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[Bone marrow edema in the knee. Differential diagnosis and therapeutic possibilities].


Abstract and Figures

The Bone marrow edema (BME) is a common finding when evaluating patients with knee pain by magnetic resonance imaging (MRI). The typical signal patterns of BME are unspecific and can be found with different diseases of the knee. Since different therapeutic approaches are mandatory, differential diagnosis of the several forms of BME is important. In this review, painful BME will be separated into three different etiological groups. Group 1 ischemic BME: osteonecrosis, osteochondritis dissecans, bone marrow edema syndrome and complex regional pain syndrome. Group 2 mechanical BME: bone bruises, microfracture, stress-BME und stress fracture. Group 3 reactive BME: inflammatory gonarthritis, degenerative gonarthrosis, postoperative and tumours. The typical MRI morphologies and differential diagnosis of these BME manifestations will be described. The different therapeutic consequences will also be briefly mentioned.
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Painful bone marrow edema of the knee: differential
diagnosis and therapeutic concepts
Siegfried Hofmann, MD
, Josef Kramer, MD
, Anosheh Vakil-Adli, MD
Nicolas Aigner, MD
, Martin Breitenseher, MD
General and Orthopaedic Hospital Stolzalpe, 8852 Stolzalpe, Austria
Institute MR and CT Diagnostic at the Schillerpark, 4020 Linz, Austria
St. Vincents Hospital, 4020 Linz, Austria
Orthopaedic Hospital, Speising, Vienna, Austria
Department of Osteology, University Radiology Clinic, Vienna, Austria
During the last decade, MRI has been the imaging
modality of choice for evaluating patients with pain-
ful bones or joints with normal or unspecific radio-
graphs [1]. Characteristic MRI signal alterations have
been described for most bone and joint diseases, and
MRI examination has become the diagnostic standard
for many patients with painful knee joints. The most
important functional units of the joint, in particular
cartilage, subchondral bone, the capsularligament
complex, and the surrounding soft tissues, can be
visualized simultaneously with MRI [2] . For thera-
peutic decision making, the correct interpretation of
the MRI findings is of utmost importance [3]. Bone
marrow edema (BME), with its typical signal appear-
ance on MRI, is a common but nonspecific signal
pattern that can be found in the bony parts of the
joints in several diseases [4,5]. Bone marrow edema
can be categorized into three distinct groups accord-
ing to cause:
1. Ischemic BME
Bone marrow edema syndrome (BMES)
Osteochondritis dissecans (OCD)
Complex regional pain syndrome (CRPS)
2. Mechanical BME
Bone contusion (bone bruise)
Stress-related BME
Stress fracture
3. Reactive BME
Postoperative BME
Tumor-related BME
Because only marrow structures are involved in
BME, plain-film radiographs and CT are unable to
detect changes with sufficient sensitivity. Bone scin-
tigraphy can detect early changes in vascularization
in areas with BME by increased tracer accumulation
[6], but its spatial anatomic resolution is poor, and
differentiation from other disorders characterized by
increased tracer uptake is generally impossible [7].
BME is not visible with arthroscopy. Only MR
imaging provides adequate detection of BME. BME
is characterized by low signal intensity compared
with unaffected bone marrow on T1-weighted
images. O n T2-weighted images, especially when
fat-suppression techniques are used, high signal in-
tensities in the low-signal areas of the T1-weighted
images are typical for BME (Fig. 1). After intrave-
nous administration of contrast agents, enhancement
of the BME lesion is more evident, indicating hyper-
vascularity and repair activity [8]. On histologic
examination, BME is caused by increased intra- and
0030-5898/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
* Corresponding author.
E-mail address:
(S. Hofmann).
Orthop Clin N Am 35 (2004) 321333
extracellular fluid within bone marrow inducing new
bone formation and repair processes [9].
Pain is caused by the increased intraosseous
pressure (normal pressusre, 2030 mm Hg) because
of the abnormally high fluid content in the marrow
spaces [1012]. The characteristic symptom of BME
in the knee is pain during mechanical loading com-
bined with more or less severe complaints during
night. Also typical is pain in the affected area when it
is tapped [4]. Until now there has been no explana-
tion why the intensity or extent of BME in MRI does
not always correlate with pain. Sometimes BME of
the knee is observed in asymptomatic patients [13];
on the other hand, BM E is som etimes th e only
definite morphologic alteration in long- lasting com-
plaints [5]. This article discusses the various causes of
painful BME of the knee joint. The aim is to allow
proper diagnosis using clinical, radiographic and
MRI findings. The therapeutic concepts for the dif-
ferent BME entities are also addressed.
Ischemic bone marrow edema
A common cause of BME is an ischemic process,
which frequently is combined with other causative
factors. Ischemic BME includes osteonecrosis, OCD,
and CRPS.
Osteonecrosis is characterized by ischemic necro-
sis of bony structures (bone marrow, trabecula e,
cortex) in the epiphysis of convex joint compart-
ments. By far the most frequently involved location
is the hip joint, followed by the knee. In osteonecrosis
Fig. 1. Bone marrow edema syndrome (BMES): typical signal pattern of diffuse BME in different MRI sequences of coronal
images. (A) T1-weighted image. (B) Fat-suppressed T2-weighted image. (C) Fat suppressed T2-weighted image after contrast
media. Note the diffuse extension of one complete quadrant of the knee.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333322
of the knee joint, two distinct types, secondary and
spontaneous osteonecrosis [SONK]) can be differenti-
ated [14,15]. Secondary osteonecrosis can be observed
in younger patients ( 20 55 years) who frequently
have typical risk factors for osteonecrosis. Multiple
necrosis and infarcts involving both knee joints and
other sites can be detected in most of these cases. The
etiology of secondary osteonecrosis is similar to that
of osteonecrosi s of th e hip for s ever al ische mic
factors [16]. In addition, the course of the disease
can be staged like osteonecrosis of the hip joint [4].
Initially, in the reversible initial stage (ARCO I), there
are only focal subchondral areas of BME. Frequently,
however, the location is not confined to the loading
zone. At this time the BME pattern is nonspecific.
In irreversible early stage (ARCO II), a subchondral
osteonecrotic area is surrounded by a reactive inter-
face (Fig. 2). In this stage, plain radiographs are still
negative and therefore are not useful for diagnostic
evaluation. Concomitant BME is commonly seen ad-
jacent to the necrotic area. This appearance may en-
large the necrotic area on T2-weighted images or even
hide a small subchondral necrotic lesion in the early
phase. Diagnosis of secondary osteo necrosis with
concomitant edema can be made without difficulty
in most cases, however, by the pathognomonic signal
changes on MR [15,17].
