ArticleReview: The Effect of Concentrated Bone Marrow Aspirate in Operative Treatmentof Fifth Metatarsal Stress Fractures; A Double-Blind Randomized ControlledTrialSarah E.
Norman Minnis – 100621451University of Ontario Institute of Technology Article AbstractBackgroundFifth metatarsal(MT-V) stress fractures often exhibit delayed union and are high-risk fracturesfor non-union. Surgical treatment, currently considered as the gold standard,does not give optimal results, with a mean time to fracture union of 12-18weeks. In recent studies, the use of bone marrow cells has been introduced toaccelerate healing of fractures with union problems. The aim of this randomizedtrial is to determine if operative treatment of MT-V stress fractures with useof concentrated blood and bone marrow aspirate (cB?+?cBMA) is more effectivethan surgery alone. We hypothesize that using cB?+?cBMA in the operativetreatment of MT-V stress fractures will lead to an earlier fracture union.Methods/DesignA prospective,double-blind, randomized controlled trial (RCT) will be conducted in anacademic medical center in the Netherlands. Ethics approval is received. 50patients will be randomized to either operative treatment with cB?+?cBMA,harvested from the iliac crest, or operative treatment without cB?+?cBMA butwith a sham-treatment of the iliac crest.
The fracture fixation is the same inboth groups, as is the post-operative care. Follow up will be one year. Theprimary outcome measure is time to union in weeks on X-ray. Secondary outcomemeasures are time to resumption of work and sports, functional outcomes (SF-36,FAOS, FAAM), complication rate, composition of osteoprogenitors in cB?+?cBMAand cost-effectiveness. Furthermore, a bone biopsy is taken from every stressfracture and analysed histologically to determine the stage of the stressfracture. The difference in primary endpoint between the two groups is analysedusing student’s t-test or equivalent. DiscussionThis trial willlikely provide level-I evidence on the effectiveness of cB?+?cBMA in theoperative treatment of MT-V stress fractures.
Overview of the ArticleThe objective ofthe study was to determine the effect of adding concentrated blood and bonemarrow aspirate (cB + cBMA) to surgical intervention of stress fractures of thefifth metatarsal (MT-V) on the time to union in comparison to surgery alone (Weel et al., 2015). There are threedivisions of the foot, which include the forefoot, midfoot, and the hindfoot.The forefoot is comprised of the metatarsals and phalanges.
They articulateproximally with the tarsal bone, distally with the phalanges, and bothproximally and distally to adjacent metatarsals (Salt, 2018). While running,the body puts the majority of its body weight in this area of the foot. Theextensive and repeated stress can cause damage overtime, wherein the forces onthe bone outrun the natural remodelling process in the loaded bones (Weel et al., 2015). This mayresult in a weak spot or stress reaction in the affected area, which wouldlikely develop into a stress fracture without sufficient intervention. Thistype of injury is commonly seen in high level athletes and soldiers (Weel et al., 2015).Though the exacthealing pathways of stress fractures is not clear, they do not seem to heal thesame way as a normal, traumatic fracture would.
Instead of healing via callusformation, stress fractures heal primarily with bone remodelling across thefracture 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 StemCells (BMSCs). The bone remodelling phase is initiated as the last phase,wherein the callus formation is only formed along the exit point of thefracture, towards the medullary cavity. In all, this process is much slower,and has a higher propensity to fail (Weelet al.
, 2015).This studycomprised of 50 subjects who presented with a MT-V stress fracture that wasdiagnosed on X-ray or other radiologic imaging. The cB +cBMA was harvestedusing the needle aspiration technique to extract the bone marrow from eachpatient’s iliac crest (Weel etal.
, 2015). There was a total of 60 cc of bone marrow aspirate drawnfrom 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 theoperation after the decortication, where the outer layer of the affected bone isremoved. This enables the physician to create the internal bone graftsurrounding the fracture zone, providing a natural scaffolding (Weel et al.
, 2015). Bonematerial removed for decortication was used for a histological analysis, whichwill be used to further understand the general healing process of stressfractures (Weel et al., 2015).Similar torecent studies, the first group that received operative treatment withoutcB?+?cBMA had an average healing time of 12 weeks. This healing time wasdefined as the time to union, identified on an x-ray or other diagnosticimaging (Weel et al., 2015).In the second group that received the cB?+?cBMA with operative treatment, themean time to union was 10 weeks.
The results of this trial demonstrate that operativetreatment with cB?+?cBMA for MT-V stress fractures have a faster union time of10 weeks, compared to a 12 to 18 week recovery time with operative treatmentalone (Weel et al., 2015) . Operativetreatment of MT-V stress fractures should be performed with cB?+?cBMA for allelite level athletes, as it has been proven to reduce recovery time byapproximately two weeks. In addition to a faster return to sport for athletes,this alternative treatment method reduces the risk of reccurrence, as stressfractures are more subjective to re-fracture (Weel et al.
, 2015). Discussion Akinesiologist is someone who is adept in the field of preventing and managinginjuries. Regardless of the type of kinesiologist, whether you are a physiotherapist,athletic therapist, general practitioner, chiropractor, chiropodist, etc., alarge portion of patients you treat will likely be athletes. While the majorityof athletes a kinesiologist treats are likely eager to get back onto theplaying field, it is your responsibility as the kinesiologist to accuratelydiagnose and provide the quickest and most effective mode of treatment.
Anathlete with a metatarsal stress fracture similar to that described in thestudy will go to a medical proffessional for proper diagnosis and treatment. Havingread this article and being aware of a treatment option with cB + cBMA will provideyou as a kinesiologist with additional information that will help get yourathlete back to sport two weeks before the traditional operation without cB +cBMA. This is beneficial as a kinesiologist as this type of metatarsal stressfracture is the most common, constituting 25% of all stress fractures in thefoot. Hence, having this additional knowledge that helps improve the outcome ofspecific injuries known for their lengthy recovery time and risk of reccurrence,it will set you apart from other people in your field.This study wasof particular interest to me as I am a soccer player who obtained a distalstress fracture of my MT-III or MT-IV in the spring of 2017.
This was a resultof the increased training frequency in combination with a lack of arch supportin my soccer cleats. The recovery process was very slow, and took approximately14 weeks before I was cleared to play soccer again. In addition to finding astudy in which the mechanism of injury was similar to my own, I was alsointrigued by the overall objective of the study. The objective was to determinean alternative treatment option that provided patients with an MT stressfracture with a more efficient recovery time, and less probability orrecurrence, specifically aimed toward elite level athletes who need to be backon the field as soon as possible. To conclude, this article noteably caught myattention as I experienced first-hand how challenging it is to be an athletewith a stress fracture, and having to sit on the side lines while your teamplays.
In my opinion, medical advancements targetting quicker recovery time arewell worth the time, money and resources. As a kinesiologyundergraduate student who seeks to become a doctor of sports medicine, I willlikely encounter many elite level athletes with a MT-V stress fracture. I willnot only have a broader knowledge of available treatment options, I will aloshave a greater understanding of the general healing pathway of stressfractures, which will enable me to provide my patients predisposed to thesetypes of overuse injuries with more preventative measures to avoid the injuryaltogether. ReferencesSalt, J. (2018). Week 2 Foot, Ankle andLower Leg Conditions 2-3.
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BMCMusculoskeletal Disorders, 16(1), 211.