Regeneration of articular cartilage of the knee

Peptide Regulation of Chondrogenic Stem Cell Differentiation

The search for innovative ways to treat osteoarthritis (OA) is an urgent task for molecular medicine and biogerontology. OA leads to disability in persons of middle and older age, while safe and effective methods of treating OA have not yet been discovered. The directed differentiation of mesenchymal stem cells (MSCs) into chondrocytes is considered one of the possible methods to treat OA. This review describes the main molecules involved in the chondrogenic differentiation of MSCs. The peptides synthesized on the basis of growth factors' structures (SK2.1, BMP, B2A, and SSPEPS) and components of the extracellular matrix of cartilage tissue (LPP, CFOGER, CMP, RDG, and N-cadherin mimetic peptide) offer the greatest promise for the regulation of the chondrogenic differentiation of MSCs. These peptides regulate the WNT, ERK-p38, and Smad 1/5/8 signaling pathways, gene expression, and the synthesis of chondrogenic differentiation proteins such as COL2, SOX9, ACAN, etc.

Generation of hyaline-like cartilage tissue from human mesenchymal stromal cells within the self-generated extracellular matrix

Chondrocytic hypertrophy, a phenotype not observed in healthy hyaline cartilage, is often concomitant with the chondrogenesis of human mesenchymal stromal cells (hMSCs). This undesired feature represents one of the major obstacles in applying hMSCs for hyaline cartilage repair. Previously, we developed a method to induce hMSC chondrogenesis within self-generated extracellular matrix (mECM), which formed a cartilage tissue with a lower hypertrophy level than conventional hMSC pellets. In this study, we aimed to test the utility of hypoxia and insulin-like growth factor-1 (IGF1) on further reducing hypertrophy. MSC-mECM constructs were first subjected to chondrogenic culture in normoxic or hypoxic (5%) conditions. The results indicated that hMSC-derived cartilage formed in hypoxic culture displayed a significantly reduced hypertrophy level than normoxic culture. However, hMSC chondrogenesis was also suppressed under hypoxic culture, partially due to the reduced activity of the IGF1 pathway. IGF1 was then supplemented in the chondrogenic medium, which promoted remarkable hMSC chondrogenesis under hypoxic culture. Interestingly, the IGF1-enhanced hMSC chondrogenesis, under hypoxic culture, was not at the expense of promoting significantly increased hypertrophy. Lastly, the cartilage tissues created by hMSCs with different conditions were implanted into osteochondral defect in rats. The results indicated that the tissue formed under hypoxic condition and induced with IGF1-supplemented chondrogenic medium displayed the best reparative results with minimal hypertrophy level. Our results demonstrate a new method to generate hyaline cartilage-like tissue from hMSCs without using exogenous scaffolds, which further pave the road for the clinical application of hMSC-based cartilage tissue engineering. STATEMENT OF SIGNIFICANCE: In this study, hyaline cartilage-like tissues were generated from human mesenchymal stromal cells (hMSCs), which displayed robust capacity in repairing the osteochondral defect in rats. In particular, the extracellular matrix created by hMSCs was used, so no exogenous scaffold was needed. Through a series of optimization, we defined that hypoxic culture and supplementation of insulin-like growth factor-1 (IGF-1) in chondrogenic medium resulted in robust cartilage formation with minimal hypertrophy. We also demonstrated that hypoxic culture suppressed chondrogenesis and hypertrophy through modulating the Wnt/β-catenin and IGF1 pathways, respectively. Our results demonstrate a new method to generate hyaline cartilage-like tissue from hMSCs without using exogenous scaffolds, which will further pave the road for the clinical application of hMSCs-based cartilage tissue engineering.