SONK is observed in older patients ( > 55 years)
without the classic osteonecrosis risk factors. There is
a predominance of females with isolated involvement
of the medial femoral condyle [15,16]. In a prospec-
tive MR study of 176 patients suffering from knee
pain, 3.4% had SONK. For patients over 65 years of
age, the prevalence was even higher (9.4%) [18]. MRI
and histology demonstrate subchondral microfrac-
tures combined with ischemic necrosis [19,20]. The
course of SONK can be also divided into different
stages, but the appearance and course differ signifi-
cantly from second ary osteonecrosis [20]. Initially
(stage I), subchondral BME is observed in the load-
bearing zone of the femoral condyle (Fig. 3). Involve-
ment of the weight-bearing zone of the tibia is
uncommon [15]. Normally, because of this typical
location and the age of the patient, a definite diagno-
sis can be made in this early phase. The initial stage is
reversible. Further progression leads to early sub-
chondral fracture with flattening of the condyle (stage
II), to osteochondral fracture (stage III) and, subse-
quently, to secondary osteoarthritis (stage IV) [20].
Bone marrow edema syndrome
Whether BMES represents a distinct disease (tran-
sient osteoporosis, algodystrophy, transient bone mar-
row edema syndrome) [21,22] or is a subtype of
osteonecrosis [2325] remains controversial. Most
likely, BMES is caused by diffuse subacute ischemia,
which completely heals in most cases because of a
sufficient repair mechanism [12]. No pathologic plain
radiographic findings can be observed during the
initial period of 4 to 6 weeks. Afterwards, a slight
demineralization of the affected area can be seen. As
a result, BMES is often also referred to as transient
osteoporosis. Histologic examination shows no signs
characteristic of osteoporosis, although loss of hy-
droxyapatite content within the bone is observed in
BMES of the hip [9]. A reasonable diagnosis of
Fig. 2. Secondary osteonecrosis. (A) T1-weighted and (B) fat suppressed T2-weighted images with two typical osteonecrosis
lesions, reactive interface, and concomitant BME in the patella and femoral condyle.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333 323
BMES can be made by MRI only. Extensive, diffuse
BME involving an entire quadrant of the knee joint is
typical (see Fig. 1). An important differentiation from
other diseases with BME is the diffuse extension, the
lack of any other morphologic alterations, no history
of trauma, and the reversible course in most cases
[12]. Spontaneous healing lasts from 3 to 12 months
(average, 6 months). In contrast to BMES of the hip,
a concomitant extensive joint effusion is uncommon
in BMES of the knee. A special migratory form can
be observed in rare cases [22,26]. After BME dis-
appears from an initially affected quadrant, new BME
may be observed in a different site in the knee (Fig. 4)
Osteochondritis dissecans
OCD usually affects the knee. OCD is the mani-
festation of osteonecrosi s in j uveniles, when the
growth plate is partly still open. The cause is probably
multifactorial and the consequence of abnormal ossi-
fication or focal stress combined with ischemia [29].
The prognosis and the course of the disease are much
better than for osteonecrosis in adults [30]. OCD can
even be observed in the convex epiphysis of joints
and can be separated into five different stages. Unlike
secondary osteonecrosis in adults, the affected area in
OCD appears relatively small in most cases [31].
Initially on MRI a nonspecific subchondral BME
Fig. 4. Fat-suppressed T2-weighted coronal images showing migratory BMES. (A) Primary lesion (lateral). (B) Three months
later the lateral lesion has healed; there is new BME in the medial condyle.
Fig. 3. T2-weighted fat-suppressed images of stage II spontaneous osteonecrosis of the knee (SONK). (A) Coronal view.
(B) Sagittal view. Note the diffuse extension of the BME and the low signal line indicating subchondral fracture.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333324
(stage I) can be seen. Location, extension, and age of
the patient allow diagnosis in most cases. In stage II,
plain radiographs are still negative, but in MRI the
demarcation of a necrotic area from surrounding bone
is already visible (Fig. 5). In contrast to osteonecrosis
in older patients, stage II is still reversible. Stages III
through V can be diagnosed on plain radiographs.
Concomitant BME can occur in all stages, but it is not
as common as in osteonecrosis [29].
Chronic regional pain syndrome
CRPS is also known as algodystrophy, reflex
sympathetic dystrophy, or Morbus-Sudeck syndrome
[32]. Following a trauma or i njury of unknown
origi n, a continuous burning pain, trophic distur-
bances, sensorimotor alterations, and, frequently,
psychic imbalance are observed. Initially one joint
is affected, but in chronic cases the entire extremity
may be involved. In CRPS three different stages
(acute, dystrophy, and atrop hy) can be sep arated
[33]. In most cases, the diagnosis can be suspected
by history and clinical findings. In the initial stage,
bone scintigraphy shows intense tracer uptake by the
involved joint and periarticular tissues [7]. On plain
radiographs, the earliest signs are typically patchy
structural changes after 6 to 12 weeks. MRI is not
the modality of choice in the diagnostic process of
CRPS [32], but it can contribute to diagnosis in ques-
tionable cases in the acute stage [7]. Characteristic
findings on MRI in acute CRPS are diffuse BME on
both sides of the affected j oint and edematous
changes in periarticular soft tissue. In most cases,
joint effusion is visible [7,34]. In the initial stage, an
acute infection must be excluded. Differentiation
from edema caused by other disease is possible in
most cases. In migratory BMES, however, soft tissue
involvement is possible too. A continuous transition
from migratory BMES to CRPS may be possible [7].
Mechanical bone marrow edema
In almost all cases plain radiographs and CT allow
sufficient diagnosis in the acute phase following
injury to the extremity. Patients with nonspecific pain
that does not respond to therapy following a trauma
or overloading and who have negative plain radio-
graphs present a difficult diagnostic situation. Al-
though its specificity is very low, the advantage of
bone scintigraphy in occult trauma or mechanical
overload lies in its high sensitivity. In a consecutive
series of 176 patients, BME was detected on MRI in
72% after trauma [31]. MRI significantly facilitates
diagnosis of posttraumatic or overloading pain.
Bone contusion (bone bruise)
Bone bruise is caused by direct injury to the bone.
On histologic evaluation, diffuse BME, microfrac-
tures of trabeculae, and hemorrhage can be found
[35]. Bone contusions of the knee joint are a common
finding and are frequently observed after direct con-
tact, compression, or distraction injuries [36].By
definition, a bone bruise is not visible as a fracture
on plain-film radiographs or CT. In bone scintigra-
phy, increased tracer uptake in the affected area may
help diagnosis. Today, MRI is the modality of choice
for detecting bone contusions. A diffuse subcortical
BME is visible in the painful area with enhancement
Fig. 5. Stage II osteochondritis dissecans (OCD) with concomitant BME sagittal images. (A) T1-weighted image. (B) Fat-
suppressed T2-weighted image.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333 325
after administration of contrast agents. Besides the
diffuse BME pattern, no signs of osteonecrosis or
fractures are visible on MRI (Fig. 6). A focal demin-
eralization zone may be observed on plain radio-
graphs 6 to 12 weeks after injury [37].
Microfractures are traumatic injuries of the bone
marrow in which cortical involvement is common.
There is no clear delimitation between bone bruise
and microfracture. Even in bone contusion of joint
structures, osteochondral microfractures may be pos-
sible. Plain-film radiographs are not helpful for
detecting microfractures. The fra cture line can be
detected on high-resolution CT, however. On T1-
weighted MRI, the microfracture is characterized by
a broad band of low signal in the bone marrow
coursing until the cortic al surface . Even on T2-
weighted MRI a thin band of low signal indicates
the fracture line surrounded by BME (Fig. 7) [38].
