An injectable bone substitute composed of beta-tricalcium phosphate granules, methylcellulose and hyaluronic acid inhibits connective tissue influx into its implantation bed in vivo

Injectable in situ gelling methylcellulose-based hydrogels for bone tissue regeneration

Injectable bone substitutes (IBSs) represent a compelling choice for bone tissue regeneration, as they can be exploited to optimally fill complex bone defects in a minimally invasive manner. In this context, in situ gelling methylcellulose (MC) hydrogels may be engineered to be free-flowing injectable solutions at room temperature and gels upon exposure to body temperature. Moreover, incorporating a suitable inorganic phase can further enhance the mechanical properties of MC hydrogels and promote mineralization, thus assisting early cell adhesion to the hydrogel and effectively guiding bone tissue regeneration. In this work, thermo-responsive IBSs were designed selecting MC as the organic matrix and calcium phosphate (CaP) or CaP modified with graphene oxide (CaPGO) as the inorganic component. The resulting biocomposites displayed a transition temperature around body temperature, preserved injectability even after loading with the inorganic components, and exhibited adequate retention on an ex vivo calf femoral bone defect model. The addition of CaP and CaPGO promoted the in vitro mineralization process already 14 days after immersion in simulated body fluid. Interestingly, combined X-ray diffraction and solid state nuclear magnetic resonance characterizations revealed that the formed biomimetic phase was constituted by crystalline hydroxyapatite and amorphous calcium phosphate. In vitro biological characterization revealed the beneficial impact of CaP and CaPGO, indicating their potential in promoting cell adhesion, proliferation and osteogenic differentiation. Remarkably, the addition of GO, which is very attractive for its bioactive properties, did not negatively affect the injectability of the hydrogel nor the mineralization process, but had a positive impact on cell growth and osteogenic differentiation on both pre-differentiated and undifferentiated cells. Overall, the proposed formulations represent potential candidates for use as IBSs for application in bone regeneration both under physiological and pathological conditions.

Anterior Cervical Discectomy and Fusions Supplemented With Cellular or Noncellular Allografts Have Similar Radiographic Fusion and Clinical Outcomes

STUDY DESIGN

A retrospective, single-center study.

OBJECTIVE

The aim of this study was to assess radiographic fusion after anterior cervical discectomy and fusion (ACDF) supplemented with either demineralized bone matrix or ViviGen in a polyetheretherketone biomechanical interbody cage.

SUMMARY OF BACKGROUND DATA

Cellular and noncellular allografts are utilized as adjuncts in attempts to improve fusion after ACDF. The purpose of this study was to assess radiographic fusion and clinical outcomes after ACDF supplemented with cellular or noncellular allografts.

MATERIALS AND METHODS

A single surgeon's clinical practice database was interrogated for consecutive patients who underwent a primary ACDF using cellular or noncellular allograft from 2017 to 2019. These subjects were matched by age, sex, body mass index, smoking status, and levels operated. Patient demographic and preoperative and postoperative patient-reported outcome measures (PROMs) including Visual Analog Scale Pain, Neck Disability Index, EuroQol-5 Dimension (EQ-5D), Patient-Reported Outcomes Measurement Information System (PROMIS), and Eating Assessment Tool 10 were collected preoperatively and at 3, 6, and 12 months postoperatively. Radiographic evidence of fusion was determined by <2 mm motion between spinous processes on flexion and extension radiographs and assessing bony bridging at 3, 6, and 12 months postoperatively.

RESULTS

There were 68 total patients, with 34 patients in each group, and 69 and 67 operative levels in the cellular and noncellular allograft groups, respectively. There was no difference in age, sex, body mass index, or smoking status between groups ( P >0.05). There was no difference in number of 1-level, 2-level, 3-level, or 4-level ACDFs between cellular and noncellular groups ( P >0.05). At 3, 6, and 12 months postoperatively, there was no difference in the percent of operated levels with <2 mm motion between spinous processes, complete bony bridging, or both <2 mm motion and complete bony bridging in the cellular and noncellular groups ( P >0.05). There was no difference in the number of patients fused at all operated levels at 3, 6, or 12 months postoperatively ( P >0.05). No patient required revision ACDF for symptomatic pseudarthrosis. There was no significant difference in PROMs between the cellular and noncellular groups at 12 months postoperatively except for improved EQ-5D and PROMIS-physical in the cellular compared with noncellular group ( P =0.03).

