Bone Marrow Aspirate Concentrate Harvesting and Processing Technique

The Analgesic Efficacy of Intradiscal Injection of Bone Marrow Aspirate Concentrate and Culture-Expanded Bone Marrow Mesenchymal Stromal Cells in Discogenic Pain: A Systematic Review

Pain originating from the intervertebral disc (discogenic pain) is a prevalent manifestation of low back pain and is often challenging to treat. Of recent interest, regenerative medicine options with injectable biologics have been trialed in discogenic pain and a wide variety of other painful musculoskeletal conditions. In particular, the role of bone marrow aspirate concentrate (BMAC) and culture-expanded bone marrow derived mesenchymal stromal cells (BM-MSCs) in treating discogenic pain remains unclear. The primary objective of this systematic review was to appraise the evidence of intradiscal injection with BMAC and culture-expanded BM-MSCs in alleviating pain intensity from discogenic pain. Secondary outcomes included changes in physical function after intradiscal injection, correlation between stromal cell count and pain intensity, and anatomical changes of the disc assessed by radiographic imaging after intradiscal injection. Overall, 16 studies consisting of 607 participants were included in qualitative synthesis without pooling. Our synthesis revealed that generally intradiscal autologous or allogeneic BMAC and culture-expanded BM-MSCs improved discogenic pain compared to baseline. Intradiscal injection was also associated with improvements in physical functioning and positive anatomical changes on spine magnetic resonance imaging (improved disc height, disc water content, Pfirrmann grading) although anatomical findings were inconsistent across studies. However, the overall GRADEscore for this study was very low due to heterogeneity and poor generalizability. There were no serious adverse events reported post intradiscal injection except for a case of discitis.

Effectiveness of Bone Marrow-Derived Platelet-Rich Fibrin on Rotator Cuff Healing in a Rabbit Degenerative Model

BACKGROUND

Platelet-rich fibrin (PRF) is a second-generation platelet concentrate. Although peripheral blood-derived PRF (P-PRF) is commonly applied in biological augmentation, there is no report about the therapeutic effect of bone marrow-derived PRF (BM-PRF) for degenerative rotator cuff tears (RCTs).

PURPOSE/HYPOTHESIS

To examine the effects of platelet-rich plasma (PRP), P-PRF, and BM-PRF during rotator cuff repair (RCR) in degenerative RCTs in rabbits. We hypothesized that BM-PRF would accelerate the bone-tendon healing after RCR.

STUDY DESIGN

Controlled laboratory study.

METHODS

Degenerative RCT models were created 2 weeks before beginning the study, and 68 juvenile rabbits were divided into 4 groups: the control, PRP, P-PRF, and BM-PRF groups. RCR without augmentation was done in the control group. PRP was prepared by centrifuging peripheral blood twice using a plastic tube. P-PRF and BM-PRF were prepared by centrifuging peripheral blood and bone marrow, respectively, using a glass tube. Rabbits from PRP, P-PRF, and BM-PRF groups were administered the augmentation in a similar fashion for RCR, between the rotator cuff and the footprint of the humerus. At 4, 8, and 12 weeks, rabbits were euthanized and histologically assessed using hematoxylin and eosin staining, Alcian blue staining, and immunohistochemical staining for type I and III collagen. The sections were also evaluated with immunofluorescence staining of vascular endothelial growth factor (VEGF) at 4 weeks.

RESULTS

The continuity was significantly better in the BM-PRF group at 4 weeks (P < .05). Immunofluorescence staining demonstrated that VEGF-positive stained cells were significantly greater in the BM-PRF group than in the control group (P < .01). The modified tendon maturing score was significantly greater in the BM-PRF group than in the control and PRP groups at 12 weeks (P < .05). There was no significant difference in the modified tendon maturing score of the P-PRF group compared with the control group.

CONCLUSION

The rabbit model of degenerative RCTs demonstrated that RCR combined with BM-PRF enhanced tendon-bone continuity and increased the VEGF-positive cells at 4 weeks and obtained preferable tendon-bone maturation at 12 weeks.

CLINICAL RELEVANCE

RCR augmented with BM-PRF has the potential to improve clinical outcomes for RCTs.

Bone marrow aspirate concentrate quality is affected by age and harvest site

PURPOSE

To compare the number and properties of bone marrow stromal cells (BMSCs) collected from bone marrow aspirate concentrate (BMAC) obtained from different harvest sites and from patients of different ages.

METHODS

BMAC was obtained from two groups of patients based on age (n = 10 per group): 19.0 ± 2.7 years for the younger and 56.8 ± 12.5 for the older group. In the latter, BMAC was obtained from both iliac crest and proximal tibia for a donor-matched analysis. Mononucleated cell count and CFU-F assay were performed, together with phenotype characterization of BMSCs from iliac crest and proximal tibia, the study of chondrogenic and osteogenic differentiation capacity, histological staining and spectrophotometric quantification, and the analysis of mRNAs expression.

RESULTS

Cells derived from iliac crest and proximal tibia showed the same phenotypic pattern at flow cytometry, as well as similar chondrogenic and osteogenic potential. However, a significantly higher number of mononuclear cells per ml was observed in younger patients (3.8 ± 1.8 × 10⁷) compared to older patients (1.2 ± 0.8 × 10⁷) (p < 0.0005). The latter yield, obtained from the iliac crest, was significantly higher than resulting from the BMAC harvested from the proximal tibia in the same group of patients (0.3 ± 0.2 × 10⁷, p < 0.0005). This result was confirmed by the CFU-F analysis at day 10 (15.9 ± 19.4 vs 0.6 ± 1.0, p = 0.001) and day-20 (21.7 ± 23.0 vs 2.9 ± 4.2, p = 0.006).

CONCLUSION

Harvest site and age can affect the quality of BMAC. BMSCs obtained from iliac crest and proximal tibia present comparable mesenchymal markers expression as well as osteogenic and chondrogenic differentiation potential, but iliac crest BMAC presents a four times higher number of mononucleated cells with significantly higher clonogenic capacity compared to the tibia. BMAC of younger patients also had a three-time higher number of mononucleated cells. The identification of BMAC characteristics could help to optimize its preparation and to identify the most suitable indications for this orthobiologic treatment in the clinical practice.

Mesenchymal stem cells augmentation for surgical procedures in patients with symptomatic chondral defects of the knee: a systematic review

Background

The efficacy and safety profile of mesenchymal stem cells (MSCs) augmentation in chondral procedures are controversial. This systematic review updated the current evidence on MSCs augmentation for chondral procedures in patients with symptomatic chondral defects of the knee.

Methods

This study followed the PRISMA guidelines. The literature search was updated in August 2022. Two independent authors accessed PubMed, Google scholar, Embase, and Scopus. No additional filters or time constrains were used for the search. A cross reference of the bibliographies was also performed. All the clinical studies investigating surgical procedures for chondral defects of the knee augmented with MSCs were accessed. Defects of both tibiofemoral and patellofemoral joints were included. The following patient reported outcomes measures (PROMs) were retrieved at baseline and last follow-up: Visual Analogic Scale (VAS), Tegner Activity Scale, Lysholm Knee Scoring System, International Knee Documentation Committee (IKDC). Return to daily activities and data on hypertrophy, failure, revision surgery were also collected. Failures were defined as the recurrence of symptoms attributable to the index procedure. Revisions were defined as any reoperation at the site of the index procedure.

Results

A total of 15 clinical studies (411 procedures) were included. Patients returned to their prior sport activity at 2.8 ± 0.4 months. All the PROMs improved at last follow-up: Tegner (P = 0.0002), Lysholm (P < 0.0001), the IKDC (P < 0.0001), VAS (P < 0.0001). At a mean of 30.1 ± 13.9 months, 3.1% (2 of 65 patients) reported graft hypertrophy, 3.2% (2 of 63) were considered failures. No surgical revision procedures were reported. Given the lack of available quantitative data for inclusion, a formal comparison of surgical procedures was not conducted.

Conclusion

MSCs augmentation in selected chondral procedures could be effective, with a low rate of complications. Further investigations are required to overcome the current limitations to allow the clinical translation of MSCs in regenerative medicine.

