Das Knochenmarködemsyndrom-Register

Zusammenfassung

Unter dem Begriff des Knochenmarködemsyndroms (KMÖS) subsumieren sich verschiedene Krankheitsbilder unterschiedlicher Ätiologie. Entsprechend dem Erscheinungsbild, den vorliegenden Risikofaktoren und den Begleitumständen wird die Erkrankung oft als Beginn einer Osteonekrose, als transiente Osteoporose oder als Begleitreaktion auf andere Knochenerkrankungen interpretiert. Auch als Folge eines traumatischen Geschehens (“bone bruise”) oder einer mechanischen Überlastung (“Stressfraktur”) wird häufig ein Knochenmarködem als MRT-Korrelat gesehen. Gemeinsam ist allen Formen der Knochenschmerz als Leitsymptom, der oft über Wochen oder Monate bestehen bleiben kann und den betroffenen Patienten relevant einschränkt. Entsprechend vielfältig sind die angebotenen und praktizierten Therapiemöglichkeiten. Neben verschiedenen konservativen Verfahren steht die medikamentöse The-rapie im Mittelpunkt, die aus Mangel an anderen Alternativen fast regelhaft als Offla-bel-Anwendung erfolgt. Allen Therapieformen gemein ist dabei ein Mangel an belastbarer Evidenz für oder gegen die praktizierten Konzepte. Vorbereitend zur Verbesserung der Evidenzlage mittels entsprechender Studien und gegebenenfalls langfristig der Entwicklung von Standards oder einer Leitlinie zur Behandlung dieses heterogenen Krankheitsbildes ist zunächst eine Bestandsaufnahme der aktuellen Situation im deutschsprachigen Raum sinnvoll. Mit einem Fallregister, initiiert von der DGOU und dem BVOU, soll die praktisch vorhandene Erfahrung in der Therapie des Knochenmarködemsyndroms gesammelt und gebündelt werden, um aus diesen Daten zukünftig eine valide Behandlungsempfehlung erstellen zu können. Der vorliegende Artikel beschreibt das Konzept und die Rationale dieses Registers und fasst die bisher vorhandene Evidenz kurz zusammen.

Summary

The term “bone marrow edema syndrome” (BMES) combines a variety of diseases of very different etiology. Depending on the onset and clinical presentation and associated risk factors or comorbidities, the disease is classified as an early form of osteonecrosis or a local transient osteoporosis, and can also accompany other bone and joint conditions. As “bone bruise”, the lesions appear after trauma or after repetitive or excessive mechanical strain as insufficiency fractures. A bone marrow edema is seen on the MRI in correlation with the pain, which is the leading symptom and can last for weeks or month. As diverse as the presentation of the disease are the possible treatment options. While therapy concepts vary widely, they all have in common a lack in sufficient evidence for their efficiency. Next to conservative care options, medication therapy is often applied. Due to a lack of alternatives, the off-label use is then common practice. Ultimately, we aim to enhance the level of evidence for the treatment of bone marrow edema syndrome by employing sensible prospective and randomized studies, and to compose a treatment guideline, based on the results of such trials. In preparation towards this final goal it seems necessary to first assess the current status quo in treatment regimens among the germanspeaking physicians. The German Society of Orthopedics and Trauma (DGOU), as well as the Professional Association of Orthopedics and Trauma (BVOU) initiated a case-based register to gather and record all expertise and experience that is currently present, regarding the diagnostics, the treatment and outcome of bone marrow edema syndrome. Based on this data pool, future studies could be planned and initiated, and treatment guidelines be devised. This article describes the concept and rationale of the register, and summarizes the evidence already present.

Schlüsselwörter

“Bone bruise” - lokale transiente Osteoporose - evidenzbasierte Medizin - Registerstudie

Keywords

“Bone bruise” - local transient osteoporosis - register study - evidence based medicine

• Literatur

• 1 Manara M, Varenna M. A clinical overview of bone marrow edema. Reumatismo 2014; 66 (02) 184-196.
• 2 Patel S. Primary bone marrow oedema syndromes. Rheumatology (Oxford) 2014; 53 (05) 785-792.
• 3 Craiovan BS, Baier C, Grifka J. et al. [Bone marrow edema syndrome (BMES)]. Orthopade 2013; 42 (03) 191-204.
• 4 Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Bone marrow edema syndrome. Skeletal Radiol 2009; 38 (05) 425-436.
• 5 Trevisan C, Klumpp R, Compagnoni R. Risk factors in transient osteoporosis: a retrospective study. 2517-2522.
• 6 Marcacci M, Andriolo L, Kon E. et al. Aetiology and pathogenesis of bone marrow lesions and osteonecrosis of the knee. EFORT Open Rev 2016; 01 (05) 219-224.
• 7 Bouquot JE, McMahon RE, Glueck CJ. Bone marrow edema: mild or nascent variant of ischemic bone disease. J Oral Maxillofac Surg 2008; 66 (01) 205-208.
• 8 Matcuk Jr GR, Mahanty SR, Skalski MR. et al. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol 2016; 23 (04) 365-375.
• 9 Cano-Marquina A, Tarin JJ, Garcia-Perez MA, Cano A. Transient regional osteoporosis. Maturitas 2014; 77 (04) 324-329.
• 10 Horas K, Fraissler L, Maier G. et al. High Prevalence of Vitamin D Deficiency in Patients With Bone Marrow Edema Syndrome of the Foot and Ankle. Foot Ankle Int. 2017 Mar 01:1071100717697427.
• 11 Beckmann J, Roth A, Niethard C. et al. [Bone marrow edema and atraumatic necrosis of the femoral head : Therapy]. Orthopade 2015; 44 (09) 662-671.
• 12 Zhang Q, Liu L, Sun W. et al. Extracorporeal shockwave therapy in osteonecrosis of femoral head: A systematic review of now available clinical evidences. Medicine (Baltimore) 2017; 96 (04) e5897.
• 13 Geith T, Mutschler W, Berger F. [Therapy of bone marrow edema syndrome in the knee with denosumab. Case report]. Unfallchirurg 2015; 118 (03) 230-232.
• 14 Rolvien T, Schmidt T, Butscheidt S. et al. Denosumab is effective in the treatment of bone marrow oedema syndrome. Injury 2017; 48 (04) 874-879.
• 15 Calvo E, Fernandez-Yruegas D, Alvarez L. Core decompression shortens the duration of pain in bone marrow oedema syndrome. Int Orthop 2000; 24 (02) 88-91.
• 16 Beckmann J, Schmidt T, Schaumburger J. et al. Infusion, core decompression, or infusion following core decompression in the treatment of bone edema syndrome and early avascular osteonecro-sis of the femoral head. Rheumatol Int 2013; 33 (06) 1561-1565.
• 17 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 (01) 22-33.
• 18 Grovle L, Hasvik E, Rashid HU, Haugen AJ. Primary bone marrow oedema syndrome: proposed outcome measures for pain and physical functioning. Rheumatology (Oxford) 2014; 53 (10) 1910-1911.
• 19 d’Agostino C, Romeo P, Lavanga V. et al. Effectiveness of extracorporeal shock wave therapy in bone marrow edema syndrome of the hip. Rheumatol Int 2014; 34 (11) 1513-1518.
• 20 Martinelli N, Bianchi A, Sartorelli E. et al. Treatment of bone marrow edema of the talus with pulsed electromagnetic fields: outcomes in six patients. J Am Podiatr Med Assoc 2015; 105 (01) 27-32.
• 21 Gao F, Sun W, Li Z. et al. Extracorporeal shock wave therapy in the treatment of primary bone marrow edema syndrome of the knee: a prospective randomised controlled study. BMC Musculoskelet Disord 2015; 16: 379.
• 22 Capone A, Podda D, Ennas F. et al. Hyperbaric oxygen therapy for transient bone marrow oedema syndrome of the hip. Hip Int 2011; 21 (02) 211-216.
• 23 Meizer R, Meraner D, Meizer E. et al. Outcome of painful bone marrow edema of the femoral head following treatment with parenteral iloprost. Indian J Orthop 2009; 43 (01) 36-39.
• 24 Rohner E, Zippelius T, Steindl D. et al. Effects of intravenous iloprost therapy in patients with bone marrow oedema of the foot and ankle. Eur J Orthop Surg Traumatol 2014; 24 (08) 1609-1616.
• 25 Jager M, Zilkens C, Bittersohl B. et al. Efficiency of iloprost treatment for osseous malperfusion. Int Orthop 2011; 35 (05) 761-765.
• 26 Aigner N, Meizer R, Meraner D. et al. Bone marrow edema syndrome in postpartal women: treatment with iloprost. Orthop Clin North Am 2009; 40 (02) 241-247.
• 27 Mayerhoefer ME, Kramer J, Breitenseher MJ. et al. Short-term outcome of painful bone marrow oedema of the knee following oral treatment with iloprost or tramadol: results of an exploratory phase II study of 41 patients. Rheumatology (Oxford) 2007; 46 (09) 1460-1465.
• 28 Bartl C, Imhoff A, Bartl R. Treatment of bone marrow edema syndrome with intravenous ibandronate. Arch Orthop Trauma Surg 2012; 132 (12) 1781-1788.
• 29 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 (12) 2063-2068.
• 30 Meier C, Kraenzlin C, Friederich NF. et al. Effect of ibandronate on spontaneous osteonecrosis of the knee: a randomized, double-blind, placebo-controlled trial. Osteoporos Int 2014; 25 (01) 359-366.
• 31 Baier C, Schaumburger J, Gotz J. et al. Bisphosphonates or prostacyclin in the treatment of bonemarrow oedema syndrome of the knee and foot. Rheumatol Int 2013; 33 (06) 1397-1402.
• 32 Simon MJ, Barvencik F, Luttke M. et al. Intravenous bisphosphonates and vitamin D in the treatment of bone marrow oedema in professional athletes. Injury 2014; 45 (06) 981-987.
• 33 McQueen F, Lloyd R, Doyle A. et al. Zoledronic acid does not reduce MRI erosive progression in PsA but may suppress bone oedema: the Zoledronic Acid in Psoriatic Arthritis (ZAPA) Study. Ann Rheum Dis 2011; 70 (06) 1091-1094.
• 34 Kraenzlin ME, Graf C, Meier C. et al. Possible beneficial effect of bisphosphonates in osteonecrosis of the knee. Knee Surg Sports Traumatol Arthrosc 2010; 18 (12) 1638-1644.
• 35 Emad Y, Ragab Y, El-Shaarawy N, Rasker JJ. Transient osteoporosis of the hip, complete resolution after treatment with alendronate as observed by MRI description of eight cases and review of the literature. Clin Rheumatol 2012; 31 (11) 1641-1647.