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Hammersen T, Buchert J, Zietzschmann S, Diederichs S, Richter W. Inverse Regulation of Cartilage Neogenesis at Physiologically Relevant Calcium Conditions by Human Articular Chondrocytes and Mesenchymal Stromal Cells. Cells 2023; 12:1659. [PMID: 37371129 DOI: 10.3390/cells12121659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/07/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
Elaborate bioreactor cultivation or expensive growth factor supplementation can enhance extracellular matrix production in engineered neocartilage to provide sufficient mechanical resistance. We here investigated whether raising extracellular calcium levels in chondrogenic cultures to physiologically relevant levels would provide a simple and inexpensive alternative to enhance cartilage neogenesis from human articular chondrocytes (AC) or bone marrow-derived mesenchymal stromal cells (BMSC). Interestingly, AC and BMSC-derived chondrocytes showed an opposite response to a calcium increase from 1.8 mM to 8 mM by which glycosaminoglycan (GAG) and collagen type II production were elevated during BMSC chondrogenesis but depressed in AC, leading to two-fold higher GAG/DNA values in BMSC-based neocartilage compared to the AC group. According to control treatments with Mg2+ or sucrose, these effects were specific for CaCl2 rather than divalent cations or osmolarity. Importantly, undesired pro-hypertrophic traits were not stimulated by calcium treatment. Specific induction of PTHrP mRNA and protein by 8.0mM calcium only in AC, along with negative effects of recombinant PTHrP1-34 on cartilage matrix production, suggested that the PTHrP pathway contributed to the detrimental effects in AC-based neocartilage. Altogether, raising extracellular calcium levels was discovered as a novel, simple and inexpensive stimulator for BMSC-based cartilage neogenesis without the need for special bioreactors, whereas such conditions should be avoided for AC.
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Affiliation(s)
- Tim Hammersen
- Research Center for Experimental Orthopaedics, Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Justyna Buchert
- Research Center for Experimental Orthopaedics, Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Severin Zietzschmann
- Orthopaedic Hospital, Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Solvig Diederichs
- Research Center for Experimental Orthopaedics, Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Wiltrud Richter
- Research Center for Experimental Orthopaedics, Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
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2
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Jørgensen AEM, Schjerling P, DellaValle B, Rungby J, Kjær M. Acute loading has minor influence on human articular cartilage gene expression and glycosaminoglycan composition in late-stage knee osteoarthritis: a randomised controlled trial. Osteoarthritis Cartilage 2023:S1063-4584(23)00335-7. [PMID: 36720425 DOI: 10.1016/j.joca.2023.01.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/06/2023] [Accepted: 01/21/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Osteoarthritis (OA) remains clinically challenging. Regular physical exercise improves symptoms though it is unclear whether exercise influences cartilage at the molecular level. Thus, we aimed to determine the effect of acute loading on gene expression and glycosaminoglycan (GAG) content in human OA cartilage. DESIGN Patients with primary knee OA participated in this single-blind randomised controlled trial initiated 3.5 h prior to scheduled joint replacement surgery with or without loading by performing one bout of resistance exercise (one-legged leg press). Cartilage from the medial tibia condyle was sampled centrally, under the meniscus, and from peripheral osteophytes. Samples were analysed for gene expression by real-time reverse transcriptase polymerase chain reaction, and hyaluronidase-extracted matrix was analysed for GAG composition by immuno- and dimethyl-methylene blue assays. RESULTS Of 32 patients randomised, 31 completed the intervention: mean age 69 ± 7.5 years (SD), 58% female, BMI 29.4 ± 4.4 kg/m2. Exercise increased chondroitin sulphate extractability [95% CI: 1.01 to 2.46; P = 0.0486] but cartilage relevant gene expression was unchanged. Regionally, the submeniscal area showed higher MMP-3, MMP-13, IGF-1Ea, and CTGF, together with lower lubricin and COMP expression compared to the central condylar region. Further, osteophyte expression of MMP-1, MMP-13, IGF-1Ea, and TGF-β3 was higher than articular cartilage and lower for aggrecan, COMP, and FGF-2. Hyaluronidase-extracted matrix from central condylar cartilage contained more GAGs but less chondroitin sulphate compared to submeniscal cartilage. CONCLUSION Acute exercise had minor influence on cartilage GAG dynamics, indicating that osteoarthritic cartilage is not significantly affected by acute exercise. However, the regional differences suggest a chronic mechanical influence on human cartilage. CLINICALTRIALS GOV REGISTRATION NUMBER NCT03410745.
