Injectable Lyophilized Chitosan-Thrombin-Platelet-Rich Plasma (CS-FIIa-PRP) Implant to Promote Tissue Regeneration: In Vitro and Ex Vivo Solidification Properties

Freeze-dried chitosan formulations solubilized in platelet-rich plasma (PRP) are currently evaluated as injectable implants with the potential for augmenting the standard of care for tissue repair in different orthopedic conditions. The present study aimed to shorten the solidification time of such implants, leading to an easier application and a facilitated solidification in a wet environment, which were direct demands from orthopedic surgeons. The addition of thrombin to the formulation before lyophilization was explored. The challenge was to find a formulation that coagulated fast enough to be applied in a wet environment but not too fast, which would make handling/injection difficult. Four thrombin concentrations were analyzed (0.0, 0.25, 0.5, and 1.0 NIH/mL) in vitro (using thromboelastography, rheology, indentation, syringe injectability, and thrombin activity tests) as well as ex vivo (by assessing the implant's adherence to tendon tissue in a wet environment). The biomaterial containing 0.5 NIH/mL of thrombin significantly increased the coagulation speed while being easy to handle up to 6 min after solubilization. Furthermore, the adherence of the biomaterial to tendon tissues was impacted by the biomaterial-tendon contact duration and increased faster when thrombin was present. These results suggest that our biomaterial has great potential for use in regenerative medicine applications.

Chitosan-platelet-rich plasma implants improve rotator cuff repair in a large animal model: Pilot study

Freeze-dried formulations of chitosan can be solubilized in platelet-rich plasma (PRP) to form injectable implants that are used as an adjunct treatment during surgical repair of the rotator cuff. The purpose of the current study was to assess chitosan-PRP implant residency, test safety, and assess efficacy over standard-of-care controls in a sheep model of rotator cuff repair. The infraspinatus tendon was transected unilaterally and immediately repaired with suture anchors in 22 skeletally mature ewes. In treatment groups, formulations containing chitosan, trehalose, and calcium chloride were solubilized with autologous leukocyte-rich PRP and injected at the tendon-bone interface and on top of the repaired site (1 mL or 2 mL doses). Implant residency was assessed histologically at 1 day. Outcome measures included MRI assessment at baseline, 6 weeks, and 12 weeks, histopathology and clinical pathology. Chitosan-PRP implants were resident at the injection site at 1 day and induced recruitment of polymorphonuclear cells. The tendon gap, which corresponds to the length of abnormally hyperintense tissue attached to the humeral head, was decreased by treatment with the 2 mL dose when compared to controls at 12 weeks on MRI images. Some histological features were improved by the 2 mL dose treatment compared to controls at 12 weeks. There was no treatment-specific effect on all standard safety outcome measures, which suggests high safety. This study provides preliminary evidence on the safety and efficacy of chitosan-PRP implants in a large animal model that could potentially be translated to a clinical setting.

Chitosan-Platelet-Rich Plasma Implants Improve Rotator Cuff Repair in a Large Animal Model: Pivotal Study

The purpose of this study was to assess the safety and efficacy of chitosan-platelet-rich plasma (PRP) hybrid implants used as an adjunct to surgical rotator cuff repair in a pivotal Good Laboratory Practice (GLP)-compliant study. The infraspinatus tendon was transected in 48 skeletally mature ewes and repaired with a transosseous-equivalent (TOE) technique. In the two treatment groups, a chitosan-PRP solution was injected at the footprint between the tendon and the bone and on top of the repaired site (2 mL or 3 mL doses, n = 12 per group). To further assess chitosan safety, a chitosan-water solution was injected at the same sites (3 mL, n = 12). Outcome measures included Magnetic Resonance Imaging (MRI) assessment and clinical pathology at 3 months and 6 months and histopathology at 6 months. The tendon gap was decreased at 3 months on MRI images and certain histopathological features were improved at 6 months by chitosan-PRP treatment compared to controls. The group treated with chitosan-water was not different from controls. Chitosan-PRP treatment induced no negative effects in the sheep, which suggests high safety. This study provides further evidence on the safety and efficacy of chitosan-PRP for rotator cuff repair augmentation, which could eventually be used in a clinical setting.

