Bone marrow edema (BME) is a rare cause of pain in the foot. We reviewed 19 patients with unilateral bone marrow edema of ischemic, stress or osteoarthritic origin located in the hindfoot treated with the vasoactive prostacyclin analogue iloprost. The patients’ mean age was 61,5 years (25–76) and the duration of symptoms lasted 19 weeks before the therapy started. Bone marrow edema was located 9x in the talus, 3x in the calcaneus, 3x in the navicular bone and 2x in the cuboid. 11 cases were estimated to have a primary ischemic origin, the other 8 ones to be secondary to an activated osteoarthritis or to mechanic stress. Our therapy consisted of a series of five infusions with 20 μg (50 μg in the first six patients) of iloprost given over 6 hours on 5 consecutive days each. Mazur’s foot score was used to assess function before and 3 months after therapy. During this time, the score improved from a mean of 54,9 (range 23–73) before to 87,8 points (47–100) 3 months after therapy, with the best results in ischemic lesions with an improvement from 56,2 to 93,9 points and inferior results in patients with osteoarthritic edema as well as edema due to stress with a change in the score from 53 to 79,3 points. Magnetic resonance imaging showed complete recovery of the bone marrow edema within 3 months in 12 patients, 3x partial regression and no change in 4 cases with bone marrow edema due to activated osteoarthritis. We conclude that the parenteral application of the vasoactive drug iloprost might be a viable method in the treatment of bone marrow edema of different origins but especially in ischemic ones. In edema secondary to osteoarthrosis or stress, therapy effect with iloprost is of a symptomatic character depending on the grade of the basic disease

Aims. Arthroscopic microfracture is a conventional form of treatment for patients with osteochondritis of the talus, involving an area of < 1.5 cm. 2. However, some patients have persistent pain and limitation of movement in the early postoperative period. No studies have investigated the combined treatment of microfracture and shortwave treatment in these patients. The aim of this prospective single-centre, randomized, double-blind, placebo-controlled trial was to compare the outcome in patients treated with arthroscopic microfracture combined with radial extracorporeal shockwave therapy (rESWT) and arthroscopic microfracture alone, in patients with ostechondritis of the talus. Methods. Patients were randomly enrolled into two groups. At three weeks postoperatively, the rESWT group was given shockwave treatment, once every other day, for five treatments. In the control group the head of the device which delivered the treatment had no energy output. The two groups were evaluated before surgery and at six weeks and three, six and 12 months postoperatively. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Secondary outcome measures included a visual analogue scale (VAS) score for pain and the area of bone marrow oedema of the talus as identified on sagittal fat suppression sequence MRI scans. Results. A total of 40 patients were enrolled and randomly divided into the two groups, with 20 in each. There was no statistically significant difference in the baseline characteristics of the groups. No complications, such as wound infection or neurovascular injury, were found during follow-up of 12 months. The mean AOFAS scores in the rESWT group were significantly higher than those in the control group at three, six, and 12 months postoperatively (p < 0.05). The mean VAS pain scores in the rESWT group were also significantly lower than those in the control group at these times (p < 0.05). The mean area of bone marrow oedema in the rESWT group was significantly smaller at six and 12 months than in the control group at these times (p < 0.05). Conclusion. Local shockwave therapy was safe and effective in patients with osteochondiritis of the talus who were treated with a combination of arthroscopic surgery and rESWT. Preliminary results showed that, compared with arthroscopic microfracture alone, those treated with arthroscopic microfracture combined with rESWT had better relief of pain at three months postoperatively and improved weightbearing and motor function of the ankle. Cite this article: Bone Joint J 2023;105-B(10):1108–1114

