Tibial segmental bone defect treated with bone plate and cage filled with either xenogeneic composite or autologous cortical bone graft

3D Biomimetic Porous Titanium (Ti6Al4V ELI) Scaffolds for Large Bone Critical Defect Reconstruction: An Experimental Study in Sheep

Simple Summary

The authors propose a new reconstructive technique that proved to be suitable to reach this purpose through the use of a custom-made biomimetic porous titanium scaffold. An in vivo study was undertaken where a complete critical defect was experimentally created in the diaphysis of the right tibia of twelve sheep and replaced with a five-centimeter porous scaffold of electron beam melting (EBM)-manufactured titanium alloy or a porous hydroxyapatite scaffold. Our results show that EBM-formed titanium devices, if used to repair critical bone defects in a large animal model, can guarantee immediate body weight-bearing, a rapid functional recovery, and a good osseointegration. The porous hydroxyapatite scaffolds proved to be not suitable in this model of large bone defect due to their known poor mechanical properties.

Abstract

The main goal in the treatment of large bone defects is to guarantee a rapid loading of the affected limb. In this paper, the authors proposed a new reconstructive technique that proved to be suitable to reach this purpose through the use of a custom-made biomimetic porous titanium scaffold. An in vivo study was undertaken where a complete critical defect was experimentally created in the diaphysis of the right tibia of twelve sheep and replaced with a five-centimeter porous scaffold of electron beam melting (EBM)-sintered titanium alloy (EBM group n = 6) or a porous hydroxyapatite scaffold (CONTROL group, n = 6). After surgery, the sheep were allowed to move freely in the barns. The outcome was monitored for up to 12 months by periodical X-ray and clinical examination. All animals in the CONTROL group were euthanized for humane reasons within the first month after surgery due to the onset of plate bending due to mechanical overload. Nine months after surgery, X-ray imaging showed the complete integration of the titanium implant in the tibia diaphysis and remodeling of the periosteal callus, with a well-defined cortical bone. At 12 months, sheep were euthanized, and the tibia were harvested and subjected to histological analysis. This showed bone tissue formations with bone trabeculae bridging titanium trabeculae, evidencing an optimal tissue-metal interaction. Our results show that EBM-sintered titanium devices, if used to repair critical bone defects in a large animal model, can guarantee immediate body weight-bearing, a rapid functional recovery, and a good osseointegration. The porous hydroxyapatite scaffolds proved to be not suitable in this model of large bone defect due to their known poor mechanical properties.

Pre-Clinical Evaluation of Biological Bone Substitute Materials for Application in Highly Loaded Skeletal Sites

The development of bone substitute materials (BSMs) intended for load-bearing bone defects is highly complicated, as biological and mechanical requirements are often contradictory. In recent years, biological BSMs have been developed which allow for a more efficient integration of the material with the surrounding osseous environment and, hence, a higher mechanical stability of the treated defect. However, while these materials are promising, they are still far from ideal. Consequently, extensive preclinical experimentation is still required. The current review provides a comprehensive overview of biomechanical considerations relevant for the design of biological BSMs. Further, the preclinical evaluation of biological BSMs intended for application in highly loaded skeletal sites is discussed. The selected animal models and implantation site should mimic the pathophysiology and biomechanical loading patterns of human bone as closely as possible. In general, sheep are among the most frequently selected animal models for the evaluation of biomaterials intended for highly loaded skeletal sites. Regarding the anatomical sites, segmental bone defects created in the limbs and spinal column are suggested as the most suitable. Furthermore, the outcome measurements used to assess biological BSMs for regeneration of defects in heavily loaded bone should be relevant and straightforward. The quantitative evaluation of bone defect healing through ex vivo biomechanical tests is a valuable addition to conventional in vivo tests, as it determines the functional efficacy of BSM-induced bone healing. Finally, we conclude that further standardization of preclinical studies is essential for reliable evaluation of biological BSMs in highly loaded skeletal sites.