Physically Crosslinked Chitosan/PVA Hydrogels Containing Honey and Allantoin with Long-Term Biocompatibility for Skin Wound Repair: An In Vitro and In Vivo Study

Chitosan/PVA hydrogel films crosslinked by the freeze-thaw method and containing honey and allantoin were prepared for application as wound dressing materials. The effects of the freeze-thaw process and the addition of honey and allantoin on the swelling, the gel content and the mechanical properties of the samples were evaluated. The physicochemical properties of the samples, with and without the freeze-thaw process, were compared using FTIR, DSC and XRD. The results showed that the freeze-thaw process can increase the crystallinity and thermal stability of chitosan/PVA films. The freeze-thaw process increased the gel content but did not have a significant effect on the tensile strength. The presence of honey reduced the swelling and the tensile strength of the hydrogels due to hydrogen bonding interactions with PVA and chitosan chains. Long-term cell culture experiments using normal human dermal fibroblast (NHDF) cells showed that the hydrogels maintained their biocompatibility, and the cells showed extended morphology on the surface of the hydrogels for more than 30 days. The presence of honey significantly increased the biocompatibility of the hydrogels. The release of allantoin from the hydrogel was studied and, according to the Korsmeyer-Peppas and Weibull models, the mechanism was mainly diffusional. The results for the antimicrobial activity against E. coli and S. aureus bacteria showed that the allantoin-containing samples had a more remarkable antibacterial activity against S. aureus. According to the wound healing experiments, 98% of the wound area treated by the chitosan/PVA/honey hydrogel was closed, compared to 89% for the control. The results of this study suggest that the freeze-thaw process is a non-toxic crosslinking method for the preparation of chitosan/PVA hydrogels with long term biocompatibility that can be applied for wound healing and skin tissue engineering.

Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial

Purpose

To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA).

Methods

Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale.

Results

The study included 25 shoulders of 22 patients who completed baseline and 12 months’ patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA.

Conclusions

The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings.

Level of Evidence

Level II, randomized controlled trial.

Robust Segmentation-Free Algorithm for Homogeneity Quantification in Images

OBJECTIVE

Homogeneity is a notion used to describe images in various fields and is often linked to critical aspects of those fields. However, this term is rarely defined in the literature and no gold standard exists for its quantification. A few quantification algorithms have been proposed, but they lack both simplicity and robustness. As a result, the scientific community uses the notion of homogeneity in subjective analysis, preventing objective comparison of a large number of data or of different studies. The main objectives of this manuscript are to propose a definition of homogeneity and an algorithm for its quantification.

METHOD

This algorithm, called MASQH, rely on a multi-scale, statistical and segmentation-free approach and outputs a single homogeneity index, which makes it robust and easy to use.

RESULTS

The performance and reliability of the method are demonstrated through three case studies: Firstly, on synthetic images to study the behavior and assess the relevance of the algorithm in diverse situations and hence, in various potential fields. Secondly, on histological images derived from experimental chitosan-platelet-rich-plasma hybrid biomaterial, where the quantitative results are compared to a qualitative classification provided by an expert in the field. Thirdly, on experimental nanocomposites images for which results are compared to two other homogeneity quantification algorithms from the field of nanocomposites.

CONCLUSION AND SIGNIFICANCE

By quantifying homogeneity, the MASQH method may help to compare disparate studies in the literature and quantitatively demonstrate the impact of homogeneity in various fields. The MASQH method is freely available online.

Platelet-rich therapies as an emerging platform for regenerative medicine

INTRODUCTION

The combination of human plasma components with the multiple secretome from platelets has provided a new biological tool that is shaping a new future for its direct application in tissue regeneration as well as in cell culture and advanced therapy by means of its use as a clinical-grade supplement.

