The role of electrical stimulation in the management of avascular necrosis of the femoral head in adults: a systematic review

BACKGROUND

Avascular necrosis of the femoral head causes significant morbidity and occurs in up to 20,000 people per year. A variety of nonoperative and operative measures have been trialled however a definitive treatment algorithm is yet to be established. Young adults in many cases have undergone multiple surgical procedures in their lifetime with increasing risks of complications. Less invasive techniques may help reduce the number of operations required and positively influence the natural history of the disease process. Our aim was to navigate the literature and examine the results of electrical stimulation of the femoral head in avascular necrosis.

METHODS

The following defined search strategy was used to perform a systematic review using MEDLINE and Google Scholar databases: ((avascular necrosis) OR (osteonecrosis)) AND (femoral head) AND ((electrical stimulation) OR (capacitive coupling) OR (pulsed electromagnetic fields)). Articles were reviewed and data compiled into tables for analysis.

RESULTS

Fourty six articles were identified with a total of 10 articles meeting the inclusion criteria. 8 articles were prospective studies and 2 were retrospective. Early Ficat stages showed the best responses to treatment via pulsed electromagnetic fields with improvements in both clinical and radiographic parameters. Direct current and capacitative coupling have had a more ambiguous outcome.

CONCLUSIONS

Pulsed electromagnetic fields may have a role in the management of early avascular necrosis. The paucity of clinical studies into this technique indicates a need for further studies.

Cellular mechanosensitivity to substrate stiffness decreases with increasing dissimilarity to cell stiffness

Computational modelling has received increasing attention to investigate multi-scale coupled problems in micro-heterogeneous biological structures such as cells. In the current study, we investigated for a single cell the effects of (1) different cell-substrate attachment (2) and different substrate modulus [Formula: see text] on intracellular deformations. A fibroblast was geometrically reconstructed from confocal micrographs. Finite element models of the cell on a planar substrate were developed. Intracellular deformations due to substrate stretch of [Formula: see text], were assessed for: (1) cell-substrate attachment implemented as full basal contact (FC) and 124 focal adhesions (FA), respectively, and [Formula: see text]140 KPa and (2) [Formula: see text], 140, 1000, and 10,000 KPa, respectively, and FA attachment. The largest strains in cytosol, nucleus and cell membrane were higher for FC (1.35[Formula: see text], 0.235[Formula: see text] and 0.6[Formula: see text]) than for FA attachment (0.0952[Formula: see text], 0.0472[Formula: see text] and 0.05[Formula: see text]). For increasing [Formula: see text], the largest maximum principal strain was 4.4[Formula: see text], 5[Formula: see text], 5.3[Formula: see text] and 5.3[Formula: see text] in the membrane, 9.5[Formula: see text], 1.1[Formula: see text], 1.2[Formula: see text] and 1.2[Formula: see text] in the cytosol, and 4.5[Formula: see text], 5.3[Formula: see text], 5.7[Formula: see text] and 5.7[Formula: see text] in the nucleus. The results show (1) the importance of representing FA in cell models and (2) higher cellular mechanical sensitivity for substrate stiffness changes in the range of cell stiffness. The latter indicates that matching substrate stiffness to cell stiffness, and moderate variation of the former is very effective for controlled variation of cell deformation. The developed methodology is useful for parametric studies on cellular mechanics to obtain quantitative data of subcellular strains and stresses that cannot easily be measured experimentally.

Engineering a Cell Home for Stem Cell Homing and Accommodation

Distilling complexity to advance regenerative medicine from laboratory animals to humans, in situ regeneration will continue to evolve using biomaterial strategies to drive endogenous cells within the human body for therapeutic purposes; this approach avoids the need for delivering ex vivo-expanded cellular materials. Ensuring the recruitment of a significant number of reparative cells from an endogenous source to the site of interest is the first step toward achieving success. Subsequently, making the "cell home" cell-friendly by recapitulating the natural extracellular matrix (ECM) in terms of its chemistry, structure, dynamics, and function, and targeting specific aspects of the native stem cell niche (e.g., cell-ECM and cell-cell interactions) to program and steer the fates of those recruited stem cells play equally crucial roles in yielding a therapeutically regenerative solution. This review addresses the key aspects of material-guided cell homing and the engineering of novel biomaterials with desirable ECM composition, surface topography, biochemistry, and mechanical properties that can present both biochemical and physical cues required for in situ tissue regeneration. This growing body of knowledge will likely become a design basis for the development of regenerative biomaterials for, but not limited to, future in situ tissue engineering and regeneration.

A Concert between Biology and Biomechanics: The Influence of the Mechanical Environment on Bone Healing

In order to achieve consistent and predictable fracture healing, a broad spectrum of growth factors are required to interact with one another in a highly organized response. Critically important, the mechanical environment around the fracture site will significantly influence the way bone heals, or if it heals at all. The role of the various biological factors, the timing, and spatial relationship of their introduction, and how the mechanical environment orchestrates this activity, are all crucial aspects to consider. This review will synthesize decades of work and the acquired knowledge that has been used to develop new treatments and technologies for the regeneration and healing of bone. Moreover, it will discuss the current state of the art in experimental and clinical studies concerning the application of these mechano-biological principles to enhance bone healing, by controlling the mechanical environment under which bone regeneration takes place. This includes everything from the basic principles of fracture healing, to the influence of mechanical forces on bone regeneration, and how this knowledge has influenced current clinical practice. Finally, it will examine the efforts now being made for the integration of this research together with the findings of complementary studies in biology, tissue engineering, and regenerative medicine. By bringing together these diverse disciplines in a cohesive manner, the potential exists to enhance fracture healing and ultimately improve clinical outcomes.

Mechanisms of bone response to injury

Bone, despite its relatively inert appearance, is a tissue that is capable of adapting to its environment. Wolff’s law, first described in the 19th century, describes the ability of bone to change structure depending on the mechanical forces applied to it. The mechanostat model extended this principle and suggested that the amount of strain a bone detects depends on bone strength and the amount of muscle force applied to the bone. Experimental studies have found that low-magnitude, high-frequency mechanical loading is considered to be the most effective at increasing bone formation. The osteocyte is considered to be the master regulator of the bone response to mechanical loading. Deformation of bone matrix by mechanical loading is thought to result in interstitial fluid flow within the lacunar–canalicular system, which may activate osteocyte mechanosensors, leading to changes in osteocyte gene expression and ultimately increased bone formation and decreased bone resorption. However, repetitive strain applied to bone can result in microcracks, which may propagate and coalesce, and if not repaired predispose to catastrophic fracture. Osteocytes are a key component in this process, whereby apoptotic osteocytes in an area of microdamage promote targeted remodeling of the damaged bone. If fractures do occur, fracture repair can be divided into 2 types: primary and secondary healing. Secondary fracture repair is the most common and is a multistage process consisting of hematoma formation and acute inflammation, callus formation, and finally remodeling, whereby bone may return to its original form.

