A systematic review of the concept and clinical applications of Bone Marrow Aspirate Concentrate in Orthopaedics

INTRODUCTION: Mesenchymal stem cells (MSC's) are believed to have multipotent plasticity with the capability to differentiate along multiple cell lineages such as cartilage, bone, tendon, muscle, and nerve. Such multipotency has the potential to play an important role in the repair and reconstruction of multiple tissues across a number of orthopaedic specialties. Bone marrow and fat are the most abundant and accessible source of MSC's with bone marrow aspirate the most commonly being reported to stimulate healing. METHODS: This review examines the current reported 20 Q2 clinical applications of bone marrow aspirate concentrate and its effectiveness. RESULTS: The published studies reported techniques of collection and preparation of BMAC in addition to its applications in a number of orthopaedic sub-specialities. Studies could be sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (31), reconstruction of osseous defects/non-union (20), treatment of avascular necrosis (9), repair of cartilage defects (8), treatment of sports injuries and tendon injury/repair (9), injection in regenerative therapy (4), treatment of spine conditions (4) including enhancing postoperative fusion and degenerative disc pathology and orthopaedic oncology (4). A few published studies combined the use of platelet-rich plasma (PRP) with BMAC (4) or compared them in different applications (5). CONCLUSIONS: BMAC has been used in bone, cartilage and tendon injuries with encouraging results

A systematic review of the concept and clinical applications of bone marrow aspirate concentrate in tendon pathology

Tendon pathologies are a group of musculoskeletal conditions frequently seen in clinical practice. They can be broadly classified into traumatic, degenerative and overuse-related tendinopathies. Rotator cuff tears, Achilles tendinopathy and tennis elbow are common examples of these conditions. Conventional treatments have shown inconsistent outcomes and might fail to provide satisfactory clinical improvement. With the growing trend towards the use of mesenchymal stem cells (MSCs) in other branches of medicine, there is an increasing interest in treating tendon pathologies using the bone marrow MSC. In this article, we provide a systematic literature review documenting the current status of the use of bone marrow aspirate concentrate (BMAC) for the treatment of tendon pathologies. We also asked the question on the safety of BMAC and whether there are potential complications associated with BMAC therapy. Our hypothesis is that the use of BMAC provides safe clinical benefit when used for the treatment of tendinopathy or as a biological augmentation of tendon repair. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist while preparing this systematic review. A literature search was carried out including the online databases of PubMed, EMBASE, ClinicalTrial.gov and the Cochrane Library from 1960 to the end of May 2015. Relevant studies were selected and critically appraised. Data from eligible studies were extracted and classified per type of tendon pathology. We included 37 articles discussing the application and use of BMAC for the treatment of tendon pathologies. The Critical Appraisal Skills Program (CASP) appraisal confirmed a satisfactory standard of 37 studies. Studies were sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (n = 18), where five studies looked at the evaluation of aspiration techniques (n = 5), augmentation of rotator cuff tears (n = 5), augmentation of tendo-achilles tendon (n = 1), treatment of gluteal tendon injuries (n = 1), management of elbow epicondylitis (n = 2), management of patellar tendinopathy (n = 1) and complications related to BMAC (n = 5). Multiple experimental studies investigated the use of BMAC for tendon repair; nonetheless, there are only limited clinical studies available in this field. Unfortunately, due to the scarcity of studies, which were mainly case series, the current level of evidence is weak. We strongly recommend further future randomised controlled studies in this field to allow scientists and clinicians make evidence-based conclusions

Septic arthritis of the hip in adults with sickle cell anemia

Although the presence of osteonecrotic bone is known to make joints more prone to infection, acute septic joint in hip osteonecrosis has not frequently been reported in adults with sickle cell disease. The clinical features at the time of admission, imaging findings suggesting the diagnosis, modes of treatment and sequelae of septic arthritis of twenty-four hip joints with osteonecrosis in patients with sickle cell disease were studied retrospectively over a 25-years period. This study evaluated also the complications, the efficiency and the risk of total hip arthroplasty in these patients. Most patients were in the third decade of life. Staphylococcus and Gram negative infection predominated. Treatment was first conservative but most of the patients needed surgery to treat infection and sequelae related to infection. A total hip arthroplasty was performed later in twenty joints. No deaths were observed, but complications occurred. Twenty of the patients in our study underwent delayed total hip arthroplasties following repeated aspirations of the joint and intravenous antibiotics. With an experienced surgical and medical team and multidisciplinary management of these patients undergoing total hip arthroplasty after hip infection, our rate of complications was acceptable

