Nucleated Cell Count Has Negligible Predictive Value for the Number of Colony-Forming Units for Connective Tissue Progenitor Cells (Stem Cells) in Bone Marrow Aspirate Harvested From the Proximal Humerus During Arthroscopic Rotator Cuff Repair

The Choice of Anticoagulant Influences the Characteristics of Bone Marrow Aspirate Concentrate and Mesenchymal Stem Cell Bioactivity In Vitro

Bone marrow aspirate concentrate (BMC) is commonly used as a therapeutic agent to resolve orthopedic injuries, using its unique cellularity to reduce inflammation and prime the region for repair. The aspiration of the bone marrow is performed using either sodium citrate (SC) or heparin sodium (HS) as an anticoagulant and processed via centrifugation to concentrate the cellular constituents. To date, the consideration of the impact of the two commonly used anticoagulants on the mesenchymal stem/stromal cell (MSC) population has been overlooked. The current study assesses the differences in the BMCs produced using 15% SC and HS at 1,000 U/mL or 100 U/mL final v./v. as an anticoagulant using in vitro metrics including total nucleated cell counts (TNC) and viability, the ability for mesenchymal stromal/stem cells (MSCs) to establish colony-forming units with fibroblast morphology (CFU-f), and cytokine expression profile of the MSC cultures. Our findings demonstrate that HS-derived BMC cultures result in higher CFU-f formation and CFU-f frequency at both concentrations assessed compared to SC-derived BMC cultures. In addition, there were significant differences in 27% (7 of 26) of the cytokines quantified in HS-derived BMC cultures compared to SC-derived BMC cultures with implications for MSC plasticity and self-renewal.

Editorial Commentary: Allogenic Dermal Fibroblasts in Collagen Matrix Scaffold Enhance Rotator Cuff Repair in an Animal Model

There has been a recent surge of interest on the use of biologic supplements to facilitate rotator cuff repair healing. Experimental evidence appears to support use of allogenic dermal fibroblasts (ADFs), either in the form of local injection or tenocytes embedded in collagen matrix scaffold, to enhance healing of a repaired rotator cuff tendon tear in an animal model. When compared with the ADFs, the platelet-rich plasma (PRP)-induced response seems to be limited in terms of the specific increases in local collagen 1 concentration, thus resulting in a bone-tendon healing response that is inferior in both biology and biomechanical behavior under the same laboratory conditions. While on the one hand, there is pilot data supporting use of dermal fibroblast in the clinical setting, thus reinforcing the animal study findings, on the other hand, we are also aware of the encouraging biologic changes that occurred in the retrieved acellular dermal matrix (ADM) allograft that was used for superior capsular reconstruction as a treatment of irreparable rotator cuff tears. In theory, ADFs locally instilled as an injection should further enhance the healing response compared to the ADM. However, this needs to be further studied to be able to be widely applicable clinically.

Arthroscopy Annual Research Awards: Something to Celebrate

With sincere appreciation to the AANA Education Foundation for their generous support, we announce our Annual Awards for the best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2021, as well as the Most Downloaded and Most Cited papers published 5 years ago. Also, as is customary and as we require of authors, our editors update their annual disclosures of potential conflicts of interest. Finally, we annually update our masthead, thus introducing a new Associate Editor and many new members of the Editorial Board and Social Media Board.

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.

Editorial Commentary: Shoulder Rotator Cuff Tendon Repair Using Bone Marrow Aspirate: Stem Cell Quantity Does Not Equal Quality

The use of biological agents in orthopaedic surgery is rapidly evolving. The potential to augment the healing environment at a surgical repair site is an especially exciting possibility. There are a few popular biological agents, including platelet-rich plasma, concentrated bone marrow aspirate (BMA), and adipose-derived connective tissue progenitor cells. BMA is an especially appealing biological agent because it can be harvested from a variety of sources, including the iliac crest, distal femur, and proximal humerus. As a result, BMA is readily accessible with minimal added surgical time and morbidity during surgical procedures on the hip, knee, and shoulder. In particular, the surgically repaired rotator cuff tendon is a prime candidate for biological augmentation, and the proximal humerus is an appealing source of concentrated BMA given its ease of access and low harvesting morbidity at the time of arthroscopic repair. The nucleated cell count may be considered a surrogate for the quality of BMA and can be readily calculated at the time of harvest. However, the quantity of nucleated cells does not necessarily equate to the quality of nucleated cells as colony-forming units after cell culture, nor do we know how ex vivo cell culture correlates with in vivo stem cell proliferation and healing. Most of all, future research must determine what factors (if any) do positively correlate with the number of colony-forming units.