Polyetheretherketone (PEEK) cage filled with cancellous allograft in anterior cervical discectomy and fusion

From July 2004 to June 2005, 19 patients with 25 discs underwent anterior cervical discectomy and interbody fusion (ACDF) in which polyetheretherketone (PEEK) cages were filled with freeze-dried cancellous allograft bone. This kind of bone graft was made from femoral condyle that was harvested during total knee arthroplasty. Patient age at surgery was 52.9 (28-68) years. All patients were followed up at least 1 year. We measured the height of the disc and segmental sagittal angulation by pre-operative and post-operative radiographs. CT scan of the cervical spine at 1 year was used to evaluate fusion rates. Odom's criteria were used to assess the clinical outcome. All interbody disc spaces achieved successful union at 1-year follow-up. The use of a PEEK cage was found to increase the height of the disc immediately after surgery (5.0 mm pre-operatively, 7.3 mm immediately post-operatively). The final disc height was 6.2 mm, and the collapse of the disc height was 1.1 mm. The segmental lordosis also increased after surgery (2.0 degrees pre-operatively, 6.6 degrees immediately post-operatively), but the mean loss of lordosis correction was 3.3 degrees at final follow-up. Seventy-four percent of patients (14/19) exhibited excellent/good clinical outcomes. Analysis of the results indicated the cancellous allograft bone-filled PEEK cage used in ACDF is a good choice for patients with cervical disc disease, and avoids the complications of harvesting iliac autograft.

Non-Steroidal Anti-inflammatory Drug (NSAID)-Derived Poly(anhydrideesters) in Bone and Periodontal Regeneration

Bioresorbable polymers offer the potential to deliver biologically active agents that selectively modulate wound healing in bone and periodontal regeneration. This preliminary study characterizes early wound healing in calvarial defects grafted with demineralized bone matrix (DBM) overlaid with membranes made from a novel class of non-steroidal anti-inflammatory drug (NSAID)-derived poly(anhydride-esters). These polymers chemically incorporate either salicylic acid (SA) or 5-(2',4'-difluorophenyl)salicylic acid (diflunisal) into the polymeric backbone and release the NSAIDs upon hydrolysis. Inflammatory cell infiltrate in response to the novel NSAID-derived polymers was compared to defects grafted with DBM alone at 10 days and to defects grafted with DBM and overlaid with poly(lactic acid) (PLA; Atrisorb) at 21 days in 8 Wistar rats (350-450 g). Histological analysis of the calvarial sites at 10 days revealed that the NSAID-derived polymers were associated with moderate levels of inflammation similar to defects grafted without polymer (2.3 +/- 0.96 versus 2.0 +/- 0.82, respectively), consistent with the therapeutic activity of salicylic acid and diflunisal. Defects grafted with DBM and overlaid with NSAID-derived polymers at 21 days exhibited mild inflammation; whereas, defects treated with PLA were consistently associated with moderate to severe inflammatory cell infiltrate (1.8 +/- 0.50 versus 2.7 +/- 0.58, respectively). Histopathological findings, such as foreign body giant cells or fibrous encapsulation, were not observed in any defects with NSAID-derived polymers. Cellular features consistent with bone formation were found in all grafted defects. This novel class of non-steroidal anti-inflammatory drug-derived poly(anhydride-esters) were well tolerated and elicited no demonstrable increase in inflammation, as shown with PLA, during osseous wound healing in a regenerative application.

Evaluation of DBM/AM composite as a graft substitute for posterolateral lumbar fusion

Demineralized bone matrix (DBM) has been investigated as a bone graft substitute for spinal fusion with less morbidity. Various carriers have been added to DBM to enhance its handling characteristics. This study investigates the spinal fusion induced by a composite of DBM and acellular dermal matrix (AM) in comparison with autologous bone in an athymic rat spinal fusion model. Single-level intertransverse process fusions were performed in 60 athymic nude rats grafted with 2 mL/kg of DBM/AM composite, AM alone, or autologous bone. Fusion was assessed at 6 weeks by radiography, manual palpation, and histology. At 6 weeks, 70% of the animals from the DBM/AM composite group exhibited complete spine fusion, whereas 35% from the autologous bone group and 20% from AM group showed bridging with some gaps. The DBM/AM composite induced a significantly higher fusion rate than both the autologous bone and AM groups (p < 0.001) in all measured parameters. The current study demonstrated that using DBM/AM composite can have more robust fusion than autologous bone at 6 weeks in an athymic rat spinal fusion model.

Demineralized bone matrix composite grafting for posterolateral spinal fusion

In a prospective series, the 24-month fusion status was evaluated radiographically among patients undergoing instrumented posterolateral lumbosacral spinal fusion. Seventy-three patients had a diagnosis of degenerative disk disease or degenerative spondylolisthesis and had supplemental bone grafting with demineralized bone matrix (DBM) putty (Grafton DBM; Osteotech, Eatontown, NJ) enriched with aspirated bone marrow (DBM bone marrow), DBM putty combined with iliac crest autograft (DBM autograft), or autograft. Overall, approximately 63% (12 of 19) of DBM bone marrow, 70% (19 of 27) of DBM autograft, and 67% (18 of 27) of autograft patients were fused at 24 months (P = .875). These findings suggest that both DBM composites offer similar performance to autograft in posterolateral spinal fusion.

Osseous healing with a composite of allograft and demineralized bone matrix: adverse effects of smoking

We report on our use of a composite graft of lyophilized cancellous allogenic chips and demineralized bone matrix (DBM; Grafton; Osteotech, Eatontown, NJ) to manage traumatic osseous defects and nonunions. Data were prospectively collected from all patients who received this composite bone graft between 1996 and 2000. Only acute fractures with bone loss resulting in a uncontained defect and atrophic non-unions were included in the present study. Demographic data and complications related to composite use, tobacco use, and other comorbidities that could affect healing were evaluated. One hundred seven patients (112 bone graft sites) were followed up for a mean of 32 months (range, 12-60 months). Graft sites included the forearm, femur and tibia. Of the 112 patients, there were 56 smokers (25 non-unions and 31 fractures) and 56 non-smokers (28 fractures and 28 non-unions). Healing occured in 38/56 smokers compared with 49/56 non-smokers. In failed cases, smoking was characteristic in 7/9 non-unions and 11/16 fractures. There were 26 acute uncontained injuries, 29 acute contained defects, and 67 nonunions. Grafting sites were radius/ulna (13 cases), humerus (17), femur (31), and tibia/fibula (51). Significant comorbidities were diabetes mellitus (4 cases), fungal osteomyelitis (1), and pulmonary alveolar proteinosis (1). Eight (73%) of the 11 patients with graft failure had a significant smoking history. This composite graft is an option for managing osseous defects and nonunions traditionally treated with autologous bone grafting but should be used with caution when treating patients who are smokers.

Homogeneous osteogenesis and bone regeneration by demineralized bone matrix loading with collagen-targeting bone morphogenetic protein-2

Considerable research has been focused on the development of bone morphogenetic protein-2 (BMP-2) delivery system for homologous and efficient bone regeneration. The aim of the present study was to develop a collagen-based targeting bone repair system. A collagen-binding domain (CBD) was added to the N-terminal of native BMP-2 to allow it bind to collagen specifically. We showed that the collagen-binding bone morphogenetic protein-2 (named bone morphogenetic protein2-h, BMP2-h) had maintained the full biological activity as compared to rhBMP2 lacking the CBD. In vitro functional study also demonstrated that collagen matrix could maintain higher bioactivity of BMP2-h than native BMP-2. When demineralized bone matrix (DBM) impregnated with BMP2-h was implanted subcutaneously in rats, homogeneous bone formation was observed. Moreover, in a rabbit mandible defect model, surgical implantation of collagen matrix loaded with BMP2-h exhibited remarkable osteoinductive properties and excellent homogeneous bone formation. Our studies suggested that this novel collagen-based BMP-2 targeting bone repair system induced better bone formation not only in quantity but also in quality. Similar approaches may also be used for the repair of other tissue injuries.

