Hitting the Mark: Optimizing the Use of Calcium Phosphate Injections for the Treatment of Bone Marrow Lesions of the Proximal Tibia and Distal Femur 

Presentation on theme: "Hitting the Mark: Optimizing the Use of Calcium Phosphate Injections for the Treatment of Bone Marrow Lesions of the Proximal Tibia and Distal Femur "— Presentation transcript:

1 Hitting the Mark: Optimizing the Use of Calcium Phosphate Injections for the Treatment of Bone Marrow Lesions of the Proximal Tibia and Distal Femur  Brian J. Rebolledo, M.D., Kevin M. Smith, M.D., Jason L. Dragoo, M.D.  Arthroscopy Techniques  Volume 7, Issue 10, Pages e1013-e1018 (October 2018) DOI: /j.eats Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

2 Fig 1 Patient positioning and room setup. The patient is placed in the supine position on a radiolucent table (left leg shown). A radiolucent bump is used under the knee, which elevates the operative extremity and allows for unobstructed anteroposterior and lateral fluoroscopic images. Standard arthroscopic instruments are set up for arthroscopy, which will be performed after completing the injection of calcium phosphate. Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

3 Fig 2 A true AP view of the knee is obtained while using a radiopaque surgical tool (clamp, injecting cannula, etc.) to localize the targeted area before incision. (AP, anteroposterior.) Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

4 Fig 3 Preoperative coronal MRI of lateral tibial plateau bone marrow lesion. The fluoroscopic AP image should be referenced to the preoperative coronal MRI to ensure that the bone marrow lesion has been appropriately located. (AP, anteroposterior; MRI, magnetic resonance imaging.) Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

5 Fig 4 A perfect lateral radiograph of the knee is obtained using the cannula to localize the target area as determined by preoperative sagittal magnetic resonance imaging. The skin is marked to establish the position in the lateral dimension. Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

6 Fig 5 The location of the symptomatic bone marrow lesion on the sagittal and coronal magnetic resonance imaging scans must be correlated on fluoroscopic imaging. (AP, anteroposterior.) Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

7 Fig 6 The fluoroscopic lateral image should be referenced to the preoperative sagittal MRI to ensure that the bone marrow lesion has been appropriately located. (MRI, magnetic resonance imaging.) Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

8 Fig 7 Using the skin markings to match positions on the anteroposterior and lateral imaging, a vertical 2-cm incision is made through skin and underlying subcutaneous tissue. This incision allows the debridement or irrigation of any extravasated cement from the soft tissues. Dissection is then carried down to bone using a hemostat, and soft tissue is cleared to prevent interposition between the cannula and cortex. Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

9 Fig 8 The cannula is drilled into position under fluoroscopic guidance that matches the BML on magnetic resonance imaging. The goal is to remain parallel to the joint surface and to remain immediately below the articular surface, with ideal placement of the cannula <1 cm from the articular surface. The proximity of the cannula to the joint line is a critical consideration. No portion of the BML toward the joint surface should be left without cement treatment. The cannula should be positioned to initially treat the area of the BML that is farthest from the starting point of the needle. (BML, bone marrow lesion.) Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

10 Fig 9 The injectable calcium phosphate is delivered to the subchondral bone under fluoroscopic guidance; this is performed with a slow and gentle pressure during the injection process to allow the marrow cavity pressure to equilibrate and prevent excessive postoperative pain. If resistance during injection is experienced in side-targeted cannula delivery, then the cannula should be rotated to fill in a different direction. This strategy allows for 360° delivery of calcium phosphate injection around the cannula. If a larger area is affected, then the cannula can be pulled back toward the starting point to target a more peripheral area that remains parallel to the articular surface and is along the subchondral bone; however, a second cortical puncture should not be made because it will allow cement extravasation. Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions

11 Fig 10 After waiting 7 minutes for the calcium phosphate to harden, knee arthroscopy is performed, allowing for the removal of any calcium phosphate that may have extruded into the joint. This risk may be increased if (1) there are insufficiency fractures present that violate the subchondral plate or (2) if the cement was injected into the distal femur, because more of the distal femur is intra-articular. Cement particles encountered within the joint are brittle and prone to fragment if using an arthroscopic grasper. Suction alone or the use of a large-diameter arthroscopic shaver is typically used to remove any cement debris. Arthroscopy Techniques 2018 7, e1013-e1018DOI: ( /j.eats ) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions