Advancement of the Subchondral Bone Plate in Translational Models of Osteochondral Repair: Implications for Tissue Engineering Approaches

Osteochondral tissue engineering‑based subchondral bone plate repair (Review)

Osteochondral defects are a series of pathological changes from the chondral surface to the deeper trabecular bone caused by trauma or degenerative changes; they typically induce serious joint dysfunction. Over the past few decades, various techniques have been attempted to repair these defects. Tissue‑engineered osteochondral grafts (TEOGs) with sophisticated architecture have been extensively explored for osteochondral regeneration. However, controversies persist regarding standards for clinical application of TEOGs. The present review focused on the design of TEOGs, emphasizing their capacity to repair the subchondral bone plate (SBP). The effect of animal models on techniques to repair osteochondral defects was also reviewed. To improve the evaluation of SBP regeneration, four typical histological characteristics (abnormal height, uneven surface, poor integration and loose internal structure) are summarized based on cases of unsatisfactory SBP regeneration. Incorporating mesenchymal stem cells with appropriate growth factors into trilayer or multilayer tissue‑engineered scaffolds is a promising strategy to avoid unsatisfactory SBP regeneration. Large animal models are recommended for translation to the clinic and there is a need to establish detailed and comprehensive osteochondral defect models in the future.

Cartilage Tissue Engineering in Practice: Preclinical Trials, Clinical Applications, and Prospects

Articular cartilage defects significantly compromise the quality of life in the global population. Although many strategies are needed to repair articular cartilage, including microfracture, autologous osteochondral transplantation, and osteochondral allograft, the therapeutic effects remain suboptimal. In recent years, with the development of cartilage tissue engineering, scientists have continuously improved the formulations of therapeutic cells, biomaterial-based scaffolds, and biological factors, which have opened new avenues for better therapeutics of cartilage lesions. This review focuses on advances in cartilage tissue engineering, particularly in preclinical trials and clinical applications, prospects, and challenges.

Drug/bioactive eluting chitosan composite foams for osteochondral tissue engineering

Joint defects associated with a variety of etiologies often extend deep into the subchondral bone leading to functional impairment and joint immobility, and it is a very challenging task to regenerate the bone-cartilage interface offering significant opportunities for biomaterial-based interventions to improve the quality of life of patients. Herein drug-/bioactive-loaded porous tissue scaffolds incorporating nano-hydroxyapatite (nHAp), chitosan (CS) and either hydroxypropyl methylcellulose (HPMC) or Bombyx mori silk fibroin (SF) are fabricated through freeze drying method as subchondral bone substitute. A combination of spectroscopy and microscopy (Fourier transform infrared (FTIR) spectroscopy, scanning electron microscopy (SEM), X-ray diffraction (XRD), energy dispersive X-ray (EDX), and X-ray fluorescence (XRF) were used to analyze the structure of the porous biomaterials. The compressive mechanical properties of these scaffolds are biomimetic of cancellous bone tissues and capable of releasing drugs/bioactives (exemplified with triamcinolone acetonide, TA, or transforming growth factor-β1, TGF-β1, respectively) over a period of days. Mouse preosteoblast MC3T3-E1 cells were observed to adhere and proliferate on the tissue scaffolds as confirmed by the cell attachment, live-dead assay and alamarBlue™ assay. Interestingly, RT-qPCR analysis showed that the TA downregulated inflammatory biomarkers and upregulated the bone-specific biomarkers, suggesting such tissue scaffolds have long-term potential for clinical application.

Mesenchymal Stem Cell Studies in the Goat Model for Biomedical Research-A Review of the Scientific Literature

Mesenchymal stem cells (MSCs) are multipotent cells, defined by their ability to self-renew, while maintaining the capacity to differentiate into different cellular lineages, presumably from their own germinal layer. MSCs therapy is based on its anti-inflammatory, immunomodulatory, and regenerative potential. Firstly, they can differentiate into the target cell type, allowing them to regenerate the damaged area. Secondly, they have a great immunomodulatory capacity through paracrine effects (by secreting several cytokines and growth factors to adjacent cells) and by cell-to-cell contact, leading to vascularization, cellular proliferation in wounded tissues, and reducing inflammation. Currently, MSCs are being widely investigated for numerous tissue engineering and regenerative medicine applications. Appropriate animal models are crucial for the development and evaluation of regenerative medicine-based treatments and eventual treatments for debilitating diseases with the hope of application in upcoming human clinical trials. Here, we summarize the latest research focused on studying the biological and therapeutic potential of MSCs in the goat model, namely in the fields of orthopedics, dermatology, ophthalmology, dentistry, pneumology, cardiology, and urology fields.