Soft tissue and cellular preservation in vertebrate skeletal elements from the Cretaceous to the present

Soft tissues and cell-like microstructures derived from skeletal elements of a well-preserved Tyrannosaurus rex (MOR 1125) were represented by four components in fragments of demineralized cortical and/or medullary bone: flexible and fibrous bone matrix; transparent, hollow and pliable blood vessels; intravascular material, including in some cases, structures morphologically reminiscent of vertebrate red blood cells; and osteocytes with intracellular contents and flexible filipodia. The present study attempts to trace the occurrence of these four components in bone from specimens spanning multiple geological time periods and varied depositional environments. At least three of the four components persist in some skeletal elements of specimens dating to the Campanian. Fibrous bone matrix is more altered over time in morphology and less likely to persist than vessels and/or osteocytes. Vessels vary greatly in preservation, even within the same specimen, with some regions retaining pliability and other regions almost crystalline. Osteocytes also vary, with some retaining long filipodia and transparency, while others present with short and stubby filipodia and deeply pigmented nuclei, or are pigmented throughout with no nucleus visible. Alternative hypotheses are considered to explain the origin/source of observed materials. Finally, a two-part mechanism, involving first cross-linking of molecular components and subsequent mineralization, is proposed to explain the surprising presence of still-soft elements in fossil bone. These results suggest that present models of fossilization processes may be incomplete and that soft tissue elements may be more commonly preserved, even in older specimens, than previously thought. Additionally, in many cases, osteocytes with defined nuclei are preserved, and may represent an important source for informative molecular data.

Calcium sulfate–carboxymethylcellulose bone graft binder: Histologic and morphometric evaluation in a critical size defect

Calcium sulfate (CS) is widely used as a bone graft binder and expander. Recent reports indicate that carboxymethylcellulose (CMC) can improve the clinical properties of CS when used as binder for particulate bone grafts; however, limited information is available on the effects of CMC on bone regeneration. The purpose of this study was to evaluate the histologic and morphometric characteristics of bone formation in calvarial defects grafted with a CS-based putty containing 10% CMC in combination with allogeneic demineralized bone matrix (DBM). Bone formation and graft/binder resorption were compared with a surgical grade CS and DBM in paired critical-sized calvarial defects in 25 Wistar rats (350-450 g). Six animals each provided paired defects at 7, 14, 21, and 28 days postsurgery for nondecalcified processing and microscopic analysis. Defects grafted with CS or CS-CMC putty as the DBM binder exhibited similar patterns and proportions of bone formation, fibrous tissue/marrow, and residual DBM particles. Comparable mean +/- SD proportions of new bone formation (31.7 +/- 9.5 and 33.7 +/- 12.9), fibrous tissue/marrow (54.2 +/- 8.3 and 53.0 +/- 10.8), residual DBM particles (8.3 +/- 6.8 and 10.1 +/- 6.3), and residual binder material (5.5 +/- 4.6 and 3.7 +/- 3.5) were found at 28 days for defects grafted with CS and CS-CMC putty, respectively. Thus, CMC was found to improve the handling characteristics of CS and, when used in conjunction with DBM, supported comparable levels bone formation and patterns of binder/scaffold resorption as CS and DBM in a calvarial defect model.

Assessment of bovine biomaterials containing bone morphogenetic proteins bound to absorbable hydroxyapatite in rabbit segmental bone defects

PURPOSE: To evaluate the osteo-regenerative capacity of two proprietary bone grafting materials, using a segmental defect model in both radial diaphyses of rabbits. METHODS: The right defect was filled with pooled bone morphogenetic proteins (pBMPs) bound to absorbable ultrathin powdered hydroxyapatite (HA) mixed with inorganic and demineralized bone matrix and bone-derived collagen, derived from bovine bone (Group A). The left defect was filled with bovine demineralized bone matrix and pBMPs bound to absorbable ultrathin powdered HA (Group B). In both groups, an absorbable membrane of demineralized bovine cortical was used to retain the biomaterials in the bone defects, and to guide the tissue regeneration. The rabbits were euthanized 30, 90 and 150 days after surgery. Radiographic, tomographic and histologic evaluations were carried out on all specimens. RESULTS: At 30 days, the demineralized cortical bone cover was totally resorbed in both groups. HA was totally resorbed from Group A defects, whereas HA persisted in Group B defects. A prominent foreign body reaction was evident with both products, more pronounced in sections from Group B. At 90 days, the defects in Group B exhibited more new bone than Group A. However, at 150 days after surgery, neither treatment had stimulated complete repair of the defect. CONCLUSION: The partial bone healing of the segmental defect occurred with low or none performance of the biomaterials tested.

Effect of hydrogen peroxide on osteoinduction by demineralized bone

The osteoinductive capacity of demineralized bone matrix (DBM) has led to wide use of this material for surgical reconstruction. Preparation of DBM often includes sterilization with ethylene oxide, disinfection with various chemical agents, or irradiation. Exposure to hydrogen peroxide (H2O2) is used for both sterilization and bleaching of bone, the latter primarily for cosmetic reasons. We investigated the effect of H2O2, on the osteoinductive capacity of DBM. Cortical bone implants prepared from rat femurs were placed into 3% H2O2 solution. Control specimens were not exposed to H2O2. Bones were then lipid-extracted, demineralized, sterilized with ethylene oxide, and freeze-dried in an identical manner. Allografts were implanted into rat hosts for 1 to 3 weeks. Osteoinduction proceeded rapidly in implants not exposed to H2O2, with chondrocytes and new bone appearing in the implant. After 3 weeks, perforations in the implant were largely replaced with new bone. In contrast, osteoinduction did not occur in implants treated with H2O2. Perforations in H2O2-treated implants were filled with vascularized fibrous tissue, but no cartilage or bone. These findings reveal that H2O2 used for disinfection or bleaching of DBM can abolish its osteoinductive capacity in rats.

A comparison of ProOsteon, DBX, and collagraft in a rabbit model

Many bone graft substitutes (BGSs) have been developed and are commercially available. These products differ in the tailoring of their properties, including size, form, osteoconductivity, osteoinductivity, and resorption kinetics. Differential enhancement of these properties may optimize the performance of these materials for varying applications. BGSs offer an opportunity to lessen morbidity of harvesting and use of autogenous and/or allograft bone. The purpose of this study is to quantitatively compare the magnitude of bony ingrowth and biodegradation of different commercially available BGS materials in a rabbit femoral defect model. BGSs from each of three classes (ceramic (ProOsteon), demineralized bone matrix (DBX), and composite (Collagraft)) were implanted in cylindrical defects in bilateral femoral condyles of 12 adult New Zealand White rabbits. Each of the three BGS materials and the empty controls were compared. The specimens were harvested at 3 months postimplantation for radiographic and histologic evaluation. Histomorphometry yielded resorption of graft material remaining in the index defect. Magnitude of bony ingrowth was assessed based on an 8-bit 256 densitometry model. Histomorphometric analysis of the data demonstrated statistical differences in the resorption and magnitude of bony ingrowth of the three BGS materials. The three BGS were significantly different for ingrowth (p = 0.046) when using the Wilcoxon Test. The ceramic graft material averaged 47% bony ingrowth. Rabbit-based DBX material showed extensive osseous ingrowth (35%) and the composite graft material demonstrated significant bony ingrowth (56%). The control, as anticipated, showed the least amount of bony ingrowth (29%). Fisher's Exact Test yielded statistical differences (p = 0.0003) when comparisons for resorption were conducted. An ideal BGS material should be biocompatible, be able to withstand the local load environment for a given application, degrade in concert with bony replacement, and be both osteoinductive and osteoconductive. This in-vivo, head-to-head comparison of three commercially available BGS materials in an animal model compares these characteristics and demonstrates differences between them, which may act as a guide in the use of these products in human applications.

