Healing bone using recombinant human bone morphogenetic protein 2 and copolymer

Repair of alveolar cleft bone defects in rabbits by active bone particles containing modified rhBMP-2

Objective: A model of alveolar cleft phenotype was established in rabbits to evaluate the effect of active bone particles containing modified rhecombinant human BMP-2 on the repair of the alveolar cleft. Methods: 2-month-old Japanese white rabbits were selected and randomly divided into four groups: normal, control, material and BMP groups. Blood biochemical analysis, skull tomography (microfocus computerized tomography), and histological and immunohistochemical staining analysis of paraffin sections were performed 3  and 6 months after operation. Results: Both types of collagen particles showed good biocompatibility and promoted bone regeneration. The effect of active bone particles on bone repair and regeneration was better than that of bone collagen particles. Conclusions: Active bone particles containing modified rhecombinant human BMP-2 can be used for incisors regeneration.

Systematic Review of the Preclinical Technology Readiness of Orthopedic Gene Therapy and Outlook for Clinical Translation

Bone defects and improper healing of fractures are an increasing public health burden, and there is an unmet clinical need in their successful repair. Gene therapy has been proposed as a possible approach to improve or augment bone healing with the potential to provide true functional regeneration. While large numbers of studies have been performed in vitro or in vivo in small animal models that support the use of gene therapy for bone repair, these systems do not recapitulate several key features of a critical or complex fracture environment. Larger animal models are therefore a key step on the path to clinical translation of the technology. Herein, the current state of orthopedic gene therapy research in preclinical large animal models was investigated based on performed large animal studies. A summary and an outlook regarding current clinical studies in this sector are provided. It was found that the results found in the current research literature were generally positive but highly methodologically inconsistent, rendering a comparison difficult. Additionally, factors vital for translation have not been thoroughly addressed in these model systems, and the risk of bias was high in all reviewed publications. These limitations directly impact clinical translation of gene therapeutic approaches due to lack of comparability, inability to demonstrate non-inferiority or equivalence compared with current clinical standards, and lack of safety data. This review therefore aims to provide a current overview of ongoing preclinical and clinical work, potential bottlenecks in preclinical studies and for translation, and recommendations to overcome these to enable future deployment of this promising technology to the clinical setting.

Growth Factors, Carrier Materials, and Bone Repair

This chapter provides an overview of the growth factors active in bone regeneration and healing. Both normal and impaired bone healing are discussed, with a focus on the spatiotemporal activity of the various growth factors known to be involved in the healing response. The review highlights the activities of most important growth factors impacting bone regeneration, with a particular emphasis on those being pursued for clinical translation or which have already been marketed as components of bone regenerative materials. Current approaches the use of bone grafts in clinical settings of bone repair (including bone grafts) are summarized, and carrier systems (scaffolds) for bone tissue engineering via localized growth factor delivery are reviewed. The chapter concludes with a consideration of how bone repair might be improved in the future.

Associations between variants of bone morphogenetic protein 7 gene and growth traits in chickens

1. Enhancing bone strength to solve leg disorders in poultry has become an important goal in broiler production. Bone morphogenetic protein 7 (BMP7), a member of the BMP family, represents an attractive therapeutic target for bone regeneration in humans and plays critical roles in skeletal development. 2. The objective of this study was to investigate the relationship between BMP7 gene expression, single-nucleotide polymorphisms (SNPs) and growth traits in chickens. Here, a SNP (c.1995T>C) in the chicken (Gallus gallus) BMP7 gene was identified, that was associated with growth and carcass traits. 3. Genotyping revealed that the T allele occurred more frequently in breeds with high growth rates, whereas the C allele was predominant in those with low growth rates. The expression level of BMP7 in the thigh bone of birds with the TT genotype was significantly higher than in those with the CC genotype at 21, 42 and 91 d of age. 4. These findings suggest that selecting the birds with the TT genotype of SNP c.1995T>C could improve bone growth, could reduce leg disorders in fast-growing birds. The SNP c.1995T>C may serve as a selective marker for improving bone growth and increasing the consistency of body weights in poultry breeding.

The effect of immunonutrition (glutamine, alanine) on fracture healing

Background

Methods

Results

Conclusion

Stem cell therapy: is there a future for reconstruction of large bone defects?

Large bone defects caused by fracture, non-union and bone tumor excision has been a major clinical problem. Autogenous bone grafting and Ilizarov method are commonly performed to treat them. However, bone grafting has limitation in volume of available bone, and Ilizarov method requires long periods of time to treat. Accordingly, there is need for stem cell therapy for bone repair and/or regeneration. Mesenchymal stem cells (MSCs) hold the ability to differentiate into osteoblasts and are available from a wide variety of sources. The route of "intramembranous ossification (direct bone formation)" by transplantation of undifferentiated MSCs has been tested but it did not demonstrate the success initially envisaged. Recently another approach has been examined being the transplantation of "MSCs pre-differentiated in vitro into cartilage-forming chondrocytes" into bone defect, in brief, representing the route of "endochondral ossification (indirect bone formation)". It's a paradigm shift of Stem Cell Therapy for bone regeneration. We have already reported on the healing of large femur defects in rats by transplantation of "MSCs pre-differentiated in vitro into cartilage-forming chondrocytes". We named the cells as Mesenchymal Stem Cell-Derived Chondrocytes (MSC-DCs). The success of reconstruction of a massive 15-mm femur defect (approximately 50% of the rat femur shaft length) provides a sound foundation for potential clinical application of this technique. We believe our results may offer a new avenue of reconstruction of large bone defect, especially in view of the their high reproducibility and the excellent biomechanical strength of repaired femora.

