Clinical application of concentrated bone marrow aspirate in orthopaedics: A systematic review

Table 2 Studies evaluating concentrated bone marrow aspirate in the treatment of osteochondral defects

Ref.	Tissue	BMAC preparation	Concen-tration	Study design/methods/follow up	Outcomes measured	Results	LOE
Buda et al[11]	OCL of talus	Scaffold was a hyaluronic acid membrane loaded with previously cultured chondrocytes (ACI) or with BMAC. Platelet rich fibrin gel was produced the day before surgery using Vivostat System 1 (vivolution A/S). Harvested and processed 120 mL of the patient’s venous blood to obtain 6 mL of platelet rich fibrin gel. 60 mL BMA was harvested from posterior iliac crest using Smart PRepI to obtain 6 mL of BMAC. 1 g powder mixed with 2 mL BMAC and 1 mL platelet rich fibrin gel. The hyaluronic acid membrane was cut and loaded with 2 mL BMAC and 1 mL platelet rich fibrin gel. A layer of platelet rich fibrin gel was placed over the implant once in place to provide additional stability	NS	n (total) = 80: (1) n = 40 - autologous chondrocytes implantation; (2) n = 40 with BMAC. Follow up: 48 mo	Clinical scores, XR, MRI Mocart score, T2 mapping	Groups had similar results at 48 mo. No statistically significant difference in clinical outcomes. Return to sport was slightly better with BMAC. MRI MOCART score was similar in both groups. T2 mapping highlighted a higher presence of hyaline like values and lower incidence of fibrocartilage in BMAC group	IV
Buda et al[12]	OCL of knee	Combined with either MAST or HA matrix	NS	n = 30. One step arthroscopic BMAC transplant with scaffold. Follow up: 29 mo	Clinical inspection, MRI, IKDC, KOOS	Good clinical outcome and osteochondral regeneration on MRI and biopsies in both groups	IV
Buda et al[13]	OCL of talus	Scaffolds either: (1) porcine collagen powder SpongostanI Powder (J and J) mixed with autologous cell concentrate and platelet gel; or (2) hyaluronic acid membrane (fidia advanced biopolymers) with addition of platelet gel. Platelet rich fibrin gel was produced the day before surgery using Vivostat System 1 (vivolution A/S). Harvested and processed 120 mL of the patient’s venous blood to obtain 6 mL of platelet rich fibrin gel. 60 mL BMA was harvested from posterior iliac crest using Smart PRepI to obtain 6mL of BMAC. 1 g powder mixed with 2 mL BMAC and 1ml platelet rich fibrin gel. The hyaluronic acid membrane was cut and loaded with 2 mL BMAC and 1 mL platelet rich fibrin gel. A layer of platelet rich fibrin gel was placed over implant once in place to provide additional stability	NS	n = 64. One step arthroscopic BMAC transplant with scaffold (collagen powder of hyaluronic acid membrane) and platelet gel. Follow up: 53 mo	AOFAS scale score, radiographic, scaffold type, lesion area, previous surgery, lesion depth	Mean preop AOFAS was 65.2. Regardless of scaffolding type all patients showed similar pattern of clinical improvement at each follow-up. No correlation between area of lesion and pre-op AOFAS score but did observe relationship between area and AOFAS at each follow up post-operatively. No relationship between AOFAS score and depth of lesion	IV
Buda et al[14]	OCL of knee	Scaffold either MAST or HA matrix + PRF	NS	n = 20. Follow up: 24 mo	Clinical, MRI	Significant improvement at 12 and 24 mo, satisfactory MRI	IV
Giannini et al[15]	OCL of talus	Porcine collagen powder (J and J) or hyaluronic membrane scaffold. 60 mL of bone marrow harvested from posterior iliac crest and concentrated by SmartPrep to 6 mL of BMC. One step delivery system	NS	n = 49 received either BMA with collagen scaffold or BMA with HA membrane scaffold. Follow up: 48 ± 6 mo	AOFAS, radiograph, MRI	AOFAS improved P < 0.0005. T2 mapping analysis showed regenerated tissue with T2 values similar to hyaline cartilage in a mean of 78% of the repaired lesion area	IV
Giannini et al[16]	OCL of talus	One step arthroscopic transplantation. Platelet gel using Vivostat system. 60 mL BMA harvested from posterior iliac crest. Concentrated using SmartPReP in order to obtain 6 mL of concentrate. Scaffold: Either collagen powder (Spongostan1 Powder) or hyalyronic acid membrane. Scaffold was loaded with 2 mL BMAC and 1 mL PRF	NS	n = 25 in BMAC group. Study also compared to ACI	AOFAS, histology	Statistically significant improvement in mean AOFAS scores post-operatively (P < 0.0005). Only 1 superficial infection noted. Nearly homogeneous regenerated tissue on MOCART MRI in 82% of cases. Hypertrophy found in 2 cases on histology	IV
Giannini et al[17]	OCL of talus	Porcine collagen powder (J and J) or hyaluronic membrane scaffold. 60 mL of bone marrow harvested from posterior iliac crest and concentrated by SmartPrep to 6 mL of BMC. One step delivery system	NS	(1) n = 23 - Collagen scaffold + BMA; (2) n = 25 HA membrane scaffold + BMA. Follow up: 29 mo (24-35)	AOFAS, histology	AOFAS improved, Histology showed regenerated tissue in various degrees of remodeling	IV
Gobbi et al[18]	OCL of knee	Hyaluronic acid-based scaffold was used with BMAC	6 × baseline	n = 25 HA-BMAC, n = 25 microfracture. Observed prospectively for 5 yr	Patient-reported scoring tools: IKDC Subjective Knee Evaluation, KOOS, Lysholm Knee Questionnaire, and Tegner activity scale	Microfracture - 64% normal/nearly normal according to IKDC objective score at 2 yr and declined to 28% at 5 yr	II
		60 cc of BMA from Iliac Crest spun to 6 × normal concentration. Batroxobin enzyme used to activate BMAC				HA-BMAC - 100% normal/nearly normal objective IKDC at 2 yr, 100% at 5 yr for ALL outcomes measured
Hannon et al[19]	OCL of talus	60 mL of BMA from ipsilateral iliac crest, concentrated by Arteriocyte Magellan Autologous Platelet Separator System to obtain 3 mL of BMAC	NS	(1) n = 12 BMS; (2) n = 22 BMAC+BMS. Follow up: 48.3 mo for BMAC + BMS, 78.3 mo for BMS	AOFAS, FAOS, SF-12, MOCART	Mean FAOS and SF-12 PCS scores improved pre to post operatively (P < 0.01) for both groups. MOCART score significantly higher in cBMA + BMS (P = 0.023). T2 relaxation values in cBMA + BMS group significantly higher with measurements of adjacent cartilage	III
Kennedy et al[2]	OCL of talus	60 mL of BMA from ipsilateral iliac crest, concentrated by commercially available BMAC centrifuge system to obtain 4 mL of pluripotent cells	NS	n = 72. AOT with BMAC. Follow up: 28 mo	FAOS, SF-12	FAOS, SF-12 significantly improved from pre to post-op	III

KOOS: Knee injury and Osteoarthritis Outcome Score; NS: Not significant; OCL: Osteochondral lesions; BMA: Bone marrow aspirate; MRI: Magnetic resonance imaging.