Serial imaging in a case of regional migratory osteoporosis

Kamble B Ravindra; Sanjeev Mudakavi; N Diwakar; GK Iyer

doi:10.4103/1115-3474.155747

CASE REPORT

Year : 2016 | Volume : 23 | Issue : 1 | Page : 36-39

Serial imaging in a case of regional migratory osteoporosis

Kamble B Ravindra, Sanjeev Mudakavi, N Diwakar, GK Iyer
Department of Radiology, Vikram Hospital, Bangalore, Karnataka, India

Date of Web Publication

6-Jan-2016

Correspondence Address:
Kamble B Ravindra
Department of Radiology, Vikram Hospital, Millers Road, Bangalore - 560 052, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1115-3474.155747

Abstract

Regional migratory osteoporosis (RMO) is an uncommon disorder that predominantly affects middle-aged males, presenting as migrating arthralgia involving the lower extremities. It is a transient condition that involves joints without preexisting disease and resolves spontaneously without long-term sequelae. We describe serial imaging findings in a patient with RMO followed over a period using various imaging modalities which showed typical migrating osteopenia involving the knee, ankle, and foot.

Keywords: Computed tomography; joints; magnetic resonance imaging; regional migratory osteoporosis

How to cite this article:
Ravindra KB, Mudakavi S, Diwakar N, Iyer G K. Serial imaging in a case of regional migratory osteoporosis. West Afr J Radiol 2016;23:36-9

How to cite this URL:
Ravindra KB, Mudakavi S, Diwakar N, Iyer G K. Serial imaging in a case of regional migratory osteoporosis. West Afr J Radiol [serial online] 2016 [cited 2023 Feb 4];23:36-9. Available from: https://www.wajradiology.org/text.asp?2016/23/1/36/155747

Introduction

Regional migratory osteoporosis (RMO) is the term first given by Duncan et al., who described it as polyarticular disease.^[1] It was first described as transient osteoporosis in 1959 by Curtiss and Kincaid in pregnant women in third trimester as an uncommon and self-limiting disease.^[2] Very few cases have been described in literature till now, where the affected bones shows transient areas of signal changes due to bone edema which resolve spontaneously and sometimes shows migratory pattern affecting other bones. We present a case of classical RMO with serial imaging.

Case Report

A 41-year-old, overweight gentleman presented with progressive pain in his right knee for 2 weeks duration. Clinical examination and radiograph of knee showed no abnormality. Subsequently, magnetic resonance imaging (MRI) of knee was done in another hospital in March 2011, which showed hyperintense signal changes in the medial femoral condyle on the fat suppressed T2-weighted (T2W) images (TR 800 and TE 17) and hypointensity on T1W (TR 400 and TE 21) images [Figure 1]. All laboratory investigations were normal. He was advised biopsy for confirmation, but patient was undecided. His pain resolved spontaneously. However, the pain in right knee recurred in November 2011 and this time computed tomography (CT) done at other center showed mild osteopenia in the intercondylar region with minimal sclerosis of the medial femoral condyle [Figure 2]. He was then reassured that the condition is benign and treated symptomatically. Later, bone scan was also done which showed increased uptake (not shown).

Figure 1: (a) T2-weighted (T2W) fat suppressed coronal image showing medial condylar hyperintense signal changes. (b) T1W coronal image showing medial condylar hypointensity

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Figure 2: Reconstructed CT coronal image showing minimal sclerosis in medial femoral condyle. No obvious erosion noted. CT = Computed tomography

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In February 2012, his symptoms recurred involving right knee and also left ankle. He was referred to our hospital. MRI imaging done at our center on 1.5T Siemens Avanto MRI machine with following parameters(PD TSE FS TR 3500 TE 42 and FOV 256 × 256, T2 TSE TR 4340 TE 82 FOV 320 × 320, T1W SE TR 512 TE 11 FOV 320 × 320) were used. Proton density fat-saturated (PDFS) images showed hyperintense signal changes in intercondylar region and medial condyle of right femur. However as compared to previous images, the signal intensity in medial femoral condyle had reduced [Figure 3]. Hyperintense signals were also noted in left talus [Figure 4]. This confirmed the diagnosis of RMO.

Figure 3: PDFS coronal (a) and axial (b) shows hyperintense signal changes in medial femoral condyle and intercondylar region. As compared to [Figure 1], signal changes in medial condyle have reduced and increased in intercondylar region. PDFS = Proton density fat-saturated

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Figure 4: (a) PDFS sagittal and (b) T1W sagittal images showing hyperintense signal changes in talus on PDFS and hypointense on T1W

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In December 2012, right knee was again symptomatic and imaging revealed increased signals in medial condyle of femur with complete disappearance of signals from intercondylar region seen on previous MR scans [Figure 5].