Use of Xenopus Frogs to Study Renal Development/Repair

The Xenopus genus includes several members of aquatic frogs native to Africa but is perhaps best known for the species Xenopus laevis and Xenopus tropicalis. These species were popularized as model organisms from as early as the 1800s and have been instrumental in expanding several biological fields including cell biology, environmental toxicology, regenerative biology, and developmental biology. In fact, much of what we know about the formation and maturation of the vertebrate renal system has been acquired by examining the intricate genetic and morphological patterns that epitomize nephrogenesis in Xenopus. From these numerous reports, we have learned that the process of kidney development is as unique among organs as it is conserved among vertebrates. While development of most organs involves increases in size at a single location, development of the kidney occurs through a series of three increasingly complex nephric structures that are temporally distinct from one another and which occupy discrete spatial locales within the body. These three renal systems all serve to provide homeostatic, osmoregulatory, and excretory functions in animals. Importantly, the kidneys in amphibians, such as Xenopus, are less complex and more easily accessed than those in mammals, and thus tadpoles and frogs provide useful models for understanding our own kidney development. Several descriptive and mechanistic studies conducted with the Xenopus model system have allowed us to elucidate the cellular and molecular mediators of renal patterning and have also laid the foundation for our current understanding of kidney repair mechanisms in vertebrates. While some species-specific responses to renal injury have been observed, we still recognize the advantage of the Xenopus system due to its distinctive similarity to mammalian wound healing, reparative, and regenerative responses. In addition, the first evidence of renal regeneration in an amphibian system was recently demonstrated in Xenopus laevis. As genetic and molecular tools continue to advance, our appreciation for and utilization of this amphibian model organism can only intensify and will certainly provide ample opportunities to further our understanding of renal development and repair.

Direct cryopreservation of adherent cells on an elastic nanofiber sheet featuring a low glass-transition temperature

Electrospun nanofibers, featured a lower glass-transition temperature than the freezing temperature and a loose mesh structure, allows the direct cryopreservation of adherent cells towards the investigation of cell-material composites.

Ageing in the musculoskeletal system

The extent of ageing in the musculoskeletal system during the life course affects the quality and length of life. Loss of bone, degraded articular cartilage, and degenerate, narrowed intervertebral discs are primary features of an ageing skeleton, and together they contribute to pain and loss of mobility. This review covers the cellular constituents that make up some key components of the musculoskeletal system and summarizes discussion from the 2015 Aarhus Regenerative Orthopaedic Symposium (AROS) (Regeneration in the Ageing Population) about how each particular cell type alters within the ageing skeletal microenvironment.

HAp incorporated ultrafine polymeric fibers with shape memory effect for potential use in bone screw hole healing

In the clinical setting of bone fracture healing, hardware removal often causes localized microtrauma and residual screw holes may act as stress risers to place the patient at a risk of refracture. To address this noted issue, this study proposed to develop a biologically mimicking and mechanically self-actuated nanofibrous screw-like scaffold/implant for potential in situ bone regeneration. By incorporating nano-hydroxyapatite (HAp) into a shape memory copolymer poly(d,l-lactide-co-trimethylene carbonate) (PLMC) via co-electrospinning, composite nanofibers of HAp/PLMC with various HAp proportions (1, 2 and 3 wt%) were successfully generated. Morphological, thermal and mechanical properties as well as the shape memory effect of the resultant HAp/PLMC nanofibers were characterized using a variety of techniques. Thereafter, osteoblasts isolated from rat calvarial were cultured on the fibrous HAp/PLMC scaffold to assess its suitability for bone regeneration in vitro. We found that agglomerates gradually appeared on the fiber surface with increasing HAp loading fraction. The switching temperature for actuating shape recovery T_s (i.e., glass transition temperature T_g) of the fibrous HAp/PLMC was readily modulated to fall between 43.5 and 51.3 °C by varying the HAp loadings. Excellent shape memory properties were achieved for the HAp/PLMC composite nanofibers with a shape recovery ratio of R_r > 99% and shape fixity ratio of R_f > 99%, and the shape recovery force of the HAp/PLMC nanofibers was also strengthened compared to that of the HAp-free PLMC nanofibers. Moreover, we demonstrated that the engineered screw-like HAp/PLMC scaffold/implant (ϕ = 5 mm) was able to return from a slender bar to its original stumpy shape in a time frame of merely 8 s at 48 °C. Biological assay results corroborated that the incorporation of HAp to PLMC nanofibers significantly enhanced the alkaline phosphatase secretion as well as mineral deposition in bone formation. These attractive results warrant further investigation in vivo on the feasibility of applying the biomimicking nanofibrous HAp/PLMC scaffold with shape memory effect for bone screw hole healing.

Regeneration of hair and other skin appendages: A microenvironment-centric view

Advances in skin regeneration have resulted in techniques and products that have allowed regeneration of both the dermis and epidermis. Yet complete skin regeneration requires the adnexal skin structures. Thus it is crucial to understand the regenerative potential of hair follicles where genetic, nutritional, and hormonal influences have important effects and are critical for skin regeneration. The follicular stem cell niche serves as an anatomical compartment, a structural unit, a functional integrator, and a dynamic regulator necessary to sustain internal homeostasis and respond to outside stimuli. In particular, mechanics such as pressure, compression, friction, traction, stretch, shear, and mechanical wounding can influence hair loss or growth. Relevant niche signaling pathways such as Wnt, bone morphogenetic protein, fibroblast growth factor, Shh, and Notch may yield potential targets for therapeutic interventions.

Injectable porous nano-hydroxyapatite/chitosan/tripolyphosphate scaffolds with improved compressive strength for bone regeneration

In this study we have fabricated porous injectable spherical scaffolds using chitosan biopolymer, sodium tripolyphosphate (TPP) and nano-hydroxyapatite (nHA). TPP was primarily used as an ionic crosslinker to crosslink nHA/chitosan droplets. We hypothesized that incorporating nHA into chitosan could support osteoconduction by emulating the mineralized cortical bone structure, and improve the Ultimate Compressive Strength (UCS) of the scaffolds. We prepared chitosan solutions with 0.5%, 1% and 2% (w/v) nHA concentration and used simple coacervation and lyophilization techniques to obtain spherical scaffolds. Lyophilized spherical scaffolds had a mean diameter of 1.33mm (n=25). Further, portion from each group lyophilized scaffolds were soaked and dried to obtain Lyophilized Soaked and Dried (LSD) scaffolds. LSD scaffolds had a mean diameter of 0.93mm (n=25) which is promising property for the injectability. Scanning Electron Microscopy images showed porous surface morphology and interconnected pore structures inside the scaffolds. Lyophilized and LSD scaffolds had surface pores <10 and 2μm, respectively. 2% nHA/chitosan LSD scaffolds exhibited UCS of 8.59MPa compared to UCS of 2% nHA/chitosan lyophilized scaffolds at 3.93MPa. Standardize UCS values were 79.98MPa and 357MPa for 2% nHA/chitosan lyophilized and LSD particles respectively. One-way ANOVA results showed a significant increase (p<0.001) in UCS of 1% and 2% nHA/chitosan lyophilized scaffolds compared to 0% and 0.5% nHA/chitosan lyophilized scaffolds. Moreover, 2% nHA LSD scaffolds had significantly increased (p<0.005) their mean UCS by 120% compared to 2% nHA lyophilized scaffolds. In a drawback, all scaffolds have lost their mechanical properties by 95% on the 2nd day when fully immersed in phosphate buffered saline. Additionally live and dead cell assay showed no cytotoxicity and excellent osteoblast attachment to both lyophilized and LSD scaffolds at the end of 14th day of in vitro studies. 2% nHA/chitosan scaffolds showed higher osteoblast attachment than 0% nHA/chitosan scaffolds.

Substrate Modulus Regulates Osteogenic Differentiation of Rat Mesenchymal Stem Cells through Integrin β1 and BMP Receptor Type IA

Osteoblast differentiation of mesenchymal stem cells is regulated by both soluble factor (e.g., bone morphogenetic proteins (BMP)) and mechanically transduced signaling, but the mechanisms have only been partially elucidated. In this study, physical association of BMP Receptor I (BMPRI) with integrin β1 sub-unit (Iβ1) was hypothesized to mediate osteoblast differentiation of rat bone marrow-derived mesenchymal stem cells (MSCs) on bone-like substrates. The effects of substrate modulus on osteoblast differentiation of MSCs were investigated for 2D poly(ester urethane) films with moduli varying from 5 - 266 MPa, which spans the range from collagen fibrils to trabecular bone. SMAD1/5 and p44/42 MAPK signaling, expression of markers of osteoblast differentiation, and matrix mineralization increased with increasing substrate modulus. The effects of substrate modulus on osteoblast differentiation were mediated by Iβ1, which was also expressed at higher levels on increasingly rigid substrates. Förster resonance energy transfer (FRET) and immunoprecipitation (IP) experiments showed that physical association of Iβ1 and BMP Receptor I (BMRPRI) increased with substrate modulus, resulting in activation of the BMP signaling pathway. Thus, these studies showed that integrin and BMP signaling converge to regulate osteoblast differentiation of MSCs, which may potentially guide the design of scaffolds and rhBMP-2 delivery systems for bone regeneration.

Mechanical stress regulates osteogenic differentiation and RANKL/OPG ratio in periodontal ligament stem cells by the Wnt/β-catenin pathway

BACKGROUND

The balance between osteoblastic and osteoclastic activity is critical in orthodontic tooth movement (OTM). Mesenchymal stem cells (MSCs) play an important role in maintaining bone homeostasis, and periodontal ligament stem cells (PDLSCs) are tissue-specific MSCs in the periodontal ligament. However, whether PDLSCs are required for periodontal tissue remodeling during OTM is not fully understood.

METHODS

Here, we used PDGFRα and Nestin to trace PDLSCs during OTM in rats. We treat human PDLSCs with 100kpa static pressure for 1h or 12h in vitro, and examined the phenotypic changes and expression of RANKL and OPG in these cells.

RESULTS

In vivo, we found that positive signals of PDGFRα and Nestin in the PDL gradually increased and then decreased on the pressure side to which pressure was applied. In vitro, the osteogenic differentiation of PDLSCs was significantly increased after force treatment for 1h relative to 12h. In contrast, the expression ratio of RANKL/OPG was reduced at 1h and significantly increased at 12h. Furthermore, we found that the Wnt/β-catenin pathway was dynamically activated in the PDL and in PDLSCs after mechanical stimulation. Importantly, the canonical Wnt pathway inhibitor DKK1 blocked the osteogenesis effect and rescued the ratio of RANKL/OPG in PDLSCs under force treatment for 1h.

CONCLUSIONS

Our findings reveal that PDLSCs participate in OTM and that the Wnt/β-catenin pathway maintains bone homeostasis during tooth movement by regulating the balance between osteoblastic and osteoclastic activity.

GENERAL SIGNIFICANCE

We describe a novel potential mechanism related to tooth movement.

Mechanotransduction: Relevance to Physical Therapist Practice-Understanding Our Ability to Affect Genetic Expression Through Mechanical Forces

Mechanotransduction, the mechanism by which mechanical perturbation influences genetic expression and cellular behavior, is an area of molecular biology undergoing rapid exploration and discovery. Cells are sensitive to forces such as shear, tension, and compression, and they respond accordingly through cellular proliferation, migration, tissue repair, altered metabolism, and even stem cell differentiation and maturation. The study of how cells sense and respond to mechanical stimulation is under robust expansion, with new scientific methods and technologies at our disposal. The application of these technologies to physical therapist practice may hold answers to some of our age-old questions while creating new avenues for our profession to optimize movement for societal health. Embracing this science as foundational to our profession will allow us to be valuable scientific collaborators with distinctive knowledge of the effects of loading. These partnerships will be key to augmenting the clinical utility of emerging therapies such as regenerative medicine, tissue engineering, and gene therapy. Collaboration with other scientific disciplines in these endeavors, along with the inclusion and application of these discoveries in our academic programs, will enhance the understanding of the impact of our practice on biologic and genetic processes. A basic understanding of mechanotransduction and its relevance to physical therapist practice is warranted to begin the conversation.