Correlation between the subchondral bone marrow lesions and cartilage repair tissue after matrix-associated autologous chondrocyte implantation in the knee: a cross-sectional study

BACKGROUND

The contribution of the subchondral bone in the development and progression of osteoarthritis (OA) has long been recognized, but its role in cartilage repair procedures has only recently attracted more attention.

PURPOSE

To explore the correlation between the cartilage repair tissue (RT) and the subchondral bone marrow lesions (BMLs) after matrix-associated autologous chondrocyte implantation (MACI) in the knee joint.

MATERIAL AND METHODS

A total of 30 patients who underwent MACI in the knee from January 2015 to June 2018 and follow-up magnetic resonance imaging (MRI) scan were recruited in this study. The MRI results of cartilage RT were evaluated using T2* relaxation time. Subchondral BMLs were also qualitatively evaluated by use of the two-dimensional proton density-weighted fat-suppressed (2D-PD-FS) and three-dimensional dual-echo steady-state (3D-DESS) sequences.

RESULTS

The univariate analysis displayed a significant negative correlation between subchondral BMLs and cartilage RT (P < 0.01). In the minimally adjusted model (only age, sex, and body mass index [BMI] adjusted), the results did not show obvious changes (β = -6.54, 95% confidence interval [CI] = -10.99 to -2.09; P = 0.008). After adjustment for the full models (age, sex, BMI, defect size, combined injury, and preoperative duration of symptoms adjusted), the connection was also detected (β = -6.66, 95% CI -11.82 to -1.50; P = 0.019).

CONCLUSION

After MACI, the subchondral BMLs are significantly correlated with cartilage RT-T₂* relaxation time. The role of subchondral bone in cartilage repair procedures should not be underestimated.

Turning Nature's own processes into design strategies for living bone implant biomanufacturing: a decade of Developmental Engineering

A decade after the term developmental engineering (DE) was coined to indicate the use of developmental processes as blueprints for the design and development of engineered living implants, a myriad of proof-of-concept studies demonstrate the potential of this approach in small animal models. This review provides an overview of DE work, focusing on applications in bone regeneration. Enabling technologies allow to quantify the distance between in vitro processes and their developmental counterpart, as well as to design strategies to reduce that distance. By embedding Nature's robust mechanisms of action in engineered constructs, predictive large animal data and subsequent positive clinical outcomes can be gradually achieved. To this end, the development of next generation biofabrication technologies should provide the necessary scale and precision for robust living bone implant biomanufacturing.

Innovative Tissue-Engineered Strategies for Osteochondral Defect Repair and Regeneration: Current Progress and Challenges

Clinical treatments for the repair of osteochondral defects (OCD) are merely palliative, not completely curative, and thus enormously unfulfilled challenges. With the in-depth studies of biology, medicine, materials, and engineering technology, the conception of OCD repair and regeneration should be renewed. During the past decades, many innovative tissue-engineered approaches for repairing and regenerating damaged osteochondral units have been widely explored. Various scaffold-free and scaffold-based strategies, such as monophasic, biphasic, and currently fabricated multiphasic and gradient architectures have been proposed and evaluated. Meanwhile, progenitor cells and tissue-specific cells have also been intensively investigated in vivo as well as ex vivo. Concerning bioactive factors and drugs, they have been combined with scaffolds and/or living cells, and even released in a spatiotemporally controlled manner. Although tremendous progress has been achieved, further research and development (R&D) is needed to convert preclinical outcomes into clinical applications. Here, the osteochondral unit structure, its defect classifications, and diagnosis are summarized. Commonly used clinical reparative techniques, tissue-engineered strategies, emerging 3D-bioprinting technologies, and the status of their clinical applications are discussed. Existing challenges to translation are also discussed and potential solutions for future R&D directions are proposed.

