Cartilage repair in the knee with subchondral drilling augmented with a platelet-rich plasma-immersed polymer-based implant.

PURPOSE: The aim of our study was to analyse the clinical and histological outcome after the treatment of focal cartilage defects in non-degenerative and degenerative knees with bone marrow stimulation and subsequent covering with a cell-free resorbable polyglycolic acid-hyaluronan (PGA-HA) implant immersed with autologous platelet-rich plasma (PRP). METHODS: Fifty-two patients (mean age 44 years) with focal chondral defects in radiologically confirmed non-degenerative or degenerative knees were subjected to subchondral drilling arthroscopically. Subsequently, defects were covered with the PGA-HA implant immersed with autologous PRP. At 2-year follow-up, the patients' situation was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and compared to the pre-operative situation and 3-12-month follow-up. Biopsies (n = 4) were harvested at 18-24 months after implantation and were analysed by histology and collagen type II immune staining. RESULTS: At 1- and 2-year follow-up, the KOOS showed clinically meaningful and significant (p < 0.05) improvement in all subcategories compared to baseline and to 3-month follow-up. There were no differences in KOOS data obtained after 2 years compared to 1 year after the treatment. Histological analysis of the biopsy tissue showed hyaline-like to hyaline cartilage repair tissue that was rich in cells with a chondrocyte morphology, proteoglycans and type II collagen. CONCLUSIONS: Covering of focal cartilage defects with the PGA-HA implant and PRP after bone marrow stimulation improves the patients' situation and has the potential to regenerate hyaline-like cartilage. LEVEL OF EVIDENCE: Case series, Level IV.

A cell-free scaffold-based cartilage repair provides improved function hyaline-like repair at one year.

BACKGROUND: Bone marrow stimulation techniques in cartilage repair such as drilling are limited by the formation of fibrous to hyaline-like repair tissue. It has been suggested such techniques can be enhanced by covering the defect with scaffolds. We present an innovative approach using a polyglycolic acid (PGA)-hyaluronan scaffold with platelet-rich-plasma (PRP) in drilling. QUESTIONS/PURPOSES: We asked whether (1) PRP immersed in a cell-free PGA-hyaluronan scaffold improves patient-reported 1-year outcomes for the Knee injury and Osteoarthritis Score (KOOS), and (2) implantation of the scaffold in combination with bone marrow stimulation leads to the formation of hyaline-like cartilage repair tissue. PATIENTS AND METHODS: We reviewed 52 patients who had arthroscopic implantation of the PGA-hyaluronan scaffold immersed with PRP in articular cartilage defects of the knee pretreated with Pridie drilling. Patients were assessed by KOOS. At 9 months followup, histologic staining was performed in specimens obtained from five patients to assess the repair tissue quality. RESULTS: The KOOS subscores improved for pain (55 to 91), symptoms (57 to 88), activities of daily living (69 to 86), sports and recreation (36 to 70), and quality of life (38 to 73). The histologic evaluation showed a homogeneous hyaline-like cartilage repair tissue. CONCLUSIONS: The cell-free PGA-hyaluronan scaffold combined with PRP leads to cartilage repair and improved patient-reported outcomes (KOOS) during 12 months of followup. Histologic sections showed morphologic features of hyaline-like repair tissue. Long-term followup is needed to determine if the cartilage repair tissue is durable. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Osteogenic differentiation of human mesenchymal stromal cells on surface-modified titanium alloys for orthopedic and dental implants.

PURPOSE: Surface properties of titanium alloys, used for orthopedic and dental applications, are known to affect implant interactions with host tissues. Osteointegration, bone growth and remodeling in the area surrounding the implants can be implemented by specific biomimetic treatments; these allow the preparation of micro/nanostructured titanium surfaces with a thickened oxide layer, doped with calcium and phosphorus ions. We have challenged these experimental titanium alloys with primary human bone marrow stromal cells to compare the osteogenic differentiation outcomes of the cells once they are seeded onto the modified surfaces, thus simulating a prosthetic device-biological interface of clinical relevance. METHODS: A specific anodic spark discharge was the biomimetic treatment of choice, providing experimental titanium disks treated with different alkali etching approaches. The disks, checked by electron microscopy and spectroscopy, were subsequently used as substrates for the proliferation and osteogenic differentiation of human cells. Expression of markers of the osteogenic lineage was assessed by means of qualitative and quantitative PCR, by cytochemistry, immunohistochemistry, Western blot and matrix metalloprotease activity analyses. RESULTS: Metal surfaces were initially less permissive for cell growth. Untreated control substrates were less efficient in sustaining mineralized matrix deposition upon osteogenic induction of the cells. Interestingly, bone sialo protein and matrix metalloprotease 2 levels were enhanced on experimental metals compared to control surfaces, particularly for titanium oxide coatings etched with KOH. DISCUSSION: As a whole, the KOH-modification of titanium surfaces seems to allow the best osteogenic differentiation of human mesenchymal stromal cells, representing a possible plus for future clinical prosthetic applications.

DLX5 overexpression impairs osteogenic differentiation of human bone marrow stromal cells.

The transcription factor DLX5 belongs to a family of homeoproteins required for craniofacial morphogenesis and forebrain development. DLX5 is expressed during formation of several skeletal elements such as cartilage, teeth and bone, and its knockout causes severe craniofacial malformations with a delay in the ossification process. Bone marrow contains mesenchymal progenitor cells which may differentiate along multiple pathways, therefore representing an interesting in vitro and in vivo model to study the mesodermal lineage differentiation. Here we report the effect of DLX5 overexpression in ex vivo expanded human bone marrow stromal cells by retroviral infection on the osteogenic lineage differentiation. A reduced mineral deposition was observed in DLX5-transduced cells upon osteogenic induction in culture. When DLX5-transduced cells were implanted in immunodeficient mice, a 60% reduction in bone matrix deposition was observed, whereas the in vitro chondrogenic potential was unaffected. A quantitative gene expression study indicated that DLX5 overexpression does not affect the early osteogenic commitment of bone marrow stromal cells but prevents their terminal differentiation. This block may be mediated by the observed persistent expression of SOX2, a transcription factor known to inhibit osteogenic differentiation.

Electrospun silk fibroin fibers for storage and controlled release of human platelet lysate.

Human platelet lysate (hPL) is a pool of growth factors and cytokines able to induce regeneration of different tissues. Despite its good potentiality as therapeutic tool for regenerative medicine applications, hPL has been only moderately exploited in this field. A more widespread adoption has been limited because of its rapid degradation at room temperature that decreases its functionality. Another limiting factor for its extensive use is the difficulty of handling the hPL gels. In this work, silk fibroin-based patches were developed to address several points: improving the handling of hPL, enabling their delivery in a controlled manner and facilitating their storage by creating a device ready to use with expanded shelf life. Patches of fibroin loaded with hPL were synthesized by electrospinning to take advantage of the fibrous morphology. The release kinetics of the material was characterized and tuned through the control of fibroin crystallinity. Cell viability assays, performed with primary human dermal fibroblasts, demonstrated that fibroin is able to preserve the hPL biological activity and prolong its shelf-life. The strategy of storing and preserving small active molecules within a naturally-derived, protein-based fibrous scaffold was successfully implemented, leading to the design of a biocompatible device, which can potentially simplify the storage and the application of the hPL on a human patient, undergoing medical procedures such as surgery and wound care. STATEMENT OF SIGNIFICANCE: Human platelets lysate (hPL) is a mixture of growth factors and cytokines able to induce the regeneration of damaged tissues. This study aims at enclosing hPL in a silk fibroin electrospun matrix to expand its utilization. Silk fibroin showed the ability to preserve the hPL activity at temperature up to 60 °C and the manipulation of fibroin's crystallinity provided a tool to modulate the hPL release kinetic. This entails the possibility to fabricate the hPL silk fibroin patches in advance and store them, resulting in an easy and fast accessibility and an expanded use of hPL for wound healing.

Platelet-rich plasma-based bioactive membrane as a new advanced wound care tool.