YAP-Mediated Mechanotransduction in Skeletal Muscle

Skeletal muscle is not only translating chemical energy into mechanical work, it is also a highly adaptive and regenerative tissue whose architecture and functionality is determined by its mechanical and physical environment. Processing intra- and extracellular mechanical signaling cues contributes to the regulation of cell growth, survival, migration and differentiation. Yes-associated Protein (YAP), a transcriptional coactivator downstream of the Hippo pathway and its paralog, the transcriptional co-activator with PDZ-binding motif (TAZ), were recently found to play a key role in mechanotransduction in various tissues including skeletal muscle. Furthermore, YAP/TAZ modulate myogenesis and muscle regeneration and abnormal YAP activity has been reported in muscular dystrophy and rhabdomyosarcoma. Here, we summarize the current knowledge of mechanosensing and -signaling in striated muscle. We highlight the role of YAP signaling and discuss the different routes and hypotheses of its regulation in the context of mechanotransduction.

Effects of Yogasanas on osteoporosis in postmenopausal women

Background:

Osteoporosis is commonly encountered by postmenopausal women. There is an increased need for a low cost and efficient treatment alternative to address this population.

Aims:

To study the effects of integrated yoga on bone mineral density (BMD) in postmenopausal women with osteoporosis.

Settings and Designs:

Experimental pre-post study conducted in a community setting.

Materials and Methods:

30 females in the age group of 45–62 years suffering from postmenopausal osteoporosis with a dual-energy X-ray absorptiometry (DEXA) score of ≤−2.5 underwent a 6 months fully supervised yoga session. All the participants completed the study. Pretraining and posttraining BMD was calculated. Outcome measure: DEXA score at the lumbar spine.

Statistical Analysis:

The study was statistically analyzed using paired t-test to see the significance of pretraining and posttraining effects of a yoga session.

Results:

Improvement in T-score of DEXA scan of −2.55 ± 0.25 at posttraining as compared to a pretraining score of −2.69 ± 0.17.

Conclusions:

Integrated yoga is a safe mode of physical activity which includes weight bearing as well as not weight bearing asanas, Pranayama, and suryanamaskar, all of which helps induce improvement in BMD in postmenopausal osteoporotic females.

Review of the cellular and biological principles of distraction osteogenesis: An in vivo bioreactor tissue engineering model

Distraction osteogenesis (DO) is a widely used technique in plastic and orthopaedic surgery. During the process, mechanical force is applied to fractured bone to enhance the regenerative processes and induce new bone formation. Although there is an abundance of literature on the clinical process of DO, there is a distinct lack of focus on the underlying biological principles governing this process. DO follows the basic premises of tissue engineering. The mechanical stress stimulates mesenchymal stem cell differentiation down an osteoblastic lineage on a matrix background. The aim of this review is to give an overview of the current knowledge of the molecular mechanism governing this process.

The Accordion Maneuver: A Noninvasive Strategy for Absent or Delayed Callus Formation in Cases of Limb Lengthening

The distraction osteogenesis (DO) technique has been used worldwide to treat many orthopaedic conditions. Although successful, absent or delayed callus formation in the distraction gap can lead to significant morbidities. An alternate cycle of distraction-compression (accordion maneuver) is one approach to accelerate bone regeneration. The primary aim of our study is to report our experience with the accordion maneuver during DO and to provide a detailed description of this technique, as performed in our center. The secondary aim is to present a review of the literature regarding the use of accordion maneuver. We reviewed the database of all patients undergoing limb lengthening from the year of 1997 to 2012. Four patients (6.15%) out of 65 showed poor bone regenerate in their tibiae and therefore accordion maneuver was applied for a mean of 6.75 weeks. Of these, three patients have had successful outcome with this technique. The literature showed that this technique is successful approach to trigger bone healing. However, details of how and when to apply this combination of distraction-compression forces were lacking. In conclusion, the accordion technique is safe noninvasive approach to promote bone formation, thus avoiding more invasive surgical procedures in cases of poor callus formation in limb lengthening.

Overcoming translational challenges - The delivery of mechanical stimuli in vivo

Despite major medical advances, non-union bone fractures and skeletal defects continue to place significant burden on the patient, the clinicians and the healthcare system as a whole. Current bone substitute approaches are still limited in effectiveness and to date no adequate bone substitute material has been developed for routine clinical application. Tissue engineering presents a novel approach to tackling this clinical burden and developing an acceptable solution for the treatment of skeletal defects. Over the past three decades the field has evolved to appreciate the key biological, material and physical parameters influencing the development of a cell-based tissue engineered therapy and to create associated technologies to exploit such parameters. In recent years a number of therapies have started progressing along the pre-clinical pipeline to build a case for regulatory approval and ultimately clinical adoption. However, little emphasis has been given to the translational challenges faced when moving from "bench-to-bedside". One particular challenge lies in the delivery of functional mechanical stimuli to implanted cell populations to activate and promote osteogenic activities. This review introduces novel bio-magnetic approaches to overcoming this challenge.

Comprehensive Review of Adipose Stem Cells and Their Implication in Distraction Osteogenesis and Bone Regeneration

Bone is one of the most dynamic tissues in the human body that can heal following injury without leaving a scar. However, in instances of extensive bone loss, this intrinsic capacity of bone to heal may not be sufficient and external intervention becomes necessary. Several techniques are available to address this problem, including autogenous bone grafts and allografts. However, all these techniques have their own limitations. An alternative method is the technique of distraction osteogenesis, where gradual and controlled distraction of two bony segments after osteotomy leads to induction of new bone formation. Although distraction osteogenesis usually gives satisfactory results, its major limitation is the prolonged duration of time required before the external fixator is removed, which may lead to numerous complications. Numerous methods to accelerate bone formation in the context of distraction osteogenesis have been reported. A viable alternative to autogenous bone grafts for a source of osteogenic cells is mesenchymal stem cells from bone marrow. However, there are certain problems with bone marrow aspirate. Hence, scientists have investigated other sources for mesenchymal stem cells, specifically adipose tissue, which has been shown to be an excellent source of mesenchymal stem cells. In this paper, the potential use of adipose stem cells to stimulate bone formation is discussed.