Reorientation technique has benefits in bone marrow aspiration of stem cells

We treated patients with osteoarthritis of the knee using injections of bone marrow aspirate concentrate (stem cell therapy). Since multiple controversial harvesting methods using different sites, needles, volumes and techniques have been described, we aimed to compare those methods. Four different harvesting sites at the iliac crest, three different types of needles, three different types of volumes and two different harvesting techniques were compared in 48 bone marrow aspirations. The conventional technique (Group 1) was compared with a reorientation technique (Group 2). The number of leucocytes and CD34 + cells and the viability in bone marrow aspirate (BMA) were analysed with a CytoFLEX Flow Cytometer. The reorientation technique showed significantly higher cell counts than the conventional technique in all parameters. Leucocytes per nl increased from 5 ± 2 to 12 ± 4 (p < .001), and CD 34 + cells per μl increased from 40 ± 40 to 140 ± 98 (p = .003). There was no difference between anterior and posterior harvesting at the iliac crest or between use of a thick and use of a thin needle. Use of the reorientation technique, compared to employing the conventional technique, has a significant advantage since the number of leucocytes and CD34 + cells can be tripled. For the use of bone marrow aspirate in the case of arthritis, it might therefore be a future option to harvest a maximum cell yield through the new reorientation technique and to omit centrifugation. However, the clinical relevance of these findings remains the subject of future studies.

Level of Evidence: Level I.

Clinical relevance: Enhanced technique of BMA for knee surgeons to ensure the maximum cell yield for stem cell therapy in regenerative medicine.

Bone Marrow Aspirate Concentrate Augmentation May Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial

PURPOSE

To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and magnetic resonance imaging (MRI) findings in anterior cruciate ligament (ACL) reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts.

METHODS

A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACL reconstruction using BTB allografts. Patients were randomized to 2 groups: (1) bone marrow aspirate was collected from the iliac crest, concentrated, and approximately 2.5 mL was injected into the BTB allograft, or (2) a small sham incision was made at the iliac crest (control). MRI was performed at 3 months and 9 months postoperatively to determine the signal intensity ratio of the ACL graft.

RESULTS

Seventy-three patients were available for follow-up at 1-year postoperatively (36 BMAC, 37 control). International Knee Documentation Committee (IKDC) scores were significantly greater in the BMAC group versus the control at the 9-month postoperative period (81.6 ± 10.5 vs 74.6 ± 14.2, P = .048). There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months (89% vs 85%; P = .7). Three months postoperatively, signal intensity ratio of the inferior third of the ACL graft was significantly greater in the BMAC group versus the control group (3.2 ± 2.2 vs 2.1 ± 1.5; P = .02).

CONCLUSIONS

Patients who received BMAC augmentation of the BTB allograft during ACL reconstruction demonstrated greater signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had greater patient-reported outcomes (IKDC) at 9 months postoperatively when compared with those who underwent a standard surgical procedure. There was no significant difference in the proportion of patients who met the minimal clinically important difference for IKDC between the BMAC and control groups at 9 months, suggesting limited clinical significance at this time point.

LEVEL OF EVIDENCE

I, randomized control trial.

State of the field: cellular and exosomal therapeutic approaches in vascular regeneration

Pathologies of the vasculature including the microvasculature are often complex in nature, leading to loss of physiological homeostatic regulation of patency and adequate perfusion to match tissue metabolic demands. Microvascular dysfunction is a key underlying element in the majority of pathologies of failing organs and tissues. Contributing pathological factors to this dysfunction include oxidative stress, mitochondrial dysfunction, endoplasmic reticular (ER) stress, endothelial dysfunction, loss of angiogenic potential and vascular density, and greater senescence and apoptosis. In many clinical settings, current pharmacologic strategies use a single or narrow targeted approach to address symptoms of pathology rather than a comprehensive and multifaceted approach to address their root cause. To address this, efforts have been heavily focused on cellular therapies and cell-free therapies (e.g., exosomes) that can tackle the multifaceted etiology of vascular and microvascular dysfunction. In this review, we discuss 1) the state of the field in terms of common therapeutic cell population isolation techniques, their unique characteristics, and their advantages and disadvantages, 2) common molecular mechanisms of cell therapies to restore vascularization and/or vascular function, 3) arguments for and against allogeneic versus autologous applications of cell therapies, 4) emerging strategies to optimize and enhance cell therapies through priming and preconditioning, and, finally, 5) emerging strategies to bolster therapeutic effect. Relevant and recent clinical and animal studies using cellular therapies to restore vascular function or pathologic tissue health by way of improved vascularization are highlighted throughout these sections.

Advancing Regenerative Cellular Therapies in Non-Scarring Alopecia

Alopecia or baldness is a common diagnosis in clinical practice. Alopecia can be scarring or non-scarring, diffuse or patchy. The most prevalent type of alopecia is non-scarring alopecia, with the majority of cases being androgenetic alopecia (AGA) or alopecia areata (AA). AGA is traditionally treated with minoxidil and finasteride, while AA is treated with immune modulators; however, both treatments have significant downsides. These drawbacks compel us to explore regenerative therapies that are relatively devoid of adverse effects. A thorough literature review was conducted to explore the existing proven and experimental regenerative treatment modalities in non-scarring alopecia. Multiple treatment options compelled us to classify them into growth factor-rich and stem cell-rich. The growth factor-rich group included platelet-rich plasma, stem cell-conditioned medium, exosomes and placental extract whereas adult stem cells (adipose-derived stem cell-nano fat and stromal vascular fraction; bone marrow stem cell and hair follicle stem cells) and perinatal stem cells (umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs), Wharton jelly-derived MSCs (WJ-MSCs), amniotic fluid-derived MSCs (AF-MSCs), and placental MSCs) were grouped into the stem cell-rich group. Because of its regenerative and proliferative capabilities, MSC lies at the heart of regenerative cellular treatment for hair restoration. A literature review revealed that both adult and perinatal MSCs are successful as a mesotherapy for hair regrowth. However, there is a lack of standardization in terms of preparation, dose, and route of administration. To better understand the source and mode of action of regenerative cellular therapies in hair restoration, we have proposed the "À La Mode Classification". In addition, available evidence-based cellular treatments for hair regrowth have been thoroughly described.

Bioengineered Living Bone Grafts-A Concise Review on Bioreactors and Production Techniques In Vitro

It has been observed that bone fractures carry a risk of high mortality and morbidity. The deployment of a proper bone healing method is essential to achieve the desired success. Over the years, bone tissue engineering (BTE) has appeared to be a very promising approach aimed at restoring bone defects. The main role of the BTE is to apply new, efficient, and functional bone regeneration therapy via a combination of bone scaffolds with cells and/or healing promotive factors (e.g., growth factors and bioactive agents). The modern approach involves also the production of living bone grafts in vitro by long-term culture of cell-seeded biomaterials, often with the use of bioreactors. This review presents the most recent findings concerning biomaterials, cells, and techniques used for the production of living bone grafts under in vitro conditions. Particular attention has been given to features of known bioreactor systems currently used in BTE: perfusion bioreactors, rotating bioreactors, and spinner flask bioreactors. Although bioreactor systems are still characterized by some limitations, they are excellent platforms to form bioengineered living bone grafts in vitro for bone fracture regeneration. Moreover, the review article also describes the types of biomaterials and sources of cells that can be used in BTE as well as the role of three-dimensional bioprinting and pulsed electromagnetic fields in both bone healing and BTE.

Impact of the Process Variables on the Yield of Mesenchymal Stromal Cells from Bone Marrow Aspirate Concentrate

Human bone marrow (BM) has been highlighted as a promising source of mesenchymal stromal cells (MSCs) containing various growth factors and cytokines that can be potentially utilized in regenerative procedures involving cartilage and bone. However, the proportion of MSCs in the nucleated cell population of BM is only around 0.001% to 0.01% thereby making the harvesting and processing technique crucial for obtaining optimal results upon its use in various regenerative processes. Although several studies in the literature have given encouraging results on the utility of BM aspiration concentrate (BMAC) in various regenerative procedures, there is a lack of consensus concerning the harvesting variables such as choice of anesthetic agent to be used, site of harvest, size of the syringe to be used, anticoagulant of choice, and processing variables such as centrifugation time, and speed. In this review article, we aim to discuss the variables in the harvesting and processing technique of BMAC and their impact on the yield of MSCs in the final concentrate obtained from them.

Clinical and functional evaluation of bone marrow aspirate concentrate vs autologous conditioned serum in the treatment of knee osteoarthritis

BACKGROUND AND AIM

The aim of this study was to compare the efficacy of a single Bone Marrow Aspirate Concentrate (BMAC) with a cycle of 4 Autologous Conditioned Serum (ACS) injections in the treatment of early-stage knee osteoarthritis (OA).

METHODS

Two groups of 12 patients with degenerative knee OA were treated with a single BMAC injection and with a cycle of 4 ACS injections respectively. Follow-up was set at baseline (t0), one-month (t1) and six-months (t2) evaluating VAS for pain, WOMAC index and range of motion (ROM).