Our knowledge of primary bone marrow edema (BME) of the knee is still limited. A major contributing factor is that it shares several radiological findings with a number of vascular, traumatic, and inflammatory conditions having different histopathological features and etiologies. BME can be primary or secondary. The most commonly associated conditions are osteonecrosis, osteochondritis dissecans, complex regional pain syndrome, mechanical strain such as bone contusion/bruising, micro-fracture, stress fracture, osteoarthritis, and tumor. The etiology and pathogenesis of primary BME are unclear. Conservative treatment includes analgesics, non-steroidal anti-inflammatory drugs, weight-bearing limitations, physiotherapy, pulsed electromagnetic fields, prostacyclin, and bisphosphonates. Surgical treatment, with simple perforation, fragment stabilization, combined scraping and perforation, and eventually osteochondral or chondrocyte transplant, is reserved for the late stages. This retrospective study of a cohort of patients with primary BME of the knee was undertaken to describe their clinical and demographic characteristics, identify possible risk factors, and assess treatment outcomes. We reviewed the records of 48 patients with primary BME of the knee diagnosed on MRI by two radiologists and two orthopedists. History, medications, pain type, leisure activities, smoking habits, allergies, and environmental factors were examined. Analysis of patients’ characteristics highlighted that slightly overweight middle-aged female smokers with a sedentary lifestyle are the typical patients with primary BME of the knee. In all patients, the chief symptom was intractable day and night pain (mean value, 8.5/10 on the numerical rating scale) with active as well as passive movement, regardless of BME extent. Half of the patients suffered from thyroid disorders; indeed, the probability of having a thyroid disorder was higher in our patients than in two unselected groups of patients, one referred to our orthopedic center (odds ratio, 18.5) and another suffering from no knee conditions (odds ratio, 9.8). Before pain onset, 56.3% of our cohort had experienced a stressful event (mourning, dismissal from work, concern related to the COVID-19 pandemic). After conservative treatment, despite the clinical improvement and edema resolution on MRI, 93.8% of patients described two new symptoms: a burning sensation in the region of the former edema and a reduced ipsilateral patellar reflex. These data suggest that even though the primary BME did resolve on MRI, the knee did not achieve full healing

Bone marrow edema syndrome (BMES) is a common cause of severe bone and joint pain. Intra-articular migrating of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease. We reviewed 8 patients (4 female, 4 male) with unilateral BMES located in the knee. The patients were aged 39–56 years (mean 50.2). In all the patients bone marrow edema (BME) found in the primary magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice. The final MR investigation performed on average 8 months after baseline (range, 7–11 months) showed full resolution of BMES in 6 patients. One patient had small residual edematous bone areas. No quadrant was newly affected. Improvement of the MR imaging pattern was correlated with the clinical outcome in all patients. The severity of effort-induced pain (VAS) was reduced from 7.5 (2.0–10.0) at baseline to 5.9 (2.4–7.9) after 3 months and to 0.6 (0–0.9) after the final examination. Pain at rest (VAS) diminished from 3.9 (1.5–7.8) to 2.8 (1.4–6.0) after 3 months and to 0 at the final follow-up. All patients became asymptomatic after a mean of 9 months (6–11). Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended

The aim of this prospective study was to determine the prevalence of bone marrow oedema (BME) in asymptomatic knees of athletes and to investigate the factors associated with appearance of BME in this group. A total of 25 asymptomatic athletes who competed at an international, national or county level during their most recent sport season were recruited in this study and had MRI scan of both knees (n=50). MRI scans were reported independently by two experienced musculoskeletal radiologists. Statistical analysis included Cohen's kappa test to identify inter-observer agreement for MRI diagnosis of bone marrow oedema and multiple logistic regression model to identify the factors associated with BME on MRI scan. There was very good agreement between radiologists for diagnosis of BME (Kappa = 0.896). Seven participants (28%) were found to have BME. Six of the participants had BME in unilateral knees and one participant had BME in bilateral knees. The commonest location of BME was medial femoral condyle (62.5%) The amount of time spent in preseason training (34-38 weeks) was significantly associated with appearance of BME (P=0.048). BME seems to be common in asymptomatic athletes and one should realize that this finding might not be related to the clinical complaints of the patients. The results of the present study show that there is a training effect associated with BME. Knowing what is a ‘normal’ or ‘abnormal’ scan is important for a competitive athlete, as erroneously diagnosing BME as the underlying cause of athletes' symptoms could lead to decreased playing time or inappropriate therapy

Aims. Pain is the most frequent complaint associated with osteonecrosis of the femoral head (ONFH), but the factors contributing to such pain are poorly understood. This study explored diverse demographic, clinical, radiological, psychological, and neurophysiological factors for their potential contribution to pain in patients with ONFH. Methods. This cross-sectional study was carried out according to the “STrengthening the Reporting of OBservational studies in Epidemiology” statement. Data on 19 variables were collected at a single timepoint from 250 patients with ONFH who were treated at our medical centre between July and December 2023 using validated instruments or, in the case of hip pain, a numerical rating scale. Factors associated with pain severity were identified using hierarchical multifactor linear regression. Results. Regression identified the following characteristics as independently associated with higher pain score, after adjustment for potential confounders: Association Research Circulation Osseous classification stage IIIa or IIIb, bone marrow oedema, grade 3 joint effusion, as well as higher scores on pain catastrophizing, anxiety, and central sensitization. The final model explained 69.7% of observed variance in pain scores, of which clinical and radiological factors explained 37%, while psychological and neurophysiological factors explained 24% and demographic factors explained 8.7%. Conclusion. Multidimensional characteristics jointly contribute to the severity of pain associated with ONFH. These findings highlight the need to comprehensively identify potential contributors to pain, and to personalize management and treatment accordingly. Cite this article: Bone Joint Res 2024;13(11):673–681

