Current concepts and perspectives for articular cartilage regeneration

Nanotechnology-Assisted mesenchymal stem cells treatment for improved cartilage regeneration: A review of current practices

Cartilage tissue does not promptly elicit an inflammatory response upon injury, hence constraining its capacity for healing and self-regeneration. Mesenchymal Stem Cells (MSC) therapy, enhanced by nanotechnology, offers promising advancements in cartilage repair. Injuries to cartilage often cause chronic pain, where current treatments are inadequate. As MSCs can readily differentiate into chondrocytes and secrete soluble factors, they are essential components in tissue engineering of cartilage repair. Although, like other stem cell applications, clinical applications are restricted by poor post implantation survival and differentiation. Recent studies show that nanoparticles (NPs) can further improve MSC outcomes by promoting cell adhesion, and chondrogenic differentiation allowing for sustained growth factor release. In addition, nanomaterials can improve the biological activity of MSCs, by also facilitating the composition of a conducive microenvironment for cartilage repair. In this review, the application of nanofibrous scaffolds, hydrogels and nanoscale particulate matter to improve mechanical properties in cartilage tissue engineering, are discussed. Moreover, the MSCs and nanotechnology synergistic effects present hope of overcoming the limitations of conventional treatments. Nanotechnology greatly enhances the MSC based cartilage regeneration strategies and could provide better treatment for cartilage related diseases in the future. Future research should be aimed at standardizing MSC harvesting and culturing protocols and contrasting their long-term efficacy.

Advancement of 3D biofabrication in repairing and regeneration of cartilage defects

Three-dimensional (3D) bioprinting, an additive manufacturing technology, fabricates biomimetic tissues that possess natural structure and function. It involves precise deposition of bioinks, including cells, and bioactive factors, on basis of computer-aided 3D models. Articular cartilage injuries, a common orthopedic issue. Current repair methods, for instance microfracture procedure (MF), autologous chondrocyte implantation (ACI), and osteochondral autologous transfer surgery have been applied in clinical practice. However, each procedure has inherent limitation. For instance, MF surgery associates with increased subchondral cyst formation and brittle subchondral bone. ACI procedure involves two surgeries, and associate with potential risks infection and delamination of the regenerated cartilage. In addition, chondrocyte implantation's efficacy depends on the patient's weight, joint pathology, gender-related histological changes of cartilage, and hormonal influences that affect treatment and prognosis. So far, it is a still a grand challenge for achieving a clinical satisfactory in repairing and regeneration of cartilage defects using conditional strategies. 3D biofabrication provide a potential to fabricate biomimetic articular cartilage construct that has shown promise in specific cartilage repair and regeneration of patients. This review reported the techniques of 3D bioprinting applied for cartilage repair, and analyzed their respective merits and demerits, and limitations in clinical application. A summary of commonly used bioinks has been provided, along with an outlook on the challenges and prospects faced by 3D bioprinting in the application of cartilage tissue repair. It provided an overall review of current development and promising application of 3D biofabrication technology in articular cartilage repair.

The influence of cell and platelet number on clinical outcomes provided by a one-step scaffold transplantation with bone marrow concentrate for the treatment of osteochondral lesions of the talus

PURPOSE

The aim of this study was to investigate if the numbers of cells and platelets in the bone marrow aspirate concentrate (BMAC) added to a hyaluronic acid membrane influence the clinical outcome up to long-term follow-up in the treatment of osteochondral lesions of the talus (OLTs).

METHODS

A total of 102 patients with symptomatic OLTs underwent this one-step treatment. Eighty-five patients (53 men, 32 women, age 32.3 ± 10.6 years, lesion size 2.7 ± 1.6 cm2) were prospectively evaluated at baseline and at 2-5-10 years using the AOFAS ankle-hindfoot score, the NRS for pain, and the Tegner score. Satisfaction and failures were documented as well. Laboratory analysis of BMAC was performed for the count of mononucleated cells (MNCs) and platelets.

