Intraosseous Delivery of Autologous Biologic Therapies for Osteoarthritis

APEX Biologix
10 min read

APEX Webinar Recap Featuring Dr. Walter Sussman l April 2026

Osteoarthritis (OA) has long been viewed as a cartilage problem. But what if we’ve been focusing on only half the picture?

In a recent APEX educational webinar, Dr. Walter Sussman, board-certified PM&R and Sports Medicine specialist, explored one of the most exciting shifts in regenerative medicine today - treating the osteochondral unit, including subchondral bone,  through intraosseous delivery of autologous biologic therapies.

The result? A fresh framework for understanding joint pain, patient selection, and long-term outcomes in OA care.

Why Bone Matters in Osteoarthritis

Traditional OA treatment often centers on cartilage loss, narrowing joint space, and symptom management with injections or medication.

But Dr. Sussman emphasized that subchondral bone plays a critical role in:

    • Mechanical support of cartilage
    • Shock absorption
    • Metabolic signaling
    • Pain generation via nociceptive nerve fibers

MRI imaging frequently reveals bone marrow lesions (BMLs) even when X-rays appear relatively normal.

“If we’re not looking for these lesions, we may be missing half the picture.” - Dr. Walter Sussman

Two Different OA Patients = Two Different Treatment Paths

Dr. Sussman shared a highly practical clinical framework:

The Inflammatory Knee

Symptoms:

    • Achy
    • Throbbing
    • Stiff
    • Night pain

Often responds well to:

    • Intra-articular platelet-rich plasma (PRP)
    • Bone marrow aspirate concentrate (BMAC)
    • Viscosupplementation
    • Anti-inflammatory strategies

The Load-Sensitive Knee

Symptoms:

    • Sharp pain with weight-bearing
    • Medial joint line pain
    • Some relief with unloading or bracing

These patients often experience limited improvement with traditional intra-articular injections and may be stronger candidates for intraosseous biologic treatment targeting the subchondral bone.

What Are Bone Marrow Lesions Telling Us?

BMLs are more than imaging findings, they may be powerful predictors of disease progression.

Dr. Sussman reviewed studies showing:

  • Larger BMLs correlate with painful knees

  • Presence of BMLs increases likelihood of OA progression

  • Extensive lesions may predict progression to total knee arthroplasty

One study cited showed patients with larger lesions were up to 13x more likely to require knee replacement.

Intraosseous Biologics: What Does the Evidence Show?

This was one of the most compelling parts of the webinar.

Studies comparing intra-articular vs intraosseous biologic injections demonstrated:

Better Pain Relief

Patients receiving combined intra-articular + intraosseous PRP demonstrated greater pain reduction than joint injections alone.

Better Function

BMAC delivered intraosseously showed improved functional outcomes over intra-articular treatment.

Possible Disease Modification

Some patients demonstrated:

    • Increased fibrocartilage volume on MRI
    • Resolution of bone marrow lesions
    • Delayed progression toward surgery

15-Year Follow-Up Data

Perhaps most impressive: 82% of patients receiving intraosseous BMAC avoided total knee replacement at 15 years.  

PRP or BMAC: Which Should You Choose?

Dr. Sussman addressed a common question: should clinicians recommend PRP or BMAC?

His perspective:

      • PRP may be cost-effective in many settings
      • But for subchondral lesions, the long-term BMAC data is especially compelling

Meniscus + Bone + Joint = Treat the Whole Knee

Another valuable takeaway: consider OA as a whole-joint disease.

When meniscal pathology coexists with BMLs, combining:

    • Intra-meniscal PRP
    • Intra-articular treatment
    • Intraosseous biologics

may provide stronger outcomes than isolated treatment alone.

Final Takeaway

By understanding the role of the osteochondral unit and targeting the pain-generating subchondral bone, clinicians may unlock new options for patients who have historically had few.

“There are breadcrumbs in the literature showing us how we should be practicing.” - Dr. Walter Sussman

Missed the Webinar?

Watch the on-demand replay of the APEX Webinar featuring Dr. Walter Sussman to learn how intraosseous biologic therapies are reshaping osteoarthritis care and patient outcomes.

You can also explore the APEX Resource Library for additional clinical education, webinar replays, treatment insights, and regenerative medicine resources designed to support providers in advancing patient care.

Hands-On Regenerative Medicine Training at the XCELL Learning Center

Clinicians interested in advancing their regenerative medicine skills can participate in immersive training programs at the XCELL Learning Center in Clearwater, Florida.

Programs include:

  • Hands-on procedural training

  • Cadaver-based workshops

  • Faculty-led education from leaders in orthobiologics

Explore upcoming training opportunities designed to support responsible adoption of regenerative medicine, visit: xclearningcenter.com

References

Su, K., et al. Comparison of hyaluronic acid and PRP intra-articular injection with combined intra-articular and intraosseous PRP injections to treat patients with knee osteoarthritis. Clin Rheumatol. 2018;37(5):1341-1350. doi: 10.1007/s10067-018-3985-6

Hernigou, P., et al. Subchondral bone or intra-articular injection of bone marrow concentrate mesenchymal stem cells in bilateral knee osteoarthritis: what better postpone knee arthroplasty at fifteen years? A randomized study. Int Orthop. 2021;45(2):391-399. doi: 10.1007/s00264-020-04687-7

Hernigou, P., et al. Human bone marrow mesenchymal stem cell injection in subchondral lesions of knee osteoarthritis: a prospective randomized study versus contralateral arthroplasty at a mean fifteen year follow-up. Int Orthop. 2021;45(2):365-373. doi: 10.1007/s00264-020-04571-4

Zhang, K., et al. The Combined Intraosseous Administration of Orthobiologics Outperformed Isolated Intra-articular Injections in Alleviating Pain and Cartilage Degeneration in a Rat Model of MIA-Induced Knee Osteoarthritis. Am J Sports Med. 2024;52(1):140-154. doi: 10.1177/03635465231212668

Malanin, D., et al. Intraosseous Injection of Autologous Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma for Treatment of Knee Osteoarthritis. Traumatol Orthop Russ. 2021;27(4):69-81. doi: 10.21823/2311-2905-1669

Nicolella, D., et al. Mechanical contributors to sex differences in idiopathic knee osteoarthritis. Biol Sex Differ. 2012;3(1):28. doi: 10.1186/2042-6410-3-28

Audrey, H., et al. The truth behind subchondral cysts in osteoarthritis of the knee. Open Orthop J. 2014;8:7-10. doi: 10.2174/1874325001408010007

Li, G., et al. Subchondral bone in osteoarthritis: insight into risk factors and microstructural changes. Arthritis Res Ther. 2013;15(6):223. doi: 10.1186/ar4405

Favreau, H., et al. Knee Osteoarthritis Diagnosis: Future and Perspectives. Biomedicines. 2025;13(7):1644. doi: 10.3390/13071644

Hu, W., et al. Microenvironment in subchondral bone: predominant regulator for the treatment of osteoarthritis. Ann Rheum Dis. 2021;80(4):413-422. doi: 10.1136/218089

Felson, D., et al. The association of bone marrow lesions with pain in knee osteoarthritis. Ann Intern Med. 2001;134(7):541-549. doi: 10.7326/0003-4819-134-7-200104030-00007