Harnessing and modulating inflammation in strategies for bone regeneration

HtrA3 paves the way for MSC migration and promotes osteogenesis

Mesenchymal stem cell (MSC) migration determines the healing capacity of bone and is crucial in promoting bone regeneration. Migration of MSCs is highly dependent on degradation of extracellular matrix by proteolytic enzymes. However, the underlying mechanisms of how enzymolysis paves the way for MSCs to migrate from their niche to the defect area is still not fully understood. Here, this study shows that high-temperature requirement A3 (HtrA3) overcomes the physical barrier and provides anchor points through collagen IV degradation, paving the way for MSC migration. HtrA3 is upregulated in MSCs at the leading edge of bone defect during the early stage of healing. HtrA3 degrades the surrounding collagen IV, which increases the collagen network porosity and increases integrin β1 expression. Subsequently, integrin β1 enhances the mechanotransduction of MSCs, thus remodeling the cytoskeleton, increasing cellular stiffness and nuclear translocation of YAP, eventually promoting the migration and subsequent osteogenic differentiation of MSCs. Local administration of recombinant HtrA3 in rat cranial bone defects significantly increases new bone formation and further validates the enhancement of MSC migration. This study helps to reveal the novel roles of HtrA3, explore potential targets for regenerative medicine, and offer new insights for the development of bioactive materials.

Matrix Metalloproteinase-Responsive Hydrogel with On-Demand Release of Phosphatidylserine Promotes Bone Regeneration Through Immunomodulation

Inflammation-responsive hydrogels loaded with therapeutic factors are effective biomaterials for bone tissue engineering and regenerative medicine. In this study, a matrix metalloproteinase (MMP)-responsive injectable hydrogel is constructed by integrating an MMP-cleavable peptide (pp) into a covalent tetra-armed poly-(ethylene glycol) (PEG) network for precise drug release upon inflammation stimulation. To establish a pro-regenerative environment, phosphatidylserine (PS) is encapsulated into a scaffold to form the PEG-pp-PS network, which could be triggered by MMP to release a large amount of PS during the early stage of inflammation and retain drug release persistently until the later stage of bone repair. The hydrogel is found to be mechanically and biologically adaptable to the complex bone defect area. In vivo and in vitro studies further demonstrated the ability of PEG-pp-PS to transform macrophages into the anti-inflammatory M2 phenotype and promote osteogenic differentiation, thus, resulting in new bone regeneration. Therefore, this study provides a facile, safe, and promising cell-free strategy on simultaneous immunoregulation and osteoinduction in bone engineering.

In vitro co-culture models for the assessment of orthopedic antibacterial biomaterials

The antibacterial biofunctionality of bone implants is essential for the prevention and treatment of implant-associated infections (IAI). In vitro co-culture models are utilized to assess this and study bacteria-host cell interactions at the implant interface, aiding our understanding of biomaterial and the immune response against IAI without impeding the peri-implant bone tissue regeneration. This paper reviews existing co-culture models together with their characteristics, results, and clinical relevance. A total of 36 studies were found involving in vitro co-culture models between bacteria and osteogenic or immune cells at the interface with orthopedic antibacterial biomaterials. Most studies (∼67%) involved co-culture models of osteogenic cells and bacteria (osteo-bac), while 33% were co-culture models of immune cells and bacterial cells (im-bac). All models involve direct co-culture of two different cell types. The cell seeding sequence (simultaneous, bacteria-first, and cell-first) was used to mimic clinically relevant conditions and showed the greatest effect on the outcome for both types of co-culture models. The im-bac models are considered more relevant for early peri-implant infections, whereas the osteo-bac models suit late infections. The limitations of the current models and future directions to develop more relevant co-culture models to address specific research questions are also discussed.

Intraoperative tissue sampling for histology in chronic osteomyelitis shows high neutrophil infiltration centrally and low remains in debrided presumed infection-free regions

INTRODUCTION

Histology of debrided bone tissue is a confirmatory diagnostic criterion for fracture related infection (FRI) and prosthetic joint infection (PJI). The aim of the present study was to describe the histopathology of the first and last debrided bone tissue in chronic osteomyelitis (CO) according to the international diagnostic guidelines for FRI and PJI.

METHODS

15 patients with CO were allocated to surgical treatment using a one-stage protocol including extensive debridement. Suspected infected bone tissue eradicated early in the debridement procedure was collected as a clearly infected sample (S1). Likewise, the last eradicated bone tissue was collected as a suspected non-infected sample (S2). The samples were processed for histology. HE-stained sections were patho-morphologically examinated. Immunohistochemistry with MAC-387 antibodies towards calprotectin was used for estimation of neutrophil granulocyte (NP) score (0, 1, 2 or 3).

RESULTS

S1 samples showed a mean NP score of 2.6 (3 is confirmatory for infection). Following debridement, the NP score was significantly (p = 0.005) reduced to a mean NP score of 1.6. The S1 samples showed a mix of fibrovascular tissue, dense fibrosis, viable bone, bone necrosis and bone debris. S2 samples contained mostly viable bone tissue, however, often small fragments of necrotic bone or bone debris were present.

CONCLUSION

The inflammatory response of CO still exists after debridement, although the response fades from the center. Therefore, sampling of debrided bone tissue for histology must be performed initially during surgery, otherwise there is a risk for underestimation of NP infiltration. The present results might also be highly relevant for FRI and PJI.

Cracking the Code: The Role of Peripheral Nervous System Signaling in Fracture Repair

PURPOSE OF REVIEW

The traditionally understated role of neural regulation in fracture healing is gaining prominence, as recent findings underscore the peripheral nervous system's critical contribution to bone repair. Indeed, it is becoming more evident that the nervous system modulates every stage of fracture healing, from the onset of inflammation to repair and eventual remodeling.

RECENT FINDINGS

Essential to this process are neurotrophins and neuropeptides, such as substance P, calcitonin gene-related peptide, and neuropeptide Y. These molecules fulfill key roles in promoting osteogenesis, influencing inflammation, and mediating pain. The sympathetic nervous system also plays an important role in the healing process: while local sympathectomies may improve fracture healing, systemic sympathetic denervation impairs fracture healing. Furthermore, chronic activation of the sympathetic nervous system, often triggered by stress, is a potential impediment to effective fracture healing, marking an important area for further investigation. The potential to manipulate aspects of the nervous system offers promising therapeutic possibilities for improving outcomes in fracture healing. This review article is part of a series of multiple manuscripts designed to determine the utility of using artificial intelligence for writing scientific reviews.

Activin A marks a novel progenitor cell population during fracture healing and reveals a therapeutic strategy

Insufficient bone fracture repair represents a major clinical and societal burden and novel strategies are needed to address it. Our data reveal that the transforming growth factor-β superfamily member Activin A became very abundant during mouse and human bone fracture healing but was minimally detectable in intact bones. Single-cell RNA-sequencing revealed that the Activin A-encoding gene Inhba was highly expressed in a unique, highly proliferative progenitor cell (PPC) population with a myofibroblast character that quickly emerged after fracture and represented the center of a developmental trajectory bifurcation producing cartilage and bone cells within callus. Systemic administration of neutralizing Activin A antibody inhibited bone healing. In contrast, a single recombinant Activin A implantation at fracture site in young and aged mice boosted: PPC numbers; phosphorylated SMAD2 signaling levels; and bone repair and mechanical properties in endochondral and intramembranous healing models. Activin A directly stimulated myofibroblastic differentiation, chondrogenesis and osteogenesis in periosteal mesenchymal progenitor culture. Our data identify a distinct population of Activin A-expressing PPCs central to fracture healing and establish Activin A as a potential new therapeutic tool.

Immunomodulatory functions of microorganisms in tissue regenerative healing

External pathogenic microorganisms and commensal microorganisms in the body have either harmful or beneficial impacts on the regenerative repair of tissues, and the immune system plays a crucial regulatory role in this process. This review summarises our current understanding of microorganism-immune system interactions, with a focus on how these interactions impact the renewal and repair ability of tissues, including skin, bone, gut, liver, and nerves. This review concludes with a discussion of the mechanisms by which microbes act on various types of immune cells to affect tissue regeneration, offers potential strategies for using microbial therapies to enhance the regenerative repair function of tissues, and suggest novel therapeutic approaches for regenerative medicine. STATEMENT OF SIGNIFICANCE: Microbiological communities have crucial impacts on human health and illness by participating in energy collection and storage and performing various metabolic processes. External pathogenic microorganisms and commensal microorganisms in the body have either harmful or beneficial impacts on the regenerative repair of tissues, and the immune system plays a critical regulatory role in this process. This study reviews the important correlation between microorganisms and the immune system and investigates the mechanism of various microorganism that participate in the regeneration and repair of tissues and organs by modulating immune system.