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Affiliation(s)
- A E M Jørgensen
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M81, Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark; Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - P Schjerling
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M81, Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark; Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B DellaValle
- Department of Endocrinology, Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark; Copenhagen Center for Translational Research, Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark; GLX Analytix ApS, Copenhagen, Denmark
| | - J Rungby
- Department of Endocrinology, Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark; Copenhagen Center for Translational Research, Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - M Kjær
- Institute of Sports Medicine Copenhagen, Department of Orthopaedic Surgery M81, Copenhagen University Hospital of Bispebjerg and Frederiksberg, Copenhagen, Denmark; Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Lückgen J, Raqué E, Reiner T, Diederichs S, Richter W. NFκB inhibition to lift the mechano-competence of mesenchymal stromal cell-derived neocartilage toward articular chondrocyte levels. Stem Cell Res Ther 2022; 13:168. [PMID: 35477424 PMCID: PMC9044876 DOI: 10.1186/s13287-022-02843-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Fully functional regeneration of skeletal defects by multipotent progenitor cells requires that differentiating cells gain the specific mechano-competence needed in the target tissue. Using cartilage neogenesis as an example, we asked whether proper phenotypic differentiation of mesenchymal stromal cells (MSC) into chondrocytes in vitro will install the adequate biological mechano-competence of native articular chondrocytes (AC). Methods The mechano-competence of human MSC- and AC-derived neocartilage was compared during differentiation for up to 35 days. The neocartilage layer was subjected to physiologic dynamic loading in a custom-designed bioreactor and assayed for mechano-sensitive gene and pathway activation, extracellular matrix (ECM) synthesis by radiolabel incorporation, nitric oxide (NO) and prostaglandin E2 (PGE2) production. Input from different pathways was tested by application of agonists or antagonists. Results MSC and AC formed neocartilage of similar proteoglycan content with a hardness close to native tissue. Mechano-stimulation on day 21 and 35 induced a similar upregulation of mechano-response genes, ERK phosphorylation, NO production and PGE2 release in both groups, indicating an overall similar transduction of external mechanical signals. However, while AC maintained or enhanced proteoglycan synthesis after loading dependent on tissue maturity, ECM synthesis was always significantly disturbed by loading in MSC-derived neocartilage. This was accompanied by significantly higher COX2 and BMP2 background expression, > 100-fold higher PGE2 production and a weaker SOX9 stimulation in response to loading in MSC-derived neocartilage. Anabolic BMP-pathway activity was not rate limiting for ECM synthesis after loading in both groups. However, NFκB activation mimicked the negative loading effects and enhanced PGE2 production while inhibition of catabolic NFκB signaling rescued the load-induced negative effects on ECM synthesis in MSC-derived neocartilage. Conclusions MSC-derived chondrocytes showed a higher vulnerability to be disturbed by loading despite proper differentiation and did not acquire an AC-like mechano-competence to cope with the mechanical stress of a physiologic loading protocol. Managing catabolic NFκB influences was one important adaptation to install a mechano-resistance closer to AC-derived neocartilage. This new knowledge asks for a more functional adaptation of MSC chondrogenesis, novel pharmacologic co-treatment strategies for MSC-based clinical cartilage repair strategies and may aid a more rational design of physical rehabilitation therapy after AC- versus MSC-based surgical cartilage intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-022-02843-x.
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Affiliation(s)
- Janine Lückgen
- Research Centre for Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Elisabeth Raqué
- Research Centre for Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Tobias Reiner
- Department of Orthopaedic and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Solvig Diederichs
- Research Centre for Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Wiltrud Richter
- Research Centre for Experimental Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
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Nasrollahzadeh N, Karami P, Wang J, Bagheri L, Guo Y, Abdel-Sayed P, Laurent-Applegate L, Pioletti DP. Temperature evolution following joint loading promotes chondrogenesis by synergistic cues via calcium signaling. eLife 2022; 11:72068. [PMID: 35256051 PMCID: PMC8903839 DOI: 10.7554/elife.72068] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/12/2022] [Indexed: 12/29/2022] Open
Abstract
During loading of viscoelastic tissues, part of the mechanical energy is transformed into heat that can locally increase the tissue temperature, a phenomenon known as self-heating. In the framework of mechanobiology, it has been accepted that cells react and adapt to mechanical stimuli. However, the cellular effect of temperature increase as a by-product of loading has been widely neglected. In this work, we focused on cartilage self-heating to present a 'thermo-mechanobiological' paradigm, and demonstrate how the coupling of a biomimetic temperature evolution and mechanical loading could influence cell behavior. We thereby developed a customized in vitro system allowing to recapitulate pertinent in vivo physical cues and determined the cells chondrogenic response to thermal and/or mechanical stimuli. Cellular mechanisms of action and potential signaling pathways of thermo-mechanotransduction process were also investigated. We found that co-existence of thermo-mechanical cues had a superior effect on chondrogenic gene expression compared to either signal alone. Specifically, the expression of Sox9 was significantly upregulated by application of the physiological thermo-mechanical stimulus. Multimodal transient receptor potential vanilloid 4 (TRPV4) channels were identified as key mediators of thermo-mechanotransduction process, which becomes ineffective without external calcium sources. We also observed that the isolated temperature evolution, as a by-product of loading, is a contributing factor to the cell response and this could be considered as important as the conventional mechanical loading. Providing an optimal thermo-mechanical environment by synergy of heat and loading portrays new opportunity for development of novel treatments for cartilage regeneration and can furthermore signal key elements for emerging cell-based therapies.