RESULTS

The AOFAS improved from baseline (59.1 ± 13.7) to the final follow-up (82.3 ± 14.9, p < 0.0005). NRS improved from 7.1 ± 1.1 at baseline to 3.9 ± 2.8 at the final follow-up (p < 0.0005). Tegner improved from a pre-op 2.0 median to 3.0 at the final follow-up (p < 0.0005), not reaching the pre-injury level. MNCs and platelets in BMAC were 148.2 ± 54.2 × 109/L and 454.3 ± 277.5 × 109/L, respectively. MNCs correlated with NRS at 2 years (p = 0.018; rho=-0.260). However, MNCs number, as well as platelet number, did not influence the improvement from baseline of the clinical scores at all follow-up evaluations.

CONCLUSION

This study demonstrated, in a large series of patients evaluated up to a long-term follow-up, that the number of MNCs and platelets present in BMAC does not influence the overall clinical outcomes in patients affected by OLTs treated with a one-step hyaluronic acid scaffold implantation augmented with BMAC.

LEVEL OF EVIDENCE

IV.

Cell-free biomimetic osteochondral scaffold for the treatment of knee articular surface lesions: Clinical outcomes differ based on patient and lesion characteristics

PURPOSE

A cell-free biomimetic osteochondral scaffold was developed to treat cartilage knee lesions, with positive clinical results documented in small case series. However, clear evidence on patient and lesion characteristics that might affect the outcome is still lacking. The aim of this study is to analyse a large cohort of patients treated with this scaffold to investigate factors that could influence the clinical outcome.

METHODS

Two hundred and three patients (mean age 30.7 ± 10.9 years) treated with this scaffold were prospectively evaluated at baseline, 6-, 12- and 24-month follow-up. The clinical outcome was analysed using the International Knee Documentation Committee (IKDC) score, and the activity level was assessed with the Tegner score. The influence of patient and lesion characteristics on clinical outcomes was analysed.

RESULTS

Mild and severe adverse reactions were found in 39.0% and 1.5% of patients, respectively. The failure rate was 2.0%, increasing to 12.3% when including also clinical failures. The IKDC subjective score increased from 43.3 ± 15.9 to 61.0 ± 16.2 at 6 months, 68.3 ± 18.5 at 12 months and 73.8 ± 18.3 at 24 months (p < 0.0005). The Tegner improved from 2.5 ± 1.7 to 4.2 ± 1.7 at 24 months (p < 0.0005), without reaching the pre-injury level (6.0 ± 2.2) (p < 0.0005). The IKDC objective score changed from 68.5% normal and nearly normal knees before the treatment to 90.1% at 24 months. At 24 months, age showed a correlation with the IKDC subjective score (ρ = -0.247; p < 0.0005), women had a lower score (p < 0.0005), as well as patients with patellar lesions (p = 0.002). Previous surgery correlated with lower results (p = 0.003), while better results were found in osteochondritis dissecans (OCD) compared to degenerative lesions (p = 0.001).

CONCLUSION

This cell-free biomimetic scaffold is a safe and effective treatment for cartilage knee lesions, offering positive clinical results at 2 years with a low failure rate. Better outcomes were observed in younger patients, in lesions of the femoral condyles and in OCD, while joints affected by patellar lesions, patients who underwent previous knee surgery, and women may expect lower results.

LEVEL OF EVIDENCE

Level III, cohort study.

