Updated: 6/9/2021

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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(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

QID: 6025
FIGURES:
1

core decompression.

32%

(111/352)

2

biopsy of the femoral head.

5%

(18/352)

3

protected weight bearing and observation.

52%

(184/352)

4

total hip arthroplasty.

8%

(28/352)

5

percutaneous cannulated pin fixation of the femoral neck.

2%

(8/352)

L 2 E

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(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

QID: 5993
FIGURES:
1

protected weight bearing and anti-inflammatory drugs.

47%

(217/463)

2

core decompression of the femoral head.

14%

(67/463)

3

vascularized free fibular grafting to the femoral head.

3%

(12/463)

4

bipolar hemiarthroplasty of the hip.

5%

(25/463)

5

total hip arthroplasty.

30%

(140/463)

N/A E

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Evidence (8)
EXPERT COMMENTS (16)
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