Chronic skin ulcers, consequence of diabetes and other pathological conditions, heavily compromise the patient life quality and represent a high and constantly growing cost for National Health Services. Autologous platelet-rich plasma (PRP), has been proposed to treat these lesions. The absence of guidelines for the PRP production and the need of a fresh preparation for each treatment lead us to develop a protocol for the production of an allogenic PRP-based bioactive membrane (BAM), standardized for platelet concentration and growth factor release. This work compares BAMs obtained starting from two different platelet concentrations. There was no direct correlation between the amount of growth factors released by BAM in vitro and the initial platelet count. However, different release kinetics were noticed for different growth factors, suggesting that they were differently retained by the two BAMs. The angiogenic potential of both BAMs was determined by Luminex Angiogenesis Assay. The biological activity of the factors released by the two BAMs was confirmed by cell proliferation and migration. A diabetic mouse chronic ulcer model was used to define the best PRP therapeutic dose in vivo. Both BAMs induced wound healing by increasing the thickness of the regenerated epidermis and the vessel number. However, a too high platelet concentration resulted in a slowdown of the membrane resorption that interfered with the skin healing. Overall, the results indicate that the BAMs could represent a natural and effective wound healing tool for the treatment of skin ulcers. Copyright © 2016 John Wiley & Sons, Ltd.

A tissue engineering approach to bone repair in large animal models and in clinical practice.

The repair of large segmental bone defects due to trauma, inflammation and tumor surgery remains a major clinical problem. Animal models were developed to test bone repair by tissue engineering approaches, mimicking real clinical situations. Studies differed with regard to animals (dog, sheep, goat), treated bone (femur, tibia, mandible), chemistry and structure of the scaffolds. Still, an advantage in the bone formation and in the healing of the segmental defect was always observed when scaffolds were seeded with bone marrow derived stromal cells (BMSCs). In the year 1998 was performed the first implantation of a porous ceramic construct in a bone segmental defect of a patient; it was the first construct seeded with cultured autologous osteogenic cells. Since then, only few other similar cases were treated by the same approach. However, in other fields, such as oral and maxillofacial surgery, injectable cells/platelet-rich plasma composites have been used as grafting materials for maxillary sinus floor augmentation and/or onlay plasty. More recently, the reconstruction of a human mandible was also reported by means of a bone-muscle-flap in vivo prefabrication technique, where the patient served as his own bioreactor. Indeed continuous implementations test and provide new means of defects treatment and cure. However, based on results so far obtained in animal models and pilot clinical studies, one can affirm that the bone tissue engineering approaches, although successful in most cases, need further validation before a wide application in clinics. In particular, the supply of oxygen and nutrients to the cells in the inner part of the implanted scaffolds remains a major concern, requiring additional investigations.

Stem cells associated with macroporous bioceramics for long bone repair: 6- to 7-year outcome of a pilot clinical study.

Extensive bone loss is still a major problem in orthopedics. A number of different therapeutic approaches have been developed and proposed, but so far none have proven to be fully satisfactory. We used a new tissue engineering approach to treat four patients with large bone diaphysis defects and poor therapeutic alternatives. To obtain implantable three-dimensional (3D) living constructs, cells isolated from the patients' bone marrow stroma were expanded in culture and seeded onto porous hydroxyapatite (HA) ceramic scaffolds designed to match the bone deficit in terms of size and shape. During the surgical session, an Ilizarov apparatus or a monoaxial external fixator was positioned on the patient's affected limb and the ceramic cylinder seeded with cells was placed in the bone defect. Patients were evaluated at different postsurgery time intervals by conventional radiographs and computed tomography (CT) scans. In one patient, an angiographic evaluation was performed at 6.5 years follow-up. In this study we analyze the long-term outcome of these patients following therapy. No major complications occurred in the early or late postoperative periods, nor were major complaints reported by the patients. No signs of pain, swelling, or infection were observed at the implantation site. Complete fusion between the implant and the host bone occurred 5 to 7 months after surgery. In all patients at the last follow-up (6 to 7 years postsurgery in patients 1 to 3), a good integration of the implants was maintained. No late fractures in the implant zone were observed. The present study shows the long-term durability of bone regeneration achieved by a bone engineering approach. We consider the obtained results very promising and propose the use of culture-expanded osteoprogenitor cells in conjunction with porous bioceramics as a real and significant improvement in the repair of critical-sized long bone defects.

