SLR - April 2023 - Adam Bhatti, DPM
Title: Bone Marrow Aspirate Concentrate (BMAC) Improves Outcomes in Adults with Osteochondral Dissecans of the Talus and Achilles Rupture.Reference: Bachir RM, Zaia IM, Santos GS, Fonseca LFD, Boni G, Guercia RF, Ferreira GF, Lana JFSD. Bone Marrow Aspirate Concentrate Improves Outcomes in Adults With Osteochondral Dissecans of the Talus and Achilles Rupture. Arthroscopy. 2023 Mar;39(3):881-886. doi: 10.1016/j.arthro.2022.11.034. Epub 2022 Dec 8. PMID: 36543662
Level of Evidence: IV
Scientific Literature Review
Reviewed by: Adam Bhatti, DPM
Residency Program: Eastern Virginia Medical School, Norfolk, VA
Podiatric Relevance: The topic of orthobiologics in surgical intervention has grown tremendously in recent years. This necessitates further research to advance understanding of the role of respective growth factors and their receptors in the process of healing musculoskeletal injuries. This literature review is relevant to the field of podiatry as it pertains to the use of orthobiologics in the treatment of frequently encountered athletic injuries. The purpose of this literature review was to analyze the clinical outcomes of the application of bone marrow aspirate concentrate (BMAC) in achilles tendon and osteochondral injuries of the talus. They hypothesized that the applications of BMAC provide safe clinical benefits and outcomes.
Methods: 11 scientific studies involving a total 527 subjects (mean age: 36.26 years) with talus and achilles tendon injuries with a mean follow-up of 12 to 58 months were included. 7 studies were performed in the USA, 3 in Italy/Ireland, 1 in Turkey. 3 studies assessed BMAC to 129 patients without a control group for comparison. Patients with talar injuries were subjected to an array of interventions in conjunction with BMAC including: subchondroplasty, juvenile chondrocyte implantation, autologous osteochondral transplant, and bone marrow stimulation. A single study was found evaluating the use of BMAC with acute achilles tendon rupture. Pain assessment and functional outcomes were measured using the VAS, AOFAS, and the Foot and Ankle Outcome Score scale.
Results: BMAC in conjunction with subchondroplasty yielded pain relief and immediate return to weight-bearing without compromising the potential of future treatments. Although yielding similar functional results to BMAC alone, bone marrow stimulation in adjunct with BMAC demonstrated improved integration of regenerative tissue with decreased fissures/fibrillation on MRI. For talus OCD’s measuring larger than 1.5 cm2, one study revealed improved clinical results at 2 year follow-up with particulate juvenile articular cartilage in comparison to BMAC from the iliac crest. Following the clinical application of BMAC there were 2 cases of superficial peroneal nerve dysesthesia, and 4 patients required revision procedures due to their injuries remaining symptomatic after juvenile allogenic chondrocyte implantation. Clinical application of BMAC in isolation in the treatment of acute achilles tendon rupture demonstrated very promising results with early mobilization without re-rupture without adverse clinical reactions.
Conclusions: Autologous in nature, BMAC offers minimal-to-no risk of disease transmission or rejection. Adverse reactions and complications, though mild, are typically self-limiting in nature. Although evidence suggests BMAC yields promising clinical results with functional outcomes and pain reduction in adult acute achilles tendon ruptures and osteochondral injuries of the talus, the patient demographic is imperative to maximizing healing potential - factors such as BMI, co-morbidities, and activity level were not mentioned. An additional consideration is the site of harvest of BMAC, though non-weight bearing bones are preferred, the tibia and calcaneus are often employed. Future research focusing on standardized interventions would allow for more in-depth meta-analyses to be performed. Furthermore this would supplement our knowledge and understanding surrounding the clinical applications of orthobiologics in musculoskeletal injuries of the foot and ankle.