PDFS coronal (a) and axial (b) showing hyperintense signal changes in medial femoral condyle. As compared to [Figure 3], the signals from intercondylar region have resolved

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In November 2013, pain recurred again. MRI this time showed hyperintensity on PDFS images in the posterior aspect of the lateral tibial condyle and patella without signal changes in femoral condyles [Figure 6]. Imaging of ankle showed normal talus. However, calcaneum and medial cuneiform showed hyperintensity [Figure 7]. Significant resolution of the hyperintensity in medial femoral condyle and talus was noted. This time patient was treated with bisphosphonates.

Figure 6: PDFS axial images showing hyperintense signal changes in lateral posterior tibial condyle (a) and patella (b), and no signal changes in femoral condyles (c)

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Figure 7: PDFS coronal image showing hyperintensity in calcaneum and medial cuneiform

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Discussion

Transient osteoporosis is a condition that affects the weight-bearing joints of lower extremity, noticed in overweight, middle-aged males in 4^th–7^th decades, commonly affecting hip followed by knee, foot, and ankle joint.^[3] It was originally described in 1959 by Curtiss and Kincaid in pregnant women (third trimester) as self-limiting disease.^[2] The term, regional migratory osteoporosis was coined by Duncan et al., who described it as polyarticular disease.^[1] It can affect same joint at different locations, or affect different joints. When it affects different joints then disease can be called as RMO.^[4],[5] Migration of the disease has been described in sequential form involving different portion of the same bone, intra-articular spread,^[6] proximal to distal spread,^[7] as well as involvement of the contralateral joint.^[8]

The average period of migration of the disease was 4 months and slightly lesser duration of 3 months for the next.^[8] Others have mentioned durations of few months to a few years.^[9],[10]

Patients usually presents with pain, which can be severe making them nonambulatory. On examination, there can be tenderness with or without joint effusion.^[11]

The etiology of this condition is unknown. Various theories are described like neurogenic compression theory,^[2] localized hyperemia due to venous return obstruction,^[12] bone marrow edema due to ischemia,^[13] ischemic vasculopathy,^[14] reflex sympathetic dystrophy,^[15] and subchondral fracture or trauma.^[16],[17] Recent authors have stressed the association of RMO with systemic osteoporosis.^[18],[19] One theory is that noxious stimuli such as trauma causes trabecular disruption leading to the exaggerated activation of regional acceleratory phenomena which causes increase in perfusion, metabolism, and cell turnover leading to osteoporosis and subchondral fractures;^[1],[20] which may cause marrow edema seen on MRI and increase uptake on scintigraphy.^[21]

Histopathological studies show bone edema with reactive bone formation without bone necrosis which is nonspecific.^[22]

Radiographs are normal in early phase, however, can show focal osteoporosis.^[14] MRI show high signals on T2W and low signal on T1W similar to bone marrow edema.^[23],[24] Early avascular necrosis may appear similar to RMO on imaging.^[25] Radionuclide scan shows increase uptake.^[26]

The main differential diagnosis can be inflammatory, infectious, degenerative, or crystal arthritis.^[27],[28] Normal laboratory findings, clinical history, and imaging features should suggest diagnosis of RMO.

We describe a case of RMO followed over months affecting right medial femoral condyle at first, then spreading to intercondylar region followed by talus of left ankle, and again right medial femoral condyle. Later, affecting lateral tibial condyle and foot bones with complete resolution of edema of medial femoral condyle and talus. Our case is unique as it showed features of classical RMO affecting multiple joints in same patient with all the patterns of migration described earlier in the literature. Initially medial femoral condyle was involved, which later resolved and then recurred at same location; which to our knowledge was not described earlier.

RMO should be diagnosed based on the typical radiological appearance when other causes have been excluded. Careful analysis of the MRI findings is necessary to recognize this disease and avoid invasive investigations since it is self-limiting and has no long-term complications.

The purpose of this article is to increase awareness of this rare condition and report the findings seen on the serial imaging.