BMP delivery complements the guiding effect of scaffold architecture without altering bone microstructure in critical-sized long bone defects: A multiscale analysis

Scaffold architecture guides bone formation. However, in critical-sized long bone defects additional BMP-mediated osteogenic stimulation is needed to form clinically relevant volumes of new bone. The hierarchical structure of bone determines its mechanical properties. Yet, the micro- and nanostructure of BMP-mediated fast-forming bone has not been compared with slower regenerating bone without BMP. We investigated the combined effects of scaffold architecture (physical cue) and BMP stimulation (biological cue) on bone regeneration. It was hypothesized that a structured scaffold directs tissue organization through structural guidance and load transfer, while BMP stimulation accelerates bone formation without altering the microstructure at different length scales. BMP-loaded medical grade polycaprolactone-tricalcium phosphate scaffolds were implanted in 30mm tibial defects in sheep. BMP-mediated bone formation after 3 and 12 months was compared with slower bone formation with a scaffold alone after 12 months. A multiscale analysis based on microcomputed tomography, histology, polarized light microscopy, backscattered electron microscopy, small angle X-ray scattering and nanoindentation was used to characterize bone volume, collagen fiber orientation, mineral particle thickness and orientation, and local mechanical properties. Despite different observed kinetics in bone formation, similar structural properties on a microscopic and sub-micron level seem to emerge in both BMP-treated and scaffold only groups. The guiding effect of the scaffold architecture is illustrated through structural differences in bone across different regions. In the vicinity of the scaffold increased tissue organization is observed at 3 months. Loading along the long bone axis transferred through the scaffold defines bone micro- and nanostructure after 12 months.

How does the pathophysiological context influence delivery of bone growth factors?

"Orthobiologics" represents an important category of therapeutics for the regeneration of bone defects caused by injuries or diseases, and bone growth factors are a particularly rapidly growing sub-category. Clinical application of bone growth factors has accelerated in the last two decades with the introduction of BMPs into clinical bone repair. Optimal use of growth factor-mediated treatments heavily relies on controlled delivery, which can substantially influence the local growth factor dose, release kinetics, and biological activity. The characteristics of the surrounding environment, or "context", during delivery can dictate growth factor loading efficiency, release and biological activity. This review discusses the influence of the surrounding environment on therapeutic delivery of bone growth factors. We specifically focus on pathophysiological components, including soluble components and cells, and how they can actively influence the therapeutic delivery and perhaps efficacy of bone growth factors.

Use of perfusion bioreactors and large animal models for long bone tissue engineering

Tissue engineering and regenerative medicine (TERM) strategies for generation of new bone tissue includes the combined use of autologous or heterologous mesenchymal stem cells (MSC) and three-dimensional (3D) scaffold materials serving as structural support for the cells, that develop into tissue-like substitutes under appropriate in vitro culture conditions. This approach is very important due to the limitations and risks associated with autologous, as well as allogenic bone grafiting procedures currently used. However, the cultivation of osteoprogenitor cells in 3D scaffolds presents several challenges, such as the efficient transport of nutrient and oxygen and removal of waste products from the cells in the interior of the scaffold. In this context, perfusion bioreactor systems are key components for bone TERM, as many recent studies have shown that such systems can provide dynamic environments with enhanced diffusion of nutrients and therefore, perfusion can be used to generate grafts of clinically relevant sizes and shapes. Nevertheless, to determine whether a developed tissue-like substitute conforms to the requirements of biocompatibility, mechanical stability and safety, it must undergo rigorous testing both in vitro and in vivo. Results from in vitro studies can be difficult to extrapolate to the in vivo situation, and for this reason, the use of animal models is often an essential step in the testing of orthopedic implants before clinical use in humans. This review provides an overview of the concepts, advantages, and challenges associated with different types of perfusion bioreactor systems, particularly focusing on systems that may enable the generation of critical size tissue engineered constructs. Furthermore, this review discusses some of the most frequently used animal models, such as sheep and goats, to study the in vivo functionality of bone implant materials, in critical size defects.

Porous scaffold architecture guides tissue formation

Critical-sized bone defect regeneration is a remaining clinical concern. Numerous scaffold-based strategies are currently being investigated to enable in vivo bone defect healing. However, a deeper understanding of how a scaffold influences the tissue formation process and how this compares to endogenous bone formation or to regular fracture healing is missing. It is hypothesized that the porous scaffold architecture can serve as a guiding substrate to enable the formation of a structured fibrous network as a prerequirement for later bone formation. An ovine, tibial, 30-mm critical-sized defect is used as a model system to better understand the effect of the scaffold architecture on cell organization, fibrous tissue, and mineralized tissue formation mechanisms in vivo. Tissue regeneration patterns within two geometrically distinct macroscopic regions of a specific scaffold design, the scaffold wall and the endosteal cavity, are compared with tissue formation in an empty defect (negative control) and with cortical bone (positive control). Histology, backscattered electron imaging, scanning small-angle X-ray scattering, and nanoindentation are used to assess the morphology of fibrous and mineralized tissue, to measure the average mineral particle thickness and the degree of alignment, and to map the local elastic indentation modulus. The scaffold proves to function as a guiding substrate to the tissue formation process. It enables the arrangement of a structured fibrous tissue across the entire defect, which acts as a secondary supporting network for cells. Mineralization can then initiate along the fibrous network, resulting in bone ingrowth into a critical-sized defect, although not in complete bridging of the defect. The fibrous network morphology, which in turn is guided by the scaffold architecture, influences the microstructure of the newly formed bone. These results allow a deeper understanding of the mode of mineral tissue formation and the way this is influenced by the scaffold architecture. © 2012 American Society for Bone and Mineral Research.

Comparative study of Chinese hamster ovary cell versus Escherichia coli-derived bone morphogenetic protein-2 using the critical-size supraalveolar peri-implant defect model

BACKGROUND

Chinese hamster ovary (CHO) cell-derived recombinant human bone morphogenetic protein-2 (rhBMP-2) has been introduced for spine, long bone, and craniofacial indications. Escherichia coli- (E. coli) derived rhBMP-2 displays comparable efficacy to CHO cell-derived rhBMP-2 in vitro and in small-animal models. The objective of this study is to evaluate the efficacy of E. coli-derived rhBMP-2 compared to the benchmark CHO cell-derived rhBMP-2 using an established large-animal model.

METHODS

Contralateral, critical-size supraalveolar peri-implant defects in six adult male Hound Labrador mongrel dogs received CHO cell- or E. coli-derived rhBMP-2 (0.2 mg/mL) in an absorbable collagen sponge (ACS) carrier. In each quadrant, three dental implants were placed. A titanium mesh device was used to support space provision. The animals received fluorescent bone markers for qualitative evaluations. Animals were euthanized at 8 weeks for histopathologic and histometric evaluation.

