Figure 1
Pelvic plain film
There are no fracture lines or focal bone lesions. The femoral heads sphericity is preserved. There are no significant degenerative changes.
Idiopathic transient osteoporosis of the hip
SectionMusculoskeletal system
Case TypeClinical Cases
AuthorsFrancisco Rego Costa, Teresa Fernandes
Connected authors
32 years, female
Clinical History
A patient in the third trimester of pregnancy started complaining of difficulty walking due to severe left hip pain radiating to the thigh. She reported progressive worsening of symptoms and persistence of pain after childbirth. There was no history of trauma, fever, steroid usage or complaints related to other joints.
Imaging Findings
A plain film of the pelvis was unremarkable.
MRI of the pelvis demonstrated diffuse bone marrow oedema at the head and neck of the left femur with low signal intensity on T1 weighted-images (WI) and high signal intensity on fat-suppressed T2WI. There were no signs of avascular necrosis or fractures. Minimal joint effusion of the left hip was also present.
A 3 months follow-up MRI showed complete resolution of the oedema and normal bone marrow signal. The contour of the femoral head was preserved.
MRI of the pelvis demonstrated diffuse bone marrow oedema at the head and neck of the left femur with low signal intensity on T1 weighted-images (WI) and high signal intensity on fat-suppressed T2WI. There were no signs of avascular necrosis or fractures. Minimal joint effusion of the left hip was also present.
A 3 months follow-up MRI showed complete resolution of the oedema and normal bone marrow signal. The contour of the femoral head was preserved.
Discussion
Idiopathic transient osteoporosis of the hip (ITOH) is an uncommon disorder first described in pregnancy [1, 2, 8]. The aetiology remains unknown, even though various causes such as vascular disorders, trauma or sympathetic overactivity have been proposed [3, 4, 5, 6, 8].
ITOH is a rare cause of hip pain that most commonly occurs in middle-aged men (40-60 years-old) [6, 8, 10].
The typical clinical presentation is acute onset of pain in and around the hip joint that increases in weight-bearing positions [3]. Unilateral involvement is more common [1].
This condition has a self-limited course and spontaneous resolution in 6-12 months is the rule [1, 3, 5, 6, 8]. Management is conservative and essentially encompasses symptomatic relief and reduced weight bearing to prevent stress fractures [1, 5, 6, 7, 9]. Recurrence is possible in the same or in a different joint.
Radiographs are initially normal. Osteopenia and subchondral bone loss at the femoral head and neck may be evident later on (usually 4-8 weeks after the onset of symptoms) [3].
MR imaging is the most reliable method to the early diagnosis of ITOH [1, 3], showing areas of bone marrow oedema with low T1 and high T2 signal intensity affecting the femoral head, neck and also the intertrochanteric region [8, 9, 10]. Joint effusion commonly accompanies this disorder. These findings disappear after the clinical symptoms subside. Resolution of the condition is usually documented with a follow-up MRI [3, 5, 6, 8].
Awareness of this diagnosis as a cause of hip pain and its characteristic imaging appearance are important to prevent unnecessary intervention [1, 5, 6, 7, 9].
ITOH is a rare cause of hip pain that most commonly occurs in middle-aged men (40-60 years-old) [6, 8, 10].
The typical clinical presentation is acute onset of pain in and around the hip joint that increases in weight-bearing positions [3]. Unilateral involvement is more common [1].
This condition has a self-limited course and spontaneous resolution in 6-12 months is the rule [1, 3, 5, 6, 8]. Management is conservative and essentially encompasses symptomatic relief and reduced weight bearing to prevent stress fractures [1, 5, 6, 7, 9]. Recurrence is possible in the same or in a different joint.
Radiographs are initially normal. Osteopenia and subchondral bone loss at the femoral head and neck may be evident later on (usually 4-8 weeks after the onset of symptoms) [3].
MR imaging is the most reliable method to the early diagnosis of ITOH [1, 3], showing areas of bone marrow oedema with low T1 and high T2 signal intensity affecting the femoral head, neck and also the intertrochanteric region [8, 9, 10]. Joint effusion commonly accompanies this disorder. These findings disappear after the clinical symptoms subside. Resolution of the condition is usually documented with a follow-up MRI [3, 5, 6, 8].
