Bisphosphonates or prostacyclin in the treatment of bone-marrow oedema syndrome of the knee and foot
Department of Orthopaedic Surgery, University Hospital of Regensburg, Bad Abbach, Germany, . Rheumatology International
(Impact Factor: 1.52).
11/2012; 33(6). DOI: 10.1007/s00296-012-2584-0
Bone-marrow oedema (BME) represents a reversible but mostly painful increase in interstitial fluid. The exact pathogenetic processes still remain unknown. Treatment options are mainly symptomatic with core decompression as golden standard leading to immediate pain relieve. Recently, it has been shown that intravenous prostacyclin and bisphosphonates are useful in achieving a reduction in BME with a considerable improvement in the accompanying symptoms. We compared the outcome of both intravenously applied prostacyclin (Ilomedin(®), 10 patients) and bisphosphonate (Bondronat(®), 10 patients) in treatment of BME of the knee and foot. We could find a significant improvement of WOMAC score, SF-36 score and VAS 3 months and 1 year after therapeutic intervention in both the prostacyclin and the bisphosphonate group. Concerning the MRI scans in both groups, we found a distinct reduction of BME in 47 % and a complete regression in 40 %. Comparing both groups, the improvement of the scores was greater in the prostacyclin group than in the bisphosphonate group; the difference, however, was not significant. Intravenous bisphosphonates as well as prostacyclin are of efficient therapeutic benefit in treatment of BME with a quicker and greater effect of prostacyclin.
Available from: Wei Sun
- "Core decompression has been reported as the standard surgical treatment of recurrent or persistent painful BMES, particularly of the hip, and improves symptoms of pain through relief of intraosseous pressure[1,2,5,7,16,17]. However, surgery is costly and associated with risks[2,5,6]. A consensus is required regarding the importance of an early treatment to relieve pain and to avoid weakening the bone trabeculae, which could potentially lead to a collapse or fracture of the subchondral bone. "
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The aim of this prospective study was to evaluate the effectiveness of extracorporeal shock wave therapy (ESWT) in normalizing the symptoms and imaging features of primary bone marrow edema syndrome (BMES) of the knee.
This study compared the outcomes of ESWT (Group A) (n = 20) and intravenously applied prostacyclin and bisphosphonate (Group B) (n = 20) in the treatment of BMES of the knee in our department between 2011 and 2013. The Visual Analog Scale for pain (VAS, 100 mm), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), the SF-36 scores and MRI scans as well as plain radiographs were obtained before and after therapy between two groups.
Compared with Group B, we found greater improvement in VAS, the WOMAC Osteoarthritis Index and SF-36 score at 1, 3 and 6 months post-treatment in Group A (P < 0.05). Furthermore, MRI scans showed a higher incidence of distinct reduction and complete regression of bone marrow edema at 6 months in Group A (95 vs. 65 %; P = 0.018). The MRI at 1 year follow-up showed complete regression in all patients in Group A. However, two cases in Group B continued to normalize over the subsequent follow-up period.
ESWT can produce rapid pain relief and functional improvement. It may be an effective, reliable, and non-invasive technique for rapid treatment of BMES of the knee.
Research Registry UIN 528, September 03, 2015.
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ABSTRACT: Beim Knochenmarködem (KMÖ) handelt es sich um eine pathologische Vermehrung der interstitiellen Flüssigkeit im Knochen mit unspezifischem Erscheinungsbild im Magnetresonanztomogramm (MRT). Unterschieden werden das traumatische, das atraumatische, oft ischämische, das reaktive und das mechanische KMÖ. Das schmerzhafte KMÖS wird uneinheitlich als eigene Entität oder als reversibles Vorstadium der Osteonekrose (ON) betrachtet. Die Gefahr seines Übergangs in eine ON mit Gelenkdestruktion ist immer gegeben. Am häufigsten sind das Hüft-, Knie- und obere Sprunggelenk betroffen. Diagnostische Methode der Wahl ist das MRT. Je nach Ätiologie ist eine konservative oder operative Therapie zu diskutieren. Das KMÖS wird primär konservativ behandelt. Die Infusion von Prostazyklin oder Bisphosphonaten stellt eine gute Option für viele KMÖ dar. Etabliertes Verfahren ist die sog. „core decompression“. Beim ischämischen KMÖ sowie im Frühstadium einer ON könnte eine Kombination beider Verfahren von Vorteil sein.
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ABSTRACT: Bone marrow oedema (BMO) is a multifactorial condition. The conservative treatment options include immobilisation of the affected region and systemic intravenous iloprost therapy. Whereas many studies confirm the positive effect of iloprost therapy in larger joints, e.g. knee and hip, there have been few studies of BMO in smaller areas such as the ankle joint or midfoot. The purpose of this study is to show that treatment with iloprost leads to positive long-term outcomes for BMO of the foot and ankle.
Twenty-three patients with BMO of the ankle joint or midfoot, Association Research Circulation Osseous (ARCO) stages 1-2, were included in this study. A questionnaire was used to record the Ankle-hindfoot, Kaikkonen, SF-36 and VAS scores before and after iloprost therapy. In addition, all patients underwent MRI for radiological follow-up monitoring 3 months after treatment.
A significant improvement in function based on the ankle-hindfoot and Kaikkonen scale was demonstrated after iloprost therapy. In 22 patients, follow-up MRI after 3 months showed complete regression of the oedema.
Based on the positive results of our study, we recommend treatment with iloprost for BMO of the upper ankle joint and foot at ARCO stages 1-2.
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