Role of scaffold internal structure on in vivo bone formation in macroporous calcium phosphate bioceramics.

Purpose of this study was the analysis of the role of density and pore interconnection pathway in scaffolds to be used as bone substitutes. We have considered 2 hydroxyapatite bioceramics with identical microstructure and different macro-porosity, pore size distribution and pore interconnection pathway. The scaffolds were obtained with two different procedures: (a) sponge matrix embedding (scaffold A), and (b) foaming (scaffold B). Bone ingrowth within the two bioceramics was obtained using an established model of in vivo bone formation by exogenously added osteoprogenitor cells. The histological analysis of specimens at different time after in vivo implantation revealed in both materials a significant extent of bone matrix deposition. Interestingly enough, scaffold B allowed a faster occurrence of bone tissue, reaching a steady state as soon as 4 weeks. Scaffold A on the other hand reached a comparable level of bone formation only after 8 weeks of in vivo implantation. Both scaffolds were well vascularised, but larger blood vessels were observed in scaffold A. Here we show that porosity and pore interconnection of osteoconductive scaffolds can influence the overall amount of bone deposition, the pattern of blood vessels invasion and finally the kinetics of the bone neoformation process.

Reconstruction of extensive long bone defects in sheep using resorbable bioceramics based on silicon stabilized tricalcium phosphate.

In this study we evaluated the performance of Skelite, a resorbable bioceramic based on silicon stabilized tricalcium phosphate (Si-TCP), in promoting the repair of a large-sized, experimentally induced defect in a weight-bearing long bone sheep model. Eighteen 2-year-old ewes were used in this study. Animals were sacrificed at 3, 6, and 12 months. One animal entered a very prolonged followup and was sacrificed 2 years after surgery. Bone formation and scaffold resorption were evaluated by sequential x-ray studies, CT scans, histology, immunohistology, microradiography, and quantitative analysis of x-ray studies (optical density) and microradiographs (percentage of bone and scaffold area). Our data show an excellent implant integration and significant bone regeneration within the bone substitute over the course of the experiment. Progressive osteoclastic resorption of the biomaterial was also evident. At 1 year from surgery, the remaining scaffold was approximately 10-20% of the scaffold initially implanted, while after 2 years it was essentially completely resorbed. At the end of the observation period, the segmental defect was filled with newly formed, highly mineralized, lamellar bone.

Bone marrow stromal cells and their use in regenerating bone.

Tissue engineering approaches have recently been devised to repair large bone losses. Tissue engineering takes advantages of the combined use of cultured living cells and 3D scaffolds to deliver vital cells to the damaged site of the patient. Cultured bone marrow stromal cells (BMSCs) can be regarded as a mesenchymal progenitor/precursor cell population derived from adult stem cells. When implanted in immunodeficient mice, BMSCs combined with mineralized 3D scaffolds to form a primary bone tissue that is highly vascularized. We have used autologous BMSC/bioceramic composites to treat full-thickness gaps of tibial diaphysis in sheep. The healing process has been investigated. The sequence of events is as follows: (1) bone formation on the outer surface of the implant; (2) bone formation in the inner cylinder canal; (3) formation of fissures and cracks in the implant body; (4) bone formation in the bioceramic pores. Similar composites whose size and shape reflected each bone defect have been implanted at the lesion sites of three patients. External fixation was used. Patients have been followed for more than three years. The results obtained are very promising and we propose the use of culture-expanded osteoprogenitor cells in conjunction with hydroxyapatite bioceramics as a significant improvement in the repair of critical size long bone defects.

Extracellular matrix deposition and scaffold biodegradation in an in vitro three-dimensional model of bone by X-ray computed microtomography.