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Affiliation(s)
- Naser Nasrollahzadeh
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, EPFL, Switzerland
| | - Peyman Karami
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, EPFL, Switzerland
| | - Jian Wang
- Institut des Matériaux et Institut des Sciences et Ingénierie Chimiques, Laboratoire des Polymères, Lausanne, Switzerland
| | - Lida Bagheri
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, EPFL, Switzerland
| | - Yanheng Guo
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, EPFL, Switzerland
| | - Philippe Abdel-Sayed
- Regenerative Therapy Unit, Department of Musculoskeletal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Lee Laurent-Applegate
- Regenerative Therapy Unit, Department of Musculoskeletal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Dominique P Pioletti
- Laboratory of Biomechanical Orthopedics, Institute of Bioengineering, EPFL, Switzerland
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Boos MA, Lamandé SR, Stok KS. Multiscale Strain Transfer in Cartilage. Front Cell Dev Biol 2022; 10:795522. [PMID: 35186920 PMCID: PMC8855033 DOI: 10.3389/fcell.2022.795522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022] Open
Abstract
The transfer of stress and strain signals between the extracellular matrix (ECM) and cells is crucial for biochemical and biomechanical cues that are required for tissue morphogenesis, differentiation, growth, and homeostasis. In cartilage tissue, the heterogeneity in spatial variation of ECM molecules leads to a depth-dependent non-uniform strain transfer and alters the magnitude of forces sensed by cells in articular and fibrocartilage, influencing chondrocyte metabolism and biochemical response. It is not fully established how these nonuniform forces ultimately influence cartilage health, maintenance, and integrity. To comprehend tissue remodelling in health and disease, it is fundamental to investigate how these forces, the ECM, and cells interrelate. However, not much is known about the relationship between applied mechanical stimulus and resulting spatial variations in magnitude and sense of mechanical stimuli within the chondrocyte’s microenvironment. Investigating multiscale strain transfer and hierarchical structure-function relationships in cartilage is key to unravelling how cells receive signals and how they are transformed into biosynthetic responses. Therefore, this article first reviews different cartilage types and chondrocyte mechanosensing. Following this, multiscale strain transfer through cartilage tissue and the involvement of individual ECM components are discussed. Finally, insights to further understand multiscale strain transfer in cartilage are outlined.
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Affiliation(s)
- Manuela A. Boos
- Department of Biomedical Engineering, The University of Melbourne, Parkville, VIC, Australia
| | - Shireen R. Lamandé
- Musculoskeletal Research, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Kathryn S. Stok
- Department of Biomedical Engineering, The University of Melbourne, Parkville, VIC, Australia
- *Correspondence: Kathryn S. Stok,
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Szojka ARA, Li DX, Sopcak MEJ, Ma Z, Kunze M, Mulet-Sierra A, Adeeb SM, Westover L, Jomha NM, Adesida AB. Mechano-Hypoxia Conditioning of Engineered Human Meniscus. Front Bioeng Biotechnol 2021; 9:739438. [PMID: 34540817 PMCID: PMC8446439 DOI: 10.3389/fbioe.2021.739438] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 08/18/2021] [Indexed: 02/05/2023] Open
Abstract
Meniscus fibrochondrocytes (MFCs) experience simultaneous hypoxia and mechanical loading in the knee joint. Experimental conditions based on these aspects of the native MFC environment may have promising applications in human meniscus tissue engineering. We hypothesized that in vitro “mechano-hypoxia conditioning” with mechanical loading such as dynamic compression (DC) and cyclic hydrostatic pressure (CHP) would enhance development of human meniscus fibrocartilage extracellular matrix in vitro. MFCs from inner human meniscus surgical discards were pre-cultured on porous type I collagen scaffolds with TGF-β3 supplementation to form baseline tissues with newly formed matrix that were used in a series of experiments. First, baseline tissues were treated with DC or CHP under hypoxia (HYP, 3% O2) for 5 days. DC was the more effective load regime in inducing gene expression changes, and combined HYP/DC enhanced gene expression of fibrocartilage precursors. The individual treatments of DC and HYP regulated thousands of genes, such as chondrogenic markers SOX5/6, in an overwhelmingly additive rather than synergistic manner. Similar baseline tissues were then treated with a short course of DC (5 vs 60 min, 10–20% vs 30–40% strain) with different pre-culture duration (3 vs 6 weeks). The longer course of loading (60 min) had diminishing returns in regulating mechano-sensitive and inflammatory genes such as c-FOS and PTGS2, suggesting that as few as 5 min of DC was adequate. There was a dose-effect in gene regulation by higher DC strains, whereas outcomes were inconsistent for different MFC donors in pre-culture durations. A final set of baseline tissues was then cultured for 3 weeks with mechano-hypoxia conditioning to assess mechanical and protein-level outcomes. There were 1.8–5.1-fold gains in the dynamic modulus relative to baseline in HYP/DC, but matrix outcomes were equal or inferior to static controls. Long-term mechano-hypoxia conditioning was effective in suppressing hypertrophic markers (e.g., COL10A1 10-fold suppression vs static/normoxia). Taken together, these results indicate that appropriately applied mechano-hypoxia conditioning can support meniscus fibrocartilage development in vitro and may be useful as a strategy for developing non-hypertrophic articular cartilage using mesenchymal stem cells.
