Review: The Effect of Concentrated Bone Marrow Aspirate in Operative Treatment
of Fifth Metatarsal Stress Fractures; A Double-Blind Randomized Controlled
Sarah E. Norman Minnis – 100621451
University of Ontario Institute of Technology
(MT-V) stress fractures often exhibit delayed union and are high-risk fractures
for non-union. Surgical treatment, currently considered as the gold standard,
does not give optimal results, with a mean time to fracture union of 12-18
weeks. In recent studies, the use of bone marrow cells has been introduced to
accelerate healing of fractures with union problems. The aim of this randomized
trial is to determine if operative treatment of MT-V stress fractures with use
of concentrated blood and bone marrow aspirate (cB?+?cBMA) is more effective
than surgery alone. We hypothesize that using cB?+?cBMA in the operative
treatment of MT-V stress fractures will lead to an earlier fracture union.
double-blind, randomized controlled trial (RCT) will be conducted in an
academic medical center in the Netherlands. Ethics approval is received. 50
patients will be randomized to either operative treatment with cB?+?cBMA,
harvested from the iliac crest, or operative treatment without cB?+?cBMA but
with a sham-treatment of the iliac crest. The fracture fixation is the same in
both groups, as is the post-operative care. Follow up will be one year. The
primary outcome measure is time to union in weeks on X-ray. Secondary outcome
measures are time to resumption of work and sports, functional outcomes (SF-36,
FAOS, FAAM), complication rate, composition of osteoprogenitors in cB?+?cBMA
and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress
fracture and analysed histologically to determine the stage of the stress
fracture. The difference in primary endpoint between the two groups is analysed
using student’s t-test or equivalent.
This trial will
likely provide level-I evidence on the effectiveness of cB?+?cBMA in the
operative treatment of MT-V stress fractures.
Overview of the Article
The objective of
the study was to determine the effect of adding concentrated blood and bone
marrow aspirate (cB + cBMA) to surgical intervention of stress fractures of the
fifth metatarsal (MT-V) on the time to union in comparison to surgery alone (Weel et al., 2015).
There are three
divisions of the foot, which include the forefoot, midfoot, and the hindfoot.
The forefoot is comprised of the metatarsals and phalanges. They articulate
proximally with the tarsal bone, distally with the phalanges, and both
proximally and distally to adjacent metatarsals (Salt, 2018). While running,
the body puts the majority of its body weight in this area of the foot. The
extensive and repeated stress can cause damage overtime, wherein the forces on
the bone outrun the natural remodelling process in the loaded bones (Weel et al., 2015). This may
result in a weak spot or stress reaction in the affected area, which would
likely develop into a stress fracture without sufficient intervention. This
type of injury is commonly seen in high level athletes and soldiers (Weel et al., 2015).
Though the exact
healing pathways of stress fractures is not clear, they do not seem to heal the
same way as a normal, traumatic fracture would. Instead of healing via callus
formation, stress fractures heal primarily with bone remodelling across the
fracture line (Weel et al., 2015).
This is largely due to an absence of a major factor initiating the cascade repair,
which is the coactivation of the inflammatory response and Bone Marrow Stem
Cells (BMSCs). The bone remodelling phase is initiated as the last phase,
wherein the callus formation is only formed along the exit point of the
fracture, towards the medullary cavity. In all, this process is much slower,
and has a higher propensity to fail (Weel
et al., 2015).
comprised of 50 subjects who presented with a MT-V stress fracture that was
diagnosed on X-ray or other radiologic imaging. The cB +cBMA was harvested
using the needle aspiration technique to extract the bone marrow from each
patient’s iliac crest (Weel et
al., 2015). There was a total of 60 cc of bone marrow aspirate drawn
from the patients’ iliac crest. The articulate was processed in a centrifuge,
wherein the cBMA was separated from the plasma (Weel et al., 2015). This was to be used during the
operation after the decortication, where the outer layer of the affected bone is
removed. This enables the physician to create the internal bone graft
surrounding the fracture zone, providing a natural scaffolding (Weel et al., 2015). Bone
material removed for decortication was used for a histological analysis, which
will be used to further understand the general healing process of stress
fractures (Weel et al., 2015).
recent studies, the first group that received operative treatment without
cB?+?cBMA had an average healing time of 12 weeks. This healing time was
defined as the time to union, identified on an x-ray or other diagnostic
imaging (Weel et al., 2015).