Augmentation of demineralized bone matrix (DBM) mineralization by a synthetic growth factor mimetic

These studies evaluated whether F2A4-K-NS, a peptide mimetic of FGF-2, could augment ectopic bone production following the subcutaneous implant of human demineralized bone matrix (DBM). DBM was formulated into a gel with and without F2A4-K-NS, and injected subcutaneously into athymic rats. After 28 days the resultant tissue was excised and fixed. The tissue was examined with soft X-rays and microcomputerized tomography (micro-CT), and by histological methods. Inclusion of F2A4-K-NS with DBM resulted in an increased mineral deposition as determined by soft X-ray and micro-CT analysis and von Kossa staining. DBM-containing tissues showed extensive mineralization compared to the carrier alone, which was poorly mineralized. The mineralization was qualitatively and quantitatively the most extensive in the samples containing F2A4-K-NS plus DBM. Additionally, the highest amount of von Kossa staining for calcium was observed in tissues from animals that had received DBM plus F2A4-K-NS. In these studies, 100 ng of peptide per 0.2 mL of injectable DBM gel generated the most optimal results. The synthetic peptide F2A4-K-NS augmented DBM-induced ectopic mineralization in athymic animals.

Effects of demineralized bone matrix on proliferation and osteogenic differentiation of mesenchymal stem cells from human umbilical cord

BACKGROUND

Mesenchymal stem cells or mesenchymal progenitor cells are defined as self-renewable, multipotent progenitor cells with the unlimited capacity to differentiate into multiple lineage-specific cells that form bone, cartilage, fat, and muscle tissues. Demineralized bone matrix (DBM) has been extensively utilized in orthopaedic, periodontal, and maxillofacial applications and widely investigated as a biomaterial to promote new bone formation.

OBJECTIVE

To isolate and characterize umbilical cord mesenchymal stem (UCMS) cells and examine the biological activity of DBM in the UCMS cells

MATERIAL AND METHOD

UCMS cells were obtained from human umbilical cord culture. Cells were treated with or without DBM over 7 days of culture. Cell proliferation was examined by direct cell counting. Osteogenic differentiation of the UCMS cells was analysed with alkaline phosphatase staining assay.

RESULTS

Phenotypic characteristics ofhuman UCMS cells were spindle and stellate shapes with fine homogenous cytoplasm, typically associated with fibroblast-like cells. The control cells (without DBM treatment) exhibited a spindle shape with little extracellular matrix, whereas the DBM treated cells appeared shortened and flattened, and they were surrounded by extracellular matrix. DBM inhibited the growth of the UCMS cells by 50%, as determined by direct cell counting. Morphologic and histochemical studies confirmed that DBM had a strong stimulatory effect on the alkaline phosphatase activities of UCMS cells, a very early marker of cell differentiation into the osteogenic lineage.

CONCLUSION

Mesenchymal progenitor cells derived from umbilical cord could differentiate along an osteogenic lineage and thus provide an alternative source for cell-based therapies and tissue engineering strategies.

Bioabsorbable scaffold for in situ bone regeneration

A non-porous poly-DL-lactide tubular chamber filled by demineralised bone matrix (DBM) and bone marrow stromal cells (BMSC) in combination, was evaluated as a scaffold for guided bone regeneration (GBR) in an experimental model using the rabbit radius. The tubular chamber had an internal diameter of 4.7 mm, a wall thickness of 0.4 mm and a length of 18 mm. Autologous BMSC were obtained, under general anaesthesia from rabbit iliac crest and isolated by centrifugation technique. Allogenic DBM was obtained from cortico-cancellous bone of rabbits. In general anaesthesia, a 10-mm defect was bilaterally created in the radii of 10 rabbits. On the right side (experimental side) the defect was bridged with the chamber filled with both BMSC and DBM. On the left side (control side) the defect was treated by positioning DBM and BMSC between the two stumps. At an experimental time of 4 months histology and histomorphometry demonstrated that the presence of a tubular chamber significantly improved bone regrowth in the defect The mean thickness of newly-formed bone inside the chamber was about 56.7+/-3.74% of the normal radial cortex, in comparison with 46.7+/-10.7% when DBM and BMSC without the chamber were placed in the defect, P<0.05). These results confirmed the effectiveness of the chamber as a container for factors promoting bone regeneration.

Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing

BACKGROUND

Delayed union or nonunion of a fracture of the humerus is an infrequent but debilitating complication. Open reduction and internal fixation combined with autologous bone-grafting can result in reliable healing of the fracture; however, there is morbidity associated with the bone-graft donor site. This study was designed to evaluate healing of ununited fractures of the humeral shaft treated by one surgeon at one institution with a strict and consistent surgical protocol but with the use of two different types of bone graft: autologous iliac crest bone graft and demineralized bone matrix.

METHODS

A consecutive retrospective cohort series was analyzed. From 1992 to 1999, forty-five patients with an aseptic, atrophic delayed union or nonunion of a humeral shaft fracture were treated with open reduction and internal fixation with a plate and autologous iliac crest bone graft. The mean time from the fracture to the surgery was 14.0 months, and the mean duration of follow-up was 32.8 months. From 2000 to 2003, thirty-three patients with the same condition were treated with the same protocol with the exception that demineralized bone matrix was used instead of autologous iliac crest bone graft. The mean time from the fracture to the surgery in that group was 22.6 months, and the mean duration of follow-up was 20.4 months. All patients in both groups were assessed clinically and radiographically.

RESULTS

Osseous union was noted clinically and radiographically following the index surgery in 100% of the forty-five patients treated with autologous bone graft and 97% (thirty-two) of the thirty-three patients treated with demineralized bone matrix. The mean time to union was 4.5 months in the group treated with autologous bone graft and 4.2 months in the group treated with demineralized bone matrix. The overall functional outcome did not differ between the groups; however, twenty (44%) of the autologous bone-graft recipients had donor site morbidity, including a prolonged pain in the majority and a superficial infection requiring irrigation and débridement in one patient.

CONCLUSIONS

Healing of an ununited humeral shaft fracture can be achieved consistently with rigid plate fixation and lag-screw compression augmented with either autologous cancellous bone graft or commercially available demineralized bone matrix. The harvest of the autologous bone graft is frequently associated with complications.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Intervariability and intravariability of bone morphogenetic proteins in commercially available demineralized bone matrix products

STUDY DESIGN

Enzyme-linked immunosorbent assay was used to detect bone morphogenetic proteins (BMPs) 2, 4, and 7 in 9 commercially available ("off the shelf") demineralized bone matrix (DBM) product formulations using 3 different manufacturer's production lots of each DBM formulation.

OBJECTIVES

To evaluate and compare the quantity of BMPs among several different DBM formulations (inter-product variability), as well as examine the variability of these proteins in different production lots within the same DBM formulation (intra-product variability).

SUMMARY OF BACKGROUND DATA

DBMs are commonly used to augment available bone graft in spinal fusion procedures. Surgeons are presented with an ever-increasing variety of commercially available human DBMs from which to choose. Yet, there is limited information on a specific DBM product's osteoinductive efficacy, potency, and constancy.