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Affiliation(s)
- Alexander R A Szojka
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - David Xinzheyang Li
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Department of Civil and Environmental Engineering, Faculty of Engineering, University of Alberta, Edmonton, AB, Canada
| | - Malou E J Sopcak
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Zhiyao Ma
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Melanie Kunze
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Aillette Mulet-Sierra
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Samer M Adeeb
- Department of Civil and Environmental Engineering, Faculty of Engineering, University of Alberta, Edmonton, AB, Canada
| | - Lindsey Westover
- Department of Mechanical Engineering, Faculty of Engineering, University of Alberta, Edmonton, AB, Canada
| | - Nadr M Jomha
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adetola B Adesida
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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Heparan Sulfate Deficiency in Cartilage: Enhanced BMP-Sensitivity, Proteoglycan Production and an Anti-Apoptotic Expression Signature after Loading. Int J Mol Sci 2021; 22:ijms22073726. [PMID: 33918436 PMCID: PMC8038223 DOI: 10.3390/ijms22073726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022] Open
Abstract
Osteoarthritis (OA) represents one major cause of disability worldwide still evading efficient pharmacological or cellular therapies. Severe degeneration of extracellular cartilage matrix precedes the loss of mobility and disabling pain perception in affected joints. Recent studies showed that a reduced heparan sulfate (HS) content protects cartilage from degradation in OA-animal models of joint destabilization but the underlying mechanisms remained unclear. We aimed to clarify whether low HS-content alters the mechano-response of chondrocytes and to uncover pathways relevant for HS-related chondro-protection in response to loading. Tissue-engineered cartilage with HS-deficiency was generated from rib chondrocytes of mice carrying a hypomorphic allele of Exostosin 1 (Ext1), one of the main HS-synthesizing enzymes, and wildtype (WT) littermate controls. Engineered cartilage matured for 2 weeks was exposed to cyclic unconfined compression in a bioreactor. The molecular loading response was determined by transcriptome profiling, bioinformatic data processing, and qPCR. HS-deficient chondrocytes expressed 3-6% of WT Ext1-mRNA levels. Both groups similarly raised Sox9, Col2a1 and Acan levels during maturation. However, HS-deficient chondrocytes synthesized and deposited 50% more GAG/DNA. TGFβ and FGF2-sensitivity of Ext1gt/gt chondrocytes was similar to WT cells but their response to BMP-stimulation was enhanced. Loading induced similar activation of mechano-sensitive ERK and P38-signaling in WT and HS-reduced chondrocytes. Transcriptome analysis reflected regulation of cell migration as major load-induced biological process with similar stimulation of common (Fosl1, Itgα5, Timp1, and Ngf) as well as novel mechano-regulated genes (Inhba and Dhrs9). Remarkably, only Ext1-hypomorphic cartilage responded to loading by an expression signature of negative regulation of apoptosis with pro-apoptotic Bnip3 being selectively down-regulated. HS-deficiency enhanced BMP-sensitivity, GAG-production and fostered an anti-apoptotic expression signature after loading, all of which may protect cartilage from load-induced erosion.
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Engineered human meniscus' matrix-forming phenotype is unaffected by low strain dynamic compression under hypoxic conditions. PLoS One 2021; 16:e0248292. [PMID: 33690647 PMCID: PMC7946300 DOI: 10.1371/journal.pone.0248292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/23/2021] [Indexed: 02/07/2023] Open
Abstract
Low oxygen and mechanical loading may play roles in regulating the fibrocartilaginous phenotype of the human inner meniscus, but their combination in engineered tissues remains unstudied. Here, we investigated how continuous low oxygen (“hypoxia”) combined with dynamic compression would affect the fibrocartilaginous “inner meniscus-like” matrix-forming phenotype of human meniscus fibrochondrocytes (MFCs) in a porous type I collagen scaffold. Freshly-seeded MFC scaffolds were cultured for 4 weeks in either 3 or 20% O2 or pre-cultured for 2 weeks in 3% O2 and then dynamically compressed for 2 weeks (10% strain, 1 Hz, 1 h/day, 5 days/week), all with or without TGF-β3 supplementation. TGF-β3 supplementation was found necessary to induce matrix formation by MFCs in the collagen scaffold regardless of oxygen tension and application of the dynamic compression loading regime. Neither hypoxia under static culture nor hypoxia combined with dynamic compression had significant effects on expression of specific protein and mRNA markers for the fibrocartilaginous matrix-forming phenotype. Mechanical properties significantly increased over the two-week loading period but were not different between static and dynamic-loaded tissues after the loading period. These findings indicate that 3% O2 applied immediately after scaffold seeding and dynamic compression to 10% strain do not affect the fibrocartilaginous matrix-forming phenotype of human MFCs in this type I collagen scaffold. It is possible that a delayed hypoxia treatment and an optimized pre-culture period and loading regime combination would have led to different outcomes.
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9
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Szojka AR, Marqueti RDC, Li DX, Molter CW, Liang Y, Kunze M, Mulet-Sierra A, Jomha NM, Adesida AB. Human engineered meniscus transcriptome after short-term combined hypoxia and dynamic compression. J Tissue Eng 2021; 12:2041731421990842. [PMID: 33613959 PMCID: PMC7874349 DOI: 10.1177/2041731421990842] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/10/2021] [Indexed: 12/30/2022] Open
Abstract
This study investigates the transcriptome response of meniscus fibrochondrocytes (MFCs) to the low oxygen and mechanical loading signals experienced in the knee joint using a model system. We hypothesized that short term exposure to the combined treatment would promote a matrix-forming phenotype supportive of inner meniscus tissue formation. Human MFCs on a collagen scaffold were stimulated to form fibrocartilage over 6 weeks under normoxic (NRX, 20% O2) conditions with supplemented TGF-β3. Tissues experienced a delayed 24h hypoxia treatment (HYP, 3% O2) and then 5 min of dynamic compression (DC) between 30 and 40% strain. Delayed HYP induced an anabolic and anti-catabolic expression profile for hyaline cartilage matrix markers, while DC induced an inflammatory matrix remodeling response along with upregulation of both SOX9 and COL1A1. There were 41 genes regulated by both HYP and DC. Overall, the combined treatment supported a unique gene expression profile favouring the hyaline cartilage aspect of inner meniscus matrix and matrix remodeling.
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Affiliation(s)
- Alexander Ra Szojka
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada
| | - Rita de Cássia Marqueti
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada.,Graduate Program of Rehabilitation Sciences, University of Brasília (UnB), Brasília, Distrito Federal, Brazil
| | - David Xinzheyang Li
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada.,Department of Civil and Environmental Engineering, Faculty of Engineering, University of Alberta, Edmonton, AB, Canada
| | - Clayton W Molter
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada
| | - Yan Liang
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada
| | - Melanie Kunze
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada
| | - Aillette Mulet-Sierra
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada
| | - Nadr M Jomha
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada
| | - Adetola B Adesida
- Department of Surgery, Divisions of Orthopaedic Surgery and Surgical Research, Faculty of Medicine & Dentistry, University of Alberta, Li Ka Shing Centre for Health Research Innovation, Edmonton, AB, Canada
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Yu L, Yang Y, Zhang B, Bai X, Fei Q, Zhang L. Rapid human-derived iPSC osteogenesis combined with three-dimensionally printed Ti6Al4V scaffolds for the repair of bone defects. J Cell Physiol 2020; 235:9763-9772. [PMID: 32424865 DOI: 10.1002/jcp.29788] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/30/2020] [Accepted: 05/04/2020] [Indexed: 12/15/2022]
Abstract
Human-induced pluripotent stem cells (iPSCs) are an alternative source of mesenchymal stem cells used for bone regeneration. However, the current osteogenically induced methods for iPSCs are slow and complex. We have used retinoic acid (RA) to induce osteogenic iPSCs within 10 days and assess whether a rapid differentiation could improve the osteogenic potential of the three-dimensionally printed Ti6Al4V (3DTi) scaffolds. First, the osteogenic differentiation of iPSCs was induced with RA, and the osteogenic potential of iPSCs was evaluated using standard assays. In addition, a 5-mm mandibular bone defect was generated in rats and was repaired with 3DTi scaffolds that were seeded with iPSC-induced osteoblasts. The capacity of seeded scaffolds for the enhancement of bone regeneration in vivo was assessed. Finally, we tested the potential mechanisms of RA-dependent iPSC bone induction and its effect on the Wnt/β-catenin pathway. The results showed that iPSCs could form osteocytes within 10 days. Animal experiments confirmed that rapid osteo-induced iPSCs could enhance the bone regeneration and osteointegration capacity of the 3DTi scaffolds. Mechanistically, RA could activate the AKT/GSK3β/β-catenin pathway during the process of iPSCs osteogenesis. The rapid osteoinduction of iPSCs combined with 3DTi scaffolds is a safe, effective, and reproducible method for repairing mandibular bone defects.
