The Subchondroplasty Procedure for Bone Marrow Lesions; what is it and when is it indicated?

Assume that you schedule an office assessment for knee pain, altered function and a slight limp. I complete the examination and review the radiograph only to find it “normal”. The examination excludes referral from the low back and hip so the next step is an MRI. 48 hours later I am able to diagnose a Bone Marrow Lesion (BML) as the cause of the problem. The Bone Marrow Lesion is an abnormal area of defect inside the bone. Also called Bone Marrow Edema (BME), they are defects typically found below or adjacent to a joint. They appear a hazy white area on the MRI against the background of darker, unaffected bone and bone marrow. Pathologists have shown that the BML represents a healing response as a result of a bone injury that doesn’t heal properly. In other cases, the MRI finding may be consistent with a stress reaction that forms from overuse or poor joint mechanics.

Obesity and poor diet are thought to increase the likelihood of developing BML. They are more commonly found in middle-aged patients rather than younger patients. Patients with poor joint alignment (bow legs or knock knees) are more likely to develop BML. Adults who quickly increase activity may develop Bone Marrow Lesions or Edema.

As in most initial diagnoses, a course of conservative treatment should be instituted so as to allow the body to heal itself. If the lesion doesn’t heal with medications, braces, non-weight bearing, injections and physical therapy, then an intraosseous injection into the lesion is indicated. Left untreated, the problem may result in the loss of joint support and the development of osteoarthritis.

I treat the symptomatic, non-responsive BML with an intraossous, intralesional procedure called a subchondroplasty whereby Bone Marrow Concentrate rich in stem cells and growth factors is injected into the non-healing insufficiency fracture. Fluoroscopy is used (intraoperative X-ray) to guide the placement of a special drillable cannula into the bone defect.  At times, should the BML be of sufficient size as to cause me to be concerned about a possible fracture, I will use a Calcium Phosphate preparation in addition to the Bone Marrow Concentrate. The engineered Calcium Phosphate readily fills the subchondral defect and mimics the properties of cancellous bone eventually being resorbed and replaced with new bone.

Most Orthopedic Surgeons believe that Chronic Bone Marrow Lesions will not heal without intervention. Additionally, the pain generator in osteoarthritis diagnosed by narrowing of a joint space may in fact be secondary to a BML. Bone Marrow Edema and lesions were among the topics I reviewed during my Instructional Programs in St Petersburg, Russia, two weeks ago. To learn about chronic joint pain with a “normal “or even abnormal X-ray, call for a consultation and evaluation.

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On Stem Cells, Bone Marrow Concentrate and Non-unions of Bones

On Stem Cells, Bone Marrow Concentrate and Non-unions of Bones

With all of our attention directed to arthritis, patients need to be reminded of the continued successes we are experiencing when using Bone Marrow Concentrate in fractures that fail to heal. When a fracture fails to heal in the expected average time, that is a Delayed Union. When it looses the ability to heal all together, that’s a Non-Union. The reasons that a fracture might fail to heal are beyond the scope of this Blog but non-union is not a rare complication. Areas of predilection toward difficulty in healing have to do with blood supply. The upper end of the femur (hip), navicular bone at the wrist, upper end of the humerus (shoulder), and clavicle as well as the tibia are areas of predilection. Historically, the only remedy has been a major operative procedure and even at that, there is a high failure rate with multiple complications including infection. It has been said that the only thing worse than an infected non-union is cancer. Let me share with you the story of two recent patients for whom I successfully intervened with Bone Marrow Concentrate when prior attempts at achieving fracture healing, one through surgery had failed.

VDVR is a 46-year-old woman who ten years ago sustained multiple fractures to her spine and lower extremities while serving in Iraq. She had undergone numerous surgical procedures, all successful except the inability to cause healing of fractures to her left calcaneus and talus. She had been left with Oxycontin addiction and crutch dependency. After several further orthopedic consultations she had a choice of amputation or more major surgical repair attempts with only 50% chance of success. Twelve weeks ago, I performed a Bone Marrow Concentrate/ Stem Cell intervention to her left calcaneus and talus. Last week she called and indicated she no longer required narcotics and could walk without crutches. The X-ray I received a day or two after the call was indicative of fracture healing.

JM is a 76-year old man with an established non-union of the left clavicle, of several years duration. He was experiencing arthritic changes in his left shoulder and asked me to try and achieve healing of the clavicle, even after several years while I was injecting Bone Marrow Concentrate into his arthritic left shoulder.  About 16 weeks ago, I completed a stem cell intervention to his left shoulder and into the area of non-union of the outer one-third of the left clavicle. When I saw him in follow-up last week, the collarbone was completely healed. He had been afraid to undergo a surgical repair because of the high incidence of infection, failure and neurovascular injury associated with surgery of non-union at the clavicle.

