Can Autologous Bone Marrow Aspirate Be Beneficial For DFUs?

By Gerit Mulder, DPM, MS, FRCST, FAPWCA

It is well known that diabetic foot ulcers contribute to extensive morbidity and mortality in patients with diabetes.1 Advanced biological and topical drug treatments have been introduced over the last two decades in an attempt to expedite wound closure, thereby reducing the risk of infection, amputation and other complications. These products include topical growth factors (Regranex®, Systagenix) as well as bioengineered living cell products, with the most frequently applied being Apligraf® (Organogenesis) and Dermagraft® (Advanced Biohealing).

   The success of advanced modalities is limited by a number of factors including but not limited to cost/reimbursement, offloading, wound debridement, the level of inflammatory cells and infection. Difficulties in successfully addressing all factors contributing to ulcer chronicity reduce both the efficacy and willingness of the clinician to apply advanced modalities to the majority of their patients. With appropriate offloading and a good standardized approach to wound care, many patients with diabetes will heal successfully. However, this does not mean that one should not consider biological materials and drugs in non-responders or patients who are more difficult to heal.

   Patients with underlying bone deformities resulting in repetitive pressure, tissue damage and ulceration are subject to a high probability of recurrence after complete wound closure. Even if it were possible for the tissue to re-establish normal tensile strength, the risk of recurrence will not be significantly reduced if one does not address the underlying cause. Removal or remodeling of underlying bone through surgery may be the only remaining option to reduce the risk of recurrence, provided that the patient has adequate blood flow to undergo surgery and does not have other medical or personal contraindications.

   Despite surgery, patients with diabetes may be slow to heal due to underlying deficiencies in tissue repair as well as metabolic considerations, including decreased fibroblast and macrophage activity, and decreased levels of glycosylated hemoglobin.2 New adjunctive treatments for a wound still present at the time of surgery include the use of bone marrow aspirate (BMA) derived stem cells in conjunction with a xenograft or allograft (non-human or human acellular tissue).

A Closer Look At The Research On Bone Marrow Aspirate

The more recent literature suggests the use of autologous stem cells derived from bone marrow have the potential to treat many disorders.3-5 This is due to the stem cells’ plasticity and ability to differentiate into various types of tissues, including endothelium, liver, muscle, skin, bone, cartilage, brain, fibroblasts and keratinocytes. The cells are known to assist with the tissue repair process by secreting large amounts of growth factors and cytokines. Badiavas and colleagues attained similar results in three patients, all of whom had complete closure of their ulcers, which had been present for a year or more.6 Patients received bone marrow aspirate and cultured cells within three months although one patient received bioengineered skin.

   Yoshikawa and co-workers in 2008 conducted the largest study to date using BMA-derived mesenchymal stem cells with or without autologous grafts.7 The study included 20 patients with non-healing wounds of varying etiology. The authors reported complete healing in 18 patients and showed regeneration of native tissue by histologic examination.

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