The development of an in vitro model of bone and the optimization of tools for determining the biological processes occurring during bone repair remains a major goal in the field of bone tissue engineering. Recently, a model based on a three-dimensional co-culture of osteoblasts and osteoclast precursors in Skelite(TM) scaffolds was developed. Although induction of osteoblast and osteoclast differentiation was observed, a complete evaluation of bone deposition and biodegradation processes was missing due to technical limitations. In the current study, both X-ray computed microtomography and histological analysis were used to monitor these two key biological processes in the same in vitro model. Either osteoblasts or a combination of osteoblasts and osteoclasts were seeded on Skelite(TM) scaffolds. Scaffold biodegradation and increased bone deposition together with a more organized extracellular matrix were observed in the co-cultures, highlighting the role of osteoclasts in the determination and regulation of bone deposition. Results confirmed the potential and relevance of co-culturing osteoblasts and osteoclasts to resemble native tissue. The combination of X-ray computed microtomography and histology presented in this study could be useful in future studies for the validation and development of new in vitro culture systems for bone tissue engineering.

In vitro and in vivo osteoinductive and osteoconductive properties of a synthetic bone substitute.

PURPOSE: The present study tested a recently introduced bone substitute material (BSM) with a novel structure to determine its osteoinductive and osteoconductive properties in vitro and in vivo. The specific aims were to determine the microstructure of the as-manufactured BSM, as analyzed with scanning electron microscopy, and to characterize different cellular interactions. MATERIALS AND METHODS: Human bone marrow stromal cells were cultured in the presence of the BSM. In vitro, attachment of osteoblastlike cells (SAOS-2) to the BSM was observed with the scanning electron microscope. The expression of genes related to osteogenic differentiation (alkaline phosphatase, bone sialoprotein, type I collagen, and osteocalcin) was determined by reverse-transcriptase polymerase chain reaction. In vivo, bone formation was examined with a murine model of ectopic bone formation through histology and computed tomographic scanning by using tissue-engineered constructs with the BSM and ovine bone marrow stromal cells. RESULTS: Early cellular attachment could be detected as early as 6 hours. Cellular morphology developed in the following 66 hours toward a starlike appearance. Human bone marrow stromal cells cultured in the presence of the BSM showed no reduction in their viability. Osteocalcin was up-regulated during cell culturing, demonstrating an osteoinductive effect of BSM. Histologic and computed tomographic analyses showed the formation of new bone surrounding BSM particles, and a vascular meshwork was observed in the porosity of the particles. CONCLUSION: The analyzed bone substitute of synthetic origin presented osteoinductive properties that may exert a differentiative stimulus upon osteoprogenitor cells. The tested material allowed cellular adhesion of osteoblastlike cells and, following tissue construct implantation in vivo, supported the formation of new bone.

A platelet-rich plasma-based membrane as a periosteal substitute with enhanced osteogenic and angiogenic properties: a new concept for bone repair.

The periosteum plays a pivotal role during bone development and repair contributing to bone vascularization and osteoprogenitor cells source. We propose a periosteal substitute engineered using a platelet-rich plasma (PRP) membrane incorporating autologous bone marrow-derived mesenchymal stem cells (PRP/BMSC gel membrane) to be wrapped around an osteoconductive scaffold for regeneration of compromised bone defects. The PRP/BMSC gel membrane was optimized using different compositions for optimal release of vascular endothelial growth factor (VEGF) and platelet derived growth factor-BB (PDGF-BB). Survival and proliferation of cells in the PRP gel membrane with time were confirmed in addition to their osteogenic capacity. Furthermore, to evaluate the possible effects of the PRP/BMSC gel membrane on surrounding progenitor cells in the injury area, we found that the PRP gel membrane products could significantly induce the migration of human endothelial cells in vitro, and increased the expression of bone morphogenetic protein 2 in cultured BMSC. These cells also secreted significant amounts of soluble proangiogenic factors, such as PDGF-BB, VEGF, and interleukin-8 (IL-8). Finally, the functionality of the PRP/BMSC gel membrane periosteal substitute for bone regeneration was tested in vivo both in an ectopic mouse model as well as in a rabbit segmental bone defect model providing evidence of its capacity to biomimic a periosteal response enhancing bone regeneration.

Encapsulation of human articular chondrocytes into 3D hydrogel: phenotype and genotype characterization.