Therapeutic role of aripiprazole in cartilage defects explored through a drug repurposing approach

Articular cartilage has a limited regenerative capacity, resulting in poor spontaneous healing of damaged tissue. Despite various scientific efforts to enhance cartilage repair, no single method has yielded satisfactory results. With rising drug development costs, drug repositioning has emerged as a viable alternative. This study aimed to identify a drug capable of improving cartilage defects by analyzing chondrogenesis-related microarray data from the Gene Expression Omnibus (GEO) public database. We utilized datasets GSE69110, GSE107649, GSE111822, and GSE116173 to identify genes associated with cartilage differentiation, employing StringTie for differential gene expression analysis and extracting drug data from the Drug-Gene Interaction database. Additionally, we aimed to verify the cartilage regeneration potential of the identified drug through experiments using cellular and animal models. We evaluated the effects of aripiprazole on adipose-derived mesenchymal stem cells (ADMSCs) and chondrocytes using qRT-PCR and a 3D pellet culture system. In vivo, we assessed cartilage restoration by combining aripiprazole with a scaffold and implanting it into artificially induced cartilage defects in Sprague-Dawley rats. Subsequent mRNA sequencing provided insights into the mechanistic pathways involved. Our results showed that aripiprazole significantly increased mRNA expression of COL2A1 and SOX9, markers of chondrogenesis, and promoted chondrogenic condensation in vitro. Furthermore, aripiprazole effectively enhanced cartilage regeneration in the rat model. KEGG pathway and Gene Ontology Biological Processes (GOBP) analyses of the mRNA sequencing data revealed that aripiprazole upregulated genes related to ribosomes and cytoplasmic translation, thereby facilitating chondrogenesis. In conclusion, our findings suggest that aripiprazole is a promising candidate for improving damaged cartilage, offering a novel approach to cartilage regeneration.

Pathologically altered articular cartilage attracts intense chondrocyte invasion into the extracellular matrix: in vitro pilot study

BACKGROUND

Due to non-vascularized and aneural structure, articular cartilage has limited self-repairing capacity. The aim of this study was to investigate the revitalization of inflammatory injured articular cartilage matrices by human nasal chondrocytes (hNC).

MATERIALS AND METHODS

Cartilage matrix was prepared by devitalization of articular cartilage samples obtained intraoperatively from an adult patient undergoing knee joint replacement. hNC were obtained from native tissues by enzymatic digestion with further expansion over two passages. The obtained nasal chondrocytes were used to seed decellularized scaffolds, which were then cultured in vitro for 7, 14, or 21 days in chondrogenic medium. Migration was observed by histologic staining with fast green, safranin-O, and hematoxylin and scanning electron microscopy. Biochemical analysis was performed to determine the glycosaminoglycan (GAG) and DNA content of the cartilage using dimethylmethylene blue and CyQuant Cell Proliferation Assay Kit.

RESULTS

We seeded healthy and inflamed cartilage with nasal chondrocytes and found that the cells actively invade mainly pathologically altered cartilage. The results of biochemical quantitative analysis showed that the amount of DNA significantly increased by day 7 and decreased by day 14, while the quantitative values of GAGs had the opposite trend. Histological staining showed that cartilage formation occurred on day 7, intercellular spaces were filled with de novo synthesized cartilage matrix with significantly low GAG content on day 14, and newly formed GAG-rich cartilage was observed on day 21. The obtained data on cartilage regeneration were confirmed by scanning electron microscopy.

CONCLUSIONS

Our preliminary results showed that human nasal chondrocytes are capable of infiltrating the pathologically altered extracellular matrix of articular cartilage damaged by arthritis, thereby promoting its repair to a physiologically relevant state.

Sex does not influence the long-term outcome of matrix-assisted autologous chondrocyte transplantation

PURPOSE

Regenerative techniques for articular cartilage lesions demonstrated heterogeneous clinical results. Several factors may influence the outcome, with sex being one of the most debated. This study aimed at quantifying the long-term influence of sex on the clinical outcome obtained with a regenerative procedure for knee chondral lesions.

METHODS

Matrix-assisted autologous chondrocyte transplantation (MACT) was used to treat 235 knees which were prospectively evaluated with the International Knee Documentation Committee (IKDC), EuroQol visual analogue scale, and Tegner scores at 14-year mean follow-up. A multilevel analysis was performed with the IKDC subjective scores standardised according to the age/sex category of each patient and/or the selection of a match-paired subgroup to compare homogeneous men and women patients.

