BONE MARROW LESIONS IN KNEE JOINT I DR.RAJAT JANGIR ORTHOPAEDIC DOCTOR IN JAIPUR Dr.RAJAT JANGIR Professor & Head Senior Consultant Arthroscopy and Joint Replacement (Specialist in Shoulder Knee Hip Surgery) 67/34 Mansarovar Jaipur Appointment: +91 8104855900 Email: ligamentsurgeon@gmail.com https://www.shoulderkneejaipur.com/ Professor Department of Sports Medicine MG Hospital, Jaipur ============================================================ * Vast experience and specialisation in the field of Arthroscopy and sports surgery. * M.S. orthopaedics from BJ Medical College, Civil hospital, Ahmedabad * Fellowship in Arthroscopy and Sports injury with Prof Joon Ho Wang at Samsung Medical Center, South Korea * Shoulder Surgery (Madrid, Spain) * Diploma in Sports Medicine from InternationaI Olympic Committee * Invited as Athlete Medical Doctor at Rio Olympic 2016 * Done Rajasthan's first "All Inside Physeal Preserving ACL reconstruction" in 13 year old Athlete Rated as one of best orthopedic surgeon with excellence in Knee Shoulder Arthroscopy & Joint replacements' KNEE PAIN BONE PAIN OSTEOPOROSIS KNEE REPLACEMENT KNEE REPLACEMENT IN JAIPUR LIGAMENT SURGEON IN JAIPUR SHOULDER PAIN SPORTS INJURY

1. BONE MARROW OEDEMA
BONE MARROW LESIONS
Dr.RAJAT JANGIR
Jaipur

2. High signal intensity on MRI fluid-sensitive sequences

3. • Imaging abnormalities may occur in several
pathological conditions
• associated with a broad range of symptoms*
*Kon E, Ronga M, Filardo G, et al. Bone marrow lesions and subchondral bone pathology of the knee. Knee Surg Sports

4. BME
• 1988
• 10 patients transient osteoporosis of the hip
or knee,
• T1 weighted
• T2 weighted images
• MR abnormalities interpreted a transient
increase in the bone marrow water content
(edema)

6. 2000 Zanetti et al
• 16 TKR
• MRI 1 to 4 days before surgery
• Imaging WITH histopathology
• 11% bone marrow necrosis
• 8% abnormal trabeculae
• 4% bone marrow fibrosis
• 4% BME
• 2% bone marrow bleeding

7. • MOST COMMON IS Trauma
• Histology: areas of bone impaction and
bleeding caused by trauma
• Reversible and resolve in approximately 2 to 4
months*
*Kon E, Ronga M, Filardo G, et al. Bone marrow lesions and subchondral bone pathology of the knee. Knee Surg
Sports

8. Bone contusion with ACL tear and impaction of the lateral
femoral condyle into the postero- lateral tibial plateau (pivot
shift)*

9. Contusion of lateral femoral condyle
by patellar Dislocation

10. • Diffuse peri-articular high signal intensity on MRI
• Favorable clinical progression with complete resolution of
symptoms
• Transient osteoporosis,
• Regional migratory osteoporosis,
• Complex regional pain syndrome
Gil HC, Levine SM, Zoga AC. Semin Musculoskelet Radiol. 2006;10:177–186
Transient BME syndromes

11. All these disorders exhibit diffuse and poorly delimited
periarticular edema with preservation of the articular surface.

12. • Currently considered a subchondral
insufficiency fracture*
• Bone marrow lesion (BML), reflecting this
structural lesion of subchondral bone rather
than regional edema.
• lett SK, Hackney LA, Heilmeier U, et al. Skeletal Radiol. 2015;44:1785–1794.
SONK

14. BML/Insuciency Fracture
• Classification of BME
• No consensus

15. Meniscus-Cartilage-Subchondral bone unit
Abnormality of functional unit meniscal and/or chondral
injury
increases the load to the subchondral bone
subchondral insufficiency
fracture

16. Histologic examination
Failed subchondral bone
Microfractures of bony trabeculae cell & vessel abnormalities
focal necrosis after a few days
Necrotic tissue is replaced by new trabecular bone.
If regeneration process is insufficient
collapse of articular surface
Gil HC, Levine SM, Zoga AC. Semin Musculoskelet Radiol. 2006;10:177–186

17. Symtomatology BML
• Previously asymptomatic and
• Previous pain due to earlier degenerative
osteoarthritis
• OA acute increase in pain effusion, functional
limitation, and pain localized to BML
topography.