RESULTS

We reported a significant improvement in WOMAC after BMAC injection both at t1 (p= 0,001) as well as t2 (p< 0,001), plus a reduction of VAS values in BMAC group at six months follow-up (p = 0,024). In contrast, no significant differences in ROM between the two groups were observed.

CONCLUSIONS

Both the approaches are safe and effective in the treatment of knee OA, with a major efficacy of BMAC.

High Variability of Mesenchymal Stem Cells Obtained via Bone Marrow Aspirate Concentrate Compared With Traditional Bone Marrow Aspiration Technique

Background:

Bone marrow aspirate (BMA) is a common source for harvesting mesenchymal stem cells (MSCs), other progenitor cells, and associated cytokines and growth factors to be used in the biologic treatment of various orthopaedic pathologies. The aspirate is commonly centrifuged into a concentrated volume that can be immediately administered to a patient using commercially available kits. However, the handling and efficacy of BMA concentrate (BMAC) are still controversial.

Purpose:

To characterize BMA versus BMAC for MSC quantity, potency, and cytokine profile.

Study Design:

Controlled laboratory study.

Methods:

From 8 participants (age, 17-68 years), 30 mL of bone marrow was aspirated by a single surgeon from either the proximal humerus or distal femur and was separated into 2 equal samples. One sample was kept as BMA, and the other half was centrifuged into BMAC. The 2 samples then underwent flow cytometry for detection of MSCs, cell analysis for colony-forming units (CFUs), and cytokine profiling. A 2-tailed t test was used to detect differences between MSCs, CFUs, and cytokine density concentrations between BMA and BMAC.

Results:

The average concentration of MSCs in both BMA and BMAC was 0.001%. Average MSC events detected by flow cytometry were significantly higher in BMA versus BMAC (15.1 and 8.1, respectively; P < .045). Expanded MSCs demonstrated similar phenotypes, but CFUs were significantly increased in BMA compared with BMAC (104 vs 68 CFUs, respectively; P < .001). Total protein concentration and cytokine profiling demonstrated great variability between BMA and BMAC and between patients. Most importantly, BMAC failed to concentrate MSCs in 6 of 8 samples.

Conclusion:

There is great variability in MSC concentration, total protein concentration, and cytokine profile between BMA and BMAC.

Clinical Relevance:

When studying the clinical efficacy of BMAC, one must also evaluate the sample itself to determine the presence, concentration, and potency of MSCs if this is to be considered a cell-based therapy. Further standard operating procedures need to be investigated to ensure reproducible results and appropriate treatments.

Combined Bone Marrow Aspirate and Platelet-Rich Plasma for Cartilage Repair: Two-Year Clinical Results

PURPOSE

To evaluate the clinical and biological outcome of combined bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) on a collagen scaffold for treating cartilage lesions in the knee.

METHODS AND MATERIALS

Ten patients (mean age 29.4 years, range 18-36) suffering from large full-thickness cartilage in the knee were treated with BMAC and PRP from January 2015 to December 2016. In a 1-step procedure autologous BMAC and PRP was seeded onto a collagen scaffold and sutured into the debrided defect. Patients were evaluated by clinical outcome scores (IKDC [International Knee Documentation Committee Subjective Knee Form], KOOS [Knee Injury and Osteoarthritis Outcome Score], and pain score using the Numeric Rating Scale [NRS]) preoperatively, after 3 months, and after 1 and 2 years. Second-look arthroscopies were performed (n = 7) with biopsies of the repair tissue for histology. All patients had magnetic resonance imaging (MRI) preoperatively, after 1 year, and after 2 to 3.5 years with MOCART (magnetic resonance observation of cartilage repair tissue) scores evaluating cartilage repair.

RESULTS

After 1 year significant improvements were found in IKDC, KOOS symptoms, KOOS ADL (Activities of Daily Living), KOOS QOL (Quality of Life), and pain at activity. At the latest follow-up significant improvements were seen in IKDC, KOOS symptoms, KOOS QOL, pain at rest, and pain at activity. MRI MOCART score for cartilage repair improved significantly from baseline to 1-year follow-up. Histomorphometry of repair tissue demonstrated a mixture of fibrous tissue (58%) and fibrocartilage (40%).

CONCLUSION

Treatment of cartilage injuries using combined BMAC and PRP improved subjective clinical outcome scores and pain scores at 1 and 2 years postoperatively. MRI and histology indicated repair tissue inferior to the native hyaline cartilage.

Bone Marrow Aspirate in Spine Surgery: Case Series and Review of the Literature

Background With the modernization of biotechnology, there has been a concerted effort to create novel biomaterials to promote arthrodesis for spine surgery. The novel use of the stem cells from bone marrow aspirate (BMA) to augment spine surgery is a burgeoning field because these cells are considered to be both osteoinductive and osteogenic. We sought to review the evidence behind the use of BMAs in spinal fusions and report the results of our own case series. Methods PubMed and EMBASE databases were searched for studies that investigated the use of stem cells for spine surgery. For our own case series, the medical records of 150 consecutive patients who underwent a lumbar spinal fusion with BMA were retrospectively reviewed for adverse events (AEs) for up to two years after surgery. Results In our case series, there were no AEs identified in 49% of our patients. Of the identified AEs, 61% were unrelated to the use of BMA (e.g., UTI and heart failure), with the remaining 39% likely unrelated to its use (e.g., back pain and anemia). There was a 92.8% arthrodesis rate with the use of BMA. Conclusions We reviewed the rationale, basic science, and clinical science for BMA usage in spine surgery and concluded that BMA is safe for use in spine surgery and is associated with a high rate of arthrodesis.

Does the Source of Mesenchymal Stem Cell Have an Effect in the Management of Osteoarthritis of the Knee? Meta-Analysis of Randomized Controlled Trials

STUDY DESIGN

Meta-analysis.

OBJECTIVES

To compare the efficacy and safety of bone marrow(BM)-derived mesenchymal stem cell(MSCs) and adipose-derived(AD) MSCs in the management of osteoarthritis of knee from randomized controlled trials(RCTs) available in the literature.

MATERIALS AND METHODS

We conducted electronic database searche from PubMed, Embase, and Cochrane Library till May 2020 for RCTs analyzing the efficacy and safety of MSCs in management of osteoarthritis of knee. Visual Analog Score(VAS) for Pain, Western Ontario McMaster Universities Osteoarthritis Index(WOMAC), Lysholm Knee Scale(Lysholm), Whole-Organ Magnetic Resonance Imaging Score(WORMS), Knee Osteoarthritis Outcome Score(KOOS), and adverse events were the outcomes analyzed. Analysis was performed in R platform using OpenMeta[Analyst] software.

RESULTS

Nineteen studies involving 811 patients were included for analysis. None of the studies compared the source of MSCs for osteoarthritis of knee and results were obtained by pooled data analysis of both sources. At 6 months, AD-MSCs showed significantly better VAS(P<0.001,P=0.069) and WOMAC(P=0.134,P=0.441) improvement than BM-MSCs, respectively, compared to controls. At 1 year, AD-MSCs outperformed BM-MSCs compared to their control in measures like WOMAC(P=0.007,P=0.150), KOOS(P<0.001;P=0.658), and WORMS(P<0.001,P=0.041), respectively. Similarly at 24 months, AD-MSCs showed significantly better Lysholm score(P=0.037) than BM-MSCs(P=0.807) although VAS improvement was better with BM-MSCs at 24 months(P<0.001). There were no significant adverse events with either of the MSCs compared to their controls.

CONCLUSION

Our analysis establishes the efficacy, safety, and superiority of AD-MSC transplantation, compared to BM-MSC, in the management of osteoarthritis of knee from available literature. Further RCTs are needed to evaluate them together with standardized doses.

Cell Therapy: Types, Regulation, and Clinical Benefits

Cell therapy practices date back to the 19th century and continue to expand on investigational and investment grounds. Cell therapy includes stem cell- and non-stem cell-based, unicellular and multicellular therapies, with different immunophenotypic profiles, isolation techniques, mechanisms of action, and regulatory levels. Following the steps of their predecessor cell therapies that have become established or commercialized, investigational and premarket approval-exempt cell therapies continue to provide patients with promising therapeutic benefits in different disease areas. In this review article, we delineate the vast types of cell therapy, including stem cell-based and non-stem cell-based cell therapies, and create the first-in-literature compilation of the different "multicellular" therapies used in clinical settings. Besides providing the nuts and bolts of FDA policies regulating their use, we discuss the benefits of cell therapies reported in 3 therapeutic areas-regenerative medicine, immune diseases, and cancer. Finally, we contemplate the recent attention shift toward combined therapy approaches, highlighting the factors that render multicellular therapies a more attractive option than their unicellular counterparts.

