Disclosures: Matthew R. Robinson, DO: Nothing to disclose

Case Description: Osteonecrosis is a known cause of pain and has previously been associated with long-term bisphosphonates with regard to the jaw. This case report outlines a patient prescribed bisphosphonates with professional/extracurricular repetitive knee trauma who developed osteonecrosis that was successfully treated with prolotherapy to tissues surrounding the left lateral femoral condyle.

Setting: VA-based outpatient Pain clinic.

Patient: The patient is a 75-year-old male with history of osteoporosis on weekly alendronate who reported repetitive knee trauma working as a mechanic and participating in gardening and yoga for several hours per day. He developed focal left lateral knee pain suspicious of osteonecrosis on radiographic plain films. All other knee physical exam findings were negative.

Assessment/Results: An MRI later confirmed osteonecrosis of the left lateral femoral condyle. The patient failed conservative therapy and deemed nonsurgical per Orthopedic surgery referral. Thus, the patient agreed to a trial of prolotherapy. The patient reported complete resolution of knee pain on follow-up visits 1, 6, and 8 months later.

Discussion: Prolotherapy is hypothesized to cause cell death leading to release of various growth factors that cause a local inflammatory response resulting in the production of type one and three collagen. Additionally, it is hypothesized that analgesia may be related to a direct effect on nerves via a sclerosing mechanism on vasa nervorum and destruction of myelin lamellae. No changes were seen on follow-up MRI and we are unable to place prolotherapy injectate directly into necrotic bone making this an unlikely etiology of improvement. Thus, we hypothesize this analgesia is more appropriately related to the direct effect of prolotherapy on nearby sensory nerves.

Conclusion: Regardless of the cause of osteonecrosis, the patient benefited from targeted prolotherapy to his lateral knee. This is a pathology not addressed in previous prolotherapy literature and requires further research to support the utility of prolotherapy in treating osteonecrosis-mediated pain.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/lateral-femoral-condyle-osteonecrosis-after-prolonged-bisphosphonate-use-and-subsequent-management-with-prolotherapy-a-case-report/