AREAS COVERED

Some relevant aspects related to the biology, growth factor delivery and molecular pathways driving the biological effects of platelet-rich therapies are summarized. Their use as clinical-grade cell supplements and advanced therapies is also carefully described.

EXPERT OPINION

Platelet-rich plasma therapies, and especially PRGF, contain an incredible number of biologically active agents that may exert regenerative and therapeutic potential. Here, we highlight the latest advances in this biological approach for the delivery of autologous growth factors with some of the recent new applications including the development of a clinical-grade supplement for advanced therapy.

Neovascularization of engineered tissues for clinical translation: Where we are, where we should be?

One of the key challenges in engineering three-dimensional tissue constructs is the development of a mature microvascular network capable of supplying sufficient oxygen and nutrients to the tissue. Recent angiogenic therapeutic strategies have focused on vascularization of the constructed tissue, and its integration in vitro; these strategies typically combine regenerative cells, growth factors (GFs) with custom-designed biomaterials. However, the field needs to progress in the clinical translation of tissue engineering strategies. The article first presents a detailed description of the steps in neovascularization and the roles of extracellular matrix elements such as GFs in angiogenesis. It then delves into decellularization, cell, and GF-based strategies employed thus far for therapeutic angiogenesis, with a particularly detailed examination of different methods by which GFs are delivered in biomaterial scaffolds. Finally, interdisciplinary approaches involving advancement in biomaterials science and current state of technological development in fabrication techniques are critically evaluated, and a list of remaining challenges is presented that need to be solved for successful translation to the clinics.

A novel image analysis algorithm reveals that media conditioned with chitosan and platelet-rich plasma biomaterial dose dependently increases fibroblast migration in a scratch assay

Chitosan (CS) and Platelet-Rich Plasma (PRP) both display interesting properties for wound healing applications. A hybrid CS-PRP biomaterial was previously developped, consisting of a freeze dried CS formulation solubilized in PRP that promotes tissue repair and regeneration. The purpose of the current study was to investigate the ability of the CS-PRP biomaterial to stimulate cell migrationin vitro. Scratch assays revealed that CS-PRP significantly stimulates the migration rate of cells compared to cells in culture medium but not differently than PRP alone. The increase in the migration rate is dose-dependent at low dose and reaches a plateau corresponding with maximum cell motility. Cell migration rate as a function of the number of platelets that have degranulated in culture medium (to which total concentration of growth factors contributing to cell response is proportionnal), follows a modified Hill model. To analyze photographs taken during the assay and follow cell migration, an open source image analysis algorithm was developed: SAMScratch (Systematic Area Measurement of Scratch - available here:https://github.com/Biomaterials-and-Cartilage-Laboratory/SAM-Scratch). Compared with other existing analysis tools, the algorithm is precise in the determination of the scratch area and performs equally well with usual and challenging images. This study resulted in the creation of a freely available application for scratch assay analysis and provided evidence that CS-PRP implants hold promise for treatment of wounds.

Multiple platelet-rich plasma preparations can solubilize freeze-dried chitosan formulations to form injectable implants for orthopedic indications

BACKGROUND

Platelet-rich plasma (PRP) has been used to solubilize freeze-dried chitosan (CS) formulations to form injectable implants for tissue repair.

OBJECTIVE

To determine whether the in vitro performance of the formulations depends on the type of PRP preparation used to solubilize CS.

METHODS

Formulations containing 1% (w/v) CS with varying degrees of deacetylation (DDA 80.5-84.8%) and number average molar mass (Mn 32-55 kDa), 1% (w/v) trehalose and 42.2 mM calcium chloride were freeze-dried. Seven different PRP preparations were used to solubilize the formulations. Controls were recalcified PRP.

RESULTS

CS solubilization was achieved with all PRP preparations. CS-PRP formulations were less runny than their corresponding PRP controls. All CS-PRP formulations had a clotting time below 9 minutes, assessed by thromboelastography, while the leukocyte-rich PRP controls took longer to coagulate (>32 min), and the leukocyte-reduced PRP controls did not coagulate in this dynamic assay. In glass culture tubes, all PRP controls clotted, expressed serum and retracted (43-82% clot mass lost) significantly more than CS-PRP clots (no mass lost). CS dispersion was homogenous within CS-PRP clots.

