Subscribe to RSS
DOI: 10.1055/s-0037-1619011
Differenzierung subchondraler Insuffizienzfrakturen von Osteonekrosen
Differentiation of subchondral insufficiency fractures from osteonecrosisPublication History
eingereicht:
10 February 2016
angenommen:
28 March 2016
Publication Date:
21 December 2017 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00034914/201603/lookinside/thumbnails/10-1055-s-0037-1619011_de-1.jpg)
Zusammenfassung
Osteonekrosen und subchondrale Insuffizienzfrakturen beruhen auf unterschiedlichen Pathomechanismen. So ist bei der Osteonekrose die Blutversorgung des Knochens gestört, sodass auch ein multifokaler Befall auftreten kann. Bei der subchondralen Insuffizienzfraktur ist die Blutversorgung intakt, der Knochen jedoch in seiner Architektur gestört, sodass dieser normalen Belastungen nicht mehr standhalten kann. Neben der Anamnese des Patienten ist radiologisch die charakteristische Form der Demarkierungsrespektive Frakturlinie zur Gelenkfläche ein entscheidendes Diagnosekriterium. Ein Knochenmarködem liegt in beiden Entitäten vor und gilt bei der Osteonekrose als Risikofaktor eines Gelenkflächeneinbruchs. Die Quantifizierung der Knochenveränderung hilft dem zuweisenden Kollegen in der Entscheidung der Therapiewahl, da diese die Prognose beeinflusst. Eine frühzeitige Diagnostik mittels MRT ist notwendig, da konventionell radiologische Frühzeichen fehlen. Hierdurch kann eine adäquate Therapie zeitgerecht eingeleitet werden, um einen Gelenkflächeneinbruch mit sekundärer Arthrose zu verhindern.
Summary
Osteonecrosis and subchondral insufficiency fractures rely on different pathomechanisms. Osteonecrosis is based on an insufficient blood supply of the bone, and thus may occur multifocal. The blood supply in subchondral insufficiency fractures is intact, however, the bony architecture is disturbed. Therefore, even normal load weakens the bone and may lead to a fracture. Beside clinical history, the shape of the demarcationor fracture-line in relation to the joint surface on radiological images is characteristic. Bone marrow edema is evident in both entities and can be considered as a risk factor for collapse of the articular surface in osteonecrosis. Additionally, the extent of osteonecrosis or insufficiency fractures should be reported, as it affects prognosis and therapy. Initial radiographs may be unremarkable. Therefore, MRI is crucial for early stage diagnosis and timely treatment in order to prevent from articular surface collapse and secondary osteoarthritis.
-
Literatur
- 1 Kidwai AS, Hemphill SD, Griffiths HJ. Radiologic case study. Spontaneous osteonecrosis of the knee reclassified as insufficiency fracture. Orthopedics 2005; 28 (03) 236: 333-336.
- 2 Yamamoto T, Bullough PG. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg Am 2000; 82 (06) 858-866.
- 3 Manaster BJ. et al. 10 Bone Marrow Edema and Necrosis: Osteonecroisis. Canada: Amirsys; 2010: 2-13.
- 4 Murphey MD, Foreman KL, Klassen-Fischer MK. et al. From the radiologic pathology archives imaging of osteonecrosis: radiologic-pathologic correlation. Radiographics 2014; 34 (04) 1003-1028.
- 5 Blijham GH, Vermeulen A, Mendes de Leon DE. Osteonecrosis of sternum and rib in a patient treated for Hodgkin’s disease. Cancer 1985; 56 (09) 2292-2294.
- 6 Riggs 3rd JH, Schultz GD, Hanes SA. Radiation induced fracture of the scapula. J Manipulative Physiol Ther 1990; 13 (08) 477-481.
- 7 Breitenseher M. 5.4 Hüftkopfnekrose. Stuttgart, New York: Georg Thieme; 2013: 268-271.
- 8 Krestan CR, Nemec U, Nemec S. Imaging of insufficiency fractures. Semin Musculoskelet Radiol 2011; 15 (03) 198-207.
- 9 Ikemura S, Yamamoto T, Motomura G. et al. The utility of clinical features for distinguishing subchondral insufficiency fracture from osteonecrosis of the femoral head. Arch Orthop Trauma Surg 2013; 133 (12) 1623-1627.
- 10 Lafforgue P. Pathophysiology and natural history of avascular necrosis of bone. Joint Bone Spine 2006; 73 (05) 500-507.
- 11 Taylor LJ. Multifocal avascular necrosis after shortterm high-dose steroid therapy. A report of three cases. J Bone Joint Surg Br 1984; 66 (03) 431-433.
- 12 Viana SL, Machado BB, Mendlovitz PS. MRI of subchondral fractures: a review. Skeletal Radiol 2014; 43 (11) 1515-1527.
- 13 Ikemura S, Yamamoto T, Motomura G. et al. MRI evaluation of collapsed femoral heads in patients 60 years old or older: Differentiation of subchondral insufficiency fracture from osteonecrosis of the femoral head. AJR Am J Roentgenol 2010; 195 (01) W63-W86.
