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Adhikari B, Stager MA, Collins EG, Fischenich KM, Olusoji J, Ruble AF, Payne KA, Krebs MD. Sustained release of MAPK14-targeting siRNA from polyelectrolyte complex hydrogels mitigates MSC osteogenesis in vitro with potential application in growth plate injury. J Biomed Mater Res A 2024; 112:2346-2357. [PMID: 39145460 DOI: 10.1002/jbm.a.37784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 07/13/2024] [Accepted: 07/30/2024] [Indexed: 08/16/2024]
Abstract
The growth plate is a cartilage structure at the end of long bones which mediates growth in children. When fractured, the formation of bony repair tissue known as a "bony bar" can occur and cause limb deformities. There are currently no effective clinical solutions for the prevention of the bony bar formation or regeneration of healthy growth plate cartilage after a fracture. This study employs previously developed alginate/chitosan polyelectrolyte complex (PEC) hydrogels as a sustained release vehicle for the delivery of short-interfering RNA (siRNA). Specifically, the siRNA targets the p38-MAPK pathway in mesenchymal stem cells (MSCs) to prevent their osteogenic differentiation. In vitro experimental findings show sustained release of siRNA from the hydrogels for 6 months. Flow cytometry and confocal imaging indicate that the hydrogels release siRNA to effectively knockdown GFP expression over a sustained period. MAPK-14 targeting siRNA was used to knockdown the expression of MAPK-14 and correspondingly decrease the expression of other osteogenic genes in MSCs in vitro over the span of 21 days. These hydrogels were used in a rat model of growth plate injury to determine whether siMAPK-14 released from the gels could inhibit bony bar formation. No significant reduction of bony bar formation was seen in vivo at the one concentration of siRNA examined. This PEC hydrogel represents a significant advancement for siRNA sustained delivery, and presents an interesting potential therapeutic delivery system for growth plate injuries and other regenerative medicine applications.
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Affiliation(s)
- Bikram Adhikari
- Quantitative Biosciences and Bioengineering, Colorado School of Mines, Golden, Colorado, USA
| | - Michael A Stager
- Chemical and Biological Engineering, Colorado School of Mines, Golden, Colorado, USA
| | - Elise G Collins
- Chemical and Biological Engineering, Colorado School of Mines, Golden, Colorado, USA
| | - Kristine M Fischenich
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesutomisin Olusoji
- Quantitative Biosciences and Bioengineering, Colorado School of Mines, Golden, Colorado, USA
| | - Ana Ferreira Ruble
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Karin A Payne
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Melissa D Krebs
- Quantitative Biosciences and Bioengineering, Colorado School of Mines, Golden, Colorado, USA
- Chemical and Biological Engineering, Colorado School of Mines, Golden, Colorado, USA
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2
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Dorchei F, Heydari A, Kroneková Z, Kronek J, Pelach M, Cseriová Z, Chorvát D, Zúñiga-Navarrete F, Rios PD, McGarrigle J, Ghani S, Isa D, Joshi I, Vasuthas K, Rokstad AMA, Oberholzer J, Raus V, Lacík I. Postmodification with Polycations Enhances Key Properties of Alginate-Based Multicomponent Microcapsules. Biomacromolecules 2024; 25:4118-4138. [PMID: 38857534 DOI: 10.1021/acs.biomac.4c00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Postmodification of alginate-based microspheres with polyelectrolytes (PEs) is commonly used in the cell encapsulation field to control microsphere stability and permeability. However, little is known about how different applied PEs shape the microsphere morphology and properties, particularly in vivo. Here, we addressed this question using model multicomponent alginate-based microcapsules postmodified with PEs of different charge and structure. We found that the postmodification can enhance or impair the mechanical resistance and biocompatibility of microcapsules implanted into a mouse model, with polycations surprisingly providing the best results. Confocal Raman microscopy and confocal laser scanning microscopy (CLSM) analyses revealed stable interpolyelectrolyte complex layers within the parent microcapsule, hindering the access of higher molar weight PEs into the microcapsule core. All microcapsules showed negative surface zeta potential, indicating that the postmodification PEs get hidden within the microcapsule membrane, which agrees with CLSM data. Human whole blood assay revealed complex behavior of microcapsules regarding their inflammatory and coagulation potential. Importantly, most of the postmodification PEs, including polycations, were found to be benign toward the encapsulated model cells.
