Bone marrow aspiration concentration, sometimes referred to as stem cell therapy, is an injection procedure that may help some patients with chronic ankle pain. Bone marrow aspirate concentrate (BMAC) comes from a patient’s own bone marrow. This solution contains many cell types and biofactors such as cytokines (messenger cells that stimulate immune response), growth factors (repair cells), and hematopoietic (blood) stem cells, but most notably contain mesenchymal stem cells (MSCs – the cells that can differentiate into connective tissue) and platelets (with healing factors).” (1)

The research on bone marrow aspirate concentrate for ankle osteoarthritis

There should always be a realistic expectation of what stem cells can do for advanced ankle osteoarthritis, even when stem cells are administered during a surgery. There is very limited research and the use of this treatment should be discussed with your doctor. There are no definitive studies to suggest stem cell therapy can help reverse or treat ankle osteoarthritis.

An August 2021 study (2) evaluated the long-term follow-ups in patients undergoing a one-step procedure of debridement (removing dead tissue and debris) and bone marrow aspirate concentrate seeded in situ (at the site of the degenerative disease in the ankle) for the treatment of osteochondral lesions of the talus in ankles affected by osteoarthritis, documenting the duration of the clinical benefit and its efficacy in postponing end-stage procedures.

  • Results: Almost two out of the three patients in the study were satisfied with results. Failure rate was 33.3%.
  • Older patients and those with more complex cases requiring previous or combined surgeries had lower outcomes, as well as those affected by grade 3 osteoarthritis, who experienced a high failure rate of 71.4%.

A February 2022 study (3) evaluated a single-stage treatment of osteochondral defects of the ankle with bone marrow concentrate (BMC) in 94 patients. The “results strongly indicate that this bone marrow concentrate (BMC) treatment is safe for, and well tolerated by, patients with osteochondral defects of the ankle as both primary treatment and those who have failed primary treatment. This technique provides a safe, efficacious alternative to currently employed cartilage repair techniques, with favorable outcomes and a low complication rate at 36 months.”

December 2016 research in the Journal of experimental orthopedics from doctors at the Steadman Philippon Research Institute (4) hypothesized that bone marrow aspirate concentrate may be useful in regeneration of tissue, enhancing the quality of cartilage repair. As a result, BMAC promotes a potentially healthy environment for hyaline cartilage growth and repair.

Research cited in this study:

  • A study published in Clinical Orthopaedics and Related Research, reported that 94 % of patients returned to low impact sports activity at an average 4.4 months after bone marrow aspirate transplantation and 77 % of patients returned to high impact sports activity at an average 11.3 months. (5)
  • The same researchers in 2013 reported that 73 % of the 36 patients playing sports before surgery were able to return to sports. They also reported that 22 % of these 36 patients were able to return to sport, but at a lower level than before surgery. (6)
  • A 2011 study reported that 95 % of patients who had undergone Autologous Osteochondral Transplantation and Bone Marrow Aspirate Concentrate returned to their pre-symptom level of sporting activity at an average 13 weeks.(7)

A 2016 report in the Journal of experimental orthopaedics (8) examined ways to save the ankle from fusion and replacement. In this study, Italian researchers discussed joint saving procedures such as:

  • Surgical procedures such as Arthroscopic debridement, arthrodiastasis, and osteotomy are the current joint sparing procedures, but, in the available studies, controversial results were achieved
  • Better results for patients they speculated could be achieved with Mesenchymal stem cells (MSCs). They write that stem cells may be a good solution to prevent or reverse ankle degeneration, due to their immunomodulatory features (able to control the catabolic joint environment) and their regenerative osteochondral capabilities (able to treat the chondral defects).

In research from Korea, doctors found that after ankle surgery, such as osteotomy, ankle bones treated with bone marrow stem cell injections repaired significantly better than those not treated (9).

A heavily cited and received 2015 study showed that stem cell treatments were able to regrow cartilage in ankles significant enough to improve function and pain levels in selected patients. Walking distances were shown to dramatically improve in the patient group.(10)

In a post-surgical study from December 2018, (11) researchers found the injection of bone marrow mesenchymal stem cells could improve the repair process of the osteonecrosis.

A July 2020 case study (12) presented first documented use  of adipose-derived mesenchymal stem cell therapy therapy in combination with arthroscopic excision and curettage of an osteochondral lesion of the ankle. The patient had had prior unsuccessful ankle surgery and a most recent failure of a periosteal (ankle bone graft) graft. The doctors of this case reported:

  • “The novel use of autologous adipose-derived mesenchymal stem cell (ADMSC) therapy in combination with arthroscopic curettage resulted in robust hyaline-like cartilage repair, smooth integration with native cartilage and concurrent functional improvement.”

In a June 2022 study (13), surgeons suggest that “cell therapies augmentation for surgical procedures may enhance cartilage regeneration in chondral defects of the talus. Patient reported outcomes were significant improved from baseline to the last follow-up, indicating that (stem cell) procedures may be effective in restoring ankle function, reducing the symptoms and improving the physical activity of the patients.”