Knee Osteochondral Defect Reconstruction With Autologous Bone Grafting and Mesenchymal Cell Transplantation

Osteochondral defects of the knee are common in orthopaedic patients. They are challenging to treat, especially in young, highly demanding patients who do not qualify for arthroplasty. Among the many possibilities to treat osteochondral lesions presented so far, none is ideal. Because of the poor healing potential of cartilage, treatment outcomes significantly worsen with larger lesions. The treatment of large defects usually requires expensive solutions, sometimes including second-stage surgery. Using mesenchymal stem cell transplantation and cancellous bone autografts, the technique presented here for osteochondral lesion reconstruction can be effectively used to treat large osteochondral lesions in a single-stage procedure.

Magnetic Hydrogel for Cartilage Tissue Regeneration as well as a Review on Advantages and Disadvantages of Different Cartilage Repair Strategies

There is a clear clinical need for efficient cartilage healing strategies for treating cartilage defects which burdens millions of patients physically and financially. Different strategies including microfracture technique, osteochondral transfer, and scaffold-based treatments have been suggested for curing cartilage injuries. Although some improvements have been achieved in several facets, current treatments are still less than satisfactory. Recently, different hydrogel-based biomaterials have been suggested as a therapeutic candidate for cartilage tissue regeneration due to their biocompatibility, high water content, and tunability. Specifically, magnetic hydrogels are becoming more attractive due to their smart response to magnetic fields remotely. We seek to outline the context-specific regenerative potential of magnetic hydrogels for cartilage tissue repair. In this review, first, we explained conventional techniques for cartilage repair and then compared them with new scaffold-based approaches. We illustrated various hydrogels used for cartilage regeneration by highlighting the magnetic hydrogels. Also, we gathered in vitro and in vivo studies of how magnetic hydrogels promote chondrogenesis as well as studied the biological mechanism which is responsible for cartilage repair due to the application of magnetic hydrogel.

Report on a large animal study with Göttingen Minipigs where regenerates and controls for articular cartilage were created in a large number. Focus on the conditions of the operated stifle joints and suggestions for standardized procedures

The characterization of regenerated articular cartilage (AC) can be based on various methods, as there is an unambiguous accepted criterion neither for the natural cartilage tissue nor for regenerates. Biomechanical aspects should be considered as well, leading to the need for more equivalent samples. The aim of the study was to describe a large animal model where 8 specimens of regenerated AC can be created in one animal plus the impact of two surgeries on the welfare of the animals. The usefulness of the inclusion of a group of untreated animals (NAT) was to analyzed. Based on the histological results the conditions of the regenerates were to be described and the impact on knee joints were to be explored in terms of degenerative changes of the cartilage. The usefulness of the statistical term “effect size” (ES) will be explained with histological results. We analyzed an animal model where 8 AC regenerates were obtained from one Göttingen Minipig, on both sides of the trochleae. 60 animals were divided into 6 groups of 10 each, where the partial thickness defects in the trochlea were filled with matrices made of Collagen I with or without autologous chondrocytes or left empty over the healing periods of 24 and 48 weeks. One additional control group consisting of 10 untreated animals was used to provide untouched “external” cartilage. We harvested 560 samples of regenerated tissue and “external” controls, besides that, twice the number of further samples from other parts of the joints referred to as “internal” controls were also harvested. The animals recovered faster after the 1^st operation when the defects were set compared to the 2^nd operation when the defects were treated. 9% of all animals were lost. Other complications were for example superficial infections, seroma, diarrhea, febrile state and an injury of a claw. The histological results of the treatments proved the robustness of the study design where we included an “external” control group (NAT) in which the animals were not operated. Comparable significant differences between treated groups and the NAT group were detected both after ½ year and after 1 year. Spontaneous regenerated AC as control revealed differences after an observation time of nearly 1 year. The impact of the treatment on cartilage adjacent to the defect as well as the remaining knee joint was low. The ES was helpful for planning the study as it is shown that the power of a statistical comparison seems to be more influenced by the ES than by the sample size. The ranking of the ES was done exemplarily, listing the results according to their magnitude, thus making the results comparable. We were able to follow the 3 R requirements also in terms of a numerical reduction of animals due to the introduction of a group of untreated animals. This makes the model cost effective. The presented study may contribute as an improvement of the standardization of large animal models for research and regulatory requirements for regenerative therapies of AC.