RESULTS

Clinical healing included significant swelling, but none of the animals experienced wound dehiscences. CHO cell- and E. coli-derived rhBMP-2 supported comparable bone formation (new bone area, 35.8 ± 3.6 versus 30.1 ± 2.2 mm(2); bone density, 31.8% ± 1.6% versus 35.6% ± 2.5%; and osseointegration, 32.9% ± 7.4% versus 33.7% ± 8.1%) without statistically significant differences between treatments. Newly formed immature delicate trabecular bone in fibrovascular marrow filled the space underneath the titanium mesh and extended coronally above the mesh. Seroma formation was frequently observed. There were no discernable qualitative histologic differences between treatments.

CONCLUSION

CHO cell- and E. coli-derived rhBMP-2 in an ACS carrier appear equally effective at inducing local bone formation in support of dental implant osseointegration.

The influence of Bone Morphogenic Protein-2 on the consolidation phase in a distraction osteogenesis model

We asked whether locally applied recombinant-Bone Morphogenic Protein-2 (rh-BMP-2) with an absorbable Type I collagen sponge (ACS) carrier could enhance the consolidation phase in a callotasis model. We performed unilateral transverse osteotomy of the tibia in 21 immature male rabbits. After a latency period of 7 days, a 3-weeks distraction was begun at a rate of 0.5mm/12h. At the end of the distraction period (Day 28) animals were randomly divided into three groups and underwent a second surgical procedure: 6 rabbits in Group I (Control group; the callus was exposed and nothing was added), 6 rabbits in Group II (ACS group; receiving the absorbable collagen sponge soaked with saline) and 9 rabbits in Group III (rh-BMP-2/ACS group; receiving the ACS soaked with 100μg/kg of rh-BMP-2, Inductos(®), Medtronic). Starting at Day 28 we assessed quantitative and qualitative radiographic parameters as well as densitometric parameters every two weeks (Days 28, 42, 56, 70 and 84). Animals were sacrificed after 8 weeks of consolidation (Day 84). Qualitative radiographic evaluation revealed hypertrophic calluses in the Group III animals. The rh-BMP-2/ACS also influenced the development of the cortex of the calluses as shown by the modified radiographic patterns in Group III when compared to Groups I and II. Densitometric analysis revealed the bone mineral content (BMC) was significantly higher in the rh-BMP-2/ACS treated animals (Group III).

Successful transplant of mesenchymal stem cells in induced osteonecrosis of the ovine femoral head: preliminary results

PURPOSE

Evaluate the bone tissue recovery following transplantation of ovine mesenchymal stem cells (MSC) from bone marrow and human immature dental-pulp stem cells (hIDPSC) in ovine model of induced osteonecrosis of femoral head (ONFH).

METHODS

Eight sheep were divided in three experimental groups. First group was composed by four animals with ONFH induced by ethanol through central decompression (CD), for control group without any treatment. The second and third group were compose by two animals, six weeks after ONFH induction received transplantation of heterologous ovine MSC (CD + oMSC), and hIDPSC (CD + hIDPSC), respectively. In both experiments the cells were transplanted without application of any type of immunosupression protocol.

RESULTS

Our data indicate that both cell types used in experiments were able to proliferate within injured site providing bone tissue recovery. The histological results obtained from CD+hIDPSC suggested that the bone regeneration in such animals was better than that observed in CD animals.

CONCLUSION

Mesenchymal stem cell transplant in induced ovine osteonecrosis of femoral head by central decompression technique is safe, and apparently favors bone regeneration of damaged tissues.

Osteogenic protein-1 delivered by hydroxyapatite-coated implants improves bone ingrowth in extracortical bone bridging

BACKGROUND

Extracortical bone bridging for treatment of massive bone loss can improve stability and longevity of massive endoprostheses. Osteogenic protein-1 (OP-1), when used with allograft bone, reportedly improves extracortical bone bridging and bone ingrowth.

QUESTIONS/PURPOSES

We asked whether OP-1 delivered by hydroxyapatite (HA) without bone grafting could improve bone ingrowth and bone formation in the context of extracortical bone bridging.

METHODS

We implanted unilateral segmental femoral diaphyseal replacement prostheses in 18 dogs (three groups of six dogs). The groups consisted of an HA-coated group augmented with OP-1, an HA-coated group, and a plain porous group. Bone grafting techniques were not used to augment bone formation. The implants were retrieved at 12 weeks for histologic assessment.

RESULTS

After removing one specimen owing to a complication, 17 femora were analyzed (six HA-coated augmented with OP-1, five HA-coated, and six plain). We observed better bone ingrowth in the HA-coated OP-1 group than in the plain porous and HA-coated groups, with no difference between the latter two groups. There also was better bone apposition and callus height in the HA-coated OP-1 group than in the plain group but no differences between the HA-coated OP-1 and HA-coated groups or between the HA-coated and plain groups.

CONCLUSIONS

OP-1 (2.9 mg) delivered by HA-coated segmental replacement prostheses in this canine extracortical bone bridging model revealed improved bone ingrowth over HA-coated implants without OP-1 or plain porous-coated prostheses.

Rh-BMP-2 in distraction osteogenesis: dose effect and premature consolidation

We asked whether locally applied recombinant-bone morphogenic protein-2 (rh-BMP-2) with a type I collagen carrier could enhance the consolidation phase in distraction osteogenesis and whether a dose effect could be reported. We performed unilateral transverse osteotomy of the tibia in 15 immature male rabbits. In Group I (five rabbits), 750 microg of rh-BMP-2 on the type I collagen sponge (Inductos, Medtronic) was locally applied on the day of osteotomy; the Group II animals (five rabbits) received 375 microg of the drug and the Group III (control group, five rabbits) had no local application. After 7 days, 3 weeks of distraction was begun at a rate of 0.5 mm/12 h. Starting week 2 of distraction, we assessed radiographic, ultrasonographic, and densitometric parameters once per week. Animals were sacrificed after a 3-week consolidation period. Radiographic evaluation revealed increased regenerate ossification in the rh-BMP-2 groups compared with the control group. The bone mineral content was significantly higher in the rh-BMP-2 treated groups at each time point. A dose effect is shown as densitometric parameters were significantly higher between Groups I and II. 3/5 of the Group I treated animals developed a premature bony union in the regenerate resulting in premature fusion and incomplete distraction.