18. OA knees imaging
• The thickness and dimensions of the subchondral low-signal-intensity
image are believed to correlate with the lesion prognosis.
• low-signal-intensity lines on T2-weighted images with length > 14 mm
or thickness > 4 mm are risk factors for lesion progression and
subchondral bone collapse #
#Lecouvet FE, et al. Early irreversible osteon crosis versus transient lesions of the femoral condyles: prognostic value of subchondral bone and marrow changes on MR
imaging. AJR Am J Roentgenol

19. Clinical Presentation
• Although SONK is not a very rare condition
• Few studies on epidemiology
• Incidence of 3.4% among > 50 years 9.4% > 65
years
• Women are typically more affected, although in
some studies that performed MRI, the incidence
among men and women was similar@
• Overweight and those with poor bone quality#
@ Lotke PA, Abend JA, Ecker ML. e treatment of osteonecrosis of the medial femoral condyle. Clin Orthop Relat Res. 1982;171:109–116.
#Davies-Tuck ML, Wluka AE, Wang Y, English DR, Giles GG, Cicuttini F. e natural history of bone marrow lesions in community-based adults with no clini- cal
knee osteoarthritis. Ann Rheum Dis. 2009;68:904–908.

20. • Correlations between BME and pain and progression in patients
• Pain had a 3.31-fold higher likelihood of having BME compared with
patients with the same radiological degree of arthrosis but without pain #
• Greater progression of articular space narrowing among patients with
osteoarthritis and BML #
• The presence of BME in the medial and lateral knee compartments was
associated with 6.5-fold and 7-fold greater probabilities, respectively, of
osteoarthritis progression@
# Felson DT, Chaisson CE, Hill CL, et al. e association of bone marrow lesions with pain in knee osteoarthritis. Ann Intern Med
@ Felson DT, McLaughlin S, Goggins J, et al. Bone marrow edema and its relation to progression of knee osteoarthritis. Ann Intern Med. 2003;139:330–336

21. • Need for TKR higher among patients with BML
• This correlation is even more significant in
cases of global lesions affecting one full
femoral condyle or tibial plateau, which are
typical of insufficiency fracture
Scher C. Bone marrow edema in the knee in osteoarthrosis and association with total knee arthroplasty within a three-year follow-up
Tanamas SK et al. Bone marrow lesions in people with knee osteoarthritis predict progression of disease and joint replacement: a longitudinal study.
Rheumatology (Oxford)

22. Treatment
• Surgical or nonsurgical.
• Surgery for large lesions (>5 cm2 or >50% of
the condyle)
• Conservative NSAIDS combined with reduced
load on for 3 to 8 months

23. Prostacyclin
• Improve the perfusion of tissues, exact
mechanism unknown
• Significant improvement in pain over the
period of 3 to 6 months of follow-up
• results are poor in more advanced stages

24. Bisphosphonates
• Inhibit osteoclast activity
• avoid the collapse of subchondral bone.
• Results are controversial

25. Surgical treatment
• Subchondroplasty, is an option still in
development, albeit with promising initial
results
• Stabilizes microfractures affecting by filling the
spaces between the trabeculae with a calcium
phosphate–based bone substitute.

27. Although initial studies demonstrated pain
improvement and delay of total knee
arthroplasty
in some situations, the results cannot yet be
generalized for all patients

28. bone substitute
• Injectable
• capable of filling the spaces between trabeculae
• endothermic crystallization reaction to avoid overheating
• mechanical resistance similar to that of bone

29. Conclusions
• Still great controversy regarding the cause and clinical
impact of BME images on MRI.
• Different forms of treatment have been proposed with
promising results.
• However, a more detailed study is still needed to better
understand the patterns of bone edema to improve the
knowledge of the natural history of each type of lesion
and thus determine the indication of treatments.