Finally, a step forward in nomenclature of subchondral nonneoplastic bone lesions

Abstract

This paper is a commentary on the article entitled “Nomenclature of Subchondral Nonneoplastic Bone.

Lesions1” by Gorbachova, Amber, Beckmann, Bennett, Chang, Davis, Gonzalez, Hansford, Howe, Lenchik, Winalski, and Bredella. The purpose of this commentary is to provide an orthopaedic perspective on the aforementioned article and critique their analysis and proposal regarding nomenclature of subchondral bone lesions. It provides an overview and a section by section evaluation of a well-designed and executed article.

The paper entitled “Nomenclature of Subchondral Nonneoplastic Bone Lesions [1]” by Gorbachova, Amber, Beckmann, Bennett, Chang, Davis, Gonzalez, Hansford, Howe, Lenchik, Winalski, and Bredella is a welcome addition and clarification to what is a muddied and confusing pool of terms used to describe subchondral pathologies. The proposed revised nomenclature has been well thought out on a clinical, histopathologic, and imaging basis, taking into account history of injury and chronicity when applying specific phrasing. As an orthopedic surgeon, the universal adoption of this nomenclature will not only help with communication of the underlying disease process, but will also aid in prognosis and treatment which an ideal classification does. In my opinion, as both radiologists and orthopedic surgeons, we too often loosely use terms such as “bone edema” and “bone bruises” without fully understanding the underlying pathologic processes and implications. This article represents an applauded step towards universalization of appropriate terminology and improved understanding.

Generally speaking, I understand the rationale and concur with the proposed terms put forth in this paper but there are some highlights from an orthopaedic standpoint. The discussion of “edemalike marrow signal” and the avoidance of the term “bone marrow lesion” in the situations where pathologies lack specificity. The term bone marrow lesions can cause confusion and undue anxiety on physicians at times, but also on patients reading their reports. One of the most important discussions in the paper centers around “osteochondral lesions” and the importance of clarification when possible rather than a waste basket usage of this term. This becomes especially important in the setting of osteochondral defects and osteochondritis dissecans as proper evaluation and terminology of the pathology helps to drive decision-making and ultimately surgical vs non-surgical treatments. This is also true of epiphyseal or cartilage collapse as improper use has the potential for patient harm. For instance, as pointed out in the discussion in the paper, once articular collapse has occurred the typical disease process resulting in that collapse is non-reversible and most oftentimes progressive. Therefore, if articular collapse is used improperly a patient may undergo unnecessary surgical intervention. The same can also be said for osteonecrosis and transient osteoporosis of the hip as well as the other categories but there is no need to belabor the point as the authors do a nice job laying it out in the paper itself. Here is a brief commentary from an orthopaedic perspective presenting the material as they did in the original paper. Please refer to that paper for the full description and reasoning for normalizing terminology.