Alleviation of synovitis caused by joint instability with application of platelet-rich plasma

INTRODUCTION

Synovitis is an early set and persistent change during the progression of osteoarthritis, which causes symptoms such as pain and swelling of the joints. Platelet-rich plasma (PRP) can release quantities of growth factors and cytokines, and is proved effected in promoting restoration of multiple soft tissues.

MATERIALS AND METHODS

In this study, twenty rabbits were used to establish animal model of synovitis, with the method of severing the anterior and posterior cruciate ligaments and removing the medial meniscus. Then the rabbits were evenly divided into the PRP group and the control group, and each group received injections of PRP and saline respectively once a week for 3 weeks consecutively, with the first injection administered 3 weeks postoperatively.

RESULTS

The platelet count, the concentrations of growth factors in PRP and whole blood were investigated, and the IL-1β concentration in the joint fluid was detected via ELISA. The synovium as well as the adjacent articular cartilage were collected for histological assessment. The platelet concentration in PRP is 6.8 fold of that in the whole blood. The IL-1β level in the PRP group was lower than that in the control group 2 and 3 weeks after the administration of PRP. Histological investigation showed that the inflammatory reaction of the synovium and impact on the cartilage was much abated in the PRP group.

CONCLUSIONS

PRP can effectively alleviate the synovitis caused by osteoarthritis following loss of joint stability. Given the autologous origin, its low cost and low risk features of PRP, it's a promising choice for OA patients to control the symptoms caused by synovitis.

Arthroscopic treatment of osteochondral knee defects with resorbable biphasic synthetic scaffold: clinical and radiological results and long-term survival analysis

PURPOSE

The aim of our study is to evaluate the long-term results in patients treated with a fully arthroscopic TruFit system for osteochondral lesions of the femoral condyle, analyzing the clinical and radiological outcomes, survival rate, complications, and correlations.

METHODS

The study included all patients treated with the TruFit system with a full-thickness focal lesion of the knee cartilage (grade IV according to the ICRS classification), entirely arthroscopically with a minimum follow-up of five years. All patients were evaluated clinically prior to surgery (T₀) and at two consecutive follow-ups (T₁ 36.4 ± 17.03 months and T₂ 101.63 ± 19.02 months), using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Hospital for Special Surgery Score (HSS). At the final follow-up, the magnetic resonance imaging (MRI) was evaluated by two orthopaedists using the magnetic resonance observation of cartilage repair tissue (MOCART) score.

RESULTS

The sample was formed of 21 patients, of which 14 were males (67%) and 7 females (33%), with a mean age of 51.29 ± 10.70. Of the 21 patients, two underwent prosthetic knee replacement at 24 and 65 months, respectively. At T₀, the HSS and the KOOS score were, respectively, 60.71 ± 11.62 and 57.71 ± 6.11. For both clinical values, a significant improvement was noted between T₀ and T₁ (p < 0.05) and between T₀ and T₂ (p < 0.05). At the final follow-up, the MOCART value was found to be 45.78 ± 5.27.

CONCLUSIONS

The study results highlighted the safety and potential of the arthroscopic TruFit system procedure, which offered a good clinical outcome with stable results at long-term follow-up although we found no correlations between the MRI and clinical results.

