Name: IntraOsseous BioPlasty™ Technology: A Versatile Option in the Biologic Treatment of Bone Marrow Edema
Uploaded: 2018-10-24T00:00:00Z
Channel: Arthrex

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VPT1-01069-EN | A | IntraOsseous BioPlasty™ Technology: A Versatile Option in the Biologic Treatment of Bone Marrow Edema

Sam Akhavan

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IntraOsseous BioPlasty™ Technology: A Versatile Option in the Biologic Treatment of Bone Marrow Edema

I'm very excited today to talk about Intraosseous bioplastic as a biologic treatment for bone marrow edema. One of the first questions I think we have to ask ourselves if we're going to treat this is what is bone marrow edema? How do we define it? Well, it's actually a term used to describe an MRI finding of hyperintense marrow signal against a fluid sensitive fat suppressed background. Essentially, what you're looking for is bright marrow against a dark background. Your sequences that you're going to see this the best on are your proton density, fat sats, your T2 fat sats, and your STR images. If you're going to treat bone marrow edema, I think it's very important to classify what the cause of the bone marrow edema is. A lot of these cases will be self-limiting, but some of them actually require treatment. The most common bone marrow edema that we see is probably acute trauma, such as a bone bruise, such as what you would see following an ACL. These again for the most part are self-limiting and do not require treatment. You can also see it in the setting of avascular necrosis. In chronic cases, there may not be a significant amount of edema. However, if you happen to catch this patient acutely, there will be significant hyperintense edema within either the medial femoral condyle or the medial tibial plateau. You can also see it in the setting of stress in this efficiency fracture. Sometimes you can see this on an x ray, but a lot of times what you will see is hyperintense edema surrounding the fracture line on an MRI. And then finally we can also see this in the setting of osteoarthritis. But it's a different mechanism. This is more of an overload mechanism that you're seeing. What's the significance of bone marrow edema in osteoarthritis. Well we've all seen this patient walk into our clinic with very little pain. And a lot of studies have shown the joint space narrowing is not actually predictive to somebody needing a knee replacement. Cartilage studies have shown that for pain, cartilage volume and thickness is actually very weakly correlated. However, bone marrow lesions have the strongest correlation to patients actually having pain. Taking this a step further, there have been several studies that have looked at bone marrow edema and found that its presence makes a patient almost nine times more likely to need total knee arthroplasty than somebody who has not. A longitudinal Canadian study of 123 patients, 4 to 7 years out, with an end point of total knee replacements, found that the most predictive factors for somebody needing a knee replacement is a bone marrow lesion, either of the medial compartment or the medial tibial plateau. How does this happen in the setting of arthritis? Well, you have chronic overload, which will lead to concentrated stress in an area of high bone turnover. What we're hoping is that these patients will go on to heal, but most of the time they actually end up going to not healing and have essentially a fracture, nonunion and a subsequent increase in their bone marrow edema. The reason you want to try to address this is if you don't, this may lead to subchondral bone attrition, which can lead to Lead to deformity. Progressive malalignment, which could make their joint replacements significantly harder. How do we treat bone marrow edema? Well, for the most part, you can try conservative measures, rest non-weight bearing injections in the setting of arthritis on load or bracing activity modifications. However, in the last several years there has been increased interest in surgically treating these. Our treatments to date have been really limited to stabilizing the bone marrow edema lesions. So essentially injecting calcium phosphate into the area with no real attempt to get the lesion to heal, you have to be very wary for this treatment in the setting of avascular necrosis, because you need a biologic solution to a biologic problem. Here's an example of a patient two years out following calcium phosphate stabilization of a bone marrow edema lesion. And you can see you can still see the drillhole where this was introduced two years out as my joint replacement likes to say, once you do this you've essentially have started a clock towards the patient getting total knee replacements, which can be a significant factor, especially if your patient is younger. This is where Intraosseous bioplastic has provided us with a brand new tool in the treatment of osteoarthritis and bone marrow edema. This allows biologic treatment of the lesions both for trauma, stress fractures and osteoarthritis. But it has also added diversity of treatment because now you can actually have a solution for early stage avascular necrosis. One of the keys to this procedure is the drill. The drill allows us not only access to the lesion, but also reduces intraosseous pressures in patients with bone marrow edema. It is through this that we can actually inject our biologic as well. Does intraosseous pressure matter? Well, studies have shown that in patients with knee pain, intraosseous pressures are elevated have