RESULTS

At 14 years, men and women showed a failure rate of 10.7% and 28.8%, respectively (p < 0.0005). An overall improvement was observed in both sexes. Women had more patellar lesions and men more condylar lesions (p = 0.001), and the latter also presented a higher preinjury activity level (p < 0.0005). Men had significantly higher IKDC subjective scores at all follow-ups (at 14 years: 77.2 ± 18.9 vs. 62.8 ± 23.1; p < 0.0005). However, the analysis of homogeneous match-paired populations of men and women, with standardised IKDC subjective scores, showed no differences between men and women (at 14 years: -1.6 ± 1.7 vs. -1.9 ± 1.6).

CONCLUSION

Men and women treated with MACT for knee chondral lesions presented a significant improvement and stable long-term results. When both sexes are compared with homogeneous match-paired groups, they have similar results over time. However, women present more often unfavourable lesion patterns, which proved more challenging in terms of long-term outcome after MACT.

LEVEL OF EVIDENCE

Level II.

Advances in the Development of Granular Microporous Injectable Hydrogels with Non-spherical Microgels and Their Applications in Tissue Regeneration

Granular microporous hydrogels are emerging as effective biomaterial scaffolds for tissue engineering due to their improved characteristics compared to traditional nanoporous hydrogels, which better promote cell viability, cell migration, cellular/tissue infiltration, and tissue regeneration. Recent advances have resulted in the development of granular hydrogels made of non-spherical microgels, which compared to those made of spherical microgels have higher macroporosity, more stable mechanical properties, and better ability to guide the alignment and differentiation of cells in anisotropic tissue. The development of these hydrogels as an emerging research area is attracting increasing interest in regenerative medicine. This review first summarizes the fabrication techniques available for non-spherical microgels with different aspect-ratios. Then, it introduces the development of granular microporous hydrogels made of non-spherical microgels, their physicochemical characteristics, and their applications in tissue regeneration. The limitations and future outlook of research on microporous granular hydrogels are also critically discussed.

Effects of mechanical properties of carbon-based nanocomposites on scaffolds for tissue engineering applications: a comprehensive review

Mechanical properties, such as elasticity modulus, tensile strength, elongation, hardness, density, creep, toughness, brittleness, durability, stiffness, creep rupture, corrosion and wear, a low coefficient of thermal expansion, and fatigue limit, are some of the most important features of a biomaterial in tissue engineering applications. Furthermore, the scaffolds used in tissue engineering must exhibit mechanical and biological behaviour close to the target tissue. Thus, a variety of materials has been studied for enhancing the mechanical performance of composites. Carbon-based nanostructures, such as graphene oxide (GO), reduced graphene oxide (rGO), carbon nanotubes (CNTs), fibrous carbon nanostructures, and nanodiamonds (NDs), have shown great potential for this purpose. This is owing to their biocompatibility, high chemical and physical stability, ease of functionalization, and numerous surface functional groups with the capability to form covalent bonds and electrostatic interactions with other components in the composite, thus significantly enhancing their mechanical properties. Considering the outstanding capabilities of carbon nanostructures in enhancing the mechanical properties of biocomposites and increasing their applicability in tissue engineering and the lack of comprehensive studies on their biosafety and role in increasing the mechanical behaviour of scaffolds, a comprehensive review on carbon nanostructures is provided in this study.

Young Age and Concomitant or Prior Bony Realignment Procedures are Associated with Decreased Risk of Failure of Osteochondral Allograft Transplantation in the Knee: A Nationwide Database Study

OBJECTIVE

Osteochondral allograft (OCA) transplantation is a restorative surgical option for large, full-thickness chondral or osteochondral defects in the knee. Variability in outcomes reporting has led to a broad range of graft survival rates. Using rate of salvage surgery following OCA as a failure metric, the purpose of this study was to analyze the incidence and risk factors for failure in a nationwide cohort.