Autologous bone marrow aspirate concentrate (BMAC) for treatment of keratocystic odontogenic tumour (KCOT)-a case report

Management of keratocystic odontogenic tumor (KCOT) has always remained a conundrum due to its aggressive behavior, indicating wide resection. Achieving an esthetically and functionally acceptable reconstruction remains a challenge. Herein, we present a novel and less invasive technique for the treatment of KCOT. A 55-year-old female presenting with pain in the lower jaw for the past 3 months was diagnosed with a large KCOT extending from 35 to 47 region. CT images revealed buccal and lingual cortical bone erosion. Management was done in two stages: cyst curettage and chemical cauterization, followed by application of Bone Marrow Aspirate Concentrate (BMAC) with a delay of two months, to increase the thickness of eroded cortical bone. On follow-up at one year, ossification of the defect was observed. BMAC is a cocktail of mesenchymal stromal cells, hematopoietic stem cells, fibroblasts, mononuclear cells, macrophages, endothelial cells, progenitor cells, growth factors and cytokines. BMAC cocktail provide an anti-inflammatory, anti-fibrotic, anti-apoptotic, and immunomodulatory environment. Autologous platelet rich plasma provides various growth factors (TGF-β, PDGF, EGF, HGF, NGF, IGF-1) and cytokines. Addition of PRP in BMAC cocktail enhance the regeneration of tissues, where PRP act as a functional regenerative scaffold for cell integration, proliferation, and differentiation that can expedite macroscale musculoskeletal tissue healing. Autologous BMAC with corticocancellous bone acts as an osteoconductive scaffold capable of regenerating the large bone defect created by the curettage of KCOT.

Acetabular Bone Marrow Aspiration During Total Hip Arthroplasty

Biologically augmented surgical treatments of orthopaedic conditions are increasingly popular. Bone marrow aspirate concentrate is a key orthobiologic tissue source, and the field is moving from the standard iliac crest marrow aspiration toward local aspirations of marrow depots that are accessible during the standard-of-care procedures in an attempt to reduce morbidity, surgery time, and cost. Here, we present the aspiration of the standard iliac marrow depot, but through a novel acetabular approach during total hip arthroplasty. This procedure markedly simplifies biologic augmentation with bone marrow aspirate concentrate in this large patient cohort.

Sternal Bone Marrow Harvesting and Culturing Techniques from Patients Undergoing Cardiac Surgery

Background: Mesenchymal stromal cells (MSCs) are the most prominent cell type used in clinical regenerative medicine and stem cell research. MSCs are commonly harvested from bone marrow that has been aspirated from patients’ iliac crest. However, the ethical challenges of finding consenting patients and obtaining fresh autologous cells via invasive extraction methods remain to be barriers to MSC research. Methods: Techniques of harvesting sternal bone marrow, isolating and culturing MSCs, MSC surface phenotyping, and MSC differentiation are described. Samples from 50 patients undergoing a sternotomy were collected, and the time taken to reach 80% confluency and cell count at the second splitting of MSC were measured. Results: MSC isolated from the sternal bone marrow of patients undergoing cardiac surgery demonstrated successful MSC surface phenotyping and MSC differentiation. The mean cell count at the time of the second split was 1,628,025, and the mean time taken to reach the second split was 24.8 days. Conclusion: Herein, we describe the first reported technique of harvesting sternal bone marrow from patients already undergoing open-chest cardiac surgery to reduce the invasiveness of bone marrow harvesting, as well as the methods of isolating, culturing, and identifying MSCs for the clinical application of constructing autologous MSC-derived biomaterials.

Characterization of the stemness and osteogenic potential of oral and sinus mucosal cells

BACKGROUND/PURPOSE

Covering the wounds from guided bone regeneration and sinus floor elevation with oral and sinus mucosa is a fundamental criterion for success. This study aimed to verify the regeneration capability of the mucosal connective tissue stromal cells by characterizing their stemness and osteogenic potentials.

METHODS

Bone marrow stromal cells (BMSCs), alveolar mucosa cells (AMCs), keratinized gingival cells (KGCs), and sinus mucosal cells (SMCs), were isolated from four Sprague-Dawley rats. The morphology and viability of the cells were investigated under a confocal microscope and by Alamar Blue. Stem cell surface markers were evaluated by flow cytometry. Expressions of pluripotent factors after initial seeding and an early osteogenic gene following 24 h of osteoinduction were evaluated by realtime PCR. Trilineage differentiation capability in long-term inductive cell culture was assessed by Alizarin Red, Alcian Blue, and Oil Red O staining.

RESULTS

BMSCs and AMCs were larger cells with smaller aspect ratios relative to KGCs and SMCs, and BMSCs revealed the greatest initial viability but the slowest proliferation. More than 94% of BMSCs, AMCs, and KGCs were double-positive for CD73 and CD90. Compared with BMSCs, AMCs expressed significantly higher Oct4 but reduced Cbfa1 after initial seeding, and AMCs and SMCs expressed significantly higher Cbfa1 following 24 h of osteoinduction. In long-term inductive cell culture, osteogenesis was observed in BMSCs, AMCs, and SMCs, chondrogenesis was observed in BMSCs, AMCs, and KGCs, and adipogenesis was evident in only BMSCs.

CONCLUSION

AMCs contain a high percentage of stem/progenitor cells and show differentiation capability toward osteogenic lineage.

Ultrapurified Alginate Gel Containing Bone Marrow Aspirate Concentrate Enhances Cartilage and Bone Regeneration on Osteochondral Defects in a Rabbit Model

BACKGROUND

Ultrapurified alginate (UPAL) gel implantation has been demonstrated as effective in cartilage repair for osteochondral defects; however, cell transplantation within UPAL gels would be required to treat larger defects.

HYPOTHESIS

The combination of UPAL gel and bone marrow aspirate concentrate (BMAC) would enhance cartilage repair and subchondral bone repair for large osteochondral defects.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 104 osteochondral defects (1 defect per knee) of 52 rabbits were randomly divided into 4 groups (26 defects per group): defects without any treatment (Defect group), defects treated using UPAL gel alone (UPAL group), defects treated using UPAL gel containing allogenic bone marrow mesenchymal stromal cells (UPAL-MSC group), and defects treated using UPAL gel containing BMAC (UPAL-BMAC group). At 4 and 16 weeks postoperatively, macroscopic and histologic evaluations and measurements of repaired subchondral bone volumes of reparative tissues were performed. Collagen orientation and mechanical properties of the reparative tissue were assessed at 16 weeks.

RESULTS

The defects in the UPAL-BMAC group were repaired with hyaline-like cartilage with well-organized collagen structures. The histologic scores at 4 weeks were significantly higher in the UPAL-BMAC group (16.9 ± 2.0) than in the Defect group (4.7 ± 1.9; P < .05), the UPAL group (10.0 ± 3.3; P < .05), and the UPAL-MSC group (12.2 ± 2.9; P < .05). At 16 weeks, the score in the UPAL-BMAC group (24.4 ± 1.7) was significantly higher than those in the Defect group (9.0 ± 3.7; P < .05), the UPAL group (14.2 ± 3.9; P < .05), and the UPAL-MSC group (16.3 ± 3.6; P < .05). At 4 and 16 weeks, the macroscopic evaluations were significantly superior in the UPAL-BMAC group compared with the other groups, and the values of repaired subchondral bone volumes in the UPAL-BMAC group were significantly higher than those in the Defect and UPAL groups. The mechanical properties of the reparative tissues were significantly better in the UPAL-BMAC group than in the other groups.

CONCLUSION

The implantation of UPAL gel containing BMAC-enhanced hyaline-like cartilage repair and subchondral bone repair of osteochondral defects in a rabbit knee model.

CLINICAL RELEVANCE

These data support the potential clinical application of 1-step treatment for large osteochondral defects using biomaterial implantation with cell transplantation.