Protein-reactive nanofibrils decorated with cartilage-derived decellularized extracellular matrix for osteochondral defects

Cartilage defect is difficult to heal due to its avascular properties. Implantation of mesenchymal stem cell is one of the most promising approach for regenerating cartilage defects. Here we prepared polymeric nanofibrils decorated with cartilage-derived decellularized extracellular matrix (dECM) as a chondroinductive scaffold material for cartilage repair. To fabricate nanofibrils, eletrospun PCL nanofibers were fragmented by subsequent mechanical and chemical process. The nanofibrils were surface-modified with poly(glycidyl methacrylate) (PGMA@NF) via surface-initiated atom transfer radical polymerization (SI-ATRP). The epoxy groups of PGMA@NF were subsequently reacted with dECM prepared from bovine articular cartilage. Therefore, the cartilage-dECM-decorated nanofibrils structurally and biochemically mimic cartilage-specific microenvironment. Once adipose-derived stem cells (ADSCs) were self-assembled with the cartilage-dECM-decorated nanofibrils by cell-directed association, they exhibited differentiation hallmarks of chondrogenesis without additional biologic additives. ADSCs in the nanofibril composites significantly increased expression of chondrogenic gene markers in comparison to those in pellet culture. Furthermore, ADSC-laden nanofibril composites filled the osteochondral defects compactly due to their clay-like texture. Thus, the ADSC-laden nanofibril composites supported the long-term regeneration of 12 weeks without matrix loss during joint movement. The defects treated with the ADSC-laden PGMA@NF significantly facilitated reconstruction of their cartilage and subchondral bone ECM matrices compared to those with ADSC-laden nanofibrils, non-specifically adsorbing cartilage-dECM without surface decoration of PGMA.

Microfracture for cartilage repair in the knee: a systematic review of the contemporary literature

PURPOSE

To systematically review and evaluate novel clinical data following microfracture treatment of knee articular cartilage defects.

METHODS

A systematic review was performed by searching PubMed, ScienceDirect, and Cochrane Library databases for clinical trials on microfracture treatment, published between 2013 and 2018. Titles, abstracts, and articles were reviewed, and data concerning patient demographics, study design, pre-, intra-, and postoperative findings were extracted. PRISMA guidelines were applied. The methodological quality of the included studies was analyzed by the modified Coleman Methodology Score (CMS), and aggregate data were generated.

RESULTS

Eighteen studies including 1830 defects (1759 patients) were included. Of them, 8 (59% of patients) were cohort studies without a comparison group. Overall study quality was moderate (mean total CMS: 64 points), mainly due to low patient numbers, short follow-up periods, lack of control groups and structural repair tissue evaluation, and inhomogeneity in outcome parameters. Microfracture treatment of full-thickness articular cartilage defects (3.4 ± 2.1 cm²) was performed at 43.4 ± 68.0 months of symptom duration. Postoperative assessment at 79.5 ± 27.2 months revealed failure rates of 11-27% within 5 years and 6-32% at 10 years. Imaging analysis was conducted in 10 studies, second-look arthroscopies were reported twice (n = 205 patients) and revealed well integrated fibrocartilaginous repair tissue.

CONCLUSIONS

Microfracture provides good function and pain relief at the mid-term and clinically largely satisfying results thereafter. Standardized, high-quality future study designs will better refine optimal indications for microfracture in the context of cartilage repair strategies.

LEVEL OF EVIDENCE

This systematic review is based on studies with levels of evidence ranging between I and IV (see results section and Table). Therefore, and according to this journals Instructions for Authors (SYSTEMATIC REVIEWS AND META-ANALYSES are assigned a level of evidence equivalent to the lowest level of evidence used from the manuscripts analysed), level of evidence is IV.

