Vascular endothelial growth factor gene-activated matrix (VEGF165-GAM) enhances osteogenesis and angiogenesis in large segmental bone defects

Osteoblast-specific Angiopoietin 1 overexpression increases bone mass

Although osteoblasts express the angiogenic protein Angiopoietin 1 (Ang1), the role of Ang1 in bone formation remains largely unknown. Here we report that Ang1 overexpression in osteoblasts driven by the osteoblast-specific 2.3 kb alpha 1 type 1 collagen promoter results in increased bone mass in vivo. In Ang1-transgenic mice (Ang1-Tg), bone volume and bone parameters increased significantly compared with wild-type littermates, although the Ang1 receptor, Tie2 was not expressed in osteoblasts. Tie2 is primarily expressed in vascular endothelial cells, and Ang1-Tie2 signaling is reportedly crucial for angiogenesis. We found that the number of vascular endothelial cells was significantly elevated in Ang1-Tg mice compared with that of wild-type littermates, an increase accompanied by increased alkaline-phosphatase activity, a marker of osteoblast activation. The number of osteoclasts in the bone of Ang1-Tg mice did not differ from wild-type littermates. These results indicate that angiogenesis induced by Ang1 expressed in osteoblasts is coupled with osteogenesis.

VEGF: an essential mediator of both angiogenesis and endochondral ossification

During bone growth, development, and remodeling, angiogenesis as well as osteogenesis are closely associated processes, sharing some essential mediators. Vascular endothelial growth factor (VEGF) was initially recognized as the best-characterized endothelial-specific growth factor, which increased vascular permeability and angiogenesis, and it is now apparent that this cytokine regulates multiple biological functions in the endochondral ossification of mandibular condylar growth, as well as long bone formation. The complexity of VEGF biology is paralleled by the emerging complexity of interactions between VEGF ligands and their receptors. This narrative review summarizes the family of VEGF-related molecules, including 7 mammalian members, namely, VEGF, placenta growth factor (PLGF), and VEGF-B, -C, -D, -E, and -F. The biological functions of VEGF are mediated by at least 3 corresponding receptors: VEGFR-1/Flt-1, VEGFR-2/Flk-1, VEGFR-3/Flt-4 and 2 co-receptors of neuropilin (NRP) and heparan sulfate proteoglycans (HSPGs). Current findings on endochondral ossification are also discussed, with emphasis on VEGF-A action in osteoblasts, chondroblasts, and chondroclasts/osteoclasts and regulatory mechanisms involving oxygen tension, and some growth factors and hormones. Furthermore, the therapeutic implications of recombinant VEGF-A protein therapy and VEGF-A gene therapy are evaluated. Abbreviations used: VEGF, Vascular endothelial growth factor; PLGF, placenta growth factor; NRP, neuropilin; HSPGs, heparan sulfate proteoglycans; FGF, fibroblast growth factor; TGF, transforming growth factor; HGF, hepatocyte growth factor; TNF, tumor necrosis factor; ECM, extracellular matrix; RTKs, receptor tyrosine kinases; ERK, extracellular signal kinases; HIF, hypoxia-inducible factor.

VEGF producing bone marrow stromal cells (BMSC) enhance vascularization and resorption of a natural coral bone substitute

Bone graft substitutes often exhibit poor bone regeneration in large defects because of inadequate vascularization. Studies have shown that if blood supply is compromised, application of osteogenic factors alone could not induce successful healing. This study was to evaluate the effects of vascular endothelial growth factor, which combined with a coralline scaffold, on vascularization, scaffold resorption and osteogenesis in a rabbit radius critical size defect model. The scaffold was either coated with a control-plasmid DNA (group 1), coated with VEGF-plasmid DNA (group 2), loaded with mesenchymal stem cells (BMSC) transfected with control plasmid (group 3) or with both stem cells and the VEGF plasmid (group 4). X-rays were taken every 4 weeks up to week 16, when animals were euthanized. The volume of new bone was measured by mu-CT scans and blood vessels were counted after anti-CD31 staining of endothelial cells. The results from the solitary VEGF- and VEGF-transfected cells (groups 2 and 4) demonstrated significantly enhanced vascularization, osteogenesis and resorption of the carrier when compared to the control group. The highest degree of osteogenesis was found when the carrier was loaded with BMSC (group 3), whereas VEGF-transfected cells led to the highest vascularization and fastest resorption of the bone substitute. Additionally, VEGF-transfected BMSC led to a more homogenous vascularization of the defect. The results indicate that VEGF can be a helpful factor to improve healing in large bone defects, in which bone substitutes will otherwise not be vascularized and replaced by fresh bone.