Sometimes the concomitant edema partially hides the
fracture line, and diagnosis is more difficult. In
compression fractures, extensive BME can usually
be observed. In contrast, distraction injuries may
show only minimal BME, and therefore misdiagnosis
with MRI is possible [39,40].
Stress-related bone marrow edema
Frequently, with mechanical stress or frontal mal-
alignment, subchondral BME of the overloaded com-
Fig. 6. Fat-suppressed T2-weighted images of bone bruise after anterior cruciate ligament rupture.(A) Sagittal view shows BME
of the lateral posterior tibia and central femoral condyle. (B) Coronal view of the same lesion.
Fig. 7. Microfracture: osteochondral microfracture not visible on radiographs. (A) Sagittal T1-weighted image. (B) Coronal fat-
suppressed T2-weighted image shows fracture in the lateral tibia plateau.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333326
partment can be observed [41]. In most patients this
chronic mechanic overloading leads to progressive
early arthritic changes (subchondral sclerosis and
thinning of the hyaline cartilage) on radiographs.
Stress-related BME can be observed without any
arthritis in the knee, however. In MR examinations
in a healthy population without arthritis, subchondral
BME could be demonstrated after mechanical stress
combined with artificial malalignment of the mechan-
ical axis [42]. On MRI, stress-related BME is char-
acterized by wedge-shaped subchondral BME in the
femur and tibia of the involved compartment with the
base of the wedge located at the site of the greatest
load (Fig. 8). Frequently, there are additional arthritic
signs with typical chondral and subchondral signal
changes, as discussed later. Therefore a continuous
transition from stress-related BME to activated oste-
oarthritis may be considered.
Stress fractures
Stress fractures can be divided into fatigue and
insufficiency fractures. A fatigue fracture is caused
by repeated overloading of normal bony structures.
In contrast, insufficiency fractures occur sponta-
neously, without any trauma or overloading in patho-
logic, altered bony tissues (eg, osteoporotic bones)
[43]. Differentiation between microfractures and
stress-related fractures is not possible with conven-
tional imaging modalities. The patient’s history can
help differentiate between microfracture (with a his-
tory of trauma) and stress fracture (with a history
of overloading).
Reactive bone marrow edema
Reactive BME occurs in a group of disorders in
which the underlying disease or a prior s urgical
procedure dominates the history, clinical findings,
prognosis, and course of the disease. BME in
these patients represents only a severe concomitant
component without any main influence on the ther-
apeutic management. In most cases there are no
essential differential diagnostic difficulties in separat-
ing reactive BME from the other types of BME de-
scribed previously.
The most important diseases in which reactive
BME is noted are chronic polyarthritis, reactive
arthritis, bacterial arthritis, and osteomyelitis. Differ-
ential diagnosis is of utmost importance for ther-
apeutic management. In contrast to other imaging
modalities, MRI allows early detection, exact assess-
ment of bony involvement (location and extent),
evaluation of the severity of disease, and its differ-
entiation from other diseases [1]. MRI should not be
used as the primary modality but should be used
when the diagnosis is questionable. In the initial stage
of chronic polyarthritis, MR imaging allows evalua-
tion of a joint effusion, synovial involvement, bony
erosions, periarticular soft tissue involvement, and
relatively early alterations of hyaline cartilage [44].
Intravenous administration of contrast agent may be
helpful for assessment of inflammatory activity [45].
In the acute phase of chronic polyarthritis a more or
less severe concomitant BME may be observed [46].
Fig. 8. Sagittal views of stress-related BME: lateral compartment osteoarthritis with valgus deformity and beginning
osteoarthritis. (A) T1-weighted image. (B) Fat-suppressed T2-weighted image.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333 327
In most cases, however, a correct assignment of this
reactive BME is not difficult [44]. Reactive arthritis
can be observed as a concomitant finding in several
diseases. It is important to differentiate reactive
arthritis from bacterial arthritis. Normally in reactive
arthritis there are no pathologic changes within the
bone marrow, but in rare cases BME can be observed
on MRI [47]. Frequently, in these cases, differentia-
tion from an initial stage of chronic polyarthritis is
not possible by MRI [1].
In bacterial gonarthritis, MRI is helpful for evalu-
ating the involvement of cartilage, joint capsule, soft
tissue structures, and the bone marrow. MRI, however,
is indicated in unclear cases only [48]. A concomitant
BME in bacterial arthritis must be conside red as
possible direct involvement of the bony structures
[1]. In the initial stage of osteomyelitis, only diffuse
BME is visible, and differentiation between acute
infectious alterations within the bone and concomi-
tant BME may be difficult. In this situation intrave-
nous administration of contrast agent may facilitate
diagnosis [1]. Changes in signal intensity are non-
specific, however, and it can be difficult to differen-
tiate concomitant BME from other forms of diffuse
BME. In most cases an exact diagnosis can be made
by history, clinical and laboratory findings, plain-film
radiographs, and appearance in MR imaging [49].
Assessment of osteomyelitis following to trauma or
surgery remains still a problem, however.
Normally MRI is not used f or diagnosis and
therapy planning in chronic degenerative joint dis-
eases. In unclear cases, however, MRI may be helpful
in detecting additional changes such as joint effusion,
subchondral edema, geodes, and reactive synovitis
(Fig. 9). Histologic evaluation of subchondral BME
in arthritic knee joints shows several pathologic
changes in the bone marrow [50]. In a recent study
it has been shown that subchondral BME is correlated
to pain in patients with painful osteoarthritis of the
knee [10]. A longitudinal follow-up study of these
patients over 30 months documented for the first
time that, besides mechanical malalignment, BME
represented the main risk factor for osteoarthritic
progression [41]. There is no strong delimitation
between stress-related BME, described previously,
and subchondral BME in osteoarthritis.
Postoperative bone marrow edema
MRI is indicated for follow-up examinations after
surgery and when there is continued or recurrent pain
after surgery. In the knee joint postoperative BME is
frequently observed after reconstructions of liga-
ments, dri lling, and surgical procedures involving
the osteochondral compartment (Fig. 10). This reac-
tive BME can be seen up to 6 to 12 months after
surgery [51], and an appropriate diagnosis and as-
signment are not difficult in most cases. In patients
with persisting or recurrent pain after arthroscopies
with partial meniscectomies [52 54] or ligament
reconstructions [55], subchondral signal alterations
have been described on MRI. In 94 patients with
meniscal tears who did not show any subchondral
signal alterations on MRI before surgery, a partial
meniscectomy was performed arthroscopically. MRI
Fig. 9. Coronal views of medial osteoarthritis. (A) T1-weighted image. (B) Fat-suppressed T2-weighted image shows BME in the
tibial plateau and focal in the femoral condyle.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333328
control examinations performed in all patients within
2 years revealed that 34% had femoral or tibial
subchondral BME in the region of the meniscectomy.