CONCLUSIONS

Similar radiographic fusion rates were achieved with cellular and noncellular allografts at all operated levels with similar PROMs in the cellular and noncellular groups at 3, 6, and 12 months postoperatively. Thus, ACDFs supplemented with cellular allograft demonstrate adequate radiographic fusion rates when compared with noncellular allografts with similar patient outcomes.

LEVEL OF EVIDENCE

Level III.

Multicolor biosensor for hyaluronidase based on target-responsive hydrogel and etching of gold nanorods by H2O2

Hyaluronidase (HAase) is a potential tumor biomarker for diseases of the digestive tract and nervous system, the development of simple and sensitive techniques for HAase determination is urgent needed. Gold nanorods (Au NRs) can be etched by H₂O₂ with high efficiency and display color changing. In this work, a HAase-responsive hydrogel system had been designed and the amount of H₂O₂ spilled from the system had a close relationship with the amount of HAase, then the spilled H₂O₂ had been applied to etch Au NRs. The color change of the solution was used to realize semi-quantitative determination of HAase. Furthermore, the longitudinal peak shift of Au NRs had a linear correlation with the concentration of HAase in the range of 10-60 U/mL (within 40 min) and the limit of detection (LOD) was 3.8 U/mL (S/N = 3), which can be used to realize accurate quantitative analysis of HAase. The proposed method has been applied to monitor HAase in serum of pancreatic cancer patients with satisfied results.

Biocompatibility of Veratric Acid-Encapsulated Chitosan/Methylcellulose Hydrogel: Biological Characterization, Osteogenic Efficiency with In Silico Molecular Modeling

The limitations of graft material, and surgical sites for autografts in bone defects treatment have become a significant challenge in bone tissue engineering. Phytocompounds markedly affect bone metabolism by activating the osteogenic signaling pathways. The present study investigated the biocompatibility of the bio-composite thermo-responsive hydrogels consisting of chitosan (CS), and methylcellulose (MC) encapsulated with veratric acid (VA) as a restorative agent for bone defect treatment. The spectroscopy analyses confirmed the formation of CS/MC hydrogels and VA encapsulated CS/MC hydrogels (CS/MC-VA). Molecular analysis of the CS-specific MC decamer unit with VA complex exhibited a stable integration in the system. Further, Runx2 (runt-related transcription factor 2) was found in the docking mechanism with VA, indicating a high binding affinity towards the functional site of the Runx2 protein. The formulated CS/MC-VA hydrogels exhibited biocompatibility with the mouse mesenchymal stem cells, while VA promoted osteogenic differentiation in the stem cells, which was verified by calcium phosphate deposition through the von Kossa staining. The study results suggest that CS/MC-VA could be a potential therapeutic alternative source for bone regeneration.

Assessment of tricalcium phosphate/titanium dioxide (TCP/TiO2) nanocomposite scaffold compared with bone autograft and hydroxyapatite (HA) on the healing of segmental femur bone defect in rabbits

Bone healing is a tissue process after a surgical operation. Many formulated materials have been designed for improving these procedures. The purpose of this study was to evaluate the effectiveness of nanocomposite tricalcium phosphate scaffolds combined with Titanium dioxide scaffold (TCP/TiO2) for femoral defects regeneration in rabbits. We studied 80 mature male New Zealand white rabbits weighing between 3 and 3.5 kg. Rabbits were subdivided into four groups. Anesthesia was performed before surgical operation by 50 mg/kg Ketamine 10% and 5 mg/kg xylazine 5% intramuscularly. We inducted a 6 × 5 mm diameter cylinder defect on the femur. Animals were separated into four trial groups of 20 animals each. After defecting, the experimental groups include control, autograft, hydroxyapatite, and TCP/TiO2 (received pure nanocomposite TCP/TiO2 material). A pathologist evaluated the sections on days 15, 30, 45, and 60 after surgery. The improvement of new and lamellar bone formation was the best in the nanocomposite TCP/TiO2 group at various point times, especially 60 days after surgery. We found that TCP/TiO2 nanocomposite has a significant improving function in the remodeling of bone in the defect areas. Graphical abstract.

Sudoku of porous, injectable calcium phosphate cements – Path to osteoinductivity

With the increase of global population, people's life expectancy is growing as well. Humans tend to live more active lifestyles and, therefore, trauma generated large defects become more common. Instances of tumour resection or pathological conditions and complex orthopaedic issues occur more frequently increasing necessity for bone substitutes. Composition of calcium phosphate cements (CPCs) is comparable to the chemical structure of bone minerals. Their ability to self-set and resorb in vivo secures a variety of potential applications in bone regeneration. Despite the years-long research and several products already reaching the market, finding the right properties for calcium phosphate cement to be osteoinductive and both injectable and suitable for clinical use is still a sudoku. This article is focused on injectable, porous CPCs, reviewing the latest developments on the path toward finding osteoinductive material, which is suitable for injection.

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Phase separation is an essential factor to be improved to obtain injectable material; several methods have been proposed.

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Osteoinductive bone substitutes – possible solution for bad mechanical performance of CPCs.

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Osteoinductivity of CPC could be attained even without the addition of different supplements.

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Less complex composition of CPC – potentially reduced price of the final product and wider availability on the market.

Rheological properties and decomposition rates of Gellan gum/hyaluronic acid/β-tricalcium phosphate mixtures

The effects of β-tricalcium phosphate (TCP) on the mixture of low acyl gellan gum (LA-GAGR) and hyaluronic acid (HA) were investigated for the rheological properties and decomposition rates. All the tested mixture samples exhibited shear-thinning and typical viscoelastic behaviors. The sample made with 1.0% TCP and 0.30% LA-GAGR had the highest viscosity and loss and storage moduli and displayed gel-like behavior with the highest swelling capacity. The same mixture also exhibited the lowest average cumulative decomposition rate. High concentrations of LA-GAGR and TCP increased the degree of cross-linking of the polysaccharides, and as a result, the mixture was more elastic and less fluidic and decomposed slower. The samples prepared by gradual mixing of LA-GAGR and TCP decomposed slower than the sample prepared by sudden mixing, which indicates the well-dispersed TCP enhanced cross-linking of the polymers. This study demonstrates the possible applicability of natural polysaccharide-based shear-thinning gels for biomedical applications.

In Vivo Biocompatibility Investigation of an Injectable Calcium Carbonate (Vaterite) as a Bone Substitute including Compositional Analysis via SEM-EDX Technology

Injectable bone substitutes (IBS) are increasingly being used in the fields of orthopedics and maxillofacial/oral surgery. The rheological properties of IBS allow for proper and less invasive filling of bony defects. Vaterite is the most unstable crystalline polymorph of calcium carbonate and is known to be able to transform into hydroxyapatite upon contact with an organic fluid (e.g., interstitial body fluid). Two different concentrations of hydrogels based on poly(ethylene glycol)-acetal-dimethacrylat (PEG-a-DMA), i.e., 8% (w/v) (VH-A) or 10% (w/v) (VH-B), were combined with vaterite nanoparticles and implanted in subcutaneous pockets of BALB/c mice for 15 and 30 days. Explants were prepared for histochemical staining and immunohistochemical detection methods to determine macrophage polarization, and energy-dispersive X-ray analysis (EDX) to analyze elemental composition was used for the analysis. The histopathological analysis revealed a comparable moderate tissue reaction to the hydrogels mainly involving macrophages. Moreover, the hydrogels underwent a slow cellular infiltration, revealing a different degradation behavior compared to other IBS. The immunohistochemical detection showed that M1 macrophages were mainly found at the material surfaces being involved in the cell-mediated degradation and tissue integration, while M2 macrophages were predominantly found within the reactive connective tissue. Furthermore, the histomorphometrical analysis revealed balanced numbers of pro- and anti-inflammatory macrophages, demonstrating that both hydrogels are favorable materials for bone tissue regeneration. Finally, the EDX analysis showed a stepwise transformation of the vaterite particle into hydroxyapatite. Overall, the results of the present study demonstrate that hydrogels including nano-vaterite particles are biocompatible and suitable for bone tissue regeneration applications.