Morroniside Inhibits Inflammatory Bone Loss through the TRAF6-Mediated NF-κB/MAPK Signalling Pathway

Osteoporosis is a chronic inflammatory disease that severely affects quality of life. Cornus officinalis is a Chinese herbal medicine with various bioactive ingredients, among which morroniside is its signature ingredient. Although anti-bone resorption drugs are the main treatment for bone loss, promoting bone anabolism is more suitable for increasing bone mass. Therefore, identifying changes in bone formation induced by morroniside may be conducive to developing effective intervention methods. In this study, morroniside was found to promote the osteogenic differentiation of bone marrow stem cells (BMSCs) and inhibit inflammation-induced bone loss in an in vivo mouse model of inflammatory bone loss. Morroniside enhanced bone density and bone microstructure, and inhibited the expression of IL6, IL1β, and ALP in serum (p < 0.05). Furthermore, in in vitro experiments, BMSCs exposed to 0-256 μM morroniside did not show cytotoxicity. Morroniside inhibited the expression of IL6 and IL1β and promoted the expression of the osteogenic transcription factors Runx2 and OCN. Furthermore, morroniside promoted osteocalcin and Runx2 expression and inhibited TRAF6-mediated NF-κB and MAPK signaling, as well as osteoblast growth and NF-κB nuclear transposition. Thus, morroniside promoted osteogenic differentiation of BMSCs, slowed the occurrence of the inflammatory response, and inhibited bone loss in mice with inflammatory bone loss.

Periprosthetic Joint Infections of the Knee Lastingly Impact the Bone Homeostasis

After periprosthetic joint infection (PJI)-dependent revision surgery, a significantly elevated number of patients suffer from prosthesis failure due to aseptic loosening and require additional revision surgery despite clearance of the initial infection. The mechanisms underlying this pathology are not well understood, as it has been assumed that the bone stock recovers after revision surgery. Despite clinical evidence suggesting decreased osteogenic potential in PJI, understanding of the underlying biology remains limited. In this study, we investigated the impact of PJI on bone homeostasis in a two-stage exchange approach at explantation and reimplantation. Sixty-four human tibial and femoral specimens (20 control, 20 PJI septic explantation, and 24 PJI prosthesis reimplantation samples) were analyzed for their bone microstructure, cellular composition, and expression of relevant genetic markers. Samples were analyzed using X-ray microtomography, Alcian blue and tartrate-resistant acid phosphatase staining, and RT-qPCR. In patients with PJI, bone volume (BV/TV; 0.173 ± 0.026; p < 0.001), trabecular thickness (164.262 ± 18.841 μm; p < 0.001), and bone mineral density (0.824 ± 0.017 g/cm2 ; p = 0.049) were reduced; trabecular separation (1833.939 ± 178.501 μm; p = 0.005) was increased. While prevalence of osteoclasts was elevated (N.Oc/BS: 0.663 ± 0.102, p < 0.001), osteoblast cell numbers were lower at explantation (N.Ob/BS: 0.149 ± 0.021; p = 0.047). Mean expression of bone homeostasis markers osteocalcin, osteopontin, Runx2, TSG-6, and FGF-2 was significantly reduced at prosthesis explantation. Despite partial recovery, all analyzed parameters were still significantly impacted at reimplantation. In contrast, mean expression of osteoclastogenesis-stimulating cytokine IL-17a was significantly increased at both explantation and reimplantation. In this study, we found a strong and lasting impact of PJI on the bone homeostasis on a molecular, cellular, and microstructural level. These changes may be responsible for the increased risk of prosthesis failure due to aseptic loosening. Our data suggest there is significant potential in modulating bone homeostasis to improve prosthesis fixation and long-term clinical outcome in affected patients. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Post craniotomy pain management in Copenhagen rat by intraperitoneal or oral dosage of Tramadol: a comparative evaluation

Calvarial craniotomy in animal models involves pain and distress. Moderate to severe pain in laboratory animals requires adequate pain management strategies. According to previous studies, the options available for suitable analgesia for rat calvarial craniotomy are very few. For most analgesic treatments, injectable routes of administration are predominantly used. However, these routes require restraining the animals, which may cause unnecessary pain, distress and suffering. As a well-fare measure, we focused on pain management by oral administration of analgesia. In this particular study, which is a sub-study of a major experiment on bone regeneration with different polymeric scaffold materials, we have compared the analgesic efficacy of intraperitoneal (I/P) and oral administration of tramadol (10 mg/kg) over a period of 96 h post-surgery in rat craniotomy models. The focus of our study is to evaluate the potential pain reduction efficacy of orally administered Tramadol without any restraining involved. We have used various non-invasive methods to assess the pain-alleviating efficacy of tramadol administered through different methods. We found that the efficacy of oral administration of tramadol is comparable to I/P administration in alleviating pain. Additionally, oral administration through drinking water has the benefit of not putting the animal under unwanted restraining stress.

Prediction of the Postoperative Bone Regeneration Rate After Mandibular Reduction: From the Perspective of Preoperative Inflammatory and Immune Status

BACKGROUND

Following mandibular reduction, bone regeneration in the angle region is a problem that can affect facial aesthetics and lead to revision surgery. The bone regeneration rate (BRR) varies between individuals and is difficult to predict. However, studies focusing on preoperative patient-related factors are lacking. As bone regeneration is closely related to the inflammatory and immune status of the organism, according to in vitro and in vivo evidence, preoperative inflammatory indicators were included in this study as potential predictors.

METHODS

Demographic and preoperative laboratory data were included as independent variables. The BRR calculated from computed tomography data was included as the dependent variable. Univariate analysis and multiple linear regression analysis were used to determine the key factors influencing the BRR. The ROC curves were used to analyse the corresponding predictive efficacy.

RESULTS

23 patients (46 mandibular angles) fulfilled the inclusion criteria. The mean bilateral BRR was 23.82 ± 9.90%. Preoperative monocyte count (M) was an independent positive factor for BRR, and age was a negative factor. Only M had a good predictive ability, and its optimal cut-off point to distinguish patients with BRR greater than 30% was 0.305 × 109/L. Other parameters were not significantly correlated with BRR.

CONCLUSIONS

Patient age and preoperative M may influence BRR, with M having a positive effect and age having a negative effect. According to the preoperative blood routine tests that are readily available, using the diagnostic threshold (M [Formula: see text] 0.305 × 109/L) derived from this study, surgeons can better predict BRR and identify patients whose BRR is greater than the mean level.

LEVEL OF EVIDENCE IV

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Recent Advances in the Production of Pharmaceuticals Using Selective Laser Sintering

Selective laser sintering (SLS) is an additive manufacturing process that has shown promise in the production of medical devices, including hip cups, knee trays, dental crowns, and hearing aids. SLS-based 3D-printed dosage forms have the potential to revolutionise the production of personalised drugs. The ability to manipulate the porosity of printed materials is a particularly exciting aspect of SLS. Porous tablet formulations produced by SLS can disintegrate orally within seconds, which is challenging to achieve with traditional methods. SLS also enables the creation of amorphous solid dispersions in a single step, rather than the multi-step process required with conventional methods. This review provides an overview of 3D printing, describes the operating mechanism and necessary materials for SLS, and highlights recent advances in SLS for biomedical and pharmaceutical applications. Furthermore, an in-depth comparison and contrast of various 3D printing technologies for their effectiveness in tissue engineering applications is also presented in this review.

Prolonged release of an antimicrobial peptide GL13K-loaded thermosensitive hydrogel on a titanium surface improves its antibacterial and anti-inflammatory properties

The application of titanium in the orthopedic and dental fields is associated with bacterial infection and chronic inflammation, especially in the early stages after its implantation. In the present study, we investigated the antibacterial and anti-inflammatory activities of a titanium surface that was immobilized in a thermosensitive PLGA-PEG-PLGA hydrogel containing the antimicrobial peptide GL13K. The FTIR results confirmed the successful loading of GL13K. The degradation of the hydrogel and release of GL13K persisted for two weeks. The modified titanium surface exhibited a significant inhibitory effect on Porphyromonas gingivalis in contact with its surface, as well as an inhibitory effect on P.g in the surrounding environment by releasing GL13K antimicrobial peptides. The modified titanium surfaces were biocompatible with RAW264.7. Furthermore, the expression of pro-inflammatory cytokines IL-1β, TNF-α and iNOS was down-regulated, whereas anti-inflammatory cytokines Arg-1, IL-10 and VEGF-A were up-regulated on the modified titanium surfaces on days 3 and 5. This effect was attributed to the polarization of macrophages from the M1 to M2 phenotype, which was confirmed by the detection of macrophage M1/M2 biomarkers via immunofluorescence staining and flow cytometry. Thus, the thermosensitive PLGA-PEG-PLGA hydrogel release system carrying the antimicrobial peptide GL13K on a titanium surface exhibited antibacterial and anti-inflammatory properties and promoted macrophage polarization from the M1 to M2 phenotype, which may help create a favourable niche for bone formation under infective condition.

Molecular Basis beyond Interrelated Bone Resorption/Regeneration in Periodontal Diseases: A Concise Review

Periodontitis is the sixth most common chronic inflammatory disease, destroying the tissues supporting the teeth. There are three distinct stages in periodontitis: infection, inflammation, and tissue destruction, where each stage has its own characteristics and hence its line of treatment. Illuminating the underlying mechanisms of alveolar bone loss is vital in the treatment of periodontitis to allow for subsequent reconstruction of the periodontium. Bone cells, including osteoclasts, osteoblasts, and bone marrow stromal cells, classically were thought to control bone destruction in periodontitis. Lately, osteocytes were found to assist in inflammation-related bone remodeling besides being able to initiate physiological bone remodeling. Furthermore, mesenchymal stem cells (MSCs) either transplanted or homed exhibit highly immunosuppressive properties, such as preventing monocytes/hematopoietic precursor differentiation and downregulating excessive release of inflammatory cytokines. In the early stages of bone regeneration, an acute inflammatory response is critical for the recruitment of MSCs, controlling their migration, and their differentiation. Later during bone remodeling, the interaction and balance between proinflammatory and anti-inflammatory cytokines could regulate MSC properties, resulting in either bone formation or bone resorption. This narrative review elaborates on the important interactions between inflammatory stimuli during periodontal diseases, bone cells, MSCs, and subsequent bone regeneration or bone resorption. Understanding these concepts will open up new possibilities for promoting bone regeneration and hindering bone loss caused by periodontal diseases.

Erythromycin Restores Osteoblast Differentiation and Osteogenesis Suppressed by Porphyromonas gingivalis Lipopolysaccharide

The macrolide erythromycin (ERM) inhibits excessive neutrophil accumulation and bone resorption in inflammatory tissues. We previously reported that the expression of developmental endothelial locus-1 (DEL-1), an endogenous anti-inflammatory factor induced by ERM, is involved in ERM action. Furthermore, DEL-1 is involved in the induction of bone regeneration. Therefore, in this study, we investigated whether ERM exerts an osteoblastogenic effect by upregulating DEL-1 under inflammatory conditions. We performed in vitro cell-based mechanistic analyses and used a model of Porphyromonas gingivalis lipopolysaccharide (LPS)-induced periodontitis to evaluate how ERM restores osteoblast activity. In vitro, P. gingivalis LPS stimulation suppressed osteoblast differentiation and bone formation. However, ERM treatment combined with P. gingivalis LPS stimulation upregulated osteoblast differentiation-related factors and Del1, indicating that osteoblast differentiation was restored. Alveolar bone resorption and gene expression were evaluated in a periodontitis model, and the results confirmed that ERM treatment increased DEL-1 expression and suppressed bone loss by increasing the expression of osteoblast-associated factors. In conclusion, ERM restores bone metabolism homeostasis in inflammatory environments possibly via the induction of DEL-1.

The decisive early phase of bone regeneration

Bone has a remarkable endogenous regenerative capacity that enables scarless healing and restoration of its prior mechanical function, even under challenging conditions such as advanced age and metabolic or immunological degenerative diseases. However - despite much progress - a high number of bone injuries still heal with unsatisfactory outcomes. The mechanisms leading to impaired healing are heterogeneous, and involve exuberant and non-resolving immune reactions or overstrained mechanical conditions that affect the delicate regulation of the early initiation of scar-free healing. Every healing process begins phylogenetically with an inflammatory reaction, but its spatial and temporal intensity must be tightly controlled. Dysregulation of this inflammatory cascade directly affects the subsequent healing phases and hinders the healing progression. This Review discusses the complex processes underlying bone regeneration, focusing on the early healing phase and its highly dynamic environment, where vibrant changes in cellular and tissue composition alter the mechanical environment and thus affect the signalling pathways that orchestrate the healing process. Essential to scar-free healing is the interplay of various dynamic cascades that control timely resolution of local inflammation and tissue self-organization, while also providing sufficient local stability to initiate endogenous restoration. Various immunotherapy and mechanobiology-based therapy options are under investigation for promoting bone regeneration.

Inflammation of Bone in Patients with Periprosthetic Joint Infections of the Knee

Despite the general success of total knee arthroplasty (TKA), addressing periprosthetic joint infection (PJI) and the resulting long-term complications is a growing medical need given the aging population and the increasing demand for arthroplasty. A larger proportion of patients face revision surgery because of the long-term complication of aseptic loosening despite clearance of the infection. The pathomechanisms leading to prosthetic loosening are not understood as it has been widely assumed that the bone stock recovers after explantation revision surgery. While clinical observations suggest a reduced osteogenic potential in patients with PJI, knowledge regarding the relevant biology is sparse. In the present study, we investigated the inflammatory impact of PJI on the bone and bone marrow in the vicinity of the joint. Additionally, we evaluated changes in the local inflammatory environment in a 2-stage exchange at both explantation and reimplantation.

Methods

In this study, we analyzed 75 human bone and bone-marrow specimens (obtained from 65 patients undergoing revision arthroplasty with cement for the treatment of PJI) for markers of inflammation. Samples were analyzed using hematoxylin and eosin overview staining, fluorescent immunohistochemical staining, flow cytometry, and polymerase chain reaction (PCR).

Results

Leukocyte prevalence was significantly elevated at explantation (femur, +218.9%; tibia, +134.2%). While leukocyte prevalence decreased at reimplantation (femur, -49.5%; tibia, -34.2%), the number of cells remained significantly higher compared with the control group (femur, +61.2%; tibia, +54.2%). Expression of inflammatory markers interleukin (IL)-1α (femur, +2,748.7%; tibia, +1,605.9%), IL-6 (femur, +2,062.5%; tibia, +2,385.7%), IL-10 (femur, +913.7%; tibia, +897.5%), IL-12 (femur, +386.1%; tibia, +52.5%), IL-18 (femur, +805.3%; tibia, +547.7%), and tumor necrosis factor (TNF)-α (femur, +296.9%; tibia, +220.9%) was significantly elevated at prosthesis explantation in both femoral and tibial specimens. Expression remained significantly elevated at reimplantation for all inflammatory markers except IL-12 compared with the control group. Conversely, there were only limited inflammatory changes in the bone marrow environment.

Conclusions

The present study demonstrated a strong and lasting upregulation of the proinflammatory environment in the joint-surrounding osseous scaffold in patients with PJI. Our data suggest that modulating the inflammatory environment has substantial potential to improve the clinical outcome in affected patients.

In Vitro and In Vivo Evaluation of Injectable Strontium-Modified Calcium Phosphate Cement for Bone Defect Repair in Rats

Calcium phosphate cement (CPC) has been widely studied, but its lack of osteoinductivity and inadequate mechanical properties limit its application, while strontium is able to promote bone formation and inhibit bone resorption. In this study, different proportions of tristrontium silicate were introduced to create a novel strontium-modified calcium phosphate cement (SMPC). The physicochemical properties of SMPC and CPC were compared, and the microstructures of the bone cements were characterized with scanning electron microscopy assays. Then, the effect of SMPC on cell proliferation and differentiation was examined. Furthermore, local inflammatory response and osteogenesis after SMPC implantation were also confirmed in the study. Finally, a rat model of isolated vertebral defects was used to test the biomechanical properties of the cements. The results showed that SMPC has better injectability and a shorter setting time than CPC. Meanwhile, the addition of tristrontium silicate promoted the mechanical strength of calcium phosphate cement, and the compressive strength of 5% SMPC increased to 6.00 ± 0.74 MPa. However, this promotion effect gradually diminished with an increase in tristrontium silicate, which was also found in the rat model of isolated vertebral defects. Furthermore, SMPC showed a more preferential role in promoting cell proliferation and differentiation compared to CPC. Neither SMPC nor CPC showed significant inflammatory responses in vivo. Histological staining suggested that SMPCs were significantly better than CPC in promoting new bone regeneration. Importantly, this osteogenesis effect of SMPC was positively correlated with the ratio of tristrontium silicate. In conclusion, 5% SMPC is a promising substitute material for bone repair with excellent physicochemical properties and biological activity.

Nanozymes for Regenerative Medicine

Nanozymes refer to nanomaterials that catalyze enzyme substrates into products under relevant physiological conditions following enzyme kinetics. Compared to natural enzymes, nanozymes possess the characteristics of higher stability, easier preparation, and lower cost. Importantly, nanozymes possess the magnetic, fluorescent, and electrical properties of nanomaterials, making them promising replacements for natural enzymes in industrial, biological, and medical fields. On account of the rapid development of nanozymes recently, their application potentials in regeneration medicine are gradually being explored. To highlight the achievements in the regeneration medicine field, this review summarizes the catalytic mechanism of four types of representative nanozymes. Then, the strategies to improve the biocompatibility of nanozymes are discussed. Importantly, this review covers the recent advances in nanozymes in tissue regeneration medicine including wound healing, nerve defect repair, bone regeneration, and cardiovascular disease treatment. In addition, challenges and prospects of nanozyme researches in regeneration medicine are summarized.