Orthogonal bone plate stabilization for limb-sparing surgery

This report describes limb-sparing surgery in a 35 kg, six-year-old Hungarian Vizsla with a distal radial lytic bone lesion. Preoperative biopsy had suggested a bone cyst, however histopathology on the excised bone segment was indicative of an osteosarcoma. Following excision of the tumour, the bone defect was filled with a composite bone graft and stabilized with a custom-made dorsal 3.5/2.7 mm pancarpal arthrodesis plate and an orthogonally positioned medial 2.7 mm compression plate. This technique has not previously been described for limb-sparing procedures. No complications were encountered, and despite the owners declining adjunctive chemotherapy, the dog was alive 34 months postoperatively with near normal limb function.

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.

Goniometria dos membros torácicos e pélvicos de ovinos em duas faixas etárias

O trabalho teve por objetivo comparar os valores goniométricos das articulações dos membros torácicos e pélvicos em ovinos da raça Santa Inês em duas faixas etárias (jovens e adultos). Foram utilizados 30 ovinos hígidos, fêmeas, divididos em dois grupos: Grupo 1 com 15 animais jovens (idade entre 6 e 12 meses), Grupo 2 com 15 animais adultos (entre 3 e 6 anos). Foram aferidas a máxima flexão, a máxima extensão e calculou-se a amplitude de movimento das articulações, direita e esquerda, dos membros torácicos (ombro, cotovelo e carpo) e pélvicos (coxofemoral, joelho e tarso), com o emprego de um goniômetro universal de plástico. Cada articulação foi aferida em triplicata por dois avaliadores com o animal em estação. Não foram detectadas diferenças estatísticas entre as médias em ambos os lados, entre os avaliadores ou entre os grupos. Foi possível assim concluir que, em ovinos hígidos, os valores goniométricos não foram influenciados pela idade.

Goniometric measurements of the forelimb and hindlimb joints in sheep

OBJECTIVES

The aim of this study was to evaluate angle-of-motion values for the forelimb and hindlimb in clinically healthy adult Santa Ines sheep by means of a standard goniometer.

METHODS

Twenty female Santa Ines sheep, ranging in age between three- to six-years-old, and weighing 32-45 kg (mean ± standard deviation [SD]: 30.4 ± 3.7) were used. A standard transparent plastic goniometer was used to measure passive maximum flexion, maximum extension, and range-of-motion (ROM) of the shoulder, elbow, carpal, hip, stifle, and tarsal joints in the right and left limbs. The goniometric measurements were done with the sheep awake and in a standing position. The measurements were made in triplicate by two independent investigators.

RESULTS

In all evaluated joints, there was no significant difference either between the means of the two sides or between measurements performed by the two investigators. The mean ± SD values of the measurements (degrees) were as follows: 20 ± 1 (flexion), 170 ± 2 (extension), and 150 ± 2 (ROM) for the carpal joint; 34 ± 4 (flexion), 145 ± 6 (extension), and 110 ± 4 (ROM) for the elbow joint; 88 ± 2 (flexion), 144 ± 6 (extension), and 56 ± 5 (ROM) for shoulder joint; 35 ± 4 (flexion), 163 ± 3 (extension), and 129 ± 4 (ROM) for tarsal joint; 46 ± 4 (flexion), 146 ± 6 (extension), and 100 ± 4 (ROM) for the stifle joint; 54 ± 3 (flexion), 143 ± 7 (extension), and 89 ± 5 (ROM) for the hip joint.

CLINICAL SIGNIFICANCE

The data obtained provide useful and objective information on the joints. More studies are necessary using other sheep breeds.