Alginate bone scaffolds coated with a bioactive lactose modified chitosan for human dental pulp stem cells proliferation and differentiation

Bioactive and biodegradable porous scaffolds can hasten the healing of bone defects; moreover, patient stem cells seeded onto scaffolds can enhance the osteoinductive and osteoconductive properties of these biomaterials. In this work, porous alginate/hydroxyapatite scaffolds were functionalized with a bioactive coating of a lactose-modified chitosan (CTL). The highly interconnected porous structure of the scaffold was homogeneously coated with CTL. The scaffolds showed remarkable stability up to 60 days of aging. Human Dental Pulp Stem Cells (hDPSCs) cultured in the presence of CTL diluted in culture medium, showed a slight and negligible increase in terms of proliferation rate; on the contrary, an effect on osteogenic differentiation of the cells was observed as a significant increase in alkaline phosphatase activity. hDPSCs showed higher cell adhesion on CTL-coated scaffolds than on uncoated ones. CTL coating did not affect cell proliferation, but stimulated cell differentiation as shown by alkaline phosphatase activity analysis.

Novel Histomorphometrical Approach to Evaluate the Integration Pattern and Functionality of Barrier Membranes

GBR (guided bone regeneration) is a standard procedure for building up bony defects in the jaw. In this procedure, resorbable membranes made of bovine and porcine collagen are increasingly being used, which, in addition to many possible advantages, could have the potential disadvantage of a shorter barrier functionality, especially when augmenting large-volume defects. Thus, it is of importance to evaluate the integration behavior and especially the standing time of barrier membranes using specialized methods to predict its respective biocompatibility. This study is intended to establish a new histomorphometrical analysis method to quantify the integration rate of collagen-based barrier membranes. Three commercially available barrier membranes, i.e., non-crosslinked membranes (BioGide^® and Jason^® membrane), a ribose-crosslinked membrane (Ossix^® Plus), and a newly developed collagen–hyaluronic acid-based (Coll-HA) barrier membrane were implanted in the subcutaneous tissue of 48 6–8-week-old Wistar rats. The explants, after three timepoints (10, 30, and 60 days), were processed and prepared into histological sections for histopathological (host tissue response) and histomorphometrical (cellular invasion) analyses. 10 days after implantation, fragmentation was not evident in any of the study groups. The sections of the Coll-HA, Jason^® and BioGide^® membranes showed a similar mild inflammatory reaction within the surrounding tissue and an initial superficial cell immigration. Only in the Ossix^® Plus group very little inflammation and no cell invasion was detected. While the results of the three commercially available membranes remained intact in the further course of the study, only fragments of the Coll-HA membrane were found 30 and 60 days after implantation. Histomorphometrically, it can be described that although initially (at 10 days post-implantation) similar results were found in all study groups, after 30 days post-implantation the cellular penetration depth of the hyaluronic acid-collagen membrane was significantly increased with time (**** p < 0.0001). Similarly, the percentage of cellular invasion per membrane thickness was also significantly higher in the Coll-HA group at all timepoints, compared to the other membranes (**** p < 0.0001). Altogether, these results show that the histomorphometrical analysis of the cellular migration can act as an indicator of integration and duration of barrier functionality. Via this approach, it was possible to semi-quantify the different levels of cellular penetration of GBR membranes that were only qualitatively analyzed through histopathological approaches before. Additionally, the results of the histopathological and histomorphometrical analyses revealed that hyaluronic acid addition to collagen does not lead to a prolonged standing time, but an increased integration of a collagen-based biomaterial. Therefore, it can only partially be used in the dental field for indications that require fast resorbed membranes and a fast cell or tissue influx such as periodontal regeneration processes.

Biomaterials for Periodontal and Peri-Implant Regeneration

Periodontal and peri-implant regeneration is the technique that aims to restore the damaged tissue around teeth and implants. They are surrounded by a different apparatus, and according to it, the regenerative procedure can differ for both sites. During the last century, several biomaterials and biological mediators were proposed to achieve a complete restoration of the damaged tissues with less invasiveness and a tailored approach. Based on relevant systematic reviews and articles searched on PubMed, Scopus, and Cochrane databases, data regarding different biomaterials were extracted and summarized. Bone grafts of different origin, membranes for guided tissue regeneration, growth factors, and stem cells are currently the foundation of the routinary clinical practice. Moreover, a tailored approach, according to the patient and specific to the involved tooth or implant, is mandatory to achieve a better result and a reduction in patient morbidity and discomfort. The aim of this review is to summarize clinical findings and future developments regarding grafts, membranes, molecules, and emerging therapies. In conclusion, tissue engineering is constantly evolving; moreover, a tailor-made approach for each patient is essential to obtain a reliable result and the combination of several biomaterials is the elective choice in several conditions.