Craniomaxillofacial derived bone marrow mesenchymal stem/stromal cells (BMSCs) for craniomaxillofacial bone tissue engineering: A literature review

Craniomaxillofacial bone defects seriously affect the appearance, function, and psychological status of patients. Traditional autologous bone grafting is very challenging due to the limited sources of bone tissue, excessive surgical trauma, and high incidence of related complications. Craniomaxillofacial bone tissue engineering (BTE) strategies based on bone marrow mesenchymal stem cells (BMSCs) are emerging as an alternative. Craniomaxillofacial BMSCs (C-BMSCs) are homologous to craniomaxillofacial bones, which develop from the mesoderm and neural crest. This article aims to compare the differences in osteogenesis, angiogenesis, and immune regulation of C-BMSCs and other sources of BMSCs, and propose ideas and strategies such as 3D printing and mechanotherapy to completely harness the characteristics of C-BMSCs. In conclusion, C-BSMCs are a promising source of stem cells for the repair and reconstruction of craniomaxillofacial bone defects, and more attention should be paid to accelerating their basic research and clinical practices.

Long-Term Controlled Growth Factor Release Using Layer-by-Layer Assembly for the Development of In Vivo Tissue-Engineered Blood Vessels

The development of a well-designed tissue-engineered blood vessel (TEBV) still remains a challenge. In recent years, approaches in which the host response to implanted biomaterials is used to generate vascular constructs within the patient's body have gained increasing interest. The delivery of growth factors to these in situ-engineered vascular grafts might enhance myofibroblast recruitment and the secretion of essential extracellular matrix proteins, thereby optimizing their functional properties. Layer-by-layer (LbL) coating has emerged as an innovative technology for the controlled delivery of growth factors in tissue engineering applications. In this study, we combined the use of surface-etched polymeric rods with LbL coatings to control the delivery of TGF-β1, PDGF-BB, and IGF-1 and steer the foreign body response toward the formation of a functional vascular graft. Results showed that the regenerated tissue is composed of elastin, glycosaminoglycans, and circumferentially oriented collagen fibers, without calcification or systemic spill of the released growth factors. Functional controlled delivery was observed, whereas myofibroblast-rich tissue capsules were formed with enhanced collagen and elastin syntheses using TGF-β1 and TGF-β1/PDGF-BB releasing rods, when compared to control rods that were solely surface-engineered by chloroform etching. By combining our optimized LbL method and surface-engineered rods in an in vivo bioreactor approach, we could regulate the fate and ECM composition of in situ-engineered vascular grafts to create a successful in vivo vascular tissue-engineered replacement.

Apoptotic cells derived micro/nano-sized extracellular vesicles in tissue regeneration

Extracellular vesicles (EVs), products released by cells in multiple biological activities, are currently widely accepted as functional particles and intercellular communicators. From the orthodox perspective, EVs derived from apoptotic cells (apoEVs) are responsible for cell debris clearance, while recent studies have demonstrated that apoEVs participate in tissue regeneration. However, the underlying mechanisms and particular functions in tissue regeneration promotion of apoEVs remain ambiguous. Some molecules, such as caspases, active during apoptosis also function in tissue regeneration triggered by apoptosis,. ApoEVs are generated in the process of apoptosis, carrying cell contents to manifest biological effects, and possessing biomarkers to target phagocytes. The regenerative effect of apoEVs might be due to their abilities to facilitate cell proliferation and regulate inflammation. Such regenerative effect has been observed in various tissues, including skin, bone, cardiovascular system, and kidney. Engineered apoEVs are produced to amplify the biological benefits of apoEVs, rendering them optional for drug delivery. Meanwhile, challenges exist in thorough mechanistic exploration and standardization of production. In this review, we discussed the link between apoptosis and regeneration, current comprehension of the origination and investigation strategies of apoEVs, and mechanisms in tissue regeneration by apoEVs and their applications. Challenges and prospects are also discussed here.

Apoptotic cell-derived micro/nanosized extracellular vesicles in tissue regeneration

Extracellular vesicles (EVs), products released by cells in multiple biological activities, are currently widely accepted as functional particles and intercellular communicators. From the orthodox perspective, EVs derived from apoptotic cells (apoEVs) are responsible for cell debris clearance, while recent studies have demonstrated that apoEVs participate in tissue regeneration. However, the underlying mechanisms and particular functions in tissue regeneration promotion of apoEVs remain ambiguous. Some molecules active during apoptosis also function in tissue regeneration triggered by apoptosis, such as caspases. ApoEVs are generated in the process of apoptosis, carrying cell contents to manifest biological effects and possess biomarkers to target phagocytes. The regenerative effect of apoEVs might be due to their abilities to facilitate cell proliferation and regulate inflammation. Such regenerative effect has been observed in various tissues, including skin, bone, cardiovascular system, and kidneys. Engineered apoEVs are produced to amplify the biological benefits of apoEVs, rendering them optional for drug delivery. Meanwhile, challenges exist in thorough mechanistic exploration and standardization of production. In this review, we discussed the link between apoptosis and regeneration, current comprehension of the origination and investigation strategies of apoEVs, and mechanisms in tissue regeneration of apoEVs and their applications. Challenges and prospects are also addressed here.

MiR-27a-3p Targets GLP1R to Regulate Differentiation, Autophagy, and Release of Inflammatory Factors in Pre-Osteoblasts via the AMPK Signaling Pathway

Objective: Osteoporosis is caused by the dysregulation of bone homeostasis which is synergistically mediated by osteoclasts and osteoblasts. MiR-27a-3p is a key inhibitor of bone formation. Hence, unearthing the downstream target gene of miR-27a-3p is of great significance to understand the molecular mechanism of osteoporosis. Methods: Bioinformatics analysis was utilized to find the downstream target gene of miR-27a-3p, and dual-luciferase reporter assay was conducted to validate the interplay of miR-27a-3p and GLP1R. Besides, qRT-PCR, Western blot, and enzyme-linked immunosorbent assay (ELISA) were employed to verify the impact of miR-27a-3p on GLP1R expression and the differentiation, autophagy, and inflammatory response of MC3T3-E1 pre-osteoblasts. Results: Dual-luciferase assay validated that miR-27a-3p directly targeted GLP1R. Additionally, posttreatment of MC3T3-E1 cells with miR-27a-3p mimics resulted in a remarkable decrease in expression levels of GLP1R, cell differentiation marker gene, autophagy marker gene, and AMPK. These results indicated that miR-27a-3p targeted GLP1R to inhibit AMPK signal activation and pre-osteoblast differentiation and autophagy, while promoting the release of inflammatory factors. Conclusion: The miR-27a-3p/GLP1R regulatory axis in pre-osteoblasts contributes to understanding the molecular mechanism of osteoporosis.

Monocytes and pyrophosphate promote mesenchymal stem cell viability and early osteogenic differentiation

Pyrophosphate-containing calcium phosphate implants promote osteoinduction and bone regeneration. The role of pyrophosphate for inflammatory cell-mesenchymal stem cell (MSC) cross-talk during osteogenesis is not known. In the present work, the effects of lipopolysaccharide (LPS) and pyrophosphate (PPi) on primary human monocytes and on osteogenic gene expression in human adipose-derived MSCs were evaluated in vitro, using conditioned media transfer as well as direct effect systems. Direct exposure to pyrophosphate increased nonadherent monocyte survival (by 120% without LPS and 235% with LPS) and MSC viability (LDH) (by 16-19% with and without LPS). Conditioned media from LPS-primed monocytes significantly upregulated osteogenic genes (ALP and RUNX2) and downregulated adipogenic (PPAR-γ) and chondrogenic (SOX9) genes in recipient MSCs. Moreover, the inclusion of PPi (250 μM) resulted in a 1.2- to 2-fold significant downregulation of SOX9 in the recipient MSCs, irrespective of LPS stimulation or culture media type. These results indicate that conditioned media from LPS-stimulated inflammatory monocytes potentiates the early MSCs commitment towards the osteogenic lineage and that direct pyrophosphate exposure to MSCs can promote their viability and reduce their chondrogenic gene expression. These results are the first to show that pyrophosphate can act as a survival factor for both human MSCs and primary monocytes and can influence the early MSC gene expression. Graphical abstract.

Facile fabrication of a biocompatible composite gel with sustained release of aspirin for bone regeneration

Hydrogels are extracellular-matrix-like biomimetic materials that have wide biomedical applications in tissue engineering and drug delivery. However, most hydrogels cannot simultaneously fulfill the mechanical and cell compatibility requirements. In the present study, we prepared a semi-interpenetrating network composite gel (CG) by incorporating short chain chitosan (CS) into a covalent tetra-armed poly(ethylene glycol) network. In addition to satisfying physicochemical, mechanics, biocompatibility, and cell affinity requirements, this CG easily encapsulated acetylsalicylic acid (ASA) via electrostatic interactions and chain entanglement, achieving sustained release for over 14 days and thus promoting periodontal ligament stem cell (PDLSC) proliferation and osteogenic differentiation. In vivo studies corroborated the capacity of PDLSCs and ASA-laden CG to enhance new bone regeneration in situ using a mouse calvarial bone defect model. This might be attributed to PDLSCs and host mesenchymal stem cells expressing monocyte chemoattractant protein-1, which upregulated M2 macrophage recruitment and polarization in situ, indicating its appealing potential in bone tissue engineering.

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A facile method to prepare the composite gels with advantages of easy operation, good biocompatibility and biodegradability.

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Composite gels can simultaneously fulfill the mechanical strength and cell-compatibility requirements.

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Composite gels can achieve the loading and sustained release of acetylsalicylic acid via electrostatic interaction and chain entanglement.

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Acetylsalicylic-acid-encapsulated composite gel is paramount to promote PDLSCs-mediated bone regeneration.

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The underlying mechanism might be associated with upregulation of MCP-1 and macrophage M2 polarization.

Bioclickable Mussel-Derived Peptides With Immunoregulation for Osseointegration of PEEK

Polyether ether ketone (PEEK)–based biomaterials have been widely used in the field of spine and joint surgery. However, lack of biological activity limits their further clinical application. In this study, we synthesized a bioclickable mussel-derived peptide Azide-DOPA₄ as a PEEK surface coating modifier and further combined bone morphogenetic protein 2 functional peptides (BMP2p) with a dibenzylcyclooctyne (DBCO) motif through bio-orthogonal reactions to obtain DOPA₄@BMP2p-PEEK. As expected, more BMP2p can be conjugated on PEEK after Azide-DOPA₄ coating. The surface roughness and hydrophilicity of DOPA₄@BMP2p-PEEK were obviously increased. Then, we optimized the osteogenic capacity of PEEK substrates. In vitro, compared with the BMP2p-coating PEEK material, DOPA₄@BMP2p-PEEK showed significantly higher osteogenic induction capability of rat bone marrow mesenchymal stem cells. In vivo, we constructed a rat calvarial bone defect model and implanted PEEK materials with a differently modified surface. Micro-computed tomography scanning displayed that the DOPA₄@BMP2p-PEEK implant group had significantly higher new bone volume and bone mineral density than the BMP2p-PEEK group. Histological staining of hard tissue further confirmed that the DOPA₄@BMP2p-PEEK group revealed a better osseointegrative effect than the BMP2p-PEEK group. More importantly, we also found that DOPA₄@BMP2p coating has a synergistic effect with induced Foxp3+ regulatory T (iTreg) cells to promote osteogenesis. In summary, with an easy-to-perform, two-step surface bioengineering approach, the DOPA₄@BMP2p-PEEK material reported here displayed excellent biocompatibility and osteogenic functions. It will, moreover, offer insights to engineering surfaces of orthopedic implants.

Beyond immunosuppressive effects: dual roles of myeloid-derived suppressor cells in bone-related diseases

Myeloid-derived suppressor cells (MDSCs) are a heterogeneous population of immature myeloid cells (IMCs) with immunosuppressive functions, whereas IMCs originally differentiate into granulocytes, macrophages, and dendritic cells (DCs) to participate in innate immunity under steady-state conditions. At present, difficulties remain in identifying MDSCs due to lacking of specific biomarkers. To make identification of MDSCs accurately, it also needs to be determined whether having immunosuppressive functions. MDSCs play crucial roles in anti-tumor, angiogenesis, and metastasis. Meanwhile, MDSCs could make close interaction with osteoclasts, osteoblasts, chondrocytes, and other stromal cells within microenvironment of bone and joint, and thereby contributing to poor prognosis of bone-related diseases such as cancer-related bone metastasis, osteosarcoma (OS), rheumatoid arthritis (RA), osteoarthritis (OA), and orthopedic trauma. In addition, MDSCs have been shown to participate in the procedure of bone repair. In this review, we have summarized the function of MDSCs in cancer-related bone metastasis, the interaction with stromal cells within the bone microenvironment as well as joint microenvironment, and the critical role of MDSCs in bone repair. Besides, the promising value of MDSCs in the treatment for bone-related diseases is also well discussed.

The effect of acemannan in implant placement with simultaneous guided bone regeneration in the aesthetic zone: a randomized controlled trial

Acemannan, a linear polysaccharide produced by Aloe vera, has been shown to have important biological effects promoting wound healing and tissue regeneration. The aim of this randomized clinical trial was to investigate the impact of acemannan in guided bone regeneration (GBR) with simultaneous implant placement. Twenty patients were randomly allocated to a test group (deproteinized bovine bone with particulate acemannan (mean size 32.45 μm)) and a control group (deproteinized bovine bone only). Twenty implants were placed with simultaneous GBR. Radiographic measurements were conducted on cone beam computed tomography (CBCT) scans immediately post-surgery and at 3 and 6 months. Vertical and horizontal dimensions of the buccal bone were measured at the implant platform (0) and at points 2, 4, 6, and 8 mm apically. The dimensional reduction of vertical and horizontal buccal bone was significantly smaller in the test group at 3 months postoperative (P < 0.05) at every position measured (0, 2, 4, 6, 8 mm), but the difference was not statistically significant at 6 months. Acemannan was found to be a safe and predictable biomaterial for GBR, which resulted in enhanced dimensional stability of the regenerated tissue at 3 months. However, these results were not replicated at 6 months. Further studies are required to document the long-term efficacy and potential of acemannan use as a supplement in bone regeneration.

Ganoderma lucidum (Reishi) an edible mushroom; a comprehensive and critical review of its nutritional, cosmeceutical, mycochemical, pharmacological, clinical, and toxicological properties

Reishi owes an exceptional value in nutritional, cosmeceutical, and medical treatments; however, none of the studies has provided its future-driven critical assessment. This study documents an up-to-date review (2015-2020, wherever applicable) and provide valuable insights (preclinical and clinical evidence-based) with comprehensive and critical assessments. Various databases 'Google scholar', 'Web of Science', 'ScienceDirect', 'PubMed', 'Springer Link', books, theses, and library resources were used. The taxonomic chaos of G. lucidum and its related species was discussed in detail with solution-oriented emphasis. Reishi contains polysaccharides (α/β-D-glucans), alkaloids, triterpenoids (ganoderic acids, ganoderenic acids, ganoderol, ganoderiol, lucidenic acids), sterols/ergosterol, proteins (LZ-8, LZ-9), nucleosides (adenosine, inosine, uridine), and nucleotides (guanine, adenine). Some active drugs are explored at an optimum level to make them potential drug candidates. The pharmacological potential was observed in diabetes, inflammation, epilepsy, neurodegeneration, cancer, anxiety, sedation, cardiac diseases, depression, hepatic diseases, and immune disorders; however, most of the studies are preclinical with a number of drawbacks. In particular, quality clinical data are intensely needed to support pharmacological activities for human use. The presence of numerous micro-, macro, and trace elements imparts an essential nutritional and cosmeceutical value to Reishi, and various marketed products are available already, but the clinical studies regarding safety and efficacy, interactions with foods/drinks, chronic use, teratogenicity, mutagenicity, and genotoxicity are missing for Reishi. Reishi possesses many valuable pharmacological activities, and the number of patents and clinical trials is increasing for Reishi. Yet, a gap in research exists for Reishi, which is discussed in detail in the forthcoming sections.

Microarray Analysis of Differential Gene Expression Between Traumatic Temporomandibular Joint Fibrous and Bony Ankylosis in a Sheep Model

Background

The type of traumatic temporomandibular joint (TMJ) ankylosis depends on the degree of severity of TMJ trauma. Here, we performed comprehensive differential molecular profiling between TMJ fibrous and bony ankylosis.

Material/Methods

Six sheep were used and a bilateral different degree of TMJ trauma was performed to induce fibrous ankylosis in one side and bony ankylosis in the other side. The ankylosed calluses were harvested at days 14 and 28 postoperatively and analyzed by Affymetrix OviGene-1_0-ST microarrays. DAVID was used to perform the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis for the different expression genes (DEGs). The DEGs were also typed into protein–protein interaction (PPI) networks to get the interaction data. Ten DEGs, including 7 hub genes from PPI analysis, were confirmed by real-time PCR.

Results

We found 90 and 323 DEGs at least 2-fold at days 14 and 28, respectively. At day 14, bony ankylosis showed upregulated DEGs, such as TLR8, SYK, NFKBIA, PTPRC, CD86, ITGAM, and ITGAL, indicating a stronger immune and inflammatory response and cell adhesion, while genes associated with anti-adhesion (PRG4) and inhibition of osteoblast differentiation (SFRP1) had higher expression in fibrous ankylosis. At day 28, bony ankylosis showed increased biological process related to new bone formation, while fibrous ankylosis was characterized by a prolonged immune and inflammatory reaction.