There was no correlation between the incidence of
BME and age, gender, or constitution of the hyaline
cartilage. The percentage of the removed meniscus
was identified as a risk factor, however [52]. This
subchondral BME will disappear in many cases if
partial weight bearing is induced by early diagnosis
[54]. The risk of developing manifest osteonecrosis
after partial meniscectomy seems to increase in
patients older than 50 years [53,56]. Clinical symp-
toms, course, and imaging findings of postoperative
BME after arthroscopy are the same as for SONK
[57]. Furthermore, histologic examinations demon-
strated subchondral microfractures comp arable to
SONK in these cases [58]. Predisposing factors may
be ischemia and local traumatizing during arthros-
copy as well as mechanic overloading (missing effect
of shock absorption and further deterioration of the
mechanical axis because of the removal of the me-
niscus) [54,58].
Tumors and tumorlike lesions of the knee joint
Benign and malignant tumors of the knee joint are
fairly common. After initial plain radiographs, MRI
with contrast administration should be performed for
exact assessment of bone involvement and involve-
ment of soft tissue structures [44]. MRI morphology
of tumors in the knee joint is the same as in other
joints. Concomitant reactive BME can be observed in
almost all stages of various tumors [59]. In most
cases better delineation of concomitant edema from
tumor tissue is possible by using intravenous contrast
agent [1]. Characteristic MRI findings of tumors
together with specific plain-film abnormalities allow
a clear differentiation from other entities with BME in
almost all cases [44].
Therapeutic concepts
Therapeutic management of BME depends es-
sentially on the disease that causes the BME. Non-
steroidal anti-inflammatory drug (NSAID) or pain
medications have shown only a limited effect, espe-
cially for the night pain. Mechanical unloading by
partial weight bearing or drilling the edematous bone
may lead to pain relief [23]. An interesting new
treatment is the medication therapy with Iloprost
(Ilomedin, Schering, Berlin, Germany), a prostacyclin
analogue [60]. The effect of iloprost has been evalu-
ated in two prospective MRI studies in patients with
painful BME of the knee (BMES, bone bruise, stress-
related BME, and reactive BME with osteoarthritis).
The preliminary data have shown clinical success for
pain relief and rapi d reg ression of the BME and
subchondral lesions on MRI [61]. Iloprost may be a
successful therapeutic approach for patients with
painful BME in the future.
Ischemic bone marrow edema
In osteonecrosis differentiating secondary osteo-
necrosis from SONK is important for therapeutic
decision making. In secondary osteonecrosis, de-
creasing intraosseous pressure by core decompres-
sion, a minimal surgical procedure, can lead to
immediate pain relief [17]. Repair of manifest necro-
sis (irreversible stage II osteonecrosis) is not possible
by drilling only, however [8]. In early-stage osteo-
necrosis without joint space destruction (stages III),
core decompression has shown clinical success in
79% with an average follow-up of 7 years [17].
Fig. 10. Postoperative BME: sagittal views 6 weeks after osteochondral transplantation (mosaicplasty). (A) T1-weighted image.
(B) Fat-suppressed T2-weighted image shows perifocal BME around the cylindrical transplants.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333 329
Because osteonecrotic areas are relatively large, and
multiple sites are involved, a bonecartilage trans-
plantation is not a reasonable alt ernative in most
cases. After an osteochondral fracture and clinical
and radiographic progression (stages III and IV), total
knee arthroplasty is recommended [17]. In SONK
with subchondral BME in the initial stage, a prog-
nostic assessment is important. Lesions that involve
more than 50% of the bone in the joint have a
worse prognosis [15]. In a retrospective MRI study
of 23 patients who received no treatment, the pres-
ence of a subchondral hypointense line more than
4 mm thick or 14 mm long on T2-weighted images
indicated a significant risk for early osteochondral
fracture and progression (see Fig. 3) [62].Inthe
initial stage, conservative therapy with partial weight
bearing can be recommended, because in many cases
the necrosis may stabilize. In pat ients with risk
factors or flattening of the fem oral condyle an d
mechanical malalignment, a realignment osteotomy
should be consi dered, depending on the patient’s
age [63]. Additionally de
bridement, curettage, and
drilling can be tried arthroscopically [14]. In most
cases cartilage transplantation seems not to be rea-
sonable because of the patient’s age. A good thera-
peutic solution in advanced stages is a minimally
invasive unicondylar prosthesis [15].
In BMES the aim of treatment is pain relief and
shortening of the spontaneous course. NSAID and
pain medications are not very successful. Mechanic
unloading by partial weight bearing decreases com-
plaints but has only a limited effect on night pain.
In BMES of the hip joint, core decompression has
demonstrated immediate pain relief and significant
shortening of the spontaneous clinical course [23].
For the knee joint similar data are not available. In
OCD the therapeutic considerations are not influ-
enced by concomitant BME. In stage I and II OCD
conservative therapy (mechanical unloading by par-
tial weight bearing) or drilling in selected cases seems
to be reasonable. In lat e stages surgical t herapy
includes simple drilling, stabilization of the fragment,
curettage combined with drilling, and lastly osteo-
chondral or chondrocyte transplantation [64]. In the
therapeutic management of CRPS several considera-
tions must be taken in account. Sympathiolytic
agents, various drugs, and physiotherapy have been
recommended with varying degrees of success [32].
Mechanical bone marrow edema
In bone bruises the primary goal of treatment
is symptomatic pain relief by mechanical unloading
and interruption of sports activities for at least
6 weeks. After pain is relieved and before full weight
bearing resumes, a control examination with MRI
can be recommended [36]. In stress-related BME
the main goal of therapy is relief of pain by NSAID
or analgesics as well as mechanical unloading by
partial weight bearing. Pat ients with stress-related
BME combined with malalignment of the mechani-
cal axis show a great risk for decompensation of
the compartment, and therefore realignment should
be considered in patients younger than 60 years of
age. The treatment of microfractures and stress frac-
tures is similar to the treatment for bone bruises, but
unloading is recommended for 6 to 12 weeks. Fur-
thermore, the cause of a stress fracture should be
evaluated, and prophylactic recommendations should
be included.
Reactive bone marrow edema
Reactive BME represents only a more or less
severe concomitant component without any main
influence to the therapeutic management. Only in
osteoarthritis of the knee does subchondral BME
represent an important risk factor for progression,
indicating the beginning decompensation of the joint
[41]. Therefore arthroscopic de
bridement in osteo-
arthritis should be combined with decompression
and/or mechanical realign ment of the mechanical
axis. In patients with osteoarthriti s who are older
than 60 years, the indication for arthroscopy should
be restrictive, because there is a high risk of less
postoperative pain relief, rapid progression of osteo-
arthritis, and eventually development of postopera-
tive SONK [18,52,54].
BME is a common finding when patients with
knee pain are evaluated by MRI. The typical MRI
signal patterns for BME are nonspecific, however,
and occur in several diseases of the knee. This article
categorizes painful BME of the knee joint into three
distinct etiological groups: ischemic BME (osteone-
crosis, OCD, BMRS, and CRPS), mechanical BME
(bone bruise, microfracture, stress-related BME, and
stress fracture), and reactive BME (inflammatory
gonarthritis, degenerative gonarthrosis, postoperative
BME, and tumor-related BME). The therapeu tic
concepts have been described briefly in a short
overview of the different therapeutic approaches.
