Subchondroplasty Complications: Bone Cement to Treat Bone Marrow Lesions in a Knee? - Regenexx®

Subchondroplasty Complications: Bone Cement to Treat Bone Marrow Lesions in a Knee?

subchondroplasty complications

One of the hottest trends in arthritis treatment right now is the idea that you need to treat bone marrow lesions if found on MRI as well as cartilage. This is a new procedure called subchondroplasty. This opportunity has excited the companies that make bone cement, and they have created devices to inject this into these weak bone areas. While some of the bone cement-injected patient knees I’ve seen presented at conferences seem to do well, I’d like to present a patient we saw in clinic last week who did very poorly.

What Is a BML?

BML means bone marrow lesion. Another name for it is BME, or bone marrow edema. It’s a bright or dark spot (depending on the type of MRI sequence) that’s seen in the bone, usually in a patient with arthritis. For many years these were ignored by doctors, but in the last decade and especially the last five years, it’s become clear that in many patients, these spots in the bone that represent swelling or bone damage are part of the arthritis process. In addition, other research shows that while many patients with lost cartilage or torn meniscus tissue don’t feel pain, patients with BMLs are more likely to have pain. Hence, it may make sense to treat BMLs to help arthritis.

What Is Bone Cement?

Bone cement is an injectable paste that hardens in the body and takes the place of bone. It’s supposed to be broken down by the body and replaced by bone. One type of bone cement is basically plexiglass (polymethyl methacrylate). This type of bone cement heats up (exothermic) when it cures, so it could be harmful to local cells on that basis alone. The type of bone cement used typically to treat BMLs is endothermic (doesn’t heat up). This is usually calcium phosphate cement, which is closer to the actual bone composition than plexiglass.

What Is Subchondroplasty?

The procedure used to treat BMLs is called subchondroplasty. Its name stems from the idea that treating (plasty) below (sub) the cartilage (chondral) may help the cartilage repair itself better than just treating the joint. Is this true? Nobody knows for sure as right now it’s more of a theory with some “one off” before and after cases that look impressive.

Bone Cement Companies Get in on the Action

Given that bone cement is in itself an industry and that there is an opportunity in developing devices to help place this product in BMLs in knee arthritis patients, we’ve seen bone cement manufacturers start studies to treat knee arthritis. The concept is that if you can stabilize these weak areas in the bone, you can help the patients’ pain and maybe their cartilage. I have seen some nice cases presented at conferences showing that injecting bone cement can help patients. Having said that, I have also seen cases presented where the cement seeped from the bone into the joint and caused some real disasters.

Our Patient Where Bone Cement Was a Disaster

A patient presented to us recently to treat his knee arthritis with stem cells. He had previously had an arthroscopic debridement surgery and at the same time, the orthopedic surgeon injected bone cement into his BMLs. The surgeon admitted that this was his first case of a bone cement injection. The patient proceeded to get much worse, so we asked for a new MRI, which is above. Note that the two images on the right are the “before” images showing the BML bright spots in the bone (yellow dashed circles). Note that the after images are the two on the left. What we should be seeing is normal dark bone, but instead what we see in the red dashed circles is a disaster. The bone looks like it has died off and tried to heal, leaving gaps and holes. In addition, he has lost significant cartilage between the two films. Given that this is about nine months after the bone cement injections, this bone cement procedure has done the opposite of what was expected.

What Else Could Be Injected?

We’ve had data since the 1990s, mostly published by Phillipe Hernigou in Europe, showing that injecting bone marrow concentrate (same-day stem cell procedure, or BMC) can help heal bone. Hence, it would make sense that instead of bone cement, this may be a better substance as it’s natural and from the patient. This is one area where our knee arthritis research has focused. We are now readying for publication a matched case-control series showing that injecting these BMLs with BMC does help knee arthritis outcome in patients receiving a same-day stem cell procedure in their joint. Meaning that in patients with knee arthritis and BMLs, their function was better when the bone and the joint were injected versus just the joint.

The upshot? The pictures above look awful, so it’s unclear why this happened. Was the patient allergic to a component of the bone cement? Did this get infected? Is this just how some patients respond to bone cement? There are more questions than answers, but right now we’ll just stick with injecting the patients’ own stem cells into BMLs!

 

 

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Read 15 Comments
  1. My doctor is a sports medicine specialist. He doesn’t do any surgery. He’s very good at injecting my joints. He uses a ultrasound & I don’t feel anything. But he injected my knee with Cynvisc from a chicken & it made my knee hurt in the miniscus area (inside of the knee). Next he’s going to try the same material wiyhoutvthe chicken tissue, in case I’m allergic to the chicken protien.
    I had an MRI done recently, & they insisted I hold my knee straight for 49 minutes. I couldn’t walk out of the building, & when I got home my knee turned all black. So I have a new tearf in my meniscus. How long does it take for a new tear to heal?
    Do I need to find an interventional doctor, instead of the one I’m seeing, to get the best treatment?

