There is an increasing number of reports on the treatment of knee osteoarthritis (OA) using mesenchymal stem cells (MSCs). However, it is not known what would better drive osteoarthritis stabilization to postpone total knee arthroplasty (TKA): targeting the synovial fluid by injection or targeting on the subchondral bone with MSCs implantation. A prospective randomized controlled clinical trial was carried out between 2000 and 2005 in 120 knees of 60 patients with painful bilateral knee osteoarthritis with a similar osteoarthritis grade. During the same anaesthesia, a bone marrow concentrate of 40 mL containing an average 5727 MSCs/mL (range 2740 to 7540) was divided in two equal parts: after randomization, one part (20 mL) was delivered to the subchondral bone of femur and tibia of one knee (subchondral group) and the other part was injected in the joint for the contralateral knee (intra-articular group). MSCs were counted as CFU-F (colony fibroblastic unit forming). Clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (including MRIs) at two year follow-up. Subsequent revision surgeries were identified until the most recent follow-up (average of 15 years, range 13 to 18 years). At two year follow-up, clinical and imaging (MRI) improvement was higher on the side that received cells in the subchondral bone. At the most recent follow-up (15 years), among the 60 knees treated with subchondral cell therapy, the yearly arthroplasty incidence was 1.3% per knee-year; for the 60 knees with intra-articular cell therapy, the yearly arthroplasty incidence was higher (p = 0.01) with an incidence of 4.6% per knee-year. For the side with subchondral cell therapy, 12 (20%) of 60 knees underwent TKA, while 42 (70%) of 60 knees underwent TKA on the side with intra-articular cell therapy. Among the 18 patients who had no subsequent surgery on both sides, all preferred the knee with subchondral cell therapy. Implantation of MSCs in the subchondral bone of an osteoarthritic knee is more effective to postpone TKA than injection of the same intra-articular dose in the contralateral knee with the same grade of osteoarthritis.

Subchondral bone or intra-articular injection of bone marrow concentrate mesenchymal stem cells in bilateral knee osteoarthritis: what better postpone knee arthroplasty at fifteen years? A randomized study.

Les ostéonécroses non traumatiques des épiphyses de l’adulte sont liées à trois étiologies essentielles : la prise de corticoïdes, l’intoxication éthylique, la drépanocytose. Indépendamment de ces trois étiologies principales, il existe de nombreuses autres étiologies telles que des troubles du métabolisme lipidique etc. qui peuvent aussi être à l’origine de nécroses épiphysaires. Les nécroses touchent essentiellement l’articulation de la hanche. Certaines étiologies peuvent être à l’origine d’ostéonécroses multifocales qui atteignent alors préférentiellement, après la hanche, l’épaule et le genou. Les autres localisations sont rares en dehors de certaines étiologies qui ont des atteintes spécifiques (le rachis dans la drépanocytose). Le diagnostic au stade précoce repose essentiellement sur l’imagerie par résonance magnétique (IRM) qui, dans la majorité des cas, permet d’obtenir un diagnostic certain de la pathologie. Les modalités thérapeutiques des ostéonécroses épiphysaires dépendent essentiellement du stade diagnostique. Le traitement conservateur de l’articulation est possible si le diagnostic a été effectué suffisamment précocement, en particulier par l’IRM.

Ostéonécroses non traumatiques des épiphyses de l'adulte

Post-traumatic osteonecrosis of the humeral head has a risk of progression to collapse in absence of treatment. The purpose of this study was to evaluate the results of mesenchymal stem cell grafting of the pre-collapse humeral head (study group) in adult patients with osteonecrosis and to compare the results with a simple core decompression without cells (control group). Patients After inclusion and randomization of 50 patients, 26 patients were enrolled in a single-blinded study for the cell therapy group. Twenty-four other patients were treated with simple core decompression without cells (control group). After a mean of 12-year (range 10 to 15) follow-up, X-ray and MRI were used to evaluate the radiological results, while the Constant score and the visual analog scale were chosen to assess the clinical results. The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow concentration. The average total number of MSCs (counted as the number of colony-forming units-fibroblast) injected in each humeral head was a total injection of average 180,000 ± 35,000 cells (range 74,000 to 460,000). Both the treatment and control groups had a significantly improved clinical score (p < 0.01). At the last follow-up, pain on the visual analog scale and Constant score in the study group had significant improvement (respectively p < 0.001 and p < 0.01) as compared to the control group. Collapse was observed more frequently in the control group (87.5% versus 11.5% for cell therapy, p < 0.0001). The survival rates based on the requirement for further shoulder surgery (arthroplasty) as an endpoint were higher in the cell therapy group in comparison to those in the control group (92% versus 25%; p < 0.0001). Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.