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Affiliation(s)
- Lingjia Yu
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yong Yang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Bin Zhang
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, China
| | - Xiaofeng Bai
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, China
| | - Qi Fei
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lei Zhang
- Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University, Shenyang, China
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Walsh SK, Schneider SE, Amundson LA, Neu CP, Henak CR. Maturity-dependent cartilage cell plasticity and sensitivity to external perturbation. J Mech Behav Biomed Mater 2020; 106:103732. [PMID: 32321631 DOI: 10.1016/j.jmbbm.2020.103732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/04/2020] [Accepted: 03/13/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Articular cartilage undergoes biological and morphological changes throughout maturation. The prevalence of osteoarthritis in the aged population suggests that maturation predisposes cartilage to degradation and/or impaired regeneration, but this process is not fully understood. Therefore, the objective of this study was to characterize the cellular and genetic profile of cartilage, as well as biological plasticity in response to mechanical and culture time stimuli, as a function of animal maturity. METHODS/DESIGN Porcine articular cartilage explants were harvested from stifle joints of immature (2-4 weeks), adolescent (5-6 months), and mature (1-5 years) animals. Half of all samples were subjected to a single compressive mechanical load. Loaded samples were paired with unloaded controls for downstream analyses. Expression of cartilage progenitor cell markers CD105, CD44, and CD29 were determined via flow cytometry. Expression of matrix synthesis genes Col1, Col2, Col10, ACAN, and SOX9 were determined via qPCR. Tissue morphology and matrix content were examined histologically. Post-loading assays were performed immediately and following 7 days in culture. RESULTS CD105 and CD29 expression decreased with maturity, while CD44 expression was upregulated in cartilage from mature animals. Expression of matrix synthesis genes were generally upregulated in cartilage from mature animals, and adolescent animals showed the lowest expression of several matrix synthesizing genes. Culture time and mechanical loading analyses revealed greater plasticity to mechanical loading and culture time in cartilage from younger animals. Histology confirmed distinct structural and biochemical profiles across maturity. CONCLUSION This study demonstrates differential, nonlinear expression of chondroprogenitor markers and matrix synthesis genes as a function of cartilage maturity, as well as loss of biological plasticity in aged tissue. These findings have likely implications for age-related loss of regeneration and osteoarthritis progression.
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Affiliation(s)
- Shannon K Walsh
- Comparative Biomedical Sciences Program, University of Wisconsin-Madison, Madison, WI, USA.
| | - Stephanie E Schneider
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, CO, USA.
| | - Laura A Amundson
- Department of Animal Sciences, University of Wisconsin-Madison, Madison, WI, USA.
| | - Corey P Neu
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, CO, USA.
| | - Corinne R Henak
- Department of Mechanical Engineering, University of Wisconsin-Madison, Madison, WI, USA; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI, USA; Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI, USA.
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12
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Dolzani P, Assirelli E, Pulsatelli L, Meliconi R, Mariani E, Neri S. Ex vivo physiological compression of human osteoarthritis cartilage modulates cellular and matrix components. PLoS One 2019; 14:e0222947. [PMID: 31550275 PMCID: PMC6759151 DOI: 10.1371/journal.pone.0222947] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/10/2019] [Indexed: 01/05/2023] Open
Abstract
Mechanical stimulation appears to play a key role in cartilage homeostasis maintenance, but it can also contribute to osteoarthritis (OA) pathogenesis. Accumulating evidence suggests that cartilage loading in the physiological range contributes to tissue integrity maintenance, whereas excessive or reduced loading have catabolic effects. However, how mechanical stimuli can regulate joint homeostasis is still not completely elucidated and few data are available on human cartilage. We aimed at investigating human OA cartilage response to ex vivo loading at physiological intensity. Cartilage explants from ten OA patients were subjected to ex vivo controlled compression, then recovered and used for gene and protein expression analysis of cartilage homeostasis markers. Compressed samples were compared to uncompressed ones in presence or without interleukin 1β (IL-1β) or interleukin 4 (IL-4). Cartilage explants compressed in combination with IL-4 treatment showed the best histological scores. Mechanical stimulation was able to significantly modify the expression of collagen type II (collagen 2), aggrecan, SOX9 transcription factor, cartilage oligomeric matrix protein (COMP), collagen degradation marker C2C and vascular endothelial growth factor (VEGF). Conversely, ADAMTS4 metallopeptidase, interleukin 4 receptor alpha (IL4Rα), chondroitin sulfate 846 epitope (CS846), procollagen type 2 C-propeptide (CPII) and glycosaminoglycans (GAG) appeared not modulated. Our data suggest that physiological compression of OA human cartilage modulates the inflammatory milieu by differently affecting the expression of components and homeostasis regulators of the cartilage extracellular matrix.
