case_images: PMC7100546_01
case_images: BMAC intervention strategy to treat femoral head ON. Bone marrow (BM) aspiration was performed from the posterior superior iliac crest area and the BM aspirate was concentrated (BMAC) using a commercial filtration system to concentrate the mononuclear fraction containing BMSC and BM-EPC. Five sequential intralesional and intraarticular BMAC injection sessions were performed in both knees using ultrasound guidance. Twelve months post-treatment radiological improvements were observed in previously ON areas that supported the positive clinical progression.
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case_images: F1
case_images: Under sterile conditions, the BM aspiration site (Posterior Superior Iliac Spine:PSIS) was marked upon visualization with ultrasound guidance, followed by injection of 2% lidocaine in the soft tissue and periosteum (Figure 1). The injections were performed under local anesthesia, sterile conditions and ultrasound guidance, using a 18-gauge 3.5-inch needle inserted 2 cm deep into the condyle bone (Figure 1).
case_images: BMA enrichment using filtration system. (A) CD45- CD44+ CD90+ CD105+ MSC/EPC subpopulation was enriched after BMA concentration. Isotype controls were used to exclude background staining. (B) Upon BMAC seeding in vitro, passage 2 cultures showed MSC-related phenotypic profile and tripotential differentiation capacity. Generated MSC cultures were negative for CD14, CD34, CD45, and highly positive (>90%) for CD73, CD90, CD105, CD166 markers. Differentiation was evident on day 21 for osteogenesis by mineral deposit (Alizarin Red staining), for adipogenesis by lipid accumulation (Oil Red staining), and for chondrogenesis by glycosaminoglycan production (Alcian Blue staining). Control cultures showed no differentiation capacity for all inductions tested.
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case_images: F2
case_images: MSC/EPC subpopulation enrichment (43% of total) (Figure 2A). MSC-related phenotypic profile and tri-potentiality (bone-fat-cartilage) was established in BMAC cells cultured for two passages in vitro (Figure 2B).
case_images: Evaluation of patient-reported outcomes measurement (PROM). Patient had significantly improved VAS, WOMAC and KOOS between 1 and 3 months after BMAC injections for both knees. Thereafter, all clinically validated scores showed stable values between 3 and 12 months supporting the positive clinical progression.
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case_images: F3
case_images: Clinically, the PROM showed significant improvement over time, starting right after the end of the sequential therapy one (1) month after its start and for a 24-months follow-up (Figure 3).
case_images: Radiological evaluation of ON affected areas by magnetic resonance imaging (MRI). (A) Pre-treatment sagittal and axial T2FS MRI indicated extensive bilateral ON and bone infarction, particularly of lateral femoral condyles and anterior weight-bearing surfaces of the medial femoral condyle. (B) Post-treatment sagittal and axial T2FS MRI showed in both knees bone maturation in ON areas, less BM edema, and reduced subchondral fluid.
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case_images: F4
case_images: With exception of the lateral condyle of the right knee, which showed persistent irregularities and fragmentation/collapse of the central and posterior weight bearing surfaces, the rest of structures did not show signs of collapse or fragmentation (Figure 4).