Biomedical potential of chitosan/HA and chitosan/β-1,3-glucan/HA biomaterials as scaffolds for bone regeneration--A comparative study

The aim of this work was to compare biomedical potential of chitosan/hydroxyapatite (chit/HA) and novel chitosan/β-1,3-glucan/hydroxyapatite (chit/glu/HA) materials as scaffolds for bone regeneration via characterization of their biocompatibility, porosity, mechanical properties, and water uptake behaviour. Biocompatibility of the scaffolds was assessed in direct-contact with the materials using normal human foetal osteoblast cell line. Cytotoxicity and osteoblast proliferation rate were evaluated. Porosity was assessed using computed microtomography analysis and mechanical properties were determined by compression testing. Obtained results demonstrated that chit/HA scaffold possessed significantly better mechanical properties (compressive strength: 1.23 MPa, Young's modulus: 0.46 MPa) than chit/glu/HA material (compressive strength: 0.26 MPa, Young's modulus: 0.25 MPa). However, addition of bacterial β-1,3-glucan to the chit/HA scaffold improved its flexibility and porosity. Moreover, chit/glu/HA scaffold revealed significantly higher water uptake capability (52.6% after 24h of soaking) compared to the chit/HA (30.7%) and thus can serve as a very good drug delivery carrier. Chit/glu/HA scaffold was also more favourable to osteoblast survival (near 100% viability after 24-h culture), proliferation, and spreading compared to the chit/HA (63% viability). The chit/glu/HA possesses better biomedical potential than chit/HA scaffold. Nevertheless, poor mechanical properties of the chit/glu/HA limit its application to non-load bearing implantation area.

Distraction Osteogenesis Using Bone Matrix Osteotensors in Ectodermal Dysplasia: A Case Report

INTRODUCTION

Ectodermal dysplasia patients require complex oral rehabilitation. Bone matrix Osteotensors activate the patient's own stem cells to promote new bone formation through an autogenous growth factor cascade generated by a targeted flapless bone distraction before implant and/or bone graft therapy.

MATERIALS AND METHODS

The maxillary and mandibular bone were activated 21 (for type I bone) to 45 days (for type IV bone) before implant and/or bone substitute installation. Purpose-designed Osteotensors initiated massive recruitment of stem cells in the intended bone recipient site, thereby triggering neoangiogenesis and osteogenesis. After new bone formation, root-form implants and Diskimplants were installed. Functional loading was obtained at 48 hours using highly rigid, screw-secured fixed upper and lower full-arch prostheses.

RESULTS

At 3 years, all implants appeared clinically and radiologically osseointegrated with an excellent functional and esthetic outcome.

CONCLUSION

Flapless distraction osteogenesis using bone matrix Osteotensors several weeks before surgery improved the initial quality and volume of the recipient bone bed. This minimally invasive approach allows future successful immediate implant-supported complete maxillomandibular fixed rehabilitation without preliminary grafting procedures in patients with an unfavorable initial bone anatomy.

Wolff's law in action: a mechanism for early knee osteoarthritis

There is growing interest in the role of bone in knee osteoarthritis. Bone is a dynamic organ, tightly regulated by a multitude of homeostatic controls, including genetic and environmental factors. One such key environmental regulator of periarticular bone is mechanical stimulation, which, according to Wolff’s law, is a key determinant of bone properties. Wolff’s law theorizes that repetitive loading of bone will cause adaptive responses enabling the bone to better cope with these loads. Despite being an adaptive response of bone, the remodeling process may inadvertently trigger maladaptive responses in other articular structures. Accumulating evidence at the knee suggests that expanding articular bone surface area is driven by mechanical stimulation and is a strong predictor of articular cartilage loss. Similarly, fractal analysis of bone architecture provides further clues that bone adaptation may have untoward consequences for joint health. This review hypothesizes that adaptations of periarticular bone in response to mechanical stimulation cause maladaptive responses in other articular structures that mediate the development of knee osteoarthritis. A potential disease paradigm to account for such a hypothesis is also proposed, and novel therapeutic targets that may have a bone-modifying effect, and therefore potentially a disease-modifying effect, are also explored.

Bone geometry of the hip is associated with obesity and early structural damage--a 3.0 T magnetic resonance imaging study of community-based adults

Introduction

The mechanism by which obesity increases the risk of hip osteoarthritis is unclear. One possibility may be by mediating abnormalities in bony geometry, which may in turn be associated with early structural abnormalities, such as cartilage defects and bone marrow lesions.

Methods

One hundred and forty one older adults with no diagnosed hip osteoarthritis had weight and body mass index measured between 1990 and 1994 and again in 2009 to 2010. Acetabular depth and lateral centre edge angle, both measures of acetabular over-coverage, as well as femoral head cartilage volume, cartilage defects and bone marrow lesions were assessed with 3.0 T magnetic resonance imaging performed in 2009 to 2010.

Results

Current body mass index, weight and weight gain were associated with increased acetabular depth and lateral centre edge angle (all P ≤ 0.01). For every 1 mm increase in acetabular depth, femoral head cartilage volume reduced by 59 mm³ (95% confidence interval (CI) 20 mm³ to 98 mm³, P < 0.01). Greater acetabular depth was associated with an increased risk of cartilage defects (odds ratio (OR) 1.22, 95% CI 1.03 to 1.44, P = 0.02) and bone marrow lesions (OR 1.29, 95% CI 1.01 to 1.64, P = 0.04) in the central region of the femoral head. Lateral centre edge angle was not associated with hip structure.

Conclusions

Obesity is associated with acetabular over-coverage. Increased acetabular depth, but not the lateral centre edge angle, is associated with reduced femoral head cartilage volume and an increased risk of cartilage defects and bone marrow lesions. Minimising any deepening of the acetabulum (for example, through weight management) might help to reduce the incidence of hip osteoarthritis.

Biohybrid hematopoietic niche for expansion of hematopoietic stem/progenitor cells by using geometrically controlled fibrous layers

Biohybrid hematopoietic niche for expansion of hematopoietic stem/progenitor cells.

