Infusionstherapie bei Hüftkopfnekrose und Knochenmarködemsyndrom

Zusammenfassung

Eine vermehrte Ansammlung von interstitieller Flüssigkeit kommt beim sogenannten Knochenmarködemsyndrom (KMÖ) wie auch bei Osteonekrosen (ON) vor. Der exakte Pathomechanismus bleibt unklar. Therapieoptionen sind meistens symptomatischer Art mit dem operativen Goldstandard der retrograden Anbohrung (sogenannte „core decompression”), die zu einer sofortigen Druckentlastung und damit Schmerzreduktion führt. In jüngerer Zeit konnte in einigen wenigen Arbeiten gezeigt werden, dass die intravenöse Applikation von Iloprost und Bisphosphonaten ebenfalls eine Reduktion derÖdeme und Schmerzen bewirken kann. In der vorliegenden Arbeit sollen die bisherigen Berichte durch eigene Erfahrungen zweier retrospektiver Studienüberprüft werden. Hierzu wurden jeweils zehn Patienten mit KMÖ des Knies und Fußes einer intravenösen Therapie mit Iloprost bzw. Ibandronat zugeführt. Ferner wurden je zwölf Patienten mit KMÖ der Hüfte einer Infusionstherapie mit Iloprost einer Anbohrung oder der Kombination aus Anbohrung und Infusion gegenübergestellt. Signifikante Verbesserungen der erhobenen Scores (WOMAC, SF-36, VAS) konnten in beiden Studien verzeichnet werden. DasÖdem konnte deutlich reduziert werden. Im Vergleich der Gruppen war der Effekt von Prostacyclin sowie der Kombinationstherapie rascher und stärker sowie anhaltender. Die intravenöse Applikation von Bisphosphonaten und Iloprost stellt eine effiziente therapeutische Option in der Therapie des KMÖ dar. Prostacyclin wirkt rascher und stärker, ferner stellt die Kombinationsmethode aus Anbohrung und Infusion eine weitere Optimierung dar, insbesondere auch für die ON.

Summary

An increase in interstitial fluid occurs in bonemarrow edema (BME) as well as osteonecrosis (ON). The exact pathogenetic processes still remain unknown. Treatment options are mainly symptomatic with core decompression as golden standard leading to immediate pain relieve. Recently, it has been shown in few articles that intravenous prostacycline and bisphosphonates are also effective in achieving a reduction in BME with a considerable improvement in the accompanying symptoms. With the manuscript in hand we wanted to prove those descriptions by own results in two restrospective studies. We compared the outcome of both intravenously applied prostacycline (Ilomedin®, 10 patients) or bisphosphonate (Bondronat®, 10 patients) in treatment of BME of the knee and foot. Furthermore, the effect of intraveneously applied iloprost alone (12 patients) was studied against core decompression alone (12 patients) as well as iloprost following core decompression (12 patients). Significant improvement of scores (WOMAC, SF-36, VAS) could be recorded in both studies. The edema could be reduced distinctly. Comparing both groups, the effect of prostacyline and of the combined therapy was faster, greater and of longer duration. Intraveneously applied prostacycline and bisphosphonates are an effective treatment option for BME. Prostacylin and the combination of core decompression and infusion seem to be a further optimization, also in the treatment of ON.

Schlüsselwörter

Knochenmarködem - Osteonekrose - Prostacyclin - Iloprost - Bisphosphonat - Ibandronat

Keywords

Bone marrow edema - osteonecrosis - prostacycline - Iloprost - bisphosphonate - Ibandronat

