Subchondral stem cell therapy versus contralateral total knee arthroplasty for osteoarthritis following secondary osteonecrosis of the knee
The Regenerative Clinic's view on this research
Mr Ali Noorani “This study is a very interesting study which looked at the use of subchrondral stem cell therapy using bone marrow aspirate concentrate (BMAC). A perspective randomised controlled clinical trial was carried out in 60 knees in 30 patients. The patients were aged between 18 and 41 with a mean age of 28 i.e. they were young patients. All the patients presented with bilateral osteoarthritis of the knees, secondary to osteonecrosis related to use of cortical steroids in a relationship with different severe medical conditions. One side, a total knee replacement was carried out and the other side as a comparison, patients received an injection of bone marrow aspirate concentrate (BMAC). This was injected into the subchondral bone of the femur and tibia. Various outcomes were measured, and the patients underwent a long term follow up. Average follow up was 12 years with a range of between 8 and 16 years. Interestingly, the outcome scores in this paper from the scores were very similar. However, 70% of the patients preferred the bone marrow aspirate injections as opposed to total knee replacements. In addition, what is quite shocking is that 6 patients who had total knee replacements before, had revision surgery i.e. approximately 20%, whereas only 1 patient in the bone marrow procedure proceeded to have a total knee replacement. This study is quite significant, it is a study with a high level of evidence, not only does it show that BMAC can be fairly effective in osteoarthritis of the knee, secondary to osteonecrosis, but these results are sustained. It also shows that this is an are excellent joint preservation techniques as only 1/30 patients ended up having total knee replacement in the bone marrow group, whereas 20% of the patients who had knee replacement unfortunately had to have a revision knee replacement. As these patients are young, we expect the revision rate to be much higher and near enough 100% during the patient’s lifetime.”
PURPOSE: Total knee arthroplasty (TKA) implanted in patients with secondary osteonecrosis (ON) related to corticosteroids have relatively poor outcome (20% revision rate) at a mean follow-up of only eight years. With the hypothesis that subchondral bone marrow injection might improve knees in these patients, we evaluated 30 patients who had bilateral knee osteoarthritis with severe joint space narrowing and received TKA in one knee and subchondral bone marrow concentrate injection in the contralateral knee.
MATERIAL AND METHODS: A prospective randomized controlled clinical trial was carried out in 60 knees of 30 patients (mean age 28 years, 18-41) who presented bilateral osteoarthritis secondary to knee ON related to corticosteroids in relation with different severe medical conditions. During the same anesthesia, one knee received TKA; for the other knee, a bone marrow graft containing an average of 6500 MSCs/mL (counted as CFU-F, range 3420 to 9830) was delivered to the subchondral bone of the femur and tibia. The length of anesthesia related to each procedure (bone marrow aspiration and subchondral injection of concentrated bone marrow versus total knee arthroplasty) was measured. Peri-operative outcomes, morbidity, complications, and safety of the two procedures were compared. Subsequent admissions for revision surgery were identified. At the most recent follow-up (average of 12 years, range 8 to 16 years), clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (MRIs for knees with subchondral bone marrow injection).
RESULTS: Anesthesia related to the TKA side was longer than for the cell therapy group. Medical and surgical complications were more frequent after TKA. A higher number of thrombophlebitis was observed on the side with TKA (15%) versus none on the side with cell therapy (0%). At the most recent follow-up (average of 12 years, range 8 to 16 years), six (out of 30) TKA knees needed subsequent surgery versus only one with cell therapy. The Knee Score had improved and remained similar in the TKA and cell therapy groups (respectively 80.3 points ± 11 versus 78.3 ± 23); 21 patients preferred the knee with cell therapy and 9 preferred the knee with TKA. Knees with cell therapy had improvement on cartilage and bone marrow lesions observed at the site of bone marrow subchondral injection.
CONCLUSIONS: Subchondral autologous bone marrow concentrate was an effective procedure for treating young patients with knee osteoarthritis following secondary ON of the knee related to corticosteroids with a lower complication rate and a quicker recovery as compared with TKA.