Platelet-rich plasma: growth factors and pro- and anti-inflammatory properties

BACKGROUND

Platelet-rich plasma (PRP) promotes regeneration of bone, presumably through the action of concentrated growth factors. However, it is not clear how PRP affects the inflammatory response. The purpose of this study was to analyze the growth factors in PRP and to study the effects of PRP on monocyte cytokine release and lipoxin A(4) (LXA(4)) generation.

METHODS

PRP was prepared from healthy donors. Platelet-derived growth factor (PDGF)-AB, PDGF-BB, transforming growth factor-beta1, insulin-like growth factor-I, fibroblast growth factor-basic (FGF-b), epidermal growth factor (EGF), vascular endothelial growth factor, interleukin-12 (p40/70), and regulated on activation, normal T-cell expressed and secreted (RANTES) levels were evaluated by enzyme-linked immunosorbent assay and bead-based multiplexing. Peripheral blood monocytes were isolated and cultured with or without PRP. Cytokine, chemokine, and LXA(4) levels as well as monocyte chemotactic migration were analyzed.

RESULTS

Growth factors were increased significantly in PRP compared to whole blood (WB) and platelet-poor plasma. Monocyte chemotactic protein-1 (MCP-1) was suppressed significantly by PRP, whereas RANTES was increased significantly in monocyte cultures. LXA(4) levels were significantly higher in PRP compared to WB. PRP stimulated monocyte chemotaxis in a dose-dependent fashion, whereas RANTES, in part, was responsible for PRP-mediated monocyte migration.

CONCLUSIONS

PRP is a rich source of growth factors and promoted significant changes in monocyte-mediated proinflammatory cytokine/chemokine release. LXA(4) was increased in PRP, suggesting that PRP may suppress cytokine release, limit inflammation, and, thereby, promote tissue regeneration.

Bone regeneration by regulated in vivo gene transfer using biocompatible polyplex nanomicelles

Gene therapy is a promising strategy for bone regenerative medicine. Although viral vectors have been intensively studied for delivery of osteogenic factors, the immune response inevitably inhibits bone formation. Thus, safe and efficient non-viral gene delivery systems are in high demand. Toward this end, we developed a polyplex nanomicelle system composed of poly(ethyleneglycol) (PEG)-block-catiomer (PEG-b-P[Asp-(DET)]) and plasmid DNA (pDNA). This system showed little cytotoxicity and excellent transfection efficiency to primary cells. By the transfection of constitutively active form of activin receptor-like kinase 6 (caALK6) and runt-related transcription factor 2 (Runx2), the osteogenic differentiation was induced on mouse calvarial cells to a greater extent than when poly(ethylenimine) (PEI) or FuGENE6 were used; this result was due to low cytotoxicity and a sustained gene expression profile. After incorporation into the calcium phosphate cement scaffold, the polyplex nanomicelles were successfully released from the scaffold and transfected surrounding cells. Finally, this system was applied to in vivo gene transfer for a bone defect model in a mouse skull bone. By delivering caALK6 and Runx2 genes from nanomicelles incorporated into the scaffold, substantial bone formation covering the entire lower surface of the implant was induced with no sign of inflammation at 4 weeks. These results demonstrate the first success in in vivo gene transfer with therapeutic potential using polyplex nanomicelles.

New technologies for the enhancement of skeletal repair

Although fracture healing is a well-optimized biological process that leads to healing, approximately 10-20% of fractures result in impaired or delayed healing and these fractures may benefit from the use of biotechnologies to enhance skeletal repair. Peptide signaling molecules such as the bone morphogenetic proteins have been shown to stimulate the healing of fresh fractures, nonunions, and spinal fusions and side effects from their use appear to be minimal. Other growth factors currently being studied for local application include growth and differentiation factor-5 (GDF-5), vascular endothelial growth factor (VEGF), transforming growth factor beta (TGFbeta), and platelet-derived growth factor (PDGF). Molecules such as prostaglandin E receptor agonists and the thrombin-related peptide, TP508, have shown promise in animal models of fracture repair. Gene therapy using various growth factors or combinations of factors might also aid in fracture repair, particularly as new methods for delivery that do not require viral vectors are developed. Systemic therapy with agents such as parathyroid hormone (PTH), growth hormone (GH), and the HMG-CoA reductase inhibitors are also under investigation. As these and other technologies are shown to be safe and effective, their use will become a part of the standard of care in managing skeletal injuries.

Tissue-Engineering zur Knorpelreparatur verbessert durch Gentransfer

Cartilage tissue engineering is the creation of functional substitutes of native articular cartilage in bioreactors by attaching chondrogenic cells to polymer scaffolds. One limitation of tissue engineering is the delivery of regulatory signals to cells according to specific temporal and spatial patterns. Using gene transfer techniques, polypeptide growth factor genes such as the human insulin-like growth factor I (IGF-I) gene can be transferred into chondrocytes. When these modified cells are used for cartilage tissue engineering, the resulting cartilaginous constructs have improved structural and functional characteristics compared to constructs based on nonmodified cells. The combination of cartilage tissue engineering with overexpression of potential therapeutic genes using gene transfer technologies provides a basis for the development of novel molecular therapies for the repair of cartilage defects.