METHODS

There were protein extracts from each DBM sample separately dialyzed 4 times against distilled water at 4 degrees C for 48 hours. The amount of BMP-2, BMP-4, and BMP-7 was determined using enzyme-linked immunosorbent assay. RESULTS.: The concentrations of detected BMP-2 and BMP-7 were low for all DBM formulations, only nanograms of BMP were extracted from each gram of DBM (20.2-120.6 ng BMP-2/g DBM product; 54.2-226.8 ng BMP-7/g DBM). The variability of BMP concentrations among different lots of the same DBM formulation, intra-product variability, was higher than the variability of concentrations among different DBM formulations, inter-product variability (coefficient of variation range BMP-2 [16.34% to 76.01%], P < 0.01; BMP-7 [3.71% to 82.08%], P < 0.001). BMP-4 was undetectable.

CONCLUSIONS

The relative quantities of BMPs in DBMs are low, in the order of 1 x 10(-9) g of BMP/g of DBM. There is higher variability in concentration of BMPs among 3 different lots of the same DBM formulation than among different DBM formulations. This variability questions DBM products' reliability and, possibly, efficacy in providing consistent osteoinduction.

Influence of fluvastatin on bone formation induced by demineralized bone matrix in mice

In the last decade, statins became widely used drugs in hypercholesterolemia treatment. Several studies have demonstrated that statins may also be successfully administered in the treatment of osteoporosis. There are, however, no reports regarding the effect of statins on heterotopic ossification (HO). In this paper, we examined the influence of fluvastatin on heterotopically induced bone formation in mice. HO was induced by implantation of rat-derived demineralized bone matrix (DBM) into intramuscular pockets in CFW mice. Mice in the experimental groups received fluvastatin at 3.6 mg/kg per day for 25 consecutive days whilst mice in the control group received placebo. Twenty five days after DBM implantation blood samples were collected to measure total serum cholesterol (TC), triglycerides (TG), low density lipoprotein cholesterol (LDL-C) and alkaline phosphatase (AP) activity. Mass of mineral deposited in the induced ossicle was established after hydrolysis of soft tissues surrounding the induced ossicles. In fluvastatin-treated mice, the mass of mineral deposited in heterotopically induced ossicles and AP serum concentration were significantly increased while TG and TC concentrations were decreased, when compared to mice receiving placebo. These results show that administration of statins, in some instances, may affect heterotopic ossification and that during hypocholesterolemic treatment of patients with predisposition to HO, following hip arthroplasty, such treatment may increase risk of HO.

[Bone grafts in orthopedic surgery]

In orthopedic surgery the demand for the use of bone grafts increases daily because of the increasing quantity and complexity of surgical procedures. At present, the gold standard is the autologous bone graft but the failure rate, morbidity of the donor site and limited availability have stimulated a proliferation for finding materials that work as bone graft substitutes. In order to have good success, we must know the different properties of these choices and the environment where the graft is going to be used. As bone graft substitutes and growth factors become clinical realities, a new gold standard will be defined. Tissue engineering and gene therapy techniques have the objective to create an optimum bone graft substitute with a combination of substances with properties of osteconduction, osteogenesis and osteoinduction.

Demineralized bone matrix gelatin as scaffold for osteochondral tissue engineering

To develop a single-unit osteochondral tissue with demineralized bone matrix gelatin (BMG), rabbit chondrocytes were cultured on demineralized bone matrix gelatin for 6 weeks. The engineered osteochondral tissue was characterized with histology, immunolocalization, TEM, SEM, biochemical assay, and gene expression analysis. About 1.3mm viable neo-cartilage was produced on demineralized BMG. RT-PCR, immunohistochemistry, TEM, biochemical assay, and histology revealed hyaline-like cartilage with zonal layers, intense type II collagen expression, and abundant proteoglycan content formed upon BMG compared with normal cartilage. But hydroxyproline content and type I collagen gene and protein expressions were significantly lower. We consider engineering cartilage tissue with chondrocytes cultured on allogenic demineralized BMG is a good approach for osteochondral tissue engineering.

The Effect of Residual Calcium in Decalcified Freeze-dried Bone Allograft in a Critical-sized Defect in the Rattus norvegicus Calvarium

Demineralized freeze-dried bone allograft (DFDBA), a widely used graft material in periodontal regenerative procedures, is processed with hydrochloric acid in the attempt to expose proteins located within the bone matrixes that are capable of inducing new bone formation. However, the degree of DFDBA demineralization varies between tissue banks, which may have an effect on clinical regeneration. This study uses the critical-sized defect (CSD) model to evaluate the wound-healing response to the residual calcium of donor bone. If the percentage of residual calcium in a graft were demonstrated to significantly enhance wound healing, then periodontal patients may benefit from further standardization of human-allograft processing. Sixty adult, male, Harlan Sprague-Dawley rats (Rattus norvegicus) were randomly and equally divided into 4 test groups (ie, DFDBA at 1%, 2%, and 3% to 6% residual calcium levels and FDBA at 23% residual calcium) and a control group (no allograft). An 8-mm-diameter craniotomy was made in the rat calvarium, and polytetrafluoroethylene membranes with pore sizes of 0.50 μm were placed intracranially and ectocranially. Treatment materials were carefully placed into the CSD with a new sterilized dental amalgam carrier. Tetracycline hydrochloride was injected intraperitoneally for labeling new bone growth, and animals were euthanized 12 weeks postsurgery. As a result, histomorphometric bone fill at 12 weeks showed a statistically significant increase in the 2% DFDBA group as compared to all other groups. The authors conclude that a 2% residual calcium level in human DFDBA appears to significantly (P ≤ .05) enhance osseous wound healing in the rat calvarium.

Mineralised tissues as nanomaterials: analysis by atomic force microscopy

Mineralised tissues, such as bone, consist of two material phases: collagen protein fibrils that form the structural models upon which the mineral, calcium hydroxyapatite, is subsequently deposited. Collagen and mineral are removed in a three-dimensional manner by osteoclasts during bone turnover in skeletal growth or repair, and matrix proteins are replaced by the synthetic activity of osteoblasts and then calcify. The resolution of atomic force microscopy and use of unmodified, fully calcified samples has enabled the imaging of the overall bone and dentine structure, including collagen and mineral phases. Mineral crystals, in the diameter size range of 225 nm up to 1.4 microm, were found in unmodified bone and dentine respectively. D-banded collagen is observed in dentine after acid treatment and in bone after osteoclast-mediated matrix resorption; axial periodicity values of approximately 67 and 69 nm are observed, respectively. These experimental approaches have enabled the structure of mineralised tissues to be examined in native samples and will facilitate the study of bone structure in important clinical disorders of the skeleton, such as osteoporosis.

Low oxygen tension enhances chondroinduction by demineralized bone matrix in human dermal fibroblasts in vitro

Endochondral bone formation is induced by demineralized bone powder (DBP) when DBP is implanted subcutaneously in rodents. Previously, we developed an in vitro model of this process, wherein human dermal fibroblasts (hDFs) differentiate to chondrocytes when cultured in a three-dimensional porous collagen sponge containing DBP. In other studies, medium perfusion was beneficial in maintaining phenotype and viability of many cell types in plain porous collagen sponges, including fibroblasts, bone marrow stromal cells, osteoblasts, and epidermal cells. In contrast, medium perfusion inhibited chondrogenesis by articular chondrocytes; reduction of oxygen tension to 5%, however, restored chondrogenesis. These observations are consistent with the fact that in vivo cartilage is avascular and relatively hypoxic compared with other vascularized tissues. In this study, we tested the hypothesis that low oxygen tension (hypoxia, 5% oxygen) would enhance induced chondrogenesis in hDFs cultured with DBP. As expected, hypoxia upregulated hypoxia-inducible factor-1alpha in hDFs in all conditions (i.e. +/- perfusion, +/- DBP). Hypoxia increased accumulation of cartilage-specific matrix chondroitin 4-sulfate in hDFs, but only in the presence of DBP (165%, compared to normoxia, p < 0.05). Hypoxia did not appear to have detrimental effects on cell viability and proliferation. In sum, hypoxia enhanced cartilage matrix accumulation by hDFs cultured with DBP. These defined conditions can optimize the use of dermal fibroblasts for cartilage tissue engineering.