- 14 Yamamoto T, Schneider R, Iwamoto Y, Bullough PG. Bilateral rapidly destructive arthrosis of the hip joint resulting from subchondral fracture with superimposed secondary osteonecrosis. Skeletal Radiol 2010; 39 (02) 189-192.
- 15 Prescott JW, Yu JS. The aging athlete: part 1, “boomeritis” of the lower extremity. AJR Am J Roentgenol 2012; 199 (03) W294-W306.
- 16 Roemer FW, Frobell R, Hunter DJ. et al. MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis. Osteoarthritis Cartilage 2009; 17 (09) 1115-1131.
- 17 Ishihara K, Miyanishi K, Ihara H. et al. Subchondral insufficiency fracture of the femoral head may be associated with hip dysplasia: a pilot study. Clin Orthop Relat Res 2010; 468 (05) 1331-1335.
- 18 Iwasaki K, Yamamoto T, Motomura G. et al. Radiologic measurements associated with the prognosis and need for surgery in patients with subchondral insufficiency fractures of the femoral head. AJR Am J Roentgenol 2013; 201 (01) W97-W103.
- 19 Iwasaki K, Yamamoto T, Motomura G. et al. Prognostic factors associated with a subchondral insufficiency fracture of the femoral head. Br J Radiol 2012; 85 (1011): 214-218.
- 20 Zurlo JV. The double-line sign. Radiology 1999; 212 (02) 541-542.
- 21 Pappas JN. The musculoskeletal crescent sign. Radiology 2000; 217 (01) 213-214.
- 22 Nam KW, Kim YL, Yoo JJ. et al. Fate of untreated asymptomatic osteonecrosis of the femoral head. J Bone Joint Surg Am 2008; 90 (03) 477-484.
- 23 Shimizu K, Moriya H, Akita T. et al. Prediction of collapse with magnetic resonance imaging of avascular necrosis of the femoral head. J Bone Joint Surg Am 1994; 76 (02) 215-223.
- 24 Beltran J, Knight CT, Zuelzer WA. et al. Core decompression for avascular necrosis of the femoral head: correlation between long-term results and preoperative MR staging. Radiology 1990; 175 (02) 533-536.
- 25 Ha YC, Jung WH, Kim JR. et al. Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am 2006; 88 (Suppl. 03) 35-40.
- 26 Mont MA, Zywiel MG, Marker DR. et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am 2010; 92 (12) 2165-2170.
- 27 Ito H, Matsuno T, Minami A. Relationship between bone marrow edema and development of symptoms in patients with osteonecrosis of the femoral head. AJR Am J Roentgenol 2006; 186 (06) 1761-1770.
- 28 Iida S, Harada Y, Shimizu K. et al. Correlation between bone marrow edema and collapse of the femoral head in steroid-induced osteonecrosis. AJR Am J Roentgenol 2000; 174 (03) 735-743.
- 29 Mueller D, Schaeffeler C, Baum T. et al. Magnetic resonance perfusion and diffusion imaging characteristics of transient bone marrow edema, avascular necrosis and subchondral insufficiency fractures of the proximal femur. Eur J Radiol 2014; 83 (10) 1862-1869.
- 30 Ozel BD, Ozel D, Ozkan F, Halefoglu AM. Diffusion-weighted magnetic resonance imaging of femoral head osteonecrosis in two groups of patients: Legg-Perthes-Calve and Avascular necrosis. Radiol Med 2016; 121 (03) 206-213 [Epub 2015 Oct 13].
- 31 Yamamoto T. Subchondral insufficiency fractures of the femoral head. Clin Orthop Surg 2012; 04 (03) 173-180.
- 32 Pivec R, Johnson AJ, Harwin SF, Mont MA. Differentiation, diagnosis, and treatment of osteoarthritis, osteonecrosis, and rapidly progressive osteoarthritis. Orthopedics 2013; 36 (02) 118-125.
- 33 Milgram JW. Malignant transformation in bone lipomas. Skeletal Radiol 1990; 19 (05) 347-352.
- 34 Domson GF, Shahlaee A, Reith JD. et al. Infarct-associated bone sarcomas. Clin Orthop Relat Res 2009; 467 (07) 1820-1825.
- 35 Ramachandran M, Ward K, Brown RR. et al. Intravenous bisphosphonate therapy for traumatic osteonecrosis of the femoral head in adolescents. J Bone Joint Surg Am 2007; 89 (08) 1727-1734.
- 36 Sen RK. Management of avascular necrosis of femoral head at pre-collapse stage. Indian J Orthop 2009; 43 (01) 6-16.
- 37 Wassenaar RP, Verburg H, Taconis WK, van der Eijken JW. Avascular osteonecrosis of the femoral head treated with a vascularized iliac bone graft: preliminary results and follow-up with radiography and MR imaging. Radiographics 1996; 16 (03) 585-594.
- 38 Vande Berg BC, Malghem JJ, Lecouvet FE. et al. Idiopathic bone marrow edema lesions of the femoral head: predictive value of MR imaging findings. Radiology 1999; 212 (02) 527-535.