Exaggerated inflammatory response after use of recombinant bone morphogenetic protein in recurrent unicameral bone cysts

BACKGROUND

Recurrent unicameral bone cysts (UBCs) can result in significant morbidity during a child's physical and emotional development. Multiple treatment options are available and a review of the literature fails to clearly define the optimal treatment for UBCs. Recombinant bone morphogenetic protein (BMP) has been used with success in other disorders of poor bone formation. This manuscript is the first to report on the use of recombinant BMP in the treatment of UBCs.

METHODS

Three patients with recurrent UBCs underwent revision surgery with recombinant BMP. Radiographic and medical review was performed and is reported here.

RESULTS

In these patients, the use of BMP failed to fully resolve their UBC; 2 patients had complete recurrence that required further surgery. In addition to poor radiographic results, all patients developed exaggerated inflammatory responses in the acute postoperative period. Each child developed clinically significant limb swelling and pain that mimicked infection.

CONCLUSIONS

On the basis of our poor radiographic results and a paradoxical clinical result, we no longer recommend the use of recombinant BMP in the manner reported here for the treatment of recurrent UBCs.

LEVEL OF EVIDENCE

Level IV, case series.

Delivery systems for bone growth factors — the new players in skeletal regeneration

Given the challenge of an increasing elderly population, the ability to repair and regenerate traumatised or lost tissue is a major clinical and socio-economic need. Pivotal in this process will be the ability to deliver appropriate growth factors in the repair cascade in a temporal and tightly regulated sequence using appropriately designed matrices and release technologies within a tissue engineering strategy. This review outlines the current concepts and challenges in growth factor delivery for skeletal regeneration and the potential of novel delivery matrices and biotechnologies to influence the healthcare of an increasing ageing population.

Evaluation of an injectable, photopolymerizable three-dimensional scaffold based on D: ,L: -lactide and epsilon-caprolactone in a tibial goat model

An in situ crosslinkable, biodegradable, methacrylate-encapped porous bone scaffold composed of D: ,L: -lactide, epsilon-caprolactone, 1,6-hexanediol and poly(ortho-esters), in which crosslinkage is achieved by photoinitiators, was developed for bone tissue regeneration. Three different polymer mixtures (pure polymer and 30% bioactive glass or alpha-tricalcium phosphate added) were tested in a uni-cortical tibial defect model in eight goats. The polymers were randomly applicated in one of four (6.0 mm diameter) defects leaving a fourth defect unfilled. Biocompatibility and bone healing properties were evaluated by serial radiographies, histology and histomorphometry. The pure polymer clearly showed excellent biocompatibility and moderate osteoconductive properties. The addition of alpha-TCP increased the latter characteristics. This product offers potentials as a carrier for bone healing promoter substances.

Use of bone morphogenetic proteins for augmentation of bone regeneration

A large body of preclinical and clinical data now documents that recombinant BMPs can be used for skeletal regeneration in humans and animals. Recombinant human BMP-2 and BMP-7 have been approved for use in human patients with long-bone fractures and nonunions and in patients undergoing lumbar fusion or various maxillofacial and dental regenerative procedures. These products have also been made available for veterinary use.

Use of a composite pedicled muscle flap and rhBMP-7 for mandibular reconstruction

The aim of this study was to investigate the feasibility of reconstructing critical size continuity osteoperiosteal defects of the mandible using a composite of recombinant BMP-7 contained in a bovine type-1 collagen carrier wrapped in a pedicled sterno-occipitalis muscle flap. At 3 months following surgery, bridging of the surgical defect was noted in three subjects (60%). Histologically, the induced bone regenerate showed maturation from woven to lamellar bone. Islands of cartilage were distributed throughout the defect. Replacement ossification of the degenerated muscle was a common feature in all specimens. Microradiography showed a gradual increase in the calcification of mineralized tissue from the margin to the centre of the newly generated bone. This research represents a proof of the concept that bone can be satisfactorily formed within a muscular scaffolding at the site of the created defect in a one-stage procedure.

Unexpected absence of effect of rhBMP-7 on distraction osteogenesis

We asked whether locally applied rhBMP-7 with a Type I collagen carrier could enhance the consolidation phase in distraction osteogenesis. We performed unilateral transverse osteotomy of the tibia in 28 immature male rabbits. In half the animals (14 rabbits), 70 microg rhBMP-7 (28.5 mg rhBMP-7/CC, OP-1) was applied locally on the day of the osteotomy; the control group (14 rabbits) had no local application. After 7 days, 3 weeks of distraction was begun at a rate of 0.5 mm every 12 hours. Starting with Week 2 of distraction, we assessed radiographic, ultrasonographic, and densitometric parameters once per week. Animals were sacrificed after 3 weeks of distraction, and after 1, 2, and 3 weeks of additional consolidation. Radiographic evaluation revealed a tendency for increased bony union and bone differentiation in the control group compared with the rhBMP-7/CC group. The bone mineral content was higher in the control group at each time. Ultrasonographic evaluation revealed the development of a cyst in the regenerate in 92% of the animals in the rhBMP-7/CC group versus 0% in the control group. Ultrasonography and histomorphometry showed delayed regenerate development in the rhBMP-7/CC group. We suggest the poor results related to the relatively large bulk of the solid carrier of the OP-1 that might have acted as a mechanical obstacle to osteogenesis.

The effects of extracorporeal shockwave on acute high-energy long bone fractures of the lower extremity

INTRODUCTION

High-energy long bone fractures of the lower extremity are at risk of poor fracture healing and high rate of non-union. Extracorporeal shockwave was shown effective to heal non-union of long bone fracture. However, the effect of shockwave on acute fractures is unknown. The purpose of this study was to investigate the effects of shockwave on acute high-energy fractures of the lower extremity.

