Updated: 9/11/2018

Idiopathic Transient Osteoporosis of the Hip (ITOH)

Topic
Review Topic
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Questions
3
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Evidence
4
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Introduction
  •  ITOH also known as
    • bone marrow edema syndrome
    • regional migratory osteoporosis
    • migratory osteolysis
  • Epidemiology
    • demographics
      • men >women (3:1)
      • 2 groups
        • middle aged (40-55y) men 
        • women in 3rd trimester of pregnancy
      • rare in Asians
    • location
      • usually unilateral
      • may recur
  • Pathogenesis
    • local hyperemia and imparied venous return with marrow edema and increased intramedullary pressure
  • Prognosis
    • resolves spontaneously in 6-8mths
Presentation
  • Symptoms
    • progressive, atraumatic hip and groin pain over several weeks
    • may be unable to bear weight
  • Physical exam
    • local tenderness
    • reduced 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
    • AVN
  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
Examination Preserved except at extremes of ROM Marked reduced ROM especially internall 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
 

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Questions (3)

(SAE07HK.65) A 42-year-old man reports the recent onset of right hip pain. A radiograph and MRI scan are shown in Figures 38a and 38b. A WBC count, erythrocyte sedimentation rate, and hip aspiration are within normal limits. Management should now consist of Review Topic

QID: 6025
FIGURES:
1

core decompression.

20%

(6/30)

2

biopsy of the femoral head.

7%

(2/30)

3

protected weight bearing and observation.

73%

(22/30)

4

total hip arthroplasty.

0%

(0/30)

5

percutaneous cannulated pin fixation of the femoral neck.

0%

(0/30)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(SAE07HK.33) A 58-year-old man reports a 2-month onset of groin pain with no history of trauma. Examination reveals that range of motion of the hip is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment should consist of Review Topic

QID: 5993
FIGURES:
1

protected weight bearing and anti-inflammatory drugs.

40%

(20/50)

2

core decompression of the femoral head.

24%

(12/50)

3

vascularized free fibular grafting to the femoral head.

2%

(1/50)

4

bipolar hemiarthroplasty of the hip.

8%

(4/50)

5

total hip arthroplasty.

26%

(13/50)

N/A

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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