Novel techniques in the development of osteoporosis drug therapy: the osteoclast ruffled-border vacuolar H(+)-ATPase as an emerging target

INTRODUCTION

Bone loss occurs in many diseases, including osteoporosis, rheumatoid arthritis and periodontal disease. For osteoporosis alone, it is estimated that 75 million people are afflicted worldwide, with high risks of fractures and increased morbidity and mortality. The demand for treatment consumes an ever-increasing share of healthcare resources. Successive generations of antiresorptive bisphosphonate drugs have reduced side effects, minimized frequency of dosing, and increased efficacy in halting osteoporotic bone loss, but their shortcomings have remained significant to the extent that a monoclonal antibody antiresorptive has recently taken a significant market share. Yet this latter, paradigm-shifting approach has its own drawbacks.

AREAS COVERED

This review summarizes recent literature on bone-remodeling cell and molecular biology and the background for existing approaches and emerging therapeutics and targets for treating osteoporosis. The authors discuss vacuolar H(+)-ATPase (V-ATPase) molecular biology and the recent advances in targeting the osteoclast ruffled-border V-ATPase (ORV) for the development of novel antiresorptive drugs. They also cover examples from the V-ATPase-targeted drug discovery literature, including conventional molecular biology methods, in silico drug discovery, and gene therapy in more detail as proofs of concept.

EXPERT OPINION

Existing therapeutic options for osteoporosis have limitations and inherent drawbacks. Thus, the search for novel approaches to osteoporosis drug discovery remains relevant. Targeting the ORV may be one of the more selective means of regulating bone resorption. Furthermore, this approach may be effective without removing active osteoclasts from the finely balanced osteoclast-osteoblast coupling required for normal bone remodeling.

Vascular analysis as a proxy for mechanostransduction response in an isogenic, irradiated murine model of mandibular distraction osteogenesis

INTRODUCTION

Head and neck cancer is a debilitating and disfiguring disease. Although numerous treatment options exist, an array of debilitating side effects accompany them, causing physiological and social problems. Distraction osteogenesis (DO) can avoid many of the pathologies of current reconstructive strategies; however, due to the deleterious effects of radiation on bone vascularity, DO is generally ineffective. This makes investigating the effects of radiation on neovasculature during DO and creating quantifiable metrics to gauge the success of future therapies vital. The purpose of this study was to develop a novel isogenic rat model of impaired vasculogenesis of the regenerate mandible in order to determine quantifiable metrics of vascular injury and associated damage.

METHODS

Male Lewis rats were divided into two groups: DO only (n=5) AND Radiation Therapy (XRT)+DO (n=7). Afterwards, a distraction device was surgically implanted into the mandible. Finally, they were distracted a total of 5.1mm. Animals were perfused with a radiopaque casting agent concomitant with euthanasia, and subsequently demineralization, microcomputed tomography, and vascular analysis were performed.

RESULTS

Vessel volume fraction, vessel thickness, vessel number, and degree of anisotropy were diminished by radiation. Vessel separation was increased by radiation.

CONCLUSION

The DO group experienced vigorous vessel formation during distraction and neovascularization with a clear, directional progression, while the XRT/DO group saw weak vessel formation during distraction and neovascularization. Further studies are warranted to more deeply examine the impairments in osteogenic mechanotransductive pathways following radiation in the murine mandible. This isogenic model provides quantifiable metrics for future studies requiring a controlled approach to immunogenicity.

Stem Cells toward the Future: The Space Challenge

Astronauts experience weightlessness-induced bone loss due to an unbalanced process of bone remodeling that involves bone mesenchymal stem cells (bMSCs), as well as osteoblasts, osteocytes, and osteoclasts. The effects of microgravity on osteo-cells have been extensively studied, but it is only recently that consideration has been given to the role of bone MSCs. These live in adult bone marrow niches, are characterized by their self-renewal and multipotent differentiation capacities, and the published data indicate that they may lead to interesting returns in the biomedical/bioengineering fields. This review describes the published findings concerning bMSCs exposed to simulated/real microgravity, mainly concentrating on how mechanosignaling, mechanotransduction and oxygen influence their proliferation, senescence and differentiation. A comprehensive understanding of bMSC behavior in microgravity and their role in preventing bone loss will be essential for entering the future age of long-lasting, manned space exploration.

Effect of glimepiride on the skeletal system of ovariectomized and non-ovariectomized rats

BACKGROUND

Diabetes mellitus type 2 and osteoporosis are major health problem, especially in postmenopausal women. Glimepiride is a third-generation sulfonylurea derivative and is used as a first-line drug in the treatment of type 2 diabetes mellitus. The effect of this drug on bone tissue is unknown. The aim of the present study was to investigate the influence of glimepiride on the skeletal system in ovariectomized and non-ovariectomized rats.

METHODS

The experiment was conducted on 3-month-old female Wistar rats, divided into 4 groups (n=10 per group): I (NOVX)-non-ovariectomized control rats, II (NOVX+G)-non-ovariectomized rats receiving glimepiride (0.8 mg/kg po), III (OVX)-ovariectomized control rats, IV (OVX+G)-ovariectomized rats receiving glimepiride (0.8 mg/kg po). Bilateral ovariectomy was performed 7 days before the start of the experiment, under ketamine-xylazine anesthesia. Glimepiride was administered once daily for 28 days. The effect of glimepiride on the skeletal system was assessed based on macrometric parameters, histomorphometric parameters and mechanical properties of the tibial metaphysis, femoral diaphysis and femoral neck. Bone mass, mineral mass, calcium and phosphorus content, as well as serum estrogen, osteocalcin and RatLaps levels were also studied.

RESULTS

Estrogen deficiency in ovariectomized rats caused increased bone remodeling, with an intensification of bone resorption and formation, and mineralization impairment. Glimepiride in ovariectomized rats inhibited the development of changes in the skeletal system caused by estrogen deficiency, intensifying bone formation. In the presence of estrogens (in non-ovariectomized rats), glimepiride also intensified bone formation, but to a lesser extent.

CONCLUSIONS

Glimepiride, in the therapy of type 2 diabetes mellitus in postmenopausal women, may have a beneficial effect on bone remodeling and may reduce the risk of development of osteoporosis.

