Regenerative medicine for early osteoarthritis.

The concept of early osteoarthritis (OA) is based on the expectation that if found and treated in the early stage, the progression of the disease might be arrested before affected joints are irreversibly destroyed. This notion of early OA detection can also bear meaning for regenerative medicine (RM) which is purposed to cure a disease by regenerating the damaged tissue. RM can be a category of disease-modifying osteoarthritis drugs (DMOADs) and provide an attractive treatment for OA, restoring structural damage incurred during the disease by repopulating cells and reconstituting. While cell therapy including the use of stem cells is conflated with RM, it may also comprise gene therapy, exosomes, and other cell or cell-free-derived products. Considering that not all early OA will become advanced OA and that RM has a characteristic of personalized medicine, it would be very important to foretell, even roughly, which patients will progress rapidly and who will favorably respond to regenerative treatment. Subclassification and comprehensive endotyping or phenotyping (E/P) can be very helpful in detecting the population who would benefit from RM as well as rapid progressors who need closer monitoring.

GSTT1 as a Predictive Marker and Enhancer for Osteogenic Potential of Human Adipose-Derived Stromal/Stem Cells.

Adipose-derived stromal/stem cells (ASCs) have been extensively studied as cell sources for regenerative medicine for bone because of their excellent proliferative capacity and the ability to obtain a large number of cells with minimal donor morbidity. On the other hand, the differentiation potential of ASCs is generally lower than that of bone marrow-derived stromal/stem cells and varies greatly depending on donors. In this study, we mined a marker that can predict the osteogenic potential of ASC clones and also investigated the usefulness of the molecule as the enhancer of osteogenic differentiation of ASCs as well as its mechanism of action. Through RNA-seq gene analysis, we discovered that GSTT1 (Glutathione S-transferase theta-1) was the most distinguished gene marker between highly osteogenic and poorly osteogenic ASC clones. Knockdown of GSTT1 in high osteogenic ASCs by siGSTT1 treatment reduced mineralized matrix formation. On the other hand, GSTT1 overexpression by GSTT1 transfection or GSTT1 recombinant protein treatment enhanced osteogenic differentiation of low osteogenic ASCs. Metabolomic analysis confirmed significant changes of metabolites related to bone differentiation in ASCs transfected with GSTT1. A high total antioxidant capacity, low levels of cellular reactive oxygen species, and increased GSH/GSSG ratios were also detected in GSTT1-transfected ASCs. When the in vivo effect of GSTT1-transfected ASCs on bone regeneration was investigated with segmental long-bone defect model in rats, bone regeneration was significantly better after implantation of GSTT1-transfected ASCs compared with that of control vector-transfected ASCs. In conclusion, GSTT1 can be a useful marker to screen the highly osteogenic ASC clones and also a therapeutic factor to enhance the osteogenic differentiation of poorly osteogenic ASC clones. © 2023 American Society for Bone and Mineral Research (ASBMR).

Regenerative medicine for osteonecrosis of the femoral head : present and future.

Cite this article: Bone Joint Res 2023;12(1):5-8.

Metabolic Switch Under Glucose Deprivation Leading to Discovery of NR2F1 as a Stimulus of Osteoblast Differentiation.