A three-dimensional computed tomography study to determine the ideal method for fluoroscopically-guided bone marrow aspiration from the iliac crest

Bone marrow aspiration (BMA) through the iliac crest is potentially unsafe due to the vicinity of neurovascular structures in the greater sciatic notch. Our objective was to investigate the safety of a recently described BMA technique, specifically a trajectory from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS). We conducted a chart review of 260 patients, analyzing three-dimensional reconstructed computed tomography images of the pelvis and sacrum to validate that this new approach offers a wide safety margin from the greater sciatic notch. Analysis of three-dimensional computed tomography scans demonstrated that the PSIS to AIIS trajectory never crossed the greater sciatic notch. The trajectory was noted to be at least one cm away from the greater sciatic notch in all measurements. The new trajectory entered the PSIS at 25.29 ± 4.34° (left side) and 24.93 ± 4.15° (right side) cephalad from the transverse plane, and 24.58 ± 4.99° (left side) and 24.56 ± 4.67° (right side) lateral from the mid-sagittal plane. The area of bone marrow encountered with the new approach was approximately 22.5 cm2. Utilizing the same CT scans, the trajectory from the traditional approach crossed the greater sciatic notch in all scans, highlighting the potential for violating the greater sciatic notch boundary and damaging important neurovascular structures. Statistically significant sex-related differences were identified in needle trajectory angles for both approaches. We conclude that based on this three-dimensional computed tomography study, a trajectory from the PSIS to the AIIS for BMA may offer a wide safety margin from the greater sciatic notch.

Stem Cells and Intervertebral Disc Regeneration Overview-What They Can and Can't Do

BACKGROUND

Low back pain (LPB) is the main cause of disability worldwide with enormous socioeconomic burdens. A major cause of LBP is intervertebral disc degeneration (IDD): a chronic, progressive process associated with exhaustion of the resident cell population, tissue inflammation, degradation of the extracellular matrix and dehydration of the nucleus pulposus. Eventually, IDD may lead to serious sequelae including chronic LBP, disc herniation, segmental instability, and spinal stenosis, which may require invasive surgical interventions. However, no treatment is actually able to directly tackle IDD and hamper the degenerative process. In the last decade, the intradiscal injection of stem cells is raising as a promising approach to regenerate the intervertebral disc. This review aims to describe the rationale behind a regenerative stem cell therapy for IDD as well as the effect of stem cells following their implantation in the disc environment according to preclinical studies. Furthermore, actual clinical evidence and ongoing trials will be discussed, taking into account the future perspective and current limitations of this cutting-edge therapy.

METHODS

A literature analysis was performed for this narrative review. A database search of PubMed, Scopus and ClinicalTrials.gov was conducted using "stem cells" combined with "intervertebral disc", "degeneration" and "regeneration" without exclusion based on publication date. Articles were firstly screened on a title-abstract basis and, subsequently, full-text were reviewed. Both preclinical and clinical studies have been included.

RESULTS

The database search yielded recent publications from which the narrative review was completed.

CONCLUSIONS

Based on available evidence, intradiscal stem cell therapy has provided encouraging results in terms of regenerative effects and reduction of LBP. However, multicenter, prospective randomized trials are needed in order confirm the safety, efficacy and applicability of such a promising treatment.

An Update on Mesenchymal Stem Cell-Centered Therapies in Temporomandibular Joint Osteoarthritis

Temporomandibular joint osteoarthritis (TMJOA) is a degenerative disease characterized by cartilage degeneration, disrupted subchondral bone remodeling, and synovitis, seriously affecting the quality of life of patients with chronic pain and functional disabilities. Current treatments for TMJOA are mainly symptomatic therapies without reliable long-term efficacy, due to the limited self-renewal capability of the condyle and the poorly elucidated pathogenesis of TMJOA. Recently, there has been increased interest in cellular therapies for osteoarthritis and TMJ regeneration. Mesenchymal stem cells (MSCs), self-renewing and multipotent progenitor cells, play a promising role in TMJOA treatment. Derived from a variety of tissues, MSCs exert therapeutic effects through diverse mechanisms, including chondrogenic differentiation; fibrocartilage regeneration; and trophic, immunomodulatory, and anti-inflammatory effects. Here, we provide an overview of the therapeutic roles of various tissue-specific MSCs in osteoarthritic TMJ or TMJ regenerative tissue engineering, with an additional focus on joint-resident stem cells and other cellular therapies, such as exosomes and adipose-derived stromal vascular fraction (SVF). Additionally, we summarized the updated pathogenesis of TMJOA to provide a better understanding of the pathological mechanisms of cellular therapies. Although limitations exist, MSC-centered therapies still provide novel, innovative approaches for TMJOA treatment.

Current evidence on mesenchymal stem cell therapy for traumatic spinal cord injury: systematic review and meta-analysis

BACKGROUND AIMS

The authors aim to analyze the evidence in the literature regarding the efficacy and safety of mesenchymal stem cell (MSC) therapy in human subjects with traumatic spinal cord injury (SCI) and identify its potential role in the management of SCI.

METHODS

The authors conducted independent and duplicate searches of electronic databases, including PubMed, Embase and the Cochrane Library, until May 2020 for studies analyzing the efficacy and safety of stem cell therapy for SCI. American Spine Injury Association (ASIA) impairment scale (AIS) grade improvement, ASIA sensorimotor score, activities of daily living score, residual urine volume, bladder function improvement, somatosensory evoked potential (SSEP) improvement and adverse reactions were the outcomes analyzed. Analysis was performed in R platform using OpenMeta[Analyst] software.

RESULTS

Nineteen studies involving 670 patients were included for analysis. On analysis, the intervention group showed statistically significant improvement in AIS grade (P < 0.001), ASIA sensory score (P < 0.017), light touch (P < 0.001), pinprick (P = 0.046), bladder function (P = 0.012), residual urine volume (P = 0.023) and SSEP (P = 0.002). However, no significant difference was noted in motor score (P = 0.193) or activities of daily living score (P = 0.161). Although the intervention group had a significant increase in complications (P < 0.001), no serious or permanent adverse events were reported. On subgroup analysis, low concentration of MSCs (<5 × 107 cells) and initial AIS grade A presentation showed significantly better outcomes than their counterparts.

CONCLUSIONS

The authors' analysis establishes the efficacy and safety of MSC transplantation in terms of improvement in AIS grade, ASIA sensory score, bladder function and electrophysiological parameters like SSEP compared with controls, without major adverse events. However, further research is needed to standardize dose, timing, route and source of MSCs used for transplantation.

Arthroscopic Autologous Chondrocyte Bone Grafting of a Lateral Tibial Plateau Chondral Defect

Tibial plateau chondral defects can be difficult to diagnose and treat. Although grafting of femoral and patella chondral defects has become relatively commonplace, the tibial plateau offers unique challenges for some of the grafting techniques used in these locations, mostly because of limitations with exposure even in an open approach. Arthroscopic surgery makes treatment of these lesions more feasible, as it affords better access and visualization of tibial defects. The purpose of this article is to describe the arthroscopic management of a lateral tibial plateau chondral defect via autologous chondrocyte bone grafting. The technique consists of harvest of autologous cartilage from the intercondylar notch and repair of the tibial plateau defect with a slurry of autologous chondrocytes and bone marrow aspirate concentrate. In addition, CO₂ is used as a medium to distend the joint in a tight compartment to keep the chondral defect dry. This technique is technically simple and does not require an extensive open technique or an expensive osteochondral allograft. It also avoids the staged management required in other types of autologous chondrocyte implantation, which require cartilage biopsy to produce a final product for implantation.

Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain

Musculoskeletal pain is a challenging condition for both patients and physicians. Many adults have experienced one or more episodes of musculoskeletal pain at some time of their lives, regardless of age, gender, or economic status. It affects approximately 47% of the general population. Of those, about 39–45% have long-lasting problems that require medical consultation. Inadequately managed musculoskeletal pain can adversely affect quality of life and impose significant socioeconomic problems. This manuscript presents a comprehensive review of the management of chronic musculoskeletal pain. It briefly explores the background, classifications, patient assessments, and different tools for management according to the recently available evidence. Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain. Both pharmacological, non-pharmacological, as well as interventional pain therapy are important to enhance patient’s recovery, well-being, and improve quality of life. Accordingly, recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications. In patients who have had an inadequate response to pharmacotherapy, the proper use of interventional pain therapy and the other alternative techniques are vital for safe and effective management of chronic pain patients.

Biologics in shoulder and elbow pathology

In recent years, orthobiologics have been of increasing clinical interest in the treatment of shoulder and elbow pathology. In some conditions, such as rotator cuff injury and lateral epicondylitis, there have been high-quality trials that support the use of platelet-rich plasma in reducing pain, restoring functionality, and improving clinical outcomes. However, as the numbers of both cellular-based biologics and the conditions being augmented by biologics continue to expand, there is a substantial need for high-quality investigations to support their routine use in most shoulder and elbow conditions. The purpose of this review is to summarize the current evidence of orthobiologics in the management of shoulder and elbow injury, as nonoperative treatment and as augments to operative treatment.

