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Idiopathic transient osteoporosis of the hip.

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Vol 40, No. 6, June 1997, pp 1178-1 179
0 1997, American College of Rheumatology
Clinical history
This patient is a 45-year-old man with left hip
pain and no history of trauma. Physical examination
revealed an antalgic gait. Laboratory findings were
within normal limits.
Radiologic findings
A plain radiograph of the left hip performed in
May showed normal results. A T1-weighted magnetic
resonance (MR) image (TR 500 msec; TE 30 msec)
performed at that time showed diffuse low signal
throughout the femoral head (Figure 1).A TZweighted
image showed increased signal throughout the femoral
head and the presence of a joint effusion. The bones in
the pelvis and especially the acetabulum were normal in
appearance on the MR image. A followup T1-weighted
MR image (TR 500 msec; TE 30 msec) in December
showed complete resolution of the abnormal signal in
the left femoral head (Figure 2).
Diagnosis: Idiopathic transient osteoporosis of the hip
Figure 1. A coronal T1-weighted image (TR 500 msec; TE 30 msec)
performed in May, demonstrating diffuse low signal throughout the
head (arrow)-
weight-bearing. The symptoms become severe enough to
result in a limp. The clinical findings are self-limited and
resolve in 2-6 months without permanent sequelae.
Idiopathic transient osteoporosis of the hip
(ITOH) is a painful, self-limited, idiopathic process that
is typically seen in young and middle-aged adults, particularly men. In male patients, either hip may be
involved. In women, the left hip is involved much more
frequently and many present during the third trimester
of pregnancy (1-3).
Hip pain begins spontaneously, without an antecedent history of trauma. The condition is aggravated by
Nancy M. Major, MD, Clyde A. Helms, MD: Duke University
Medical Center, Durham, North Carolina.
Address reprint requests to Clyde A. Helms, MD, Musculoskeletal Section, Department of Radiology, Box 3808, Duke University
Medical Center, Durham, NC 27710.
Submitted for publication July 16, 1996; accepted in revised
form September 18, 1996.
Figure 2. A magnetic resonance image obtained 7 months later, when
the patient’s symptoms had resolved, showing normal hips bilaterally.
Joint fluid may be increased. Biopsy of the synovium
reveals normal findings or slight (mild, minimal, or
equivocal) chronic inflammation.
Radiographic findings are characteristic and become apparent within weeks or months of the onset of
clinical findings. Progressive and marked osteoporosis of
the femoral head is identified on plain radiographs.
Osteoporosis is not found in the acetabulum, but may be
seen in the femoral neck. The joint space is normal and
the femoral subchondral bone is intact. Magnetic resonance imaging shows decreased signal on T1-weighted
images and increased signal on T2-weighted images,
compatible with edema, and may demonstrate these
changes before osteoporosis is identified on the plain
film. Radionuclide studies, similarly, will be positive,
showing abnormal accumulation of bone-seeking isotope before plain film radiographic changes.
The cause of ITOH is unknown. It has been
regarded by many as a self-limited ischemic necrosis;
however, most investigators believe that it is a distinctly
different entity (4). Its similarity to reflex sympathetic
dystrophy suggests a related neurogenic pathogenesis
(5). In addition, ITOH has been reported to be bilateral
in distribution in a few patients with simultaneous or
successive involvement of the hip joints or other
The differential diagnosis would include avascular necrosis, which can be present when plain radiograph
findings are normal. Early MR imaging could demonstrate signal abnormality in the femoral head, but would
progress to a well-defined low-signal geographic area in
the anterosuperior portion of the femoral head (Figure
3). Septic arthritis is an additional consideration; however, joint space narrowing and osseous erosion are
eventually observed. Inflammatory arthritides such as
rheumatoid arthritis would cause an intense synovial
inflammation resulting in osseous and cartilaginous erosions. Also, symmetric involvement is more characteristic of rheumatoid arthritis.
Monarticular processes such as synovial chondromatosis and pigmented villonodular synovitis (PVNS)
can produce osteoporosis, but it is generally not striking.
present in both Of these
Osseous erosions are
disorders. In synovial chondromatosis (ossified type),
intraarticular ossifications may be identified on the plain
film. In the nonossified type, MR imaging will show the
cartilaginous loose bodies within the joint. In PVNS,
Figure 3. A coronal T1-weighted image (TR 500; TE 30) in a patient
with bilateral avascular necrosis, showing the characteristic welldefined low-signal periphery, with high or mixed signal centrally which
is virtually diagnostic of avascular necrosis.
low-signal hemosiderin deposits within the joint will be
seen on both T1- and TZweighted images. Occasionally,
the plain film may reveal a dense joint effusion.
MR imaging is considered the best method of
evaluation if the plain films are normal (6-9). It will
differentiate ITOH from avascular necrosis, and it may
demonstrate other findings to help limit the differential
diagnosis. It will help guide treatment, which is different
for each entity.
1. Wilson A, Murphy W, Hardy D, Totty W: Transient osteoporosis:
transient bone marrow edema? Radiology 167:757-760, 1988
2. Beaulieu J, Rezzano C, Levine R: Transient osteoporosis of the hip
in pregnancy: review of the literature and a case report. Clin Orthop
115:165-168, 1976
3. Hofmann S, Engel A, Neuhold A, Leder K, Kramer J, Plenk H:
Bone-marrow oedema syndrome and transient osteoporosis of the
hip. J Bone Joint Surg Br 75B:210-216, 1992
4. Guerra J, Steinberg M: Distinguishing transient osteoporosis from
avascular necrosis of the hip. J Bone Joint Surg A m 77A:616-624,
5. Lequesne M: Transient osteoporosis of the hip: a nontraumatic
variety of Sudeck’s atrophy. Ann Rheum Dis 27:463-471, 1968
6. Alarc6n G, Sanders C, Daniel W: Transient osteoporosis of the hip:
magnetic resonance imaging. J Rheumatol 14:1184-1189, 1987
7. Daniel W, Sanders P, Alarcon G: The early diagnosis of transient
osteoporosis by MRI. J Bone Joint Surg Am 74A1262-1264, 1992
8. Potter H, Moran M, Schneider R, B a n d M, Sherman C, Markisz
J: Magnetic resonance imaging in diagnosis of transient osteoporosis of the hip. Clin Orthop 280:223-229, 1992
9. Takatori Y , Kokubo T, Ninomiyd S, Nakamurd T, Okutsu I,
Kamogawa M: Transient osteoporosis of the hip: magnetic resonance imaging. Clin Orthop 271:lYO-194, 1991
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hip, idiopathic, transiente, osteoporosi
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