CONCLUSIONS

In vitro performance of the CS-PRP formulations was comparable for all types of PRPs assessed.

Freeze-dried chitosan-platelet-rich plasma implants improve supraspinatus tendon attachment in a transosseous rotator cuff repair model in the rabbit

Rotator cuff tears result in shoulder pain, stiffness, weakness and loss of motion. After surgical repair, high failure rates have been reported based on objective imaging and it is recognized that current surgical treatments need improvement. The aim of the study was to assess whether implants composed of freeze-dried chitosan (CS) solubilized in autologous platelet-rich plasma (PRP) can improve rotator cuff repair in a rabbit model. Complete tears were created bilaterally in the supraspinatus tendon of New Zealand White rabbits ( n = 4 in a pilot feasibility study followed by n = 13 in a larger efficacy study), which were repaired using transosseous suturing. On the treated side, CS-PRP implants were injected into the transosseous tunnels and the tendon itself, and healing was assessed histologically at time points ranging from one day to two months post-surgery. CS-PRP implants were resident within transosseous tunnels and adhered to tendon surfaces at one day post-surgery and induced recruitment of polymorphonuclear cells from 1 to 14 days. CS-PRP implants improved attachment of the supraspinatus tendon to the humeral head through increased bone remodelling at the greater tuberosity and also inhibited heterotopic ossification of the supraspinatus tendon at two months. In addition, the implants did not induce any detectable deleterious effects. This preliminary study provides the first evidence that CS-PRP implants could be effective in improving rotator cuff tendon attachment in a small animal model.

Surface functionalization of electrospun scaffolds using recombinant human decorin attracts circulating endothelial progenitor cells

Decorin (DCN) is an important small leucine-rich proteoglycan present in the extracellular matrix (ECM) of many organs and tissues. Endothelial progenitor cells (EPCs) are able to interact with the surrounding ECM and bind to molecules such as DCN. Here, we recombinantly produced full-length human DCN under good laboratory practice (GLP) conditions, and after detailed immunological characterization, we investigated its potential to attract murine and human EPCs (mEPCs and hECFCs). Electrospun polymeric scaffolds were coated with DCN or stromal cell-derived factor-1 (SDF-1α) and were then dynamically cultured with both cell types. Cell viability was assessed via imaging flow cytometry. The number of captured cells was counted and compared with the non-coated controls. To characterize cell-scaffold interactions, immunofluorescence staining and scanning electron microscopy analyses were performed. We identified that DCN reduced T cell responses and attracted innate immune cells, which are responsible for ECM remodeling. A significantly higher number of EPCs attached on DCN- and SDF-1α-coated scaffolds, when compared with the uncoated controls. Interestingly, DCN showed a higher attractant effect on hECFCs than SDF-1α. Here, we successfully demonstrated DCN as promising EPC-attracting coating, which is particularily interesting when aiming to generate off-the-shelf biomaterials with the potential of in vivo cell seeding.

Biodegradable Scaffolds for Bone Regeneration Combined with Drug-Delivery Systems in Osteomyelitis Therapy

A great deal of research is ongoing in the area of tissue engineering (TE) for bone regeneration. A possible improvement in restoring damaged tissues involves the loading of drugs such as proteins, genes, growth factors, antibiotics, and anti-inflammatory drugs into scaffolds for tissue regeneration. This mini-review is focused on the combination of the local delivery of antibiotic agents with bone regenerative therapy for the treatment of a severe bone infection such as osteomyelitis. The review includes a brief explanation of scaffolds for bone regeneration including scaffolds characteristics and types, a focus on severe bone infections (especially osteomyelitis and its treatment), and a literature review of local antibiotic delivery by the combination of scaffolds and drug-delivery systems. Some examples related to published studies on gentamicin sulfate-loaded drug-delivery systems combined with scaffolds are discussed, and future perspectives are highlighted.