    1. Adele,
      Sounds like a Physician who can do the type of exam that can determine what’s causing all of these issues, and has all of the possible regenerative treatments available might be a good idea, as using the right treatment for the right issue is key. These are Physicians who can do that: https://www.regenexx.com/find-a-physician/

  2. Hello,

    I have bone marrow edema on the lateral aspect of my knee and quite a lot of pain after a failed microfracture. Most of my lateral meniscus’ posterior horn was taken out years ago too.

    I am considering the Regenexx procedure and in case it works i would not like to wear down the joint more. So i was thinking having a meniscus transplant (synthetic) before or after regenexx. Is this a valid point? is it possible?

  3. Are you able to help the subchondroplasty patient featured in this article with any of your typical treatments? Or is there nothing that can be done?

  4. What are the constrains that hold you back from performing the Regenexx-C in Europe?
    It can be really hard for many of us to travel to Cayman Islands as the cost just goes through the roof especially when someone has multiple sites to treat.
    Teknon in Barcelona are doing a cultured MSC stem cell procedure that is approved in EU.
    You seem however to be the leader doing this and it could help a lot of people in EU.

    1. Michail, the EMA has been trying to phase out these existing culture sites and force them through a drug regulatory pathway. Hence, whether they continue to exist will likely be more about whether individual EU countries continue to have policies that are counter to Brussels. Spain is one of those countries that has had more lax regulations toward autologous culture. We expand based on finding physicians with the right training first, so if a physician from Sapin who had the right training approached us and that country allowed culturing, we would certainly be happy to serve the EU with a culture site.

  5. I had a previous surgery (2 years ago) to remove a cyst from my navicular bone. Due to the large size of the cyst it was very difficult to reconstruct the bone. Was doing well now I can’t walk due to pain (no diagnosis as to why I can’t walk now). My surgeon wants to perform a subchondroplasty? I am unsure able this procedure. Would I be a candidate for Regenexx-C treatment?

    1. Suzy,
      We’d need more information through the Candidacy process, but we treat bone cysts and BMLs regularly. We have seen very significant complications to the Subchondroplasty procedure. If you would like see if you are a Candidate for a Regenexx procedure, please submit the Candidate form to the right of the blog, or let us know and we can assist you in that process.

  6. I have had this exact experience with the Subchondroplasty procedure, it seems on a much larger scale from looking at the photo (without being a Doctor, I am unsure). The “bone filler” went beyond a small cyst in my lower Tibia, right above my Talus, and suffocated any healthy bone it touched in my Tibia. A biopsy now reads “Non Viable bone.” The bottom part of my tibia bone is dead. My outlook was a full recovery and back to a normal life, with such a small cyst repair, and I feel like I have taken 20 steps in the wrong direction. If I would have known other options were available or the possible negative side effects (which were never discussed with me and are not being advertised anywhere by the company responsible for this procedure), I would have gone with a different procedure. I have also spoken with about 10 other people suffering from the similar experiences. I am the only person who does not have some sort of prosthetic … YET!

    1. Jessica,
      Hoping you never will! There is a blog coming out soon about bone cement being used in spinal compression fractures…

      1. Hi
        I’m a 55 yr old overweight female that had the sunchondroplasty done May 31, 2018 on front of tibia
        I am almost 4 weeks in and I can hardly stand for more than 10-15 minutes. My knee throbs and I get stabbing pains that most of the time bring me to tears if I don’t keep up with pain meds
        Jessica how long was it for you before they found out your bone was dieing and not healing

        1. I am so sorry to hear of your suffering. I am also sorry it took me so long to respond. Unfortunately you have a long road ahead of you. It takes 6-12 months for the Injection to Absorb, I did notice my bone getting whiter and whiter, and it stayed painful before the 12 months were up. After a year of no one knowing I finally received a Biopsy of the white area which confirmed the bone death in the area of the injection and the point beyond it.
          I would at least wait 6-8 months (just a guess) to ask for a biopsy (if your bones are showing white on XRay , if the product is suffocating the bone then maybe that will be enough time for a biopsy to
          Show “non viable bone” as well as any product that is still there. This early I fear that the only results you would get would read the product they injected. Stay strong and email me charityrebel@yahoo.com
          I’m no Doctor this is just my experience. It took me a long two years to figure out this was an issue and I am finding more and more people with the same results. Let’s just hope in your case, you are still sore from the surgery. My initial recovery was 6-8 weeks and every bit of it was painful. It isn’t as easy a surgery as they say. Please email me whenever. I am an open book with what happened.

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