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Affiliation(s)
- Paolo Dolzani
- Laboratorio di Immunoreumatologia e Rigenerazione Tissutale, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Elisa Assirelli
- Laboratorio di Immunoreumatologia e Rigenerazione Tissutale, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Lia Pulsatelli
- Laboratorio di Immunoreumatologia e Rigenerazione Tissutale, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Riccardo Meliconi
- Unità di Medicina e Reumatologia, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Erminia Mariani
- Laboratorio di Immunoreumatologia e Rigenerazione Tissutale, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Simona Neri
- Laboratorio di Immunoreumatologia e Rigenerazione Tissutale, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- * E-mail:
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13
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The Role of Extracellular Matrix Expression, ERK1/2 Signaling and Cell Cohesiveness for Cartilage Yield from iPSCs. Int J Mol Sci 2019; 20:ijms20174295. [PMID: 31480758 PMCID: PMC6747490 DOI: 10.3390/ijms20174295] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/26/2019] [Accepted: 08/29/2019] [Indexed: 02/07/2023] Open
Abstract
Current therapies involving chondrocytes or mesenchymal stromal cells (MSCs) remain inefficient in restoring cartilage properties upon injury. The induced pluripotent stem-cell (iPSC)-derived mesenchymal progenitor cells (iMPCs) have been put forward as a promising alternative cell source due to their high proliferation and differentiation potential. However, the observed cell loss during in vitro chondrogenesis is currently a bottleneck in establishing articular chondrocyte generation from iPSCs. In a search for candidate mechanisms underlying the low iPSC-derived cartilage tissue yield, global transcriptomes were compared between iMPCs and MSCs and the cell properties were analyzed via a condensation assay. The iMPCs had a more juvenile mesenchymal gene signature than MSCs with less myofibroblast-like characteristics, including significantly lower ECM- and integrin-ligand-related as well as lower α-smooth-muscle-actin expression. This correlated with less substrate and more cell-cell adhesion, impaired aggregate formation and consequently inferior cohesive tissue properties of the iMPC-pellets. Along lower expression of pro-survival ECM molecules, like decorin, collagen VI, lumican and laminin, the iMPC populations had significantly less active ERK1/2 compared to MSCs. Overall, this study proposes that this ECM and integrin-ligand shortage, together with insufficient pro-survival ERK1/2-activity, explains the loss of a non-aggregating iMPC sub-fraction during pellet formation and reduced survival of cells in early pellets. Enhancing ECM production and related signaling in iMPCs may be a promising new means to enrich the instructive microenvironment with pro-survival cues allowing to improve the final cartilage tissue yield from iPSCs.
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14
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Mechanosensitive MiRs regulated by anabolic and catabolic loading of human cartilage. Osteoarthritis Cartilage 2019; 27:1208-1218. [PMID: 31009748 DOI: 10.1016/j.joca.2019.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/26/2019] [Accepted: 04/10/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Elucidation of whether miRs are involved in mechanotransduction pathways by which cartilage is maintained or disturbed has a particular importance in our understanding of osteoarthritis (OA) pathophysiology. The aim was to investigate whether mechanical loading influences global miR-expression in human chondrocytes and to identify mechanosensitive miRs responding to beneficial and non-beneficial loading regimes as potential to obtain valuable diagnostic or therapeutic targets to advance OA-treatment. METHOD Mature tissue-engineered human cartilage was subjected to two distinct loading regimes either stimulating or suppressing proteoglycan-synthesis, before global miR microarray analysis. Promising candidate miRs were selected, re-evaluated by qRT-PCR and tested for expression in human healthy vs OA cartilage samples. RESULTS After anabolic loading, miR microarray profiling revealed minor changes in miR-expression while catabolic stimulation produced a significant regulation of 80 miRs with a clear separation of control and compressed samples by hierarchical clustering. Cross-testing of selected miRs revealed that miR-221, miR-6872-3p, miR-6723-5p were upregulated by both loading conditions while others (miR-199b-5p, miR-1229-5p, miR-1275, miR-4459, miR-6891-5p, miR-7150) responded specifically after catabolic loading. Mechanosensitivity of miR-221 correlated with pERK1/2-activation induced by both loading conditions. The miR-response to loading was transient and a constitutive deregulation of mechano-miRs in OA vs healthy articular cartilage was not observed. CONCLUSIONS MiRs with broader vs narrower mechanosensitivity were discovered and the first group of mechanosensitive miRs characteristic for non-beneficial loading was defined that may shape the proteome differentially when cartilage tissue is disturbed. The findings prompt future investigations into miR-relevance for mechano-responsive pathways and the corresponding miR-target molecules.