S. Hofmann et al / Orthop Clin N Am 35 (2004) 321–333330
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... [1] Various diagnoses, especially such as degenerative arthritis, are known to contribute to BME. [1,2] The exact pathogenetic processes of painful BME in osteoarthritic knees and the role are not currently known. [3][4][5] BME in bone underneath cartilage significantly increases the risk for structural progression in knee osteoarthritis, and it is explained to be strongly related to malalignment toward the side affected by the lesion. [2,5] The increased mechanical load in knee osteoarthritic cases can cause microfractures to occur in the subchondral metaphyseal area, leading to the involved compartment collapses. ...
... BME is recognized to be related to biomechanical changes of knee osteoarthritis. [1,3,5,6] BME is usually self-limiting in the nature course and the symptoms resolve spontaneously over a period of 6 months, or occasionally 12 months, [7] which is invariably associated with severe and long-lasting disability. [8,9] Various treatments have been recommended in order to shorten the natural course of the disease. ...
... There is no consensus regarding treatment for BME seen on MRI in osteoarthritic knees. [2,3,5,8,25] Conservative treatment is recommended to be able to regress BME, including reduction of weight-bearing load, analgesic and anti-inflammatory medication, and physiotherapy. [3,8,26,27] The potent osteoclast inhibitor alendronate has proved to be effective and tolerant in metabolic bone disease such as osteoporosis conditions and BME. ...
Full-text available
Bone marrow edema (BME) represents a reversible but highly painful finding in magnetic resonance imaging (MRI) of patients with knee osteoarthritis. The aim of this retrospective study was to evaluate the efficacy of extracorporeal shock wave treatment (ESWT) on painful BME in osteoarthritis of the knee. This study focuses on people who had early-to-mid stage osteoarthritis with knee pain and MRI findings of BME. Patients who underwent ESWT treatment or prescribed alendronate treatment in our department were analyzed. Knee pain and function were measured using the visual analog scale (VAS) for pain and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), respectively. The degree of BME was measured with MRI scans. A total of 126 patients who received ESWT treatment (Group A, n = 82) or alendronate treatment (Group B, n = 44) were included. All patients were followed up clinically and radiographically for a minimum of 12 months. The mean follow-up was 23.5 months (range, 12–38 months). The VAS and WOMAC score decreased more significantly after treatment in Group A than that in Group B (P <.01) within 3 months. In 6-month MRI follow-ups, there was higher incidence of distinct reduction and complete regression of BME of the affected knee in Group A than that in Group B (P <.01). ESWT is an effective, reliable, and noninvasive treatment in patients with painful BME in osteoarthritis of the knee followed by a rapid normalization of the MRI appearance. It has the potential to shorten the natural course of this disease.
... It is a common finding in MR-imaging of patients with joint pain following largely non-diagnostic or normal radiographs. Although various vascular factors are known to contribute to bone marrow edema (BME), the exact pathogenetic processes are not currently known [3]. The natural time-course for improvement of clinical symptoms and normalization in MRI lasts from 3 to 18 months [4]. ...
... In general, the therapeutic approach to BMESK is based on its suspected etiology and ranges from various symptomatic therapies to core decompression (CD) [1][2][3][4][5]. Non-surgical treatments that have been reported as being beneficial include reduction in weight-bearing load of the joint, analgesic and anti-inflammatory medication, glucocorticosteroids, bisphosphonates, calcium channel blockers and prostaglandin inhibitors (e.g. ...
... Non-surgical treatments that have been reported as being beneficial include reduction in weight-bearing load of the joint, analgesic and anti-inflammatory medication, glucocorticosteroids, bisphosphonates, calcium channel blockers and prostaglandin inhibitors (e.g. iloprost) [2][3][4]. Unfortunately, conservative treatment approaches are unable to relieve symptoms in some cases [1,5]. Surgical CD, which reduces pain through relief of intraosseous pressure, is usually used as the last resort, particularly as the condition is self-limiting in the majority of patients [1,5,6]. ...
Full-text available
Background The aim of this prospective study was to evaluate the effectiveness of extracorporeal shock wave therapy (ESWT) in normalizing the symptoms and imaging features of primary bone marrow edema syndrome (BMES) of the knee. Methods This study compared the outcomes of ESWT (Group A) (n = 20) and intravenously applied prostacyclin and bisphosphonate (Group B) (n = 20) in the treatment of BMES of the knee in our department between 2011 and 2013. The Visual Analog Scale for pain (VAS, 100 mm), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), the SF-36 scores and MRI scans as well as plain radiographs were obtained before and after therapy between two groups. Results Compared with Group B, we found greater improvement in VAS, the WOMAC Osteoarthritis Index and SF-36 score at 1, 3 and 6 months post-treatment in Group A (P < 0.05). Furthermore, MRI scans showed a higher incidence of distinct reduction and complete regression of bone marrow edema at 6 months in Group A (95 vs. 65 %; P = 0.018). The MRI at 1 year follow-up showed complete regression in all patients in Group A. However, two cases in Group B continued to normalize over the subsequent follow-up period. Conclusions ESWT can produce rapid pain relief and functional improvement. It may be an effective, reliable, and non-invasive technique for rapid treatment of BMES of the knee. Trial registration Research Registry UIN 528, September 03, 2015.
... MRI is especially helpful in diagnosis. However, the differential diagnosis should be made meticulously not to miss a serious underlying pathology [7][8][9][10][11]. Some signal changes are evident on MRI and are characterized by low signal intensity in T1-weighted images and high signal intensity in T2-weighted imaging [4,10,12,13]. ...
... Patients may be advised to rest for 3-6 weeks and NSAIDs are given for symptoms. Oral NSAID can provide symptomatic relief without changing the underlying pathology [9,17,18]. ...
Full-text available
Bone marrow edema syndrome is characterized by increased interstitial fluid in the bone marrow and is a rare disease in children and adolescents. Therefore, to make this diagnosis, it should be considered in the differential diagnosis of musculoskeletal system pain. With this perspective, the aim was to present a 17-year-old patient who was diagnosed on magnetic resonance imaging with bone marrow edema and to highlight characteristics of this rare condition in the pediatric and adolescent population.
... comprehension of the mechanisms underlying the disease, although several aspects remain to be clarified. As evidence of this progress, at least three classifications [2][3][4] have been proposed and updated over the years. Moreover, the definition of the condition has also been modified, introducing the more appropriate term of Bone Marrow Lesion (BML) [5,6]. ...
Full-text available
Background Prompt diagnosis of bone marrow lesion (BML) is difficult but critical for correct treatment. Magnetic resonance imaging is the gold standard, although expensive and time consuming. Simple and reliable clinical test for BML detection is lacking. Aim of the study is to describe a new manual clinical test called Percussion Test (PT) and to statistically determine its diagnostic accuracy in BML, compared to MRI imaging. Methods After evaluation of the inclusion and exclusion criteria, 218 consecutive patients with unilateral knee pain and age comprised between 18 and 80 years old were enrolled in our observational prospective study. Informed consent was obtained for each patient. After medical history collection, PT was performed by a single operator as described. MRI was performed in the affected knee to detect the presence of BML. Coherence in PT and MRI assessment was evaluated in each quadrant of the knee via contingency tables, as sensitivity, specificity, NPV, PPV and diagnostic accuracy were calculated. Results No correlation with a positive PT was demonstrated for the covariables gender ( p = 0.156), age ( p = 0.272) and BMI ( p = 0.639). PT showed a sensitivity ranging from 60.6 (40.6–80.6) to 79.5 (63.0–96.0) and a specificity ranging from 85.7 (80.0–91.5) to 96.0 (93.1–98.9) depending on knee quadrant. Diagnostic accuracy ranged from 81.6 (75.9–86.6) to 89.4 (84.6–93.2), and p -value was < 0.00001 in a chi-squared analysis for all quadrants. Conclusions PT showed sensitivity and specificity values that are comparable with other clinical tests routinely adopted in clinical practice. In the absence of other reliable clinical test, PT has the potential to become a useful bedside tool in the diagnosis and management of BMLs.
