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<v ->Now the second category of transient painful osteopenia

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or transient painful marrow edema

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was designated regional migratory osteoporosis.

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It was popularized in several articles

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from physicians in the Detroit area.

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And as you can see these articles in 1967 and 1969

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had descriptions of a small number of patients

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who were presented with acute migratory painful disorder

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of the joints of the lower extremity.

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I don't believe that any of their cases

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were of the upper extremity.

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They said what they were able to observe on the radiographs

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was patchy osteopenia looking like what we see

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in complex regional pain syndrome

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or reflex sympathetic dystrophy syndrome.

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I show you two images from their case

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showing you on the left image, the patchy osteopenia

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and then over a period of time

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in this case, two years, the osteopenia disappeared.

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And then typically this might migrate to another joint.

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My friend, Michelle Lakin went a step further and he said

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if you look at this migratory pattern

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sometimes it's not the entire joint

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that is involved but a partial form is seen.

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And he described two particular partial forms.

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The first that was seen in the hands

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and feet he described as a radial type,

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where only one or a few digits were involved

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with the regional osteopenia.

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The second was a zonal type,

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particularly in the hip and knee

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where only a portion of the bone was involved.

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So we have to add this to the equation

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of this migratory form of osteoporosis.

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Now, is regional migratory osteoporosis

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associated with marrow edema?

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Here the evidence is clear,

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that, yes, just as with transient osteoporosis of the hip

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if you apply MR imaging to those patients

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who have this migratory form of osteoporosis,

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typically in the lower extremity moving from one site

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to the other by MR, marrow edema would be seen

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without findings of osteonecrosis.

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And that was shown for example in the article

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indicating here in clinical radiology in 2005.

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So to show you the classic description

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and a case of this transient painful marrow edema

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I show you this particular case

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from quite a while ago, but it's a nice case.

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Typically, this condition occurred in men

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more often than in women, generally in about the third

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to the fifth or sixth decade of life in the lower extremity,

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with rare examples in the upper extremity.

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The pain and swelling would last for a period of months,

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it would go away, the osteopenia and the marrow edema

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would then move to another location,

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often the next nearest joint.

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Here's an example showing you just that,

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here the initial site of involvement

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as it often is is the hip,

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four months later it's a portion of the knee.

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Six months later we're seeing marrow edema

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involving the hind foot,

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classic transient painful marrow edema.

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Now, one of the most interesting articles in this condition

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is a fairly recent one appearing

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in the European Journal of Radiology

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by Kaheer and his colleague.

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And this looked at where the initial edema occurred

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and where it went.

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And as you look at initial joint involvement

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as I indicated before,

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the hip was the classic first site of involvement,

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the others might be but the hip was most frequent.

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And then the marrow edema migrated,

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and usually to the next nearest joint.

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So the knee was the next location that was most common.

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Upper extremity involvement was rare or never.

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And then a pattern that was seen was migration,

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zonal in type from one part of a joint

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to other part of that same joint

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and later on indeed to other joints.

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Here's an example of what might occur

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when the edema migrates within the same joint

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from one site to another.

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On your left initial involvement in portion

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of the lateral femoral condyle, subsequently that went away

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nine months later the patella became involved.

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Now the question arises, well,

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we've talked about transient osteoporosis of the hip

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and its association with insufficiency fractures,

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what about regional migratory osteoporosis,

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is it associated with insufficiency fractures?

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And it's very interesting that only a few articles

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have found an association of the migratory form

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of osteoporosis with insufficiency fractures.

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Here is one of the articles

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written by Toms and his associate in 2005.

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It's a description of five cases

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of regional migratory osteoporosis,

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one of which had imaging findings

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suggesting subchondral insufficiency fractures.

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And here, for example,

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is that case is that a cuboid fracture

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migrating three months here to the talus,

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is that a fracture?

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You could make the argument

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that yes it might represent a subchondral fracture.

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We had an interesting case not too long ago,

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at the top row of images this is April, 2011,

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we saw marrow edema involving the posterior aspect

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of the lateral femoral condyle.

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In June of 2011 that marrow edema had gone away

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now it was located more anteriorly

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within the lateral femoral condyle,

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but now we can see a subchondral insufficiency fracture.

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So once again it raises the possibility

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that the initial abnormality is the osteopenia

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and the marrow edema and the insufficiency fracture occurs

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because of the bone weakening

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associated with the marrow edema.

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The final type of transient painful osteoporosis

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and transient painful marrow edema

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is transient osteoporosis of bones

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other than the femoral head that generally do not migrate.

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And we wrote an article on this in which we saw

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as a number of cases, five patients, six tali

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in which the marrow edema involved the entire

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or a portion of the talus.

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And we followed these patients and in fact did CT

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in some of them and we never discovered

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a insufficiency fracture in any of those patients.

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In all cases, the clinical findings which included pain

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and the imaging findings which included mainly marrow edema

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sometimes with a joint of fusion,

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went away over a period of time,

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with conservative therapy, usually within six months.