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Possible beneficial effect of bisphosphonates in osteonecrosis of the knee

  • Knee
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Osteonecrosis (ON) in the knee occurs as a localized inflammatory disease in relation to spontaneous or non-traumatic ON. Conservative treatment possibilities are limited, and prognosis appears to be poor; in most cases, ON results in knee arthroplasty. Bisphosphonates are suggested to prevent bone resorption and collapse of necrotic bone. In this observational, prospective study we investigated the effect of bisphosphonate treatment in patients with spontaneous or arthroscopy-induced ON of the knee. Twenty-eight patients with osteonecrotic lesions and bone marrow oedema in the knee were included. In 22 patients (80%), ON was identified after arthroscopic surgery of the knee; six patients were diagnosed with spontaneous ON. Patients were initially given pamidronate 120 mg i.v. divided in 3–4 perfusions over 2 weeks, followed by oral bisphosphonate treatment with alendronate 70 mg weekly for 4–6 months. Bisphosphonate treatment resulted in a rapid pain relief, VAS decreasing from 8.2 ± 1.2 at baseline to 5.02 ± 0.6 after 4–6 weeks (p < 0.001). After 6 months, the VAS decreased by 80% (p < 0.001). At the 6-month follow-up, symptoms had resolved completely in 15 patients out of 28; in 6 patients, minimal symptoms (VAS 1–2) remained. In two patients, treatment effect was unsatisfactory, and surgical intervention was needed (arthroplasty). Bone marrow oedema on MRI resolved completely in 18 patients out of 28 with substantial reduction in the remaining. Furthermore, osteonecrotic area resolved completely or demarcation with sclerotic changes of the necrotic area could be observed. Bisphosphonate treatment in patients with osteonecrosis of the knee was associated with a rapid improvement in pain score and radiological consolidation of the area of osteonecrosis. Further randomized, controlled trials are warranted to confirm the potential beneficial role of bisphosphonates in the treatment of osteonecrosis of the knee. Level of evidence: observational study, level IV.

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References

  1. Agarwala S, Jain D, Joshi VR, Sule A (2005) Efficacy of alendronate, a bisphosphonate, in the treatment of AVN of the hip. A prospective open-label study. Rheumatology (Oxford) 44:352–359

    Article  CAS  Google Scholar 

  2. Agarwala S, Shah S, Joshi VR (2009) The use of alendronate in the treatment of avascular necrosis of the femoral head: follow-up to eight years. J Bone Jt Surg Br 91:1013–1018

    Article  CAS  Google Scholar 

  3. Agarwala S, Sule A, Pai BU, Joshi VR (2002) Alendronate in the treatment of avascular necrosis of the hip. Rheumatol 41:346–347

    Article  CAS  Google Scholar 

  4. Ahlback S, Bauer GC, Bohne WH (1968) Spontaneous osteonecrosis of the knee. Arthritis Rheum 11:705–733

    Article  CAS  PubMed  Google Scholar 

  5. Aigner N, Petje G, Schneider W, Meizer R, Wlk M, Kotsaris S, Knahr K, Landsiedl F (2005) Bone marrow edema syndrome of the femoral head: treatment with the prostacyclin analogue iloprost vs. core decompression: an MRI-controlled study. Wien Klin Wochenschr 117:130–135

    Article  PubMed  Google Scholar 

  6. Al Kaar M, Garcia J, Fritschy D, Bonvin JC (1997) Aseptic osteonecrosis of the femoral condyle after meniscectomy by the arthroscopic approach. J Radiol 78:283–288

    CAS  PubMed  Google Scholar 

  7. Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME (2002) Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum 32:94–124

    PubMed  Google Scholar 

  8. Astrand J, Aspenberg P (2002) Systemic alendronate prevents resorption of necrotic bone during revascularization. A bone chamber study in rats. BMC Musculoskelet Disord 3:19–23

