Adult mesenchymal stem cells and impaction grafting: a new clinical paradigm shift

Fabrication and evaluation of a BMP-2/dexamethasone co-loaded gelatin sponge scaffold for rapid bone regeneration

Improving the osteogenic activity of BMP-2 in vivo has significant clinical application value. In this research, we use a clinical gelatin sponge scaffold loaded with BMP-2 and dexamethasone (Dex) to evaluate the osteogenic activity of dual drugs via ectopic osteogenesis in vivo. We also investigate the mechanism of osteogenesis induced by BMP-2 and Dex with C2C12, a multipotent muscle-derived progenitor cell. The results show that the gelatin scaffold with Dex and BMP-2 can significantly accelerate osteogenesis in vivo. It is indicated that compared with the BMP-2 or Dex alone, 100 nM of Dex can dramatically enhance the BMP-2-induced alkaline phosphatase activity (ALP), ALP mRNA expression and mineralization. Further studies show that 100 nM of Dex can maintain the secondary structure of BMP-2 and facilitate recognition of BMP-2 with its receptors on the surface of C2C12 cells. We also find that in C2C12, Dex has no obvious effect on the BMP-2-induced Smad1/5/8 protein expression and the STAT3-dependent pathway, but Runx2-dependent pathway is involved in the Dex-stimulated osteoblast differentiation of BMP-2 both in vitro and in vivo. Based on these results, a potential mechanism model about the synergistic osteoinductive effect of Dex and BMP-2 in C2C12 cells via Runx2 activation is proposed. This may provide a theoretical basis for the pre-clinical application of Dex and BMP-2 for bone regeneration.

Synergistic effects of dual growth factor delivery from composite hydrogels incorporating 2-N,6-O-sulphated chitosan on bone regeneration

A promising strategy to accelerate bone generation is to deliver a combination of certain growth factors to the integration site via a controlled spatial and temporal delivery mode. Here, a composite hydrogel incorporating poly(lactide-co-glycolide) (PLGA) microspheres was accordingly prepared to load and deliver the osteogenic rhBMP-2 and angiogenic rhVEGF₁₆₅ in the required manner. In addition, 2-N,6-O-sulphated chitosan (26SCS), which is a synergetic factor of growth factors, was incorporated in the composite hydrogel as well. The system showed a similar release behaviour of the two growth factors regardless of 26SCS inclusion. RhBMP-2 loaded in PLGA microspheres showed a sustained release over a period of 2 weeks, whereas rhVEGF₁₆₅ loaded in hydrogel eluted almost completely from the hydrogel over the first 16 days. Both growth factors retained their efficacy, as quantified with relevant in vitro assays. Moreover, an enhanced cell response was achieved upon the delivery of dual growth factors, compared to that obtained with a single factor. Furthermore, in the presence of 26SCS, the system revealed significantly upregulated alkaline phosphatase activity, human umbilical vein endothelial cell proliferation, sprouting, nitric oxide secretion, and angiogenic gene expression. This study highlighted that the composite hydrogel incorporated with 26SCS appears to constitute a promising approach to deliver multiple growth factors. From our findings, we could also conclude that rhBMP-2 can promote angiogenesis and that the mechanism is worthy of further study in subsequent research.

Application of 3D-printed patient-specific skeletal implants augmented with autologous skeletal stem cells

Joint replacements have proved a medical success providing symptomatic relief and return to mobility in many patients with arthritis. However, multiple revision surgeries due to joint failure can result in complex revision scenarios with significant bone tissue loss, in an elderly population, which poses a significant clinical challenge. Computer-aided design–computer-assisted manufacturing (CAD–CAM) prototyped bespoke implants are currently being used as an alternative and innovative approach for joint restoration in salvage cases, while the incorporation of autologous skeletal stem cells to optimize regenerative capacity can enhance implant osseointegration. We present a case series of 11 patients with severe disability and significant bone loss due to failed joint replacements. The choice of CAD–CAM prototyped joint implants enhanced with autologous skeletal stem cells resulted in significant patient-reported clinical and radiological improvements.