Mesenchymal stem cell therapy improved outcome of early post-traumatic shoulder osteonecrosis: a prospective randomized clinical study of fifty patients with over ten year follow-up

Knee osteonecrosis is a debilitating progressive degenerative disease characterized by subchondral bone ischemia. It can lead to localized necrosis, tissue death, and progressive joint destruction. For this reason, it is essential to diagnose and treat this disease early to avoid subchondral collapse, chondral damage, and end-stage osteoarthritis, where the only solution is total knee arthroplasty. Three types of knee osteonecrosis have been documented in the literature: spontaneous or primitive, secondary, and post arthroscopy. Spontaneous osteonecrosis is the most common type studied in the literature. Secondary osteonecrosis of the knee is a rare disease and, unlike the spontaneous one, involves patients younger than 50 years. It presents a particular set of pathological, clinical, imaging, and progression features. The management of secondary osteonecrosis is determined by the stage of the disorder, the clinical manifestation, the size and location of the lesions, whether the involvement is unilateral or bilateral, the patient's age, level of activity, general health, and life expectancy. This review aims to present the recent evidence on treatment options for secondary osteonecrosis of the knee, including conservative treatment, joint preserving surgery, and knee replacement.

/pdf/treatment-options-for-secondary-osteonecrosis-of-the-knee-2rp9zueo.pdf

Treatment options for secondary osteonecrosis of the knee.

This technical note describes a simple arthroscopic technique that was introduced without the need for further staff during an operation to address osteonecrosis of the medial femoral condyle. A 2.4 mm pin was positioned through the sleeve of an anterior cruciate ligament (ACL) tibial guide and marked with a steri-strip at its body, aiming at 5–10 mm distance between the tips of guide and the pin. The steri-strip serves as a marker and as a stop for inadvertent violation of the cartilage. The tip of the ACL was positioned just over the bone lesion, while the marked 2.4 mm pin was inserted through the ACL tibial guide from anterior surface of the femur. A stab incision was made and without advancing the sleeve to the bone, the pin was drilled to the marked position while cartilage integrity was confirmed arthroscopically. This arthroscopic technique is simple, fast and effective and is performed without the need for special equipment.

/pdf/simple-arthroscopic-technique-to-perform-retrograde-drilling-jms4xai2.pdf

Simple Arthroscopic Technique to Perform Retrograde Drilling for Osteonecrosis of the Femoral Condyles with the Use of Anterior Cruciate Ligament Guide

BACKGROUND The knee is the second-most common location for osteonecrosis, although it is affected much less often than the hip. Core decompression by precise drilling into ischemic lesions of the femoral condyle while remaining extra-articular is a challenge, particularly in obese patients. For cell therapy, exact localization of the injection point is important to avoid intra-articular injection. METHODS The precision of drilling with computer-based navigation was compared to that of conventional fluoroscopy-based drilling. A prospective, randomized study was conducted using both surgical trainees without experience and expert surgeons. First, participants performed the surgical task (core decompression) on a cadaver knee using fluoroscopic guidance or computer-based navigation. Performance was determined by the radiographic analysis of trocar placement. Next, 12 consecutive patients with bilateral symptomatic secondary (corticosteroids) osteonecrosis without collapse were included in a clinical prospective, randomized, controlled study. The 24 knees were treated using conventional fluoroscopy with expert surgeons on one side and computer-based navigation with surgical trainees on the contralateral side. Bone marrow aspirated from the two iliac crests was mixed before concentration. Each side received the same volume of concentrated bone marrow and the same number of cells (95,000 ± 25,000 cells; counted as CFU-F). RESULTS In the cadaver tests, the distance to the desired center-point of the lesion in the navigated group (1.6 mm) was significantly less than that in the control group (5.9 mm; p<0.001). Significant differences were also found in the number of drilling corrections (p<0.001), the radiation time needed (p<0.001), the risk of intra-articular penetration, and the risk of ligament injuries. In patients, computer navigation achieved results closer to the ideal position of the trocar, with better trocar placement in terms of tip-to-subchondral distance and ideal center position within the target for injection of stem cells. At the most recent follow-up (5 years), an increase in precision with computer-assisted navigation resulted in less collapse (4 vs. 1) and better volume of repair (11.4 vs 4.2 cm3) for knees treated with the computer-assisted technique. Failures were related to missing the target with intra-articular penetration. CONCLUSIONS Computer-assisted navigation improved precision with less radiation. The findings of this study suggest that computer navigation may be safely used in a basic procedure for the injection of stem cells in knee osteonecrosis.

Knee Osteonecrosis: Cell Therapy with Computer-assisted Navigation.

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Knee Osteonecrosis: Cell Therapy with Computer-assisted Navigation.