BMP growth factor signaling in a biomechanical context

Bone Morphogenetic Proteins (BMPs) are members of the transforming growth factor-β superfamily of secreted polypeptide growth factors and are important regulators in a multitude of cellular processes. To ensure the precise and balanced propagation of their pleiotropic signaling responses, BMPs and their corresponding signaling pathways are subject to tight control. A large variety of regulatory mechanisms throughout different biological levels combines into a complex network and provides the basis for physiological BMP function. This regulatory network not only includes biochemical factors but also mechanical cues. Both BMP signaling and mechanotransduction pathways are tightly interconnected and represent an elaborate signaling network active during development but also during organ homeostasis. Moreover, its dysregulation is associated with a number of human pathologies. A more detailed understanding of this crosstalk in respect to molecular interactions will be indispensable in the future, in particular to understand BMP-related diseases as well as with regard to an efficient clinical application of BMP ligands.

Mechanosignaling in bone health, trauma and inflammation

SIGNIFICANCE

Mechanosignaling is vital for maintaining the structural integrity of bone under physiologic conditions. These signals activate and suppress multiple signaling cascades regulating bone formation and resorption. Understanding these pathways is of prime importance to exploit their therapeutic potential in disorders associated with bone loss due to disuse, trauma, or disruption of homeostatic mechanisms.

RECENT ADVANCES

In the case of cells of the bone, an impressive amount of data has been generated that provides evidence of a complex mechanism by which mechanical signals can maintain or disrupt cellular homeostasis by driving transcriptional regulation of growth factors, matrix proteins and inflammatory mediators in health and inflammation. Mechanical signals act on cells in a magnitude dependent manner to induce bone deposition or resorption. During health, physiological levels of these signals are essential for maintaining bone strength and architecture, whereas during inflammation, similar signals can curb inflammation by suppressing the nuclear factor kappa B (NF-κB) signaling cascade, while upregulating matrix synthesis via mothers against decapentaplegic homolog and/or Wnt signaling cascades. Contrarily, excessive mechanical forces can induce inflammation via activation of the NF-κB signaling cascade.

CRITICAL ISSUES

Given the osteogenic potential of mechanical signals, it is imperative to exploit their therapeutic efficacy for the treatment of bone disorders. Here we review select signaling pathways and mediators stimulated by mechanical signals to modulate the strength and integrity of the bone.

FUTURE DIRECTIONS

Understanding the mechanisms of mechanotransduction and its effects on bone lay the groundwork for development of nonpharmacologic mechanostimulatory approaches for osteodegenerative diseases and optimal bone health.

Basic science of bone healing

Bone healing is a complex process that can be influenced by both host and environmental factors. In this article, we review the biology involved in the regeneration of new bone after fracture, and factors influencing bone healing, including diabetes, smoking, NSAID use, and bisphosphonates.

Effects of ageing, prolonged estrogen deficiency and zoledronate on bone tissue mineral distribution

The quantity and distribution of bone tissue mineral are key determinants of bone strength. Recent research revealed altered mineral distribution within sheep femora following estrogen deficiency. Rapid increases in bone remodeling occur at the onset of estrogen deficiency and abate over time. Therefore, altered tissue mineralization might be a transient characteristic of osteoporosis. Bisphosphonates reduce fracture incidence by 40-60% but increases in bone mineral density are insufficient to explain such changes. In this study the hypotheses that bone tissue mineralization is altered over prolonged estrogen depletion and bisphosphonate treatment were tested. Quantitative backscattered imaging (qBEI) was used to quantify bone mineral density distribution (BMDD) parameters (mean, FWHM) in trabeculae from the proximal femora of an ovariectomized sheep model that underwent estrogen deficiency for 31 months, an ovariectomized group administered with Zoledronic acid and age-matched controls. To assess the effects of normal ageing and prolonged estrogen deficiency, data were compared to BMDD data from sheep that were estrogen deficient for 12 months and age-matched controls. This study reports that normal ageing increases mean mineralization and mineral heterogeneity at a trabecular level. In contrast, prolonged estrogen deficiency leads to significantly decreased mean mineralization and further exacerbates increases in mineral heterogeneity. Interestingly, ZOL treatment of OVX sheep significantly reduced tissue mineral variability, both at a trabecular level and between femoral regions. Together, these findings indicate that ZOL treatment acts to reverse the increased mineral heterogeneity occurring during estrogen deficiency, which may contribute to its capacity to reduce osteoporotic fractures.

The role of homocysteine in bone remodeling

Bone remodeling is a very complex process. Homocysteine (Hcy) is known to modulate this process via several known mechanisms such as increase in osteoclast activity, decrease in osteoblast activity and direct action of Hcy on bone matrix. Evidence from previous studies further support a detrimental effect on bone via decrease in bone blood flow and an increase in matrix metalloproteinases (MMPs) that degrade extracellular bone matrix. Hcy binds directly to extracellular matrix and reduces bone strength. There are several bone markers that can be used as parameters to determine how high levels of plasma Hcy (hyperhomocysteinemia, HHcy) affect bone such as: hydroxyproline, N-terminal collagen 1 telopeptides. Mitochondrion serves an important role in generating reactive oxygen species (ROS). Mitochondrial abnormalities have been identified during HHcy. The mechanism of Hcy-induced bone remodeling via the mitochondrial pathway is largely unknown. Therefore, we propose a mitochondrial mechanism by which Hcy can contribute to alter bone properties. This may occur both through generations of ROS that activate MMPs and could be extruded into matrix to degrade bone matrix. However, there are contrasting reports on whether Hcy affects bone density, with some reports in favour and others not. Earlier studies also found an alteration in bone biomechanical properties with deficiencies of vitamin B12, folate and HHcy conditions. Moreover, existing data opens speculation that folate and vitamin therapy act not only via Hcy-dependent pathways but also via Hcy-independent pathways. However, more studies are needed to clarify the mechanistic role of Hcy during bone diseases.