Establishment of a preclinical ovine model for tibial segmental bone defect repair by applying bone tissue engineering strategies

Currently, well-established clinical therapeutic approaches for bone reconstruction are restricted to the transplantation of autografts and allografts, and the implantation of metal devices or ceramic-based implants to assist bone regeneration. Bone grafts possess osteoconductive and osteoinductive properties; however, they are limited in access and availability and associated with donor-site morbidity, hemorrhage, risk of infection, insufficient transplant integration, graft devitalization, and subsequent resorption resulting in decreased mechanical stability. As a result, recent research focuses on the development of alternative therapeutic concepts. The field of tissue engineering has emerged as an important approach to bone regeneration. However, bench-to-bedside translations are still infrequent as the process toward approval by regulatory bodies is protracted and costly, requiring both comprehensive in vitro and in vivo studies. The subsequent gap between research and clinical translation, hence, commercialization, is referred to as the "Valley of Death" and describes a large number of projects and/or ventures that are ceased due to a lack of funding during the transition from product/technology development to regulatory approval and subsequently commercialization. One of the greatest difficulties in bridging the Valley of Death is to develop good manufacturing processes and scalable designs and to apply these in preclinical studies. In this article, we describe part of the rationale and road map of how our multidisciplinary research team has approached the first steps to translate orthopedic bone engineering from bench to bedside by establishing a preclinical ovine critical-sized tibial segmental bone defect model, and we discuss our preliminary data relating to this decisive step.

The challenge of establishing preclinical models for segmental bone defect research

A considerable number of international research groups as well as commercial entities work on the development of new bone grafting materials, carriers, growth factors and specifically tissue-engineered constructs for bone regeneration. They are strongly interested in evaluating their concepts in highly reproducible large segmental defects in preclinical and large animal models. To allow comparison between different studies and their outcomes, it is essential that animal models, fixation devices, surgical procedures and methods of taking measurements are well standardized to produce reliable data pools and act as a base for further directions to orthopaedic and tissue engineering developments, specifically translation into the clinic. In this leading opinion paper, we aim to review and critically discuss the different large animal bone defect models reported in the literature. We conclude that most publications provide only rudimentary information on how to establish relevant preclinical segmental bone defects in large animals. Hence, we express our opinion on methodologies to establish preclinical critically sized, segmental bone defect models used in past research with reference to surgical techniques, fixation methods and postoperative management focusing on tibial fracture and segmental defect models.

Natural Bovine Anorganic Apatite and Collagen Presents Osteoconductivity and Contribute to Bone Repair of Rat Calvaria Critical Size Defect

The aim of this study was verify the biological efficacy of the use of a xenograft for bone loss therapy. Blood clot, particulate autogenous bone or anorganic bovine xenograft filled critical size defects (CSD) in rat calvaria (8mm diameter). After 0, 7, 30 and 90 days the animals were killed and macroscopic, radiographic and histopathological analysis were conducted. Although no treatment promoted the total closure of bone defect, autogenous bone group had better bone repair after 90 days, followed by xenograft group that exhibited direct bone neoformation onto, and around, the particles confirming its osteoconductivity. In conclusion, the xenograft tested in vivo showed biocompatibility, biodegradability and osteoconductive properties in rat calvaria CSD.

Histomorphometric Analysis of Bone Repair in Critical Size Defect in Rats Calvaria Treated with Hydroxyapatite and Zinc-Containing Hydroxyapatite 5%

Biomaterials for treatment of bone defects have been studied for a long time. Alloplastic materials, mainly hydroxyapatite (HA), are under intense investigation due to its biocompatibility and osteoconductive properties. The HA can be modified by the incorporation of bivalent cations as Zn2+ known as a positive effectors for bone repair. The purpose of this study was to evaluate comparatively the effectiveness of 5% zinc-containing hydroxyapatite (ZnHA) in the treatment of critical size defect (CSD) in rat’s calvaria. CSD (8mm diameter) created in the skull of forty-five Wistar rats were filled with autogenous bone, HA and ZnHA. Skulls harvested after 30, 90 and 180 days were submitted to histological processing for paraffin embedding. Sections of 5 µm-thick stained with hematoxylin and eosin (HE) allowed histomorphometric analysis. The area of neoformed bone increased (p<0.001) from 30 to 180 days irrespective to treatment groups. ZnHA and the control group showed a large at 180 days but no significant difference compared to HA. Therefore, we concluded that both biomaterials are biocompatibles and osteoconductors, promoting new bone formation and apposition of bone on the surface throughout the periods and the addition of zinc improved the osteogenesis.