Clinical Efficacy of Mesenchymal Stem Cells in Bone Regeneration in Oral Implantology. Systematic Review and Meta-Analysis

In bone regeneration, obtaining a vital bone as similar as possible to native bone is sought. This review aimed to evaluate the efficacy of stem cells in maxillary bone regeneration for implant rehabilitation and to review the different techniques for obtaining and processing these cells. A systematic review and meta-analysis were performed using the Pubmed/Medline (NCBI), Cochrane, Scielo, and Scopus databases, without restriction on the publication date. The following Mesh terms were used, combined by the Boolean operator “AND”: “dental implants” AND “stem cells” AND “bioengineering”. Applying inclusion and exclusion criteria, five articles were obtained and three were added after manual search. The results from the meta-analysis (18 patients) did not provide significant differences despite the percentage of bone formed in the maxillary sinus, favoring the stem cell group, and the analysis of the percentage of residual Bio-Oss^® showed results favoring the control group. Stem cell regeneration usually shows positive vascular and viable bone formation. In conclusion, using mesenchymal stem cells in bone regeneration provides benefits in the quality of bone, similar or even superior to autologous bone, all this through a minimally invasive procedure.

Bone Marrow Concentrate Injection Treatment Improves Short-term Outcomes in Symptomatic Hip Osteoarthritis Patients: A Pilot Study

BACKGROUND

Osteoarthritis (OA) is one of the leading causes of disability in the United States, the hip being the second most affected weightbearing joint. Autologous bone marrow concentrate (BMC) is a promising alternative therapy to conventional treatments, with the potential to mitigate inflammation and improve joint function.

PURPOSE

To investigate the effectiveness of a single intra-articular BMC injection for patients with symptomatic hip OA.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 24 patients diagnosed with symptomatic hip OA who elected to undergo a single BMC injection were prospectively enrolled in the study. Patients were excluded if they reported a preinjection Numeric Rating Scale (NRS) score for pain with activity of <6 points out of 10. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), 12-Item Short Form Health Survey (SF-12), and NRS pain scores were collected before and after the procedure (6 weeks, 3 months, and 6 months). Joint space and Tönnis OA grade scores were recorded on preinjection anteroposterior pelvis radiographs.

RESULTS

A total of 18 hips from 16 patients (7 male and 9 female) (mean age, 57.6 ± 11; mean body mass index, 25.9 ± 3.6 kg/m2) were used in the final analysis. Significant improvements were observed in NRS pain with activity (from 8 to 4.5; P < .001) and without activity (from 5 to 1; P < .001), WOMAC (from 31 to 16; P = .006), mHHS (from 63 to 80; P = .004), and HOS-ADL (from 71 to 85; P = .014) over 6 months. At 6 months, all patients maintained their improvements and did not return to preprocedure status. BMI significantly correlated with baseline WOMAC scores (P = .012) and inversely correlated with 6-month SF-12 Physical Component Summary (P = .038). Tönnis grades 2 and 3 were inversely correlated with 6-week SF-12 Mental Component Summary (P = .008) and 3-month pain with activity (P = .032). No serious adverse events were reported from the BMC harvest or injection procedure.

CONCLUSION

A single BMC injection can significantly improve subjective pain and function scores up to 6 months in patients with symptomatic hip OA. Further studies are warranted to evaluate BMC treatment against other therapeutics in a larger sample size and compare the biological signature profiles that may be responsible for the therapeutic effect.

Biological strategies for osteoarthritis: from early diagnosis to treatment

PURPOSE

To provide an updated review of the literature on the use of orthobiologics as a potential treatment option to alleviate symptoms associated with osteoarthritis (OA), slow the progression of the disease, and aid in cartilage regeneration.

METHODS

A comprehensive review of the literature was performed to identify basic science and clinical studies examining the role of orthobiologics in the diagnosis and management of osteoarthritis.

RESULTS

Certain molecules (such as interleukin-6 (IL-6), interleukin-8 (IL-8), matrix metalloproteinase (MMPs), cartilage oligomeric matrix protein (COMP), and tumor necrosis factor (TNF), microRNAs, growth differentiation factor 11 (GDF-11)) have been recognized as biomarkers that are implicated in the pathogenesis and progression of degenerative joint disease (DJD). These biomarkers have been used to develop newer diagnostic applications and targeted biologic therapies for DJD. Local injection therapy with biologic agents such as platelet-rich plasma or stem cell-based preparations has been associated with significant improvement in joint pain and function in patients with OA and has increased in popularity during the last decade. The combination of PRP with kartogenin or TGF-b3 may also enhance its biologic effect. The mesenchymal stem cell secretome has been recognized as a potential target for the development of OA therapies due to its role in mediating the chondroprotective effects of these cells. Recent experiments have also suggested the modification of gut microbiome as a newer method to prevent OA or alter the progression of the disease.

CONCLUSIONS

The application of orthobiologics for the diagnosis and treatment of DJD is a rapidly evolving field that will continue to expand. The identification of OA-specific and joint-specific biomarker molecules for early diagnosis of OA would be extremely useful for the development of preventive and therapeutic protocols. Local injection therapies with HA, PRP, BMAC, and other stem cell-based preparations are currently being used to improve pain and function in patients with early OA or those with progressed disease who are not surgical candidates. Although the clinical outcomes of these therapies seem to be promising in clinical studies, future research will determine the true role of orthobiologic applications in the field of DJS.

Transfacet Minimally Invasive Transforaminal Lumbar Interbody Fusion With an Expandable Interbody Device-Part I: 2-Dimensional Operative Video and Technical Report

BACKGROUND

Advances in operative techniques and minimally invasive technologies have evolved to maximize patient outcomes and radiographic results, while reducing morbidity and recovery time.

OBJECTIVE

To describe the operative technique for a transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) as a proposed modification to the standard approach MIS-TLIF.

METHODS

We present the case of a 72-yr-old man with left-sided lumbar radiculopathy. Preoperative imaging demonstrated degenerative lumbar anterolisthesis at L4-5, with associated canal and neuroforaminal stenosis. The patient underwent transfacet MIS-TLIF at L4-L5. We describe the preoperative planning, patient positioning, incision and dissection, pedicle screw insertion, transfacet approach to the working access corridor, discectomy, interbody device placement, fixation, and closure.

RESULTS

The transfacet MIS-TLIF utilizes 3 key techniques to safely maximize surgical correction: (1) a limited bony resection based on the superior articular process, leaving the medial inferior articular process, lateral superior articular process, and rostral pars intact, providing a working bony corridor that protects the traversing and exiting nerve roots; (2) decortication and release of the contralateral facet joint to provide additional capacity for indirect decompression and provide the first point of osseous fusion; and (3) placement of an expandable interbody device that provides additional indirect decompression to the working side and contralateral foramen.

CONCLUSION

The transfacet MIS-TLIF uniquely leverages a bony working corridor to access the disc space for discectomy and interbody placement. Transfacet MIS-TLIF is a feasible solution for lumbar spinal reconstruction to maximize direct and indirect decompression of the neuroforamina and central spinal canal in patients with lumbar degenerative diseases and low-grade spondylolisthesis.

Bone marrow aspirate clot: A feasible orthobiologic

Musculoskeletal disorders are one of the major health burdens and a leading source of disability worldwide, affecting both juvenile and elderly populations either as a consequence of ageing or extrinsic factors such as physical injuries. This condition often involves a group of locomotor structures such as the bones, joints and muscles and may therefore cause significant economic and emotional impact. Some pharmacological and non-pharmacological treatments have been considered as potential solutions, however, these alternatives have provided quite limited efficacy due to the short-term effect on pain management and inability to restore damaged tissue. The emergence of novel therapeutic alternatives such as the application of orthobiologics, particularly bone marrow aspirate (BMA) clot, have bestowed medical experts with considerable optimism as evidenced by the significant results found in numerous studies addressed in this manuscript. Although other products have been proposed for the treatment of musculoskeletal injuries, the peculiar interest in BMA, fibrin clot and associated fibrinolytic mechanisms continues to expand. BMA is a rich source of various cellular and molecular components which have demonstrated positive effects on tissue regeneration in many in vitro and in vivo models of musculoskeletal injuries. In addition to being able to undergo self-renewal and differentiation, the hematopoietic and mesenchymal stem cells present in this orthobiologic elicit key immunomodulatory and paracrine roles in inflammatory responses in tissue injury and drive the coagulation cascade towards tissue repair via different mechanisms. Although promising, these complex regenerative mechanisms have not yet been fully elucidated.