The Challenge of Managing the "Third-Space" in Total Knee Arthroplasty: Review of Current Concepts

Total knee arthroplasty (TKA) is the best treatment for advanced knee osteoarthritis and it has proven to be durable and effective. Anterior knee pain (AKP) is still one of the most frequent complications after TKA, but sometimes no recognized macroscopic causes can be found. The correct treatment of patella is considered the key for a proper management of AKP. The inclusion of patellar resurfacing during TKA has been described as a potential method for the reduction of AKP. After surgeons started to resurface the patella, new complications emerged, such as component failure, instability, fracture, tendon rupture, and soft tissue impingement. Patelloplasty has been proposed as a good alternative to resurfacing but whether or not to resurface the patella is still a controversial topic in the literature. Therefore, patellofemoral joint is a complex critical aspect in TKA and choosing between the several options of treatment of patella could not be sufficient. In this review, evidence-based studies do not succeed in resolving this difficult argument. The accurate management of the so-called “third space” should include an accurate assessment of cartilage layers, balance of soft tissue, preoperative anterior tracking, and positioning of the femoral and tibial components. In fact, the selection of suitable implants and adherence to proper surgical technique are the fundamental principles for the success of TKA.

Role of growth factors and oxygen to limit hypertrophy and impact of high magnetic nanoparticles dose during stem cell chondrogenesis

Due to an unmet clinical need of curative treatments for osteoarthritic patients, tissue engineering strategies that propose the development of cartilage tissue replacements from stem cells have emerged. Some of these strategies are based on the internalization of magnetic nanoparticles into stem cells to then initiate the chondrogenesis via magnetic compaction. A major difficulty is to drive the chondrogenic differentiation of the cells such as they produce an extracellular matrix free of hypertrophic collagen. An additional difficulty has to be overcome when nanoparticles are used, knowing that a high dose of nanoparticles can limit the chondrogenesis. We here propose a gene-based analysis of the effects of chemical factors (growth factors, hypoxia) on the chondrogenic differentiation of human mesenchymal stem cells both with and without nanoparticles. We focus on the synthesis of two of the most important constituents present in the cartilaginous extracellular matrix (Collagen II and Aggrecan) and on the expression of collagen X, the signature of hypertrophic cartilage, in order to provide a quantitative index of the type of cartilage produced (i.e. hyaline, hypertrophic). We demonstrate that by applying specific environmental conditions, gene expression can be directed toward the production of hyaline cartilage, with limited hypertrophy. Besides, a combination of the growth factors IGF-1, TGF-β3, with a hypoxic conditioning remarkably reduced the impact of high nanoparticles concentration.

TGF-β3 reduces apoptosis in ischemia-induced adipose-derived stem cells by enhancing DNA repair

Adipose-derived stem cells (ADSCs) possess good proliferative and differentiative abilities, making then a promising candidate for the treatment of cartilage defects. However, local ischemia often causes apoptosis in ADSCs. Transforming growth factor-β3 (TGF-β3) is often used as a chondrogenic differentiation cytokine whose function in apoptosis is unclear. The aim of the present study was to investigate the role of TGF-β3 in ischemia-induced ADSC apoptosis. In the present study, the phenotypes and multipotent differentiation properties of human ADSCs at passage 3 were analyzed using flow cytometry and cytochemical staining. ADSCs were cultured in a serum- and glucose-free medium under hypoxic conditions with or without exogenous TGF-β3 treatment. The apoptosis rate was measured using a TUNEL array and Annexin V/propidium iodide staining. The expression of apoptosis-associated proteins was measured using western blotting. The results revealed ADSCs cultured in normal condition have multi-lineage differentiation potential and high levels of cluster of differentiation (CD)29, CD44 and CD105 expression. Furthermore, ADSCs weakly express CD14, CD34 and CD45, with strong clone formation and migration abilities. Serum deprivation under hypoxic conditions resulted in mitochondria-mediated apoptosis in ADSCs, which was attenuated by exogenous TGF-β3 treatment via upregulation of poly ADP-ribose polymerase (PARP). The results of the present study indicate that TGF-β3 is able to protect ADSCs from ischemia-induced apoptosis via PARP-associated DNA damage repair.

