Inflammation of Your Bone Next to the Joint

One of the important distinctions of receiving treatment at Cellular Healing is the way your diagnosis and treatment plan are designed by a board certified and fellowship-trained orthopedic surgeon. We are able to recognize specific signs and symptoms of your joint which may require one or more minimally invasive procedures to optimize your results. Procedures are only recommended when a patient has a condition that will benefit by placement of cells within the bone next to the damaged cartilage.

If you have symptoms of continual pain near the bone next to the joint and this pain even occurs at night, you may have inflammation in the bone next to the joint. This inflammation is now a serious condition which will persist and worsen unless the underlying abnormal bone is treated. Think of this as a growing rust spot spreading deeper into your bone. If you had an MRI (Magnetic Resonance Imaging), this may be reported as a bone marrow lesion (BML) or subchondral edema or even as a stress fracture. This inflammation is the most important predictor of progression of your arthritis. Researchers have found a clear link between the development of bone marrow inflammation and progression of the disease as well as eventual need for joint replacement unless the inflammation is treated. [1] Normally, a MRI of your knee is ordered to determine this condition, but it is not always required especially if you have classic symptoms and positive physical tests.

Some common symptoms of inflammation of the bone near the joint include:

• Night pain which is dull constant and aching
• Constantly rubbing the joint to reduce symptoms
• Little or short term relief with injections
• Progressive pain with weight bearing or exercise

Inflamed Bone Marrow Procedure:

This procedure is used to treat acute or chronic bone marrow inflammation. This is a condition where the area underneath the cartilage becomes very inflamed causing the bone supporting the cartilage to swell and sometimes begin to collapse. At times, this is reported as a fracture or break in the bone. Your bone reacts similar to a break in the bone, but normally, this does not require fixation with pins, screws or plates. It only requires a transplant of healthy bone marrow graft from your pelvis to help correct the underlying deficiency. In rare cases, a special synthetic bone graft is injected to help provide immediate structural support to the area. The cause of this intense response of your bone is still not fully understood; however, entering into this area with a special needle and stimulating new blood flow can help to correct the problem. [2] Adding in natural growth factors, platelet rich plasma and even mesenchymal stem cells within this bone marrow graft can aide in the healing process. [3] The other choice to treat this condition is to perform a joint replacement. With joint replacement, the problem is solved by cutting out the diseased portion of bone and replacing this with a metal and plastic joint.

Bone marrow is taken from the pelvis during the surgery while you are under an anesthetic to produce a bone marrow graft. The bone marrow is then processed into two distinct products. One product is the Bone Marrow Concentrate (BMC), which contains the mesenchymal stem cells along with some Platelet Rich Plasma (PRP) and other important Plasma Proteins (PP) used in the healing process. The other product is Platelet Poor Plasma or General Fluid Concentrate (GFC), which also contains even more important plasma proteins. Additional bone marrow is harvested from the pelvic area in small batches under high suction to reduce the number of blood cells and increase the number of stem cells and other important growth factors. This is called a bone marrow aspirate (BMA). This BMA is used to supplement the grafting of the bone marrow lesion.

A specially designed bone graft delivery device is directed into the inflamed bone. Once the graft delivery device is within the inflamed area, high pressure suction is used to cause a change in the marrow pressure and the stimulation of blood flow into the area. In addition, this removes the damaged cells and prepares the area for delivery of new cells. Once the area is properly prepared, the bone marrow concentrate (BMC) and bone marrow aspirate (BMA) are mixed into a graft and very slowly placed to fill in all the damaged area. The general fluid concentrate is mixed with either the bone marrow aspirate or concentrate and made into a slurry to bind the stem cell mixture and prevent the cells from migrating out of the joint. This slurry mixture is placed into the joint to help heal the damaged areas from the other side of the joint. Patients are usually asked to maintain protected weight bearing with the use of a walker or crutches for a minimum of one week. Most patients are also provided with with a local anaesthetic around, but not within the joint as well as some oral pain medications to help control the pain which is normally minimal to moderate. You will be asked to use a blood thinner for 5 days and than continue a simple baby aspirin for a total of 2 weeks to prevent a potential blood clot. You will normally return to our office in approximately 1-2 weeks for a check up, and most patients will receive an additional platelet rich plasma (PRP) injection which acts to fertilize the process and hasten the recovery process. The PRP is just a simple blood draw and joint injection given after a local anaesthetic. Most patients can return to their normal activities of daily living in about 7-10 days. However, you are asked to reduce any excessive stress to the joint such as running or squatting for 3 months when we can re-evaluate your progress and allow you to return to all your normal activities. You will be encouraged to continue with our ten step program to help with the recovery of your joint such as goal setting, weight control, nutrition, bracing and simple exercises.

The healing process is not immediate, and most patients start to notice improvement around 3 months from the time of the procedure. We can help accelerate this healing time with the addition of low level laser, homeopathic joint injections and even nutritional supplementation. The key is to have patience with this process because it does take time for the cells to change the chronically inflamed area. Overall, we have had good success with this procedure, and most patients are satisfied with their outcomes for prolonged periods of time. A small minority of patients require an occasional platelet rich plasma injections to help with the continued healing process.

If you have more questions regarding this subchondral treatment of your joint with bone marrow, please feel free to ask any of our staff. We are here to make sure you make the right choice for your joint pain.

[1] Tanamas SK1, Wluka AE, Pelletier JP, Pelletier JM, Abram F, Berry PA, Wang Y, Jones G, Cicuttini FM. Bone marrow lesions in people with knee osteoarthritis predict progression of disease and joint replacement: a longitudinal study. Rheumatology (Oxford). 2010 Dec;49(12):2413-9. doi: 10.1093/rheumatology/keq286. Epub 2010 Sep 7.

[2] Subchondral stem cell therapy versus contralateral total knee arthroplasty for osteoarthritis following secondary osteonecrosis of the knee.

Hernigou P, Auregan JC, Dubory A, Flouzat-Lachaniette CH, Chevallier N, Rouard H.

Int Orthop. 2018 Mar 27. doi: 10.1007/s00264-018-3916-9. PubMed [citation] PMID: 29589086

[3] Sánchez M, Delgado D, Sánchez P, et al. Combination of Intra-Articular and Intraosseous Injections of Platelet Rich Plasma for Severe Knee Osteoarthritis: A Pilot Study. Biomed Res Int. 2016;2016:4868613.