• Literatur

• 1 Breitenseher MJ, Kramer J, Mayerhoefer ME. et al. [Differential diagnosis of bone marrow edema of the knee joint]. Radiologe 2006; 46: 46-54.
• 2 Karantanas AH, Drakonaki E, Karachalios T. et al. Acute non-traumatic marrow edema syndrome in the knee: MRI findings at presentation, correlation with spinal DEXA and outcome. Eur J Radiol 2008; 67: 22-33.
• 3 Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Bone marrow edema syndrome. Skeletal Radiol 2009; 38: 425-436.
• 4 Hofmann S. The painful bone marrow edema syndrome of the hip joint. Wien Klin Wochenschr 2005; 117: 111-120.
• 5 Doury P. Bone-marrow oedema, transient osteoporosis, and algodystrophy. J Bone Joint Surg Br 1994; 76: 993-994.
• 6 Hofmann S, Kramer J, Breitenseher M. et al. Knochenmarködem im Kniegelenk—Differenzialdiagnostik und therapeutische Möglichkeiten. Orthopade 2006; 35: 463-475.
• 7 Disch AC, Matziolis G, Perka C. The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost. J Bone Joint Surg Br 2005; 87: 560-564.
• 8 Koo KH, Ahn IO, Kim R. et al. Bone marrow edema and associated pain in early stage osteonecrosis of the femoral head: prospective study with serial MR images. Radiology 1999; 213: 715-722.
• 9 Plenk Jr H, Hofmann S, Eschberger J. et al. Histomorphology and bone morphometry of the bone marrow edema syndrome of the hip. Clin Orthop Relat Res 1997; 334: 73-84.
• 10 Berger CE, Kroner AH, Minai-Pour MB. et al. Biochemical markers of bone metabolism in bone marrow edema syndrome of the hip. Bone 2003; 33: 346-351.
• 11 Meizer R, Radda C, Stolz G. et al. MRI-controlled analysis of 104 patients with painful bone marrow edema in different joint localizations treated with the prostacyclin analogue iloprost. Wien Klin Wochenschr 2005; 117: 278-286.
• 12 Calder JD, Pearse MF, Revell PA. The extent of osteocyte death in the proximal femur of patients with osteonecrosis of the femoral head. J Bone Joint Surg Br 2001; 83: 419-422.
• 13 Hofmann S, Kramer J, Plenk H. Die Osteonekrose des Hüftgelenkes im Erwachsenenalter. Orthopade 2005; 34: 171-183.
• 14 Froberg PK, Braunstein EM, Buckwalter KA. Osteonecrosis, transient osteoporosis, and transient bone marrow edema: current concepts. RadiolClin North Am 1996; 34: 273-291.
• 15 Balakrishnan A, Schemitsch EH, Pearce D, McKee MD. Distinguishing transient osteoporosis of the hip from avascular necrosis. Can J Surg 2003; 46: 187-192.
• 16 Guerra JJ, Steinberg ME. Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995; 77: 616-624.
• 17 Aigner N, Petje G, Schneider W. et al. Bone marrow edema syndrome of the femoral head: treatment with the prostacyclin analogue iloprost vs. core decompression: an MRI-controlled study. Wien Klin Wochenschr 2005; 117: 130-135.
• 18 Hofmann S, Engel A, Neuhold A. et al. 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: 210-216.
• 19 Apel DM, Vince KG, Kingston S. Transient osteoporosis of the hip: a role for core decompression?. Orthopedics 1994; 17: 629-632.
• 20 Mont MA, Marulanda GA, Seyler TM. et al. Core decompression and nonvascularized bone grafting for the treatment of early stage osteonecrosis of the femoral head. Instr Course Lect 2007; 56: 213-220.
• 21 Aigner N, Schneider W, Eberl V, Knahr K. Core decompression in early stages of femoral head osteonecrosis—an MRI-controlled study. Int Orthop 2002; 26: 31-35.
• 22 Mihalko WM, Balos L, Santilli M, Mindell ER. Osteonecrosis after powered core decompression. Clin Orthop Relat Res 2003; 412: 77-83.
• 23 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: 1727-1734.
• 24 Ringe JD, Dorst A, Faber H. Effective and rapid treatment of painful localized transient osteoporosis (bone marrow edema) with intravenous ibandronate. Osteoporos Int 2005; 16: 2063-2068.
• 25 Grant SM, Goa KL. Iloprost. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in peripheral vascular disease, myocardial ischaemia and extracorporeal circulation procedures. Drugs 1992; 43: 889-924.
• 26 Agarwala S, Jain D, Joshi VR, Sule A. Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford) 2005; 44: 352-359.
• 27 Aigner N, Meizer R, Meraner D. et al. Bone marrow edema syndrome in postpartal women: treatment with iloprost. Orthop Clin North Am 2009; 40: 241-247.
• 28 Petje G, Radler C, Aigner N. et al. Pharmacological management of aseptic osteonecrosis in children. Expert Opin Pharmacother 2004; 5: 1455-1462.