References

1.	Duncan H, Frame B, Frost H, Arnstein AR. Regional migratory osteoporosis. South Med J 1969;62:41-4. [PUBMED]
2.	Curtiss PH Jr, Kincaid WE. Transitory demineralization of the hip in pregnancy. A report of three cases. J Bone Joint Surg Am 1959;41:1327-33. [PUBMED]
3.	Lakhanpal S, Ginsburg WW, Luthra HS, Hunder GG. Transient regional osteoporosis. A study of 56 cases and review of the literature. Ann Intern Med 1987;106:444-50. [PUBMED]
4.	Mavichak V, Murray TM, Hodsman AB, Robert NJ, Sutton RA. Regional migratory osteoporosis of the lower extremities with vertebral osteoporosis. Bone 1986;7:343-9. [PUBMED]
5.	Banas MP, Kaplan FS, Fallon MD, Haddad JG. Regional migratory osteoporosis. A case report and review of the literature. Clin Orthop Relat Res 1990:303-9.
6.	Minutoli F, Gaeta M, Bottari A, Blandino A. MRI findings in regional migratory osteoporosis of the knee migrating from the femur to the tibia. Clin Imaging 2006;30:428-30.
7.	Toms AP, Marshall TJ, Becker E, Donell ST, Lobo-Mueller EM, Barker T. Regional migratory osteoporosis: A review illustrated by five cases. Clin Radiol 2005;60:425-38.
8.	Karantanas AH, Nikolakopaulos I, Korompilias AV, Apostolaki E, Skoulikaris N, Eracleous E. Regional migratory osteoporosis in the knee: MRI findings in 22 patients and review of the literature. Eur J Radiol 2008;67:34-41.
9.	MacLean SB, Kumar R, Clough TM, Jenkins JPR, Barrie JL, Wood PL. Transient Regional migratory osteoporosis in the ankle and foot: A case series and literature review. Foot Ankle Online J 2009;2:1-10.
10.	Suresh SS, Thomas JK, Raniga S. Migrating transient osteoporosis of the hip in a 30-year-old man. Indian J Orthop 2009;43:301-4. [PUBMED]
11.	Nikolaou V, Pilichou A, Korres D, Efstathopoulos N. Transient osteoporosis of the knee. Orthopedics 2008;31:502.
12.	Rosen RA. Transitory demineralization of the femoral head. Radiology 1970;94:509-12. [PUBMED]
13.	Dunstan CR, Evans RA, Somers NM. Bone death in transient regional osteoporosis. Bone 1992;13:161-5.
14.	Major GA. Regional migratory osteoporosis. Postgrad Med J 1984;60:420-3. [PUBMED]
15.	Swezey RL. Transient osteoporosis of the hip, foot and knee. Arthritis Rheum 1970;13:858-68. [PUBMED]
16.	Miyanishi K, Yamamoto T, Nakashima Y, Shuto T, Jingushi S, Noguchi Y, et al. Subchondral changes in transient osteoporosis of the hip. Skeletal Radiol 2001;30:255-61.
17.	El Masry MA, Saha A, Calder SJ. Transient osteoporosis of the knee following trauma. J Bone Joint Surg Br 2005;87:1272-4.
18.	Cahir JG, Toms AP. Regional migratory osteoporosis. Eur J Radiol 2008;67:2-10.
19.	Trevisan C, Ortolani S, Monteleone M, Marinoni EC. Reginal migratory osteoporosis: A pathogenic hypothesis based on three cases and a review of literature. Clin Rheumatol 2002;21:418-25.
20.	Frost HM. Perspectives: Bone's mechanical usage windows. Bone Miner 1992;19:257-71.
21.	Negri G, Grassi S, Zappia M, Cappabianca S, Rambaldi PF, Mansi L. A new hypothesis for the bone marrow edema pathogenesis during transient osteoporosis. J Orthop Traumatol 2006;7:176-81.
22.	McCarthy EF. The pathology of transient regional osteoporosis. Iowa Orthop J 1998;18:35-42.
23.	Hofmann S, Engel A, Neuhold A, Leder K, Kramer J, Plenk H Jr. Bone-marrow oedema syndrome and transient osteoporosis of the hip. An MRI-controlled study of treatment by core decompression. J Bone Joint Surg Br 1993;75:210-6.
24.	Wilson AJ, Murphy WA, Hardy DC, Totty WG. Transient osteoporosis: Transient bone marrow edema? Radiology 1988;167:757-60.
25.	Parker RK, Ross GJ, Urso JA. Transient osteoporosis of the knee. Skeletal Radiol 1997;26:306-9.
26.	Fertakos RJ, Swayne LC, Colston WC. Three-phase bone imaging in bone marrow edema of the knee. Clin Nucl Med 1995;20:587-90.
27.	Arnstein RA. Regional osteoporosis. Orthop Clin North Am 1972;3:585-600.
28.	Langloh ND, Hunder GG, Riggs BL, Kelly PJ. Transient painful osteoporosis of the lower extremities. J Bone Joint Surg Am 1973;55:1188-96.