These are but two illustrations of what is happening in the new world of Cellular Orthopedics. The initiative is gaining traction in the orthopedic world as I more and more success stories are realized

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Stem Cells aid in fracture healing

Stem Cells aid in fracture healing

Musculoskeletal Care of the Mature Athlete

While the majority of fractures will heal with established treatment methodologies, be they operative or non-operative; about 15% will never heal (non-union) or take forever to heal (delayed-union). Recognized causes of delayed and non-union include excessive force at the time of trauma, soft tissue interposition, excessive displacement of bones, post operative infection, smoking, vascular disruption, just to name a few. The recent disaster at the Boston Marathon is the type of setting that might lead to delayed and non-union of fractures sustained. Is there a place for improving the outcome of a serious traumatic event with stem cell intervention?

Four months ago, a 26-year-old woman presented 9 months following a motor vehicle accident in which she had sustained a fracture of her calcaneus (heel bone). For some reason, the physicians in Florida opted to treat her displaced fracture without surgery. When she presented in the office, it was on crutches, in a brace and without the ability to tolerate weight bearing and totally dependent on narcotics to get through the day. After reviewing updated X-rays and an MRI, I determined that she had an impending non-union of the calcaneus in mal-position, with total disruption of the sub-talar joint (the joint between the talus and calcaneus responsible for side to side foot motion). Because she had not walked on her foot in nine months, her bones were severely osteoporotic and therefore surgical reconstruction was not a satisfactory option. I proposed a Bone Marrow Aspirate Concentrate (Stem Cell) intervention to influence fracture healing even at this late time and to perhaps cause a fusion of the sub-talar joint, something that would be necessary in 12 to 18 months to eliminate pain from post traumatic arthritis.

The patient scheduled the procedure after I had clearly explained the desired end results. While I couldn’t correct fracture alignment, I could potentially influence fracture healing and elimination of the posttraumatic arthritis in the subtalar joint. For the first six weeks following the stem cell intervention, the patient used crutches and a brace. For the second six weeks, she walked at home without a brace or crutches and with the brace out side of the home. When I last saw her in early April, she walked without any support, was brace free, no longer had pain; and most important, no longer used any medications for pain. The X-ray was compatible with fracture healing and a subtalar fusion. When last contacted, she was returning to school and a part time job. The stem cells intervention eliminated the need for surgery and influenced maximal medical improvement in weeks and not years.

I have arthritis. Give me Bone Marrow Concentrate or Give me a Joint Replacement

I have arthritis. Give me Bone Marrow Concentrate or Give me a Joint Replacement

Orthopedic Care of the Mature Athlete

The established practice leading to a diagnosis of knee osteoarthritis is based on evidence of joint pain and/or reduced space between articulating bone surfaces on X-Ray. That loss of space in the radiograph is attributed to thinning of opposing articular cartilages in your knee. New evidence however, indicates that multiple tissues composing the knee joint appear to be compromised by the disease, including the subchondral bone (bone below and supporting cartilage), articluar cartilage, the meniscus, the anterior cruciate ligament, the synovium, and the synovial fluid. A change in any of these tissues can influence load across the joint, with corresponding adaptations in the other tissues and ultimately, the cartilages. (Taken from “On the Horizon from the ORS). I `believe it important to provide continual explanation about how Regenerative Medicine works, it isn’t only fish oil. We are continuing to learn more and more about the world of Regenerative Medicine and the reason for the effectiveness of bone marrow concentrate and why BMC is proving so affective in dealing with the musculoskeletal system. It isn’t only attributable to the Adult Mesenchymal Stem Cell.

I have a fracture and it won’t heal

Let me introduce you to another component within Bone Marrow Aspirate, the Endothelial Progenitor Cell. EPCs can be defined as bone marrow-derived precursor cells with the ability to differentiate into endothelial cells and to participate in the formation of new blood vessels. Recent research indicates that Mesenchymal Stem Cells “talk” to Endothelial Progenitor Cells. It seems that in fracture repair, the synergistic effect of EPCs and MSCs is crucial for complete bone regeneration. Positive effects of Endothelial Progenitor therapy have been demonstrated in ligament tissue regeneration, as well. Regenexx has demonstrated several cases of effecting healing of a torn Anterior Cruciate Ligament using Bone Marrow Concentrate. It may well be that the Endothelial Progenitor Cells are responsible for new blood vessels and a resultant favorable environment. Delayed healing of fractures (delayed union) and a failure of healing (non-union) can be devastating to an individual. If you are that patient, ask your orthopedic surgeon about A Novel Cell-based therapy in Orthopedic Surgery: Endothelial Progenitor Cells. The bone marrow is aspirated and concentrated and then injected into the fracture site using a minimal invasive needle technique. If you are directed to surgery instead, give me a call.

Did you see that NFL Monday night Football Game? Stem Cells won that game! More about this next week.

 

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