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From Feb 2016. Reported as Transient Osteoporosis / Subchondral Fracture. Follow-up was recommended to "r/o progression to AVN". WHAT???? New MRI today shows normal marrow signal. White arrow, might hallucinate residua of old healed fracture, or not. No AVN. Same anterosuperior labral tear. What is the current concept of TOP? Is the "Party Line" that it is subchondral fracture? Conference talk suggests that, but I can't see that stated in the literature. Some literature points to "potential risk of developing AVN" but I cannot find a single case of progression of TOP to AVN...what's THAT about??? Who can tell us what the truth is?     |
Friday, December 20, 2019
35M runner with chronic hip pain MRI 2016 and Now
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No Hip Injury. Instead, subacute partial tear of the Sartorius at its ASIS origin (note reactive BME). At the cranial margin of the FOV we c... -
F 62, left hip pain. Suspected impingement. There's a subchondral / subcortical bone lesion at the anterior aspect of the left femoral h...
This comment is from Tetyana Gorbachova:
ReplyDeletehttps://www.ajronline.org/doi/full/10.2214/AJR.19.21571
In a nutshell:
1) TOH is a true entity. It is closely related to SIF in a sense that SIF is a complication of TOH, very frequent one , but they are not the same. There are SIFs that do not come from TOH and TOH can be without a SIF. When see TOH one must look very closely for SIF, most of the time one will find it on high res MRI .
2) When SIF doesn't heal it leads to a collapse ( fracture of the subchondral bone plate) and subsequently to OA.
When see SIF look for collapse ( contour deformity, or fluid filled cleft) or features that predict it ( thick subchondral black area)- see paper.. Histologically collapse means secondary necrosis, as seen in non healing fractures. Hence the "AVN" contamination of the lexicon.
So the imaging follow up is appropriate to look for healing of SIF vs progression to collapse. There is no connection with primary AVN.
3) the name of TOH should be used when Xrays are positive, as the word "osteoporosis" conveys the need for protected weight baring to a clinician. When the X-rays are negative or unavailable, may call it TBMES.
That is a great nutshell. Haven't read the paper yet but jibes with my understanding completely. Any recommendation for f-u should be for collapse, not AVN as in the case presented. But mainly based on symptoms.
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