Sox9 augments BMP2-induced chondrogenic differentiation by downregulating Smad7 in mesenchymal stem cells (MSCs)

Cartilage injuries caused by arthritis or trauma pose formidable challenges for effective clinical management due to the limited intrinsic proliferative capability of chondrocytes. Autologous stem cell-based therapies and transgene-enhanced cartilage tissue engineering may open new avenues for the treatment of cartilage injuries. Bone morphogenetic protein 2 (BMP2) induces effective chondrogenesis of mesenchymal stem cells (MSCs) and can thus be explored as a potential therapeutic agent for cartilage defect repair. However, BMP2 also induces robust endochondral ossification. Although the precise mechanisms through which BMP2 governs the divergence of chondrogenesis and osteogenesis remain to be fully understood, blocking endochondral ossification during BMP2-induced cartilage formation may have practical significance for cartilage tissue engineering. Here, we investigate the role of Sox9-donwregulated Smad7 in BMP2-induced chondrogenic differentiation of MSCs. We find that overexpression of Sox9 leads to a decrease in BMP2-induced Smad7 expression in MSCs. Sox9 inhibits BMP2-induced expression of osteopontin while enhancing the expression of chondrogenic marker Col2a1 in MSCs. Forced expression of Sox9 in MSCs promotes BMP2-induced chondrogenesis and suppresses BMP2-induced endochondral ossification. Constitutive Smad7 expression inhibits BMP2-induced chondrogenesis in stem cell implantation assay. Mouse limb explant assay reveals that Sox9 expands BMP2-stimulated chondrocyte proliferating zone while Smad7 promotes BMP2-intitated hypertrophic zone of the growth plate. Cell cycle analysis indicates that Smad7 induces significant early apoptosis in BMP2-stimulated MSCs. Taken together, our results strongly suggest that Sox9 may facilitate BMP2-induced chondrogenesis by downregulating Smad7, which can be exploited for effective cartilage tissue engineering.

A quantitative, multi-national and multi-stakeholder assessment of barriers to the adoption of cell therapies

Cellular therapies, such as stem cell-based treatments, have been widely researched and numerous products and treatments have been developed. Despite this, there has been relatively limited use of these technologies in the healthcare sector. This study sought to investigate the perceived barriers to this more widespread adoption. An anonymous online questionnaire was developed, based on the findings of a pilot study. This was distributed to an audience of clinicians, researchers and commercial experts in 13 countries. The results were analysed for all respondents, and also sub-grouped by geographical region, and by profession of respondents. The results of the study showed that the most significant barrier was manufacturing, with other factors such as efficacy, regulation and cost-effectiveness being identified by the different groups. This study further demonstrates the need for these important issues to be addressed during the development of cellular therapies to enable more widespread adoption of these treatments.

The Good the Bad and the Ugly of Glycosaminoglycans in Tissue Engineering Applications

High sulfation, low cost, and the status of heparin as an already FDA- and EMA- approved product, mean that its inclusion in tissue engineering (TE) strategies is becoming increasingly popular. However, the use of heparin may represent a naïve approach. This is because tissue formation is a highly orchestrated process, involving the temporal expression of numerous growth factors and complex signaling networks. While heparin may enhance the retention and activity of certain growth factors under particular conditions, its binding 'promiscuity' means that it may also inhibit other factors that, for example, play an important role in tissue maintenance and repair. Within this review we focus on articular cartilage, highlighting the complexities and highly regulated processes that are involved in its formation, and the challenges that exist in trying to effectively engineer this tissue. Here we discuss the opportunities that glycosaminoglycans (GAGs) may provide in advancing this important area of regenerative medicine, placing emphasis on the need to move away from the common use of heparin, and instead focus research towards the utility of specific GAG preparations that are able to modulate the activity of growth factors in a more controlled and defined manner, with less off-target effects.

