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Updated: Jun 9 2021

Idiopathic Transient Osteoporosis of the Hip (ITOH)

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  • summary
    • Idiopathic Transient Osteoporosis of the Hip, is a self-limiting condition that leads to temporary loss of bone in the femoral head and neck, leading to hip pain and difficulty with ambulation. 
    • Diagnosis can be made with radiographs showing preserved joint space with diffuse osteopenia of the femoral head and neck. MRI studies will often show decreased signal with loss of fatty marrow on T1 studies. 
    • Treatment is observation with protected weight bearing as most cases resolve spontaneously within 6-8 months.
  • Epidemiology
    • Incidence 
      • rare
    • Demographics
      • men >women (3:1)
      • 2 groups
        • middle aged (40-55y) men
        • women in 3rd trimester of pregnancy
      • rare in Asians
    • Anatomic location
      • usually unilateral
      • may recur
  • Etiology
    • Pathogenesis
      • local hyperemia and impaired venous return with marrow edema and increased intramedullary pressure
      • also referred to as
        • bone marrow edema syndrome
        • regional migratory osteoporosis
        • migratory osteolysis
  • Presentation
    • Symptoms
      • progressive, atraumatic hip and groin pain over several weeks
      • may be unable to bear weight
    • Physical exam
      • local tenderness
      • often have normal hip ROM
  • Labs
    • Elevated ESR
  • Imaging
    • Radiographs
      • recommended views
        • AP
        • lateral
      • findings (xray findings in femoral head and neck lag behind clinical signs by 4-8wks)
        • subchondral cortical loss
        • diffuse osteopenia of femoral head and neck
        • joint effusion
        • joint space is always preserved
    • MRI
      • imaging modality of choice
      • shows marrow edema of femoral head and neck
      • T1
        • decreased signal, loss of fatty marrow
      • T2
        • high signal of marrow edema
        • joint effusion
    • Bone scan
      • increased uptake in femoral head
      • preceeds Xray changes
  • Differential
    • ITOH is a diagnosis of exclusion. Exclude
      • femoral neck stress fracture
      • infection
      • malignancy
        • ITOH vs. Avascular Necrosis
        • ITOH
        • Avascular Necrosis
        • Gender
        • Male (3:1)
        • Equal sex distribution
        • Age
        • Women 3rd trimester of pregnancy, middle aged men
        • 20-40yo
        • Laterality
        • Unilateral
        • Bilateral >50%
        • Risk Factors
        • 3rd trimester of pregnancy
        • ETOH, Steroids
        • Symptoms
        • Acute pain, improves with PWB
        • Insidious pain, progessively worse
        • Exmination
        • Preserved except at extremes of ROM
        • Marked reduced ROM especially internal rotation
        • Radiographs
        • Diffuse osteopenia femoral head and neck at 4-6wk
        • Localized sclerosis, crescent sign, collapse
        • Bone scan
        • Homogenous increased uptake femoral head and neck
        • Localized uptake in femoral head and neck
        • MRI
        • Diffuse edema but NO focal defects or subchondral changes. Decreased T1, increased T2 signal.
        • Focal defects/subchondral changes anterosuperior region of femoral head. Decreased T1 and T2 signal.
        • Treatment
        • Protected WB, symptomatic
        • Early surgery recommended
        • Prognosis
        • Self limiting
        • Progressive
  • Treatment
    • Nonoperative
      • symptomatic with avoidance of weightbearing
        • indications
          • first line of treatment
        • protected weightbearing to avoid stress fractures
        • resolves spontaneously in 6-8mths
  • Prognosis
    • Generally resolves spontaneously in 6-8 months
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