blinding and/or adequate topographic correlation in approximately half of studies. There was heterogeneity regarding the investigated histological features between the different disorders.

CONCLUSIONS

Current studies suggest that SBAs correlate to various histological features, including fibrosis, cell death, inflammation and bone remodeling. In the majority of studies most quality criteria were not met. Future studies should aim for high quality research, and consistency in investigated features between different disorders.

Rock Climbing-Related Bone Marrow Edema of the Hand: A Follow-up Study

OBJECTIVE

Sport climbers strain passive and active anatomical structures of their hands and fingers to the maximum during training or competition. This study was designed to investigate bone marrow edema (BME) in rock climbing athletes.

DESIGN

Systematic detection, treatment, and follow-up investigation of rock climbing athletes with BME of the hand.

SETTING

Primary-level orthopedic surgery and sports medicine division of a large academic medical center.

PATIENTS

Thirty-one high-level climbers with diffuse pain in the hand and wrist joint caused by rock climbing were included in this study.

INTERVENTIONS

The therapy consisted of consequent stress reduction and a break from sports.

MAIN OUTCOME MEASURES

Reduction of BME shown through magnetic resonance imaging (MRI) and regaining of preinjury climbing levels (Union Internationale des Associations d' Alpinisme metric scale).

RESULTS

In 28 patients, MRI revealed osseous edema because of overload at the respective area of interest, mainly in the distal radius, the distal ulna, or the carpal bones, which could not be otherwise diagnosed as inflammations, tumors, or injuries. We classified these edemas and fractures of the hamate because of overload. The edema was a stress reaction to highly intensive training and climbing with presumably high traction to the wrist area. The control MRIs demonstrated that even with a consequent stress reduction, the edemas required 3 to 4 months to disappear completely.

CONCLUSIONS

Climbers with nonspecific, diffuse pain in the wrist and/or the fingers should be examined with MRI to detect or exclude the diagnosis of a BME.

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

INTRODUCTION

Iloprost is a commercially available prostaglandin I₂ (PGI₂) analogue that is shown to have antithrombotic, vasodilatative and antiproliferative effects. A number of clinical studies have shown that Iloprost can be effective in the management of bone marrow oedema and the treatment of avascular necrosis. The aim of this manuscript is to present our current understanding on the effect of Iloprost on the treatment of these conditions.

AREAS COVERED

The authors offer a comprehensive review of the existing literature on the experimental and clinical studies analysing the effect of Iloprost on bone, bone marrow oedema and avascular necrosis.

EXPERT OPINION

The available data from the clinical studies suggest that Iloprost has limited effect in advanced stages of avascular necrosis. However, literature suggests that Iloprost administration can be a viable option in the management of bone marrow oedema and early stages of osteonecrosis. Despite these promising results its effect on bone homeostasis needs further elucidation. Moreover, further data on its safety, dosage and efficiency through randomized multicenter studies are desirable in order to reach final conclusions.

Osteonecrosis in children and adolescents with acute lymphoblastic leukemia: a therapeutic challenge

Osteonecrosis (ON) represents one of the most common and debilitating sequelae of antileukemic treatment in children and adolescents with acute lymphoblastic leukemia (ALL). Systematic screening strategies can focus on early detection and intervention to prevent ON from progressing to stages associated with pain and functional impairment. These strategies hold promise for reducing ON-associated morbidity without the risk of impairing leukemia control. Herein, we critically reviewed clinical data on pharmacological, nonpharmacological/nonsurgical, and surgical (including cellular) treatment options for ON, which are covered in the literature and/or are conceivable based on the supposed underlying ON pathophysiology. Prevention of ON progression is of paramount importance, and attempts seem to be more effective in early (precollapse) disease status than in late-stage (collapse) ON. Based on the results of ongoing prospective magnetic resonance imaging screening studies, which will hopefully identify those patients with a high risk of ON progression and debilitating sequelae, prospective interventional studies are urgently needed. Although there is still a lack of high-quality studies, based on currently available data, core decompression surgery combined with cellular therapies (eg, employing mesenchymal stem cells) appears most promising for preventing joint infraction in children at high risk of developing late-stage ON.

Hyperbaric oxygen therapy for transient bone marrow oedema syndrome of the hip

Transient bone marrow oedema syndrome of the proximal femur is characterized by acute, progressive pain in the hip that is increased by weight-bearing. Treatment includes restricted weight-bearing and analgesic medication. A prospective, randomized study was performed to compare two groups of patients affected by bone marrow oedema syndrome of the femoral head. 20 patients received pharmacological and hyperbaric oxygen therapy, and a control group of 21 patients received pharmacological therapy alone. The overall average WOMAC score at 3 months was significantly higher (p<0.001) for the hyperbaric oxygen group (70.8 points) compared with the control group (56.4 points). Magnetic Resonance Imaging at 3 months showed resolution of bone marrow oedema in 55.0% of the patients treated with hyperbaric oxygen compared with 28% in the control group. Hyperbaric oxygen therapy appears to be effective in treating transient bone marrow oedema syndrome, resulting in an accelerated recovery of hip function compared to pharmacological therapy alone.