Thermosensitive Hydrogel Based on PEO-PPO-PEO Poloxamers for a Controlled In Situ Release of Recombinant Adeno-Associated Viral Vectors for Effective Gene Therapy of Cartilage Defects

Advanced biomaterial-guided delivery of gene vectors is an emerging and highly attractive therapeutic solution for targeted articular cartilage repair, allowing for a controlled and minimally invasive delivery of gene vectors in a spatiotemporally precise manner, reducing intra-articular vector spread and possible loss of the therapeutic gene product. As far as it is known, the very first successful in vivo application of such a biomaterial-guided delivery of a potent gene vector in an orthotopic large animal model of cartilage damage is reported here. In detail, an injectable and thermosensitive hydrogel based on poly(ethylene oxide) (PEO)-poly(propylene oxide) (PPO)-PEO poloxamers, capable of controlled release of a therapeutic recombinant adeno-associated virus (rAAV) vector overexpressing the chondrogenic sox9 transcription factor in full-thickness chondral defects, is applied in a clinically relevant minipig model in vivo. These comprehensive analyses of the entire osteochondral unit with multiple standardized evaluation methods indicate that rAAV-FLAG-hsox9/PEO-PPO-PEO hydrogel-augmented microfracture significantly improves cartilage repair with a collagen fiber orientation more similar to the normal cartilage and protects the subchondral bone plate from early bone loss.

Cartilage defect location and stiffness predispose the tibiofemoral joint to aberrant loading conditions during stance phase of gait

OBJECTIVES

The current study quantified the influence of cartilage defect location on the tibiofemoral load distribution during gait. Furthermore, changes in local mechanical stiffness representative for matrix damage or bone ingrowth were investigated. This may provide insights in the mechanical factors contributing to cartilage degeneration in the presence of an articular cartilage defect.

METHODS

The load distribution following cartilage defects was calculated using a musculoskeletal model that included tibiofemoral and patellofemoral joints with 6 degrees-of-freedom. Circular cartilage defects of 100 mm2 were created at different locations in the tibiofemoral contact geometry. By assigning different mechanical properties to these defect locations, softening and hardening of the tissue were evaluated.

RESULTS

Results indicate that cartilage defects located at the load-bearing area only affect the load distribution of the involved compartment. Cartilage defects in the central part of the tibia plateau and anterior-central part of the medial femoral condyle present the largest influence on load distribution. Softening at the defect location results in overloading, i.e., increased contact pressure and compressive strains, of the surrounding tissue. In contrast, inside the defect, the contact pressure decreases and the compressive strain increases. Hardening at the defect location presents the opposite results in load distribution compared to softening. Sensitivity analysis reveals that the surrounding contact pressure, contact force and compressive strain alter significantly when the elastic modulus is below 7 MPa or above 18 MPa.

CONCLUSION

Alterations in local mechanical behavior within the high load bearing area resulted in aberrant loading conditions, thereby potentially affecting the homeostatic balance not only at the defect but also at the tissue surrounding and opposing the defect. Especially, cartilage softening predisposes the tissue to loads that may contribute to accelerated risk of cartilage degeneration and the initiation or progression towards osteoarthritis of the whole compartment.

Large Animal Models for Osteochondral Regeneration

Namely, in the last two decades, large animal models - small ruminants (sheep and goats), pigs, dogs and horses - have been used to study the physiopathology and to develop new therapeutic procedures to treat human clinical osteoarthritis. For that purpose, cartilage and/or osteochondral defects are generally performed in the stifle joint of selected large animal models at the condylar and trochlear femoral areas where spontaneous regeneration should be excluded. Experimental animal care and protection legislation and guideline documents of the US Food and Drug Administration, the American Society for Testing and Materials and the International Cartilage Repair Society should be followed, and also the specificities of the animal species used for these studies must be taken into account, such as the cartilage thickness of the selected defect localization, the defined cartilage critical size defect and the joint anatomy in view of the post-operative techniques to be performed to evaluate the chondral/osteochondral repair. In particular, in the articular cartilage regeneration and repair studies with animal models, the subchondral bone plate should always be taken into consideration. Pilot studies for chondral and osteochondral bone tissue engineering could apply short observational periods for evaluation of the cartilage regeneration up to 12 weeks post-operatively, but generally a 6- to 12-month follow-up period is used for these types of studies.

