Core decompression plus allogeneic fibular grafting for refractory transient osteoporosis of the hip: a case report and literature review

Core decompression plus allogeneic fibular grafting for refractory transient osteoporosis of the hip: a case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Core decompression plus allogeneic fibular grafting for refractory transient osteoporosis of the hip: a case report and literature review Cong Chen, Tian'en Xu, Hua-sha Jiang, Xu Wang, Ya-yi Xia, Ya-peng Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6383384/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Nov, 2025 Read the published version in BMC Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract There are no documented cases in the literature of using core decompression and allogeneic fibular grafting to treat refractory transient osteoporosis of the hip. Case presentation: This case study details a patient who received core decompression and allogeneic fibular grafting procedure to treat refractory TOH. A 100-day follow-up, the MRI results of the hip joint were normal, and the patient reported no pain during weight-bearing, which indicated successful treatment outcomes. Core decompression shortens symptoms of TOH, while allogeneic fibular grafting strengthens the femoral neck. The combination of these two approaches not only facilitates a rapid recovery from TOH but also reduces the risk of femoral neck fracture which demonstrates a successful treatment strategy. transient osteoporosis of hip (TOH) core decompression allogeneic fibular grafting Figures Figure 1 Introduction In 1959, Curtiss and Kincaid discovered a phenomenon while treating hip pain in three pregnant women. These women had hip joint pain, and X-rays indicated that their femoral heads were demineralized. However, after a few months, the pain lessened, and follow-up X-rays showed that the femoral heads had returned to normal [ 1 ]. In 1968, Lequesne coined the term "transient osteoporosis of the hip (TOH)" for this condition [ 2 ]. In later studies, bone marrow edema syndrome (BMES) and localized or regional migratory osteoporosis (RMO) were also described as the same kind of diseases as TOH [ 3 ]. Most cases of transient osteoporosis of the hip have shown symptom relief with conservative treatment [ 4 ], however, some studies have documented instances of pathological fractures occurred during this treatment [ 5 ]. Core decompression and bone grafting are common methods for treating femoral head necrosis [ 6 ]. Additionally, core decompression may reduce the duration of the disease and provide satisfactory results for transient osteoporosis of the hip, but it may reduce bone mass and increase the risk of fracture [ 7 ]. In order to alleviate the pain and prevent fractures, we adopt a treatment method of core decompression combined with allogeneic fibular grafting, we believe this is the first report of this treatment method. Case presentation On April 11, 2024, a 46-year-old male patient, who's job is teacher, presented to our outpatient clinic with a complaint of right hip pain for over two months. The visual analogue scale (VAS) score for hip joint pain during weight-bearing was 5, while the score for pain without weight-bearing was 3. MRI examination revealed diffuse low signal in the T1-weighted images (Figure a) and high signal in the T2-weighted images (Figure b) in the right femoral head and neck region. X-ray and CT examinations showed no significant abnormalities. After hospitalization, various laboratory tests were conducted, including complete blood count, c-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), and interleukin-6 (IL-6). None of these tests showed significant abnormalities. Bone scintigraphy using single-photon emission computed tomography (SPECT) revealed increased radionuclide uptake in the delayed imaging of the right femoral head and neck region. To exclude the possibility of neoplastic diseases, a core needle biopsy of the femoral neck was performed, and the results indicated no presence of benign or malignant tumor cell components. At the same time, we took the blood from the puncture site of femoral neck for culture, and no bacteria and fungi were cultivated. Based on the patient's medical history, clinical and imaging examinations, and laboratory test results, we diagnosed the condition as TOH. After 10 days treatment with non-steroidal anti-inflammatory drugs and bisphosphonates drugs, the pain have not been significantly relieved. In order to relieve pain and prevent femoral neck fracture, we performed core decompression and allogeneic fibular grafting under combined general and nerve block anesthesia on the 12th day after admission. The surgical procedure is as follows: Under the guidance of a C-arm X-ray, a guide wire was percutaneously inserted into the subchondral bone of the femoral head. A 5 cm longitudinal skin incision was made at the site of the guide wire. A cannulated drill was used to create a hole, and after decompression of the surrounding bone in the femoral head area with a mushroom-shaped drill bit, a segment of allogeneic fibular bone was implanted into the femoral neck. On the first day after operation, the patient took frontal (Figure c) and lateral (Figure d) X-rays of the right hip joint. At 24-hour postoperatively, the VAS score for hip joint pain without weight-bearing was 1, and the patient was discharged on the 4th postoperative day. At the 77-day follow-up, an X-ray examination was conducted, and the VAS score for hip joint pain without weight-bearing was 0. At the 100-day follow-up, an MRI showed resolution of bone marrow edema in the femoral head and neck (Figure e, f), with the patient reporting no weight-bearing pain and a VAS score of 0. Discussion TOH usually occurs in middle-aged men of the 40 to 60-years old and young women in the last 3 months of pregnancy [ 8 , 9 ], physicians and teacher are occupational risk factors [ 10 ], typically without a history of significant hip trauma, alcohol abuse, or extensive steroid use. The cause of TOH is not well understood, it may be related to venous dysfunction of femoral head, increased intraosseous pressure and venous hypertension was found in the lesion area [ 11 ]. Plain X-ray films usually display normal or mildly osteoporotic femoral heads. In contrast, MRI typically shows low signals on T1-weighted images and high signals on T2-weighted images, resembling bone marrow edema, which is the most useful diagnostic test [ 12 , 13 ]. While, the subchondral fracture could found on small field of view high-resolution MRI [ 14 ]. Additionally, bone scintigraphy (BS) may demonstrate increased radiotracer uptake in the affected region [ 15 ]. The most important differential diagnosis is femoral head osteonecrosis which can find the characteristic "double-line sign" on T2 imaging, because of the coexistence of osteonecrosis and osteogenesis [ 8 , 16 ]. In this case, the patient's X-ray, MRI, SPECT, bacterial cultivation and biopsy results ruled out infections, tumors and femoral head necrosis, indicated that he has TOH. Historically, conservative management was advised for transient osteoporosis of the hip since it is a self-limiting condition that can resolve independently over time, sometimes it can be treated by nonsteroidal antiinflammatory medication, protected weight bearing and physical therapy [ 4 , 17 ]. In addition, bisphosphonates, calcitonin, or teriparatide are reported to be effective methods to reduce recovery time [ 17 ]. However, many literatures have indicated the risk of femoral neck fracture with conservative treatment [ 18 – 20 ]. A systematic review showed that bisphosphonates are more effective in relieving pain in a short term (1–3 months), and core decompression is more effective in a long term (6–12 months) [ 21 ]. In a clinical study, Calvo found that core decompression significantly outperformed conservative treatment regarding both pain duration and overall therapeutic outcomes in the treatment of TOH [ 7 ]. Similarly, Bashaireh compared core decompression with conservative methods in the treatment of transient osteoporosis of the hip and arrived at the same conclusions [ 22 ]. This is a patient who has recurrent pain and the conservative treatments were ineffective. Therefore, in order to treat the pain, we used the method of core decompression. However, core decompression surgery reduces bone mass in the femoral neck, femoral head, and subtrochanteric regions, increasing the risk of fracture [ 23 ]. Consequently, we treated this patient by combining core decompression with allogeneic fibular grafting which could be used as a support bone to reduce the risk of fracture. Within 24-hour postoperatively, the patient's hip pain was significantly reduced. At the 77-day follow-up, the hip was pain-free without weight-bearing, as it was crucial to minimize the risk of femoral neck or subtrochanteric fractures, as well as femoral head necrosis. At the 100-day follow-up, MRI showed complete recovery, with no weight-bearing pain, no femoral head necrosis, and no pathological fractures occurring during the follow-up period. The patient achieved satisfactory results after the treatment, marking a successful therapeutic experience. Conclusion Core decompression with allogeneic fibular grafting is a safe and effective treatment for refractory transient osteoporosis of the hip, capable of shortening the disease course and preventing femoral neck fractures. However, long-term, large-sample studies are needed. Abbreviations BMES bone marrow edema syndrome BS bone scintigraphy CRP c-reactive protein ESR erythrocyte sedimentation rate IL-6 interleukin-6 PCT procalcitonin RMO regional migratory osteoporosis SPECT single-photon emission computed tomography TOH transient osteoporosis of hip VAS visual analogue scale Declarations Authors’ Contributions C.C. collected the medical histories, performed bone biopsy, wrote the original manuscript, made the figure and provided the financial support. YP.W. performed the operation, revised the manuscript. TE.X., HS.J. completed the follow-ups. YY.X. and X.W. gave guidance on the idea of operation and manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity. Founding This research was supported by Youth Science and Technology Program of Gansu Province (23JRRA1646), Cuiying Scientific and Technological Innovation Program of Lanzhou University Second Hospital (CY2022-YB-A01), Science and Technology Plan of Lanzhou City (2024-4-23). Data availability No datasets were generated or analysed during the current study. Ethics approval and consent to participate All procedures performed involving human participants were in accordance with the ethical standards of the institution and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study has been approved by the Ethics Committee of The Second Hospital of Lanzhou University (2025-A-081). Informed consent was obtained from all participants included in the study. Consent for publication All authors approved the manuscript. Written informed consent for the publication of this case report and any accompanying images was obtained from the patient. Competing interests The authors declare no competing interests. References Curtiss PJ, Kincaid WE. Transitory demineralization of the hip in pregnancy. A report of three cases. J Bone Joint Surg Am. 1959;41–A:1327–33. Lequesne M. Transient osteoporosis of the hip. A nontraumatic variety of Sudeck's atrophy. Ann Rheum Dis. 1968;27(5):463–71. https://doi.org/10.1136/ard.27.5.463 . Grovle L, Haugen AJ, Johansen M, Hasvik E. The terminologies of transient, migratory, or localized osteoporosis, and bone marrow edema syndrome: a scoping review. Osteoporos Int. 2024;35(2):217–26. https://doi.org/10.1007/s00198-023-06929-x . Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Transient osteoporosis. J Am Acad Orthop Sur. 2008;16(8):480–9. https://doi.org/10.5435/00124635-200808000-00007 . Brodell JD, Burns JJ, Heiple KG. Transient osteoporosis of the hip of pregnancy. Two cases complicated by pathological fracture. J Bone Joint Surg Am. 1989;71(8):1252–7. Wang Q, An J, Zhang W, Yang Z, Zhao X, Kang P. Core Decompression Prevents Progression of Asymptomatic Type C Osteonecrosis of Femoral Head According to the Japanese Investigation Committee Classification: A Retrospective Study. Orthop Surg. 2022;14(5):851–9. https://doi.org/10.1111/os.13213 . Calvo E, Fernandez-Yruegas D, Alvarez L. Core decompression shortens the duration of pain in bone marrow oedema syndrome. Int Orthop. 2000;24(2):88–91. https://doi.org/10.1007/s002640000120 . Maisi N, Patoulias D, Tsagkaris C, Tsagatakis M, Goules D. Transient Hip Osteoporosis: Etiopathogenetic, Clinical, and Imaging Approach. Mediterr J Rheumatol. 2022;33(2):196–200. https://doi.org/10.31138/mjr.33.2.196 . Galanis A, Dimopoulou S, Karampinas P, Vavourakis M, Papagrigorakis E, Sakellariou E, et al. The correlation between transient osteoporosis of the hip and pregnancy: A review. Medicine. 2023;102(41):e35475. https://doi.org/10.1097/MD.0000000000035475 . Fattah A, Abounoori M. Transient osteoporosis of the hip: Physicians the occupation of at risk. Clin Case Rep. 2021;9(10):e4968. https://doi.org/10.1002/ccr3.4968 . Koo KH, Ahn IO, Song HR, Kim SY, Jones JJ. Increased perfusion of the femoral head in transient bone marrow edema syndrome. Clin Orthop Relat R. 2002;(402):171–5. https://doi.org/10.1097/00003086-200209000-00015 Klontzas ME, Vassalou EE, Zibis AH, Bintoudi AS, Karantanas AH. MR imaging of transient osteoporosis of the hip: an update on 155 hip joints. Eur J Radiol. 2015;84(3):431–6. https://doi.org/10.1016/j.ejrad.2014.11.022 . Yamaguchi R, Yamamoto T, Motomura G, Ikemura S, Iwasaki K, Zhao G, et al. Radiological morphology variances of transient osteoporosis of the hip. J Orthop Sci. 2017;22(4):687–92. https://doi.org/10.1016/j.jos.2017.02.009 . Gulati A, Kamel SI, Desai V, Belair JA. Presence of subchondral fracture in cases diagnosed as transient osteoporosis of the hip: a retrospective independent reader-based study. Skeletal Radiol. 2024;53(5):871–9. https://doi.org/10.1007/s00256-023-04500-7 . Ulaner GA, Sawan P. Transient Osteoporosis of the Hip on FDG PET/CT. Clin Nucl Med. 2017;42(5):401–2. https://doi.org/10.1097/RLU.0000000000001630 . Chang C, Greenspan A, Gershwin ME. The pathogenesis, diagnosis and clinical manifestations of steroid-induced osteonecrosis. J Autoimmun. 2020;110:102460. https://doi.org/10.1016/j.jaut.2020.102460 . Asadipooya K, Graves L, Greene LW. Transient osteoporosis of the hip: review of the literature. Osteoporos Int. 2017;28(6):1805–16. https://doi.org/10.1007/s00198-017-3952-0 . Blake RJ, Melemai VK, Fitzpatrick BM, Hubbard DF, Dietz MJ, Watkins CM. Bilateral femoral neck fractures in pregnancy suggestive of transient osteoporosis of the hip in a patient with hyperparathyroidism: a case report. Osteoporos Int. 2025;36(2):333–7. https://doi.org/10.1007/s00198-024-07346-4 . Aynaci O, Kerimoglu S, Ozturk C, Saracoglu M. Bilateral non-traumatic acetabular and femoral neck fractures due to pregnancy-associated osteoporosis. Arch Orthop Traum Su. 2008;128(3):313–6. https://doi.org/10.1007/s00402-007-0439-z . Tabata Y, Matsui S, Miyamoto M, Omori K, Tabata Y, Majima T. Transient osteoporosis of the hip with a femoral neck fracture during follow-up: a case report. J Yeungnam Med Sci. 2023;40(2):212–7. https://doi.org/10.12701/jyms.2022.00479 . Paraskevopoulos K, Keskinis A, Vasios IS, Makiev KG, Tilkeridis K, Drosos GI, et al. Comparison of various treatment modalities for the management of bone marrow edema syndrome/transient osteoporosis in men and non-pregnant women: a systematic review. Osteoporos Int. 2023;34(2):269–90. https://doi.org/10.1007/s00198-022-06584-8 . Bashaireh KM, Aldarwish FM, Al-Omari AA, Albashaireh MA, Hajjat M, Al-Ebbini MA, et al. Transient Osteoporos Hip: Risk Therapy Open Access Rheumato. 2020;12:1–8. https://doi.org/10.2147/OARRR.S236324 . Tran TN, Warwas S, Haversath M, Classen T, Hohn HP, Jager M, et al. Experimental and computational studies on the femoral fracture risk for advanced core decompression. Clin Biomech. 2014;29(4):412–7. https://doi.org/10.1016/j.clinbiomech.2014.02.001 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Nov, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 28 Jul, 2025 Reviews received at journal 26 Jul, 2025 Reviews received at journal 25 Jul, 2025 Reviews received at journal 22 Jul, 2025 Reviewers agreed at journal 22 Jul, 2025 Reviewers agreed at journal 18 Jul, 2025 Reviewers agreed at journal 18 Jul, 2025 Reviewers invited by journal 16 Jul, 2025 Editor invited by journal 02 Jul, 2025 Editor assigned by journal 08 Apr, 2025 Submission checks completed at journal 08 Apr, 2025 First submitted to journal 05 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6383384","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":487637929,"identity":"1258f431-543f-4184-80a6-a159dc50427e","order_by":0,"name":"Cong Chen","email":"","orcid":"","institution":"Lanzhou University Second Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cong","middleName":"","lastName":"Chen","suffix":""},{"id":487637930,"identity":"a12e0c91-6a23-40cd-b6d3-4570427c269f","order_by":1,"name":"Tian'en Xu","email":"","orcid":"","institution":"Lanzhou University Second Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tian'en","middleName":"","lastName":"Xu","suffix":""},{"id":487637931,"identity":"8a3d8334-8a42-40d6-92db-30e183ea3799","order_by":2,"name":"Hua-sha Jiang","email":"","orcid":"","institution":"Lanzhou University Second Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hua-sha","middleName":"","lastName":"Jiang","suffix":""},{"id":487637932,"identity":"5a1664c0-be96-4dc8-9f9d-a0ab374cb79c","order_by":3,"name":"Xu Wang","email":"","orcid":"","institution":"Lanzhou University Second Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Wang","suffix":""},{"id":487637933,"identity":"ac8ce2d4-2147-4135-83c4-6f539aa063f5","order_by":4,"name":"Ya-yi Xia","email":"","orcid":"","institution":"Lanzhou University Second Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ya-yi","middleName":"","lastName":"Xia","suffix":""},{"id":487637934,"identity":"f2cebfe1-a454-4f26-bc89-e132038439a9","order_by":5,"name":"Ya-peng Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBACNvb+hw8+VNjw8LM3EKmFj+cMs+GMM2lykj0HiNQiJ5HDJs3bdtjYYEYCsQ5jyD0gOePM4cQNko833mCosYkmQsu5BIMPFemJ26XTii0YjqXlNhDUwthgkDjjjHXiztk5ZhKMDYeJ0MLMYHCYt405ccPNM8RqYeMxbOZtczY2uMFDrBYetmRGSCAD/ZJAjF/k5z8+/gMSlYc33vhQY0NYCzIwkEggRTlEC6k6RsEoGAWjYGQAAKH9QTt1PL6VAAAAAElFTkSuQmCC","orcid":"","institution":"Lanzhou University Second Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ya-peng","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-04-05 17:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6383384/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6383384/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03284-y","type":"published","date":"2025-11-17T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87343232,"identity":"5a3b976a-1026-43fb-92cb-ca425f61309f","added_by":"auto","created_at":"2025-07-23 01:43:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5777638,"visible":true,"origin":"","legend":"\u003cp\u003eThe imaging data of a transient osteoporosis of hip patient. Diffuse low signal in T1-weighted images (a) and diffuse high signal in T2-weighted images (b) of MRI before operation; frontal (c) and lateral (d) X-ray of the right hip joint after operation; the low signal in T1-weighted images (e) and the the high signal in T2-weighted images (f) decreased significantly at 100 days after operation.[23]\u003c/p\u003e","description":"","filename":"Figure.png","url":"https://assets-eu.researchsquare.com/files/rs-6383384/v1/2a7572506da67daa9a5af16b.png"},{"id":96650034,"identity":"d38386f9-0539-4143-af4b-77b2ed98c214","added_by":"auto","created_at":"2025-11-24 16:06:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5913265,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6383384/v1/9747fafe-dcfe-47c2-9b65-d3761cd59d80.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Core decompression plus allogeneic fibular grafting for refractory transient osteoporosis of the hip: a case report and literature review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 1959, Curtiss and Kincaid discovered a phenomenon while treating hip pain in three pregnant women. These women had hip joint pain, and X-rays indicated that their femoral heads were demineralized. However, after a few months, the pain lessened, and follow-up X-rays showed that the femoral heads had returned to normal [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 1968, Lequesne coined the term \"transient osteoporosis of the hip (TOH)\" for this condition [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In later studies, bone marrow edema syndrome (BMES) and localized or regional migratory osteoporosis (RMO) were also described as the same kind of diseases as TOH [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Most cases of transient osteoporosis of the hip have shown symptom relief with conservative treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], however, some studies have documented instances of pathological fractures occurred during this treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCore decompression and bone grafting are common methods for treating femoral head necrosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, core decompression may reduce the duration of the disease and provide satisfactory results for transient osteoporosis of the hip, but it may reduce bone mass and increase the risk of fracture [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In order to alleviate the pain and prevent fractures, we adopt a treatment method of core decompression combined with allogeneic fibular grafting, we believe this is the first report of this treatment method.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eOn April 11, 2024, a 46-year-old male patient, who's job is teacher, presented to our outpatient clinic with a complaint of right hip pain for over two months. The visual analogue scale (VAS) score for hip joint pain during weight-bearing was 5, while the score for pain without weight-bearing was 3. MRI examination revealed diffuse low signal in the T1-weighted images (Figure a) and high signal in the T2-weighted images (Figure b) in the right femoral head and neck region. X-ray and CT examinations showed no significant abnormalities. After hospitalization, various laboratory tests were conducted, including complete blood count, c-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), and interleukin-6 (IL-6). None of these tests showed significant abnormalities. Bone scintigraphy using single-photon emission computed tomography (SPECT) revealed increased radionuclide uptake in the delayed imaging of the right femoral head and neck region. To exclude the possibility of neoplastic diseases, a core needle biopsy of the femoral neck was performed, and the results indicated no presence of benign or malignant tumor cell components. At the same time, we took the blood from the puncture site of femoral neck for culture, and no bacteria and fungi were cultivated. Based on the patient's medical history, clinical and imaging examinations, and laboratory test results, we diagnosed the condition as TOH. After 10 days treatment with non-steroidal anti-inflammatory drugs and bisphosphonates drugs, the pain have not been significantly relieved. In order to relieve pain and prevent femoral neck fracture, we performed core decompression and allogeneic fibular grafting under combined general and nerve block anesthesia on the 12th day after admission. The surgical procedure is as follows: Under the guidance of a C-arm X-ray, a guide wire was percutaneously inserted into the subchondral bone of the femoral head. A 5 cm longitudinal skin incision was made at the site of the guide wire. A cannulated drill was used to create a hole, and after decompression of the surrounding bone in the femoral head area with a mushroom-shaped drill bit, a segment of allogeneic fibular bone was implanted into the femoral neck. On the first day after operation, the patient took frontal (Figure c) and lateral (Figure d) X-rays of the right hip joint. At 24-hour postoperatively, the VAS score for hip joint pain without weight-bearing was 1, and the patient was discharged on the 4th postoperative day. At the 77-day follow-up, an X-ray examination was conducted, and the VAS score for hip joint pain without weight-bearing was 0. At the 100-day follow-up, an MRI showed resolution of bone marrow edema in the femoral head and neck (Figure e, f), with the patient reporting no weight-bearing pain and a VAS score of 0.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTOH usually occurs in middle-aged men of the 40 to 60-years old and young women in the last 3 months of pregnancy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], physicians and teacher are occupational risk factors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], typically without a history of significant hip trauma, alcohol abuse, or extensive steroid use. The cause of TOH is not well understood, it may be related to venous dysfunction of femoral head, increased intraosseous pressure and venous hypertension was found in the lesion area [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Plain X-ray films usually display normal or mildly osteoporotic femoral heads. In contrast, MRI typically shows low signals on T1-weighted images and high signals on T2-weighted images, resembling bone marrow edema, which is the most useful diagnostic test [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While, the subchondral fracture could found on small field of view high-resolution MRI [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, bone scintigraphy (BS) may demonstrate increased radiotracer uptake in the affected region [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The most important differential diagnosis is femoral head osteonecrosis which can find the characteristic \"double-line sign\" on T2 imaging, because of the coexistence of osteonecrosis and osteogenesis [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In this case, the patient's X-ray, MRI, SPECT, bacterial cultivation and biopsy results ruled out infections, tumors and femoral head necrosis, indicated that he has TOH.\u003c/p\u003e\u003cp\u003eHistorically, conservative management was advised for transient osteoporosis of the hip since it is a self-limiting condition that can resolve independently over time, sometimes it can be treated by nonsteroidal antiinflammatory medication, protected weight bearing and physical therapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, bisphosphonates, calcitonin, or teriparatide are reported to be effective methods to reduce recovery time [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, many literatures have indicated the risk of femoral neck fracture with conservative treatment [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A systematic review showed that bisphosphonates are more effective in relieving pain in a short term (1\u0026ndash;3 months), and core decompression is more effective in a long term (6\u0026ndash;12 months) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn a clinical study, Calvo found that core decompression significantly outperformed conservative treatment regarding both pain duration and overall therapeutic outcomes in the treatment of TOH [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, Bashaireh compared core decompression with conservative methods in the treatment of transient osteoporosis of the hip and arrived at the same conclusions [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This is a patient who has recurrent pain and the conservative treatments were ineffective. Therefore, in order to treat the pain, we used the method of core decompression. However, core decompression surgery reduces bone mass in the femoral neck, femoral head, and subtrochanteric regions, increasing the risk of fracture [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Consequently, we treated this patient by combining core decompression with allogeneic fibular grafting which could be used as a support bone to reduce the risk of fracture. Within 24-hour postoperatively, the patient's hip pain was significantly reduced. At the 77-day follow-up, the hip was pain-free without weight-bearing, as it was crucial to minimize the risk of femoral neck or subtrochanteric fractures, as well as femoral head necrosis. At the 100-day follow-up, MRI showed complete recovery, with no weight-bearing pain, no femoral head necrosis, and no pathological fractures occurring during the follow-up period. The patient achieved satisfactory results after the treatment, marking a successful therapeutic experience.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCore decompression with allogeneic fibular grafting is a safe and effective treatment for refractory transient osteoporosis of the hip, capable of shortening the disease course and preventing femoral neck fractures. However, long-term, large-sample studies are needed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBMES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebone marrow edema syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ebone scintigraphy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ec-reactive protein\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eESR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eerythrocyte sedimentation rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIL-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003einterleukin-6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eprocalcitonin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRMO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eregional migratory osteoporosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSPECT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003esingle-photon emission computed tomography\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTOH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003etransient osteoporosis of hip\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003evisual analogue scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.C. collected the medical histories, performed bone biopsy, wrote the original manuscript, made the figure and provided the financial support. YP.W. performed the operation, revised the manuscript. TE.X., HS.J. completed the follow-ups. YY.X. and X.W. gave guidance on the idea of operation and manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFounding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Youth Science and Technology Program of Gansu Province (23JRRA1646), Cuiying Scientific and Technological Innovation Program of Lanzhou University Second Hospital (CY2022-YB-A01), Science and Technology Plan of Lanzhou City (2024-4-23).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed involving human participants were in accordance with the ethical standards of the institution and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study has been approved by the Ethics Committee of The Second Hospital of Lanzhou University (2025-A-081). Informed consent was obtained from all participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors approved the manuscript. Written informed consent for the publication of this case report and any accompanying images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCurtiss PJ, Kincaid WE. Transitory demineralization of the hip in pregnancy. A report of three cases. J Bone Joint Surg Am. 1959;41\u0026ndash;A:1327\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLequesne M. Transient osteoporosis of the hip. 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Clin Biomech. 2014;29(4):412\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.clinbiomech.2014.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.clinbiomech.2014.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"transient osteoporosis of hip (TOH), core decompression, allogeneic fibular grafting","lastPublishedDoi":"10.21203/rs.3.rs-6383384/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6383384/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThere are no documented cases in the literature of using core decompression and allogeneic fibular grafting to treat refractory transient osteoporosis of the hip. Case presentation: This case study details a patient who received core decompression and allogeneic fibular grafting procedure to treat refractory TOH. A 100-day follow-up, the MRI results of the hip joint were normal, and the patient reported no pain during weight-bearing, which indicated successful treatment outcomes. Core decompression shortens symptoms of TOH, while allogeneic fibular grafting strengthens the femoral neck. The combination of these two approaches not only facilitates a rapid recovery from TOH but also reduces the risk of femoral neck fracture which demonstrates a successful treatment strategy.\u003c/p\u003e","manuscriptTitle":"Core decompression plus allogeneic fibular grafting for refractory transient osteoporosis of the hip: a case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-23 01:43:29","doi":"10.21203/rs.3.rs-6383384/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-28T05:09:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-26T12:22:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-25T16:14:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-22T13:07:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127897976023512933875621432572372439292","date":"2025-07-22T12:15:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272426940594191164823925801082280388675","date":"2025-07-18T21:22:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164537186398345791409890720565589539178","date":"2025-07-18T17:19:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-16T15:52:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-02T12:44:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-08T11:23:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-08T11:22:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-04-05T17:41:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c2bb2973-1637-460f-870e-260876bce94b","owner":[],"postedDate":"July 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:00:19+00:00","versionOfRecord":{"articleIdentity":"rs-6383384","link":"https://doi.org/10.1186/s12893-025-03284-y","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2025-11-17 15:57:11","publishedOnDateReadable":"November 17th, 2025"},"versionCreatedAt":"2025-07-23 01:43:29","video":"","vorDoi":"10.1186/s12893-025-03284-y","vorDoiUrl":"https://doi.org/10.1186/s12893-025-03284-y","workflowStages":[]},"version":"v1","identity":"rs-6383384","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6383384","identity":"rs-6383384","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}