Enhanced articular cartilage by human mesenchymal stem cells in enzymatically mediated transiently RGDS-functionalized collagen-mimetic hydrogels

Recapitulation of the articular cartilage microenvironment for regenerative medicine applications faces significant challenges due to the complex and dynamic biochemical and biomechanical nature of native tissue. Towards the goal of biomaterial designs that enable the temporal presentation of bioactive sequences, recombinant bacterial collagens such as Streptococcal collagen-like 2 (Scl2) proteins can be employed to incorporate multiple specific bioactive and biodegradable peptide motifs into a single construct. Here, we first modified the backbone of Scl2 with glycosaminoglycan-binding peptides and cross-linked the modified Scl2 into hydrogels via matrix metalloproteinase 7 (MMP7)-cleavable or non-cleavable scrambled peptides. The cross-linkers were further functionalized with a tethered RGDS peptide creating a system whereby the release from an MMP7-cleavable hydrogel could be compared to a system where release is not possible. The release of the RGDS peptide from the degradable hydrogels led to significantly enhanced expression of collagen type II (3.9-fold increase), aggrecan (7.6-fold increase), and SOX9 (5.2-fold increase) by human mesenchymal stem cells (hMSCs) undergoing chondrogenesis, as well as greater extracellular matrix accumulation compared to non-degradable hydrogels (collagen type II; 3.2-fold increase, aggrecan; 4-fold increase, SOX9; 2.8-fold increase). Hydrogels containing a low concentration of the RGDS peptide displayed significantly decreased collagen type I and X gene expression profiles, suggesting a major advantage over either hydrogels functionalized with a higher RGDS peptide concentration, or non-degradable hydrogels, in promoting an articular cartilage phenotype. These highly versatile Scl2 hydrogels can be further manipulated to improve specific elements of the chondrogenic response by hMSCs, through the introduction of additional bioactive and/or biodegradable motifs. As such, these hydrogels have the possibility to be used for other applications in tissue engineering.

Statement of Significance

Recapitulating aspects of the native tissue biochemical microenvironment faces significant challenges in regenerative medicine and tissue engineering due to the complex and dynamic nature of the tissue. The ability to take advantage of, mimic, and modulate cell-mediated processes within novel naturally-derived hydrogels is of great interest in the field of biomaterials to generate constructs that more closely resemble the biochemical microenvironment and functions of native biological tissues such as articular cartilage. Towards this goal, the temporal presentation of bioactive sequences such as RGDS on the chondrogenic differentiation of human mesenchymal stem cells is considered important as it has been shown to influence the chondrogenic phenotype. Here, a novel and versatile platform to recreate a high degree of biological complexity is proposed, which could also be applicable to other tissue engineering and regenerative medicine applications.

Good short- to medium-term results after osteochondral autograft transplantation (OAT) in middle-aged patients with focal, non-traumatic osteochondral lesions of the knee

BACKGROUND

Osteochondral autograft transplantation (OAT) offers the opportunity to repair cartilaginous defects by restoring hyaline cartilage anatomy. Encouraging results have been reported in patients suffering from acute knee trauma or osteochondritis dissecans. Patients with focal chronic, non-traumatic osteochondral (FCNO) lesions of the knee, however, have rarely been the subject of investigation. Some authors even consider higher age as contraindications to OAT.

OBJECTIVES

To assess the short- to medium-term outcomes of OAT in middle-aged patients with FCNO lesions of the knee and to identify predictors of clinical outcome.

HYPOTHESIS

Filling FCNO defects with autologous osteochondral grafts should restore the congruency of the middle-aged knee joint and thereby reduce pain and loss of function on the one hand, and increase quality of life on the other hand.

METHODS

One hundred and twelve patients (48.01±1.12yrs) with FCNO of the knee were assessed before OAT and 26.2±0.24 months after surgery. Clinical outcome was measured by WOMAC Index and the Visual Analogue Scale (VAS) for pain.

RESULTS

Pain (pre-OAT VAS vs. post-OAT VAS: 7.14±0.19 vs. 3.74±0.26, P<0.001) was reduced and quality of life (pre-OAT WOMAC vs. post-OAT WOMAC: 134.88±5.84 vs. 65.92±5.34, P<0.001) improved. Retropatellar defects were associated with poor outcome, while overall surface and number of cylinders were not.

