Bone marrow aspirate concentrate augmentation of allograft may benefit ACL reconstruction
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Bone marrow aspirate concentrate augmentation of the bone-patellar tendon-bone allograft during ACL reconstruction may yield greater signal intensity scores on MRI at 3 months postoperatively, according to published results.
Researchers randomly assigned 80 patients undergoing ACL reconstruction with bone-patellar tendon-bone allografts to receive either an injection of bone marrow aspirate concentrate (BMAC) into the bone-patellar tendon-bone allograft (BMAC group) or a small sham incision made at the iliac crest (control group). To determine the signal intensity ratio of the ACL graft, researchers performed MRI at 3 and 9 months postoperatively. Researchers also collected IKDC, Tegner and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores.
At 1 year postoperatively, 73 patients were available for follow-up. Of these patients, 36 were in the BMAC group and 37 in the control group. Results showed patients in the BMAC group had significantly greater IKDC scores vs. the control group at 9 months postoperatively. Researchers found the proportion of patients who met the minimal clinically important difference for IKDC did not significantly differ between the BMAC group and control group at 9 months. Patients in the BMAC group had a significantly greater signal intensity ratio of the inferior third portion of the ACL graft at 3 months postoperatively compared with the control group, according to results.
“The greater [signal intensity ratio] of the inferior allograft in the BMAC group may correlate with increased graft metabolic activity and remodeling and potentially accelerated revascularization and healing at 3 months,” the authors wrote.
Perspective
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Current ACL reconstruction surgery results in generally positive outcomes, but recovery remains prolonged. The reasons are multifactorial, but graft incorporation is one of several factors contributing to that duration and recurrent tears. Orthobiologics – substances from the body intended to treat or cure musculoskeletal disease – in this case, autologous bone marrow concentrate (BMAC), attempt to improve on the body’s innate capability to heal, which can mean improved graft ligamentization. The study results, whereby BMAC-treated grafts showed accelerated maturation at 3 months but not at 9, demonstrate subtle progress in defining BMAC as a practical cell therapy product with beneficial, yet still ill-defined, biologic activity.
That the biologic change in graft appearance on MRI did not result in meaningful clinical improvement does not dismiss the potential to improve upon BMAC as our understanding of orthobiologic cell therapy grows. Indeed, we have seen BMAC used as a successful surgical adjunct in rotator cuff repair and avascular necrosis, and we know that BMAC is a biologically active therapeutic in preclinical models. However, we must understand the need to recognize BMAC as a product and not just another procedure. That product requires continued characterization, which leads to optimization of BMAC dosing, dosing frequency and delivery models critical to biologic drug therapy development, with potential to improve surgical outcomes.
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