Vascularity Related Osteoporosis

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Vascularity-related osteoporosis is arbitrarily assigned to include disuse (immobilization) osteoporosis, reflex sympathetic dystrophy (RSD), transient painful regional osteoporosis with hypervascularity, and nonspecific marrow edema. Osteoporosis and osteopenia is a condition in which bone mass is reduced with resultant increase in porosity. The former term emphasizes porosity and the latter reduced bone mass. The pathophysiology and precipitating factors are not fully clarified except disuse, hyperemia, congestion, and the "internun-cial" theory of RSD. The distribution pattern of

Rsd Radiographs

Fig. 14.8A, B Avascular osteonecrosis in alcoholics. A Anteroposterior radiograph of the left hip in a 36-year-old man with chronic alcoholism shows admixture of irregular bony condensation and lucency, deformity (curved arrow), and marked flattening of the head (open arrows). The hip joint is narrowed and the acetabular fossa deepened due to advanced secondary osteoarthritis. B Anterior pinhole scintigraph reveals intense tracer uptake in the femoral neck and narrowed joint with markedly collapsed head (open arrow)

Fig. 14.8A, B Avascular osteonecrosis in alcoholics. A Anteroposterior radiograph of the left hip in a 36-year-old man with chronic alcoholism shows admixture of irregular bony condensation and lucency, deformity (curved arrow), and marked flattening of the head (open arrows). The hip joint is narrowed and the acetabular fossa deepened due to advanced secondary osteoarthritis. B Anterior pinhole scintigraph reveals intense tracer uptake in the femoral neck and narrowed joint with markedly collapsed head (open arrow)

osteoporosis may be classified as generalized, regional, or focal, and the clinical presentation as acute, subacute, or chronic. Patients with RSD and transient regional osteoporosis may complain of pain, tenderness, and soft-tissue swelling. Disuse porosis, however, is symptom-less, unless complicated by fracture. From the view point of pathogenesis and scintigraphic description, osteoporosis can be divided into that with vascularity problems and that with metabolic or hormonal disturbances. Of these, vascularity-related osteoporosis is discussed here and the others are described in Chap. 15. Plain radiography was the primary means of

visually assessing osteoporosis. However, because of inadequate sensitivity it has been gradually replaced by radiographic bone densi-tometry, which can quantitatively measure bone mineral densities in the spine and femoral neck. Indeed, plain radiography can recognize positive change only after 30-50% loss of bone calcium. General radiographic features of osteoporosis include increased radiolucency, scarcity or absence of trabeculae, and thinning, scalloping, blurring, or tunneling of the cortex. Painful regional osteoporosis manifests as patchy areas of radiolucency due to paucity or apparent absence of trabeculae (Fig. 14.9A). On the other hand, the osteoporosis in disuse or RSD is characterized by regional involvement, manifesting as speckled, mottled, and patchy radiolucencies. RSD typically occurs in the carpal and tarsal bones. In severe RSD marked zonal lucencies may appear, for example, in the distal ends of the radius and ulna in addition to intense osteoporosis in the all carpal bones (Fig. 14.10A).

Bone scintigraphy shows conspicuous tracer uptake in transient regional porosis (Fig. 14.9B)

Mottled Lucencies

Fig. 14.9A-C Painful transient regional osteoporosis. A Lateral radiograph of the painful right hindfoot in a 40-year-old woman shows focal osteopenia in the posterior calcaneus (lower arrow) and distal tibial shaft (upper arrow). B Lateral pinhole scintigraph shows intense trac

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Fig. 14.9A-C Painful transient regional osteoporosis. A Lateral radiograph of the painful right hindfoot in a 40-year-old woman shows focal osteopenia in the posterior calcaneus (lower arrow) and distal tibial shaft (upper arrow). B Lateral pinhole scintigraph shows intense trac er uptake localized to the posterior calcaneus (lower arrow) as well as the distal tibia and talus (upper arrow). C Nuclear angiograph reveals regionally increased blood flow (arrowheads)

and mild to moderate uptake in RSD (Fig. 14.10C) and disuse porosis. In general the prominent regional tracer uptake in these conditions contrasts with systemic low uptake in postmenopausal, senescent, and metabolic osteoporosis. Nuclear angiography in transient regional osteoporosis (Fig. 14.9C) and RSD (Fig. 14.10B) demonstrates increased vascularity, permitting their distinction from disuse osteoporosis, which is not attended by hyper-perfusion. It is of interest to note that the pinhole scintigraphic uptake pattern varies somewhat between these three conditions, probably reflecting difference in the modes of osteoporosis. Thus, tracer uptake appears typically patchy and homogeneous in transient regional osteoporosis (Fig. 14.9B), band-like and mottled in RSD (Fig. 14.10C), speckled or coarsely granular in disuse porosis (Fig. 14.11), and diffusely homogeneous in regional osteoporosis of the hip (Fig. 14.15).

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