Multifocal Joint Osteonecrosis in Sickle Cell Disease

The purpose of this study was to evaluate the frequency of multifocal osteonecrosis in patients with sickle cell disease. Between 1980 and 1989, 200 patients with sickle cell disease were treated in our institution for osteonecrosis. The patient population consisted of 102 males and 88 females with a mean age of twenty-six years at the time of presentation (range, eighteen to thirty-five years) and was followed until the year 2005. This cohort of patients was follow-up during average 15 years (until the year 2005). Multifocal osteonecrosis was defined as a disease of 3 or more anatomic sites. At the time of presentation, 49 patients were identified as having multifocal osteonecrosis. At the most recent follow-up, 87 patients had multifocal osteonecrosis. So at the last follow up among these eighty-seven patients, the occurrence of osteonecrosis was 158 lesions of the proximal femur associated with 151 proximal humerus osteonecroses, thirty-three lateral femoral condyle osteonecroses, twenty-eight distal femoral metaphysis osteonecroses, twenty-seven medial femoral condyle osteonecroses, twenty-three tibial plateau osteonecroses, twenty-one upper tibial metaphysis osteonecroses and forteen ankle osteonecroses. The total number of osteonecrosis was 455 in these 87 patients. The epiphyseal lesions were more frequent than the metadiaphyseal lesions excepted in the proximal tibia (Table 3). In conclusion, in patients with sickle cell disease, the risk of multifocal osteonecrosis is very high. In patients with hip osteonecrosis, the other joints should be evaluated with radiograph and MRI if the joint is symptomatic. In patients with osteonecrosis of the knee, shoulder or ankle, the patients’ hip should be evaluated by radiographs or MRI, regardless of whether the hip is symptomatic

Ex Vivo Evaluation of Cementless Acetabular Cup Stability Using Impact Analyses with a Hammer Instrumented with Strain Sensors

International audienceThe acetabular cup (AC) implant stability is determinant for the success of cementless hip arthroplasty. A method based on the analysis of the impact force applied during the press-fit insertion of the AC implant using a hammer instrumented with a force sensor was developed to assess the AC implant stability. The aim of the present study was to investigate the performance of a method using a hammer equipped with strain sensors to retrieve the AC implant stability. Different AC implants were inserted in five bovine samples with different stability conditions leading to 57 configurations. The AC implant was impacted 16 times by the two hammers consecutively. For each impact; an indicator I S (respectively I F) determined by analyzing the time variation of the signal corresponding to the averaged strain (respectively force) obtained with the stress (respectively strain) hammer was calculated. The pull-out force F was measured for each configuration. F was significantly correlated with I S (R 2 = 0.79) and I F (R 2 = 0.80). The present method has the advantage of not modifying the shape of the hammer that can be sterilized easily. This study opens new paths towards the development of a decision support system to assess the AC implant stability

Cell therapy in bone healing disorders

In addition to osteosynthetic stabilizing techniques and autologous bone transplantations, so-called orthobiologics play an increasing role in the treatment of bone healing disorders. Besides the use of various growth factors, more and more new data suggest that cell-based therapies promote local bone regeneration. For ethical and biological reasons, clinical application of progenitor cells on the musculoskeletal system is limited to autologous, postpartum stem cells. Intraoperative one-step treatment with autologous progenitor cells, in particular, delivered promising results in preliminary clinical studies. This article provides an overview of the rationale for, and characteristics of the clinical application of cell-based therapy to treat osseous defects based on a review of existing literature and our own experience with more than 100 patients. Most clinical trials report successful bone regeneration after the application of mixed cell populations from bone marrow. The autologous application of human bone marrow cells which are not expanded ex vivo has medico-legal advantages. However, there is a lack of prospective randomized studies including controls for cell therapy for bone defects. Autologous bone marrow cell therapy seems to be a promising treatment option which may reduce the amount of bone grafting in future

Change in Effective Leg Length after Angular Deformity Correction by Hemiepiphyseal Stapling

Background: The hemiepiphyseal stapling has both positive and negative effects on effective leg length. The purpose of this study was to analyze change in effective leg length after angular correction by hemiepiphyseal stapling, and to validate in clinical cases. Methods: Mathematical analysis of a hemiepiphyseal stapling model was conducted. The induced formula was validated in 6 cases fulfilling the assumptions of the model. Anatomical parameters involved in this formula were measured in additional 21 cases undergoing hemiepiphyseal stapling or hemiepiphysiodesis. Results: Effective leg length increased or decreased according to three parameters in this model: 1) limb length distal to the operated physis (L), 2) width of the operated physis (d), and 3) the amount of angular deformity to be corrected (θ). Actual change in effective leg length of 6 cases similar to this model coincided with the predicted change at least in its direction. L/d ratio was 4.82 ± 0.51. Conclusions: Considering the narrow range of the L/d ratio, hemiepiphyseal stapling is likely to decrease effective leg length if the amount of angular correction is less than 10°, whereas to increase it if the amount of angular correction is larger than 16°. This should be taken into consideration when selecting the surgical method for angular deformity correction in skeletally immature patients. © 2010 by The Korean Orthopaedic Association.Y

Sagittal realignment osteotomy for increased posterior tibial slope after opening-wedge high tibial osteotomy: a case report

A 40 year old welder who underwent opening-wedge high tibial osteotomy for correction of alignment in a varus knee developed persistent pain with loss of knee extension. The posterior tibial slope increased from 9 degrees to 20 degrees after the osteotomy and caused the anteromedial knee pain and limited extension. The patient then underwent a revision osteotomy using a closing wedge technique to correct tibial slope. The osteotomy was performed, first from the medial cortex in the lateral direction, and second in the anteroposterior direction to remove the tibial bone in wedge shape and obtain full extension of the knee. The posterior tibial slope decreased to 8 degrees after the revision osteotomy and the patients returned to pain-free daily life. We reviewed this unique technique for correction of sagittal malalignment using a closing-wedge osteotomy for revision after opening-wedge osteotomy