AJR 2002; 178:435-437
© American Roentgen Ray Society
Subchondral Insufficiency Fracture of the Femoral Head Resulting in Rapid Destruction of the Hip Joint
A Sequential Radiographic Study
Takuaki Yamamoto1,
Kazuo Takabatake2 and
Yukihide Iwamoto1
1
Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu
University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
2
Department of Orthopaedic Surgery, Hara-Sanshin Hospital, 1-8 Daihaku-machi,
Hakata-ku, Fukuoka 812-0033, Japan.
Received May 2, 2001;
accepted after revision August 2, 2001.
Address correspondence to T. Yamamoto.
Introduction
Subchondral insufficiency fracture has been reported in both the
osteoporotic elderly and in renal transplant recipients
[1,2,3,4].
It has been reported that at the onset of pain, unenhanced radiographs show no
obvious findings, but MR imaging reveals a bone marrow edema pattern with an
associated irregular serpiginous low-signal-intensity line on the T1-weighted
images. Some cases have resolved after conservative therapy without
progressing to a state in which the femoral head collapses
[1,2,3];
however, recent reports have described patients who underwent a subchondral
collapse requiring operative treatment
[4]. The outcome of subchondral
insufficiency fracture is thus unclear.
We present a case of subchondral insufficiency fracture diagnosed
radiographically and confirmed by histology that progressed to rapid hip
destruction over a 1-month period.
Case Report
A 59-year-old woman presented at our hospital with a 1-week history of
severe right hip pain of acute onset. The pain was present at rest and kept
her awake at night. She needed a cane to ambulate. She had no history of any
antecedent trauma, corticosteroid intake, or alcohol abuse. The range of
motion in the right hip at the time of admission was preserved in all
directions: flexion, 130°; extension, 0°; abduction, 30°;
adduction, 20°; external rotation, 25°; and internal rotation,
15°. Her height was 151 cm and body weight, 69 kg. The patient's body mass
index indicated obesity (30.3 kg/m2). A blood examination revealed
no abnormality in the renal or liver functions. No evidence of infection,
neuropathy, or inflammatory diseases was noted. Three months before the onset
of hip pain, this patient had suffered an osteoporotic compression fracture in
the second lumbar spine. Bone mineral density in the left radius by dual X-ray
absorptiometry was 0.60 g/cm3 (T score: -0.78 standard deviation,
which is within normal range).
Imaging Findings
Radiography of the right hip, which was performed 2 months before the onset
of pain as a necessary workup after the patient's spine compression fracture,
was negative. The Singh index
[5] on both hips was grade 3,
which indicates definite osteoporosis. On the radiographs obtained 1 week
after the onset of pain, a slight degree of subchondral flattening was
observed at the superolateral portion of the femoral head
(Fig. 1A). This patient was
treated with antiinflammatory drugs and was provided with a wheel chair
because of the severe hip pain. On the radiographs obtained 2 weeks after the
onset of pain, the subchondral collapse was observed to have rapidly
progressed (Fig. 1B). During a
further 2-week follow-up period, the patient's pain gradually worsened. On the
radiographs obtained 4 weeks after the onset of hip pain, the subchondral
collapse was found to have progressed, and about one fourth of the femoral
head underwent collapse deformity (Fig.
1C).
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Fig. 1A. —59-year-old woman with acute onset of severe right hip pain.
Anteroposterior radiograph obtained 1 week after onset of pain shows slight
subchondral collapse (arrow) in superolateral portion of femoral
head.
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Fig. 1C. —59-year-old woman with acute onset of severe right hip pain.
Anteroposterior radiograph obtained 4 weeks after onset of pain shows further
progression of collapse and about one fourth of femoral head underwent
collapse deformity.
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MR imaging was performed 2.5 weeks after the onset of pain and showed a
pattern of bone marrow edema with a diffuse low signal intensity on
T1-weighted images and a high signal intensity on T2-weighted images,
extending from the femoral head to the intertrochanteric area (Figs.
1D and
1E). A similar bone marrow
edema pattern was seen in the medial aspect of the acetabular roof. On some
slices of the T1-weighted images, serpiginous irregular, very
low-signal-intensity bands were observed that paralleled the subchondral bone
endplate (Fig. 1D). Joint
effusion was also noted.
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Fig. 1D. —59-year-old woman with acute onset of severe right hip pain.
T1-weighted MR image obtained 2.5 weeks after onset of hip pain shows bone
marrow edema pattern in femoral head and medial aspect of acetabular roof.
Note diffuse low signal intensity with associated serpiginous irregular, very
low-signal-intensity bands (arrows).