The Hydration Characteristics of Demineralized and Nondemineralized Allograft Bone: Scientific Perspectives on Graft Function

Demineralized bone matrix grafts are osteoinductive due to the increase in bioavailability of bone morphogenetic proteins that occurs from demineralization. The manner by which demineralization increases their bioavailability, however, is not known with certainty. It is known that the mineral phase of bone masks the proteins of the organic matrix. Proteins depend on their interaction with water for their three-dimensional conformation, biologic activity, and stability. It is possible that demineralization allows a more complete hydration of bone matrix, changing the local environment and allowing the bone morphogenetic proteins to desorb and form a concentration gradient, signaling the appropriate cell types to begin the process of bone regeneration. Under similar test conditions, it was discovered that hydration of demineralized bone matrix powder produces a strong exotherm on the order of 14 degrees C whereas hydration of bone powder produces a smaller exotherm of about 2 degrees C. The details of the hydration reactions of demineralized bone matrix and bone were investigated by measuring the exotherm produced under varying conditions. The results suggest that bone mineral does mask, or limit, the ability of the organic matrix to interact with water. An understanding of the hydration characteristics of demineralized bone matrix can also help in the development of carrier systems that optimize osteoinductive potential.

The effects of demineralized bone matrix proteins and osteogenic protein-1 on bone cells isolated in culture

With the growing number of bone-related traumas and the limitations of traditional bone repair, alternative methods of bone management must be investigated. Demineralized bone matrix protein (DBX) has been used to reconstruct bone. DBX, a type of demineralized bone matrix, is a combination of several different proteins including osteogenic protein-1 (OP-1). Osteogenic protein-1 or Bone Morphogenic Protein-7 (BMP-7) was the first BMP approved for clinical use in the United States. Previous studies have shown that proliferation of osteoblasts (bone forming cells) was stimulated by OP-1. However, the effects of DBM and OP-1 at the cellular level have not been clearly defined. MG-63 osteosarcoma cells were utilized as a model and subsequently plated onto 24 well tissue culture plates at a density of 1x 10(5) ml/well. Cells were exposed to different concentrations of DBX demineralized bone matrix and OP-1 for periods of 24, 48, and 72 hours and compared with untreated controls. After each incubation period, cell morphology, cell damage, cell number, and protein concentrations were determined. Results indicate a significant increase in cell number at 72 hours in cells treated with 30% (5.66 x 10(5)) and 100% (6.3 x 10(5)) DBX treated groups when compared with the control (1.4 x 10(5)). OP-1 results do not indicate a significant increase in cell number at the 24 and 48 hour treatment phases when compared with the control (p > 0.05), however, results do show a statistically significant difference (approximately twofold, p < 0.05) between the control cells (1.9 x 10(4)) and those cells treated with low (3.9 x 10(4)) and high (4.1 x 10(4)) concentrations of OP-1 at the 72 hour time phase. The increases in cell number indicate that both DBX and OP-1 are effective in stimulating cell growth. When comparing the results of the DBX treatments with those of the OP-1 treatments, the cells treated with DBX showed a more substantial increase in bone cell proliferation after treatment than those cells treated with OP-1. This does suggest that DBX provides the most effective treatment for bone cell proliferation. Closer evaluation of the morphology especially the changes occurring at the nuclear level need to be addressed in future studies.

Assay of Bone Morphogenetic Protein-2, -4, and -7 in Human Demineralized Bone Matrix

Demineralized bone matrix (DBM) is a widely used bone graft material that derives its osteoinductive potential from matrix-associated bone morphogenetic proteins (BMPs). Prior investigations have shown that the osteoinductive potential can vary widely, with influence from both donor and processing sources. Although it is plausible that donor variance in the BMP profile can be an important consideration, the few published studies available have given inconsistent and incomplete information about this. The goal was to (1) characterize the variance of BMP-2, BMP-4, and BMP-7 in fully demineralized DBM derived from 20 appropriately screened (Food and Drug Administration and the American Association of Tissue Banks criteria) donors (male and female, 17-65 years) and (2) using literature review, infer the potential for this to be an important source of variability in graft function. BMPs were extracted with 4 M guanidine hydrochloride, and levels of BMP-2, BMP-4, and BMP-7 were measured using enzyme-linked immunosorbent assay. Measured levels were as follows: BMP-2 = 21.4 +/- 12.0 ng/g DBM, BMP-4 = 5.45 +/- 2.04 ng/g DBM, and BMP-7 = 84.1 +/- 34.4 ng/g DBM, which were significantly different (P < 0.05). There was a positive linear correlation between BMP-2 and BMP-7 (P = 0.0227). DBM derived from female donors had significantly greater concentrations of BMP-2 and BMP-7 than did that derived from male donors (P = 0.0257 and 0.0245, respectively). There was no significant correlation between donor age and the levels of any of the measured BMPs. The magnitude of variance of BMP profile appears to reasonably well correspond to the variance in osteoinductive potential cited by others, suggesting the possibility of using this as a method of donor screening.

Percutaneous reaming of simple bone cysts in children followed by injection of demineralized bone matrix and autologous bone marrow

The authors report the successful treatment of 19 patients (mean age 10 years) with active unicameral bone cysts using a combination of percutaneous reaming and injection of a mixture of demineralized bone matrix and autologous bone marrow. Follow-up ranged from 12 to 42 months (mean 28 months). All patients were asymptomatic at the latest follow-up. Two required a second intervention to accomplish complete cyst healing. Radiographic outcome was improved in all patients according to the Neer classification at the latest follow-up. There were no significant complications related to the procedure, nor did any fracture occur after initiation of the above regimen.

Demineralized bone matrix and spinal arthrodesis

Spinal fusion is a gold-standard treatment for many disorders of the spine with autogenous bone graft as the gold-standard source for augmenting fusion. However, the morbidity and limitations of autogenous bone grafting has motivated the search for bone graft alternatives. One such alternative is demineralized bone matrix (DBM). The purpose of this paper is to describe and characterize the properties of DBM in addition to reviewing the results of its use in animal and human studies of spinal fusion. A thorough and critical review of the English-language literature was conducted. DBM is both osteoconductive and osteoinductive. Studies have produced variable results with respect to spinal fusion rates. Various studies have demonstrated inferior, equal, or enhanced fusion rates. Some of the differences in these studies include the animal models used, the manner in which DBM was prepared, and the carrier with which DBM was combined. These differences may account for the dissimilar results. DBM is able to function as a graft extender in the human species.

Demineralized bone matrix: basic science and clinical applications

Bone grafting with demineralized bone matrix (DBM) is useful in reconstructive surgery to ultimately provide anatomic alignment, restore function, or augment/change the biomechanics of the foot and ankle. DBM should be used in conjunction with a transplant or implant displaying mechanical strength. DBM can augment cortical grafts used for bridging gaps or defects and lengthening procedures by increasing the connectivity of the structural graft with the host bone. Another useful application is providing a biologic boost to patients who have less-than-ideal physiology. Because DBM has higher concentrations of available bone morphogenic proteins, it can aid in the incorporation of other grafts. Other uses include delayed unions, nonunions, packing joints for arthrodesis, filling resected cysts, and filling gaps of debrided infected bone.