Femoral impaction bone grafting in revision hip arthroplasty

Aims

Femoral impaction bone grafting was first developed in 1987 using morselised cancellous bone graft impacted into the femoral canal in combination with a cemented, tapered, polished stem. We describe the evolution of this technique and instrumentation since that time.

Patients and Methods

Between 1987 and 2005, 705 revision total hip arthroplasties (56 bilateral) were performed with femoral impaction grafting using a cemented femoral stem. All surviving patients were prospectively followed for a mean of 14.7 years (9.8 to 28.3) with no loss to follow-up. By the time of the final review, 404 patients had died.

Results

There were 76 further revisions (10.8%) involving the stem; seven for aseptic loosening, 23 for periprosthetic fracture, 24 for infection, one for malposition, one for fracture of the stem and 19 cement-in-cement exchanges of the stem during acetabular revision. The 20-year survival rate for the entire series was 98.8% (95% confidence interval (CI) 97.8 to 99.8) with aseptic loosening as the endpoint, and 87.7% (95% CI 82.8 to 92.6) for revision for any reason. Survival improved with the evolution of the technique, although this was not statistically significant due to the overall low rate of further revision.

Conclusion

This is the largest series of revision total hip arthroplasties with femoral impaction grafting, and the results support the continued use of this technique. Cite this article: Bone Joint J 2016;98-B:1611–19.

The Use of Sequential VEGF- and BMP2-Releasing Biodegradable Scaffolds in Rabbit Mandibular Defects

PURPOSE

Promising developments have materialized in reconstructive surgical procedures with the applications of tissue engineering. In our study, we used tissue scaffolds fabricated from polylactic acid-polyethylene glycol (PLLA-PEG) copolymers to ensure different release rates of selective growth factors recombinant human bone morphogenetic protein 2 [rhBMP-2] and vascular endothelial growth factor (rhVEGF165) in the repair of mandibular bone defects.

MATERIALS AND METHODS

In our experimental study, 54 New Zealand rabbits were used. The rabbits were separated into 4 groups: group I (control group), PLLA-PEG scaffold only; group II, PLLA-PEG scaffold plus rhBMP-2 application; group III, PLLA-PEG scaffold plus VEGF165 application; and group IV, PLLA-PEG scaffold plus rhBMP-2 and VEGF165 applications. The rabbits were killed at 4 and 8 weeks postoperatively, and histopathologic and immunohistochemical assessments were performed.

RESULTS

The greatest bone volume was observed in rhBMP-2-containing groups, the greatest vessel volume was observed in VEGF165-containing groups; however, the scaffold containing rhBMP-2 and VEGF165 provided the best outcomes in conjunction with increased remodeling of the new bone.

CONCLUSIONS

The use of polymer tissue scaffolds that release rhVEGF165 and rhBMP-2 in coordination and mimic the natural healing process in the regeneration of especially complex tissues, such as bone, is a promising treatment alternative in the field of reconstructive surgery.

Vascularization and bone regeneration in a critical sized defect using 2-N,6-O-sulfated chitosan nanoparticles incorporating BMP-2

An ideal bone tissue engineering graft should have both excellent pro-osteogenesis and pro-angiogenesis to rapidly realize the bone regeneration in vivo. To meet this goal, 2-N,6-O-sulfated chitosan (26SCS) based nanoparticle (S-NP) was successfully developed and showed a dose-dependent enhancement on angiogenesis in vitro. For the repair of a critical sized defect in rabbit radius, we developed BMP-2 loaded S-NP (BMP-2/S-NP) with protein loading efficiency of 1.4 ± 0.2% and fabricated a gelatin sponge (G) based implant loaded with BMP-2/S-NP (BMP-2/S-NP/G). This implant exerted a delivery of BMP-2 with an initial burst release of 15.3 ± 4.1% in first 24 h and a gradual release for 21 days to 77.8 ± 3.6%. The in vitro ALP assay revealed that the activity of released BMP-2 from BMP-2/S-NP/G was maintained after 3-d and 7-d delivery and further enhanced after 14-d delivery compared with the original BMP-2. Furthermore, the in vivo effects of BMP-2/S-NP/G on the bone regeneration and vessel formation in the critical sized defect (18 mm) of rabbit radius were investigated by synchrotron radiation-based micro-computed tomography (SRμCT) imaging, three dimensional micro-computed tomographic (μCT) imaging, histological analysis, immunohistochemistry and biomechanical measurement. Based on the results, both peripheral vessel and new vessel formation were significantly increased by the BMP-2/S-NP/G treatment, along with the bridged defects at as early as 2 weeks, the healed defects at 8 weeks and the reunion of bone marrow cavity at 12 weeks. The results indicated that both controlled release of active BMP-2 and favorable vascularization at the defect site contributed by BMP-2/S-NP/G played a crucial role in accelerating and promoting bone augmentation. This study suggests that BMP-2/S-NP/G demonstrates promise for vascularization and bone regeneration in clinical case of large defect.

