Feasibility of autologous bone marrow mesenchymal stem cells cultured with autologous serum for treatment of haemophilic arthropathy

Vascular remodeling underlies rebleeding in hemophilic arthropathy

Hemophilic arthropathy is a debilitating condition that can develop as a consequence of frequent joint bleeding despite adequate clotting factor replacement. The mechanisms leading to repeated spontaneous bleeding are unknown. We investigated synovial, vascular, stromal, and cartilage changes in response to a single induced hemarthrosis in the FVIII-deficient mouse. We found soft-tissue hyperproliferation with marked induction of neoangiogenesis and evolving abnormal vascular architecture. While soft-tissue changes were rapidly reversible, abnormal vascularity persisted for months and, surprisingly, was also seen in uninjured joints. Vascular changes in FVIII-deficient mice involved pronounced remodeling with expression of α-Smooth Muscle Actin (SMA), Endoglin (CD105), and vascular endothelial growth factor, as well as alterations of joint perfusion as determined by in vivo imaging. Vascular architecture changes and pronounced expression of α-SMA appeared unique to hemophilia, as these were not found in joint tissue obtained from mouse models of rheumatoid arthritis and osteoarthritis and from patients with the same conditions. Evidence that vascular changes in hemophilia were significantly associated with bleeding and joint deterioration was obtained prospectively by dynamic in vivo imaging with musculoskeletal ultrasound and power Doppler of 156 joints (elbows, knees, and ankles) in a cohort of 26 patients with hemophilia at baseline and during painful episodes. These observations support the hypothesis that vascular remodeling contributes significantly to bleed propagation and development of hemophilic arthropathy. Based on these findings, the development of molecular targets for angiogenesis inhibition may be considered in this disease.

Osteochondral repair in hemophilic ankle arthropathy: from current options to future perspectives

Young hemophilic patients are frequently affected by ankle arthropathy. At the end stage of the disease, the current treatments are arthrodesis and arthroplasty, which have significant drawbacks. Validated procedures capable of slowing down or even arresting the progression towards the end stage are currently lacking. This review aims to discuss the rationale for and feasibility of applying, in mild hemophilic ankle arthropathy, the main techniques currently used to treat osteochondral defects, focusing in particular on ankle distraction, chondrocyte implantation, mesenchymal stem cell transplantation, allograft transplantation and the use of growth factors. To date, ankle distraction is the only procedure that has been successfully used in hemophilic ankle arthropathy. The use of mesenchymal stem cells have recently been evaluated as feasible for osteochondral repair in hemophilic patients. There may be a rationale for the use of growth factors if they are combined with the previous techniques, which could be useful to arrest the progression of the degeneration or delay end-stage procedures.

Treatment of Hemophilic Ankle Arthropathy with One-Step Arthroscopic Bone Marrow-Derived Cells Transplantation

OBJECTIVE

Ankle arthropathy is a frequent and invalidating manifestation of hemophilia. Arthrodesis is the gold standard surgical procedure in end-stage disease, with many drawbacks in young patients. Recent literature has shown increase interest in regenerative procedures in hemophilic arthropathy, which may be desirable to delay or even avoid arthrodesis. The aim of this article is to present five cases of osteochondral lesions in ankle hemophilic arthropathy treated with a regenerative procedure: bone marrow-derived cells transplantation (BMDCT).

DESIGN

We report five hemophilic patients (four cases with hemophilia type A; one case with hemophilia type B) who have undergone BMDCT treatment, synovectomy, and arthroscopic debridement, with the use of autologous platelet-rich fibrin, to treat osteochondral lesions in hemophilic ankle arthropathy. The patients, included within this retrospective study, were clinically and radiologically evaluated with serial follow-ups, using the American Orthopaedic Foot and Ankle Society (AOFAS) scores, radiographs, and magnetic resonance imaging (MRI).

RESULTS

The mean preoperative AOFAS score was 35. After a mean follow-up of 2 years, the mean postoperative AOFAS score was 81, which included three patients returning back to sporting activities. The MRI Mocart score demonstrated signs of regeneration of chondral and bony tissue. No progression of joint degeneration was shown radiographically.

CONCLUSION

BMDCT is a promising regenerative treatment for osteochondral lesions in mild ankle hemophilic arthropathy, which may be useful to delay or even avoid ankle arthrodesis. Nevertheless, longer follow-ups and a larger case series are required.

Replacing bad (F)actors: hemophilia

Hemophilia A and B are bleeding disorders that result from functional deficiencies in specific circulating blood clotting factors termed factor VIII (FVIII) and factor IX (FIX), respectively, and collectively display an incidence of 1 in 4000 male births. Stem cell transplantation therapies hold the promise of providing a cure for hemophilia, but currently available transplantable stem cell products do not confer endogenous FIX or FVIII biosynthesis. For this reason, stem cell-based approaches for hemophilia have focused primarily on genetic engineering of pluripotent or multipotent stem cells. While pluripotent stem cells have been branded with high expectation and promise, they remain poorly characterized in terms of clinical utility and safety. In contrast, adult-lineage-restricted stem cells are established agents in the clinical armamentarium. Of the clinically established stem cell types, hematopoietic stem cells (HSCs) are the most utilized and represent the standard of care for several genetic and acquired diseases. Furthermore, HSCs are ideal cellular vehicles for gene therapy applications because they self-renew, repopulate the entire blood lineage while concurrently amplifying the transgene copy number >10(6) fold, and also have direct access to the bloodstream. Current research on HSC transplantation gene therapy approaches for hemophilia A and B is focused on the following: (1) identification of safe and efficient methods of nucleic acid transfer, (2) optimization of transgene product expression, (3) minimization of conditioning-regimen-related toxicity while maintaining HSC engraftment, and (4) overcoming preexisting immunity. Based on the existing data and current rate of progress, clinical trials of HSC transplantation gene therapy for hemophilia are predicted to begin in the coming years.