Poor survival of grafted cells is the major impediment of successful cell-based therapies for bone regeneration. Implanted cells undergo rapid death in an ischemic environment largely because of hypoxia and metabolic stress from glucose deficiency. Understanding the intracellular metabolic processes and finding genes that can improve cell survival in these inhospitable conditions are necessary to enhance the success of cell therapies. Thus, the purpose of this study was to investigate changes of metabolic profile in glucose-deprived human bone marrow stromal/stem cells (hBMSCs) through metabolomics analysis and discover genes that could promote cell survival and osteogenic differentiation in a glucose-deprived microenvironment. Metabolomics analysis was performed to determine metabolic changes in a glucose stress metabolic model. In the absence of glucose, expression levels of all metabolites involved in glycolysis were significantly decreased than those in a glucose-supplemented state. In glucose-deprived osteogenic differentiation, reliance on tricarboxylic acid cycle (TCA)-predicted oxidative phosphorylation instead of glycolysis as the main mechanism for energy production in osteogenic induction. By comparing differentially expressed genes between glucose-deprived and glucose-supplemented hBMSCs, NR2F1 (Nuclear Receptor Subfamily 2 Group F Member 1) gene was discovered to be associated with enhanced survival and osteogenic differentiation in cells under metabolic stress. Small, interfering RNA (siRNA) for NR2F1 reduced cell viability and osteogenic differentiation of hBMSCs under glucose-supplemented conditions whereas NR2F1 overexpression enhanced osteogenic differentiation and cell survival of hBMSCs in glucose-deprived osteogenic conditions via the protein kinase B (AKT)/extracellular signal-regulated kinase (ERK) pathway. NR2F1-transfected hBMSCs significantly enhanced new bone formation in a critical size long-bone defect of rats compared with control vector-transfected hBMSCs. In conclusion, the results of this study provide an understanding of the metabolic profile of implanted cells in an ischemic microenvironment and demonstrate that NR2F1 treatment may overcome this deprivation by enhancing AKT and ERK regulation. These findings can be utilized in regenerative medicine for bone regeneration. © 2022 American Society for Bone and Mineral Research (ASBMR).

The Concept of Early Osteoarthritis and Its Significance in Regenerative Medicine.

Osteoarthritis (OA) has been investigated as one of important target diseases for regenerative medicine. The concept of early OA has recently emerged under the assumption that if OA is detected and intervened early, progression of OA might be arrested or delayed before irreversible destruction of the joint occurs. This concept also matters in regenerative medicine for OA because new regenerative technologies can work better when joint damage is minimal. Diagnostic criteria for early OA have been suggested in this background to find a group of patients who have a higher possibility of developing full-blown OA. However, as currently suggested criteria of early OA are mostly expert opinions lacking higher level of evidence, clinical validations are necessary to prove their value in patient care. While new treatment methods that can suppress or prevent symptoms at an early stage of OA before progressive and irreversible changes occur are being developed, detailed definition and classification of early OA agreed upon by major stakeholders in OA field and validated by prospective studies are necessary to prove the efficacy of these methods. As clinical outcome of regenerative treatment is related to patient characteristics and the status of the whole joint, it is of critical significance to predict which patient will progress and who will be responsive to regenerative treatment. While diagnostic criteria for early OA should be highly sensitive and applicable without employing biomarkers or magnetic resonance imaging, a subclassification and comprehensive endotyping /phenotyping using these techniques might be needed to detect the population who would be responsive to regenerative medicine.

Cut-out risk factor analysis after intramedullary nailing for the treatment of extracapsular fractures of the proximal femur: a retrospective study.

BACKGROUNDS: The basic method of surgical treatment for extracapsular hip fractures (ECFs), including intertrochanteric fracture and basicervical fracture (BCF), is osteosynthesis. Intramedullary nails are among the most commonly used fixation devices for these fractures. Our study aimed to report the clinical outcomes of ECF treatment with two different nail devices and to analyze the risk factors associated with screw cut-out. METHODS: We retrospectively reviewed the medical records of 273 patients (300 cases) from a single institution who underwent surgical treatment for ECF between January 2013 and October 2018. Overall, 138 patients were eligible for the study and were divided into two groups according to the osteosynthesis device used. We evaluated the clinical outcomes of fracture surgery and performed univariate and multivariate regression analyses to identify risk factors associated with screw cut-out in each group. RESULTS: We used proximal femoral nails (group 1) to treat 83 patients and cephalomedullary nails (group 2) to treat 55 patients. Nine cut-outs (group 1, 6 cases; group 2, 3 cases) occurred during follow-up. The patients' high body mass index (BMI) (p = 0.019), BCFs (p = 0.007), non-extramedullary reduction in the anteroposterior and lateral planes (p = 0.032 and p = 0.043, respectively), and anti-rotation screw pull-outs (p = 0.041) showed a positive correlation to screw cut-out in the univariate analysis of group 1. In group 2, only BCFs was positively correlated (p = 0.020). In the multivariate analysis of group 1, the patients' BMIs (p = 0.024) and BCFs (p = 0.024) showed a positive correlation with cut-out. Meanwhile, the multivariate analysis of group 2 did not identify any factors associated with cut-out. CONCLUSIONS: The cut-out risk was significantly higher in the BCF cases, regardless of the nail design used. Considerable attention should be paid to treating such unstable fractures. We expect that new-generation nails using a helical blade, or interlocking derotation and interlocking screws may improve surgical outcomes.