    Article  PubMed  Google Scholar 

  9. Astrand J, Harding AK, Aspenberg P, Tagil M (2006) Systemic zoledronate treatment both prevents resorption of allograft bone and increases the retention of new formed bone during revascularization and remodelling. A bone chamber study in rats. BMC Musculoskelet Disord 7:63

    Article  PubMed  Google Scholar 

  10. Athanasian EA, Wickiewicz TL, Warren RF (1995) Osteonecrosis of the femoral condyle after arthroscopic reconstruction of a cruciate ligament. Report of two cases. J Bone Jt Surg Am 77:1418–1422

    CAS  Google Scholar 

  11. Berger CE, Kroner AH, Kristen KH, Grabmeier GF, Kluger R, Minai-Pour MB, Leitha T, Engel A (2006) Transient bone marrow edema syndrome of the knee: clinical and magnetic resonance imaging results at 5 years after core decompression. Arthroscopy 22:866–871

    Article  PubMed  Google Scholar 

  12. Bonutti PM, Seyler TM, Delanois RE, McMahon M, McCarthy JC, Mont MA (2006) Osteonecrosis of the knee after laser or radiofrequency-assisted arthroscopy: treatment with minimally invasive knee arthroplasty. J Bone Jt Surg Am 88(Suppl 3):69–75

    Article  Google Scholar 

  13. Brahme SK, Fox JM, Ferkel RD, Friedman MJ, Flannigan BD, Resnick DL (1991) Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging. Radiology 178:851–853

    CAS  PubMed  Google Scholar 

  14. Cardozo JB, Andrade DM, Santiago MB (2008) The use of bisphosphonate in the treatment of avascular necrosis: a systematic review. Clin Rheumatol 27:685–688

    Article  PubMed  Google Scholar 

  15. DeFalco RA, Ricci AR, Balduini FC (2003) Osteonecrosis of the knee after arthroscopic meniscectomy and chondroplasty: a case report and literature review. Am J Sports Med 31:1013–1016

    PubMed  Google Scholar 

  16. Disch AC, Matziolis G, Perka C (2005) The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost. J Bone Jt Surg Br 87:560–564

    Article  CAS  Google Scholar 

  17. Faletti C, Robba T, de Petro P (2002) Postmeniscectomy osteonecrosis. Arthroscopy 18:91–94

    Article  PubMed  Google Scholar 

  18. Fledelius C, Kolding I, Bonde M, Cloos P, Christgau S (1996) Specificity of the crosslaps ELISA and the MabA7 ELISA. Osteoporosis Int 6(Suppl 1):PMO440

    Google Scholar 

  19. Forst J, Forst R, Heller K-D, Adam G (1998) Spontaneous osteonecrosis of the femoral condyle: causal treatment by early core decompression. Arch Orthop Trauma Surg 117:18–22

    Article  CAS  PubMed  Google Scholar 

  20. Garino JP, Lotke PA, Sapega AA, Reilly PJ, Esterhai JL Jr (1995) Osteonecrosis of the knee following laser-assisted arthroscopic surgery: a report of six cases. Arthroscopy 11:467–474

    Article  CAS  PubMed  Google Scholar 

  21. Garnero P, Borel O, Delmas P (2001) Evaluation of a fully automated serum assay for c-terminal cross-linking teleopeptide of type I collagen in osteoporosis. Clin Chem 47:694–702

    CAS  PubMed  Google Scholar 

  22. Gomez B Jr, Ardakani S, Ju J, Jenkins D, Cerelli MJ, Daniloff YN, Kung VT (1995) Monoclonal antibody assay for measuring bone-specific alkaline phosphatase activity in serum. Clin Chem 41:1560–1566

    CAS  PubMed  Google Scholar 

  23. Hall FM (2005) Osteonecrosis in the postoperative knee. Radiology 236:370–371

    Article  PubMed  Google Scholar 

  24. Hofmann S, Kramer J, Vakil-Adli A, Aigner N, Breitenseher M (2004) Painful bone marrow edema of the knee: differential diagnosis and therapeutic concepts. Orthop Clin North Am 35:321–333

    Article  PubMed  Google Scholar 

  25. Huskisson EC (1974) Measurement of pain. Lancet 2:1127–1131

    Article  CAS  PubMed  Google Scholar 

  26. Johnson TC, Evans JA, Gilley JA, DeLee JC (2000) Osteonecrosis of the knee after arthroscopic surgery for meniscal tears and chondral lesions. Arthroscopy 16:254–261

    Article  CAS  PubMed  Google Scholar 

  27. Kim HKW, Randall TS, Bian H, Jenkins J, Garces A, Bauss F (2005) Ibandronate for prevention of femoral head deformity after ischemic necrosis of the capital femoral epiphysis in immature pigs. J Bone Jt Surg 87:550–557

    Article  Google Scholar 

  28. La Montagna G, Malesci D, Tirri R, Valentini G (2005) Successful neridronate therapy in transient osteoporosis of the hip. Clin Rheumatol 24:67–69

    Article  PubMed  Google Scholar 

  29. Lai KA, Shen WJ, Yang CY, Shao CJ, Hsu JT, Lin RM (2005) The use of alendronate to prevent early collapse of the femoral head in patients with nontraumatic osteonecrosis. A randomized clinical study. J Bone Jt Surg Am 87:2155–2159

    Article  Google Scholar 

  30. Little DG, Peat RA, McEvoy A, Williams PR, Smith EJ, Baldock PA (2003) Zoledronic acid treatment results in retention of femoral head structure after traumatic osteonecrosis in young wistar rats. J Bone Miner Res 11:2016–2022

    Article  Google Scholar 

  31. Lotke PA, Battish R, Nelson CL (2001) Treatment of osteonecrosis of the knee. Instr Course Lect 50:483–488

    CAS  PubMed  Google Scholar 

  32. Lotke PA, Ecker ML (1988) Osteonecrosis of the knee. J Bone Jt Surg Am 70:470–473

    CAS  Google Scholar 

  33. Marulanda G, Seyler TM, Sheikh NH, Mont MA (2006) Percutaneous drilling for the treatment of secondary osteonecrosis of the knee. J Bone Jt Surg Br 88:740–746

    Article  CAS  Google Scholar 

  34. Muscolo DL, Costa-Paz M, Ayerza M, Makino A (2006) Medial meniscal tears and spontaneous osteonecrosis of the knee. Arthroscopy 22:457–460

    Article  PubMed  Google Scholar 

  35. Muscolo DL, Costa-Paz M, Makino A, Ayerza MA (1996) Osteonecrosis of the knee following arthroscopic meniscectomy in patients over 50-years old. Arthroscopy 12:273–279

    Article  CAS  PubMed  Google Scholar 

  36. Nguyen T, Zacharin MR (2006) Pamidronate treatment of steroid associated osteonecrosis in young patients treated for acute lymphoblastic leukaemia—two-year outcomes. J Pediatr Endocrinol Metab 19:161–167

    CAS  PubMed  Google Scholar 

  37. Nishii T, Sugano N, Miki H, Hashimoto J, Yoshikawa H (2006) Does alendronate prevent collapse in osteonecrosis of the femoral head? Clin Orthop Relat Res 443:273–279

    Article  PubMed  Google Scholar 

  38. Norman A, Baker ND (1978) Spontaneous osteonecrosis of the knee and medial meniscal tears. Radiology 129:653–656

    CAS  PubMed  Google Scholar 

  39. Pape D, Seil R, Anagnostakos K, Kohn D (2007) Postarthroscopic osteonecrosis of the knee. Arthroscopy 23:428–438

    Article  PubMed  Google Scholar 

  40. Patel DV, Breazeale NM, Behr CHT, Warren RF, Wickiewicz TL, O’Brien SJ (1998) Osteonecrosis of the knee: current clinical concepts. Knee Surg Sports Traumatol Arthrosc 6:2–11

