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Zachariadis CB, Leligou HC, Kourkoulis SK, Magnisalis E, Papagelopoulos PJ, Savvidou OD. Complications Following Intraosseous Injections of Calcium Phosphate Bone Cement in Subchondroplasty. J Long Term Eff Med Implants 2024; 34:15-22. [PMID: 38842229 DOI: 10.1615/jlongtermeffmedimplants.2023049584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
An alternative approach to the major problem of osteoarthritis that has begun to pique the interest of researchers focuses on the pathology of the subchondral bone, its constant cross-talk with the articular cartilage, and its interaction with the joint. The presence of bone marrow lesions, detectable on MRI scans, has proven to be a cause of pain as well as a predictor of the progression of degenerative changes. Subchondroplasty is a relatively new surgical procedure for the treatment of these lesions, in which injectable calcium phosphate bone cement is infused into the affected area percutaneously, under fluoroscopic guidance. In its use as a synthetic scaffold, calcium phosphate bone cement exhibits considerable osteoconductivity, bioabsorbability, and low toxicity, thus showing great potential for restoring subchondral biomechanical properties through structural remodeling. Although published results appear quite promising, there are certain complications that the surgeon should be aware of. We reviewed the published data regarding complications of the procedure, highlighting possible causes according to these data, and suggesting safety measures. Avascular necrosis of the talus is the most reported concern. Postsurgical pain, infection, and continuous wound drainage due to bone substitute material extravasation to the joint or soft tissue are also mentioned, necessitating further standardization of the procedure. There are no reports of permanent postoperative disability or fatal outcomes.
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Affiliation(s)
| | - Helen C Leligou
- University of West Attica, Dept. of Industrial Design and Production Engineering P. Ralli & Thivon 250, 12244 Aigaleo, Athens, Greece
| | - Stauros K Kourkoulis
- National Technical University of Athens, SAMPS, Department of Mechanics Athens, Attiki, Greece
| | - Evaggelos Magnisalis
- First Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, "ATTIKON" University General Hospital, 12462, Athens, Greece; National Technical University of Athens, SAMPS, Department of Mechanics Athens, Attiki, Greece
| | - Panayiotis J Papagelopoulos
- First Department of Orthopedics, National and Kapodistrian University of Athens, Atikon University General Hospital, Athens, Greece
| | - Olga D Savvidou
- First Department of Orthopedics, National and Kapodistrian University of Athens, Medical School, ATTIKON University General Hospital, GREECE
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Matthews M, Klein E, Weil L, Sorensen M, Fleischer A. Initial Experience With Subchondral Stabilization for Grade II Stress Fractures of the Midfoot and Forefoot. J Foot Ankle Surg 2023; 62:868-872. [PMID: 37301465 DOI: 10.1053/j.jfas.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 05/01/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
Stress fractures of the foot are often preceded by magnetic resonance imaging evidence of bone marrow edema. While new evidence suggests intraosseous injection of calcium phosphate ("subchondral stabilization") can alleviate symptoms associated with bone marrow edema, no data yet exist regarding its use in developing mid- and forefoot stress fractures. Fifty-four patients who underwent subchondral stabilization of various midfoot/forefoot bones in our practice were observed over a 5-year period. All patients were unresponsive to standard nonoperative measures for at least 6 weeks, and all had clinical exams and advanced imaging consistent with a Kaeding-Miller Grade II stress fracture. Forty patients were included with a mean age of 54.3 ± 14.9 years and mean follow-up of 14.1 ± 6.9 months. Patients saw a significant decrease in visual analog scale (VAS) pain as early as 1 month postoperatively (p < .05). Mean postoperative VAS at 12 months was 2.11 ± 2.50, and mean reduction in VAS pain from preoperative to 12 months postoperative was -5.00 (95% CI -3.44 to -6.56, p < .05). Fourteen patients (34%, 14/41) were entirely pain free at 12 months. Higher preoperative VAS pain scores (unadjusted odds ratio [OR] 2.13 [95% CI 1.20-3.77], p = .010) and treatment of more than 1 bone (unadjusted OR 6.23 [95% CI 1.39-27.8], p = .017) were associated with a greater likelihood of not achieving a pain free status at 12 months. Our initial experience with subchondral stabilization suggests the procedure may be safe and effective for use in many Kaeding-Miller Grade II stress fractures of the mid- and forefoot.
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Affiliation(s)
| | - Erin Klein
- Weil Foot and Ankle Institute, Mount Prospect, IL
| | - Lowell Weil
- Weil Foot and Ankle Institute, Mount Prospect, IL
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Ivković A, Glavčić M, Vuletić F, Janković S. Core Decompression Combined with Intraosseous Autologous Conditioned Plasma Injections Decreases Pain and Improves Function in Patients with Symptomatic Knee Bone Marrow Lesions. Biomedicines 2023; 11:1799. [PMID: 37509439 PMCID: PMC10376709 DOI: 10.3390/biomedicines11071799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
The purpose of this prospective case series was to determine the effectiveness of using a combination of the core decompression and injection of autologous conditioned plasma (ACP) for the treatment of symptomatic knee bone marrow lesions (BML), as well as to report on the preliminary clinical results based on magnetic resonance imaging (MRI) and patient-reported outcomes (PROMs). Patients with OA-related BML who failed to improve on conservative treatment for three months underwent an identical procedure consisting of arthroscopy, core decompression, and the intraosseous injection of ACP and were followed up for 12 months. A statistically significant reduction in pain and an improvement in function, as measured by the Numeric Pain Rating Scale (NPRS) and Knee Injury and Osteoarthritis Outcome Score (KOOS), was observed at one-week follow-up (8.3 ± 0.8 to 1.5 ± 1.0; p ≤ 0.001 and 33.4 ± 10.6 to 53.9 ± 13.6; p ≤ 0.001 respectively). After six weeks, weight-bearing was allowed, but the trend did not change-the NPRS continued to be low (average 1.4 on 12-month follow-up) and the total KOOS increased 44.6 points from the baseline (average 78.0 on 12-month follow-up). The Whole-Organ Magnetic Resonance Imaging Score improved from 66.1 ± 19.4 prior to surgery to 58.0 ± 15.9 (p < 0.001) after 3 months. In our study, there was no control group, randomisation was not performed, and the sample size was relatively small. A combination of core decompression and the intraosseous injection of ACP into the affected subchondral area proved to be a safe and effective procedure that provides rapid pain relief and a significant increase in joint function up to one year postoperatively.
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Affiliation(s)
- Alan Ivković
- Department of Orthopaedics and Trauma Surgery, University Hospital "Sveti Duh", 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Clinical Medicine, University of Applied Health Sciences, 10000 Zagreb, Croatia
| | - Marin Glavčić
- Department of Orthopaedic and Trauma Surgery, University Hospital "Dubrava", 10000 Zagreb, Croatia
| | - Filip Vuletić
- Department of Orthopaedics and Trauma Surgery, University Hospital "Sveti Duh", 10000 Zagreb, Croatia
| | - Saša Janković
- Department of Orthopaedics and Trauma Surgery, University Hospital "Sveti Duh", 10000 Zagreb, Croatia
- Faculty of Kinesiology, University of Zagreb, 10000 Zagreb, Croatia
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Kon E, Boffa A, Andriolo L, Di Martino A, Di Matteo B, Magarelli N, Marcacci M, Onorato F, Trenti N, Zaffagnini S, Filardo G. Subchondral and intra-articular injections of bone marrow concentrate are a safe and effective treatment for knee osteoarthritis: a prospective, multi-center pilot study. Knee Surg Sports Traumatol Arthrosc 2021; 29:4232-4240. [PMID: 33772602 DOI: 10.1007/s00167-021-06530-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/04/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Subchondral bone is becoming a treatment target for knee OA patients, with promising early findings on the use of bone marrow aspirate concentrate (BMAC). The aim of this prospective, multi-centric pilot study was to evaluate safety as well as clinical and MRI outcomes of a combined approach of intra-articular and subchondral BMAC injections. METHODS Thirty patients (19 men, 11 women, 56.4 ± 8.1 years) with symptomatic knee OA were treated with a combination of an intra-articular and two subchondral BMAC injections (femoral condyle and tibial plateau). Patients were evaluated at baseline and at 1-3-6-12 months of follow-up with the IKDC subjective, VAS, KOOS, and EQ-VAS scores. The MRI evaluation was performed with the WORMS score. RESULTS No major complications were reported and only two patients were considered treatment failures, requiring a new injective or surgical treatment. The IKDC subjective score improved significantly from 40.5 ± 12.5 to 59.9 ± 16.1 at 3 months, 59.1 ± 12.2 at 6 months, and 62.6 ± 19.4 at 12 months (p < 0.0005). A similar improvement was reported for VAS pain and all KOOS subscales at all follow-ups, while EQ-VAS did not show any significant improvement. The MRI analysis showed a significant bone marrow edema reduction (p = 0.003), while the remaining WORMS parameters did not show any significant changes. CONCLUSION The pilot evaluation of this combined BMAC injective treatment showed safety and positive outcome up to 12 months of follow-up in patients with symptomatic knee OA associated with subchondral bone alterations. These findings suggest that targeting both subchondral bone and joint environment can provide promising results, and that BMAC can be a valid option for this combined approach to treat knee OA.
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Affiliation(s)
- Elizaveta Kon
- IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Luca Andriolo
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Alessandro Di Martino
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- First Moscow State Medical University, Sechenov University, Moscow, Russia
| | | | - Maurilio Marcacci
- IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
| | | | | | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Matthews M, Klein E, Hulst Z, Patel N, Weil L, Sorensen M, Fleischer A. Comparison of Calcaneal Subchondral Injection of Calcium Phosphate and Plantar Fasciotomy vs Plantar Fasciotomy Alone for Refractory Infracalcaneal Heel Pain. FOOT & ANKLE ORTHOPAEDICS 2021; 6:24730114211050568. [PMID: 35097479 PMCID: PMC8558602 DOI: 10.1177/24730114211050568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Treatment of chronic refractory heel pain has evolved to consider calcaneal structural fatigue as a component of the symptom profile. While concomitant calcium phosphate injection has become a method of addressing the accompanying calcaneal bone marrow edema (BME) frequently seen in this population, there is no literature supporting its use compared to traditional fasciotomy. METHODS Consecutive patients with symptoms of refractory infracalcaneal heel pain and calcaneal BME were treated in our practice by either surgical fasciotomy (n = 33) or fasciotomy plus calcium phosphate injection (n = 31) between 2014 and 2019. Outcomes were retrospectively assessed via Foot and Ankle Outcome Scores (FAOS), return to activity, and complication rate. RESULTS Sixty-four patients (64 feet) were included with a mean age of 50.3 ± 12.9 years and mean follow-up of 23.2 ± 22.3 months. No differences were observed between groups preoperatively. Significant improvements in 4 of 5 FAOS subscales were observed postoperatively in both groups (P < .05 for all, paired t test). However, patients undergoing concomitant calcium phosphate injection reported significantly better scores for both activities of daily living (ADL; mean difference +10.2; 95% confidence interval [CI] 0.07-20.2) and foot-specific QOL (mean difference +21.9, 95% CI 7.0-36.6) at final follow-up compared with those undergoing plantar fasciotomy alone. All patients returned to their desired level of activity, and the frequency of complications did not differ between groups (P > .05, Fisher exact test). CONCLUSION In patients presenting with recalcitrant infracalcaneal heel pain accompanied by calcaneal BME, calcium phosphate injection into the calcaneus, when combined with plantar fasciotomy, was safe and more effective than traditional plantar fasciotomy alone. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
| | - Erin Klein
- Weil Foot and Ankle Institute, Mount Prospect, IL, USA
| | - Zachary Hulst
- Weil Foot and Ankle Institute, Mount Prospect, IL, USA
| | - Neathie Patel
- Weil Foot and Ankle Institute, Mount Prospect, IL, USA
| | - Lowell Weil
- Weil Foot and Ankle Institute, Mount Prospect, IL, USA
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Pasqualotto S, Sgroi AV, Causero A, Di Benedetto P, Zorzi C. Subchondroplasty in the Treatment of Bone Marrow Lesions of the Knee: Preliminary Experience on First 15 Patients. JOINTS 2021; 7:174-181. [PMID: 34235382 PMCID: PMC8253614 DOI: 10.1055/s-0041-1730984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/19/2021] [Indexed: 12/19/2022]
Abstract
Purpose The aim of this prospective study was to assess the effectiveness in terms of pain relief and functional improvement of the Subchondroplasty procedure in the treatment of osteoarthritis-related bone marrow lesions (BMLs) of the knee. Methods The study included first 15 consecutive patients undergone to Subchondroplasty procedure for the treatment of chronic degenerative BMLs in which previous conservative treatment have failed. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), and visual analog scale (VAS) pain scores were obtained preoperatively and at 1, 6, and 12 months of follow-up. Results WOMAC scores significantly improved from 39.7 ± 20.2 before surgery to 26.8 ± 16.1 at the 1-month follow-up ( p = 0.045). A further significant improvement to 15.5 ± 12.7 ( p = 0.02) and to 8.6 ± 3.1 ( p < 0.01) was obtained both at 6-month and at 1-year follow-up. KOOS scores improved significantly from 47.5 ± 16.6 before surgery to 65.4 ± 14.9 at 1 month ( p = 0.013) and to 80.4 ± 15.1 at 6-month follow-up ( p = 0.01). A further improvement to 85.6 ± 15.1 was recorded 1 year postoperatively, although nonsignificant. VAS score showed a significant improvement from 55.8 ± 20.5 preoperatively to 36.2 ± 16.9 at 1 month ( p = 0.008) and to 18.2 ± 17.3 at 6-month follow-up ( p = 0.005). This further improved to 12.8 ± 17.9 at 1-year follow-up, although not significantly. Conclusion Subchondroplasty procedure represents a safe and valid surgical option in the treatment of osteoarthritis-related BMLs of the knee, providing an improvement in terms of pain relief and functional recovery. Longer studies are required to evaluate how long these improvements may last. Level of Evidence Therapeutic case-series, Level IV study.
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Affiliation(s)
- Stefano Pasqualotto
- Divisione di Ortopedia e Traumatologia, IRCCS Ospedale Classificato Equiparato Sacro Cuore - Don Calabria, Negrar (Verona), Italy
| | - Andrea Vincenzo Sgroi
- Divisione di Ortopedia e Traumatologia, IRCCS Ospedale Classificato Equiparato Sacro Cuore - Don Calabria, Negrar (Verona), Italy
| | - Araldo Causero
- DAME Università degli studi di Udine, Clinica Ortopedica, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Paolo Di Benedetto
- DAME Università degli studi di Udine, Clinica Ortopedica, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Claudio Zorzi
- Divisione di Ortopedia e Traumatologia, IRCCS Ospedale Classificato Equiparato Sacro Cuore - Don Calabria, Negrar (Verona), Italy
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Chua K, Kang JYB, Ng FDJ, Pang HN, Lie DTT, Silva A, Chang PCC. Subchondroplasty for Bone Marrow Lesions in the Arthritic Knee Results in Pain Relief and Improvement in Function. J Knee Surg 2021; 34:665-671. [PMID: 31752023 DOI: 10.1055/s-0039-1700568] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Subchondroplasty is a relatively new joint preserving procedure, which involves the localized injection of calcium pyrophosphate bone substitute into the bone marrow lesion. The advent of magnetic resonance imaging (MRI) has greatly facilitated the identification of these bone marrow lesions. We investigated the clinical efficacy of subchondroplasty in the treatment of symptomatic bone marrow lesions in the knee, including knees with preexisting osteoarthritis. This study comprised of 12 patients whose knees were evaluated with standard radiographs and MRI to identify and localize the bone marrow lesions. They then underwent subchondroplasty under intraoperative radiographic guidance. Preoperative and postoperative visual analog scale (VAS) pain scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and Knee Injury and Arthritis Outcome Scores (KOOS) were obtained. VAS scores improved significantly from 7.5 ± 1.8 before surgery to 5.2 ± 2.7 after surgery. This further improved to 2.1 ± 2.4 at the one-year follow-up. KOOS scores improved significantly from 38.5 ± 17.0 before surgery to 73.2 ± 19.0 at the one-year follow-up. WOMAC scores improved significantly from 47.8 ± 20.5 before surgery to 14.3 ± 13.2 at the one-year follow-up. Subchondroplasty offers an effective way to treat subchondral bone marrow lesions in the arthritic knee, resulting in improvement in symptoms and early return to activity. Long-term studies are required to evaluate if these benefits can last. This is a Level II study.
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Affiliation(s)
- Kenon Chua
- Department of Orthopaedics, Singapore General Hospital, Singapore
| | | | | | - Hee Nee Pang
- Department of Orthopaedics, Singapore General Hospital, Singapore
| | | | - Amila Silva
- Department of Orthopaedics, Singapore General Hospital, Singapore
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Spontaneous osteonecrosis of the knee: what do we know so far? A literature review. INTERNATIONAL ORTHOPAEDICS 2020; 44:1063-1069. [PMID: 32249354 DOI: 10.1007/s00264-020-04536-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/13/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Spontaneous osteonecrosis of the knee (SONK) is said to be a relatively common disease which may lead to an end-stage osteoarthritis of the knee. The aim of this paper was to review the literature on this field published until now, discuss the results of both conservative and surgical treatment options, as well as to introduce new methods of treatment, which may be applicable in SONK treatment. METHODS We searched the PubMed and Cochrane databases until November 2019 and presented the most recent findings in this work. RESULTS The exact aetiology of SONK still remains unclear; however, recent studies suggested that early stage of SONK is rather a result of the subchondral fracture than primary osteonecrosis. So far described conservative treatment includes non-weight bearing or protected weight bearing with a knee brace, nonsteroidal anti-inflammatory drugs, analgesics, and bisphosphonates. Surgical management includes arthroscopic debridement, core decompression, osteochondral autograft, high tibial osteotomy, and unicompartmental knee arthroplasty or total knee arthroplasty. CONCLUSIONS Although the aetiology of SONK remains unknown, there are many treatment options, and the choice of the most suitable one is challenging. We think that subchondroplasty may be one of the effective methods.
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Oliver HA, Bozynski CC, Cook CR, Kuroki K, Sherman SL, Stoker AM, Cook JL. Enhanced Subchondroplasty Treatment for Post-Traumatic Cartilage and Subchondral Bone Marrow Lesions in a Canine Model. J Orthop Res 2020; 38:740-746. [PMID: 31692048 DOI: 10.1002/jor.24508] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/25/2019] [Indexed: 02/04/2023]
Abstract
This study characterizes outcomes associated with subchondroplasty (SCP) versus SCP enhanced with platelet-rich plasma (PRP) or bone marrow aspirate concentrate (BMC) treatment of impact-induced subchondral bone marrow lesions (BML) using a validated preclinical canine model. With IACUC approval, purpose-bred research hounds (n = 24) underwent arthroscopic impact injury (40 N) to both medial femoral condyles. At 3 months, functional assessments, arthroscopy, and magnetic resonance imaging (MRI) were performed. One knee in each dog (n = 24; n = 12 per endpoint) was randomly assigned to SCP with the other knee randomly assigned to SCP + PRP, SCP + BMC or sham injection (control) (n = 8 per group; n = 4 per endpoint). Dogs were evaluated at 6 and 12 months after treatment using functional assessments, radiography, arthroscopy, and MRI and humanely euthanatized at 6 or 12 months after treatment for histologic assessments. At 6 months post-treatment, comfortable range-of-motion (CROM) was higher (p < 0.04) in SCP + PRP and SCP + BMC knees compared with controls. At 1 year post-treatment, %Total Pressure Index was higher (p = 0.036) in SCP + BMC compared with controls, pain was lower (p < 0.05) in SCP + BMC and SCP + PRP compared with SCP and controls, and CROM was higher (p < 0.05) in SCP + BMC and SCP + PRP compared with SCP and controls. Knees treated with SCP + PRP and SCP + BMC had better (p < 0.05) MRI grades than SCP and controls. No statistically significant differences in arthroscopic or histologic pathology were noted. Clinical significance: Biologics added to SCP treatment may further enhance its beneficial effects by improving range-of-motion, pain severity, and limb loading through 1 year after treatment. However, these benefits must be considered alongside cost, logistics, and treatment availability. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:740-746, 2020.
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Affiliation(s)
- Harvey A Oliver
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Chantelle C Bozynski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Keiichi Kuroki
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Aaron M Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
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Levy AS, Cousins K. The rational for and efficacy of subchondroplasty in the injured worker. J Orthop 2020; 22:48-52. [PMID: 32280168 DOI: 10.1016/j.jor.2020.03.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/25/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Evaluation and treatment of workplace knee injuries with pre existing arthritis is difficult from both a causality and a clinical perspective. The current study evaluates the relevance and treatment of the bone marrow edema (BME) in injured workers. Methods 179 patients who injured their knee at work and were found to have arthritis and BME and subsequently underwent subchondral calcium phosphate injections (subchondroplasty) were reviewed. Results Radiographic arthritic status was Kellgren Lawrence 3-4 in 56%. Cartilage status was outerbridge III/IV. 86% reported marked improvement at 6 months. 74% at 3 years and 83% at 5 years. RTW was 78% at 3 months & 85% by 6 months. Survivorship was 98% at one year, 86% at 2 years, 81% at 5 years & 76% at 7 years post op. Conclusions BME (associated with trabecular fracture) is an objective measure of causality in the injured worker. The treatment of BME positive arthritis in injured workers is highly successful in terms of decreasing pain, improving function and expediting return to work.
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Affiliation(s)
- Andrew S Levy
- The Center for Advanced Sports Medicine Knee and Shoulder, 90 Millburn Ave, Suite 204 Millburn, NJ, USA
| | - Kevin Cousins
- The Center for Advanced Sports Medicine Knee and Shoulder, 90 Millburn Ave, Suite 204 Millburn, NJ, USA
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Angadi DS, Edwards D, Melton JTK. Calcium phosphate injection of symptomatic bone marrow lesions of the knee: what is the current clinical evidence? Knee Surg Relat Res 2020; 32:4. [PMID: 32660639 PMCID: PMC7219219 DOI: 10.1186/s43019-019-0013-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic bone marrow lesions (BML) in the weight-bearing portions of the knee are often associated with symptomatic degenerative arthritis resulting in pain and dysfunction. Injection of bone substitute material like calcium phosphate has been described. Whilst some studies have reported encouraging results others have shown limited benefit of this technique. AIM The aim was to collate the available evidence on the injection of calcium phosphate and systematically evaluate the results to answer the questions encountered in clinical decision making: (1) does it provide effective long-lasting pain relief to avoid further surgical intervention? (2) which factors (patient/surgical) significantly influence the outcome? and (3) does it adversely affect the outcomes of subsequent arthroplasty? METHODS A literature search was performed to identify the studies describing the clinical outcomes of calcium phosphate injection for treatment of BML. We evaluated the reported clinical outcomes with respect to pain, function and complications. Isolated case reports and studies with no objective assessment of clinical outcomes were excluded. RESULTS We noted 46 articles in the current literature of which 8 described clinical outcomes of calcium phosphate injection. Mean (plus/minus SD) score on the visual analog scale (VAS) has been reported to improve from 7.90 (± 0.38) to 2.76 (± 0.90), whereas the International Knee Documentation Committee (IKDC) score improved from 30.5 (SD not reported (NR)) to 53.0 (SD NR). Pre and post procedure Short form survey (SF-12) scores were 29.8 (SD NR) and 36.7 (SD NR), respectively. In one study, scores on the Tegner Lysholm knee scoring scale improved in 12 out of 22 patients, whereas the remainder had no change in symptoms. Extravasation of calcium phosphate into the joint was the most common complication, whereas no adverse effect has been reported on subsequent arthroplasty. CONCLUSION Limited data from the published studies would suggest that calcium phosphate injection of BML may potentially improve pain and function. However, no evidence is currently available to clearly identify patient/surgical factors that may influence the long-term outcomes of this procedure. Hence pragmatic, prospective studies with stratified patient cohorts and robust reporting of outcome measures are essential to improve the understanding of the indications and clinical effectiveness of this novel procedure.
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Affiliation(s)
- D S Angadi
- Department of Orthopaedic Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham, Gloucestershire, GL53 7AN, UK.
| | - D Edwards
- Department of Trauma and Orthopaedics, Addenbrookes Hospital, Cambridge, UK
| | - J T K Melton
- Department of Trauma and Orthopaedics, Addenbrookes Hospital, Cambridge, UK
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12
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Liu JN, Shields TG, Gowd AK, Amin NH. Surgical Treatment of Insufficiency Fractures of the Knee. Arthrosc Tech 2019; 8:e1327-e1332. [PMID: 31890503 PMCID: PMC6926317 DOI: 10.1016/j.eats.2019.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/06/2019] [Indexed: 02/03/2023] Open
Abstract
Bone marrow lesions (BMLs) in the knee represent focal edema caused by subchondral bone attrition and microfractures to the trabecular bone. These lesions are poor prognostic indicators for several orthopaedic procedures but also have been associated with the progression of osteoarthritis. Current research is aimed at treating BMLs with the intent to improve the overall structural integrity of the subchondral bone and delay the need for arthroplasty. The injection of calcium phosphate bone substitute has been proposed to treat BMLs because animal models have shown its potential to stimulate bone repair. This technical note describes the key steps involved in performing percutaneous fixation of BMLs with a hard-setting bone substitute, as well as associated pearls and pitfalls. Although continued research with prospective comparative cohorts and long-term follow-up is needed to determine the efficacy of this procedure, this intervention holds promise in delaying the need for total knee replacement in the arthritic patient with a focal lesion.
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Affiliation(s)
- Joseph N. Liu
- Loma Linda University Medical Center, Loma Linda, California, U.S.A,Address correspondence to Joseph N. Liu, M.D., Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, CA 92354, U.S.A
| | - Troy G. Shields
- Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Anirudh K. Gowd
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, U.S.A
| | - Nirav H. Amin
- Veteran's Affairs Loma Linda, Loma Linda, California, U.S.A
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13
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Astur DC, de Freitas EV, Cabral PB, Morais CC, Pavei BS, Kaleka CC, Debieux P, Cohen M. Evaluation and Management of Subchondral Calcium Phosphate Injection Technique to Treat Bone Marrow Lesion. Cartilage 2019; 10:395-401. [PMID: 29667853 PMCID: PMC6755871 DOI: 10.1177/1947603518770249] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE This study aimed to compile available data in medical literature about subchondral calcium phosphate injection, comparing results obtained with this technique, as well as indications, complications, and other important factors in treatment of bone marrow lesions. DESIGNS A literature review using PubMed and Medline database in order to identify works with terms "subchondral calcium phosphate injection," " subchondroplasty®," "bone marrow lesion," and "knee." Eight relevant articles were found. RESULTS A total of 164 patients with bone marrow lesion mainly on femoral condyle and tibial plateau recovered with significant functional improvement of knee after subchondral calcium phosphate treatment. Although 25% of them still had some type of pain complaint, they also showed improvement. There were few complications reported and return to activities occurred after 3 months on average. CONCLUSIONS Few studies evaluate the result of using subchondral calcium phosphate injection technique. However, all presented favorable results regarding pain and improvement of knee function. In addition, within 2 years, there was a 70% reduction in conversion to total knee arthroplasty in patients with previous surgical indication who choose calcium phosphate treatment.
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Affiliation(s)
- Diego Costa Astur
- Centro de Traumatologia do Esporte, Department of Orthopedics and Traumatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil,Diego Costa Astur, Sports Traumatology Center, Department of Orthopedics and Traumatology, Universidade Federal de São Paulo, Av Pacaembu 1024 01234-000, São Paulo, SP, Brazil.
| | | | | | | | | | | | | | - Moises Cohen
- Centro de Traumatologia do Esporte, Department of Orthopedics and Traumatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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14
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Barp EA, Hall JL, Reese ER, Smith HL. Subchondroplasty of the Foot: Two Case Reports. J Foot Ankle Surg 2019; 58:989-994. [PMID: 31266694 DOI: 10.1053/j.jfas.2018.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Indexed: 02/03/2023]
Abstract
Early avascular necrosis of metatarsal heads and cuboid injuries are uncommon conditions encountered by foot and ankle specialists. Treatment options are limited and typically include long periods of offloading or non-weightbearing. There is limited published information on alternative treatment approaches for such pathologies when conservative therapies fail. Presented are 2 patient cases treated with a percutaneous calcium phosphate injection after failure of standard therapy, persistent pain, and bone marrow edema in the foot.
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Affiliation(s)
- Eric A Barp
- Program Director, UnityPoint Health, Podiatric Medicine & Surgery Residency Program, Des Moines, IA.
| | | | - Eric R Reese
- Resident, UnityPoint Health, Podiatric Medicine & Surgery Residency Program, Des Moines, IA
| | - Hayden L Smith
- Medical Researcher, UnityPoint Health, Des Moines, IA; Adjunct Faculty, Carver College of Medicine, University of Iowa, Iowa City, IA
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15
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Ververidis AN, Paraskevopoulos K, Tilkeridis K, Riziotis G, Tottas S, Drosos GI. Surgical modalities for the management of bone marrow edema of the knee joint. J Orthop 2019; 17:30-37. [PMID: 31879470 DOI: 10.1016/j.jor.2019.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 08/13/2019] [Indexed: 12/15/2022] Open
Abstract
Background Bone marrow edema (BME) is a radiological term which can be found in many conditions with varied pathogenesis and histopathological images. It usually presents with pain in the affected joint and is diagnosed with MRI. Subchondroplasty (SCP) and core decompression (CD) are the surgical methods that are available to achieve pain relief and functional improvement. Both surgical methods have their own indications and are used depending on the patient's history. The aim of this literature review article is to discuss the surgical modalities for the management of bone marrow edema focusing on the knee joint. Such topic which analyzes both surgical methods for treatment of bone marrow edema of the knee joint has never been described in a review article before. Materials and methods For the purpose of our manuscript we thoroughly searched electronic databases such as Pubmed and Medline to acquire the appropriate material for our review paper. Only English articles were used in this review. In our study we included every article that had described the surgical management of BME of the knee by CD and SCP. In the discussion we included 18 studies (9 CD and 9 SCP) with a total number of patients equal to 397, while 206/397 had undergone surgical intervention (169 underwent SCP and 37 CD). Results Follow-up of 180 patients out of 206 were available for our review. A total number of 166 patients (92.2%) were successfully treated. Specifically, 29 (100%) patients were treated by CD and 137 (90.7%) by SCP. In a study, 10 patients who underwent SCP for BME secondary to advanced osteoarthritis (OA) yielded poor results. In other studies, pain persistency was observed in 2 patients, 1 patient had postoperative infection and another patient eventually underwent total knee arthroplasty (TKA). 70% prevention of TKA was achieved by SCP in a study of 66 patients with BME secondary to advanced OA. Thus, a total number of 166 patients were considered as clinical success and 14 patients as clinical failure. Conclusions The included studies that have been published referred to the surgical methods of CD or SCP for the management of BME of the knee but none of that summarizes all current studies on both methods. Those studies seem that CD is a surgical technique that is proposed to perform in patients without findings of OA that usually fail to respond to conservative treatment. On the other hand, the option of SCP technique is carried out in patients with varied stage of OA associated with subchondral BME. Both methods aim to reduce the pain and to improve function in the setting of subchondral BME. Nevertheless it is not clear in literature which method is the best according to the criteria of the use. This literature review shows a lack of standardized guidelines with respect to diagnosis and surgical treatment.
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Affiliation(s)
- Athanasios N Ververidis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Konstantinos Paraskevopoulos
- Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Konstantinos Tilkeridis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Georgios Riziotis
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Stylianos Tottas
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Georgios I Drosos
- Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
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16
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Conaway WK, Agrawal R, Nazal MR, Stelzer JW, Martin SD. Changing MRI after subchondroplasty with partial meniscectomy for knee osteoarthritis. Clin Imaging 2019; 56:13-16. [PMID: 30831532 DOI: 10.1016/j.clinimag.2019.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/05/2019] [Accepted: 02/19/2019] [Indexed: 11/29/2022]
Abstract
A 54-year old woman with primary osteoarthritis and a tibial bone marrow lesion underwent subchondroplasty with injectable calcium phosphate. Post-operatively, the patient's symptoms worsened, and she lost the ability to bear weight. Follow-up MRI revealed previously absent, diffuse STIR hyperintensity in the tibia extending far beyond the surgical site. Twelve months post-operatively, symptoms spontaneously resolved. As the prevalence of subchondroplasty grows it will be important to recognize potential complications. To the authors' best knowledge this is the first report of significantly worsening pain and difficulty bearing weight corresponding with diffuse hyperintense T2 signal in the tibia after a calcium phosphate subchondroplasty.
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Affiliation(s)
- William K Conaway
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Heath System, Suite 400, 175 Cambridge Street, Boston, MA, USA
| | - Ravi Agrawal
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Heath System, Suite 400, 175 Cambridge Street, Boston, MA, USA.
| | - Mark R Nazal
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Heath System, Suite 400, 175 Cambridge Street, Boston, MA, USA
| | - John W Stelzer
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Heath System, Suite 400, 175 Cambridge Street, Boston, MA, USA
| | - Scott D Martin
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Partners Heath System, Suite 400, 175 Cambridge Street, Boston, MA, USA.
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17
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Delgado D, Garate A, Vincent H, Bilbao AM, Patel R, Fiz N, Sampson S, Sánchez M. Current concepts in intraosseous Platelet-Rich Plasma injections for knee osteoarthritis. J Clin Orthop Trauma 2019; 10:36-41. [PMID: 30705529 PMCID: PMC6349647 DOI: 10.1016/j.jcot.2018.09.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/24/2018] [Accepted: 09/27/2018] [Indexed: 12/24/2022] Open
Abstract
Knee osteoarthritis (OA) is a degenerative process that slowly destroys the joints producing pain and loss of function, and diminishes the quality of life. Current treatments alleviate this symptomatology but do not stop the disease, being total knee arthroplasty the only definitive solution. Among the emerging treatments, Platelet-Rich Plasma (PRP) has shown promising results in the treatment of OA. However, to improve its effectiveness, it is necessary to approach this pathology targeting the whole joint, not only the cartilage, but including other tissues such as subchondral bone. The pathological processes that occur in the subchondral bone have influence of the cartilage loss, aggravating the disease. The combination of intraarticular infiltrations with intraosseous infiltrations regulates the biological processes of the tissues, reducing the inflammatory environment and modulating the overexpression of biomolecules that generate an aberrant cellular behavior. Although the first clinical results using this technique are promising, further research and developing adequate protocols are necessary to achieve good clinical results.
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Affiliation(s)
- Diego Delgado
- Advanced Biological Therapy Unit, Hospital Vithas San José, Vitoria-Gasteiz, Spain
| | - Ane Garate
- Advanced Biological Therapy Unit, Hospital Vithas San José, Vitoria-Gasteiz, Spain
| | - Hunter Vincent
- UC Davis Medical Center, Department of Physical Medicine & Rehabilitation, Sacramento, CA, USA
| | - Ane Miren Bilbao
- Arthroscopic Surgery Unit, Hospital Vithas San José, Vitoria-Gasteiz, Spain
| | - Rikin Patel
- Mercer-Buck Orthopaedics, Lawrence Township, NJ, USA
| | - Nicolás Fiz
- Arthroscopic Surgery Unit, Hospital Vithas San José, Vitoria-Gasteiz, Spain
| | - Steve Sampson
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mikel Sánchez
- Advanced Biological Therapy Unit, Hospital Vithas San José, Vitoria-Gasteiz, Spain
- Arthroscopic Surgery Unit, Hospital Vithas San José, Vitoria-Gasteiz, Spain
- Corresponding author. Arthroscopic Surgery Unit, Hospital Vithas San José, Beato Tomás de Zumarraga 10, 01008, Vitoria-Gasteiz, Spain.
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18
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Bernhard K, Ng A, Kruse D, Stone PA. Surgical Treatment of Bone Marrow Lesion Associated with Recurrent Plantar Fasciitis: A Case Report Describing an Innovative Technique Using Subchondroplasty ®. J Foot Ankle Surg 2018; 57:811-815. [PMID: 29631967 DOI: 10.1053/j.jfas.2017.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Indexed: 02/03/2023]
Abstract
Plantar fasciitis is one of the most common chief complaints seen in the foot and ankle clinic. With a relatively benign course, most cases are self-limiting or amendable to conservative therapy; ~90% of all plantar fasciitis cases will respond to these methods. When conservative treatment and time fail, surgical intervention can be necessary to improve outcomes. We present a novel method using Subchondroplasty® (SCP®; Zimmer Holdings, Inc.; Warsaw, IN) and revision fasciotomy in a case in which initial fasciotomy had failed. After the patient had failed to improve, a worsening underlying bone marrow lesion was identified at the origin of the plantar fascia; thus, SCP® was used with repeat fasciotomy. SCP® involves injecting calcium phosphate into bone marrow lesions to stimulate long-term bone repair. At 10 months after SCP®, the patient remained pain free and had returned to running at the final follow-up examination. This surgical treatment should be considered as an adjunctive procedure for those patients with plantar fasciitis, identifiable bone marrow lesions on magnetic resonance imaging, and continued pain when other treatment modalities have failed.
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Affiliation(s)
- Kaitlyn Bernhard
- Third Year Resident, Highlands-Presbyterian/St. Luke's Podiatric Medicine and Surgery Residency Program, Denver, CO
| | - Alan Ng
- Attending Staff, Highlands-Presbyterian/St. Luke's Podiatric Medicine and Surgery Residency Program, Denver, CO
| | - Dustin Kruse
- Director of Research, Highlands-Presbyterian/St. Luke's Podiatric Medicine and Surgery Residency Program, Denver, CO
| | - Paul A Stone
- Program Director, Highlands-Presbyterian/St. Luke's Podiatric Medicine and Surgery Residency Program, Denver, CO.
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19
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Brimmo OA, Bozynski CC, Cook CR, Kuroki K, Sherman SL, Pfeiffer FM, Stoker AM, Cook JL. Subchondroplasty for the treatment of post-traumatic bone marrow lesions of the medial femoral condyle in a pre-clinical canine model. J Orthop Res 2018; 36:2709-2717. [PMID: 29748965 DOI: 10.1002/jor.24046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 05/07/2018] [Indexed: 02/04/2023]
Abstract
This study characterizes long-term outcomes associated with subchondroplasty (SCP) treatment for impact-induced subchondral bone marrow lesions (BML) using a validated pre-clinical canine model. With IACUC approval, purpose-bred research hounds (n = 16) underwent arthroscopic impact injury (40N) to both medial femoral condyles. At 3 months, functional assessments, arthroscopy, and MRI were performed and knees (n = 32) were randomly assigned to SCP (3 ml fluoroscopically guided percutaneous injection of AccuFill BSM into BML bone defects) or sham injection (Control). Dogs were assessed at 3, 6, 12, and 24 months after treatment using functional assessments, radiographic evaluation, arthroscopy, and MRI. Dogs were humanely euthanatized at 3, 6, 12, or 24 months after treatment for gross, microCT, and histologic assessments. All knees had focal articular cartilage defects with associated subchondral BMLs, as well as clinical dysfunction, 3 months after injury. At the 3 and 6 months, SCP knees showed more functional impairment than Control knees, however, these differences were not statistically significant. At 1- and 2-year post-treatment, function in SCP knees was better than in Control knees with range of motion being significantly (p < 0.05) better for SCP. Radiographic, arthroscopic, MRI, gross, microCT, and histologic findings matched the functional assessments well with Control being associated with better results at the two early time points and SCP being associated with better results at 1 and 2 years. Clinical significance: SCP treatment using calcium phosphate bone void filler was associated with an initial increase in pain and dysfunction followed by symptomatic benefits for up to 2 years after treatment for post-traumatic femoral condyle BMLs in a preclinical canine model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2709-2717, 2018.
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Affiliation(s)
- Olubusola A Brimmo
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Chantelle C Bozynski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics and Mizzou BioJoint Center, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, Missouri 65212
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics and Mizzou BioJoint Center, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, Missouri 65212
| | - Keiichi Kuroki
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics and Mizzou BioJoint Center, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, Missouri 65212
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Ferris M Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics and Mizzou BioJoint Center, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, Missouri 65212
| | - Aaron M Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics and Mizzou BioJoint Center, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, Missouri 65212
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics and Mizzou BioJoint Center, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, Missouri 65212
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20
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Saltzman BM, Riboh JC. Subchondral Bone and the Osteochondral Unit: Basic Science and Clinical Implications in Sports Medicine. Sports Health 2018; 10:412-418. [PMID: 29932862 PMCID: PMC6116098 DOI: 10.1177/1941738118782453] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Context: Articular cartilage injuries and early osteoarthritis are among the most common
conditions seen by sports medicine physicians. Nonetheless, treatment options for
articular degeneration are limited once the osteoarthritic cascade has started. Intense
research is focused on the use of biologics, cartilage regeneration, and transplantation
to help maintain and improve cartilage health. An underappreciated component of joint
health is the subchondral bone. Evidence Acquisition: A comprehensive, nonsystematic review of the published literature was completed via a
PubMed/MEDLINE search of the keywords “subchondral” AND “bone” from database inception
through December 1, 2016. Study Design: Clinical review. Level of Evidence: Level 4. Methods: Articles collected via the database search were assessed for the association of bone
marrow lesions and osteoarthritis, cartilage regeneration, and ligamentous and meniscal
injury; the clinical disorder known as painful bone marrow edema syndrome; and the
subchondral bone as a target for medical and surgical intervention. Results: A complex interplay exists between the articular cartilage of the knee and its
underlying subchondral bone. The role of subchondral bone in the knee is intimately
related to the outcomes from cartilage restoration procedures, ligamentous injury,
meniscal pathology, and osteoarthritis. However, subchondral bone is often neglected
when it should be viewed as a critical element of the osteochondral unit and a key
player in joint health. Conclusion: Continued explorations into the intricacies of subchondral bone marrow abnormalities
and implications for the advent of procedures such as subchondroplasty will inform
further research efforts on how interventions aimed at the subchondral bone may provide
durable options for knee joint preservation.
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Affiliation(s)
- Bryan M Saltzman
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jonathan C Riboh
- Department of Orthopedic Surgery, Section of Sports Medicine, Duke University, Durham, North Carolina
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21
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Fodor P, Prejbeanu R, Predescu V, Codorean B, Fleaca R, Roman M, Todor A, Russu O, Bățagă T. Novel Surgical Technique for Bone Marrow Lesion — Case Report. JOURNAL OF INTERDISCIPLINARY MEDICINE 2016. [DOI: 10.1515/jim-2016-0051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Abstract
Introduction: Bone marrow lesions (BMLs) are commonly described as magnetic resonance imaging (MRI) findings associated with stress injuries or trauma. The presence of BMLs closely correlates with pain and rapid joint deterioration. Case presentation: A 51-year-old healthy man presented to our clinic with severe knee pain due to BMLs. After 3 months of conservative treatment, arthroscopy and subchondroplasty (SCP) of the medial femoral condyle was performed. The IKDC (International Knee Documentation Committee) score improved from 39.9 to 66.7 at 6 months, and to 87.4 at 1 year after surgery. The KOOS (Knee Injury and Osteoarthritis Outcome) score improved from 38.5 to 77.7 at 6 months, and to 92.6 at 1 year after surgery. The Tegner Lysholm score improved from 23 to 80 at 6 months, and to 95 at 1 year after surgery. Conclusion: SCP may provide a viable approach to reduce pain associated with BML, with minimal risk of significant complications.
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Affiliation(s)
- Pal Fodor
- University of Medicine and Pharmacy, Tîrgu Mureș, Str. Gheorghe Marinescu nr. 38 540139, Romania
| | - Radu Prejbeanu
- “Victor Babeș” University of Medicine and Pharmacy, Timișoara, Romania
| | - Vlad Predescu
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Codorean
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Radu Fleaca
- “Victor Papillan” Faculty of Medicine, “Lucian Blaga” University, Sibiu, Romania
| | - Mihai Roman
- “Victor Papillan” Faculty of Medicine, “Lucian Blaga” University, Sibiu, Romania
| | - Adrian Todor
- Iuliu Hațieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Octav Russu
- University of Medicine and Pharmacy, Tîrgu Mureș, Romania
| | - Tiberiu Bățagă
- University of Medicine and Pharmacy, Tîrgu Mureș, Romania
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22
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Abstract
OBJECTIVE Subchondroplasty is a novel minimally invasive procedure that is used to treat painful bone marrow lesions in patients with knee osteoarthritis or insufficiency fractures. The objective of this article is to describe the surgical technique and the pre- and postoperative imaging findings of a small case series acquired at a single center. CONCLUSION The radiologist should be familiar with the anticipated postoperative imaging appearances after subchondroplasty and the potential complications.
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23
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Colon DA, Yoon BJV, Russell TA, Cammisa FP, Abjornson C. Assessment of the injection behavior of commercially available bone BSMs for Subchondroplasty® procedures. Knee 2015. [PMID: 26213362 DOI: 10.1016/j.knee.2015.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Bone substitute materials (BSMs) have been commercially available for over 30 years and have been used extensively in orthopedic procedures. Some BSMs are described as "injectable." With rising focus on minimally invasive surgical procedures, the range of applications in which these materials are injectable is of clinical interest. Specifically, their performance in closed, pressurized environments in the trabecular bone with microdamage or abnormal bone remodeling have not been well characterized. This issue arises often in the presence of bone marrow lesions of the subchondral bone in early onset osteoarthritis. The objective was to evaluate the in vitro injectability of several common commercially available BSMs. It was hypothesized that some materials self-described as "injectable" would fail to function in a small microarchitecture in comparison to the large void areas. METHODS Mechanical testing was performed and force data was collected. Each sample was additionally radiographed and then imaged under micro-computed tomography (CT). RESULTS Most of the BSM materials failed to be successfully injected into a simulated trabecular model. Simplex™, AccuFill® and StrucSure™ materials were the only ones that were injected successfully. Many of the materials underwent phase separation at higher pressures and were not able to be deployed from the injection syringe. In addition, a clinically relevant difference was seen between the manners in which the materials interdigitated into the existing structure. CONCLUSION The AccuFill® was the only material able to inject in a closed model and demonstrate adequate implantation of BSM into the simulated trabecular bone. CLINICAL RELEVANCE Injectability of BSMs is clinically relevant as the interest in minimally invasive surgical procedures is rising rapidly.
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Affiliation(s)
| | | | - Thomas Anthony Russell
- Campbell Clinic, University of Tennessee Department of Orthopaedics, UTCHS, USA; CEO InnoVision, Inc. Memphis, TN, USA
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24
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Nevalainen MT, Sharkey PF, Cohen SB, Roedl JB, Zoga AC, Morrison WB. MRI findings of subchondroplasty of the knee: a two-case report. Clin Imaging 2015; 40:241-3. [PMID: 26995579 DOI: 10.1016/j.clinimag.2015.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/23/2015] [Accepted: 11/05/2015] [Indexed: 12/11/2022]
Abstract
Bone marrow lesions observed in magnetic resonance imaging (MRI) have been recognized as a source of knee pain. Subchondroplasty was developed to treat these lesions with a percutaneous injection of calcium phosphate bone substitute into the bone. As subchondroplasty may potentially become a more common procedure in the treatment of knee osteoarthritis, it is important for radiologists to recognize the typical MRI findings and not to confuse them with other pathology. Here we report the MRI findings for two patients following subchondroplasty.
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Affiliation(s)
- Mika T Nevalainen
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, 132 South 10th Street, Philadelphia, PA 19107, USA.
| | - Peter F Sharkey
- Rothman Institute, Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Steven B Cohen
- Rothman Institute, Department of Orthopedic Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Johannes B Roedl
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, 132 South 10th Street, Philadelphia, PA 19107, USA
| | - Adam C Zoga
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, 132 South 10th Street, Philadelphia, PA 19107, USA
| | - William B Morrison
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, 132 South 10th Street, Philadelphia, PA 19107, USA
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