A 2022 study (14) found that injection of bone marrow concentrate with hyaluronan (hyaluronic acid) and fibrin (blood clotting protein) is a safe treatment in patients undergoing surgical treatment for osteochondral lesions in the ankle and those whose surgical treatment has failed. The researchers continued that the injection treatment avoids the two surgical procedures required for Autologous chondrocyte implantation.
A December 2023 (15) study found “insufficient evidence to support a positive effect on clinical outcomes of bone marrow aspirate concentrate as an additive to surgical treatment of osteochondral lesions of the talus.”

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1 Sampson S, Bemden AB, Aufiero D. Autologous bone marrow concentrate: review and application of a novel intra-articular orthobiologic for cartilage disease. The Physician and sportsmedicine. 2013 Sep 1;41(3):7-18.
2 Vannini F, Filardo G, Altamura SA, Di Quattro E, Ramponi L, Buda R, Giannini S, Faldini C. Bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis: satisfactory clinical outcome at 10 years. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 Feb 19:1-7.
3 Abas S, Kuiper JH, Roberts S, McCarthy H, Williams M, Bing A, Tins B, Makwana N. Osteochondral Lesions of the Ankle Treated with Bone Marrow Concentrate with Hyaluronan and Fibrin: A Single-Centre Study. Cells. 2022 Feb 11;11(4):629.
4 Chahla J, Cinque ME, Schon JM, et al. Bone marrow aspirate concentrate for the treatment of osteochondral lesions of the talus: a systematic review of outcomes. Journal of Experimental Orthopaedics. 2016;3:33. doi:10.1186/s40634-016-0069-x.
5 Giannini S, Buda R, Vannini F, Cavallo M, Grigolo B. One-step Bone Marrow-derived Cell Transplantation in Talar Osteochondral Lesions. Clinical Orthopaedics and Related Research. 2009;467(12):3307-3320. doi:10.1007/s11999-009-0885-8.
6 Giannini S, Buda R, Battaglia M, Cavallo M, Ruffilli A, Ramponi L, Pagliazzi G, Vannini F. One-step repair in talar osteochondral lesions: 4-year clinical results and t2-mapping capability in outcome prediction. The American journal of sports medicine. 2013 Mar;41(3):511-8.
7 Kennedy JG, Murawski CD. The Treatment of Osteochondral Lesions of the Talus with Autologous Osteochondral Transplantation and Bone Marrow Aspirate Concentrate: Surgical Technique. Cartilage. 2011 Oct;2(4):327-36. doi: 10.1177/1947603511400726. PMID: 26069591; PMCID: PMC4297142.
8 Castagnini F, Pellegrini C, Perazzo L, Vannini F, Buda R. J Exp Orthop. 2016 Dec;3(1):3. doi: 10.1186/s40634-016-0038-4. Epub 2016 Jan 15. Joint sparing treatments in early ankle osteoarthritis: current procedures and future perspectives.
9 Kim YS, Lee M, Koh YG. Additional mesenchymal stem cell injection improves the outcomes of marrow stimulation combined with supramalleolar osteotomy in varus ankle osteoarthritis: short-term clinical results with second-look arthroscopic evaluation. Journal of Experimental Orthopaedics. 2016;3:12. doi:10.1186/s40634-016-0048-2.
10 Emadedin M, Ghorbani Liastani M, Fazeli R, et al.Long-Term Follow-up of Intra-articular Injection of Autologous Mesenchymal Stem Cells in Patients with Knee, Ankle, or Hip Osteoarthritis. Arch Iran Med. 2015 Jun;18(6):336-44. doi: 015186/AIM.003.
11 Hernigou P, Dubory A, Lachaniette CH, Khaled I, Chevallier N, Rouard H. Stem cell therapy in early post-traumatic talus osteonecrosis. International orthopaedics. 2018 Dec 1;42(12):2949-56.1767
12 Freitag J, Wickham J, Shah K, Tenen A. Effect of autologous adipose-derived mesenchymal stem cell therapy in the treatment of an osteochondral lesion of the ankle. BMJ Case Reports CP. 2020 Jul 1;13(7):e234595.
13 Migliorini F, Eschweiler J, Goetze C, Pastor T, Giorgino R, Hildebrand F, Maffulli N. Cell therapies for chondral defects of the talus: a systematic review. Journal of Orthopaedic Surgery and Research. 2022 Jun 11;17(1):308.
14 Abas S, Kuiper JH, Roberts S, McCarthy H, Williams M, Bing A, Tins B, Makwana N. Osteochondral lesions of the ankle treated with bone marrow concentrate with hyaluronan and fibrin: a single-centre study. Cells. 2022 Feb 11;11(4):629.
15 Klein C, Dahmen J, Emanuel KS, Stufkens S, Kerkhoffs GM. Limited evidence in support of bone marrow aspirate concentrate as an additive to the bone marrow stimulation for osteochondral lesions of the talus: a systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2023 Dec;31(12):6088-103.