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Affiliation(s)
- Faeze Dorchei
- Department for Biomaterials Research, Polymer Institute of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 41 Bratislava, Slovakia
| | - Abolfazl Heydari
- Department for Biomaterials Research, Polymer Institute of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 41 Bratislava, Slovakia
- National Institute of Rheumatic Diseases, Nábrežie I. Krasku 4, 921 12 Piešt'any, Slovakia
| | - Zuzana Kroneková
- Department for Biomaterials Research, Polymer Institute of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 41 Bratislava, Slovakia
- National Institute of Rheumatic Diseases, Nábrežie I. Krasku 4, 921 12 Piešt'any, Slovakia
| | - Juraj Kronek
- Department for Biomaterials Research, Polymer Institute of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 41 Bratislava, Slovakia
- National Institute of Rheumatic Diseases, Nábrežie I. Krasku 4, 921 12 Piešt'any, Slovakia
| | - Michal Pelach
- Department for Biomaterials Research, Polymer Institute of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 41 Bratislava, Slovakia
| | - Zuzana Cseriová
- Department for Biomaterials Research, Polymer Institute of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 41 Bratislava, Slovakia
| | - Dušan Chorvát
- Department of Biophotonics, International Laser Centre, Slovak Centre of Scientific and Technical Information, Ilkovičova 3, 841 04 Bratislava, Slovakia
| | - Fernando Zúñiga-Navarrete
- Department of Proteomics, Institute of Virology, Biomedical Research Center of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 05 Bratislava, Slovakia
| | - Peter D Rios
- CellTrans, Inc., 2201 W. Campbell Park Dr., Chicago, Illinois 60612, United States
| | - James McGarrigle
- CellTrans, Inc., 2201 W. Campbell Park Dr., Chicago, Illinois 60612, United States
| | - Sofia Ghani
- CellTrans, Inc., 2201 W. Campbell Park Dr., Chicago, Illinois 60612, United States
| | - Douglas Isa
- CellTrans, Inc., 2201 W. Campbell Park Dr., Chicago, Illinois 60612, United States
| | - Ira Joshi
- CellTrans, Inc., 2201 W. Campbell Park Dr., Chicago, Illinois 60612, United States
| | - Kalaiyarasi Vasuthas
- Centre of Molecular Inflammation Research (CEMIR), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Prinsesse Kristinas gt.1, NO-7491 Trondheim, Norway
| | - Anne Mari A Rokstad
- Centre of Molecular Inflammation Research (CEMIR), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Prinsesse Kristinas gt.1, NO-7491 Trondheim, Norway
| | - José Oberholzer
- CellTrans, Inc., 2201 W. Campbell Park Dr., Chicago, Illinois 60612, United States
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Vladimír Raus
- Institute of Macromolecular Chemistry, Czech Academy of Sciences, Heyrovského nám. 2, 162 06 Prague 6, Czech Republic
| | - Igor Lacík
- Department for Biomaterials Research, Polymer Institute of the Slovak Academy of Sciences, Dúbravská cesta 9, 845 41 Bratislava, Slovakia
- National Institute of Rheumatic Diseases, Nábrežie I. Krasku 4, 921 12 Piešt'any, Slovakia
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Zhou J, Li Q, Tian Z, Yao Q, Zhang M. Recent advances in 3D bioprinted cartilage-mimicking constructs for applications in tissue engineering. Mater Today Bio 2023; 23:100870. [PMID: 38179226 PMCID: PMC10765242 DOI: 10.1016/j.mtbio.2023.100870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 01/06/2024] Open
Abstract
Human cartilage tissue can be categorized into three types: hyaline cartilage, elastic cartilage and fibrocartilage. Each type of cartilage tissue possesses unique properties and functions, which presents a significant challenge for the regeneration and repair of damaged tissue. Bionics is a discipline in which humans study and imitate nature. A bionic strategy based on comprehensive knowledge of the anatomy and histology of human cartilage is expected to contribute to fundamental study of core elements of tissue repair. Moreover, as a novel tissue-engineered technology, 3D bioprinting has the distinctive advantage of the rapid and precise construction of targeted models. Thus, by selecting suitable materials, cells and cytokines, and by leveraging advanced printing technology and bionic concepts, it becomes possible to simultaneously realize multiple beneficial properties and achieve improved tissue repair. This article provides an overview of key elements involved in the combination of 3D bioprinting and bionic strategies, with a particular focus on recent advances in mimicking different types of cartilage tissue.