DESIGN

The M151Ortho PearlDiver database was queried for patients aged 20 to 59 who underwent primary OCA between 2010 and 2020. Patients with prior cartilage procedures or arthroplasty were excluded. Kaplan-Meier survival analysis was performed to characterize cumulative rate of salvage surgery, defined as any patient subsequently undergoing revision OCA, autologous chondrocyte implantation (ACI), osteochondral autograft transfer system (OATS), unicompartmental knee arthroplasty (UKA), or total knee arthroplasty (TKA). Multivariable logistic regression was used to determine the effect of several variables on odds of salvage surgery.

RESULTS

Around 6,391 patients met inclusion criteria. Cumulative 5-year salvage rate was 1.71%, with 68.8% in the first 2 years. Age 20 to 29 and concomitant or prior bony realignment procedures were associated with significantly decreased rate of salvage surgery (age-adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI], 0.24-0.99, P = 0.046; realignment-aOR = 0.24, 95% CI, 0.04-0.75, P = 0.046).

CONCLUSIONS

In the largest OCA cohort studied to date, less than 2% of patients required salvage surgery. Young age and bony realignment were protective. These findings suggest that OCA in the knee is a durable cartilage-restoration procedure, especially in young patients with corrected alignment.

Current and Novel Therapeutics for Articular Cartilage Repair and Regeneration

Articular cartilage repair is a sophisticated process that has is being recently investigated. There are several different approaches that are currently reported to promote cartilage repair, like cell-based therapies, biologics, and physical therapy. Cell-based therapies involve the using stem cells or chondrocytes, which make up cartilage, to promote the growth of new cartilage. Biologics, like growth factors, are also being applied to enhance cartilage repair. Physical therapy, like exercise and weight-bearing activities, can also be used to promote cartilage repair by inducing new cartilage growth and improving joint function. Additionally, surgical options like osteochondral autograft, autologous chondrocyte implantation, microfracture, and others are also reported for cartilage regeneration. In the current literature review, we aim to provide an up-to-date discussion about these approaches and discuss the current research status.

A guide to preclinical evaluation of hydrogel-based devices for treatment of cartilage lesions

The drive to develop cartilage implants for the treatment of major defects in the musculoskeletal system has resulted in a major research thrust towards developing biomaterial devices for cartilage repair. Investigational devices for the restoration of articular cartilage are considered as significant risk materials by regulatory bodies and therefore proof of efficacy and safety prior to clinical testing represents a critical phase of the multidisciplinary effort to bridge the gap between bench and bedside. To date, review articles have thoroughly covered different scientific facets of cartilage engineering paradigm, but surprisingly, little attention has been given to the preclinical considerations revolving around the validation of a biomaterial implant. Considering hydrogel-based cartilage products as an example, the present review endeavors to provide a summary of the critical prerequisites that such devices should meet for cartilage repair, for successful implantation and subsequent preclinical validation prior to clinical trials. Considerations pertaining to the choice of appropriate animal model, characterization techniques for the quantitative and qualitative outcome measures, as well as concerns with respect to GLP practices are also extensively discussed. This article is not meant to provide a systematic review, but rather to introduce a device validation-based roadmap to the academic investigator, in anticipation of future healthcare commercialization. STATEMENT OF SIGNIFICANCE: There are significant challenges around translation of in vitro cartilage repair strategies to approved therapies. New biomaterial-based devices must undergo exhaustive investigations to ensure their safety and efficacy prior to clinical trials. These considerations are required to be applied from early developmental stages. Although there are numerous research works on cartilage devices and their in vivo evaluations, little attention has been given into the preclinical pathway and the corresponding approval processes. With a focus on hydrogel devices to concretely illustrate the preclinical path, this review paper intends to highlight the various considerations regarding the preclinical validation of hydrogel devices for cartilage repair, from regulatory considerations, to implantation strategies, device performance aspects and characterizations.