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. 2003 Jun;46(3):187-92.

Distinguishing transient osteoporosis of the hip from avascular necrosis

Anita Balakrishnan  1 , Emil H Schemitsch, Dawn Pearce, Michael D McKee
Affiliations

Distinguishing transient osteoporosis of the hip from avascular necrosis

Anita Balakrishnan et al. Can J Surg. 2003 Jun.

Abstract
in English, French

Introduction: To review the circumstances surrounding the misdiagnosis of transient osteoporosis of the hip (TOH) as avascular necrosis (AVN) and to increase physician awareness of the prevalence and diagnosis of this condition in young men, we reviewed a series of cases seen in the orthopedic unit at St. Michael's Hospital, University of Toronto.

Methods: We studied the charts of patients with TOH referred between 1998 and 2001 with a diagnosis of AVN for demographic data, risk factors, imaging results and outcomes.

Results: Twelve hips in 10 young men (mean age 41 yr, range from 32-55 yr) were identified. Nine men underwent magnetic resonance imaging (MRI) before referral, which showed characteristic changes of TOH. All 10 patients were referred for surgical intervention for a diagnosis of AVN. The correct diagnosis was made after reviewing patients' charts and the scans and was confirmed by spontaneous resolution of both symptoms and MRI findings an average of 5.5 months and 7.5 months, respectively, after consultation.

Conclusions: Despite recent publications, the prevalence of TOH among young men is still overlooked and the distinctive MRI appearance still misinterpreted. Symptoms may be severe but resolve over time with reduced weight bearing. The absence of focal changes on MRI is highly suggestive of a transient lesion. A greater level of awareness of this condition is needed to differentiate TOH from AVN, avoiding unnecessary surgery and ensuring appropriate treatment.

Introduction: Dans le but d'examiner les circonstances de l'établissement d'un diagnostic erroné de nécrose avasculaire (NAV) dans les cas d'ostéoporose transitoire de la hanche (OTH) et de mieux faire connaÎtre aux médecins la prévalence de cette maladie et l'établissement de ce diagnostic chez les jeunes hommes, nous avons passé en revue une série de cas du service d'orthopédie de l'Hôpital St. Michael's, à l'Université de Toronto.

Méthodes: Nous avons étudié les dossiers de patients atteints d'OTH référés à l'hôpital entre 1998 et 2001 suite à un diagnostic de NAV afin d'examiner les données démographiques, les facteurs de risque, les constatations tirées des examens d'imagerie et les résultats.

Résultats: L'étude a porté sur 12 hanches chez 10 jeunes hommes (âge moyen, 41 ans, plage de 32 à 55 ans). Avant d'être référés à l'hôpital, neuf patients avaient subi un examen d'imagerie par résonance magnétique (IRM) qui révélait les changements caractéristiques de l'OTH. On avait dirigé les 10 patients à l'hôpital pour une intervention chirurgicale suite à un diagnostic de NAV. Le diagnostic exact, qui a été établi suite à l'examen des dossiers et des clichés d'imagerie médicale des patients, a été confirmé par la disparition spontanée des symptômes et des constatations d'IRM après une période moyenne de 5,5 mois et de 7,5 mois, respectivement, suivant la consultation.

Conclusions: Malgré des publications récentes, on continue de négliger la prévalence de l'OTH chez les jeunes hommes et de mal interpréter son aspect caractéristique dans les examens d'IRM. Les symptômes peuvent être graves mais ils disparaissent au fil du temps par réduction de la contrainte de charge. Dans les examens d'IRM, l'absence de changements focaux est une forte indication d'une lésion transitoire. Il faut mieux connaÎtre cette maladie et la distinguer de la NAV, afin d'éviter des interventions chirurgicales inutiles et de veiller à ce que le bon traitement soit administré.

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Figures

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FIG. 1. Plain radiograph of transient osteoporosis of the left hip. Osteoporosis of the left femoral head and neck as well as periacetabular osteopenia can be seen. The right hip is normal.
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FIG. 2. A coronal T 1 -weighted magnetic resonance image of both hips (left) shows diffiuse low signal intensity throughout the left femoral head and neck. A corresponding coronal T 2 -weighted image with fat saturation (right) shows diffuse high signal intensity in the left femoral head and neck with a joint effusion. These findings are typical of transient osteoporosis of the left hip.
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FIG. 3. A coronal T 1 -weighted image (left) and a T 2 -weighted image (right) obtained 4 months after a diagnosis of transient osteoporosis of the left hip by magnetic resonance imaging shows complete resolution of the previous low T 1 and high T 2 signal intensity in the femoral head and neck. A previously noted effusion has resolved.
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FIG. 4. The time to resolution of symptoms in each of the 10 patients with transient osteoporosis of the hip (TOH). Cases 5 and 6 had TOH in both hips, so the time taken for the osteoporosis in both hips to resolve has been averaged and this average is represented on the graph. In case 5 the symptoms resolved in 6 months for the left hip and 5 months for the right hip, whereas in case 6, the time taken was 6 months for both sides.
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FIG. 5. Plain radiograph of the right hip shows a large serpiginous sclerotic area in the right femoral head due to avascular necrosis. Note the distinct sclerotic margin of the lesion in the femoral head (arrowheads).
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FIG. 6. Bilateral avascular necrosis (AVN). A coronal T 1 -weighted magnetic resonance image of both hips (left) and sagittal T 1 -weighted image of the right hip (right) shows low-signal-intensity serpiginous lines in the femoral head due to AVN.
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