TRANSIENT OSTEOPOROSIS OF HIP: A forgotten entity! (E-poster no: 43415) Authors: Raju Vaishya, Virender Kumar, Vipul Vijay, Amit K Agarwal Indraprastha Apollo Hospitals, New Delhi, India

INTRODUCTION First reported by Ravault (1947) followed by Curtiss and Kincaid in 1959. Also known as Bone Marrow Oedema syndrome, Transitory demineralisation, reflex sympathetic dystrophy (RSD), Migratory osteolysis and Algodystrophy of the hip. Idiopathic & self-limiting disorder, unexplained hip joint pain with reduced mobility of the hip. Two third cases middle-aged males and rest one-third in females, exclusively in last trimester of pregnancy or in the early post-partum period. Exact etiopathogenesis unknown, can be attributed to RSD, inflammation, infection, trauma, osteoarthritis and neoplasia. Laboratory findings nonspecific , on radiograph evidence of localized osteoporosis followed by spontaneous recovery. Radiograph: Oedema before Treatment Radiograph before treatment Radiograph after treatment Radiograph: after Treatment

MATERIALS AND METHODS 14 cases of TOH (11 male and one female), right hip affected in 6 and left hip in 4 cases; two patients had bilateral affection. Clinical assessment done using Harris Hip Score. All patient underwent conservative management with protected weight bearing , NSAIDS, calcium and vitamin D. Accessed weakly for initial 2 weeks, then at 4 week interval for six months and two months interval until 1 year. During follow-up, patients underwent pelvis with hip radiograph and MRI. Patient was declared treated, with remission of presenting complaints and regaining complete movement in involved hip. MRI: Marrow Oedema before Treatment T1W and T2W MRI before treatment T1W and T2W MRI after treatment MRI: 3 months after Treatment

RESULTS The majority presented with sudden onset of pain in hip/groin region, with no associated h/o trauma. Clinical examination revealed painful hip with minimal restriction of movement Out of 14 hips studied, five hips showed localised osteopenia extending from femoral head to intratrochentric region. MRI revealed uniform and diffuse hypointensity on T1 weighted sequences and hyperintense when associated with joint effusion on T2 weighted sequences. Two cases reported non uniform signal with alternate areas of intensity. None progressed to femoral head collapse, arthritic changes or avascular necrosis of head. The average period for complete resolution of symptoms was17 weeks. No recurrence reported during 1-year follow up Intense uptake in femoral head & neck Increased uptake only in femoral head

DISCUSSION Bone marrow Oedema in head and neck of right femur TOH has been reported more frequently in healthy middle-aged males with a male: female ratio of 3:1 Clinically, TOH is affection of unilateral hip, but cases with bilateral involvement have also been reported. Xyda et al. reported postpartum bilateral TOH in 3 cases. Pain is sudden and more severe as compared to osteonecrosis, frequently accompanied by limp and an antalgic gait. Functional disability is disproportionate to symptoms (as described by Lequesne). T1 Coronal Image T1 STIR Coronal Image

DISCUSSION Radiographic findings may lag clinical symptoms by 1-2 months Initial focal osteopenia involving femoral head and neck may progress to complete effacement of the subchondral cortex of femoral head, and sometimes absence of the osseous architecture called phantom appearance Joint space preserved with no osseous erosion or sub chondral collapse. A bone scan helps in early diagnosis and shows increased uptake in all three phases representing increased capillary permeability and hyperemia, as well as increased osteoblastic activity May reveal involvement of contralateral hip, knees, or the shoulders MRI first described by Bloem (5), reveals hypointensity on T1- weighted images and hyperintensity on T2-weighted/STIR images extending from femoral head to the intertrochanteric region, usually with effusion MRI also helps in ruling out pathologies such as avascular-necrosis, infection, neoplasm mimicking TOH

DISCUSSION TOH being a self-limiting disease, a symptomatic and supportive approach is followed Judicious use of non-steroidal anti-inflammatory drugs with protected weight bearing and graduated physiotherapy regime Physiotherapy regime including abductor strengthening exercises Intermittent traction helps in prevention and correction of deformity Trevisan and Ortolani proposed densitometric assessment during the clinical management of disease Bisphosphonate, is not only efficacious for treatment but also speeds up recovery To minimize bone loss during acute episodes, calcitonin in the form of nasal spray (200 IU daily) is used Iloprost, a prostacyclin analogue, has the properties to dilate vessels and reduce permeability of capillaries. Its effectiveness in TOH is still under consideration

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