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Affiliation(s)
- Jian Zhou
- Department of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, PR China
| | - Qi Li
- Department of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, PR China
| | - Zhuang Tian
- Department of Joint Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, PR China
| | - Qi Yao
- Department of Joint Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, PR China
| | - Mingzhu Zhang
- Department of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, PR China
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Tian B, Liu J, Guo S, Li A, Wan JB. Macromolecule-based hydrogels nanoarchitectonics with mesenchymal stem cells for regenerative medicine: A review. Int J Biol Macromol 2023:125161. [PMID: 37270118 DOI: 10.1016/j.ijbiomac.2023.125161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/05/2023]
Abstract
The role of regenerative medicine in clinical therapies is becoming increasingly vital. Under specific conditions, mesenchymal stem cells (MSCs) are capable of differentiating into mesoblastema (i.e., adipocytes, chondrocytes, and osteocytes) and other embryonic lineages. Their application in regenerative medicine has attracted a great deal of interest among researchers. To maximize the potential applications of MSCs, materials science could provide natural extracellular matrices and provide an effective means to understand the various mechanisms of differentiation for the growth of MSCs. Pharmaceutical fields are represented among the research on biomaterials by macromolecule-based hydrogel nanoarchitectonics. Various biomaterials have been used to prepare hydrogels with their unique chemical and physical properties to provide a controlled microenvironment for the culture of MSCs, laying the groundwork for future practical applications in regenerative medicine. This article currently describes and summarizes the sources, characteristics, and clinical trials of MSCs. In addition, it describes the differentiation of MSCs in various macromolecule-based hydrogel nanoarchitectonics and highlights the preclinical studies of MSCs-loaded hydrogel materials in regenerative medicine conducted over the past few years. Finally, the challenges and prospects of MSC-loaded hydrogels are discussed, and the future development of macromolecule-based hydrogel nanoarchitectonics is outlined by comparing the current literature.
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Affiliation(s)
- Bingren Tian
- Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China.
| | - Jiayue Liu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao
| | - Songlin Guo
- Institute of Medical Sciences, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Aiqin Li
- Department of Day-care Unit, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jian-Bo Wan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao.
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Adhikari B, Stager MA, Krebs MD. Cell-instructive biomaterials in tissue engineering and regenerative medicine. J Biomed Mater Res A 2023; 111:660-681. [PMID: 36779265 DOI: 10.1002/jbm.a.37510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/16/2023] [Accepted: 01/29/2023] [Indexed: 02/14/2023]
Abstract
The field of biomaterials aims to improve regenerative outcomes or scientific understanding for a wide range of tissue types and ailments. Biomaterials can be fabricated from natural or synthetic sources and display a plethora of mechanical, electrical, and geometrical properties dependent on their desired application. To date, most biomaterial systems designed for eventual translation to the clinic rely on soluble signaling moieties, such as growth factors, to elicit a specific cellular response. However, these soluble factors are often limited by high cost, convoluted synthesis, low stability, and difficulty in regulation, making the translation of these biomaterials systems to clinical or commercial applications a long and arduous process. In response to this, significant effort has been dedicated to researching cell-directive biomaterials which can signal for specific cell behavior in the absence of soluble factors. Cells of all tissue types have been shown to be innately in tune with their microenvironment, which is a biological phenomenon that can be exploited by researchers to design materials that direct cell behavior based on their intrinsic characteristics. This review will focus on recent developments in biomaterials that direct cell behavior using biomaterial properties such as charge, peptide presentation, and micro- or nano-geometry. These next generation biomaterials could offer significant strides in the development of clinically relevant medical devices which improve our understanding of the cellular microenvironment and enhance patient care in a variety of ailments.