Stability of human mesenchymal stem cells during in vitro culture: considerations for cell therapy

Ex vivo expansion and manipulation of human mesenchymal stem cells are important approaches to immunoregulatory and regenerative cell therapies. Although these cells show great potential for use, issues relating to their overall nature emerge as problems in the field. The need for extensive cell quantity amplification in vitro to obtain sufficient cell numbers for use, poses a risk of accumulating genetic and epigenetic abnormalities that could lead to sporadic malignant cell transformation. In this study, we have examined human mesenchymal stem cells derived from bone marrow, over extended culture time, using cytogenetic analyses, mixed lymphocyte reactions, proteomics and gene expression assays to determine whether the cultures would retain their potential for use in subsequent passages. Results indicate that in vitro cultures of these cells demonstrated chromosome variability after passage 4, but their immunomodulatory functions and differentiation capacity were maintained. At the molecular level, changes were observed from passage 5 on, indicating initiation of differentiation. Together, these results lead to the hypothesis that human mesenchymal stem cells cultures can be used successfully in cell therapy up to passage 4. However, use of cells from higher passages would have to be analysed case by case.

Tantalum trabecular metal - addition of human skeletal cells to enhance bone implant interface strength and clinical application

The osteo-regenerative properties of allograft have recently been enhanced by addition of autogenous human bone marrow stromal cells (HBMSCs). Limitations in the use of allograft have prompted the investigation of tantalum trabecular metal (TTM) as a potential alternative. TTM is already in widespread orthopaedic use, although in applications where there is poor initial stability, or when TTM is used in conjunction with bone grafting, initial implant loading may need to be limited. The aim of this study was to evaluate the osteo-regenerative potential of TTM with HBMSCs, in direct comparison to human allograft and autograft. HBMSCs were cultured on blocks of TTM, allograft or autograft in basal and osteogenic media. Molecular profiling, confocal and scanning electron microscopy (SEM) and biochemical assays were used to characterize cell adherence, proliferation and phenotype. Mechanical testing was used to define the tensile characteristics of the constructs. HBMSCs displayed adherence and proliferation throughout TTM, evidenced by immunocytochemistry and SEM, with significant cellular ingrowth and matrix production through TTM. In contrast to cells cultured with allograft, cell proliferation assays showed significantly higher activity with TTM (p < 0.001), although molecular profiling confirmed no significant difference in expression of osteogenic genes. In contrast to acellular constructs, mechanical testing of cell-TTM constructs showed enhanced tensile characteristics, which compared favourably to cell-allograft constructs. These studies demonstrated the ability of TTM to support HBMSC growth and osteogenic differentiation comparable to allograft. Thus, TTM represents an alternative to allograft for osteo-regenerative strategies, extending its clinical applications as a substitute for allograft.