Emerging Concepts of Endotypes/Phenotypes in Regenerative Medicine for Osteoarthritis.

Osteoarthritis (OA) represents a broad spectrum of different conditions. Our present understanding of phenotypes and endotypes can explain the differences in clinical manifestations, etiology, and underlying pathophysiology. Although this concept was first applied in choosing the right target population for clinical trials of disease-modifying osteoarthritis drugs (DMOADs), given that the regenerative medicine so far has not delivered uniformly successful results in structural improvement in OA, it merits a consideration to introduce the concept of phenotype/endotype in the regenerative medicine for OA toward an effort to find the right patients for these expensive therapeutics. A better understanding of molecular endotypes facilitates defining clinical phenotypes more clearly. Based on this knowledge, these patients may respond better to treatments that can preserve joints, including regenerative medicine. On the other hand, patients who are not expected to benefit from these treatments may receive earlier total joint replacement surgery. This will result in a reduction of healthcare costs, as well as a more effective approach to new drug development. An understanding of phenotypes/endotypes will contribute to the selection of suitable patients for regenerative treatment of OA.

Cell-Membrane-Derived Nanoparticles with Notch-1 Suppressor Delivery Promote Hypoxic Cell-Cell Packing and Inhibit Angiogenesis Acting as a Two-Edged Sword.

Cell-cell interactions regulate intracellular signaling via reciprocal contacts of cell membranes in tissue regeneration and cancer growth, indicating a critical need of membrane-derived tools in studying these processes. Hence, cell-membrane-derived nanoparticles (CMNPs) are produced using tonsil-derived mesenchymal stem cells (TMSCs) from children owing to their short doubling time. As target cell types, laryngeal cancer cells are compared to bone-marrow-derived MSCs (BMSCs) because of their cartilage damaging and chondrogenic characteristics, respectively. Treating spheroids of these cell types with CMNPs exacerbates interspheroid hypoxia with robust maintenance of the cell-cell interaction signature for 7 days. Both cell types prefer a hypoxic environment, as opposed to blood vessel formation that is absent in cartilage but is required for cancer growth. Hence, angiogenesis is inhibited by displaying the Notch-1 aptamer on CMNPs. Consequently, laryngeal cancer growth is suppressed efficiently in contrast to improved chondroprotection observed in a series of cell and animal experiments using a xenograft mouse model of laryngeal cancer. Altogether, CMNPs execute a two-edged sword function of inducing hypoxic cell-cell packing, followed by suppressing angiogenesis to promote laryngeal cancer death and chondrogenesis simultaneously. This study presents a previously unexplored therapeutic strategy for anti-cancer and chondroprotective treatment using CMNPs.

Methyltransferase-like protein 7A (METTL7A) promotes cell survival and osteogenic differentiation under metabolic stress.

While bone has an inherent capacity to heal itself, it is very difficult to reconstitute large bone defects. Regenerative medicine, including stem cell implantation, has been studied as a novel solution to treat these conditions. However, when the local vascularity is impaired, even the transplanted cells undergo rapid necrosis before differentiating into osteoblasts and regenerating bone. Thus, to increase the effectiveness of stem cell transplantation, it is quintessential to improve the viability of the implanted stem cells. In this study, given that the regulation of glucose may hold the key to stem cell survival and osteogenic differentiation, we investigated the molecules that can replace the effect of glucose under ischemic microenvironment of stem cell transplantation in large bone defects. By analyzing differentially expressed genes under glucose-supplemented and glucose-free conditions, we explored markers such as methyltransferase-like protein 7A (METTL7A) that are potentially related to cell survival and osteogenic differentiation. Overexpression of METTL7A gene enhanced the osteogenic differentiation and viability of human bone marrow stem cells (hBMSCs) in glucose-free conditions. When the in vivo effectiveness of METTL7A-transfected cells in bone regeneration was explored in a rat model of critical-size segmental long-bone defect, METTL7A-transfected hBMSCs showed significantly better regenerative potential than the control vector-transfected hBMSCs. DNA methylation profiles showed a large difference in methylation status of genes related to osteogenesis and cell survival between hBMSCs cultured in glucose-supplemented condition and those cultured in glucose-free condition. Interestingly, METTL7A overexpression altered the methylation status of related genes to favor osteogenic differentiation and cell survival. In conclusion, it is suggested that a novel factor METTL7A enhances osteogenic differentiation and viability of hBMSCs by regulating the methylation status of genes related to osteogenesis or survival.