Efficient Non-Viral Gene Modification of Mesenchymal Stromal Cells from Umbilical Cord Wharton's Jelly with Polyethylenimine

Mesenchymal stromal cells (MSC) derived from human umbilical cord Wharton’s jelly (WJ) have a wide therapeutic potential in cell therapy and tissue engineering because of their multipotential capacity, which can be reinforced through gene therapy in order to modulate specific responses. However, reported methodologies to transfect WJ-MSC using cationic polymers are scarce. Here, WJ-MSC were transfected using 25 kDa branched- polyethylenimine (PEI) and a DNA plasmid encoding GFP. PEI/plasmid complexes were characterized to establish the best transfection efficiencies with lowest toxicity. Expression of MSC-related cell surface markers was evaluated. Likewise, immunomodulatory activity and multipotential capacity of transfected WJ-MSC were assessed by CD2/CD3/CD28-activated peripheral blood mononuclear cells (PBMC) cocultures and osteogenic and adipogenic differentiation assays, respectively. An association between cell number, PEI and DNA content, and transfection efficiency was observed. The highest transfection efficiency (15.3 ± 8.6%) at the lowest toxicity was achieved using 2 ng/μL DNA and 3.6 ng/μL PEI with 45,000 WJ-MSC in a 24-well plate format (200 μL). Under these conditions, there was no significant difference between the expression of MSC-identity markers, inhibitory effect on CD3+ T lymphocytes proliferation and osteogenic/adipogenic differentiation ability of transfected WJ-MSC, as compared with non-transfected cells. These results suggest that the functional properties of WJ-MSC were not altered after optimized transfection with PEI.

Arthroscopic Chondral Defect Repair With Extracellular Matrix Scaffold and Bone Marrow Aspirate Concentrate

Chondral defects of the knee are prevalent and often encountered during arthroscopic procedures. Despite the limited healing potential of chondral defects, several treatment options have been proposed. However, microfracture, osteochondral autograft (or allograft) transfer, autologous chondrocyte implantation, and matrix-induced autologous chondrocyte implantation are all associated with their respective shortcomings. As such, the optimal treatment for chondral defects of the knee remains unclear. Recently, many authors have advocated treating chondral defects with biological therapies and scaffold-based treatments. Bone marrow aspirate concentrate, a cell-based injection, has gained particular attention because of its differentiation capacity and potential role in tissue regeneration. In addition, scaffold cartilage treatments have emerged and reached clinical practice. BioCartilage is one form of scaffold, which consists of extracellular matrix, and has been claimed to promote the regeneration of hyaline-like cartilage. This article presents our technique of arthroscopic chondral defect repair using BMAC and BioCartilage.

Cellular Therapy: Shafts of Light Emerging for COVID-19

The COVID-19 pandemic has presented with debilitating respiratory consequences especially more pronounced in high risk individuals. Individuals with underlying systemic diseases are more prone and vulnerable to suffer severe consequences of SARS-CoV-2 infectivity. The pathophysiological changes identified cytokine storm mechanism for out setting the series of adverse clinical conditions. Thereby, associating it with high mortality rates. This warrants urgent consideration of divergent modalities such as the cellular therapy. Cellular therapy (CT) is a new medical paradigm wherein cellular material is administered to patients for therapeutic purposes. In this regard, mesenchymal stem cells (MSCs) have yielded the most promising results among stromal vascular fraction (SVF); placental cells; natural killer (NK) cell and platelet lysate respectively. Following the administration of the CT as per preferred route, these play pivotal role in modifying the microenvironment of the lung tissue with their distinct sets of mechanism. Evidences have shown how their immunomodulatory action repairs and prevents lung injury which in turn improvise the compliance of lungs. In this review article we have discussed these emerging novel approaches and their target step serving as a ray of hope to combat severe form of COVID-19. Currently these aren't approved for preventing or treating COVID-19 cases, however clinical trials are afoot to dispense the utmost understanding in terms of efficacy and safety concerns.

Mesenchymal Stromal Cell-Based Therapy-An Alternative to Arthroplasty for the Treatment of Osteoarthritis? A State of the Art Review of Clinical Trials

Osteoarthritis (OA) is the most common degenerative joint disorder worldwide and to date no regenerative treatment has been established in clinical practice. This review evaluates the current literature on the clinical translation of mesenchymal stromal cell (MSC)-based therapy in OA management with a focus on safety, outcomes and procedural specifics. PubMed, Cochrane Library and clinicaltrials.gov were searched for clinical studies using MSCs for OA treatment. 290 articles were initially identified and 42 articles of interest, including a total of 1325 patients, remained for further examination. Most of the included studies used adipose tissue-derived MSCs or bone-marrow-derived MSCs to treat patients suffering from knee OA. MSC-based therapy for knee OA appears to be safe and presumably effective in selected parameters. Yet, a direct comparison between studies was difficult due to a pronounced variance regarding methodology, assessed outcomes and evidence levels. Intensive scientific engagement is needed to identify the most effective source and dosage of MSCs for OA treatment in the future. Consent on outcome measures has to be reached and eventually patient sub-populations need to be identified that will profit most from MSC-based treatment for OA.

Injections of concentrated bone marrow aspirate as treatment for Discogenic pain: a retrospective analysis

Background

There are an overwhelming number of patients suffering from low back pain (LBP) resulting from disc pathology. Although several strategies are being developed pre-clinically, simple strategies to treat the large number of patients currently affected is still needed. One option is to use concentrated bone marrow aspirate (cBMA), which may be effective due to its intrinsic stem cells and growth factors.

Methods

Thirty-three patients who received intradiscal injections of cBMA to relieve LBP were followed up based on Numeric Rating Scale (NRS), Oswestry Low Back Pain Disability Index (ODI), and Short Form-36 Health Survey (SF-36) scores. Patients were also subdivided into those with a pre-injection NRS > 5 and pre-injection NRS ≤ 5. The proportion of patients demonstrating at least 50% improvement (and 95% confidence intervals) from baseline at five follow-up visits for each outcome was evaluated.

Results

At least 50% improvement in NRS was observed for 13.8, 45.8, 41.1, 23.5, and 38.9% of patients across five follow-up visits, out to 1 year. When stratified by high (> 5) versus low (≤ 5) baseline NRS scores, the values were 14.3, 45.5, 71.4, 22.2, and 44.4% among those with high baseline pain, and 13.3, 46.2, 20.0, 25.0, and 33.3% among those with low baseline pain. The 50% improvement rates across visits were 4.3, 28.6, 30.0, 22.2, and 30.8% for SF-36, and 4.2, 26.7, 36.4, 55.6, and 30.8% for ODI.

Conclusions

Intradiscal cBMA injections may be effective to reduce pain and improve function. Patients with relatively higher initial pain may have potential for greatest improvement.

Evaluation of the Consistency and Composition of Commercially Available Bone Marrow Aspirate Concentrate Systems

Background:

Bone marrow aspirate (BMA) concentrate (BMAC) has gained popularity as a treatment modality for various orthopaedic conditions; however, there are still inconsistencies in its reported therapeutic efficacy. This may be because of the many different commercial BMAC preparation systems used clinically, which generate dissimilar concentrate products.

Purpose:

To compare 3 commercially available BMAC preparation systems: Harvest SmartPrep 3, Biomet BioCUE, and Arthrex Angel. We evaluated the consistency of each of these systems and compared the composition of their concentrate products.

Study Design:

Controlled laboratory study.

Methods:

A total of 10 patients donated whole blood and BMA, which were combined and processed with the 3 different BMAC preparation systems. Samples were taken before and after processing for the measurement of white blood cells (WBC), platelets (PLT), CD34+ cells, and colony-forming unit–fibroblast (CFU-F). To evaluate consistency, the variances of cell yield and concentration increase from baseline for each cell type were compared between systems. To compare concentrate product composition, differences between the systems’ mean cell yield and concentration increase from baseline for each cell type were evaluated.

Results:

The Harvest system (variance, 0.25) concentrated WBC more consistently than the Arthrex system (variance, 3.25) (P = .024), but no other differences in consistency were noted between the 3 systems. The Harvest system recovered the greatest percentage of CFU-F (82.4% ± 18.2%), CD34+ cells (81.1% ± 28.5%), and WBC (77.3% ± 8.6%), whereas the Biomet system recovered the greatest percentage of PLTs (92.9% ± 27.3%). The Arthrex system concentrated PLT to the greatest degree (11.10 ± 2.05 times baseline), while the Biomet system concentrated WBC to the greatest degree (5.99 ± 1.04 times baseline).

