Platelet-rich plasma vs bone marrow aspirate concentrate: An overview of mechanisms of action and orthobiologic synergistic effects

Table 1 Relevant article conclusions (preclinical and clinical) in the pertinent literature on the use of bone marrow aspirate concentrate-platelet-rich plasma products and the comparison between both products

Ref.	Conclusions
Moatshe et al[3] (2017)	Strong data supporting the optimal preparation methods and composition for widely used biologic agents, such as PRP and BMAC, largely remain absent from the literature
Yamaguchi et al[8] (2019)	Different formulations of biomaterials have been used as carriers for PRP and BMAC in order to increase regenerative processes. The most common biomaterials utilized in conjunction with PRP and BMAC clinical trials are organic scaffolds and natural or synthetic polymers
Burnham et al[55] (2019)	Evidence for use of percutaneous, fluoroscopy-guided, intradiscal PRP or BMAC for the treatment of suspected discogenic low back pain appears safe, potentially positive but is limited due to low-quality studies, natural history of discogenic pain, and variable reporting characteristics
Rubio-Azpeitia et al[58] (2014)	Overall PRP stimulates MSC proliferation, preserves MSCs multipotency and does not interfere with any lineage differentiation. PRP (as platelet lysate or releasate) preserves the immune-privileged potential of MSCs and may delay the appearance of the senescent phenotype
Mishra et al[60] (2009)	Results confirm that PRP enhances MSC proliferation and suggest that PRP causes chondrogenic differentiation of MSC in vitro
Krüger et al[61] (2013)	Results suggest that human PRP may enhance the migration and stimulate the chondrogenic differentiation of human subchondral progenitor cells known from microfracture
Zhong et al[62] (2012)	Both human BMACs and PRP may provide therapeutic benefits in bone tissue engineering applications. These fractions possess a similar ability to enhance early-phase bone regeneration
Wojtowicz et al[63] (2007)	Newly formed bone augmented under the influence of PRP shows the closest similarity to the control contralateral bone in comparison to BM-MSCs
Lee et al[65] (2014)	Autologous BMAC combined with PRP injection at the osteotomy site helped improve bone healing in distraction osteogenesis of the tibia, although the effect size was small
Centeno et al[66] (2018)	ACL treatment with percutaneous injection of BMC and platelet products shows promise as a nonsurgical alternative. However, a larger randomized controlled trial is warranted to confirm these findings
Hede et al[67] (2019)	Treatment of cartilage injuries using combined BMAC and PRP improved subjective clinical outcome scores and pain scores at 1 and 2 yr postoperatively. MRI and histology indicated repair tissue inferior to the native hyaline cartilage
Campbell et al[68] (2013)	A series of orthobiologic treatments with PRP and BMAC improved the patient’s pain and strength as well as the morphologic appearance of the hip capsule and gluteus minimus tendon on MRI
Martin et al[70] (2013)	The use of a minimally invasive femoral head decompression augmented with concentrated bone marrow and PRP resulted in significant pain relief and halted the progression of disease in a majority of patients
Centeno et al[71] (2020)	Findings suggest that ultrasound-guided BMC and platelet product injections are a safe and useful alternative to conservative exercise therapy of torn, nonretracted supraspinatus tendons
Kim et al[72] (2018)	BMAC-PRP improved pain and shoulder function in patients with partial tear of the rotator cuff tendon
Cassano et al[73] (2018)	Colony-forming units were increased in both BMAC compared to BMA (P < 0.0001). Platelet counts were not significantly different between BMAC and PRP. TGF-β1 and PDGF were not different between BMAC and PRP. IL-1ra concentrations were greater (P = 0.0018) in BMAC samples than in PRP. The IL-1ra/IL-1β ratio in all BMAC samples was above the value reported to inhibit IL-1β
Sugaya et al[74] (2018)	The concentration of b-FGF was higher in BMAC than in PRP (P < 0.001), whereas no significant differences in the levels of PDGF-BB, VEGF, TGF-β1, and BMP-2 were observed between the two types of samples. BMAC had an average of 1.90% CD34+ and 0.03% CD31-45-90+105+ cells (no cells in PRP) and higher levels of b-FGF than those of PRP
Ziegler et al[75] (2019)	BMAC is a clinically relevant source of anti-inflammatory biologic therapy that may be more effective in treating osteoarthritis and for use as an intra-articular biologic source for augmented healing in the postsurgical inflammatory and healing phases, owing to its significantly higher concentration of IL-1Ra as compared with Lr-PRP and Lp-PRP. Additionally, Lr-PRP had a significantly higher concentration of IL-1Ra than Lp-PRP. In cases where increased vascularity and healing are desired for pathological or injured tissues, including muscle and tendon, Lr-PRP may be optimal given its higher overall concentrations of PDGF, TGF-β, EGF, VEGF, and soluble CD40 ligand

BMAC: Bone marrow aspirate concentrate; PRP: Platelet-rich plasma; MSC: Mesenchymal stem cell; BM-MSCs: Bone marrow mesenchymal stem cells; ACL: Anterior cruciate ligament; BMC: Bone marrow concentrate; MRI: Magnetic resonance imaging; BMA: Bone marrow aspirate; TGF-β: Transforming growth factor β; PDGF: Platelet-derived growth factor; IL: Interleukin; b-FGF: Basic fibroblast growth factor; VEGF: Vascular endothelial growth factor; BMP-2: Bone morphogenetic protein-2; Lr-PRP: Leukocyte-platelet-rich plasma; Lp-PRP: Leukocyte-poor platelet-rich plasma; EGF: Epidermal growth factor.