Conclusions

This study provides a differential gene expression profile between TMJ fibrous and bony ankylosis. Further study of these key genes may provide new ideas for future treatment of TMJ bony ankylosis.

Modulating immune microenvironment during bone repair using biomaterials: Focusing on the role of macrophages

Bone is a self-regenerative tissue that can repair small defects and fractures. In large defects, bone tissue is unable to provide nutrients and oxygen for repair, and autologous grafting is used as the gold standard. As an alternative method, the bone tissue regeneration approach uses osteoconductive biomaterials to overcome bone graft disadvantages. However, biomaterials are considered as foreign components that can stimulate host immune responses. Although traditional principles have been aimed to minimize immune reactions, the design of biomaterials has steadily shifted toward creating an immunomodulatory microenvironment to harness immune cells and responses to repair damaged tissue. Among immune cells, macrophages secrete various immunomodulatory mediators and crosstalk with bone-forming cells and play key roles in bone tissue engineering. Macrophage polarization toward M1 and M2 subtypes mediate pro-inflammatory and anti-inflammatory responses, respectively, which are crucial for bone repairing at different stages. This review provides an overview of the crosstalk between various immune cells and biomaterials, macrophage polarization, and the effect of physicochemical properties of biomaterials on the immune responses, especially macrophages, in bone tissue engineering.

Spatiotemporal Immunomodulation Using Biomimetic Scaffold Promotes Endochondral Ossification-Mediated Bone Healing

Biomaterials play an important role in treating bone defects by promoting direct osteogenic healing through intramembranous ossification (IO). However, majority of the body's bones form via cartilaginous intermediates by endochondral ossification (EO), a process that has not been well mimicked by engineered scaffolds, thus limiting their clinical utility in treating large segmental bone defects. Here, by entrapping corticosteroid dexamethasone within biomimetic recombinant human bone morphogenetic protein (rhBMP)-loaded porous mesoporous bioglass scaffolds and regulating their release kinetics, significant degree of ectopic bone formation through endochondral ossification is achieved. By regulating the recruitment and polarization of immune suppressive macrophage phenotypes, the scaffold promotes rapid chondrogenesis by activating Hif-3α signaling pathway in mesenchymal stem cells, which upregulates the expression of downstream chondrogenic genes. Inhibition of Hif-3α signaling reverses the endochondral ossification phenotype. Together, these results reveal a strategy to facilitate developmental bone growth process using immune modulating biomimetic scaffolds, thus providing new opportunities for developing biomaterials capable of inducing natural tissue regeneration.

Modulating Mechanical and Shape-Memory Properties while Mitigating Degradation-Induced Inflammation of Polylactides by Pendant Aspirin Incorporation

Synergistically modulating mechanical properties and improving shape-memory performance while mitigating degradation-induced chronic inflammation of polylactide (PLA)-based implants for biomedical applications remain elusive. We test the hypothesis that copolymerizing aspirin-functionalized glycolide with d,l-lactide could enhance the thermal processing, toughness, and shape-memory efficiency of the copolymer while mitigating local inflammatory responses upon its degradation. The content of pendant aspirin was readily modulated by monomer feeds during ring-opening polymerization, and the copolymers with ∼10% or less aspirin pendants exhibited gigapascal-tensile moduli at body temperature and significantly improved fracture toughness and energy dissipation that positively correlated with the aspirin pendant content. The copolymers also exhibited excellent thermal-healing and shape-memory efficacy, achieving a >97% temporary shape fixing ratio at room temperature and facile shape recovery at 50-65 °C. These drastic improvements were attributed to the dynamic hydrophobic aggregations among aspirin pendants that strengthen glassy-state physical entanglement of PLA while readily dissociating under stress/thermal activation. When subcutaneously implanted, the copolymers mitigated degradation-induced inflammation due to concomitant hydrolytic release of aspirin without suppressing early acute inflammatory responses. The incorporation of aspirin pendants in PLA represents a straightforward and innovative strategy to enhance the toughness, shape-memory performance, and in vivo safety of this important class of thermoplastics for biomedical applications.

Use of Therapeutic Pathogen Recognition Receptor Ligands for Osteo-Immunomodulation

Therapeutic pathogen recognition receptor (PRR) ligands are reaching clinical practice following their ability to skew the immune response in a specific direction. We investigated the effects of various therapeutic PRR ligands on bone cell differentiation and inflammation. Following stimulation, alkaline phosphatase (ALP) activity (Day 10), osteocalcin, osteonectin expression (Day 14), and calcium deposition (Day 21) were quantified in bone marrow-derived human mesenchymal stem cells (hMSCs). The osteoclastogenic response was determined by measuring tartrate-resistant acid phosphate (TRAP) activity in human monocytes. TNF-α, IL-6, IL-8, and IL-10 expressions were measured by enzyme-linked immunosorbent assay as an indicator of the ligands’ inflammatory properties. We found that nucleic acid-based ligands Poly(I:C) and CpG ODN C increased early ALP activity in hMSCs by 4-fold without affecting osteoclast formation. These ligands did not enhance expression of the other, late osteogenic markers. MPLA, Curdlan, and Pam3CSK4 did not affect osteogenic differentiation, but inhibited TRAP activity in monocytes, which was associated with increased expression of all measured cytokines. Nucleic acid-based ligands are identified as the most promising osteo-immunomodulators, as they favor early osteogenic differentiation without inducing an exaggerated immune-cell mediated response or interfering in osteoclastogenesis and thus can be potentially harnessed for multifunctional coatings for bone biomaterials.

Patient-reported outcomes and complication rates after lateral maxillary sinus floor elevation: a prospective study

Objectives

Oral surgery morbidity is highly variable based on patients’ characteristics and kind of surgical intervention. However, poor data are available in the literature regarding patient outcomes after oral surgery. The aim of this retrospective study was to evaluate patient-reported outcome and complication rates after maxillary sinus floor elevation.

Materials and methods

Data from the records of patients undergoing maxillary sinus elevation have been collected from a private dental office. Patient-reported outcome has been assessed using a 100-mm visual analog scale to evaluate the post-operative pain (VAS_pain) experienced in the first week following surgery and visual rating scales to evaluate discomfort level (VRS_discomfort: 0 to 4) and willingness to repeat the same surgical procedure (VRS_willingness: 0 to 3). Analgesics intake, swelling onset and duration, and ecchymosis have been also recorded.

Results

VAS_pain showed moderate values in the first 2 days (< 50) post-surgery, with a tendency to progressively decrease over the next 2 days. Average assumption of painkillers was 3.93 ± 3.03. Discomfort level (VRS_discomfort) after surgery was low (median: 1; IR: 1–0), while willingness to undergo the same surgical procedure was very high (77.63% of patients). Swelling and ecchymosis were experienced by 97.36% and 51.32% of patients, respectively, with a mean duration of 4.09 ± 1.43 and 2.21 ± 2.31 days, respectively. Membrane perforation occurred in 4 cases. Other post-operative complications were not observed.

Conclusions

Maxillary sinus grafting is a safe procedure, with a low complication rate and moderate morbidity that is well tolerated by patients. Particular attention is needed in case selection, surgical planning and operator expertise.

Clinical relevance

The analysis of patient-reported outcomes can be of great help in surgical planning and in providing correct and adequate treatment.

Photobiomodulation Therapy on the Guided Bone Regeneration Process in Defects Filled by Biphasic Calcium Phosphate Associated with Fibrin Biopolymer

The aim is to evaluate the effects of photobiomodulation therapy (PBMT) on the guided bone regeneration process (GBR) in defects in the calvaria of rats filled with biphasic calcium phosphate associated with fibrin biopolymer. Thirty male Wistar rats were randomly separated: BMG (n = 10), defects filled with biomaterial and covered by membrane; BFMG (n = 10), biomaterial and fibrin biopolymer covered by membrane; and BFMLG (n = 10), biomaterial and fibrin biopolymer covered by membrane and biostimulated with PBMT. The animals were euthanized at 14 and 42 days postoperatively. Microtomographically, in 42 days, there was more evident bone growth in the BFMLG, limited to the margins of the defect with permanence of the particles. Histomorphologically, an inflammatory infiltrate was observed, which regressed with the formation of mineralized bone tissue. In the quantification of bone tissue, all groups had a progressive increase in new bone tissue with a significant difference in which the BFMLG showed greater bone formation in both periods (10.12 ± 0.67 and 13.85 ± 0.54), followed by BFMG (7.35 ± 0.66 and 9.41 ± 0.84) and BMG (4.51 ± 0.44 and 7.11 ± 0.44). Picrosirius-red staining showed greater birefringence of collagen fibers in yellow-green color in the BFMLG, showing more advanced bone maturation. PBMT showed positive effects capable of improving and accelerating the guided bone regeneration process when associated with biphasic calcium phosphate and fibrin biopolymer.