Erythropoietin (EPO) — EPO-receptor signaling improves early endochondral ossification and mechanical strength in fracture healing

Beyond its role in the regulation of red blood cell proliferation, the glycoprotein erythropoietin (EPO) has been shown to promote cell regeneration and angiogenesis in a variety of different tissues. In addition, EPO has been indicated to share significant functional and structural homologies with the vascular endothelial growth factor (VEGF), a cytokine essential in the process of fracture healing. However, there is complete lack of information on the action of EPO in bone repair and fracture healing. Therefore, we investigated the effect of EPO treatment on bone healing in a murine closed femur fracture model using radiological, histomorphometric, immunohistochemical, biomechanical and protein biochemical analysis. Thirty-six SKH1-hr mice were treated with daily i.p. injections of 5000 U/kg EPO from day 1 before fracture until day 4 after fracture. Controls received equivalent amounts of the vehicle. After 2 weeks of fracture healing, we could demonstrate expression of the EPO-receptor (EPOR) in terminally differentiating chondrocytes within the callus. At this time point EPO-treated animals showed a higher torsional stiffness (biomechanical analysis: 39.6+/-19.4% of the contralateral unfractured femur) and an increased callus density (X-ray analysis (callus density/spongiosa density): 110.5+/-7.1%) when compared to vehicle-treated controls (14.3+/-8.2% and 105.9+/-6.6%; p<0.05). Accordingly, the histomorphometric examination revealed an increased fraction of mineralized bone and osteoid (33.0+/-3.0% versus 28.5+/-3.6%; p<0.05). Of interest, this early effect of the initial 6-day EPO treatment had vanished at 5 weeks after fracture. We conclude that EPO-EPOR signaling is involved in the process of early endochondral ossification, enhancing the transition of soft callus to hard callus.

A systemic provascular response in bone marrow to musculoskeletal trauma in mice

Post-natal vasculogenesis, the process by which vascular committed bone marrow stem cells or endothelial precursor cells migrate, differentiate and incorporate into the nacent endothelium and thereby contribute to physiological and pathological neurovascularisation, has stimulated much interest. Its contribution to neovascularisation of tumours, wound healing and revascularisation associated with ischaemia of skeletal and cardiac muscles is well established. We evaluated the responses of endothelial precursor cells in bone marrow to musculoskeletal trauma in mice.

Bone marrow from six C57 Black 6 mice subjected to a standardised, closed fracture of the femur, was analysed for the combined expression of cell-surface markers stem cell antigen 1 (sca-1+) and stem cell factor receptor, CD117 (c-kit+) in order to identify the endothelial precursor cell population. Immunomagnetically-enriched sca-1+ mononuclear cell (MNCsca-1+) populations were then cultured and examined for functional vascular endothelial differentiation. Bone marrow MNCsca-1+,c-kit+ counts increased almost twofold within 48 hours of the event, compared with baseline levels, before decreasing by 72 hours.

Sca-1+ mononuclear cell populations in culture from samples of bone marrow at 48 hours bound together Ulex Europus-1, and incorporated fluorescent 1,1′-dioctadecyl- 3,3,3,’3′-tetramethylindocarbocyanine perchlorate-labelled acetylated low-density lipoprotein intracellularily, both characteristics of mature endothelium.

Our findings suggest that a systemic provascular response of bone marrow is initiated by musculoskeletal trauma. Its therapeutic manipulation may have implications for the potential enhancement of neovascularisation and the healing of fractures.

Prefabrication of Vascularized Bone Flap by Demineralized Bone Matrix

Demineralized bone matrix (DBM) has been reported to have osteoconductive and osteoinductive properties and has been clinically used as a bone graft alternative. In the present study we attempted to generate a vascularized bone flap by subcutaneous implantation of DBM with a vascular loop to provide blood supply in a rat model. Thirty male Sprague-Dawley rats were divided into two groups according to the presence or absence of blood supply. In the experimental group, the bone flap was created by application of 0.4 mL of DBM onto two pieces of gelatin sponge sheets between which a vascular loop was sandwiched. A prefabricated flap without a vascular loop served as the control. The flaps were biopsied at three different time intervals postoperatively (2, 4, and 6 weeks). The results showed that DBM induced subcutaneous bone formation in both of the groups. However, in the nonvascularized group, the amount of bony tissue had decreased at four postoperative weeks and continued to do so afterwards. In contrast, bone formation was active at four weeks in the vascularized group. Our study indicated that implantation of DBM can prefabricate a bone flap. Blood supply to the flap is considered a key factor of the success of this prefabrication.