Aims. Due to its indolent clinical behaviour, the treatment paradigm of atypical cartilaginous tumours (ACTs) in the long bones is slowly shifting from intralesional resection (curettage) and local adjuvants, towards active surveillance through wait-and-scan follow-up. In this retrospective cohort study performed in a tertiary referral centre, we studied the natural behaviour of ACT lesions by active surveillance with MRI. Clinical symptoms were not considered in the surveillance programme. Methods. The aim of this study was to see whether active surveillance is safe regarding malignant degeneration and local progression. In total, 117 patients were evaluated with MRI assessing growth, cortical destruction, endosteal scalloping, periosteal reaction, relation to the cortex, and perilesional bone marrow oedema. Patients received up to six follow-up scans. Results. At the time of the first follow-up MRI, 8% of the lesions showed growth (n = 9), 86% remained stable (101), and 6% decreased in size (n = 7). During the third follow-up, with a mean follow-up time of 60 months (SD 23), 24 patients were scanned, of whom 13% had lesions that had grown and 13% lesions that had decreased in size. After 96 months (SD 37), at the sixth follow-up MRI, 100% of the lesions remained stable. None of the lesions showed malignant progression and although some lesions grew in size (mean 1 mm (SD 0.8)), no malignant progression occurred. Conclusion. We conclude that active surveillance with MRI is safe for ACTs in the long bones in the short- and mid-term follow-up. Cite this article: Bone Joint J 2024;106-B(1):86–92

Bone marrow edema (BME) is frequently observed on MR images in patients presenting with severe joint pain and may be present in numerous bone and joint diseases. BME may be subdivided into ischemic (bone marrow edema syndrome, BMES), mechanical and reactive BME. Although bone marrow edema of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool. 70 patients (36 female, 34 male) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS). The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau). The probable mode of action is that high intramedullary pressure in the BME affected bone (normal values are less than 30 mmHg) is additionally raised for a short period of time by the impact of the hammer on the bone surface, causing intense local pain. The test is economical, easy to perform in a doctor’s office, and not time-consuming but the final and evidentiary dignosis of BME can only be made by MRI. The tapping test is a good screening instrument to diagnose BME in the knee

Introduction: The purpose of this study was to compare two methods for the quantification of bone marrow edema (BME) of the knee. Materials and Methods: Forty-one patients with Bone Marrow Edema (BME) of the knee due to osteonecrosis, osteoarthritis, bone bruise or stress were included in the study. Coronal STIR images of the affected knees were obtained using either a 1.0 Tesla or a 1.5 Tesla Magnetic Resonance (MR) scanner. To monitor the BME’s progression, every knee was examined twice at a 3-month interval. Size and signal intensity of BME were semi-quantitatively assessed in consensus by two radiologists and two orthopaedic surgeons. Independently, size and signal intensity were calculated using a new computer assisted method based on grey value analysis and calculation of a threshold value between normal and edematous bone marrow. The results of the semi-quantitative method were correlated with those of the computer assisted method. Results: The correlation coefficient was 0.89 (ìstrongî) for BME size and 0.72 (ìmedium to strongî) for BME signal intensity. For the progression of size and signal intensity, correlation coefficients of 0.78 (ìstrongî) and 0.67 (ìmediumî) were found. Conclusion: Good correlation between semi-quantitative and quantitative methods of assessment of both size and intensity of BME was found. While the computer assisted method is time-consuming and reserved for scientific purposes, the semi-quantitative method is simple and offers to the experienced examiner a fast and simple means for BME recording in clinical practice

Introduction: Intra-articular migration of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease. Materials and Methods: We reviewed 8 patients (4 women, 4 men) with unilateral BMES located in the knee. The patients were aged 39 to 56 years (mean 50.2). In all the patients, bone marrow edema found in the primary magnetic resonance imaging (MRI) migrated within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice. Results: MRI showed complete restitution in 6 cases and small residual edema in one case. A final MRI control was not obtained in one painless patient. In one patient, avascular necrosis of the contralateral hip was evident after 16 months. Improvement of the MRI pattern was correlated with the clinical outcome in all patients. All patients became asymptomatic after a mean of 9 months (range, 6–11). Conclusion: Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended

Introduction. Bone Marrow Oedema Syndrome (BMOS) is an unusual and poorly understood condition. It commonly affects the hips and knees and is reported to have a tendency to recur. The foot and ankle are less frequently involved but nevertheless patients can be severely impaired. Only case reports of BMOS of the foot and ankle have been published. The aim of this study is to evaluate the sites of occurrence, risk factors, efficacy of immobilisation, response to intravenous biphosphonates and local or remote recurrence over the following years. Methods. A retrospective review of 25 adult patients who have been diagnosed with BMOS have been followed-up for an average of 5.8 years (range: 2–11). Six patients have not been traced. Results. There were 6 males and 13 females with an average age at presentation of 45.8 and 58.8 years respectively. No statistically significant risk factors could be identified. The talus was the commonest affected bone (68% of the cases) followed by the intermediate cuneiform and the adjacent second metatarsal (21%) and the cuboid with the adjacent third and fourth metatarsals (15%). All 19 patients were treated initially with a pneumatic walker: 5 patients had a resolution of their symptom at an average time of 7 weeks. Of the 14 patients who had not improved by approximately 8 weeks, nine received intravenous zolendronate along with the same pneumatic walker and 5 continued with the pneumatic walker alone. The 9 patients who received a single dose of zolendronate experienced significant improvement within an average of 3.6 weeks. Eight patients out of the 19 continue to have pain. Conclusion. BMOS is often a diagnosis of exclusion. The talus is the most affected bone in the foot and ankle. The majority of patients in this study have improved with a brace and or intravenous zolendronate

Bone marrow edema is a common cause of pain of the locomotor apparatus. We reviewed 50 patients (28 male, 22 female) with bone marrow edema of the knee. The patients mean age was 56.2 12.8 years. 8 cases were estimated to have an idiopathic BME, 10 posttraumatic and the other 32 ones to be secondary to an activated osteoarthritis or to mechanic stress. Iloprost is a vasoactive prostacyclin analogue. Therapy consisted of a series of five infusions with either 20 or 50g of iloprost given over 6 hours on 5 consecutive days each. Pain at rest as well as under stress were assessed with a semi quantitative scale from before and 4 months after therapy. MRI investigations were done before and repeated 4 months after therapy. At the clinical follow-up 4 months after therapy, pain level at rest had diminished 84% (p < 0.0001). 70% of patients referred about a reduction, 30% about no change. Pain under stress decreased 57%, (p < 0.0001). 76% of patients showed lower pain under activity, 24% no change from baseline. There was no increase of pain level in any patient. In MRI in 85% a significant reduction of the BME size or complete restitution could be observed, 15% showed no change. Response rate to iloprost infusions came to 100% in idiopathic, 100% in posttraumatic and 66% in secondary BME. A significant reduction of side effects could be reached by lowering the daily dosage from 50 to 20g. The authors conclude that parenteral application of iloprost might be a viable method in the treatment of BME of different origins

The etiology of TBMOS is not known yet.Possibly, TBMES and osteonecrosis may not be completely separate and distinct conditions. We performed a prospective study in 32 patients, among 1150 with knee pain that were examined, who fullfilled the following criteria: no history of trauma, inconclusive radiographs and MR images demonstrating a bone marrow edema pattern.The mean age of the patients was 45 years (35 to 56).Patients were followed up for three years clinical examination, laboratory examination, xrays, MRI and in most cases T99 scanning and CT scanning. The disease proved to be transient in 8 patients.In three of them edema extended to subchondral bone as in osteonecrosis with an illdefined bandlike signal.The mean width of the signal was 3 mm.In two other cases the type of manifestation has never been reported. We concluded that TBMES can extend to subchondral bone, as osteonecrosis does, through illdefined low signal band like lesions parallel to the articular surface and then resolve completely.It may also have various types of manifestation.We believe that TBME is a common status of different conditions including early avascular necrosis that the bone repair process managed to overcome

It has been suggested that transient osteoporosis or the bone marrow oedema syndrome (BMOS) may be the initial phase of osteonecrosis of the femoral head (ONFH) and that there may be a common pathophysiology. In this study, we have assessed the MR images of 200 consecutive patients with ONFH in respect of the BMO pattern in order to test this hypothesis. This pattern was not observed in the early stage of ONFH. The initial abnormal finding detected on the MR images was an abnormal band of intensity at the junction between the necrotic area and the normal bone. Structural damage of the head seems to result in the appearance of the BMO pattern and the development of pain in ONFH. There was no finding to support the existence of a continuum between BMOS and ONFH