Current status of regenerative medicine in osteoarthritis.

The high prevalence of osteoarthritis (OA), as well as the current lack of disease-modifying drugs for OA, has provided a rationale for regenerative medicine as a possible treatment modality for OA treatment. In this editorial, the current status of regenerative medicine in OA including stem cells, exosomes, and genes is summarized along with the author's perspectives. Despite a tremendous interest, so far there is very little evidence proving the efficacy of this modality for clinical application. As symptomatic relief is not sufficient to justify the high cost associated with regenerative medicine, definitive structural improvement that would last for years or decades and obviate or delay the need for joint arthroplasty is essential for regenerative medicine to retain a place among OA treatment methods. Cite this article: Bone Joint Res 2021;10(2):134-136.

Osteoarthritis Research Society International (OARSI): Past, present and future.

We provide a detailed account of the origin and establishment of the Osteoarthritis Research Society International (OARSI) and celebrate its history from inception to the current day. We discuss the mission, vision and strategic objectives of OARSI and how these have developed and evolved over the last 3 decades. We celebrate the achievements of the society as we approach its 30th birthday, honor the entire presidential line and respectfully pay tribute to the past presidents who are no longer with us. We reflect on the strong foundations of our society, OARSI's efforts to disseminate understanding of the health, disability and economic burdens of osteoarthritis (OA) to policymakers, and the exciting initiatives to make the society inclusive and international. We thank our corporate and industrial sponsors, who have supported us over many years, without whom our annual congresses would not have been possible. We celebrate our longstanding strategic partnership with our publisher, Elsevier, and the successful launch of our new journal Osteoarthritis and Cartilage Open, the most significant new development in our dissemination toolbox. For the first time in the history of the organization, our annual congress was cancelled in April 2020 and the 2021 meeting will be virtual. Despite the numerous challenges posed by the ongoing COVID-19 pandemic and the need to adapt quickly to a rapidly changing landscape, we must remain optimistic about the future. We will take advantage of new exciting opportunities to advance our mission and vision to enhance the quality of life of persons with OA.

Characterization of adipose-derived stromal/stem cell spheroids versus single-cell suspension in cell survival and arrest of osteoarthritis progression.

The current study evaluated the hypothesis that the administration of spheroidal adipose-derived stromal/stem cells (ASCs) promotes cell survival and arrests the progression of surgically induced osteoarthritis (OA) in a rat model. We also tested the optimal conditions for spheroid production from ASCs using microwell methods. The formation of ASC spheroids was optimized at a well diameter of 600 µm under cell concentrations of 106 cell/ml. When ASC spheroids cultured in 3D were compared with ASCs cultured in 2D monolayer, the cell survival and chondrogenic potential were enhanced while the apoptosis was reduced in ASC spheroids compared with ASCs in 2D monolayer culture. In vivo tracking of fluorescently labeled ASCs in the knee joints of rats with surgically induced OA showed longer fluorescent activity at a higher intensity in ASC spheroids than in ASC single-cell suspension. When OA-induced rats treated with ASC injection were sacrificed after 8 weeks, the OARSI score was enhanced in both ASC single-cell suspension and ASC spheroids compared with negative control, spheroid treatment resulting in a better score than single-cell treatment. However, injected cells were not detectable from the joints. These finding altogether suggests that ASC spheroids have better in vitro and in vivo survival and chondrogenic potential and exert greater regenerative effects for articular cartilage and arrest the progression of surgically induced OA better than ASCs in single-cell suspension by the paracrine mode of action. The study findings support the notion of developing cell therapeutics to treat OA based on ASC spheroid forms.