MATERIALS AND METHODS

Between January and October 2004, 56 patients with 59 acute high-energy fractures were enrolled in this study. Patients were randomly divided into two groups with 28 patients with 28 fractures in the study group and 28 patients with 31 fractures in the control group. Both groups showed similar age, gender, type of fracture and follow-up time. Patients in the study group received open reduction and internal fixation and shockwave treatment immediately after surgery on odd-numbered days of the week, whereas, patients in the control group received open reduction and internal fixation without shockwave treatment on even-numbered days of the week. Postoperative managements were similarly performed in both groups including crutch walking with non-weight bearing on the affected limb until fracture healing shown on radiographs. The evaluation parameters included clinical assessments of pain score and weight bearing status of the affected leg and serial radiographs at 3, 6 and 12 months. The primary end-point is the rate of non-union at 12 months, and the secondary end point is the rate of fracture healing at 3, 6 and 12 months.

RESULTS

At 12 months, the rate of non-union was 11% for the study group versus 20% for the control group (P < 0.001). Significantly, better rate of fracture healing was noted in the study group than the control group at 3, 6 and 12 months (P < 0.001).

CONCLUSION

Extracorporeal shockwave is effective on promoting fracture healing and decreasing the rate of non-union in acute high-energy fractures of the lower extremity.

The enhancement of osteogenesis by nano-fibrous scaffolds incorporating rhBMP-7 nanospheres

It is advantageous to incorporate controlled growth factor delivery into tissue engineering strategies. The objective of this study was to develop a three-dimensional (3D) porous tissue engineering scaffold with the capability of controlled releasing recombinant human bone morphogenetic protein-7 (rhBMP-7) for enhancement of bone regeneration. RhBMP-7 was first encapsulated into poly(lactic-co-glycolic acid) (PLGA) nanospheres (NS) with an average diameter of 300nm. Poly(l-lactic acid) (PLLA) scaffolds with interconnected macroporous and nano-fibrous architectures were prepared using a combined sugar sphere template leaching and phase separation technique. A post-seeding technique was then utilized to immobilize rhBMP-7 containing PLGA nanospheres onto prefabricated nano-fibrous PLLA scaffolds with well-maintained 3D structures. In vitro release kinetics indicated that nanosphere immobilized scaffold (NS-scaffold) could release rhBMP-7 in a temporally controlled manner, depending on the chemical and degradation properties of the NS which were immobilized onto the scaffold. In vivo, rhBMP-7 delivered from NS-scaffolds induced significant ectopic bone formation throughout the scaffold while passive adsorption of rhBMP-7 into the scaffold resulted in failure of bone induction due to either the loss of rhBMP-7 biological function or insufficient duration within the scaffold. We conclude that the interconnected macroporous architecture and the sustained, prolonged delivery of bioactive rhBMP-7 from NS immobilized nano-fibrous scaffolds actively induced new bone formation throughout the scaffold. The approach offers a new delivery method of BMPs and a novel scaffold design for bone regeneration.

Biodegradable polymeric scaffolds. Improvements in bone tissue engineering through controlled drug delivery

Recent advances in biology, medicine, and engineering have led to the discovery of new therapeutic agents and novel materials for the repair of large bone defects caused by trauma, congenital defects, or bone tumors. These repair strategies often utilize degradable polymeric scaffolds for the controlled localized delivery of bioactive molecules to stimulate bone ingrowth as the scaffold degrades. Polymer composition, hydrophobicity, crystallinity, and degradability will affect the rate of drug release from these scaffolds, as well as the rate of tissue ingrowth. Accordingly, this chapter examines the wide range of synthetic degradable polymers utilized for osteogenic drug delivery. Additionally, the therapeutic proteins involved in bone formation and in the stimulation of osteoblasts, osteoclasts, and progenitor cells are reviewed to direct attention to the many critical issues influencing effective scaffold design for bone repair.

Manipulations in hydrogel degradation behavior enhance osteoblast function and mineralized tissue formation

Hydrogels were prepared by copolymerizing a degradable macromer, poly(lactic acid)-b-poly(ethylene glycol)-b-poly(lactic acid) endcapped with methacrylate groups (PEG-LA-DM), with a nondegradable macromer, poly(ethylene glycol) dimethacrylate (PEGDM). Copolymer networks consisted of 100:0, 83:17, 67:33, and 50:50 PEGDM:PEG-LA-DM mass%, essentially creating scaffolds that exhibit 0, 17, 33, and 50% degradation over the time course of the experiment. Osteoblasts were photoencapsulated in these copolymer hydrogels and cultured for 3 weeks in vitro. Metabolic activity, proliferation, and alkaline phosphatase production were enhanced by an increase PEG-LADM content and corresponding degradation. Gene expression of the cultured osteoblasts, normalized to beta-actin, was analyzed, and osteopontin and collagen type I gene expression increased with degradation. Finally, as a measure of mineralized tissue formation, calcium and phosphate deposition was analyzed biochemically and histologically. Mineralization increased with increasing concentration of PEG-LA-DM and biochemically resembled that of hydroxyapatite.

Mechanical and radiological assessment of the influence of rhTGFbeta-3 on bone regeneration in a segmental defect in the ovine tibia: pilot study

Limitations in the use of autologous bone graft, which is the gold standard therapy in bone defect healing, drive the search for alternative treatments. In this study the influence of rhTGFbeta-3 on mechanical and radiological parameters of a healing bone defect in the sheep tibia was assessed. In the sheep, an 18-mm long osteoperiosteal defect in the tibia was treated by rhTGFbeta-3 seeded on a poly(L/DL-lactide) carrier (n = 4). In a second group (n = 4), the defect was treated by the carrier only, in a third group (n = 4) by autologous cancellous bone graft, and in a fourth group (n = 2) the defect remained blank. The healing process of the defect was assessed by weekly in vivo stiffness measurements and radiology as well as by quantitative computed tomographic assessment of bone mineral density (BMD) every 4 weeks. The duration of the experiment was 12 weeks under loading conditions. In the bone graft group, a marginally significant higher increase in stiffness was observed than in the PLA/rhTGFbeta-3 group (p = 0.06) and a significantly higher increase than in the PLA-only group (p = 0.03). The radiographic as well as the computed tomographic evaluation yielded significant differences between the groups (p = 0.03), indicating the bone graft treatment (bone/per area, 83%; BMD, 0.57 g/cm(3)) performing better than the PLA/rhTGFbeta-3 (38%; 0.23 g/cm(3)) and the PLA-only treatment (2.5%; 0.09 g/cm(3)), respectively. Regarding the mechanical and radiological parameters assessed in this study, we conclude that rhTGFbeta-3 has a promoting effect on bone regeneration. However, under the conditions of this study, this effect does not reach the potential of autologous cancellous bone graft transplantation.