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Affiliation(s)
- Bikram Adhikari
- Quantitative Biosciences and Engineering, Colorado School of Mines, Golden, Colorado, USA
| | - Michael A Stager
- Chemical and Biological Engineering, Colorado School of Mines, Golden, Colorado, USA
| | - Melissa D Krebs
- Quantitative Biosciences and Engineering, Colorado School of Mines, Golden, Colorado, USA
- Chemical and Biological Engineering, Colorado School of Mines, Golden, Colorado, USA
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Modification, 3D printing process and application of sodium alginate based hydrogels in soft tissue engineering: A review. Int J Biol Macromol 2023; 232:123450. [PMID: 36709808 DOI: 10.1016/j.ijbiomac.2023.123450] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/26/2022] [Accepted: 01/24/2023] [Indexed: 01/27/2023]
Abstract
Sodium alginate (SA) is an inexpensive and biocompatible biomaterial with fast and gentle crosslinking that has been widely used in biological soft tissue repair/regeneration. Especially with the advent of 3D bioprinting technology, SA hydrogels have been applied more deeply in tissue engineering due to their excellent printability. Currently, the research on material modification, molding process and application of SA-based composite hydrogels has become a hot topic in tissue engineering, and a lot of fruitful results have been achieved. To better help readers have a comprehensive understanding of the development status of SA based hydrogels and their molding process in tissue engineering, in this review, we summarized SA modification methods, and provided a comparative analysis of the characteristics of various SA based hydrogels. Secondly, various molding methods of SA based hydrogels were introduced, the processing characteristics and the applications of different molding methods were analyzed and compared. Finally, the applications of SA based hydrogels in tissue engineering were reviewed, the challenges in their applications were also analyzed, and the future research directions were prospected. We believe this review is of great helpful for the researchers working in biomedical and tissue engineering.
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Kim Y, Zharkinbekov Z, Raziyeva K, Tabyldiyeva L, Berikova K, Zhumagul D, Temirkhanova K, Saparov A. Chitosan-Based Biomaterials for Tissue Regeneration. Pharmaceutics 2023; 15:pharmaceutics15030807. [PMID: 36986668 PMCID: PMC10055885 DOI: 10.3390/pharmaceutics15030807] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Chitosan is a chitin-derived biopolymer that has shown great potential for tissue regeneration and controlled drug delivery. It has numerous qualities that make it attractive for biomedical applications such as biocompatibility, low toxicity, broad-spectrum antimicrobial activity, and many others. Importantly, chitosan can be fabricated into a variety of structures including nanoparticles, scaffolds, hydrogels, and membranes, which can be tailored to deliver a desirable outcome. Composite chitosan-based biomaterials have been demonstrated to stimulate in vivo regeneration and the repair of various tissues and organs, including but not limited to, bone, cartilage, dental, skin, nerve, cardiac, and other tissues. Specifically, de novo tissue formation, resident stem cell differentiation, and extracellular matrix reconstruction were observed in multiple preclinical models of different tissue injuries upon treatment with chitosan-based formulations. Moreover, chitosan structures have been proven to be efficient carriers for medications, genes, and bioactive compounds since they can maintain the sustained release of these therapeutics. In this review, we discuss the most recently published applications of chitosan-based biomaterials for different tissue and organ regeneration as well as the delivery of various therapeutics.
