Bone Marrow Aspiration with Injection for Patellar Subchondral Bone Bruising
Bone marrow aspiration from the hip with injection into the patella (CPT 0707T) is NOT medically necessary for a 16-year-old with patellar subchondral bone bruising, as this represents an investigational orthobiologic procedure without established efficacy for bone bruising, and the available evidence addresses only cartilage defects in different anatomical locations.
Critical Context: Wrong Indication and Wrong Location
The proposed procedure fundamentally misapplies bone marrow aspirate concentrate (BMAC) technology:
Bone bruising is not a cartilage defect: Subchondral bone bruising represents bone marrow edema and microtrabecular injury, not the full-thickness chondral lesions that orthobiologic interventions target 1.
All available evidence addresses hip and knee osteoarthritis or hip chondral injuries, not patellar pathology and certainly not bone bruising 2, 3, 4.
The evidence for BMAC in hip arthroscopy specifically addresses acetabular cartilage damage and chondrolabral junction breakdown, with studies showing benefit only for moderate cartilage damage and full-thickness chondral flaps 4.
Evidence Limitations for This Specific Case
Population Mismatch
Published studies evaluate BMAC for early osteoarthritis (Kellgren-Lawrence grade I-II or Tönnis grade I-II) in adults, with mean ages of 58 years 2.
The 16-year-old patient with bone bruising represents a completely different pathophysiology than degenerative cartilage disease 2, 3.
Anatomical Location Issues
BMAC evidence exists for hip acetabular lesions and knee osteoarthritis, but not for isolated patellar bone bruising 2, 3, 4.
The patella presents unique biomechanical challenges with the highest contact pressures in the knee, making extrapolation from other locations inappropriate 1.
Intervention Type Mismatch
Joint-preserving surgical options for chondral injuries include microfracture for lesions <3 cm² with intact subchondral plate and healthy surrounding cartilage 1.
Bone bruising does not meet criteria for microfracture or BMAC, as these require full-thickness cartilage defects with exposed subchondral bone 1.
What the Evidence Actually Supports
For Hip Chondral Defects (Not Applicable Here)
Microfracture shows effectiveness for well-circumscribed grade 4 acetabular lesions <3 cm² with 93% fill at second-look arthroscopy 1.
BMAC augmentation during hip arthroscopy for moderate cartilage damage showed 77.6% of patients reaching minimal clinically important difference for functional outcomes at 12 months 4.
For Knee Osteoarthritis (Different Pathology)
BMAC injection for severe knee OA showed >50% reduction in pain scores at 2 and 12 weeks, but this addresses degenerative disease, not traumatic bone bruising 3.
Early knee OA (Kellgren-Lawrence I-II) treated with BMAC showed 63.2% satisfaction rate, but required failed conservative treatment for 6 months and excluded higher-grade disease 2.
Standard of Care for Patellar Bone Bruising
Conservative management remains the evidence-based approach:
Bone bruising typically resolves with protected weight-bearing, activity modification, and physical therapy over 6-12 weeks.
The patient has undergone "extensive physical therapy," but the timeline and specific interventions are not detailed—inadequate conservative treatment duration may explain persistent symptoms.
The VA/DoD guidelines recommend against premature surgical intervention when conservative measures remain viable options 1.
Critical Pitfalls in This Case
Procedural Concerns
No established technique exists for BMAC injection into patellar subchondral bone—the procedure lacks technical standardization 4.
Arthroscopic chondroplasty with "interosseous bone grafting" for bone bruising has no supporting evidence and may cause harm by disrupting healing bone 1.
Regulatory and Coverage Issues
CPT code 0707T represents a Category III (emerging technology) code, indicating the procedure is investigational and lacks proven clinical benefit.
The American College of Rheumatology guidelines emphasize that unproven interventions should not delay or replace established treatments 1.
Alternative Approach
For persistent patellar symptoms after physical therapy:
Ensure adequate conservative treatment duration (minimum 3-6 months of structured rehabilitation) 1.
Consider advanced imaging (MRI) to reassess for alternative pathology such as osteochondral lesions, patellar maltracking, or occult fracture.
If true full-thickness patellar cartilage defect is identified (not bone bruising), then consider established cartilage restoration techniques with proven efficacy 1.
Topical NSAIDs provide superior pain relief for knee pathology with fewer systemic side effects than oral medications 1.
Bottom Line
This procedure is not medically necessary because: (1) bone bruising is not an indication for BMAC or bone grafting, (2) the patella is not a validated anatomical site for this intervention, (3) the patient's age and pathology do not match any published evidence, and (4) conservative management has not been exhausted with adequate duration and documentation 2, 3, 4. The proposed surgery represents an off-label application of an investigational technique for an inappropriate indication.