Content of bone morphogenetic protein-4 in human demineralized bone: relationship to donor age and ability to induce new bone formation

BACKGROUND

Bone morphogenetic proteins (BMPs) are also called growth and differentiation factors (GDFs) and form a subfamily of related proteins within the TGF-beta superfamily. BMP-4 is one ofmultifuntional growth factors with pleiotropic roles in many different cell types and is predominantly present in human bone tissue.

OBJECTIVES

To analyze the content of extractable BMP-4 in human demineralized bone as a function of age.

MATERIAL AND METHOD

Bone samples were ground and demineralized by exposure to 0.5 N HCl and then extracted by collagenase digestion. Extractable BMP-4 was analyzed using a commercially available enzyme-linked immunosorbent assay (ELISA).

RESULTS

63 samples of demineralized bone matrix (DBM) derived from 36 men and 27 women between the ages of 15-65 years. The extractable BMP-4 content appears to be age-dependent, with DBM from younger donors being most likely to have higher BMP-4 quantity. In addition, DBM with high osteoinductivity contained greater amounts of extractable BMP-4 than DBM samples with low osteoinductivity.

CONCLUSION

The BMP-4 in demineralized bone undergoes age-related decrease that may contribute to the reduction of bone volume observed with aging.

Demineralized bone promotes chondrocyte or osteoblast differentiation of human marrow stromal cells cultured in collagen sponges

Demineralized bone implants have been used for many types of craniomaxillofacial, orthopedic, periodontal, and hand reconstruction procedures. In previous studies, we showed that demineralized bone powder (DBP) induces chondrogenesis of human dermal fibroblasts in a DBP/collagen sponge system that optimized interactions between particles of DBP and target cells in cell culture. In this study, we test the hypothesis that DBP promotes chondrogenesis or osteogenesis of human marrow stromal cells (hMSCs) in 3-D collagen sponge culture, depending upon the culture conditions. We first confirmed that hMSCs have chondrogenic potential when treated with TGF-beta, either in 2-D monolayer cultures or in 3-D porous collagen sponges. Second, we found that DBP markedly enhanced chondrogenesis in hMSCs in 3-D sponges, as assessed by metachromasia and expression of chondrocyte-specific genes AGGRECAN, COL II, and COL X. Human dermal fibroblasts (hDFs) were used to define mechanisms of chondroinduction because unlike hMSCs they have no inherent chondrogenic potential. In situ hybridization revealed that hDFs vicinal to DBPs express chondrocyte-specific genes AGGRECAN or COL II. Macroarray analysis showed that DBP activates TGF-beta/BMP signaling pathway genes in hDFs. Finally, DBP induced hMSCs to express the osteoblast phenotype when cultured with osteogenic supplements. These studies show how culture conditions can influence the differentiation pathway that human marrow stromal cells follow when stimulated by DBP. These results support the potential to engineer cartilage or bone in vitro by using human bone marrow stromal cells and DBP/collagen scaffolds.

Effects of moisture and temperature on the osteoinductivity of demineralized bone matrix

Demineralized bone matrix (DBM) is a well established osteoinductive bone graft material. It has been mixed with a variety of carriers to adjust to different forms of handling for a variety of applications. The impact of the various carriers on osteoinductivity remains largely unknown. Using an in vitro cell culture assay and in vivo intramuscular implantations into nude rats, the effects of moisture from water-based carriers and the storage temperature on osteoinductivity were studied. In the dry state, DBM can preserve its osteoinductive activity when temperatures reached 65 degrees C, but in the presence of moisture, the activity decreases with incubation time. Nearly 90% of the DBM activity is lost when maintained for 5 weeks at 65 degrees C. This study further indicates that the structure and stability of the collagen network in DBM not only provide a scaffold for osteogenitor cell proliferation and differentiation, but also controls the release rate of osteoinductive growth factors.

[Repair of bone defect with allograft demineralized bone containing basic fibroblast growth factor in rabbits]

OBJECTIVE

To evaluate the ability of inductive osteogenesis of allograft demineralized bone containing basic fibroblast growth factor (bFGF/ALB) in repairing bone defect.

METHODS

Thirty-two New Zealand white rabbits were randomly divided into four groups (groups A,B,C and D, n=8). A segmental bone defect of 15 mm in length was made on the bilateral radius respectively and the defects filled with ALB/bFGF in group A, with ALB in group B, with bFGF in group C and without any materials in group D serving as blank control. At 2, 4, 6 and 8 weeks after operation, all restored bones were evaluated by roentgenography, histological observation and Ca2+ detection of osteotylus.

RESULTS

The X-ray films showed that groups A and B had a little shadow of bone formation at 2 weeks, while groups C and D had transparent shadow; that group A had denser shadow and new bone formation at 4 weeks and 6 weeks, groups B and C had a little increase of shadow and group D had little shadow at fractured ends; and that group A had formation of bone bridge at 8 weeks, the new formed bone in fractured ends of group B closed with each other, the gap still existed in group C, and the defects filled with the soft tissue in group D. The Ca2+ content of group A was higher than that of groups B, C and D at 4 weeks (P<0.05) and 8 weeks (P<0.01). The histological observation showed that the degree of bone restoration of group A was superior to that of groups B, C and D.

CONCLUSION

bFGF/ALB is a good material to improve bone restoration.

Histologic evaluation of mineralized and demineralized freeze-dried bone allograft for ridge and sinus augmentations

The objective of this study was to quantify new bone formation from biopsies of demineralized freeze-dried bone allograft (DFDBA) and freeze-dried bone allograft (FDBA) following ridge and sinus augmentations. Ninety-three patients who received maxillary sinus or ridge augmentation grafts agreed to core biopsies of their grafts when the implants were placed. Samples ranged from 6 to 36 months postgrafting. These samples were sectioned, stained, and examined histomorphometrically Seventy-two FDBA and 21 DFDBA samples were examined, and the mean percentages of new bone formed were 41.89% and 41.74%, respectively. There was no statistical difference, irrespective of graft site.

Mechanisms of action of demineralized bone matrix in the repair of cortical bone defects

Demineralized bone matrix commonly is used to enhance and to facilitate bone grafting after skeletal injury or disease; however, the biologic bases for its bone-inducing abilities remain obscure. We have taken advantage of a mouse model of cortical bone defect healing to elucidate its mechanisms of action in vivo. Demineralized bone matrix combined with hyaluronan improved skeletal healing by inducing early deposition of an osteoid matrix. Demineralized bone matrix combined with hyaluronan might accelerate bone formation because it serves as a scaffold on which osteoprogenitor cells attach. We tested this possibility by comparing demineralized bone matrix combined with hyaluronan with heat-inactivated demineralized bone matrix combined with hyaluronan and found that the intact material was superior in terms of its ability to stimulate new bone formation. We also compared the bone inducing capacity of demineralized bone matrix combined with hyaluronan with a synthetic collagen sponge and found that not only the synthetic collagen scaffold delayed bone healing but also impaired bony bridging at later stages of repair. Another important property of demineralized bone matrix combined with hyaluronan was its ability to become actively degraded by osteoclasts during healing. Therefore, demineralized bone matrix combined with hyaluronan may not only attract osteoblasts and stimulate their differentiation, but also induce bone matrix resorption, which is a critically important regulator of bone formation and mineralization.