Stem Cells for the Regeneration of Tendon and Ligament: A Perspective.

Tendons are structures that connect muscles to the bones in our body and transmit the force generated by contraction of the muscles to the bones. Ligaments are structures that connect bones to bones, with histological properties similar to tendons. In tendon and ligament tissue, there are very small amounts of cells similar to mesenchymal stem cells (MSCs) called tendon stem/progenitor cells (TSPCs), or tenogenic stem cells. While the role of specific growth factors and transcription factors is well established in the osteogenic and chondrogenic differentiation of stem cells, a consensus has not been established for tenogenic differentiation. Injuries to tendons and ligaments are very common, but natural healing is very slow and inefficient due to limited vascularization. Currently, there is no adequate method for restoring extensive tendon or ligament defects. Procedures addressing the unmet need for regeneration of these tissues are needed. In this review, the current knowledge, as well as the authors' ideas and perspective on stem cell and regenerative medicine for tendon and ligament defects are presented.

Overcoming Current Dilemma in Cartilage Regeneration: Will Direct Conversion Provide a Breakthrough?

Direct reprogramming/direct conversion/transdifferentiation is a process that induces conversion between completely different matured (differentiated) cells in higher organisms. Unlike the process of reprogramming of differentiated cells into induced pluripotent stem cells (iPSCs) and re-differentiation into the desired cell types, differentiated cells undergo the conversion into another type of differentiated cells without going through the iPSCs state. Osteoarthritis (OA) is the most common type of arthritis that causes a significant deterioration in patients' quality of life. The high prevalence of OA as well as the current lack of disease-modifying drugs has led to a rise in regenerative strategy for OA treatment. Regenerative therapy in OA started with the concept of engraftment of the administered cells within the cartilage lesion and differentiation to chondrocytes after the engraftment. However, recent studies show that cells, particularly when injected in suspension, rapidly undergo apoptosis after exerting a transient paracrine effect. In this perspective review, the general overview and current status of direct conversion are introduced along with the conceptual strategy and future directions for possible application of regenerative therapy using stem cells in OA. In vivo direct conversion may open a new stage of regenerative medicine for OA treatment. Recent advances in in vivo gene transfer and smart biomaterials can bring the concept into reality in near future. Direct conversion can be a new type of treatment technology that has the potential to overcome the limitations of current cell therapy.

Regenerative Therapy for Osteoarthritis: A Perspective.

Osteoarthritis (OA) is the most common type of arthritis and causes a significant deterioration in patients' quality of life. The high prevalence of OA as well as the current lack of disease-modifying drugs led to a rise in regenerative medicine efforts. The hope is that this will provide a treatment modality with the ability to alter the course of OA via structural modifications of damaged articular cartilage (AC). Regenerative therapy in OA starts with the concept that administered cells may engraft to a lesion site and differentiate into chondrocytes. However, recent studies show that cells, particularly when injected in suspension, rapidly undergo apoptosis after exerting a transient paracrine effect. If the injected stem cells do not lead to structural improvements of a diseased joint, the high cost of cell therapy for OA cannot be justified, particularly when compared with other injection therapeutics such as corticosteroids and hyaluronic acid. Long-term survival of implanted cells that offer prolonged paracrine effects or possible engraftment is essential for a successful cell therapy that will offer durable structural improvements. In this perspective review, the history and current status of regenerative therapy in OA are summarized along with the conceptual strategy and future directionsfor a successful regenerative therapy that can provide structural modifications in OA.

KLF10 is a modulatory factor of chondrocyte hypertrophy in developing skeleton.

To define the functional role of Krüppel-like factor (KLF) 10 as a modulator of chondrocyte hypertrophy in developing skeleton, the developmental features in the long bone of KLF10 knockout (KO) mice were investigated and the mesenchymal stem cells (MSCs) from KLF10 KO mice were characterized regarding chondrogenesis and osteogenesis. Delayed long bone growth and delayed formation of primary ossification center were observed in an early embryonic stage in KLF10 KO mouse along with very low Indian hedgehog expression in epiphyseal plate. While the chondrogenic potential of mouse MSCs from KLF10 KO mice appeared normal or slight decreased, hypertrophy and osteogenesis were extensively suppressed. These findings suggest that KLF10 is a mediator of chondrocyte hypertrophy in developing skeleton, and that suppression of KLF10 may be employed as a new strategy for preventing hypertrophy in cartilage regeneration using MSCs.