Mobilization of endothelial precursor cells: systemic vascular response to musculoskeletal trauma

Postnatal vasculogenesis, the process by which vascular committed bone marrow stem cells or endothelial precursor cells (EPC) migrate, differentiate, and incorporate into the nacent endothelium contributing to physiological and pathological neovascularization, has stimulated much interest. Its contribution to tumor nonvascularization, wound healing, and revascularization associated with skeletal and cardiac muscles ischaemia is established. We evaluated the mobilization of EPCs in response to musculoskeletal trauma. Blood from patients (n = 15) following AO type 42a1 closed diaphyseal tibial fractures was analyzed for CD34 and AC133 cell surface marker expression. Immunomagnetically enriched CD34+ mononuclear cell (MNC(CD34+)) populations were cultured and examined for phenotypic and functional vascular endothelial differentiation. Circulating MNC(CD34+) levels increased sevenfold by day 3 postinjury. Circulating MNC(AC133+) increased 2.5-fold. Enriched MNC(CD34+) populations from day 3 samples in culture exhibited cell cluster formation with sprouting spindles. These cells bound UEA-1 and incorporated fluorescent DiI-Ac-LDL intracellularily. Our findings suggest a systemic provascular response is initiated in response to musculoskeletal trauma. Its therapeutic manipulation may have implications for the potential enhancement of fracture healing.

Supercritical carbon dioxide generated vascular endothelial growth factor encapsulated poly(DL-lactic acid) scaffolds induce angiogenesis in vitro

The ability to deliver, over time, biologically active vascular endothelial growth factor-165 (VEGF) through tailored designed scaffolds offers tremendous therapeutic opportunities to tissue-engineered therapies. Porous biodegradable poly(DL-lactic) acid (PLA) scaffolds encapsulating VEGF have been generated using supercritical CO2 (scCO2) and the kinetic release and angiogenic activity of these scaffolds examined in vitro and in an ex vivo chick chorioallantoic membrane (CAM) angiogenesis model. After processing through scCO2, VEGF maintained its angiogenic activity as assessed by increased tubule formation of human umbilical vein endothelial cells (HUVEC) cultured on Matrigel (VEGF = 1937 +/- 205 microm; scCO2-VEGF = 2085 +/- 234 microm; control = 1237 +/- 179 microm). VEGF release kinetics from scCO2-VEGF incorporated PLA monolith scaffolds showed a cumulative release of VEGF (2837 +/- 761 rhog/ml) over a 21 day period in culture. In addition, VEGF encapsulated PLA scaffolds increased the blood vessel network in the CAM compared to controls; control, 24.8 +/- 9.6; VEGF/PLA, 44.1 +/- 12.1 (vessels/field). These studies demonstrate that the controlled release of growth factors encapsulated into three-dimensional PLA scaffolds can actively stimulate the rapid development of therapeutic neovascularisation to regenerate or engineer tissues.

Use of genetically engineered bone-marrow stem cells to treat femoral defects: an experimental study

BACKGROUND

Treatment of osteonecrosis continues to be a challenging problem. The replacement of necrotic bone with graft materials that promote osteogenesis and angiogenesis may provide better outcomes for early stage disease. In this study, genetically engineered bone-marrow stem cells were used to enhance repair of a defect in the distal aspect of the femur.

METHODS

Cloned bone-marrow stem cells were transfected with traceable genes. Osteoblastic and angiogenic properties of the cells were analyzed. A defect was created bilaterally in the distal portion of the femur of twenty-four mice to mimic a core decompression procedure. The cloned cells were transplanted into each defect of the right femur while the left femur served as control. Bone formation was evaluated radiographically and histomorphometrically. In addition, in twenty-four additional mice, the cells were injected into subcutaneous sites, muscles, and into the renal capsule (eight mice in each group) to evaluate ectopic osteogenesis.

RESULTS

Radiopaque tissue appeared two weeks after the cells were transplanted into bone defects and at ectopic sites. Histologic analysis demonstrated that these tissues consisted of newly formed bone from transplanted cells that expressed traceable genes. Four of six bone defects that received cell transplantation were filled with new bone at four weeks, and all of the defects (n = 6) demonstrated complete healing at six weeks. On the control side, complete repair was seen in only two of six bone defects at four weeks and in three of six defects at six weeks. Histomorphometric analysis showed that transplantation of marrow stem cells into bone defects produced more bone at an earlier time-point than occurred in the controls.

CONCLUSIONS

This study demonstrated that cloned bone-marrow stem cells can directly form bone after transplantation into bone defects and at ectopic sites, indicating that the in vitro expanded bone-marrow stem cells can serve as a graft material to enhance bone repair and to treat osteonecrosis.

CLINICAL RELEVANCE

As an alternative graft material, bone-marrow stem cells may provide new and as yet technologically unachievable solutions to many clinical problems in the areas of musculoskeletal reconstruction and tissue regeneration.