... Acute local pain may be present during activities and limb loading, but also with the joint at rest and tends to worsen at night. This kind of bone pain can be associated with local swelling and become persistent, [11][12][13][14] thus limiting significantly daily life activities. ...
Full-text available
Bone marrow edema (BME) represents an imaging finding in various diseases, and often causes pain and significant dysfunction. Although few data are available about its etiology, several hypotheses have been developed to explain the pathogenetic mechanisms of BME. Increased intravascular pressure and capillary leakage within the bone marrow would lead to nerve irritation, causing pain. Bone turnover would increase locally, due to proinflammatory molecules driven by the primary cause of BME (trauma, ischemia, arthritis, etc.). In addition to imaging findings, the clinical evaluation of a subject affected by BME should rely on an accurate functional assessment, as this condition often leads to transient disability. As regards therapeutic approaches, recent research works have reported benefits from the extracorporeal shock wave treatment (ESWT) and above all bisphosphonates. A deeper knowledge of the pathophysiological bases of the BME combined with the classic physiatric approach can allow to select the subjects affected by BME who can benefit from therapies such as bisphosphonates and ESWT, and evaluate their clinical and functional effects.
... Traditionally conservative treatments usually consists of avoiding load on the hips, physical therapy, analgesics as well as the use of nonsteroidal anti-inflammatory drugs, bisphosphonates, and vasoactive prostacyclin analog drugs like iloprost, and blood-activating and stasis-removing drugs, which can improve local hemodynamic characteristics. [7][8][9][10][11] Unfortunately, given that the cause of the disease is not well understood, these traditional treatments sometimes do not effectively relieve pain and shorten recovery time, what is worse is that some patients have gradually worsened and even developed avascular necrosis of the femoral head. Marrow core decompression is a common surgical method at present, which reduces pain through relief of intraosseous pressure, and it has been shown to provide symptom relief within 4 weeks. ...
Full-text available
The objective of this retrospective study was to evaluate the efficacy of high-energy focused extracorporeal shock wave therapy (HF-ESWT) on painful bone marrow edema syndrome (BMES) of the hip and shorten the natural course of disease.Thirty-four consecutive patients with BMES of the hip were treated with HF-ESWT in our department between August 2017and July 2018. The progression and treatment results of BMES were evaluated by imaging examination and clinical outcomes. The clinical outcomes include hip pain and function which were measured using the visual analog scale (VAS) and Harris hip score (HHS), respectively, and the VAS and HHS of all patients were calculated and evaluated before treatment (s0), at 1 month (s1), 3 months (s2), 6 months (s3)post-treatment. Imaging examination including Pelvic radiographs and frog views and double hip magnetic resonance imaging (MRI) were also obtained and scheduled before treatment, at 1, 3, 6, and the final follow-up post-treatment to exclude avascular necrosis and other pathology.All patients successfully completed the treatment and follow-up. Compared with pretherapy, the pain was alleviated to varying degrees and the HHS was significantly improved, and the VAS was significantly reduced at S1-2 (1- and 3-months post-treatment) after therapeutic intervention (P < .05). The mean improvements were strongly statistically significant between S0 and S1 and between S1 andS2 (P < .0001) and less significant between S2 and S3 (P < .01). The mean improvement between 6 months (S3) and final follow-up (more than 12 months) was not statistically significant. The MRI findings demonstrated that the diffuse BMES in the femoral head and neck disappeared completely.HF-ESWT is a safe, effective, reliable, and noninvasive treatment in patients with painful BMES of the hip, and it can accelerate the recovery of BMES of the hip, shorten the treatment time and course of disease, improve hip joint function and the quality of life of patients.
... Wie in der Sonografie gibt es auch in der MRT der Sehnen Bildartefakte Arthroskopie Abb. 3 Diese Trias ist für die differenzialdiagnostische Einordnung des Knochenödems von großer Bedeutung. Die Sensitivität für den Nachweis eines Knochenödems verleitet zur Überinterpretation von banalen Verletzungsfolgen und muss kritisch bewertet werden [12]. ...
Modern cross sectional imaging modalities have improved the diagnostic work-up of chronic ankle instability with respect to reliability, diagnostic differentiation and patient comfort. Ultrasound is essential for the clinician. High resolution ultrasound systems should experience more attention. MRI can provide a complete status of the joint structures. New 3D spin echo sequences enable high contrast imaging with isovolumetric spatial resolution. For detailed delineation of bony structures, mineralisation and image guided joint puncture (CT-fluoroscopy), computed tomography is a valuable complementary method. Radiation exposure can be reduced to <1 mSv.Nuclear medicine can play a role in the investigation of bone and joint metabolism. For diagnosis of medial and lateral ligament tears, bony lesions and ruptures of syndesmosis sensitivity and diagnostic accuracy are >90 %. The same is true for tendons, which represent the ‘second line of defense’ in the case of chronic ankle joint instability.
Bone marrow edema (BME) is a descriptive term used to describe high-signal intensity changes detected on magnetic resonance fluid-sensitive sequences that could be attributed to a number of underlying pathologies. Regardless of the cause, physiologic remodeling of the subchondral bone can be limited because of ongoing joint forces, increased focalization of stress, and reduced healing capacity of the subchondral bone. BME is a known prognostic factor associated with pain, dysfunction, and progressive cartilage damage. This review summarizes the current known causes of BMEs, theories related to histopathological changes, and current treatment options including novel biologic surgical options.
Beim Knochenmarködem handelt es sich um ein relativ junges Krankheitsbild, das nach wie vor nicht vollständig geklärt ist. Symptomatisch wird es durch Schmerzen aufgrund der Reizung neurovaskulärer Strukturen. Der Entstehung eines Knochenödems können ischämische, mechanisch-traumatische oder reaktive Ursachen zugrundeliegen. Das bildgebende Verfahren der Wahl für die Diagnostik ist die Magnetresonanztomographie (MRT). Meist kommt die T2-Gewichtung zum Einsatz, da es hierbei zu einer hyperintensen Erscheinung gegenüber der Umgebung kommt. Da die histologischen Befunde nicht einheitlich sind und sich das Knochenmarködem nur schwer definieren lässt, sollte der Bezeichnung „bone marrow edema-like lesion“ Vorzug gegeben werden.