Mesenchymal stem cells and bone regeneration

OBJECTIVE

To review the role of mesenchymal stem cells (MSC) in bone formation and regeneration, and outline the development of strategies that use MSC in bone healing and regeneration.

STUDY DESIGN

Literature review.

METHODS

Medline review, synopses of authors' published research.

RESULTS

The MSC is the basic cellular unit of embryologic bone formation. Secondary bone healing mimics bone formation with proliferation of MSC then their differentiation into components of fracture callus. Bone regeneration, where large amounts of bone must form, mimics bone healing and can be achieved with MSC combined with strategies of osteogenesis, osteoinduction, osteoconduction, and osteopromotion. MSC based strategies first employed isolated and culture expanded stem cells in an osteoconductive carrier to successfully regenerate a critical segmental defect in the femur of dogs, which was as effective as autogenous cancellous bone. Because MSC appeared to be immunologically privileged, a study using mismatched allogeneic stem cells demonstrated that these cells would regenerate bone without inciting an immunologic response, documenting the possibility of banked allogeneic MSC for bone regeneration. A technique was developed for selectively retaining MSC from large bone marrow aspirates at surgery for bone regeneration. These techniques utilized osteoconductive and osteoinductive carriers and resulted in bone regeneration that was similar to autogenous cancellous bone.

CONCLUSION

MSC can be manipulated and combined with carriers that will result in bone regeneration of critically sized bone defects.

CLINICAL RELEVANCE

These techniques can be employed clinically to regenerate bone and serve as an alternative to autogenous cancellous bone.

Effect of BMP-2 gene transfer on bone healing in sheep

Critical size defects of bone and delayed fracture healing due to metabolic disorders are still problems in orthopaedic surgery. Adenoviral vectors encoding bone morphogenetic protein-2 (Ad.BMP-2) have been used to stimulate bone formation in small animals. The present study evaluated the use of direct adenoviral gene transfer for inducing bone formation in a large animal. Standardized iliac crest defects were created surgically on both sides of the pelvic bone of white mountain sheep. The efficiency of gene transfer was evaluated using recombinant adenoviruses carrying the cDNA for luciferase. High levels of transgene expression, restricted to the site of injection, were found for the 1st week. Transgene expression then fell considerably, but could still be detected for up to 5 weeks. To investigate the effect on bone healing, Ad.BMP-2 (10(11) particles in 200 mul saline) was unilaterally injected into iliac crest defects and into tibial osteotomies. The contralateral defects remained untreated to evaluate possible systemic effects. The controls were treated with saline solution. Bone formation within the defect, assessed by micro-computed tomography (CT) measurement at 8 weeks, and callus formation after osteotomy were significantly reduced following direct application of Ad.BMP-2. The retardation compared to untreated control animals was additionally found at the contralateral iliac crest indicating a systemic inhibitory effect. Histological analysis confirmed the CT measurement and showed an increased number of inflammatory cells within both defects. Antibodies against the adenovirus and the transgene product were detected in all treated animals. These data show a systemic retardation of bone formation following a single local injection of Ad.BMP-2 in sheep. This finding stands in contrast to the data obtained from small animal models. Further studies are needed to determine the contribution of the immune response to these results, and whether a lower dose of Ad.BMP-2 would be advantageous.

Contour and volume assessment of repairing mandibular osteoperiosteal continuity defects in sheep using recombinant human osteogenic protein 1

BACKGROUND

This study describes the contour and volume of reconstructed mandibles using recombinant human osteogenic protein 1.

MATERIAL AND METHODS

The investigation was conducted on six adult sheep, where a unilateral 35 mm parasymphyseal osteoperiosteal continuity defect of the mandible was created. Recombinant human osteogenic protein 1 and type-I collagen (as carrier) were applied to the defects. Radiographic and ultrasonographic examinations were carried out at day 1 of the surgery and 2, 4, 8, and 12 weeks following the surgery. The animals were then sacrificed 3 months after the operation. Postmortem CT-scan was performed for volumetric, cross-sectional area, height and width measurements.

RESULTS

Ultrasound was more efficient than radiographs in demonstrating early callus formation at 2 weeks, while radiographic evidence of bone formation was consistently detectable only after 4 weeks. Using the combination of recombinant human osteogenic protein type 1 and type-I collagen resulted in twice the volume, cross-sectional surface area, and height when compared with those of the corresponding region of the contra-lateral non-operated side of the mandible.

CONCLUSION

Within 3 months, recombinant human osteogenic protein type 1 on type-I collagen carrier failed to restore the original contour and volume of mandibular osteoperiosteal continuity defects.

Repairing of goat tibial bone defects with BMP-2 gene-modified tissue-engineered bone

Bone defects larger than a critical size are major challenges in orthopedic medicine. We combined tissue-engineered bone and gene therapy to provide osteoprogenitor cells, osteoinductive factors, and osteo-conductive carrier for ideal bone regeneration in critical-sized bone defects. Goat diaphyseal bone defects were repaired with tissue and genetically engineered bone implants, composed of biphasic calcined bone (BCB) and autologous bone marrow derived mesenchymal stem cells (BMSC) transduced with human bone morphogenetic protein-2 (hBMP-2). Twenty six goats with tibial bone defects were divided into groups receiving implants by using a combination of BCB and BMSCs with or without the hBMP-2 gene. In eight goats that were treated with BCB that contained hBMP-2 transduced BMSC, five had complete healing and three showed partial healing. Goats in other experimental groups had only slight or no healing. Furthermore, the area and biochemical strength of the callus in the bone defects were significantly better in animals treated with genetically engineered implants. We concluded that the combination of genetic and tissue engineering provides an innovative way for treating critical-sized bone defects.