    Article  CAS  PubMed  Google Scholar 

  41. Petje G, Radler C, Aigner N, Manner H, Kriegs-Au G, Grill F (2004) Pharmacological management of aseptic osteonecrosis in children. Expert Opin Pharmacother 5:1455–1462

    Article  CAS  PubMed  Google Scholar 

  42. Prues-Latour V, Bonvin JC, Fritschy D (1998) Nine cases of osteonecrosis in elderly patients following arthroscopic meniscectomy. Knee Surg Sports Traumatol Arthrosc 6:142–147

    Article  CAS  PubMed  Google Scholar 

  43. Ramachandran M, Ward K, Brown RR, Munns CF, Cowell CT, Little DG (2007) Intravenous bisphosphonate therapy for traumatic osteonecrosis of the femoral head in adolescents. J.Bone Jt Surg Am 89:1727–1734

    Article  Google Scholar 

  44. Ringe JD, Dorst A, Faber H (2005) Effective and rapid treatment of painful localized transient osteoporosis (bone marrow edema) with intravenous ibandronate. Osteoporos Int 16:2063–2068

    Article  CAS  PubMed  Google Scholar 

  45. Russell RG (2006) Bisphosphonates: from bench to bedside. Ann NY Acad Sci 1068:367–401

    Article  CAS  PubMed  Google Scholar 

  46. Santori N, Condello V, Adriani E, Mariani PP (1995) Osteonecrosis after arthroscopic medial meniscectomy. Arthroscopy 11:220–224

    Article  CAS  PubMed  Google Scholar 

  47. Schmidt-gayk H, Spanuth E, Kotting J, Bartl R, Felsenberg D, Pfeilschifter J, Raue F, Roth HJ (2004) Performance evaluation of automated assays for beta-crosslaps, N-MID-osteocalcin and intact parathyroid hormone (BIOROSE multicenter study). Clin Chem Lab Med 42:90–95

    Article  CAS  PubMed  Google Scholar 

  48. Tagil M, Astrand J, Westman L, Aspenberg P (2004) Alendronate prevents collapse in mechanically loaded osteochondral grafts: a bone chamber study in rats. Acta Orthop Scand 75:756–761

    Article  PubMed  Google Scholar 

  49. Varenna M, Zucchi F, Binelli L, Failoni S, Gallazzi M, Sinigaglia L (2002) Intravenous pamidronate in the treatment of transient osteoporosis of the hip. Bone 31:96–101

    Article  CAS  PubMed  Google Scholar 

  50. Wang CJ, Wang FS, Yang KD, Huang CC, Lee MS, Chan YS, Wang JW, Ko JY (2008) Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate. Arch Orthop Trauma Surg 128:901–908

    Article  CAS  PubMed  Google Scholar 

  51. Watson RM, Roach NA, Dalinka MK (2004) Avascular necrosis and bone marrow edema syndrome. Radiol Clin North Am 42:207–219

    Article  PubMed  Google Scholar 

  52. Yamamoto T, Bullough PG (2000) Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Jt Surg Am 82:858–866

    CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital, 4031, Basel, Switzerland

    Marius E. Kraenzlin & Christian Meier

  2. Department of Orthopedic Surgery, Bruderholz Spital, 4101, Bruderholz, Switzerland

    Christian Graf & Niklaus F. Friedrich

  3. Endocrine Practice and Laboratory, Missionsstrasse 24, 4055, Basel, Switzerland

    Marius E. Kraenzlin, Christian Meier & Claude Kraenzlin

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  1. Marius E. Kraenzlin
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  2. Christian Graf
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Correspondence to Marius E. Kraenzlin.

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Kraenzlin, M.E., Graf, C., Meier, C. et al. Possible beneficial effect of bisphosphonates in osteonecrosis of the knee. Knee Surg Sports Traumatol Arthrosc 18, 1638–1644 (2010). https://doi.org/10.1007/s00167-010-1106-4

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  • DOI: https://doi.org/10.1007/s00167-010-1106-4

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