Bone Marrow Aspirate Concentrate in ACL Reconstruction: Systematic Review and Meta-analysis of Randomized Control Trials

Abstract

Aims: Anterior Cruciate Ligament (ACL) tears often result in long-term instability and post-traumatic osteoarthritis. Bone Marrow Aspirate Concentrate (BMAC) has been proposed as a biological supplement to improve graft–bone healing, but its clinical effectiveness and cost-benefit ratio remain uncertain. This study provides a definitive synthesis of the therapeutic, functional, and safety outcomes of BMAC augmentation in primary ACL reconstruction (ACLR) based exclusively on randomized controlled trials (RCTs). Study Design:  Meta Analysis of Randomized Control Trials. Methodology: This systematic review and meta-analysis was conducted according to PRISMA guidelines. We included six RCTs (N = 259) published up to August 15, 2025. Primary outcomes assessed included the Visual Analog Scale (VAS), Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores, as well as adverse events. The study protocol was registered on PROSPERO (CRD420261304072). Result: BMAC augmentation led to a statistically significant improvement in functional outcomes as measured by the IKDC score (MD 2.50; 95% CI: 0.89 to 4.11; P = .002), with no statistical heterogeneity (I² = 0%). While an improvement was also observed in the Lysholm score, it was only of borderline significance (MD 2.82; P = .05). Importantly, no significant difference was found in postoperative pain levels (VAS: MD 0.15; P = .26). The safety profile of BMAC was comparable to standard care, showing no increased risk of serious adverse events. Conclusion: Although BMAC augmentation in ACLR provides a statistically detectable improvement in functional outcomes on the IKDC score, this gain may not reach the threshold for a Minimal Clinically Important Difference and does not translate into a reduction in patient pain. Given the associated procedural requirements and costs, the routine clinical adoption of BMAC is currently unsupported for the general patient population.