This chapter is intended to provide a summary of the current materials used in cell encapsulation technology as well as methods for evaluating the performance of cells encapsulated in a polymeric matrix. In particular, it describes the experimental procedure to prepare a hydrogel matrix based on natural polymers for encapsulating and culturing human articular chondrocytes with the interest in cartilage regeneration. Protocols to evaluate the viability, proliferation, differentiation, and matrix production of embedded cells are also described and include standard protocols such as the MTT and [3H] Thymidine assays, reverse transcription polymerase chain reaction (RT-PCR) technique, histology, and immunohistochemistry analysis. The assessment of cell distribution within the 3D hydrogel construct is also described using APoTome analysis.

Debye function analysis and 2D imaging of nanoscaled engineered bone.

The Debye Function Analysis of diffraction patterns from nanosized mineral crystals showing different average degrees of maturity was carried out on engineered bone samples. The analysis relied on a bivariate family of atomistic hydroxyapatite nanocrystal models and provided information about crystal structure, size and shape distributions of the mineral component of the newly formed bone. An average rod-like shape of nanocrystals was found in all samples, with average sizes well matching the collagen I gap region. The diffraction patterns investigated through the Debye Function Analysis were used as signal models to perform the Canonical Correlation Analysis of high resolution X-ray micro-diffraction patterns collected on porous and resorbable hydroxyapatite/silicon-stabilized tricalcium phosphate (Si-TCP) implants. The nosologic maps clearly showed a size gradient in the new formed bone that validates the mechanism (mimicking the bone remodelling in orthotopic bones) of a continuous deposition of bone by osteoblasts, an increasing mineralization of the newly deposited bone, a growth of the new crystals, at the same time that osteoclasts adhere to the scaffold surface and resorb the bioceramic. The comparison of samples at different implantation times proved that the selective resorption of Si-TCP component from the scaffold was already evident after two and almost complete after six months.

SEM and 3D synchrotron radiation micro-tomography in the study of bioceramic scaffolds for tissue-engineering applications.

Different biomaterials have been proposed as scaffolds for the delivery of cells and/or biological molecules to repair or regenerate damaged or diseased bone tissues. Particular attention is being given to porous bioceramics that mimic trabecular bone chemistry and structure. Chemical composition, density, pore shape, pore size, and pore interconnection are elements that have to be considered to improve the efficiency of these biomaterials. Commonly, two-dimensional (2D) systems of analysis such as scanning electron microscope (SEM) are used for the characterization and comparison of the scaffolds. Unfortunately, these systems do not allow a complete investigation of the three-dimensional (3D) spatial structure of the scaffold. In this study, we have considered two different techniques, that is, SEM and 3D synchrotron radiation (SR) micro-CT to extract information on the geometry of two hydroxyapatite (HA) bioceramics with identical chemical composition but different micro-porosity, pore size distribution, and pore interconnection pathway. The two scaffolds were obtained with two different procedures: (a) sponge matrix embedding (scaffold FB), and (b) foaming (scaffold EP). Both scaffolds showed structures suitable for tissue-engineering applications, but scaffold EP appeared superior with regard to interconnection of pores, surface on which the new bone could be deposited, and percentage of volume available to bone deposition.

A simple non invasive computerized method for the assessment of bone repair within osteoconductive porous bioceramic grafts.

Single energy X-ray imaging, due to its low cost and flexibility, is one of the most used and common technique to assess bone state and bone remodeling over time. Standardized X-ray images are needed to compare sets of radiographs for semi-quantitative analyses of tissue remodeling. However, useful mathematical modeling for the analysis of high level radiographic images are not easily available. In order to propose a useful evaluation tool to a wide clinical scenario, we present an innovative calibration algorithm for a semi-quantitative analysis of non-standardized digitized X-ray images. For calibration on a unique standardization scale, three time invariant regions (ROI) of radiographs were selected and analyzed. The accuracy of the normalization method for X-ray films was successfully validated by using an aluminum step wedge for routine X-ray exposures as tool to standardize serial radiographs (Pearson correlation test: R(2) = 0.96). This method was applied to investigate the progression of the new bone deposition within ceramic scaffolds used as osteoconductive substitute in large bone defects taking advantage of a large animal model. This innovative image-processing algorithm allowed the identification and semi-quantification of the bone matrix deposited within the implant. The osteo-integration at the bone-implant interface was also investigated. A progressively increasing bone tissue deposition within the porous bioceramic implant and a progressive osteo-integration was observed during the 12 months of the trial.