Existing clinical evidence on the use of cellular bone matrix grafts in spinal fusion: updated systematic review of the literature

OBJECTIVE

Spinal fusion surgery is increasingly common; however, pseudarthrosis remains a common complication affecting as much as 15% of some patient populations. Currently, no clear consensus on the best bone graft materials to use exists. Recent advances have led to the development of cell-infused cellular bone matrices (CBMs), which contain living components such as mesenchymal stem cells (MSCs). Relatively few clinical outcome studies on the use of these grafts exist, although the number of such studies has increased in the last 5 years. In this study, the authors aimed to summarize and critically evaluate the existing clinical evidence on commercially available CBMs in spinal fusion and reported clinical outcomes.

METHODS

The authors performed a systematic search of the MEDLINE and PubMed electronic databases for peer-reviewed, English-language original articles (1970-2020) in which the articles' authors studied the clinical outcomes of CBMs in spinal fusion. The US National Library of Medicine electronic clinical trials database (www.ClinicalTrials.gov) was also searched for relevant ongoing clinical trials.

RESULTS

Twelve published studies of 6 different CBM products met inclusion criteria: 5 studies of Osteocel Plus/Osteocel (n = 354 unique patients), 3 of Trinity Evolution (n = 114), 2 of ViviGen (n = 171), 1 of map3 (n = 41), and 1 of VIA Graft (n = 75). All studies reported high radiographic fusion success rates (range 87%-100%) using these CBMs. However, this literature was overwhelmingly limited to single-center, noncomparative studies. Seven studies disclosed industry funding or conflicts of interest (COIs). There are 4 known trials of ViviGen (3 trials) and Bio4 (1 trial) that are ongoing.

CONCLUSIONS

CBMs are a promising technology with the potential of improving outcome after spinal fusion. However, while the number of studies conducted in humans has tripled since 2014, there is still insufficient evidence in the literature to recommend for or against CBMs relative to cheaper alternative materials. Comparative, multicenter trials and outcome registries free from industry COIs are indicated.

Synthetic Injectable Biomaterials for Alveolar Bone Regeneration in Animal and Human Studies

After tooth extraction, the alveolar ridge undergoes dimensional changes. Different bone regeneration biomaterials are used to reduce bone loss. The aim of this article was to systematically review the literature on the effect of injectable synthetic biomaterials and their advantages and disadvantages for new bone formation in the maxilla and mandible in animals and humans. A literature search was conducted in November 2020 via MEDLINE PubMed, Cochrane, and Embase. Of the 501 records screened, abstract analysis was performed on 49 articles, resulting in 21 studies that met the inclusion criteria. Animal studies have shown heterogeneity in terms of animal models, follow-up time, composition of the injectable biomaterial, and different outcome variables such as bone–implant contact, newly formed bone, and peri-implant bone density. Heterogeneity has also been demonstrated by human studies. The following outcomes were observed: newly formed bone, connective tissue, residual injectable bone graft substitute, radiographic density, residual bone height, and different follow-up periods. Further studies, especially in humans, based on the histological and biomechanical properties of the injectable delivery form, are needed to draw more concrete conclusions that will contribute to a better understanding of the benefits of this type of biomaterials and their role in bone regeneration.

In Vivo Analysis of the Biocompatibility and Bone Healing Capacity of a Novel Bone Grafting Material Combined with Hyaluronic Acid

