What do AO technique, external fixation and locking plate technology have in common? They are all game changers for foot and ankle surgeons. They have become gold standards. Game changers do not come along often. However, when they do, both surgeons and patients benefit. Surgeons benefit from simplification of surgical techniques and patients benefit from better outcomes.
Another game changer is bone marrow aspirate concentrate. When will this become as commonplace as American orthopedic technique, external fixation or locking plate technology?
Stephen Barrett, DPM, wrote an excellent blog discussing the biology of bone marrow aspirate concentrate for Podiatry Today (see http://www.podiatrytoday.com/blogged/exploring-potential-bone-marrow-asp... ). I am not going to reiterate what he said about what bone marrow aspirate concentrate is and what it does. However, I would like to discuss bone marrow aspirate concentrate harvesting, application and indications.
Practitioners theorize that it is better to harvest bone marrow aspirate concentrate from the iliac crest than the tibia or calcaneus. In fact, Dr. Barrett says in his blog “that tibial marrow and calcaneal marrow do not measure up to iliac crest marrow so have your orthopedic partners get this for you.” I respectfully disagree with Dr. Barrett on this point. Is there statistically significant data to say one harvest site provides that much better bone marrow aspirate concentrate? There may be a difference in the non-concentrated bone marrow aspirate but that is not what we are discussing.
The ability for podiatric surgeons to harvest from the tibia (either proximal or distal) or the calcaneus eliminates the need of an orthopedic surgeon to harvest from the iliac crest. I have harvested 60 cc of bone marrow aspirate from the calcaneus with no problem.
I will offer some tips for harvesting from the calcaneus, my preferred site.
• For clarification, the tourniquet must be down for the harvest.
• Use a Jamshidi needle, placing it into the posterior lateral aspect of the calcaneus and aiming toward the center of the calcaneus.
• Use a locking syringe to create the vacuum.
• There are a limited number of stem cells within a certain reservoir and if you continue to draw from the same spot, you are just pulling from peripheral blood.
• Reposition the cannula and trocar toward the calcaneocuboid joint. If you try to reposition the cannula with the syringe attached instead, the cannula will become clogged with cancellous bone.
• It is also helpful to pull back slowly on the cannula as you are aspirating to increase the total area of aspiration.
Surgeons most commonly use bone marrow aspirate concentrate with allograft in arthrodesis procedures. I also use bone marrow aspirate concentrate with local infiltration in the arthrodesis site without any type of allograft. I have found that closing the capsule/periosteum prior to applying the bone marrow aspirate concentrate helps prevent it from running out of the operative site.
The literature is clear about indications for using bone marrow aspirate concentrate in patients who are at high risk for non-unions in arthrodesis procedures. These patients include those with diabetes; patients with Charcot osteoarthropathy; patients who smoke; those with increased body mass index; and patients who are immunosuppressed.1
What about patients who are not at high risk? Do they not deserve the increased healing potential of bone marrow aspirate concentrate as well? Is a first metatarsophalangeal joint (MPJ) arthrodesis worthy of bone marrow aspirate concentrate? Are only midfoot and hindfoot arthrodesis procedures indicated for bone marrow aspirate concentrate? I would argue that patients who have undergone first MPJ arthrodesis with none of the aforementioned comorbidities also deserve the increased healing potential that goes with bone marrow aspirate concentrate.
In their 2009 study, Roukis and colleagues stated “autogenous bone marrow aspirate harvest from various locations about the lower extremity as described here represent safe and minimally invasive techniques useful for soft tissue and osseous healing augmentation.”2 The concerns of complications associated with harvesting are therefore minimal and should not come into the consideration of using bone marrow aspirate concentrate.
Is the cost of the procedure what prohibits the foot and ankle surgeon from using bone marrow aspirate concentrate? I am not a coding expert by any means and will not get into that discussion. However, if something will provide a better outcome for the patient, I think it is incumbent upon me to utilize it.
Bone marrow aspirate concentrate can provide your patients with significant advantages. If you have not tried bone marrow aspirate concentrate, give it a shot on one of your more difficult cases. If you are using bone marrow aspirate concentrate already, I would challenge you to consider broader applications for this game changer.
1. Scott RT, Hyer CF. Role of cellular allograft containing mesenchymal stem cells in high-risk foot and ankle reconstructions. J Foot Ankle Surg. 2013; 52(1):32-5.
2. Roukis TS, Hyer CF, Philbin TM, Berlet GC, Lee TH. Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study. J Foot Ankle Surg. 2009; 48(6):668-71.