Experimental and clinical study of the demineralized bone allografts manufactured in the tissue bank of CITO

The technology for producing demineralized bone allografts (DBA) with definable degree of demineralization and sterilization by high energy electron bean was developed in the tissue bank of Central Institute of Traumatology and Orthopaedics (CITO). The authors consider the technology to be one of the ways of producing demineralized bones. The results of the experiments show that time of demineralization process as well as the absorption dose of radioactive high energy electron beam change substantially mechanical toughness and osteoinductive properties of DBA. Mechanical properties of DBA were tested by the universal testing machine 'Zwick 1464'. Quantitative assessment of DBA osteoinductive properties resulted from the investigation of DBA samples in the culture of stromal precursor bone marrow cells and in the culture of human skin fibroblasts. Cloning efficiency of fibroblasts was considered as indecies of proliferative potential of stromal bone marrow cells, i.e. osteogenic precursor cells. The growth of the cell mass after definite time as well as the index of 3H-timidin marked cells within biological inductor were considered as indecies of proliferative potential of skin fibroblasts. The obtained results showed, that inductive properties of allografts improve when the degree of their demineralization increases whereas the dose of high energy electron radiation decreases. Mechanical toughness of DBA deteriorates when both degree of their demineralization and radiation doses increase. This emphasizes the importance of optimizing technological stages in DBA producing. Since 1998 DBA have been used in Russian clinics for bone plasty in traumatology and orthopaedics, maxilla-facial surgery, ophthalmology, and neurosurgery. The resulting analysis is based on case histories of 257 patients operated from March 1998 to July 2002. The majority of patients were children and teenagers of 3-18 years old with prime tumors, tumor-like and systemic inherited diseases of skeleton, post-traumatic complications. Observation periods were from 1.5 to 5 years and 10 months. Good and satisfactory results were obtained in 93.4% cases.

Soft-tissue vessels and cellular preservation in Tyrannosaurus rex

Soft tissues are preserved within hindlimb elements of Tyrannosaurus rex (Museum of the Rockies specimen 1125). Removal of the mineral phase reveals transparent, flexible, hollow blood vessels containing small round microstructures that can be expressed from the vessels into solution. Some regions of the demineralized bone matrix are highly fibrous, and the matrix possesses elasticity and resilience. Three populations of microstructures have cell-like morphology. Thus, some dinosaurian soft tissues may retain some of their original flexibility, elasticity, and resilience.

Selective retention of bone marrow-derived cells to enhance spinal fusion

Connective tissue progenitors can be concentrated rapidly from fresh bone marrow aspirates using some porous matrices as a surface for cell attachment and selective retention, and for creating a cellular graft that is enriched with respect to the number of progenitor cells. We evaluated the potential value of this method using demineralized cortical bone powder as the matrix. Matrix alone, matrix plus marrow, and matrix enriched with marrow cells were compared in an established canine spinal fusion model. Fusions were compared based on union score, fusion mass, fusion volume, and by mechanical testing. Enriched matrix grafts delivered a mean of 2.3 times more cells and approximately 5.6 times more progenitors than matrix mixed with bone marrow. The union score with enriched matrix was superior to matrix alone and matrix plus marrow. Fusion volume and fusion area also were greater with the enriched matrix. These data suggest that the strategy of selective retention provides a rapid, simple, and effective method for concentration and delivery of marrow-derived cells and connective tissue progenitors that may improve the outcome of bone grafting procedures in various clinical settings.

Extractable bone morphogenetic protein and correlation with induced new bone formation in an in vivo assay in the athymic mouse model

A correlation between extractable bone morphogenetic proteins (BMPs) in demineralized bone matrix (DBM) and osteoinduction has been suggested. Extractable BMP-4 and osteoinductivity of DBM from 40 donors were assessed using enzyme-linked immunosorbent assay (ELISA) and in vivo athymic mouse assay, respectively. Extractable BMP-4 level averaged 3.7 +/- 0.21 ng/g of DBM and correlated with osteoinductivity of the DBM in an in vivo assessment of induced newbone formation.

A review of osteoinductive testing methods and sterilization processes for demineralized bone

Allogeneic demineralized bone has been used extensively as a clinical graft material because it has osteoinductive and osteoconductive properties. Concerns over processing and terminal sterilization procedures that may reduce performance have led clinicians to call for assurances of product potency. There is extensive experience on effects of demineralized bone in animal and cell culture models with the possibility for future evidence-based standards for release of products. Evaluation of the current state of knowledge leads to the fact that we cannot conclude that performance of different lots of demineralized bone allografts in in vivo or in vitro test systems can be used as a measure of clinical performance. It may be possible to adopt an osteoinductivity standard for release-to-market, but it should be followed by clinical monitoring and further research.

[The influence of mesenchymal stem cells on bone tissue regeneration upon implantation of demineralized bone matrix]

Mesenchymal stem cells (MSC) are resident pluripotent cells of bone marrow stroma. MSC are able to differentiate into chondroblasts, adipocytes, neurons, glia, cardiomyocytes, or osteoblasts. The problem of MSC usage in cell therapy of bone defects is widely discussed at present. The experiments were carried out using rats of inbred line Wistar-Kyoto. MSC were isolated from bone marrow and cultivated in vitro. Demineralized bone matrices (DBM) were obtained from parietal bones of rats and hens. Part of DBM was loaded with MSC. Bone defects were made in cranium parietal regions. DBM with or without MSC or metal plates were transplanted in these regions. It was shown that the application of MSC increased angiogenesis and osteogenesis in the damaged bone. The implantation of rat's DBM with MSC led to the formation of a full value bone. MSC suppressed inflammation, when transplantation of hen's DBM was carried out. The application of MSC always improved bone tissue regeneration.

Effectiveness of local antibiotic delivery with an osteoinductive and osteoconductive bone-graft substitute

BACKGROUND

The morbidity associated with open fractures and open fracture treatment is well established. An osteoinductive and osteoconductive bone-graft substitute that prevents infection would decrease the number of procedures required to treat contaminated fractures by eliminating the need for surgical removal of cement beads and perhaps autograft harvest. We hypothesized that the combination of tobramycin-impregnated calcium sulfate pellets and demineralized bone matrix would prevent the establishment of infection in a contaminated fracture model.

METHODS

A unicortical 12-mm-diameter defect was created in the proximal tibial metaphysis of twenty-nine Spanish goats. After contaminating the wounds with an infective dose of Staphylococcus aureus, we divided the animals into four groups. The negative control group received no treatment, the positive control group received tobramycin-impregnated polymethylmethacrylate beads, the demineralized bone matrix group received 2.5 mL of demineralized bone matrix, and the experimental group received tobramycin-impregnated calcium sulfate pellets with 2.5 mL of demineralized bone matrix. Radiographs were made and intraosseous tissue cultures were performed on postoperative day 21.

RESULTS

The cultures showed no evidence of intramedullary infection in the experimental or the positive control group, but they were positive for Staphylococcus aureus in six of the seven goats in the negative control group and seven of the eight goats in the demineralized bone matrix group.

CONCLUSIONS

The combination of tobramycin-impregnated calcium sulfate pellets and demineralized bone matrix was effective in preventing intramedullary Staphylococcus aureus infection in a contaminated goat fracture model.