commonly been observed. One study showed that in patients with bone marrow lesions, intraosseous pressures increased by as much as 97% compared to patients who do not. Blood flow studies have also showed us that when you have increased pressure, you have decreased venous outflow, which can lead to hypoperfusion and hypoxia, which can then progress to avascular necrosis, thickening of the subchondral plate, and eventually sclerosis of the joint. The second key to this procedure is the biologic. We have formulated the mixture that will flow best through the drill. It's five cc's of demineralized bone matrix gel mixed with three cc's of liquid. I like to use two cc's of bone marrow concentrate with one cc of radiopaque dye, because I like to see where this goes. However, if you don't want to use radiopaque dye, you can use three cc's of bone marrow concentrate. The indications for Intraosseous bioplastics are your early stage bone marrow edema lesions. So these would be patients that are really in the repair stage about 30 to 55 years old. So your younger patients your injections again is bone graft and a biologic mixed together in a 5 to 3 ratio. And the great thing about this is you have revision options. Should this fail in 2 or 3 years, and the patient is still not ready for their knee replacements, You can repeat the intraosseous bioplastic if you really want to. You can do calcium phosphate stabilization or if they are ready, you can do a total knee arthroplasty. In essence, what we're trying to do is we're trying to push patients down this path and try to get them to heal their lesion. In the treatment of individual lesions, if you look at traumatic bone marrow edema or stress fractures, for the most part your initial treatment will always be rest and non-weight bearing. However, if you have a prolonged case or a refractory case, the drill allows you to access and decompress the pathologic bone, followed by a biologic injection of bone graft and bone marrow concentrate to speed up the healing response. In your cases of avascular necrosis, for the most part, you can wait this out. Most cases will be self-limiting. However, if the lesion is prolonged or the lesion is progressive, Doctor Mandelbaum has developed this technique of essentially retrograde drilling behind the lesion, coring out the lesion, and then using your cannulated drill to inject your biologic into the area. In the case of arthritic lesions. Injections rest on low to brace. What I'm going to tell you is, if you have that patient walk into your clinic and you ask them, the first question I ask them is, where's your main site of pain? If they're pointing to the bone and not to the joint line, that patient is most likely not going to do well with injections. That's somebody that's actually a great patient to treat your bone marrow edema lesions, intraosseous plasty allows you to access the area of edema and then fill it with the biologic options to potentially heal the lesion. We have done a prospective trial. Currently we are looking at ten patients that we have included in this. We started this about seven months ago. Our inclusion criteria were patients under 55 years old that had bone marrow edema, lesions that were deemed to be associated with osteoarthritis. In our short term follow up, we had significant reduction in their visual analog scale scores and improvement in their icdcs at three months and beyond. Here's the first patient we did. This was a 47 year old female previous partial meniscectomy medial based pain that was really located on her tibial plateau. She did have some joint line pain, but a lot of pain on her medial plateau to palpation. We used a direct approach for this. So orthogonal plane fluoroscopic imaging to try to access the lesion correlated with your MRI. And essentially this is what you do. So here's your MRI showing you your lesion. We're going to access this with the drill. The cancellation of the drill gets removed. You have your biologic. Again I obtained 60 ccs of bone from the hip to spin it down, mix it in a 5 to 3 ratio with radiopaque dye and inject into the area. The reason I like the radiopaque dye is I'd like to know exactly where this is going. So you can see from this picture here, the Radiopaque dye shows me that we have actually located our drill in the appropriate spot, and the injectable is going in the right area. Post-operatively. One of the main keys to remember to this is that this injection has no structural strength. So therefore these patients have to be non-weight bearing for a period of at least 3 to 4 weeks, followed by therapy. So in summary, there's been increased interest in the last several years for surgical treatment of bone marrow edema. Our treatments to date have been really meant to stabilize, not to heal the lesion. This has made it very made us very wary to use it in cases such as avascular necrosis and worry to use it in young patients, because you're only revision option when this fails is total knee arthroplasty or partial knee arthroplasty. Intraosseous plasty has given us the option of a biologic solution to this problem. It's diverse in that it can be used for arthritis, avascular necrosis, or stress fracture. It's potentially curative in that it allows the lesion to heal, and its ability to be repeated can lead to a longer delay to arthroplasty options for the treatment of bone marrow edema. Thank you.

IntraOsseous BioPlasty™ Technology: A Versatile Option in the Biologic Treatment of Bone Marrow Edema

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