Healing of critically sized femoral defects, using genetically modified mesenchymal stem cells from human adipose tissue

The FDA has approved the clinical use of recombinant bone morphogenetic proteins (BMPs). However, the use of recombinant BMPs in humans has required large doses of the proteins to be effective, which suggests that the delivery method of bone morphogenetic proteins needs to be optimized. Gene therapy is an alternative method to deliver such recombinant proteins, and gene transfer techniques have been tested on a variety of cell types including bone marrow cells, skin fibroblasts, peripheral blood monocytes, and muscle-derived cells. In this study, we sought to determine the ability of BMP-2-producing human adipose-derived mesenchymal stem cells to heal a critically sized femoral defect in a nude rat model. After approval by the human subjects protection committee, human adipose tissue was obtained from healthy donors. The lipoaspirate was processed as previously described (De Ugarte, D.A., et al. Cells Tissues Organs 174, 101, 2003). Cells were grown in culture and infected with a BMP-2-carrying adenovirus. Five million cells were applied to a collagen- ceramic carrier and implanted into femoral defects as previously described (Zuk, P.A., et al. Mol. Biol. 13, 4279, 2002). All animals were killed at 8 weeks. Femora were dissected out and underwent radiographic, histologic, and biomechanical analysis. Eleven of the 12 femora in the group treated with human processed lipoaspirate (HPLA) cells genetically modified to overexpress BMP-2 had healed at 8 weeks. This was assessed by radiographs, by mechanical testing, and by histology. The one femur that did not heal had a subacute infection. All eight of the femora treated with the rhBMP-2-impregnated collagen-ceramic carrier healed. No statistically significant difference was detected between these two groups. Evaluation of the control groups: group II (collagen- ceramic carrier with HPLA cells) and group III (collagen-ceramic carrier alone) showed that none of the femora had healed by 8 weeks. Our results indicate that HPLA cells genetically modified by adenoviral gene transfer to overexpress BMP-2 can induce bone formation in vivo and heal a critically sized femoral defect in an athymic rat. The HPLA cells alone did not induce significant bone formation. However, when combined with an osteoinductive factor these cells may be an effective method for enhancing bone healing and the tissue engineering of bone.

Delivery of bone morphogenetic proteins for orthopedic tissue regeneration

Carriers for bone morphogenetic proteins (BMPs) are used to increase retention of these factors at orthopedic treatment sites for a sufficient period of time to allow regenerative tissue forming cells to migrate to the area of injury and to proliferate and differentiate. Carriers can also serve as a matrix for cell infiltration while maintaining the volume in which repair tissue can form. Carriers have to be biocompatible and are often required to be bioresorbable. Carriers also have to be easily, and cost-effectively, manufactured for large-scale production, conveniently sterilized and have appropriate storage requirements and stability. All of these processes have to be approvable by regulatory agencies. The four major categories of BMP carrier materials include natural polymers, inorganic materials, synthetic polymers, composites of these materials. Autograft or allograft carriers have also used. Carrier configurations range from simple depot delivery systems to more complex systems mimicking the extracellular matrix structure and function. Bone regenerative carriers include depot delivery systems for fracture repair, three-dimensional polymer or ceramic composites for segmental repairs and spine fusion and metal or metal/ceramic composites for augmenting implant integration. Tendon/ligament regenerative carriers range from depot delivery systems to three-dimensional carriers that are either randomly oriented or linearly oriented to improve regenerative tissue alignment. Cartilage regenerative systems generally require three-dimensional matrices and often incorporate cells in addition to factors to augment the repair. Alternative BMP delivery systems include viral vectors, genetically altered cells, conjugated factors and small molecules.

Histological assessment of bioengineered new bone in repairing osteoperiosteal mandibular defects in sheep using recombinant human bone morphogenetic protein-7

Numerous experimental studies have been published about osteoinductive bone morphogenetic proteins (BMPs). However, to our knowledge there has been no detailed histological study of a mandibular defect in a large mammal, reconstructed using BMPs. We describe here the histological features of rhBMP-7-induced bone in mandibular defects in sheep.

METHODS

A 35 mm osteoperiosteal defect was created at the parasymphyseal region of the mandible in six adult sheep. The continuity of the mandible was maintained using a bony plate, and rhBMP-7 was applied on a type I collagen carrier. Bone labels were injected at selected time intervals during the follow-up period. The animals were killed after 3 months and bone samples were examined histologically, histomorphometrically, and by fluorescence microscopy.

RESULTS AND CONCLUSIONS

We found a mixture of woven and lamellar bone that contained many cells with large nuclei. This had not reorganised to form cortical bone and the rhBMP-7-induced bone was more porous than the native bone. The newly-formed bone restored both endosteal and periosteal layers. rhBMP-7-induced bone was biocompatible and induced no ossification of soft tissue or abnormal growth of nearby vital structures. The mineral apposition rate was 1.98 microm/day (range 0.62-5.63 microm/day), a value close to that reported in humans. This suggests that BMPs have a limited effect in accelerating the rate of mineralisation, but promote the pre-mineralisation processes, and perhaps the formation of woven bone.

O uso do aspirado de medula óssea de ilíaco em falhas ósseas de fêmures de camundongos: estudo experimental

Os autores estudam a utilização de medula óssea em camundongos como estimulação da formação de calo ósseo. Foram utilizados dez camundongos adultos machos de linhagem isogênica gioto com peso de aproximadamente 250 gramas, e realizadas falhas ósseas na região distal do fêmur com alternância do lado direito e esquerdo, divididos em grupos A e B, sendo como controle camundongos com falha óssea isolado e com falhas ósseas com medula óssea colhida previamente de cada camundongo. Após análise qualitativa e quantitativa foi observado que o uso do aspirado de medula óssea não leva à estimulação da formação do calo ósseo e não há o aumento de processo inflamatório local.