Morphologically, bone marrow edema (BME) is an accumulation of fluid in the bone marrow. The BME is per se non-specific but can be identified at an early stage with magnetic resonance imaging (MRI). The underlying pathomechanism remains unclear. The BME can occur as an individual entity and as an accompanying condition of many diseases. The BME can be divided into three groups, ischemic, reactive and mechanical BME. Mechanical BME occurs after trauma or repetitive strain. Typical histological changes are present and there is no clear boundary between edema and microfracture. Some forms of trauma show BME in typical localizations. Both the trauma and the possible accompanying injuries can be indirectly indicated in this way in cases with an unknown trauma mechanism. The BME can be present as an isolated entity or as a comorbidity. For initiation of therapy, a comprehensive medical history and targeted diagnostics are indispensable. In some cases BME is indicative of the trauma mechanism and possible further accompanying injuries.
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The pathomorphologies of non-traumatic femoral head osteonecroses (ON) are usually similar, despite various known pathogenetic factors. The size and position of the subchondral bone and marrow segment, becoming necrotic after the ischemic event(s), and the kind of repair processes determine the time course and thus the fate of this hip joint disease. Four cases of conservatively or core decompression-treated fermoral head ON were selected to demonstrate differently effective repair mechanisms which are discussed in respect to existing therapeutic concepts. Diagnostic criteria from magnetic resonance imaging follow-ups were correlated with light microscopy findings on undecalcified ground and microtome sections from femoral heads retrieved at total joint replacement. Initial stage (ARCO 0) and reversible early stage ON (ARCO 1) after incomplete ischemias can apparently show spontaneous sufficient repair. After extensive and complete ischemia, however, ON progresses without detectable changes on plain radiographs into irreversible early stage ON (ARCO stage 2). Only in exceptional cases (with small, medially located necroses), a spontaneous sufficient repair seems possible. Usually, early ARCO stage 2 ON with intact articular surface shows no remodeling of the subchondral necrotic bone and fatty marrow, but only ineffective repair with fibrovascular tissue invasion and bone resorption at the vital bone border. Repeated bone appositions on partly resorbed necrotic trabeculae form the sclerotic rim in this pathognomonic reactive interface. New bone formation can also be increased underneath the necrotic area and reactive interface when surrounded by accompanying bone marrow edema. Core decompression in ARCO stage 2 ON, even if it reaches the necrotic lesion, can at best delay progression of the disease, but never leads to complete reconstruction of the necrotic area. More likely, after both conservative and operative treatment, destructive resorption I without effective consecutive bone formation will lead sooner or later to collapse of the articular surface and thus to mechanical instability of transition stage ON (ARCO stage 3). On the other hand, this subchondral fracture can apparently also cause reconstructive repair which, by involving chondral and membranous ossification in this creeping 'substitution', can reduce the necrotic area. However, it cannot prevent progression into late stage ON (ARCO stage 4) with secondary joint destructions. Principally, besides the rare sufficient repair in initial and certain early ON, three forms of insufficient repair in the necrotic area can be distinguished: Lack of remodeling, destructive remodeling, and reconstructive remodeling. To date, no therapeutical intervention exists which leads to complete healing of irreversible ON stages by reconstructive repair. Improved understanding of pathomorphology and repair mechanisms, however, could be the basis for future therapeutical concepts which should aim at the complete regeneration of the osteonecrotic area.
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There is still controversy whether transient osteoporosis of the hip joint represents a distinct self-limiting disease, or reflects only an early, reversible subtype of non-traumatic osteonecrosis (ON). Transient osteoporosis has several synonyms: algodystrophy of the hip; transient marrow oedema; or bone marrow oedema syndrome – BMOES. Clinical presentation of BMOES shows mechanical hip joint pain, ON risk factors, and a diffuse bone marrow oedema in MR imaging. Histomorphological changes resemble early ON, but with diffuse sufficient repair in BMOES and focal and insufficient repair only at the border of the necrotic lesion in ON. Therefore the clinical course and outcome are significant different, with restitution occurring in BMOES, while progressive destruction of the joint takes place in ON. So far, the preferred treatment strategies are protected weight bearing for BMOES, but operative treatment for ON. In a prospective study of patients with BMOES, the clinical, radiographic, and MRI course of 43 hip joints after core decompression treatment were investigated. All patients showed immediate relief of pain after surgery and the average duration of symptoms with conservative treatment could be dramatically reduced by core decompression from 6 months down to 2 months. There were no perioperative complications. Based on our experience with over 100 BMOES patients , we are convinced that this syndrome represents not a distinct disease but an early reversible subtype of non-traumatic ON. Due to the excellent clinical results of core decompression, we recommend this operative therapeutical concept in patients with painful BMOES.
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Bei Abklrung von Kniegelenkschmerzen mit der Magnetresonanztomographie (MRT) ist das schmerzhafte Knochenmarkdem (KM) ein hufiger Befund. Das typische Signalverhalten eines KM ist jedoch unspezifisch und tritt bei zahlreichen Krankheitsbildern auf. Die Differenzialdiagnose der unterschiedlichen KM des Kniegelenks ist wichtig, da sich daraus verschiedene therapeutische Konsequenzen ergeben. In dieser bersichtsarbeit werden die schmerzhaften KM tiologisch in 3Gruppen unterteilt. Gruppe1, ischmische KM: Osteonekrose, Osteochondrosis dissecans, Knochemarkdemsyndrom und complex regional pain syndrome; Gruppe2, mechanischene KM: Knochmarkkontusion und Mikrofraktur sowie Stress-KM und Stressfraktur; Gruppe3, reaktive KM: Gonarthritis, Gonarthrose, postoperativ, und bei Tumoren. Die typische MRT-Morphologie und Differenzialdiagnose dieser unterschiedlichen KM-Erscheinungsbilder werden besprochen und die sich daraus ergebenden therapeutischen Konsequenzen kurz dargestellt.When evaluating patients with knee pain by magnetic resonance imaging (MRI) the painful bone marrow edema (BME) represents a common finding. The typical signal patterns of BME are unspecific and can be found with different diseases of the knee. Since different therapeutical approaches are mandatory differential diagnosis of these several forms of BME is important. In this review the painful BME will be separated in three different etiological groups. Group1, ischemical BME: osteonecrosis, ostechondritis dissecans, bone marrow edema syndrome and complex regional pain syndrome; group2, mechanical BME: bone bruises, microfracture, stress-BME, and stressfracture; group3, reactive BME: inflammatory gonarthritis, degenerative gonarthrosis, postoperative, and tumours. The typical MRI morphologies and differential diagnosis of these several BME appearances will be described. The different therapeutical consequences will also be mentioned briefly.
PURPOSE: To find any differential magnetic resonance (MR) imaging findings between septic arthritis and transient synovitis in pediatric patients. ings in nine pediatric patients with septic arthritis and 14 with transient synovitis were retrospectively studied. The diagnoses were made by means of joint aspiration with bacteriologic study, arthrotomy, and clinical evaluation. MR imaging-findings were analyzed with emphasis on the grade of joint effusion and alterations in signal intensity in the soft tissue and bone marrow of the affected hip joint. RESULTS: Signal intensity alterations in bone marrow (ie, low signal intensity on fat-suppressed gadolinium-enhanced T1-weighted spin-echo images and high signal intensity on fat-suppressed T2-weighted fast spin-echo images) were seen in eight of nine patients with septic arthritis. These signal intensity alterations consisted of mild juxtaarticular changes in six patients without osteomyelitis and extensive changes in the femoral head and neck in two patients with coexistent osteomyelitis. Signal intensity alterations in bone marrow were not seen in the 14 patients with transient synovitis. CONCLUSION: Signal intensity alterations in the bone marrow of the affected hip joint are useful in the differentiation of septic arthritis from transient synovitis.