DISCUSSION

Middle-aged patients with FCNO of the knee also profit from OAT at a short follow-up.

LEVEL OF EVIDENCE

IV. Mono-centric, prospective clinical series.

Autologous chondrocytes as a novel source for neo-chondrogenesis in haemophiliacs

Haemophilic arthropathy is the major cause of disability in patients with haemophilia and, despite prophylaxis with coagulation factor concentrates, some patients still develop articular complications. We evaluate the feasibility of a tissue engineering approach to improve current clinical strategies for cartilage regeneration in haemophiliacs by using autologous chondrocytes (haemophilic chondrocytes; HaeCs). Little is known about articular chondrocytes from haemophilic patients and no characterisation has as yet been performed. An investigation into whether blood exposure alters HaeCs should be interesting from the perspective of autologous implants. The typical morphology and expression of specific target genes and surface markers were therefore assessed by optical microscopy, reverse transcription plus the polymerase chain reaction (PCR), real-time PCR and flow-cytometry. We then considered chondrocyte behaviour on a bio-hybrid scaffold (based on polyvinyl alcohol/Wharton's jelly) as an in vitro model of articular cartilage prosthesis. Articular chondrocytes from non-haemophilic donors were used as controls. HaeC morphology and the resulting immunophenotype CD44(+)/CD49c(+)/CD49e(+)/CD151(+)/CD73(+)/CD49f(-)/CD26(-) resembled those of healthy donors. Moreover, HaeCs were active in the transcription of genes involved in the synthesis of the extracellular matrix proteins of the articular cartilage (ACAN, COL1A, COL2A, COL10A, COL9A, COMP, HAS1, SOX9), although the over-expression of COL1A1, COL10A1, COMP and HAS was observed. In parallel, the composite scaffold showed adequate mechanical and biological properties for cartilage tissue engineering, promoting chondrocyte proliferation. Our preliminary evidence contributes to the characterisation of HaeCs, highlighting the opportunity of using them for autologous cartilage implants in patients with haemophilia.

Updates in biological therapies for knee injuries: full thickness cartilage defect

Full thickness cartilage defect might occur at different ages, but a focal defect is a major concern in the knee of young athletes. It causes impairment and does not heal by itself. Several techniques were described to treat symptomatic full thickness cartilage defect. Recently, several advances were described on the known techniques of microfracture, osteochondral allograft, cell therapy, and others. This article brings an update of current literature on these well-described techniques for full thickness cartilage defect.

Programmed Application of Transforming Growth Factor β3 and Rac1 Inhibitor NSC23766 Committed Hyaline Cartilage Differentiation of Adipose-Derived Stem Cells for Osteochondral Defect Repair

Hyaline cartilage differentiation is always the challenge with application of stem cells for joint repair. Transforming growth factors (TGFs) and bone morphogenetic proteins can initiate cartilage differentiation but often lead to hypertrophy and calcification, related to abnormal Rac1 activity. In this study, we developed a strategy of programmed application of TGFβ3 and Rac1 inhibitor NSC23766 to commit the hyaline cartilage differentiation of adipose-derived stem cells (ADSCs) for joint cartilage repair. ADSCs were isolated and cultured in a micromass and pellet culture model to evaluate chondrogenic and hypertrophic differentiation. The function of Rac1 was investigated with constitutively active Rac1 mutant and dominant negative Rac1 mutant. The efficacy of ADSCs with programmed application of TGFβ3 and Rac1 inhibitor for cartilage repair was studied in a rat model of osteochondral defects. The results showed that TGFβ3 promoted ADSCs chondro-lineage differentiation and that NSC23766 prevented ADSC-derived chondrocytes from hypertrophy in vitro. The combination of ADSCs, TGFβ3, and NSC23766 promoted quality osteochondral defect repair in rats with much less chondrocytes hypertrophy and significantly higher International Cartilage Repair Society macroscopic and microscopic scores. The findings have illustrated that programmed application of TGFβ3 and Rac1 inhibitor NSC23766 can commit ADSCs to chondro-lineage differentiation and improve the efficacy of ADSCs for cartilage defect repair. These findings suggest a promising stem cell-based strategy for articular cartilage repair.

