Zoledronic acid is more efficient than ibandronic acid in the treatment of symptomatic bone marrow lesions of the knee

Knee Surg Sports Traumatol Arthrosc. 2020 Feb;28(2):408-417. doi: 10.1007/s00167-019-05598-w. Epub 2019 Jul 4.


Purpose: The purpose of this study was to determine the efficacy and tolerability of different antiresorptive therapeutic regimens for treating symptomatic bone marrow lesions (BML) of the knee.

Methods: Patient records of 34 patients with radiologically diagnosed, painful BML of the knee treated with either a bisphosphonate (zoledronic, ibandronic, or alendronic acid) or with a human monoclonal antibody (denosumab) were retrospectively evaluated. Response to treatment was assessed, as change in patient-reported pain, by evaluation of BML expansion on MRI using the Whole-Organ Magnetic Resonance Imaging Score (WORMS), and by laboratory analysis of bone turnover markers: C-terminal cross-linking telopeptide (CTx) and procollagen type 1 amino-terminal propeptide (P1NP). Tolerability was evaluated by documentation of adverse reactions.

Results: Zoledronic acid was more or at least equally effective as the other treatment regimens with response to treatment in 11 of 12 patients (92%). The highest rate of adverse events was noted in 4 of 12 patients (33%) treated with zoledronic acid. CTx and WORMS differentiated well between responders and non-responders, whereas P1NP failed to do so. Changes in pain correlated moderately with change in WORMS (r = - 0.32), weakly with change in CTx (r = - 0.07), and not at all with change in P1NP.

Conclusion: Zoledronic acid appeared to be more effective than other antiresorptive medications-at the cost of more frequent adverse events. While radiological and laboratory evaluation methods may allow for objective treatment monitoring, they appear to capture different dimensions than patient-reported pain.

Level of evidence: III.

Keywords: Antiresorptive medication; Biphosphonate; Bisphosphonates; Bone bruise; Bone marrow lesion; Bone marrow oedema; Bone turnover marker; Magnetic resonance imaging (MRI); Transient osteoporosis.

MeSH terms

  • Aged
  • Arthralgia / etiology
  • Arthralgia / prevention & control
  • Biomarkers / metabolism
  • Bone Density Conservation Agents / therapeutic use*
  • Bone Marrow Diseases / complications
  • Bone Marrow Diseases / diagnostic imaging
  • Bone Marrow Diseases / drug therapy*
  • Collagen Type I / metabolism
  • Denosumab / therapeutic use
  • Dietary Supplements
  • Diphosphonates / therapeutic use
  • Female
  • Humans
  • Ibandronic Acid / therapeutic use*
  • Male
  • Middle Aged
  • Peptide Fragments / metabolism
  • Peptides / metabolism
  • Procollagen / metabolism
  • Retrospective Studies
  • Vitamin D / therapeutic use
  • Zoledronic Acid / therapeutic use*


  • Biomarkers
  • Bone Density Conservation Agents
  • Collagen Type I
  • Diphosphonates
  • Peptide Fragments
  • Peptides
  • Procollagen
  • collagen type I trimeric cross-linked peptide
  • procollagen Type I N-terminal peptide
  • Vitamin D
  • Denosumab
  • Zoledronic Acid
  • Ibandronic Acid