Definition of a Critical Size Osteochondral Knee Defect and its Negative Effect on the Surrounding Articular Cartilage in the Rat

BACKGROUND

Joint trauma is predisposing to the incidence of osteoarthritis (OA) of the knee. There is a limited knowledge on the impact of posttraumatic osteochondral defects on the whole joint. This study was designed to define a critical size osteochondral defect in the knee of rats and to investigate a possible association between osteochondral defects and degeneration of the surrounding joint surface.

METHODS

Cylindrical osteochondral defects of different sizes were created in the knee joint of rats. The natural course of these lesions was studied by macroscopic observation, histology, and immunohistochemistry. Gene expression of the articular cartilage surrounding the defects in vivo and of articular chondrocytes cultured in vitro in IL1β and fibroblast growth factor 2 (FGF2) supplemented media was evaluated by quantitative polymerase chain reaction (qPCR).

RESULTS

In defects of 0.9 mm diameter, spontaneous joint surface healing was observed but also upward advancing of the subchondral bone plate at 16 weeks. Larger 1.4 mm diameter defects were critical size, not resulting in successful healing at any time point. Importantly, the articular cartilage surrounding the defects expressed FGF2 and IL1β, but not ACAN and Col2. Chondrocytes cultured in IL1β and FGF2 supplemented media lost the natural fibroblast growth factor receptors - FGFr1/FGFr3 balance and showed decreased viability.

CONCLUSIONS

A critical size osteochondral defect was defined as 1.4 mm in diameter in rat. Subchondral bone plate advancement occured rapidly. The articular cartilage surrounding osteochondral defects showed catabolic activity with expression of IL1β, FGF2 and a disturbed FGFr1/FGFr3 balance, potentially initiating a process of early osteoarthritic disease.

Bone Marrow Aspirate Concentrate-Enhanced Marrow Stimulation of Chondral Defects

Mesenchymal stem cells (MSCs) from bone marrow play a critical role in osteochondral repair. A bone marrow clot forms within the cartilage defect either as a result of marrow stimulation or during the course of the spontaneous repair of osteochondral defects. Mobilized pluripotent MSCs from the subchondral bone migrate into the defect filled with the clot, differentiate into chondrocytes and osteoblasts, and form a repair tissue over time. The additional application of a bone marrow aspirate (BMA) to the procedure of marrow stimulation is thought to enhance cartilage repair as it may provide both an additional cell population capable of chondrogenesis and a source of growth factors stimulating cartilage repair. Moreover, the BMA clot provides a three-dimensional environment, possibly further supporting chondrogenesis and protecting the subchondral bone from structural alterations. The purpose of this review is to bridge the gap in our understanding between the basic science knowledge on MSCs and BMA and the clinical and technical aspects of marrow stimulation-based cartilage repair by examining available data on the role and mechanisms of MSCs and BMA in osteochondral repair. Implications of findings from both translational and clinical studies using BMA concentrate-enhanced marrow stimulation are discussed.

Comprehensive analysis of translational osteochondral repair: Focus on the histological assessment

Articular cartilage guarantees for an optimal functioning of diarthrodial joints by providing a gliding surface for smooth articulation, weight distribution, and shock absorbing while the subchondral bone plays a crucial role in its biomechanical and nutritive support. Both tissues together form the osteochondral unit. The structural assessment of the osteochondral unit is now considered the key standard procedure for evaluating articular cartilage repair in translational animal models. The aim of this review is to give a detailed overview of the different methods for a comprehensive evaluation of osteochondral repair. The main focus is on the histological assessment as the gold standard, together with immunohistochemistry, and polarized light microscopy. Additionally, standards of macroscopic, non-destructive imaging such as high resolution MRI and micro-CT, biochemical, and molecular biological evaluations are addressed. Potential pitfalls of analysis are outlined. A second focus is to suggest recommendations for osteochondral evaluation.