In the second group that received the cB?+?cBMA with operative treatment, the
mean time to union was 10 weeks. The results of this trial demonstrate that operative
treatment with cB?+?cBMA for MT-V stress fractures have a faster union time of
10 weeks, compared to a 12 to 18 week recovery time with operative treatment
alone (Weel et al., 2015) .
treatment of MT-V stress fractures should be performed with cB?+?cBMA for all
elite level athletes, as it has been proven to reduce recovery time by
approximately two weeks. In addition to a faster return to sport for athletes,
this alternative treatment method reduces the risk of reccurrence, as stress
fractures are more subjective to re-fracture (Weel et al., 2015).
kinesiologist is someone who is adept in the field of preventing and managing
injuries. Regardless of the type of kinesiologist, whether you are a physiotherapist,
athletic therapist, general practitioner, chiropractor, chiropodist, etc., a
large portion of patients you treat will likely be athletes. While the majority
of athletes a kinesiologist treats are likely eager to get back onto the
playing field, it is your responsibility as the kinesiologist to accurately
diagnose and provide the quickest and most effective mode of treatment. An
athlete with a metatarsal stress fracture similar to that described in the
study will go to a medical proffessional for proper diagnosis and treatment. Having
read this article and being aware of a treatment option with cB + cBMA will provide
you as a kinesiologist with additional information that will help get your
athlete back to sport two weeks before the traditional operation without cB +
cBMA. This is beneficial as a kinesiologist as this type of metatarsal stress
fracture is the most common, constituting 25% of all stress fractures in the
foot. Hence, having this additional knowledge that helps improve the outcome of
specific injuries known for their lengthy recovery time and risk of reccurrence,
it will set you apart from other people in your field.
This study was
of particular interest to me as I am a soccer player who obtained a distal
stress fracture of my MT-III or MT-IV in the spring of 2017. This was a result
of the increased training frequency in combination with a lack of arch support
in my soccer cleats. The recovery process was very slow, and took approximately
14 weeks before I was cleared to play soccer again. In addition to finding a
study in which the mechanism of injury was similar to my own, I was also
intrigued by the overall objective of the study. The objective was to determine
an alternative treatment option that provided patients with an MT stress
fracture with a more efficient recovery time, and less probability or
recurrence, specifically aimed toward elite level athletes who need to be back
on the field as soon as possible. To conclude, this article noteably caught my
attention as I experienced first-hand how challenging it is to be an athlete
with a stress fracture, and having to sit on the side lines while your team
plays. In my opinion, medical advancements targetting quicker recovery time are
well worth the time, money and resources.
As a kinesiology
undergraduate student who seeks to become a doctor of sports medicine, I will
likely encounter many elite level athletes with a MT-V stress fracture. I will
not only have a broader knowledge of available treatment options, I will alos
have a greater understanding of the general healing pathway of stress
fractures, which will enable me to provide my patients predisposed to these
types of overuse injuries with more preventative measures to avoid the injury
Salt, J. (2018). Week 2 Foot, Ankle and
Lower Leg Conditions 2-3.
Retrieved from https://uoit.blackboard.com/
Weel, H., Mallee, W. H., Van Dijk, C. N., Blankevoort, L.,
Goedegebuure, S., Goslings, J. C., …
& Kerkhoffs, G. M. (2015). The
Effect of Concentrated Bone Marrow Aspirate in Operative Treatment of Fifth
Metatarsal Stress Fractures; A Double-Blind Randomized Controlled Trial. BMC
Musculoskeletal Disorders, 16(1), 211.