Original research
Bone Marrow Edema Syndrome of the Medial Femoral Condyle Treated With Extracorporeal Shock Wave Therapy: A Clinical and MRI Retrospective Comparative Study

https://doi.org/10.1016/j.apmr.2017.10.025Get rights and content

Abstract

Objective

To determine the validity of extracorporeal shock wave therapy (ESWT) in the treatment of bone marrow edema (BME) of the medial condyle of the knee.

Design

Retrospective.

Setting

Orthopedic Surgery outpatient clinic.

Participants

Symptomatic patients (N=56) affected by BME of the medial condyle of the knee. Patients were equally divided into an ESWT-treated group and a control group, which was managed conservatively.

Interventions

ESWT delivery to the medial condyle of the affected knee.

Main Outcome Measures

Clinical and functional assessment of the knee was performed with the use of the clinical and functional scores of the Knee Society Score (KSS). Pain was measured with the visual analog scale (VAS). BME area was measured with magnetic resonance imaging (MRI) before treatment and at 4 months' follow-up.

Results

Clinical evaluation of patients at final follow-up of 4 months posttreatment showed a significant improvement (P<.0001) of symptoms and knee functionality, both for range of motion and strength in both groups. VAS values were significantly improved (P<.0001) in both groups, with 3 patients in the ESWT group being pain-free (VAS=0) at 4 months' follow-up. At 4 months, MRI assessments on both sagittal and coronal views showed a significant reduction in BME in the ESWT group compared with the control group.

Conclusions

Our findings show that ESWT is a valid nonpharmacologic and noninvasive therapy for spontaneous BME of the medial condyle that improves the affected vascular and metabolic state present in this pathologic disorder through its metabolic mechanisms of action.

Section snippets

Methods

From July 2014 to January 2016, 56 patients (39 women, 17 men) came to our attention for knee pain and difficulty walking. All patients were assessed and diagnosed with symptomatic BME of the medial condyle. Informed consent was obtained from the patients for their participation in the study.

We applied the following inclusion criteria: knee pain at rest and during walking associated with MRI evidence of a bone marrow lesion, defined as a high-intensity bone signal on T2-weighted. Exclusion

Results

Both study groups were comparable and homogeneous in terms of distribution of age, sex, and affected side (table 1). Pretreatment group values for both KSS clinical scores (P=.2954) and KSS functional scores (P=.4153), VAS scores (P=.4486), and MRI edema area measurement (P=.2792) were comparable between the 2 groups.

In the ESWT group, KSS clinical scores at 1-month follow-up improved to 70.89 (+23.49%) compared with 59.29 (+13.91%) in the control group. At final follow-up, KSS clinical scores

Discussion

To this day, there is still no consensus regarding the etiology, pathogenesis, and treatment of BME. The cornerstone of BME therapy is following a protocol that avoids weight-bearing on the affected limb in association with the administration of nonsteroidal anti-inflammatory drugs, analgesics, and glucocorticosteroids. Further medical therapy can be adopted, including bisphosphonates, which improve bone density; prostaglandin analogs,11 which induce vasodilatation, reduce capillary

Conclusions

Given these encouraging results, the authors believe this protocol may be an effective alternative to the treatment of BME of the knee because it is noninvasive and short in duration, therefore allowing for good patient compliance, and with the exception of therapy-induced pain, results in no significant adverse effects.

Suppliers

  • a.

    Storz Medical Duolith SD1; Storz Medical AG.

  • b.

    ICIS View 2014.1. AGFA HealthCare.

Acknowledgments

We thank the nurse and orderly staff in our outpatient clinic at San Raffaele Hospital (Milan, Italy): Angela Marras, BSN, Nadia Spinelli, BSN, Graziella Saccà, BSN, Gianfranca Matera, BSN, Alessandra Izzo, Oronzo Vesmile, BSN, Fernando Prontera, BSN, and Ugo Angeli, BSN.

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    • The Efficacy of Conservative Treatment of Bone Marrow Edema Syndrome: A Scoping Review of the Last Ten Years of Literature

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      A noticeable increase in vascular endothelial growth factor (VEGF), transforming growth factor (TGF-Beta1), bone morphogenetic protein (BMP-2), von Willebrand factor (vWF) and alkaline phosphatase (ALP) was found in peripheral blood of patients treated with SW (13). On the other hand, ESWT might cause some adverse effects such as transient soft tissue swelling or minor bruising, skin erythema, subcutaneous congestion points, pain during administration of the therapy (132526). Lastly, an aspect that stood out in this scoping review is that no well-defined scores were applied when evaluating the BME area changes at MRI before and after treatment.

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    Disclosures: none.

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