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Roles of Local Soluble Factors in Maintaining the Growth Plate: An Update. Genes (Basel) 2023; 14:genes14030534. [PMID: 36980807 PMCID: PMC10048135 DOI: 10.3390/genes14030534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/24/2023] Open
Abstract
The growth plate is a cartilaginous tissue found at the ends of growing long bones, which contributes to the lengthening of bones during development. This unique structure contains at least three distinctive layers, including resting, proliferative, and hypertrophic chondrocyte zones, maintained by a complex regulatory network. Due to its soft tissue nature, the growth plate is the most susceptible tissue of the growing skeleton to injury in childhood. Although most growth plate damage in fractures can heal, some damage can result in growth arrest or disorder, impairing leg length and resulting in deformity. In this review, we re-visit previously established knowledge about the regulatory network that maintains the growth plate and integrate current research displaying the most recent progress. Next, we highlight local secretary factors, such as Wnt, Indian hedgehog (Ihh), and parathyroid hormone-related peptide (PTHrP), and dissect their roles and interactions in maintaining cell function and phenotype in different zones. Lastly, we discuss future research topics that can further our understanding of this unique tissue. Given the unmet need to engineer the growth plate, we also discuss the potential of creating particular patterns of soluble factors and generating them in vitro.
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Guan P, Ji Y, Kang X, Liu W, Yang Q, Liu S, Lin Y, Zhang Z, Li J, Zhang Y, Liu C, Fan L, Sun Y. Biodegradable Dual-Cross-Linked Hydrogels with Stem Cell Differentiation Regulatory Properties Promote Growth Plate Injury Repair via Controllable Three-Dimensional Mechanics and a Cartilage-like Extracellular Matrix. ACS APPLIED MATERIALS & INTERFACES 2023; 15:8986-8998. [PMID: 36752284 DOI: 10.1021/acsami.2c20722] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Recent breakthroughs in cell transplantation therapy have revealed the promising potential of bone marrow mesenchymal stem cells (BMSCs) for promoting the regeneration of growth plate cartilage injury. However, the high apoptosis rate and the uncertainty of the differentiation direction of cells often lead to poor therapeutic effects. Cells are often grown under three-dimensional (3D) conditions in vivo, and the stiffness and components of the extracellular matrix (ECM) are important regulators of stem cell differentiation. To this end, a 3D cartilage-like ECM hydrogel with tunable mechanical properties was designed and synthesized mainly from gelatin methacrylate (GM) and oxidized chondroitin sulfate (OCS) via dynamic Schiff base bonding under UV. The effects of scaffold stiffness and composition on the survival and differentiation of BMSCs in vitro were investigated. A rat model of growth plate injury was developed to validate the effect of the GMOCS hydrogels encapsulated with BMSCs on the repair of growth plate injury. The results showed that 3D GMOCS hydrogels with an appropriate modulus significantly promoted chondrogenic differentiation of BMSCs, and GMOCS/BMSC transplantation could effectively inhibit bone bridge formation and promote the repair of damaged growth plates. Accordingly, GMOCS/BMSC therapy can be engineered as a promising therapeutic candidate for growth plate injury.
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Affiliation(s)
- Pengfei Guan
- Department of Pediatric Orthopedic, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510515, China
| | - Yuelun Ji
- Department of Pediatric Orthopedic, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510515, China
| | - Xinchang Kang
- School of Chemical Engineering and Light Industry, Guangdong University of Technology, Guangzhou 510006, China
| | - Weilu Liu
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Qinfeng Yang
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Shencai Liu
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yeying Lin
- School of Chemical Engineering and Light Industry, Guangdong University of Technology, Guangzhou 510006, China
| | - Zuyu Zhang
- Department of Pediatric Orthopedic, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510515, China
| | - Junji Li
- Department of Pediatric Orthopedic, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510515, China
| | - Yue Zhang
- Guangdong Provincial Key Laboratory of Bone and Joint Degenerative Diseases, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Can Liu
- Department of Orthopedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Lei Fan
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yongjian Sun
- Department of Pediatric Orthopedic, Center for Orthopedic Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510515, China
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