Hydrogel cross-linking-programmed release of nitric oxide regulates source-dependent angiogenic behaviors of human mesenchymal stem cell.

Angiogenesis is stimulated by nitric oxide (NO) production in endothelial cells (ECs). Although proangiogenic actions of human mesenchymal stem cells (hMSCs) have been extensively studied, the mechanistic role of NO in this action remains obscure. Here, we used a gelatin hydrogel that releases NO upon crosslinking by a transglutaminase reaction ("NO gel"). Then, the source-specific behaviors of bone marrow versus adipose tissue-derived hMSCs (BMSCs versus ADSCs) were monitored in the NO gels. NO inhibition resulted in significant decreases in their angiogenic activities. The NO gel induced pericyte-like characteristics in BMSCs in contrast to EC differentiation in ADSCs, as evidenced by tube stabilization versus tube formation, 3D colocalization versus 2D coformation with EC tube networks, pericyte-like wound healing versus EC-like vasculogenesis in gel plugs, and pericyte versus EC marker production. These results provide previously unidentified insights into the effects of NO in regulating hMSC source-specific angiogenic mechanisms and their therapeutic applications.

Biomaterials in orthopaedics: the past and future with immune modulation.

Orthopaedics owes its current status of advanced care to the development of biomaterial science more than any other clinical medical specialty. The purpose of this brief review is to introduce the history and present status of biomaterials in orthopaedic field and cast a perspective on the future use of biomaterials to treat musculoskeletal disorders with particular emphasis on immune modulation. While the biomaterials in orthopaedics started from inert materials to replace the function and structure of hard tissue such as bone and cartilage, regenerative medicine will play a greater role in preventing the traumatic loss of tissues, as well as in the earlier stages of diseases. The understanding and modulation of immune response to biomaterials will further lead to the better incorporation of implants into host tissue or the near-perfect regeneration of host tissue.

Interleukin-4 Gene Transfection and Spheroid Formation Potentiate Therapeutic Efficacy of Mesenchymal Stem Cells for Osteoarthritis.

Osteoarthritis (OA) is a painful intractable disease that significantly affects patients' quality of life. However, current therapies, such as pain killers and joint replacement surgery, do not lead to cartilage protection. Mesenchymal stem cells (MSCs) have been proposed as an alternative strategy for OA therapy because MSCs can secrete chondroprotective and anti-inflammatory factors. However, interleukin-4 (IL-4), a potent anti-inflammatory cytokine, is barely produced by MSCs, and MSC therapy suffers from rapid MSC death following intra-articular implantation. MSCs in spheroids survive better than naïve MSCs in vitro and in vivo. IL-4-transfected MSCs in spheroids (IL-4 MSC spheroid) show increased chondroprotective and anti-inflammatory effects in an OA chondrocyte model in vitro. Following intra-articular implantation in OA rats, IL-4 MSC spheroids show better cartilage protection and pain relief than naïve MSCs. Thus, IL-4 MSC spheroid may potentiate the therapeutic efficacy of MSCs for OA.

Multi-Disciplinary Approaches for Cell-Based Cartilage Regeneration.

Articular cartilage does not regenerate in adults. A lot of time and resources have been dedicated to cartilage regeneration research. The current understanding suggests that multi-disciplinary approach including biologic, genetic, and mechanical stimulations may be needed for cell-based cartilage regeneration. This review summarizes contents of a workshop sponsored by International Combined Orthopaedic Societies during the 2019 annual meeting of the Orthopaedic Research Society held in Austin, Texas. Three approaches for cell-based cartilage regeneration were introduced, including cellular basis of chondrogenesis, gene-enhanced cartilage regeneration, and physical modulation to divert stem cells to chondrogenic cell fate. While the complicated nature of cartilage regeneration has not allowed us to achieve successful regeneration of hyaline articular cartilage so far, the utilization of multi-disciplinary approaches in various fields of biomedical engineering will provide means to achieve this goal faster. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:463-472, 2020.