Optimizing bone marrow harvesting sites for enhanced mesenchymal stem cell yield and efficacy in knee osteoarthritis treatment

Table 2 Clinical application of bone marrow from various anatomical locations

Anatomical site	Clinical application	Advantages	Drawbacks	Clinical considerations
Iliac crest	Gold standard site for BMAC harvesting, widely used in regenerative therapies for knee OA due to high progenitor cell yield. High culture success rate for MSCs	High nucleated cell and clone forming unit yield, extensive clinical experience, and literature supporting efficacy. MSC yield is superior and the culture success rate can reach up to 90%	Associated with donor-site morbidity, including pain, hematoma, and nerve injury. Requires a secondary surgical site, increasing invasiveness	Preferred in cases where maximum progenitor cell yield is critical. Established protocols and extensive use in knee OA treatment. Potential for postoperative complications
Proximal humerus	Emerging alternative, commonly used in shoulder surgeries such as rotator cuff repair. Offers high-quality BMAC without a secondary incision	No need for separate incisions during shoulder procedures, and high progenitor cell yield even after large volume aspirations. Reliable across patient age groups	Primarily useful in shoulder surgeries, less studied compared to the iliac crest, though efficacy is promising	Best for minimizing patient morbidity in shoulder surgeries, with comparable efficacy to iliac crest BMAC. Convenient for combined procedures
Acetabulum	Primarily used in hip surgeries, where BMAC harvesting can occur within the same surgical field, offering dual-purpose potential. Useful for hip-related therapies	Convenient for hip-related procedures, high progenitor cell counts comparable to the iliac crest. Single-session harvesting and BMAC preparation	Limited to hip-related procedures, indirect application in knee OA treatment	Suited for scenarios where a dual-purpose approach is needed, particularly in hip surgeries. Produces high-quality BMAC but is limited to specific surgeries
Distal femur	Anatomically accessible during knee surgeries, particularly TKA. Can be seamlessly integrated with the procedure for autologous therapies	Easy anatomical access during knee surgeries, minimally invasive, lower complication risk, and integrated into surgical workflow. MSCs show similar differentiation potential to those from the iliac crest	Lower MSC yield compared to iliac crest (0.67 million cells/mL vs 10.05 million cells/mL). Slightly lower MSC culture success rate	A viable alternative when iliac crest access is limited or undesirable. Moderate MSC culture success rate (approximately 71%) but lower yield. Beneficial in knee OA treatments integrated with TKA
Proximal tibia	Similar to the distal femur, the proximal tibia can be harvested during knee surgeries like TKA. Lower MSC yield compared to the iliac crest but viable for knee OA therapy	Reduces invasiveness, less risk of complications. Easier access in knee surgeries. MSCs exhibit robust differentiation capacity, although yield is lower than iliac crest	Lower MSC yield than iliac crest (1.70 million cells/mL vs 10.05 million cells/mL). MSC culture success rate is around 47%	Suitable alternative for patients contraindicated for iliac crest harvesting. Moderate MSC yield and culture success rate (approximately 47%). Useful in knee-focused procedures

BMAC: Bone marrow aspirate concentrate; MSC: Mesenchymal stem cell; OA: Osteoarthritis; TKA: Total knee arthroplasty.