Do polyunsaturated fatty acids protect against bone loss in our aging and osteoporotic population?

Age-related bone loss is inevitable in both men and women and there will soon be more people of extreme old age than ever before. Osteoporosis is a common chronic disease and as the proportion of older people, rate of obesity and the length of life increases, a rise in age-related degenerating bone diseases, disability, and prolonged dependency is projected. Fragility fractures are one of the most severe complications associated with both primary and secondary osteoporosis and current treatment strategies target weight-bearing exercise and pharmacological intervention, both with limited long-term success. Obesity and osteoporosis are intimately interrelated, and diet is a variable that plays a significant role in bone regeneration and repair. The Western Diet is characterized by its unhealthy components, specifically excess amounts of saturated fat intake. This review examines the impact of saturated and polyunsaturated fatty acid consumption on chronic inflammation, osteogenesis, bone architecture, and strength and explores the hypothesis that dietary polyunsaturated fats have a beneficial effect on osteogenesis, reducing bone loss by decreasing chronic inflammation, and activating bone resorption through key cellular and molecular mechanisms in our aging population. We conclude that aging, obesity and a diet high in saturated fatty acids significantly impairs bone regeneration and repair and that consumption of ω-3 polyunsaturated fatty acids is associated with significantly increased bone regeneration, improved microarchitecture and structural strength. However, ω-6 polyunsaturated fatty acids were typically pro-inflammatory and have been associated with an increased fracture risk. This review suggests a potential role for ω-3 fatty acids as a non-pharmacological dietary method of reducing bone loss in our aging population. We also conclude that contemporary amendments to the formal nutritional recommendations made by the Food and Nutrition Board may be necessary such that our aging population is directly considered.

The Effect of Diclofenac Sodium-Loaded PLGA Rods on Bone Healing and Inflammation: A Histological and Histomorphometric Study in the Femur of Rats

Implants made of poly(lactide-co-glycolide) (PLGA) are biodegradable and frequently provoke foreign body reactions (FBR) in the host tissue. In order to modulate the inflammatory response of the host tissue, PLGA implants can be loaded with anti-inflammatory drugs. The aim of this study was to analyze the impact of PLGA 80/20 rods loaded with the diclofenac sodium (DS) on local tissue reactions in the femur of rats. Special emphasis was put on bone regeneration and the presence of multinucleated giant cells (MGCs) associated with FBR. PLGA 80/20 alone and PLGA 80/20 combined with DS was extruded into rods. PLGA rods loaded with DS (PLGA+DS) were implanted into the femora of 18 rats. Eighteen control rats received unloaded PLGA rods. The follow-up period was of 3, 6 and 12 weeks. Each group comprised of six rats. Peri-implant tissue reactions were histologically and histomorphometrically evaluated. The implantation of PLGA and PLGA+DS8 rods induced the formation of a layer of newly formed bone islands parallel to the contour of the implants. PLGA+DS rods tended to reduce the presence of multi-nucleated giant cells (MGCs) at the implant surface. Although it is known that the systemic administration of DS is associated with compromised bone healing, the local release of DS via PLGA rods did not have negative effects on bone regeneration in the femora of rats throughout 12 weeks.

Effects of the technique and drill design used during the osteotomy on the thermal and histological stimulation

The objective of our in vivo study was to compare the effects of the osteotomy on the thermal alterations, the bone healing and count of polymorphonuclear cells, comparing the drill design (cylindrical or conical) using continuous or intermittent movement. Twelve rabbits were used, which were made four osteotomies (n = 2 per tibia) to simulate the surgical drilling sequence for the installation of a dental implant at 8 mm of length and regular diameter. Four groups were proposed: group G1, cylindrical drill with continuous movement; group G2, cylindrical drill with intermittent movement; group G3, conical drill with continuous movement; and, group G4, conical drill with intermittent movement. Thermal mean variation was 6.91 ± 1.4 °C in group 1, 4.30 ± 1.3 °C in group 2, 2.78 ± 0.6 °C in group 3, and 2.77 ± 0.7 °C in group 4. Whereas the mean area of new bone formation was 1.00 ± 0.3 mm² in group 1, 1.48 ± 0.3 mm² in group 2, 2.20 ± 0.4 mm² in group 3, and 2.43 ± 0.4 mm²in group 4. The mean count of polymorphonuclear cells, in the group 1 was 62.4 ± 5.9 cells, group 2 was 50.7 ± 4.2 cells, group 3 was 44.4 ± 3.7 cells, and group 4 was 42.4 ± 3.7 cells. The conical drill sequence produced a significantly smaller increase in temperature during both techniques (continuous and intermittent), more effective new bone formation and a smaller number of polymorphonuclear cells. During the osteotomy for the installation of implants, the professional must take to consider the drill design to perform a less traumatic surgical technique, which can improve and facilitate the healing of peri-implant tissues.

Inflammation, Bone Healing and Osteonecrosis: From Bedside to Bench

Osteonecrosis of the epiphyseal and metaphyseal regions of major weight-bearing bones of the extremities is a condition that is associated with local death of bone cells and marrow in the afflicted compartment. Chronic inflammation is a prominent feature of osteonecrosis. If the persistent inflammation is not resolved, this process will result in progressive collapse and subsequent degenerative arthritis. In the pre-collapse stage of osteonecrosis, attempt at joint preservation rather than joint replacement in this younger population with osteonecrosis is a major clinical objective. In this regard, core decompression, with/without local injection of bone marrow aspirate concentrate (BMAC), is an accepted and evidence-based method to help arrest the progression and improve the outcome of early-stage osteonecrosis. However, some patients do not respond favorably to this treatment. Thus, it is prudent to consider strategies to mitigate chronic inflammation concurrent with addressing the deficiencies in osteogenesis and vasculogenesis in order to save the affected joint. Interestingly, the processes of inflammation, osteonecrosis, and bone healing are highly inter-related. Therefore, modulating the biological processes and crosstalk among cells of the innate immune system, the mesenchymal stem cell-osteoblast lineage and others are important to providing the local microenvironment for resolution of inflammation and subsequent repair. This review summarizes the clinical and biologic principles associated with osteonecrosis and provides potential cutting-end strategies for modulating chronic inflammation and facilitating osteogenesis and vasculogenesis using local interventions. Although these studies are still in the preclinical stages, it is hoped that safe, efficacious, and cost-effective interventions will be developed to save the host’s natural joint.

Advancing application of mesenchymal stem cell-based bone tissue regeneration

Reconstruction of bone defects, especially the critical-sized defects, with mechanical integrity to the skeleton is important for a patient's rehabilitation, however, it still remains challenge. Utilizing biomaterials of human origin bone tissue for therapeutic purposes has provided a facilitated approach that closely mimics the critical aspects of natural bone tissue with regard to its properties. However, not only efficacious and safe but also cost-effective and convenient are important for regenerative biomaterials to achieve clinical translation and commercial success. Advances in our understanding of regenerative biomaterials and their roles in new bone formation potentially opened a new frontier in the fast-growing field of regenerative medicine. Taking inspiration from the role and multicomponent construction of native extracellular matrix (ECM) for cell accommodation, the ECM-mimicking biomaterials and the naturally decellularized ECM scaffolds were used to create new tissues for bone restoration. On the other hand, with the going deep in understanding of mesenchymal stem cells (MSCs), they have shown great promise to jumpstart and facilitate bone healing even in diseased microenvironments with pharmacology-based endogenous MSCs rescue/mobilization, systemic/local infusion of MSCs for cytotherapy, biomaterials-based approaches, cell-sheets/-aggregates technology and usage of subcellular vesicles of MSCs to achieve scaffolds-free or cell-free delivery system, all of them have been shown can improve MSCs-mediated regeneration in preclinical studies and several clinical trials. Here, following an overview discussed autogenous/allogenic and ECM-based bone biomaterials for reconstructive surgery and applications of MSCs-mediated bone healing and tissue engineering to further offer principles and effective strategies to optimize MSCs-based bone regeneration.

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Focusing on MSCs based bone regeneration.

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Discussed cytotherapy, cell-free therapies and cell-aggregates technology in detail.

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Stating the approaches of MSCs in diseased microenvironments.

Lactoferrin in Bone Tissue Regeneration

Among the multiple properties exhibited by lactoferrin (Lf), its involvement in bone regeneration processes is of great interest at the present time. A series of in vitro and in vivo studies have revealed the ability of Lf to promote survival, proliferation and differentiation of osteoblast cells and to inhibit bone resorption mediated by osteoclasts. Although the mechanism underlying the action of Lf in bone cells is still not fully elucidated, it has been shown that its mode of action leading to the survival of osteoblasts is complemented by its mitogenic effect. Activation of several signalling pathways and gene expression, in an LRPdependent or independent manner, has been identified. Unlike the effects on osteoblasts, the action on osteoclasts is different, with Lf leading to a total arrest of osteoclastogenesis. Due to the positive effect of Lf on osteoblasts, the potential use of Lf alone or in combination with different biologically active compounds in bone tissue regeneration and the treatment of bone diseases is of great interest. Since the bioavailability of Lf in vivo is poor, a nanotechnology- based strategy to improve the biological properties of Lf was developed. The investigated formulations include incorporation of Lf into collagen membranes, gelatin hydrogel, liposomes, loading onto nanofibers, porous microspheres, or coating onto silica/titan based implants. Lf has also been coupled with other biologically active compounds such as biomimetic hydroxyapatite, in order to improve the efficacy of biomaterials used in the regulation of bone homeostasis. This review aims to provide an up-to-date review of research on the involvement of Lf in bone growth and healing and on its use as a potential therapeutic factor in bone tissue regeneration.

Positive role of calcium phosphate ceramics regulated inflammation in the osteogenic differentiation of mesenchymal stem cells

Recently, researches have confirmed the crucial role of inflammatory response in Ca-P ceramic-induced osteogenesis, however, the underlying mechanism has not yet been fully understood. In this study, BCP and β-TCP ceramics were used as material models to investigate the effect of physicochemical properties on inflammatory response in vitro. The results showed that BCP and β-TCP could support macrophages attachment, proliferation, and spreading favorably, as well as promote gene expressions of inflammatory related cytokines (IL-1, IL-6, MCP-1, and TNF-α) and growth factors (TGF-β, FGF, PDGF, VEGF, IGF, and EGF). BCP showed a facilitating function on the gene expressions earlier than β-TCP. Further coculture experiments performed in vitro demonstrated that the CMs containing various increased cytokines for macrophages pre-culture could significantly promote MSCs osteogenic differentiation, which was confirmed by the gene expressions of osteogenic specific markers and the intracellular OCN product accumulation under the stimulation of BCP and β-TCP ceramics. Further evidence was found from the formation of mineralized nodules in BCM and TCM. In addition, this study showed a concise relationship between Ca-P ceramic induced inflammation and its osteoinductivity that the increased cytokines and growth factors from macrophages could promote MSCs osteogenic differentiation.

Differential Effector Response of Amnion- and Adipose-Derived Mesenchymal Stem Cells to Inflammation; Implications for Intradiscal Therapy

Intervertebral disc degeneration (IVDD) is a progressive condition marked by tissue destruction and inflammation. The therapeutic effector functions of mesenchymal stem cells (MSCs) makes them an attractive therapy for patients with IVDD. While several sources of MSCs exist, the optimal choice for use in the inflamed IVD remains a significant question. Adipose (AD)- and amnion (AM)-derived MSCs have several advantages compared with other sources, however, no study has directly compared the impact of IVDD inflammation on their effector functions. Human MSCs were cultured in media with or without supplementation of interleukin-1β (IL-1β) and tumor necrosis factor-α at concentrations reportedly produced by IVDD cells. MSC proliferation and production of pro- and anti-inflammatory cytokines were quantified following 24 and 48 h of culture. Additionally, the osteogenic and chondrogenic potential of AD- and AM-MSCs was characterized via histology and biochemical analysis following 28 days of culture. In inflammatory culture, AM-MSCs produced significantly more anti-inflammatory IL-10 (14.47 ± 2.39 pg/ml; p = 0.004) and larger chondrogenic pellets (5.67 ± 0.26 mm² ; p = 0.04) with greater percent area staining positively for glycosaminoglycan (82.03 ± 3.26%; p < 0.001) compared with AD-MSCs (0.00 ± 0.00 pg/ml; 2.76 ± 0.18 mm² ; 34.75 ± 2.49%; respectively). Conversely, AD-MSCs proliferated more resulting in higher cell numbers (221,000 ± 8,021 cells; p = 0.048) and produced higher concentrations of pro-inflammatory cytokines prostaglandin E₂ (1,118.30 ± 115.56 pg/ml; p = 0.030) and IL-1β (185.40 ± 7.63 pg/ml; p = 0.010) compared with AM-MSCs (109,667 ± 5,696 cells; 1,291.40 ± 78.47 pg/ml; 144.10 ± 4.57 pg/ml; respectively). AD-MSCs produced more mineralized extracellular matrix (3.34 ± 0.05 relative absorbance units [RAU]; p < 0.001) compared with AM-MSCs (1.08 ± 0.06 RAU). Under identical inflammatory conditions, a different effector response was observed with AM-MSCs producing more anti-inflammatories and demonstrating enhanced chondrogenesis compared with AD-MSCs, which produced more pro-inflammatory cytokines and demonstrated enhanced osteogenesis. These findings may begin to help inform researchers which MSC source may be optimal for IVD regeneration. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2445-2456, 2019.

Impact of Bacterial Infections on Osteogenesis: Evidence From In Vivo Studies

The clinical impact of bacterial infections on bone regeneration has been incompletely quantified and documented. As a result, controversy exists about the optimal treatment strategy to maximize healing of a contaminated defect. Animal models are extremely useful in this respect, as they can elucidate how a bacterial burden influences quantitative healing of various types of defects relative to non-infected controls. Moreover, they may demonstrate how antibacterial treatment and/or bone grafting techniques facilitate the osteogenic response in the harsh environment of a bacterial infection. Finally, it a well-known contradiction that osteomyelitis is characterized by uncontrolled bone remodeling and bone loss, but at the same time, it can be associated with excessive new bone apposition. Animal studies can provide a better understanding of how osteolytic and osteogenic responses are related to each other during infection. This review discusses the in vivo impact of bacterial infection on osteogenesis by addressing the following questions (i) How does osteomyelitis affect the radiographic bone appearance? (ii) What is the influence of bacterial infection on histological bone healing? (iii) How do bacterial infections affect quantitative bone healing? (iv) What is the effect of antibacterial treatment on the healing outcome during infection? (v) What is the efficacy of osteoinductive proteins in infected bones? (vi) What is the balance between the osteoclastic and osteoblastic response during bacterial infections? (vii) What is the mechanism of the observed pro-osteogenic response as observed in osteomyelitis? © 2019 The Authors. Journal of Orthopaedic Research^© published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:2067-2076, 2019.

Inflammation and Bone Repair: From Particle Disease to Tissue Regeneration

When presented with an adverse stimulus, organisms evoke an immediate, pre-programmed, non-specific innate immune response. The purpose of this reaction is to maintain the organism's biological integrity and function, mitigate or eradicate the injurious source, and re-establish tissue homeostasis. The initial stage of this protective reaction is acute inflammation, which normally reduces or terminates the offending stimulus. As the inflammatory reaction recedes, the stage of tissue repair and regeneration follows. If the above sequence of events is perturbed, reconstitution of normal biological form and function will not be achieved. Dysregulation of these activities may result in incomplete healing, fibrosis, or chronic inflammation. Our laboratory has studied the reaction to wear particles from joint replacements as a paradigm for understanding the biological pathways of acute and chronic inflammation, and potential translational treatments to reconstitute lost bone. As inflammation is the cornerstone for healing in all anatomical locations, the concepts developed have relevance to tissue engineering and regenerative medicine in all organ systems. To accomplish our goal, we developed novel in vitro and in vivo models (including the murine femoral continuous intramedullary particle infusion model), translational strategies including modulation of macrophage chemotaxis and polarization, and methods to interfere with key transcription factors NFκB and MyD88. We purposefully modified MSCs to facilitate bone healing in inflammatory scenarios: by preconditioning the MSCs, and by genetically modifying MSCs to first sense NFκB activation and then overexpress the anti-inflammatory pro-regenerative cytokine IL-4. These advancements provide significant translational opportunities to enhance healing in bone and other organs.

Low-Intensity Pulsed Ultrasound Prevents Development of Bisphosphonate-Related Osteonecrosis of the Jaw-Like Pathophysiology in a Rat Model

We developed a rat model of bisphosphonate-related osteonecrosis of the jaw (BRONJ) by removing a maxillary molar tooth (M1) from ovariectomized rats after treatment with alendronate. To mimic periodontitis, some of the rats were administered Porphyromonas gingivalis (p. gingivalis) at the M1 site every 2 to 3 d for 2 wk. Rats pretreated with alendronate plus p. gingivalis showed delayed healing of socket epithelia, periosteal reaction of alveolar bone formation and lower bone mineral density in the alveolus above adjacent M2 teeth. These abnormalities were prevented by tooth socket exposure to 20 min/d low-intensity pulsed ultrasound (LIPUS), which restored diminished expression of RANKL, Bcl-2, IL-6, Hsp70, NF-κB and TNF-α messenger ribonucleic acids in remote bone marrow, suggesting LIPUS prevented development of BRONJ-like pathophysiology in rat by inducing systemic responses for regeneration, in addition to accelerating local healing. Non-invasive treatment by LIPUS, as well as low-level laser therapy, may be useful for medication-related osteonecrosis of the jaw patients.