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15
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Aziz AH, Eckstein K, Ferguson VL, Bryant SJ. The effects of dynamic compressive loading on human mesenchymal stem cell osteogenesis in the stiff layer of a bilayer hydrogel. J Tissue Eng Regen Med 2019; 13:946-959. [PMID: 30793536 DOI: 10.1002/term.2827] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/26/2018] [Accepted: 02/13/2019] [Indexed: 02/05/2023]
Abstract
Bilayer hydrogels with a soft cartilage-like layer and a stiff bone-like layer embedded with human mesenchymal stem cells (hMSCs) are promising for osteochondral tissue engineering. The goals of this work were to evaluate the effects of dynamic compressive loading (2.5% applied strain, 1 Hz) on osteogenesis in the stiff layer and spatially map local mechanical responses (strain, stress, hydrostatic pressure, and fluid velocity). A bilayer hydrogel was fabricated from soft (24 kPa) and stiff (124 kPa) poly (ethylene glycol) hydrogels. With hMSCs embedded in the stiff layer, osteogenesis was delayed under loading evident by lower OSX and OPN expressions, alkaline phosphatase activity, and collagen content. At Day 28, mineral deposits were present throughout the stiff layer without loading but localized centrally and near the interface under loading. Local strains mapped by particle tracking showed substantial equivalent strain (~1.5%) transferring to the stiff layer. When hMSCs were cultured in stiff single-layer hydrogels subjected to similar strains, mineralization was inhibited. Finite element analysis revealed that hydrostatic pressures ≥~600 Pa correlated to regions lacking mineralization in both hydrogels. Fluid velocities were low (~1-10 nm/s) in the hydrogels with no apparent correlation to mineralization. Mineralization was recovered by inhibiting ERK1/2, indicating cell-mediated inhibition. These findings suggest that high strains (~1.5%) combined with higher hydrostatic pressures negatively impact osteogenesis, but in a manner that depends on the magnitude of each mechanical response. This work highlights the importance of local mechanical responses in mediating osteogenesis of hMSCs in bilayer hydrogels being studied for osteochondral tissue engineering.
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Affiliation(s)
- Aaron H Aziz
- Chemical and Biological Engineering, University of Colorado, Boulder, Colorado.,BioFrontiers Institute, University of Colorado, Boulder, Colorado
| | - Kevin Eckstein
- Mechanical Engineering, University of Colorado, Boulder, Colorado
| | - Virginia L Ferguson
- BioFrontiers Institute, University of Colorado, Boulder, Colorado.,Mechanical Engineering, University of Colorado, Boulder, Colorado.,Material Science and Engineering, University of Colorado, Boulder, Colorado
| | - Stephanie J Bryant
- Chemical and Biological Engineering, University of Colorado, Boulder, Colorado.,BioFrontiers Institute, University of Colorado, Boulder, Colorado.,Material Science and Engineering, University of Colorado, Boulder, Colorado
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Praxenthaler H, Krämer E, Weisser M, Hecht N, Fischer J, Grossner T, Richter W. Extracellular matrix content and WNT/β-catenin levels of cartilage determine the chondrocyte response to compressive load. Biochim Biophys Acta Mol Basis Dis 2017; 1864:851-859. [PMID: 29277327 DOI: 10.1016/j.bbadis.2017.12.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/15/2017] [Accepted: 12/17/2017] [Indexed: 11/19/2022]
Abstract
During osteoarthritis (OA)-development extracellular matrix (ECM) molecules are lost from cartilage, thus changing gene-expression, matrix synthesis and biomechanical competence of the tissue. Mechanical loading is important for the maintenance of articular cartilage; however, the influence of an altered ECM content on the response of chondrocytes to loading is not well understood, but may provide important insights into underlying mechanisms as well as supplying new therapies for OA. Objective here was to explore whether a changing ECM-content of engineered cartilage affects major signaling pathways and how this alters the chondrocyte response to compressive loading. Activity of canonical WNT-, BMP-, TGF-β- and p38-signaling was determined during maturation of human engineered cartilage and followed after exposure to a single dynamic compression-episode. WNT/β-catenin- and pSmad1/5/9-levels declined with increasing ECM-content of cartilage. While loading significantly suppressed proteoglycan-synthesis and ACAN-expression at low ECM-content this catabolic response then shifted to an anabolic reaction at high ECM-content. A positive correlation was observed between GAG-content and load-induced alteration of proteoglycan-synthesis. Induction of high β-catenin levels by the WNT-agonist CHIR suppressed load-induced SOX9- and GAG-stimulation in mature constructs. In contrast, the WNT-antagonist IWP-2 was capable of attenuating load-induced GAG-suppression in immature constructs. In conclusion, either ECM accumulation-associated or pharmacologically induced silencing of WNT-levels allowed for a more anabolic reaction of chondrocytes to physiological loading. This is consistent with the role of proteoglycans in sequestering WNT-ligands in the ECM, thus reducing WNT-activity and also provides a novel explanation of why low WNT-activity in cartilage protects from OA-development in mechanically overstressed cartilage.
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Affiliation(s)
- Heiko Praxenthaler
- Research Centre for Experimental Orthopaedics, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany
| | - Elisabeth Krämer
- Research Centre for Experimental Orthopaedics, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany
| | - Melanie Weisser
- Research Centre for Experimental Orthopaedics, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany
| | - Nicole Hecht
- Research Centre for Experimental Orthopaedics, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany
| | - Jennifer Fischer
- Research Centre for Experimental Orthopaedics, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Grossner
- Department of Orthopaedic and Trauma Surgery, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany
| | - Wiltrud Richter
- Research Centre for Experimental Orthopaedics, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany.
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