Introduction: Bone marrow edema (BME) is a common cause of pain in the knee with restricted treatment options. The authors performed a double-blind, randomized, active-controlled study in order to explore the clinical effects of the prostacyclin analog iloprost (Schering AG, Germany). Materials and Methods: Forty-one patients with painful bone marrow edema associated with osteonecrosis, osteoarthritis, bone bruise or axis deformities were evaluated. Patients were randomized either to iloprost (n=21, 15 male, 6 female; mean age 53 years) or to Tramadol (n=20, 12 male, 8 female; mean age 51 years). An individual dose adjustment was allowed within the range of 100–300 μg of iloprost, and 100–300 mg of Tramadol. The treatment duration was 4 weeks. The treatment period was followed by an 8-week treatment-free follow-up. During and after treatment, full weight bearing was allowed as tolerated. Efficacy of treatment was assessed by 10 cm visual analog scales for pain at rest and on exertion, Larson’s knee score, and magnetic resonance imaging. Results: The results are presented below. These clinical effects were sustained over the entire follow-up. At the end of study, 53% of iloprost patients showed healing of at least one BME affected bone as compared to only 19% of Tramadol patients. Regression of subchondral lesions occurred in 4 iloprost patients. No serious adverse events occurred; however, three Tramadol patients discontinued the treatment prematurely due to adverse events. Discussion: The authors conclude that the oral application of the vasoactive drug iloprost results in substantial treatment effects on pain relief and joint function improvement. These effects were similar for iloprost and Tramadol. Iloprost treatment was associated more often with BME regression than Tramadol. Oral iloprost may offer a new and safe treatment option for patients with painful BME

Introduction: Although bone marrow edema (BME) of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool. Methods: Seventy patients (36 women, 34 men) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS). Results: The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau). Conclusion: The tapping test is a good screening instrument to diagnose BME in the knee

Background: Although bone marrow edema (BME) of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool. Methods: 70 patients (36 female, 34 male) were investigated in this controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS). Results: The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in nonaffected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau). Implicating a threshold value of VAS 2.0 for a tapping test to be positive in the distinction of BME affected quadrants of group 1 and all quadrants of group 2 sensitivitiy was 90.4%, specitivity 83.7%, positive predictive value 73.4% and negative predictive value 94.6%. Conclusion: The tapping test is a good screening instrument to diagnose BME in the knee

Introduction. Bone marrow oedema syndrome (BMES) of the foot and ankle is an uncommon and often misdiagnosed condition. It is usually thought to be a benign self limiting condition, without any sequelae. However, it can cause disabling pain for a prolonged period of time. Materials and Methods. We retrospectively reviewed 8 patients with the diagnosis of BMES. There were 6 males and 2 females with an average age of 51 years (38–63 years). All patients had acute onset of severe pain in the foot without any history of trauma. None of the patients had history of excessive alcohol or steroid intake. 5 patients (63%) had bilateral involvement of migratory nature. All patients had characteristic features on MR scans, with involvement of 3 or more bones in the foot. Results. All patients had their limbs immobilised in a below knee cast and asked to mobilise non weight bearing for 6–8 weeks. Thereafter, they were allowed to mobilise with a pneumatic walker, increasing weight bearing as pain allowed. The walker was discarded at an average of 26 weeks. All 8 patients had complete relief of pain after an average of 14 months (4–22 months). All were able to return to their work environment but 2 complained of occasional aching and swelling of their feet, at the end of their shift at work. 2 patients were treated with bisphosphonates and 2 had targeted local anaesthetic injections with good pain relief. None were treated with Iloprost. Conclusions. BMES affecting the foot and ankle is an uncommon condition. Symptoms tend to be prolonged and may result in chronic swelling and aching around the ankle. Symptoms do tend to improve with time with or without intervention

Introduction: Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a rarely seen disease associated with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Materials and Methods: We treated 4 postpartum women (6 hips) presenting with femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. Results: Symptoms regressed rapidly during and after therapy. After 4 weeks, all patients were asymptomatic with no limitations in ambulation. In the magnetic resonance imaging assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck was found in one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (range, 14 to 43 months). Conclusion: The vasoactive drug iloprost has good analgesic potency in the treatment of postpartum women suffering from BMES and accelerates the natural benign course of the disease

Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES. The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES. Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months). The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease