Bone marrow edema (BME) is an MRI finding of hyperintense signal on a fluid sensitive, fat suppressed background and is a cause of significant knee pain. BME may be seen in acute trauma, avascular necrosis, insufficiency fracture and in osteoarthritis (OA). Patients with OA who have BME have more pain and are more likely to progress to Total Knee Arthroplasty (TKR). BME lesions have high bone turnover and have the potential to heal but, if untreated, may collapse. Treatment of bone marrow lesions with injection of bone marrow concentrate (BMC) and demineralized bone matrix, known as intraosseous bioplasty (IOBP), has shown good short-term success in some studies. Furthermore, arthroscopic menisectomy and debridement has not been shown to provide successful lasting pain relief in patients with moderate to severe OA. The aim of this study was to evaluate the benefits of combined IOBP of BME lesions with arthroscopic meniscectomy and debridement in patients with moderate to severe OA.
We prospectively followed 22 patients with moderate to severe OA who had BME lesions on MRI Scans and had failed conservative treatment with anti-inflammatories, cortisone and/or hyaluronic injections. The patients had bone marrow aspiration from the Posterior Superior Iliac Spine and underwent arthroscopic partial menisectomy, chondral debridement, and treatment of BME with IOBP with the addition of intraarticular BMC injection. The mean patient age was 60.5 (range 41-75). The mean follow-up was 14.6 months (range 12 - 21) and assessed with VAS and WOMAC scores at 6 weeks, 3 months, 6 months and 1 year. Rescue injections were also tracked. The need for additional surgeries was also followed.
The mean preoperative surgery VAS score was 7.6 (range 2-10). The mean VAS score at 6 weeks was 4.6 (range 0-8), at 3 months was 3.0 (range 0-7), at 6 months was 1.5 (range 0-6), and at 1 year was 1.1 (range 0-8). The mean preoperative WOMAC score was 72.5 (range 42-96). The mean WOMAC score at 6 weeks was 41 (range 5-71), at 3 months was 24.5 (range 0-72), at 6 months was 12.9 (range 0-48) and at 1 year was 12.2 (range 0-78). 5 patients required an injection during the first year and only 2 of the injections were intraarticular and the remaining 3 were either at the IT Band or Pes Tendon insertions. None of the patients have required any additional surgical procedures on the same knee. Compared to the preoperative values, the VAS score 6 months postoperative from surgery decreased from 7.6 to 1.5 (P<0.00001), and the WOMAC score decreased from 72.5 to 12.9 (P<0.00001). Compared to the preoperative values, the VAS score 1-year postoperative surgery decreased from 7.6 to 1.1 (P< 0.00001), and the WOMAC score decreased from 72.5 to 12.2 (P<0.00001). Two patients increased in both their VAS and WOMAC scores between 6 months postoperative surgery and 1-year postoperative surgery. One of those two patients increased her WOMAC score but also has significant lumbar radiculopathy.
Discussion And Conclusion
Typically, patients with moderate to severe osteoarthritis who undergo arthroscopic menisectomy and debridement have been shown in literature to have poor outcomes. The treatment of BME with IOBP at the time of arthroscopic menisectomy and debridement in our study has provided good pain relief at a minimum follow-up of 1 year. The addition of Intraosseous Bioplasty with Bone Marrow Aspirate Concentrate in the treatment of the Bone marrow Edema lesions may be the contributing factor for the improved results in our study. It’s possible the intraarticular injection of Bone Marrow Aspirate at the time of the procedure may also be providing some added benefit.