Quantitative MRI in the evaluation of articular cartilage health: reproducibility and variability with a focus on T2 mapping

PURPOSE

Early diagnosis of cartilage degeneration and longitudinal tracking of cartilage health including repair following surgical intervention would benefit from the ability to detect and monitor changes of the articular cartilage non-invasively and before gross morphological alterations appear.

METHODS

Quantitative MR imaging has shown promising results with various imaging biomarkers such as T2 mapping, T1 rho and dGEMRIC demonstrating sensitivity in the detection of biochemical alterations within tissues of interest. However, acquiring accurate and clinically valuable quantitative data has proven challenging, and the reproducibility of the quantitative mapping technique and its values are essential. Although T2 mapping has been the focus in this discussion, all quantitative mapping techniques are subject to the same issues including variability in the imaging protocol, unloading and exercise, analysis, scanner and coil, calculation methods, and segmentation and registration concerns.

RESULTS

The causes for variability between time points longitudinally in a patient, among patients, and among centres need to be understood further and the issues addressed.

CONCLUSIONS

The potential clinical applications of quantitative mapping are vast, but, before the clinical community can take full advantage of this tool, it must be automated, standardized, validated, and have proven reproducibility prior to its implementation into the standard clinical care routine.

Sox9 potentiates BMP2-induced chondrogenic differentiation and inhibits BMP2-induced osteogenic differentiation

Bone morphogenetic protein 2 (BMP2) is one of the key chondrogenic growth factors involved in the cartilage regeneration. However, it also exhibits osteogenic abilities and triggers endochondral ossification. Effective chondrogenesis and inhibition of BMP2-induced osteogenesis and endochondral ossification can be achieved by directing the mesenchymal stem cells (MSCs) towards chondrocyte lineage with chodrogenic factors, such as Sox9. Here we investigated the effects of Sox9 on BMP2-induced chondrogenic and osteogenic differentiation of MSCs. We found exogenous overexpression of Sox9 enhanced the BMP2-induced chondrogenic differentiation of MSCs in vitro. Also, it inhibited early and late osteogenic differentiation of MSCs in vitro. Subcutaneous stem cell implantation demonstrated Sox9 potentiated BMP2-induced cartilage formation and inhibited endochondral ossification. Mouse limb cultures indicated that BMP2 and Sox9 acted synergistically to stimulate chondrocytes proliferation, and Sox9 inhibited BMP2-induced chondrocytes hypertrophy and ossification. This study strongly suggests that Sox9 potentiates BMP2-induced MSCs chondrogenic differentiation and cartilage formation, and inhibits BMP2-induced MSCs osteogenic differentiation and endochondral ossification. Thus, exogenous overexpression of Sox9 in BMP2-induced mesenchymal stem cells differentiation may be a new strategy for cartilage tissue engineering.

Is autologous chondrocyte implantation (ACI) an adequate treatment option for repair of cartilage defects in paediatric patients?

Cartilage lesions in the knee of juvenile patients require an effective repair to regain life-long functional activity of the joint. Autologous chondrocyte implantation (ACI) is discussed to be advantageous over other methods for cartilage repair regarding long-term outcome. ACI has successfully been applied in juvenile patients, although currently recommended for patients ≥18 years of age. Only few controlled clinical trials present evidence of efficacy and safety of ACI in adolescent patients. ACI products have to undergo the process of a marketing authorisation application, including the submission of a paediatric investigation plan (PIP). Data from prospective clinical studies or retrospective collection of long-term data in paediatric patients should be submitted for risk-benefit evaluation by the Paediatric Committee (PDCO).