Local and controlled release of growth factors (combination of IGF-I and TGF-beta I, and BMP-2 alone) from a polylactide coating of titanium implants does not lead to ectopic bone formation in sheep muscle

The osteoinductive potential of growth factors leads not only to a stimulated bone formation in bony tissue but also in extra skeletal tissue. This potential depends on the dosage and potentially on the application method and may limit the clinical use. The aim of the present study was to investigate the potential of IGF-I, TGF-beta1 and BMP-2 released from a newly developed application systems of orthopaedic implants to induce ectopic bone formation in muscles. This bioactive coating showed a stimulating effect on fracture healing in several experimental studies before. Titanium discs were coated on one side with the drug carrier poly(d,l-lactide) (PDLLA), with the carrier plus IGF-I and TGF-beta1 or with the carrier plus BMP-2. The discs were implanted in the Musculus cleidomastoideus of sheep and followed up for 3 months. X-rays were taken after the operation and the day of sacrifice. The muscles plus implant were harvested and prepared for histology. Neither the radiology nor the histology revealed any signs of ectopic ossification in the implant/muscle interface or in a distance to the plate in any group. An influence of the locally applied growth factor, however, was seen in the formation of a soft tissue capsule. Histomorphometric analysis revealed a significantly larger capsule area over the growth factor coated side in comparison to the uncoated side or the pure titanium plate, indicating an effect of the applied growth factors on cells, however, not resulting in osteoinduction in muscle. The result showed that the local and controlled release of growth factors from PDLLA coated implants does not induce ectopic bone formation in sheep muscle and could be used in orthopaedic surgery to increase healing without the risk of ectopic bone formation in the surrounding soft tissue.

Shock wave treatment shows dose-dependent enhancement of bone mass and bone strength after fracture of the femur

Shock wave treatment is believed to improve bone healing after fracture. The purpose of this study was to evaluate the effect of shock wave treatment on bone mass and bone strength after fracture of the femur in a rabbit model. A standardized closed fracture of the right femur was created with a three-point bending method in 24 New Zealand white rabbits. Animals were randomly divided into three groups: (1) control (no shock wave treatment), (2) low-energy (shock wave treatment at 0.18 mJ/mm2 energy flux density with 2000 impulses), and (3) high-energy (shock wave treatment at 0.47 mJ/mm2 energy flux density with 4000 impulses). Bone mass (bone mineral density (BMD), callus formation, ash and calcium contents) and bone strength (peak load, peak stress and modulus of elasticity) were assessed at 12 and 24 weeks after shock wave treatment. While the BMD values of the high-energy group were significantly higher than the control group (P = 0.021), the BMD values between the low-energy and control groups were not statistically significant (P = 0.358). The high-energy group showed significantly more callus formation (P < 0.001), higher ash content (P < 0.001) and calcium content (P = 0.003) than the control and low-energy groups. With regard to bone strength, the high-energy group showed significantly higher peak load (P = 0.012), peak stress (P = 0.015) and modulus of elasticity (P = 0.011) than the low-energy and control groups. Overall, the effect of shock wave treatment on bone mass and bone strength appears to be dose dependent in acute fracture healing in rabbits.

Delivery of osteoinductive growth factors from degradable PEG hydrogels influences osteoblast differentiation and mineralization

Degradable poly(ethylene glycol) (PEG) hydrogels with varying mass loss profiles were investigated to assess their applicability as delivery vehicles for osteoinductive growth factors in bone tissue engineering. Protein release is readily controlled by changes in both the structure (i.e., macromer concentration) and chemistry (i.e., number of degradable units) of the starting macromer. In vitro studies indicate an increase in total protein levels, alkaline phosphatase, and mineralization by osteoblasts cultured in the presence of osteoinductive growth factors compared to cells cultured with standard media. When growth factors are delivered from a 25 wt% hydrogel, a significant increase in both alkaline phosphatase and mineralization was seen after 3 weeks of culture over growth factor delivery in a bolus fashion. Additionally, gene expression levels of both osteocalcin and type I collagen were higher at early timepoints when growth factors were released from hydrogels. These results indicate that growth factors remain active after photoencapsulation, that the sustained delivery of growth factors alters various markers of osteoblastic differentiation, and that these networks could be useful as delivery vehicles for growth factors in bone tissue engineering. Finally, ectopic bone formation was present in subcutaneous rat tissue after implantation of hydrogel networks loaded with osteoinductive growth factors.

In situ forming lactic acid based orthopaedic biomaterials: influence of oligomer chemistry on osteoblast attachment and function

The ability of osteoblasts to attach and function normally on scaffolds fabricated from synthetic materials is essential for musculoskeletal tissue engineering applications. In this study, the osteoconductivity of polymer networks formed from multifunctional lactic acid oligomers was assessed. These oligomers form highly crosslinked networks via a photoinitiated polymerization, which provides potential advantages for many orthopaedic applications. Depending on the initial oligomer chemistry and the resultant polymer hydrophobicity, protein adsorption and osteoblast function varied significantly between the various lactic acid based polymer chemistries. Results were compared to control polymers of tissue culture polystyrene (TCPS) and 50:50 poly(lactic-co-glycolic acid) (PLGA). The viability of osteoblasts attached to poly(2EG10LA) and poly(2EG6LA) was close to the TCPS and PLGA after 7 and 14 days of culture, whereas cell viability was approximately 50% lower on poly(8EG6LA). Additionally, the alkaline phosphatase activity and mineralization of attached osteoblasts were similar on poly(2EG10LA) and PLGA, whereas these markers of bone formation were significantly lower for poly(2EG6LA) and poly(8EG6LA). For example, the alkaline phosphatase activity of rat calvarial osteoblasts attached to poly(2EG10LA) was 0.048 +/- 0.006 micromol mg(-1) protein-min, but only 0.030 +/- 0.003 micromol mg(-1) protein-min for osteoblasts attached to poly(8EG6LA) after 14 days of culture. Finally, osteoblasts were seeded onto three-dimensional scaffolds to demonstrate the applicability of the scaffolds for bone tissue engineering.