Skeletal tissue regeneration: current approaches, challenges, and novel reconstructive strategies for an aging population

Loss of skeletal tissue as a consequence of trauma, injury, or disease is a significant cause of morbidity with often wide-ranging socioeconomic impacts. Current approaches to replace or restore significant quantities of lost bone come with substantial limitations and inherent disadvantages that may in themselves cause further disability. In addition, the spontaneous repair capacity of articular cartilage is limited; thus, investigation into new cartilage replacement and regeneration techniques are warranted. Along with the challenges of an increasingly aging demographic, changing clinical scenarios and rising functional expectations provide the imperative for new, more reliable skeletal regeneration strategies. The science of tissue engineering has expanded dramatically in recent years, notably in orthopedic applications, and it is clear that new approaches for de novo skeletal tissue formation offer exciting opportunities to improve the quality of life for many, particularly in the face of increasing patient expectations. However, significant scientific, financial, industrial, and regulatory challenges should be overcome before the successful development of an emergent tissue engineering strategy can be realized. We outline current practice for replacement of lost skeletal tissue and the innovative approaches in tissue regeneration that have so far been translated to clinical use, along with a discussion of the significant hurdles that are presented in the process of translating research strategies to the clinic.

In vivo evaluation of calcium polyphosphate for bone regeneration

Current problems associated with bone allografts include risk of disease transmission, limited availability, and cost. Synthetic scaffolds have been proposed as substitute graft materials to address these issues. Calcium polyphosphate is a novel synthetic scaffold material that has shown good mechanical properties and biocompatibility. Here, we evaluated calcium polyphosphate in terms of its ability to support cell proliferation and differentiation in vivo. Calcium polyphosphate, morsellized cancellous bone, and hydroxyapatite/tricalcium phosphate particles were seeded with marrow stromal cells and implanted subcutaneously in the back of NOD/Scid mice. At 7, 14, and 28 days the samples were harvested and the proliferation characteristics and gene expression were analyzed. All tested graft materials had similar proliferation characteristics and gene expression. The subcutaneous environment had a stronger impact on the proliferation and differentiation of the cells than the scaffold material itself. However, it was shown that calcium polyphosphate is superior to hydroxyapatite/tricalcium phosphate and bone in its ability to support cell survival in vivo. The study confirmed that calcium polyphosphate has potential for replacing morsellized cancellous bone as a graft material for bone regeneration.

Shed blood-derived cells from total hip arthroplasty have osteoinductive potential: a pilot study

BACKGROUND

Cell therapy using autologous cells has been used in the treatment of various medical conditions. The mononuclear cell (MNC) fraction of bone marrow (BM) contains stem/progenitor cells that could contribute to osteogenesis and angiogenesis.

QUESTIONS/PURPOSES

We asked whether MNCs derived from intraoperative shed blood (SB), consisting of peripheral blood and BM, have osteoinductive and angiogenic potential.

METHODS

We harvested SB and BM from six patients undergoing THA. Isolated MNCs from SB and BM were analyzed by flow cytometry to evaluate the CD34(+) cell fraction and 1 × 10(6) cells were seeded on an interconnective porous calcium hydroxyapatite ceramic (IP-CHA) and transplanted in the backs of athymic rats. IP-CHAs without cells were transplanted as controls and all composites were harvested after 4 and 8 weeks. Osteoinductive potential was evaluated by histologic observation, immunohistochemistry, and enzyme-linked immunosorbent assay (ELISA) using anti-osteocalcin (OC) antibodies qualitatively and quantitatively. To evaluate angiogenic potential, capillary density was measured by immunohistochemistry using Isolectin B4 4 weeks after implantation.

RESULTS

We found that CD34(+) cells existed in SB-MNCs and there was a trend toward lower frequency compared with BM-MNCs. Histologic osteoinduction, OC expression, and capillary density were increased by transplantation of MNCs from SB. Similar results were achieved with MNCs from BM.

CONCLUSIONS

MNCs from SB have equivalent osteoinductive and angiogenic potential compared with those from BM.

CLINICAL RELEVANCE

SB could be an attractive source for isolation of MNCs, enhancing osteoinduction and neovascularization, to augment the reconstruction of skeletal defects.

Impaction bone grafting in revision hip surgery: past, present and future

Joint replacement surgery can have excellent clinical results. However, as the number of patients undergoing surgery increases, the number of failed joint replacements is set to rise. One of the greatest challenges for the revision surgeon is the restoration of bone stock. This article focuses upon revision hip surgery, with particular reference to the scope of the problem; historical and current solutions to bone loss in the femur and acetabulum; the clinical results following revision surgery; and the basic science behind impaction bone grafting, before ending with possible future directions for improving the restoration of bone stock.