Awareness of this diagnosis as a cause of hip pain and its characteristic imaging appearance are important to prevent unnecessary intervention [1, 5, 6, 7, 9].
Differential Diagnosis List
Idiopathic transient osteoporosis of the hip
Avascular necrosis
Stress fracture
Septic arthritis
Final Diagnosis
Idiopathic transient osteoporosis of the hip
References
[1] Pallavi P, Padma S, Vanitha Anna Selvi D (2012) Transient osteoporosis of hip and lumbar spine in pregnancy. J Obstet Gynaecol India Dec;62 (PMID: 24293857)
[2] Ugwonali OF, Sarkissian H, Nercessian OA (2008) Bilateral osteonecrosis of the femoral head associated with pregnancy: four new cases and a review of the literature. Orthopedics Feb 31(2):183 (PMID: 19292185)
[3] Szwedowski D, Nitek Z, Walecki J (2014) Evaluation of transient osteoporosis of the hip in magnetic resonance imaging. Pol J Radiol Feb 21;79:36-8 (PMID: 24587837)
[4] Uzun M, Ayhan E, Beksac B, Karaman O (2013) Regional migratory osteoporosis and transient osteoporosis of the hip: are they all the same?. Clin Rheumatol Jun;32(6):919-23 (PMID: 23559387)
[5] Korompilias AV, Karantanas AH, Lykissas MG, Beris AE (2009) Bone marrow edema syndrome. Skeletal Radiol May;38(5):425-36 (PMID: 18629460)
[6] Korompilias AV, Karantanas AH, Lykissas MG, Beris AE (2008) Transient osteoporosis. J Am Acad Orthop Surg Aug;16(8):480-9 (PMID: 18664637)
[7] Balakrishnan A, Schemitsch EH, Pearce D, McKee MD (2003) Distinguishing transient osteoporosis of the hip from avascular necrosis. Can J Surg Jun;46(3):187-92 (PMID: 12812240)
[8] Tamburrini O, Sessa M, Della Sala M, Stanà C, De Caridi A, Carallo OF (1995) Transient osteoporosis of the hip in magnetic resonance imaging. Radiol Med Sep;90(3):187-93 (PMID: 7501820)
[9] Hayes CW, Conway WF, Daniel WW (1993) MR imaging of bone marrow edema pattern: transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis. Radiographics Sep;13(5):1001-11 (PMID: 8210586)
[10] Daniel WW, Sanders PC, Alarcon GS (1992) The early diagnosis of transient osteoporosis by magnetic resonance imaging. A case report. J Bone Joint Surg Am Sep;74(8):1262-4 (PMID: 1400558)
Case information
| URL: | https://www.eurorad.org/case/12040 |
| DOI: | 10.1594/EURORAD/CASE.12040 |
| ISSN: | 1563-4086 |
Figure 2
MR Coronal T1WI
Diffuse low signal intensity throughout the left femoral head and neck.
Figure 3
MR Coronal T2WI
Diffuse high signal intensity in the left femoral head and neck. There is a minimal joint effusion on the left hip.
Figure 4
MR Coronal T1WI (3 months interval follow-up)
Normal bone marrow signal. The femoral heads have a normal morphology.
Figure 5
MR Coronal T2WI (3 months interval follow-up)
Resolution of the oedema and normal bone marrow signal. There is no joint effusion.
Pelvic plain film
There are no fracture lines or focal bone lesions. The femoral heads sphericity is preserved. There are no significant degenerative changes.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.
MR Coronal T1WI
Diffuse low signal intensity throughout the left femoral head and neck.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto
MR Coronal T2WI
Diffuse high signal intensity in the left femoral head and neck. There is a minimal joint effusion on the left hip.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.
MR Coronal T1WI (3 months interval follow-up)
Normal bone marrow signal. The femoral heads have a normal morphology.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.
MR Coronal T2WI (3 months interval follow-up)
Resolution of the oedema and normal bone marrow signal. There is no joint effusion.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.
Rego Costa, Francisco; Department of Radiology, Hospital de São João, Porto.