Reflex sympathetic dystrophy (RSD) is a frequent condition, usually occurring after trauma of the extremities characterized by pain, swelling, and dystrophy. Its pathophysiology is poorly understood, and no universally accepted treatment exists.1 We have tried classical acupuncture in a randomized, placebocontrolled pilot project on 14 patients with recent (less than 4 months) onset. Diagnosis was made clinically and was confirmed by scintigraphy in all cases. Group A received classical acupuncture five times per week for 3 weeks by an experienced acupuncturist (O.C.). Group B received sham-acupuncture, which meant that needles were inserted outside acupuncture points by the same acupuncturist. As the clinical evaluators (V.F. and Y.A.) were also blinded, the trial adhered as closely as possible to a double-blind protocol. Both groups demonstrated a reduction of pain, as measured by visual analog scale (0 through 100) during the 3 weeks' treatment. In group A, the average reduction was from
Die Magnetresonanztomographie (MRT) ermöglicht als einzige, nicht invasive, bildgebende Methode eine Beurteilung der Funktionseinheit subchondraler Knochen und hyaliner Knorpel. Durch Kontrastmittel (KM)-Applikation als indirekte oder direkte MR-Arthrographie lässt sich die Diagnostik weiter verbessern. Durch die intravenöse KM-Gabe wird zusätzlich ein Signalanstieg im Bereich der Grenzzone zwischen Osteonekroseareal und vitalem Knochenlager erzielt. Die Aktivität dieser reaktiven Randzone ergibt möglicherweise indirekte Hinweise darauf, in wie weit eine Chance für eine Einheilung zu diesem Zeitpunkt noch möglich ist. Im Rahmen der direkten MR-Arthrographie lässt sich, verglichen mit der nativen MRT, die Stadieneinteilung der Osteochondrosis dissecans (OCD) wesentlich verbessern. Das therapeutische Konzept bei der OCD ist, so wie bei der Osteonekrose des Erwachsenenalters, ganz wesentlich vom Stadium der Erkrankung abhängig. Darüber hinaus hat sich die MRT als äußerst wertvoll in der Nachsorge und der Beurteilung des Therapieerfolgs herausgestellt. Unter Ausnützung aller Möglichkeiten hat die MRT als bildgebende Methode bei diesem Krankheitsbild mittlerweile einen hohen diagnostischen Stellenwert erreicht und sollte vor einer Therapieentscheidung in jenen Fällen, bei denen die Ausdehnung, Lokalisation und Stadieneinteilung im Nativröntgen nicht sicher erfolgen kann, durchgeführt werden. Als primär diagnostische Maßnahme ist die Arthroskopie bei der OCD nicht sinnvoll, da die subchondralen Veränderungen im Initial- und Frühstadium nicht beurteilt werden können und damit eine entsprechende Stadieneinteilung nicht möglich ist. Bei der Therapie der OCD spielen jedoch heute die verschiedenen arthroskopischen Techniken eine zentrale Rolle.
Osteonecrosis of the knee should be differentiated into two main categories: (1) primary, spontaneous, or idiopathic osteonecrosis and (2) secondary osteonecrosis (e.g., secondary to factors such as steroid therapy, systemic lupus erythematosus, alcoholism, Caisson decompression sickness, Gaucher's disease, hemoglobinopathies, etc.). Spontaneous or primary osteonecrosis of the knee presents with an acute knee pain in elderly patients. It is three times more common in women than in men. Traumatic and vascular theories have been proposed as a causative factor of osteonecrosis of the knee, but the precise etiology still remains speculative. High index of clinical awareness and a good history and physical examination are essential to make an early, accurate diagnosis. Plain radiographs are often normal during the early course of the disease and, in such instances, radioisotope bone scan and magnetic resonance imaging may be helpful. In the early stage of the disease, nonoperative treatment is indicated and many patients, if diagnosed early, have a benign course with a satisfactory pain relief and a good knee function. In patients with advanced stage of the disease, treatment options include arthroscopic debridement, curettage or drilling of the lesion, bone grafting, high tibial osteotomy, use of osteochondral allograft, and unicompartmental or total knee arthroplasty. The choice of treatment should be based on factors such as age of the patient, severity of symptoms, activity level and functional demands on the knee, site and stage of the lesion, and extent of deformity and secondary osteoarthritis. The clinical features and treatment of steroid-induced osteonecrosis of the knee are briefly discussed. In recent years, "postmeniscectomy" osteonecrosis has been reported, but at present its prevalence and pathophysiology remain unknown. It is possible that this may be a preexisting condition that was not recognized at the time of initial consultation or osteonecrosis may develop after meniscectomy in occasional cases.
Bone marrow oedema syndrome of the talus is a rare cause of pain in the foot, with limited options for treatment. We reviewed six patients who had been treated with five infusions of 50 mug of iloprost given over six hours on five consecutive days. Full weight-bearing was allowed as tolerated. The foot score as described by Mazur et al was used to assess function before and at one, three and six months after treatment. The mean score improved from 58 to 93 points. Plain radiographs were graded according to the Mont score and showed grade-I lesions before and after treatment, indicating that no subchondral fracture or collapse had occurred. MRI showed complete resolution of the oedema within three months. We conclude that the parenteral administration of iloprost may be used in the treatment of this syndrome.
Bei 10 Patienten mit einer chronischen Polyarthritis wurde an einem NMR-Gerät mit einem supraleitenden Magneten von 0,35 bzw. 0,5 Tesla statischer Feldstärke an 20 Kniegelenken die Darstellbarkeit der typischen rheumatischen Weichteilbefunde untersucht. Die Ergebnisse der Kernspintomographie wurden mit den makroskopischen intraoperativen Befunden verglichen. Es zeigte sich, daß Erguß, synoviale Schwellung im oberen Rezessus wie in der Kreuzbandregion dargestellt werden können. Es ist ebenfalls möglich, Baker Zysten und deren Inhalt abzugrenzen. Im Vergleich zur am Kniegelenk gut möglichen klinischen Untersuchung können wir aus praktischer Sicht einen wesentlichen Vorzug in der Diagnostik der synovialen Umscheidung des Kreuzbandes feststellen.
The intraosseous pressure in the femur and tibia near the knee and in the internal saphenous vein at knee level was measured in fifty-three patients with suspected knee lesions. There were four groups: with and without degenerative osteoarthritis and with and without aching rest pain of the knee region. Low intraosseous pressures were found in patients with neither osteoarthritis nor rest pain, and in half the patients with osteoarthritis but without rest pain. Low pressures were found in the tibia, but very high intraosseous pressures were found in the femur in most patients with osteoarthritis and rest pain. Patients with no osteoarthritis but with rest pain mostly had high pressures in both the tibia and the femur.