Reversal of the detrimental effects of simulated microgravity on human osteoblasts by modified low intensity pulsed ultrasound

Microgravity (MG) is known to induce bone loss in astronauts during long-duration space mission because of a lack of sufficient mechanical stimulation under MG. It has been demonstrated that mechanical signals are essential for maintaining cell viability and motility, and they possibly serve as a countermeasure to the catabolic effects of MG. The objective of this study was to examine the effects of high-frequency acoustic wave signals on osteoblasts in a simulated microgravity (SMG) environment (created using 1-D clinostat bioreactor) using a modified low-intensity pulsed ultrasound (mLIPUS). Specifically, we evaluated the hypothesis that osteoblasts (human fetal osteoblastic cell line) exposure to mLIPUS for 20 min/d at 30 mW/cm(2) will significantly reduce the detrimental effects of SMG. Effects of SMG with mLIPUS were analyzed using the MTS proliferation assay for proliferation, phalloidin for F-actin staining, Sirius red stain for collagen, and Alizarin red for mineralization. Our data showed that osteoblast exposure to SMG results in significant decreases in proliferation (∼ -38% and ∼ -44% on days 4 and 6, respectively; p < 0.01), collagen content (∼ -22%; p < 0.05) and mineralization (∼ -37%; p < 0.05) and actin stress fibers. In contrast, mLIPUS stimulation in SMG condition significantly increases the rate of proliferation (∼24% by day 6; p < 0.05), collagen content (∼52%; p < 0.05) and matrix mineralization (∼25%; p < 0.001) along with restoring formation of actin stress fibers in the SMG-exposed osteoblasts. These data suggest that the acoustic wave can potentially be used as a countermeasure for disuse osteopenia.

Mechanical forces regulate stem cell response to surface topography

The interactions between bone tissue and orthopedic implants are strongly affected by mechanical forces at the bone-implant interface, but the interplay between surface topographies, mechanical stimuli, and cell behavior is complex and not well understood yet. This study reports on the influence of mechanical stretch on human mesenchymal stem cells (hMSCs) attached to metallic substrates with different roughness. Controlled forces were applied to plasma membrane of hMSCs cultured on smooth and rough stainless steel surfaces using magnetic collagen-coated particles and an electromagnet system. Degree of phosphorylation of focal adhesion kinase (p-FAK) on the active form (Tyr-397), prostaglandin E2 (PGE2) and vascular endothelial growth factor (VEGF) levels increased on rough samples under static conditions. Cell viability and fibronectin production decreased on rough substrates, while hMSCs maturated to the osteoblastic lineage to a similar extent on both surfaces. PGE2 production and osteoprotegerin/receptor activator of nuclear factor kappa-B ligand ratio increased after force application on both surfaces, although to a greater extent on smooth substrates. p-FAK on Tyr-397 was induced fairly rapidly by mechanical stimulation on rough surfaces while cells cultured on smooth samples failed to activate this kinase in response to tensile forces. Mechanical forces enhanced VEGF secretion and reduced cell viability, fibronetin levels and osteoblastic maturation on smooth surfaces but not on rough samples. The magnetite beads model used in this study is well suited to characterize the response of hMSCs cultured on metallic surfaces to tensile forces and collected data suggest a mechanism whereby mechanotransduction driven by FAK is essential for stem cell growth and functioning on metallic substrates.

Rac1 and Cdc42 GTPases regulate shear stress-driven β-catenin signaling in osteoblasts

Beta-catenin-dependent TCF/LEF (T-cell factor/lymphocyte enhancing factor) is known to be mechanosensitive and an important regulator for promoting bone formation. However, the functional connection between TCF/LEF activity and Rho family GTPases is not well understood in osteoblasts. Herein we investigated the molecular mechanisms underlying oscillatory shear stress-induced TCF/LEF activity in MC3T3-E1 osteoblast cells using live cell imaging. We employed fluorescence resonance energy transfer (FRET)-based and green fluorescent protein (GFP)-based biosensors, which allowed us to monitor signal transduction in living cells in real time. Oscillatory (1Hz) shear stress (10 dynes/cm2) increased TCF/LEF activity and stimulated translocation of β-catenin to the nucleus with the distinct activity patterns of Rac1 and Cdc42. The shear stress-induced TCF/LEF activity was blocked by the inhibition of Rac1 and Cdc42 with their dominant negative mutants or selective drugs, but not by a dominant negative mutant of RhoA. In contrast, constitutively active Rac1 and Cdc42 mutants caused a significant enhancement of TCF/LEF activity. Moreover, activation of Rac1 and Cdc42 increased the basal level of TCF/LEF activity, while their inhibition decreased the basal level. Interestingly, disruption of cytoskeletal structures or inhibition of myosin activity did not significantly affect shear stress-induced TCF/LEF activity. Although Rac1 is reported to be involved in β-catenin in cancer cells, the involvement of Cdc42 in β-catenin signaling in osteoblasts has not been identified. Our findings in this study demonstrate that both Rac1 and Cdc42 GTPases are critical regulators in shear stress-driven β-catenin signaling in osteoblasts.

MMP9 regulates the cellular response to inflammation after skeletal injury

Like other tissue injuries, bone fracture triggers an inflammatory response, which plays an important role in skeletal repair. Inflammation is believed to have both positive and negative effects on bone repair, but the underlying cellular mechanisms are not well understood. To assess the role of inflammation on skeletal cell differentiation, we used mouse models of fracture repair that stimulate either intramembranous or endochondral ossification. In the first model, fractures are rigidly stabilized leading to direct bone formation, while in the second model, fracture instability causes cartilage and bone formation. We compared the inflammatory response in these two mechanical environments and found changes in the expression patterns of inflammatory genes and in the recruitment of inflammatory cells and osteoclasts. These results suggested that the inflammatory response could influence skeletal cell differentiation after fracture. We then exploited matrix metalloproteinase 9 (MMP9) that is expressed in inflammatory cells and osteoclasts, and which we previously showed is a potential regulator of cell fate decisions during fracture repair. Mmp9(-/-) mice heal stabilized fractures via endochondral ossification, while wild type mice heal via intramembranous ossification. In parallel, we observed increases in macrophages and T cells in the callus of Mmp9(-/-) compared to wild type mice. To assess the link between the profile of inflammatory cells and skeletal cell fate functionally, we transplanted Mmp9(-/-) mice with wild type bone marrow, to reconstitute a wild type hematopoietic lineage in interaction with the Mmp9(-/-) stroma and periosteum. Following transplantation, Mmp9(-/-) mice healed stabilized fractures via intramembranous ossification and exhibited a normal profile of inflammatory cells. Moreover, Mmp9(-/-) periosteal grafts healed via intramembranous ossification in wild type hosts, but healed via endochondral ossification in Mmp9(-/-) hosts. We observed that macrophages accumulated at the periosteal surface in Mmp9(-/-) mice, suggesting that cell differentiation in the periosteum is influenced by factors such as BMP2 that are produced locally by inflammatory cells. Taken together, these results show that MMP9 mediates indirect effects on skeletal cell differentiation by regulating the inflammatory response and the distribution of inflammatory cells, leading to the local regulation of periosteal cell differentiation.