Microwave exposure increases bone demineralization rate independent of temperature

There is a long-standing controversy regarding an effect of microwaves, independent of increasing temperature, on the rate of bone demineralization. In this study, we exposed standardized samples of gerbil femur to constant microwave exposure while maintaining the demineralizing solution (ethylenediamine tetraacetic acid, EDTA) at 20 degrees C. Random samples were selected at 3 h intervals, embedded in plastic and sectioned for histological evaluation to determine the extent of demineralization. The time to complete demineralization was significantly faster with microwave exposure (33 h) compared to non-exposure on a tissue rotator (45 h) in a limited amount (5 mL/24 h) of EDTA. The presence of bone marrow was a significant barrier to the rate of demineralization and resulted in an asymmetrical pattern of mineral extraction. Samples without bone marrow were completely demineralized after 21 h of exposure to microwaves and EDTA. Additional comparisons were made between samples exposed to an effectively infinite supply of demineralizing agent (bone marrow intact). There was a significant increase in rate with unlimited demineralizing agent with (24 h) or without (30 h) microwaves when compared to tissue demineralized on the rotator. Our results establish a positive effect of microwaves on the rate of bone demineralization which is independent of temperature.

Comparison of TGF-beta/BMP pathways signaled by demineralized bone powder and BMP-2 in human dermal fibroblasts

Demineralized bone induces chondrogenic differentiation of human dermal fibroblasts in vitro. Analyses of signaling gene expression showed that DBP and BMP-2 regulate common and distinct pathways. Although BMP-2 was originally isolated as a putative active factor in DBP, rhBMP-2 and DBP do not affect all the same genes or in the same ways.

INTRODUCTION

Demineralized bone powder (DBP) induces chondrogenic differentiation of human dermal fibroblasts (hDFs) in 3D culture, but the initiating mechanisms have not been identified. We tested the hypotheses that DBP would affect expression of signaling genes and that DBP's effects would differ from the effects of bone morphogenetic proteins (BMPs).

MATERIALS AND METHODS

A chondroinduction model was used in which hDFs were cultured with and without DBP in a porous collagen sponge. BMP-2 was delivered in a square of absorbable collagen felt inserted into a collagen sponge. Total RNA was isolated after 3 days of culture, a time that precedes expression of the chondrocyte phenotype. Gene expression was evaluated with two targeted macroarray screens. Effects of DBP and rhBMP-2 were compared by macroarray, RT-PCR, and Northern hybridization analysis of selected genes in the transforming growth factor (TGF)-beta/BMP signaling pathways.

RESULTS

By macroarray analysis of 16 signal transduction pathways, the following pathways were modulated in hDFs by DBP: TGF-beta, insulin/LDL, hedgehog, PI3 kinase/AKT, NF-kappaB, androgen, retinoic acid, and NFAT. There was convergence and divergence in DBP and rhBMP-2 regulation of genes in the TGF-beta/BMP signaling pathway. Smad target genes were the predominant group of DBP- or rhBMP-2-regulated genes. Several genes (IGF-BP3, ID2, and ID3) showed similar responses (increased expression) to DBP and rhBMP-2. In contrast, many of the genes that were greatly upregulated by DBP (TGFBI/betaig-h3, Col3A1, TIMP1, p21/Waf1/Cip1) were barely affected by rhBMP-2.

CONCLUSION

These findings indicate that multiple signaling pathways are regulated in fibroblasts by DBP, that one of the major pathways involves Smad target genes, and that DBP and rhBMP-2 elicit different gene expression responses in hDFs. Although BMP-2 was originally isolated as a putative inductive factor in DBP, rhBMP-2 and DBP do not affect all the same genes or in the same ways.

Osteochondral defect repair by demineralized cortical bone matrix

It has been reported that demineralized bone matrix (cortical or trabecular bone) contains intrinsic cytokines. In the present study, we tested allogeneic demineralized bone matrix for its capacity to resurface osteochondral defects in a rabbit model with the assumption that the intrinsic cytokines in demineralized bone matrix will facilitate the recruitment of progenitor cells from bone marrow into the defect. It was further assumed that these intrinsic bioactive factors would modulate these cells to differentiate into osteochondrogenic lineage and, thus, functionally repair the osteochondral defect. The biocompatibility of demineralized bone matrix was first tested by loading rabbit bone-marrow-derived mesenchymal stem cells into porous demineralized trabecular bone matrix that was then cultured for 3 days. The cell growth in demineralized trabecular bone matrix was examined by scanning electron microscopy. Loaded rabbit bone-marrow-derived mesenchymal stem cells attached to the trabeculae of demineralized trabecular bone matrix; some cells appeared to be round and others were spread and contacted other cells. Allogeneic rabbit demineralized cortical bone matrix or demineralized trabecular bone matrix was implanted into a full-thickness osteochondral defect in the load-bearing area of the medial femoral condyle of young adult rabbits. At 6 and 12 weeks after surgery, gross and histological examination showed that the defects were repaired up to 95% of their depth. The repair tissue using demineralized cortical bone matrix was composed of subchondral bone and a top layer of cartilage that was smooth and integrated with the adjacent cartilage in most of the specimens. Most of the repair tissue in the defect filled with demineralized trabecular bone matrix had a fibrillated surface without integration with the adjacent cartilage. These results indicate that demineralized cortical bone matrix may be potentially useful to repair osteochondral defects by managing the host's intrinsic reparative cells.

Biomaterials in craniofacial reconstruction

Biomaterials have become an integral component of craniofacial reconstruction. Their increasing ease of use, long "shelf-life," and safety enables them to be used effectively and play an important role in reducing operating times. There are various biomaterials currently available and specific usages have been characterized well in the literature. This article reviews different biomaterials that can be used in craniofacial reconstruction,including autogenous bone, methyl methacrylate and hard tissue replacement,hydroxyapatite, porous polyethylene, bioactive glass, and demineralized bone.

Histologic evaluation of demineralized freeze-dried bone allografts in barrier membrane covered periodontal fenestration wounds and ectopic sites in dogs

BACKGROUND/AIM

The aim of this study was to investigate healing responses to demineralized freeze-dried bone powder allografts in standardized periodontal fenestration defects, compared with subcutaneous wounds in a dog model.

METHODS

Circular periodontal fenestration defects were created buccally at all four canines in 14 mongrel dogs. Each site received one of the following underneath a barrier membrane: (a) ethylene oxide (EO)-sterilized demineralized freeze-dried bone allografts (DFDBA), (b) heat-treated DFDBA, (c) non-sterilized DFDBA and (d) ungrafted control. Twelve of the 14 dogs had three subcutaneous chest wall pouches created and one of the three DFDBA materials placed in each. The animals were necropsied at 4 weeks. Histologic sections were prepared through the center of the fenestration sites in an apico-coronal direction. Quantitative analysis using computer-assisted imaging technique was performed. Subcutaneous implants were evaluated histologically and quantified for associated inflammatory cell infiltrate.

RESULTS

Fenestration defects healed by partial osseous fill and cementum regeneration with formation of a periodontal ligament. The graft particles generally appeared isolated from the site of osteogenesis and covered by cementum-like substance. Graft particles incorporated into newly formed bone at a distance from the root surface was the exception. No statistically significant differences in new bone formation were observed between treatment groups within animals, but significant inter-animal variation was found (p<0.01). Quantities of retained graft particles were limited, and without cellular resorption. A bone augmentation effect was associated with the barrier in the majority of sites. No bone formation was evident at the subcutaneous sites where graft particles displayed distinctly modified surface zones and multinucleated giant cell resorption. Significantly more inflammatory infiltrate was associated with EO-sterilized grafts compared with heat-treated grafts (p=0.05).

CONCLUSION

Implantation of DFDBA neither enhanced osseous healing in periodontal fenestration defects, nor resulted in ectopic bone induction. DFDBA particles implanted in either periodontal fenestration or subcutaneous wounds evoked distinctly different healing responses.