Is tissue engineering a new paradigm in medicine? Consequences for the ethical evaluation of tissue engineering research

Ex-vivo tissue engineering is a quickly developing medical technology aiming to regenerate tissue through the introduction of an ex-vivo created tissue construct instead of restoring the damaged tissue to some level of functionality. Tissue engineering is considered by some as a new medical paradigm. We analyse this claim and identify tissue engineering's fundamental characteristics, focusing on the aim of the intervention and on the complexity and continuity of the process. We inquire how these features have an impact not only on the scientific research itself but also on the ethical evaluation of this research. We suggest that viewing tissue engineering as a new medical paradigm allows us to develop a wider perspective for successful investigation instead of focusing on isolated steps of the tissue engineering process in an anecdotal way, which may lead to an inadequate ethical evaluation. We argue that the concept of tissue engineering as a paradigm may benefit the way we address the ethical challenges presented by tissue engineering.

Acetabular bone reconstruction in revision arthroplasty: a comparison of freeze-dried, irradiated and chemically-treated allograft vitalised with autologous marrow versus frozen non-irradiated allograft

Deficiencies of acetabular bone stock at revision hip replacement were reconstructed with two different types of allograft using impaction bone grafting and a Burch-Schneider reinforcement ring. We compared a standard frozen non-irradiated bone bank allograft (group A) with a freeze-dried irradiated bone allograft, vitalised with autologous marrow (group B). We studied 78 patients (79 hips), of whom 87% (69 hips) had type III acetabular defects according to the American Academy of Orthopaedic Surgeons classification at a mean of 31.4 months (14 to 51) after surgery. At the latest follow-up, the mean Harris hip score was 69.9 points (13.5 to 97.1) in group A and 71.0 points (11.5 to 96.5) in group B. Each hip showed evidence of trabeculation and incorporation of the allograft with no acetabular loosening. These results suggest that the use of an acetabular reinforcement ring and a living composite of sterile allograft and autologous marrow appears to be a method of reconstructing acetabular deficiencies which gives comparable results to current forms of treatment.

The strong financial case for regenerative medicine and the regen industry

Although the therapeutic promise of regenerative medicine is immensely exciting, the cost of product development, and particularly of clinical trials, for the more demanding applications will be high. For this reason it is vital for scientists and start-ups who wish to see their ideas implemented to be able to convince established major pharmaceutical or device companies with the necessary 'deep pockets' that the expenditure can yield an appropriate return. It also means that governments and health insurance companies must see a gain in funding regenerative medicine for patients. To address this issue the costs of five major medical conditions that could benefit from regenerative medicine have been defined for the USA as an illustration. This choice of country was made as potentially the largest initial market and one where the billing system for healthcare allows access to individual direct and some indirect costs. The data are complemented by a number of relevant examples of costs per quality-adjusted life year to indicate where current treatment methods are weak or strong. Finally, the relationship of the nascent regen* industry to the pharma and medical device sectors is summarized to assess the challenge of encouraging their involvement.

Controversial issue: is it safe to employ mesenchymal stem cells in cell-based therapies?

The prospective clinical use of multipotent mesenchymal stromal stem cells (MSC) holds enormous promise for the treatment of a large number of degenerative and age-related diseases. However, the challenges and risks for cell-based therapies are multifaceted. The risks for patients receiving stem cells, which have been expanded in vitro in the presence of xenogenic compounds, can hardly be anticipated and methods for the culture and manipulation of "safe" MSC ex vivo are being investigated. During in vitro expansion, stem cells experience a long replicative history and are thus subject to damage from intracellular and extracellular influences. While murine MSC are prone to cellular transformation in culture, human MSC do not transform. One reason for this striking difference is that during long-term culture, human MSC finally become replicatively senescent. In consequence, this greatly restricts their proliferation and differentiation efficiency. It however also limits the yield of sufficient numbers of cells needed for therapy. Another issue is to eliminate contamination of expanding cells with serum-bound pathogenic agents in order to reduce the risks for infection. A recent technical advancement, which applies human serum platelet lysates as an alternative source for growth factors and essential supplements, allows the unimpaired proliferation of MSC in the absence of animal sera. Here, we present an update regarding cellular senescence of MSC and recent insights concerning potential risks associated with their clinical use.