Conclusion:

The consistency of the 3 systems was similar for all but 1 of the evaluated cell types. However, the composition of the concentrate products differed across systems. This may grant each system unique advantages without having to sacrifice reproducibility.

Clinical Relevance:

Understanding the consistency of different BMAC preparation systems and their product makeup may aid in determining optimal therapeutic doses of different cell types.

The role of biologic agents in the management of common shoulder pathologies: current state and future directions

The field of orthopedic surgery has seen a rapid increase in the use of various biologic agents for the treatment of common musculoskeletal injuries. Most biologic agents attempt to harness or mimic naturally occurring growth factors, cytokines, and anti-inflammatory mediators to improve tissue healing and recovery. The most commonly used biologic agents are platelet-rich plasma and cells derived from bone marrow aspirate and adipose tissue. These agents have become increasingly popular despite a relative dearth of clinical data to support their use. Much confusion exists among patients and physicians in determining the role of these agents in treating common shoulder pathologies, such as glenohumeral osteoarthritis, rotator cuff tears, and tendinopathy. This article reviews the basic science and clinical evidence for the most commonly used biologic agents in the management of common shoulder pathology.

Graft Materials and Biologics for Spinal Interbody Fusion

Spinal fusion is the most widely performed procedure in spine surgery. It is the preferred treatment for a wide variety of pathologies including degenerative disc disease, spondylolisthesis, segmental instability, and deformity. Surgeons have the choice of fusing vertebrae by utilizing cages containing autografts, allografts, demineralized bone matrices (DBMs), or graft substitutes such as ceramic scaffolds. Autografts from the iliac spine are the most commonly used as they offer osteogenic, osteoinductive, and osteoconductive capabilities, all while avoiding immune system rejection. Allografts obtained from cadavers and living donors can also be advantageous as they lack the need for graft extraction from the patient. DBMs are acid-extracted organic allografts with osteoinductive properties. Ceramic grafts containing hydroxyapatite can be readily manufactured and are able to provide osteoinductive support while having a long shelf life. Further, bone-morphogenetic proteins (BMPs), mesenchymal stem cells (MSCs), synthetic peptides, and autologous growth factors are currently being optimized to assist in improving vertebral fusion. Genetic therapies utilizing viral transduction are also currently being devised. This review provides an overview of the advantages, disadvantages, and future directions of currently available graft materials. The current literature on growth factors, stem cells, and genetic therapy is also discussed.

Stress fractures of the medial malleolus in the professional soccer player demonstrate excellent outcomes when treated with open reduction internal fixation and arthroscopic spur debridement

PURPOSE

Despite a debilitating effect on athletic performance and an incidence of up to 4% of all stress fractures, there have been only 31 documented cases of medial malleolus stress fractures (MMSF) to our knowledge in the literature. The largest series to date is presented in this study, of 16 professional soccer players undergoing uniform operative treatment. The authors attempt to justify their preferred treatment of MMSFs in the professional soccer player, with an emphasis on patient satisfaction, clinical and radiographic union, and return to high level sport. The authors aim to prove an association between lower limb varus alignment and the development of MMSFs.

METHOD

Sixteen professional soccer players of mean age 23.6 years were analysed. A biomechanic assessment was performed. Preoperative CT+-MRI scan were performed to assess fracture lines and the presence of anteromedial tibial and/or talar spurs; which are the likely pathognomic lesion in the development of MMSFs. All patients underwent open reduction and internal fixation with three screws, as well as arthroscopic debridement of impringement spurs, and concentrated bone marrow aspirate into the fracture site. Patients completed the Ogilvie-Harris score, and all patients had CT scans at 3 months and until union.

RESULTS

All the patients in this cohort had causative bony spurs that were debrided at surgery. All of the cohort achieved clinical union. All patients were able to return to professional football; at the same level as prior to the injury. There was complete cohort follow up; and 81% of patients were graded as excellent and 19% as good by the Ogilvie-Harris score. We noted 50% of our cohort demonstrated varus malalignment, either genu varum or hindfoot varus.

CONCLUSIONS

The authors conclude that open reduction and internal fixation of MMSFs with screws combined with arthroscopic spur debridement results in excellent clinical outcomes. It can be concluded that varus lower limb malalignment is a risk factor for MMSFs. Given the treatment controversy for these injuries, the results herein demonstrate that aggressive multimodal operative treatment produces excellent outcomes in high demand professional footballers. This study is the first to report a biomechanic association, which can alert the clinician to preventative measures; such as hindfoot orthoses.

LEVEL OF EVIDENCE

IV.

Bone marrow concentrate-induced mesenchymal stem cell conditioned medium facilitates wound healing and prevents hypertrophic scar formation in a rabbit ear model

Background

Hypertrophic scars (HSs) are formed via an aberrant response to the wound healing process. HSs can be cosmetic or can result in functional problems. Prolonged proliferation and remodeling phases disrupt wound healing, leading to excessive collagen production and HS formation. However, there are currently no satisfactory drugs to prevent HS formation. Mesenchymal stem cell (MSC) conditioned medium (CM) has therapeutic effects on wound healing and preventing HS formation. Bone marrow concentrate (BMC) contains various growth factors and cytokines that are crucial for regeneration and has been applied in the clinical setting. In this study, we evaluated the effects of BMC-induced MSC CM on HS formation in a rabbit ear model.

Methods

We established a rabbit ear wound model by generating full-thickness wounds in the ears of rabbits (n = 12) and treated wounds with MSC CM, BMC CM, or BMC-induced MSC CM. Dermal fibroblasts from human hypertrophic scar were stimulated with transforming growth factor beta 1 (TGF-β1) for 24 h and cultured in each culture medium for 72 h. We measured the hypertrophic scar (HS) formation during the skin regeneration by measuring the expression of several remodeling molecules and the effect of these conditioned media on active human HS fibroblasts.

Results

Our results showed that BMC-induced MSC CM had greater antifibrotic effects than MSC CM and BMC CM significantly attenuated HS formation in rabbits. BMC-induced MSC CM accelerated wound re-epithelization by increasing cell proliferation. Additionally, BMC-induced MSC CM also inhibited fibrosis by decreasing profibrotic gene and protein expression, promoting extracellular matrix turnover, inhibiting fibroblast contraction, and reversing myofibroblast activation.

Conclusions

BMC-induced MSC CM modulated the proliferation and remodeling phases of wound healing, representing a potential wound healing agent and approach for preventing HS formation.

Electronic supplementary material

The online version of this article (10.1186/s13287-019-1383-x) contains supplementary material, which is available to authorized users.

Characterization of Growth Factors, Cytokines, and Chemokines in Bone Marrow Concentrate and Platelet-Rich Plasma: A Prospective Analysis

BACKGROUND

Platelet-rich plasma (PRP) and bone marrow concentrate (BMC) are orthobiologic therapies with numerous growth factors and other bioactive molecules. Before the clinical utility of PRP and BMC is optimized as a combined therapy or monotherapy, an improved understanding of the components and respective concentrations is necessary.

PURPOSE

To prospectively measure and compare anabolic, anti-inflammatory, and proinflammatory growth factors, cytokines, and chemokines in bone marrow aspirate (BMA), BMC, whole blood, leukocyte-poor PRP (LP-PRP), and leukocyte-rich PRP (LR-PRP) from samples collected and processed concurrently on the same day from patients presenting for elective knee surgery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients presenting for elective knee surgery were prospectively enrolled over a 3-week period. Whole blood from peripheral venous draw and BMA from the posterior iliac crest were immediately processed via centrifugation and manual extraction methods to prepare LR-PRP, LP-PRP, and BMC samples, respectively. BMA, BMC, whole blood, LR-PRP, and LP-PRP samples were immediately assayed and analyzed to measure protein concentrations.

RESULTS

BMC had a significantly higher interleukin 1 receptor antagonist (IL-1Ra) concentration than all other preparations (all P < .0009). LR-PRP also had a significantly higher IL-1Ra concentration than LP-PRP (P = .0006). There were no significant differences in IL-1Ra concentration based on age, sex, body mass index, or chronicity of injury in all preparations. LR-PRP had significantly higher concentrations of platelet-derived growth factor AA (PDGF-AA) and PDGF-AB/BB than all other preparations (all P < .0006). LR-PRP also had significantly higher concentrations of matrix metalloproteinase 1 (MMP-1) and soluble CD40 ligand than all other preparations (all P < .004). LP-PRP had significantly higher concentrations of MMPs, namely MMP-2, MMP-3, and MMP-12, than all other preparations (all P < .007).

CONCLUSION

BMC 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.