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Fig. 1E. —59-year-old woman with acute onset of severe right hip pain.
T2-weighted MR image shows diffuse high signal intensity in same area as shown
on D. However, proximal superior portion of femoral head shows low
signal intensity. Note joint effusion.
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On the basis of the clinical history and imaging studies, the diagnosis of
a subchondral insufficiency fracture of the femoral head was made
[1,2,3,4].
The patient underwent hemiarthroplasty in the right hip.
Pathologic Findings
The resected femoral head was examined histologically and showed findings
similar to those reported in cases of subchondral insufficiency fracture
[4]. First, on a mid coronal
cut section, a notched linear-shaped whitish gray tissue was observed under
the cartilage flap that paralleled the subchondral bone endplate
(Fig. 1F). Second,
microscopically, the whitish gray regions consisted of fracture callus,
reactive cartilage, and granulation tissue. No evidence of any antecedent
osteonecrosis or apatite crystal deposition was present. In the marrow space,
edematous changes were seen throughout the femoral head. In addition, there
was a round to oval granulomatous lesion where tiny fragments of bone tissue
were embedded in amorphous eosinophilic debris surrounded by epithelioid
histiocytes and giant cells. Thin disconnected bone trabeculae indicative of
osteopenia were observed throughout the femoral head. On the basis of these
histopathologic findings, a diagnosis of subchondral insufficiency fracture
was confirmed.
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Fig. 1F. —59-year-old woman with acute onset of severe right hip pain.
Mid coronal cut histopathologic section shows notched linear shaped zone of
whitish grey tissue (arrows) under cartilage flap. No evidence of
opaque yellow wedge-shaped osteonecrosis is seen.
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Discussion
Before the concept of subchondral insufficiency fracture was introduced,
this case most likely would have been interpreted as osteonecrosis of the
femoral head [4]. Therefore,
one of the important differential diagnoses in determining subchondral
insufficiency fracture may include osteonecrosis. In the case reported herein,
the differentiation was made on the basis of the previously reported
characteristic findings of subchondral insufficiency fracture
[1,2,3,4].
Clinically, this condition is generally seen in elderly osteoporotic females
who are often obese. The patient's pain usually has an acute onset that
gradually worsens. No risk factors for osteonecrosis, including corticosteroid
intake, alcohol abuse, or other underlying diseases, are present.
Radiologically, a pattern of bone marrow edema with an associated serpiginous
low-signal-intensity band on the T1-weighted images has been reported to be
characteristic. In general, the circumscribed lesions on MR imaging, which are
commonly observed in osteonecrosis, are not seen. Histopathologically, a
linear notched whitish gray zone is seen that microscopically consists of
irregularly arranged fracture callus, reactive cartilage, and granulation
tissue without any evidence of antecedent osteonecrosis.
Although some of the reported cases of patients with subchondral
insufficiency fractures recovered after conservative therapy without
progressing to collapse
[1,2,3],
several patients have been recently reported with subchondral collapse
requiring operative treatment
[4]. The outcome of subchondral
insufficiency fracture is thus unclear. In general, the prognosis of a
fracture may depend on a number of variables including the patient's degree of
osteopenia, activity, weight, extent of fracture, and the adopted treatment
modality. In the case reported herein, a subchondral collapse rapidly
progressed in spite of the fact that the patient used a wheel chair. However,
histopathologic evidence of callus formation and granulation tissue around the
fracture was present, indicating the potential capacity for a resolution of
the fracture. Important factors for the rapid joint destruction in this
patient may have been the extent of a subchondral fracture, osteopenia,
obesity, and the use of antiinflammatory drugs on the fracture. However, the
outcome of subchondral insufficiency fracture may need further
investigation.
Recently, a relationship between subchondral insufficiency fracture and
rapidly destructive arthrosis of the hip joint has been suggested
[6]. Rapidly destructive
arthrosis of the hip joint has been reported
[7] generally to occur in
elderly people with severe unilateral hip pain, in whom initial radiologic
examinations show no obvious findings. Within a few months, a rapid
destruction of the hip joint occurs with few proliferative changes.
Histologically, a granulomatous lesion has been reported as a characteristic
finding [6,
8]. All these findings were
observed in our case of subchondral insufficiency fracture. Subchondral
insufficiency fracture thus seems to be one of the important factors involved
in the pathogenesis of rapidly destructive arthrosis of the hip joint.
This case indicates that some cases of subchondral insufficiency fracture
occasionally result in a rapid destruction of the hip joint once a subchondral
collapse occurs.
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