Changes of the Functional Capacity of Mesenchymal Stem Cells due to Aging or Age-Associated Disease - Implications for Clinical Applications and Donor Recruitment

SUMMARY: In contrast to stem cells of embryonic origin, autologous tissue-specific stem cells are easier to introduce into the clinical practice. In this context, molecular and cellular changes, which alter tissue-specific stem cell properties with age, are of particular interest since elderly patients represent the main target group for cell-based therapies. The clinical use of mesenchymal stem cells is an emerging field, especially because this stem cell type appears to be amenable for the treatment of a large number of diseases, such as non-healing bone defects and fractures, inflammatory relief during arthritis, and the repair of suspensory ligament tears. More than that, mesenchymal stem cells provoke effective immune suppression in the context of graft-versus-host disease. Here, we present a comprehensive overview of the recent findings with special attention to age-related changes of mesenchymal stem cell properties and the consequential impact on tissue regeneration and repair, together with the current perception concerning their therapeutic application potential as well as the challenges associated with their clinical use.

Development of in vivo muCT evaluation of neovascularisation in tissue engineered bone constructs

Due to an increasing aging population the need for innovative approaches to aid skeletal repair and reconstruction is a significant socio-economic increasing problem. The emerging discipline of tissue engineering has sort to augment the growth and repair of bone loss particularly in areas of trauma, degeneration and revision surgery. However, the initiation and development of a fully functional vascular network are critical for bioengineered bone to repair large osseous defects, whether the material is osteosynthetic (poly (d,l)-lactic acid, PLA) or natural bone allograft. Quantification and three-dimensional visualization of new vessel networks remain a problem in bone tissue engineering constructs. A novel technique utilising a radio-opaque dye and micro-computed tomography (muCT) has been developed and applied to study angiogenesis in an impaction bone graft model. Tissue-engineered constructs combining human bone marrow stromal cells (HBMSC) with natural allograft and synthetic grafts (PLA) were impacted and implanted into the subcutis of MF-1 nu/nu mice for a period of 28 days. Microfil consisting of radio-opaque polymer was perfused through the mice and scanned using a Bench Top CT system for micro-computed tomography. Analysis of three-dimensional muCT reconstructions demonstrated an increase in vessel volume and vessel number in the impacted scaffolds/HBMC compared to scaffolds alone. Vessel volume: allograft/HBMSC=0.57 mm(3)+/-0.19; allograft=0.04 mm(3)+/-0.04; PLA/HBMSC=1.19 mm(3)+/-0.31; and PLA=0.12 mm(3)+/-0.01. Penetrating vessel number: allograft/HBMSC=22.33+/-3.21; allograft=3.67+/-1.153; PLA/HBMSC=32.67+/-8.33; and PLA=7.67+/-3.06. Type 1 collagen and von Willebrand factor immunohistochemistry in scaffold/HBMSC constructs indicated the osteogenic cell phenotype, and new blood vessel formation respectively. Contrast-enhanced 3D reconstructions facilitated the visualization and quantification of neovascularisation. This novel technique has been used to demonstrate neovascularisation in impacted tissue engineered constructs providing a facile approach with wide experimental application.

Bridging the regeneration gap: stem cells, biomaterials and clinical translation in bone tissue engineering

Advances in our understanding of skeletal stem cells and their role in bone development and repair, offer the potential to open new frontiers in bone regeneration. Tissue engineering seeks to harness the regenerative capacity innate to bone for the replacement of tissue lost or damaged through a broad range of conditions associated with an increasingly aged population. The strategy entails ex vivo expansion of multipotential populations followed by delivery to the site of damage on dynamically durable-biodegradable three-dimensional structures which provide the requisite extracellular microenvironment for stem cell driven tissue development. This review will examine bone stem cell biology, and current advances in skeletal tissue engineering through the enhancement and marrying of biologically informed and clinically relevant strategies.