Multi-modality imaging of transient osteoporosis of the hip

Transient osteoporosis of the hip (TOH), also referred to as bone marrow edema syndrome (BMES) of the femoral head and neck, is an uncommon and therefore underdiagnosed benign skeletal disorder, affecting primarily women, particularly in their last trimester of pregnancy, and middle-aged men. The disease is characterized by self-limiting hip pain and radiographically evident osteopenia, but these radiographic findings can sometimes be delayed. In the early phase, the main diagnostic dilemma lies in differentiating TOH from osteonecrosis of the femoral head (ONFH). Conventional radiographs, Tc-99m bone scans (multiphase, SPECT or SPECT/CT) and MRI scans from 10 male patients with 12 TOH episodes were retrospectively and independently reviewed by two nuclear medicine physicians and a musculoskeletal radiologist. The purpose was to identify a typical imaging pattern, and secondly, to reliably distinguish TOH from ONFH. In the early phase of TOH, conventional radiography of the hip could not sufficiently detect focal osteopenia. But in all 10 patients (mean age 45 years, range, 34-62), bone scans and Mill scans demonstrated a similar pattern of diffuse hyperaemia, bony uptake, and bone marrow edema in the femoral head and neck, extending to and ending with a sharp demarcation at the intertrochanteric region. Additionally, neither SPECT nor SPECT/CT nor MRI revealed any cold area or crescent-shaped subchondral defect in the femoral head, indicating ONFH. In some cases there was a joint effusion in varying degree. In 9 patients, an uneventful recovery was eventually observed. Scintigraphically diffuse hyperaemic and/or homogeneous osseous uptake in femoral head and neck extending to the intertrochanteric region, as well as the recently introduced term transient bone marrow edema syndrome (BMES) of the hip on MRI, are probably both expressions of the same pathophysiological mechanism, and pathognomonic for TOH. Hopefully, recognizing this highly specific imaging pattern will exclude in the future more aggressive skeletal diseases like ONFH, severe arthritis, osteomyelitis or even malignancy.