The present in vivo study analyses both the inflammatory tissue reactions and the bone healing capacity of a newly developed bone substitute material (BSM) based on xenogeneic bone substitute granules combined with hyaluronate (HY) as a water-binding molecule. The results of the hyaluronate containing bone substitute material (BSM) were compared to a control xenogeneic BSM of the same chemical composition and a sham operation group up to 16 weeks post implantationem. A major focus of the study was to analyze the residual hyaluronate and its effects on the material-dependent healing behavior and the inflammatory tissue responses. The study included 63 male Wistar rats using the calvaria implantation model for 2, 8, and 16 weeks post implantationem. Established and Good Laboratory Practice (GLP)-conforming histological, histopathological, and histomorphometrical analysis methods were conducted. The results showed that the new hyaluronate containing BSM was gradually integrated within newly formed bone up to the end of the study that ended in a condition of complete bone defect healing. Thereby, no differences to the healing capacity of the control BSM were found. However, the bone formation in both groups was continuously significantly higher compared to the sham operation group. Additionally, no differences in the (inflammatory) tissue response that was analyzed via qualitative and (semi-) quantitative methods were found. Interestingly, no differences were found between the numbers of pro- and anti-inflammatory macrophages between the three study groups over the entire course of the study. No signs of the HY as a water-binding part of the BSM were histologically detectable at any of the study time points, altogether the results of the present study show that HY allows for an optimal material-associated bone tissue healing comparable to the control xenogeneic BSM. The added HY seems to be degraded within a very short time period of less than 2 weeks so that the remaining BSM granules allow for a gradual osteoconductive bone regeneration. Additionally, no differences between the inflammatory tissue reactions in both material groups and the sham operation group were found. Thus, the new hyaluronate containing xenogeneic BSM and also the control BSM have been shown to be fully biocompatible without any differences regarding bone regeneration.

Exploring the Biomaterial-Induced Secretome: Physical Bone Substitute Characteristics Influence the Cytokine Expression of Macrophages

In addition to their chemical composition various physical properties of synthetic bone substitute materials have been shown to influence their regenerative potential and to influence the expression of cytokines produced by monocytes, the key cell-type responsible for tissue reaction to biomaterials in vivo. In the present study both the regenerative potential and the inflammatory response to five bone substitute materials all based on β-tricalcium phosphate (β-TCP), but which differed in their physical characteristics (i.e., granule size, granule shape and porosity) were analyzed for their effects on monocyte cytokine expression. To determine the effects of the physical characteristics of the different materials, the proliferation of primary human osteoblasts growing on the materials was analyzed. To determine the immunogenic effects of the different materials on human peripheral blood monocytes, cells cultured on the materials were evaluated for the expression of 14 pro- and anti-inflammatory cytokines, i.e., IL-6, IL-10, IL-1β, VEGF, RANTES, IL-12p40, I-CAM, IL-4, V-CAM, TNF-α, GM-CSF, MIP-1α, Il-8 and MCP-1 using a Bio-Plex^® Multiplex System. The granular shape of bone substitutes showed a significant influence on the osteoblast proliferation. Moreover, smaller pore sizes, round granular shape and larger granule size increased the expression of GM-CSF, RANTES, IL-10 and IL-12 by monocytes, while polygonal shape and the larger pore sizes increased the expression of V-CAM. The physical characteristics of a bone biomaterial can influence the proliferation rate of osteoblasts and has an influence on the cytokine gene expression of monocytes in vitro. These results indicate that the physical structure of a biomaterial has a significant effect of how cells interact with the material. Thus, specific characteristics of a material may strongly affect the regenerative potential in vivo.

The Early Fragmentation of a Bovine Dermis-Derived Collagen Barrier Membrane Contributes to Transmembraneous Vascularization-A Possible Paradigm Shift for Guided Bone Regeneration

Collagen-based barrier membranes are an essential component in Guided Bone Regeneration (GBR) procedures. They act as cell-occlusive devices that should maintain a micromilieu where bone tissue can grow, which in turn provides a stable bed for prosthetic implantation. However, the standing time of collagen membranes has been a challenging area, as native membranes are often prematurely resorbed. Therefore, consolidation techniques, such as chemical cross-linking, have been used to enhance the structural integrity of the membranes, and by consequence, their standing time. However, these techniques have cytotoxic tendencies and can cause exaggerated inflammation and in turn, premature resorption, and material failures. However, tissues from different extraction sites and animals are variably cross-linked. For the present in vivo study, a new collagen membrane based on bovine dermis was extracted and compared to a commercially available porcine-sourced collagen membrane extracted from the pericardium. The membranes were implanted in Wistar rats for up to 60 days. The analyses included well-established histopathological and histomorphometrical methods, including histochemical and immunohistochemical staining procedures, to detect M1- and M2-macrophages as well as blood vessels. Initially, the results showed that both membranes remained intact up to day 30, while the bovine membrane was fragmented at day 60 with granulation tissue infiltrating the implantation beds. In contrast, the porcine membrane remained stable without signs of material-dependent inflammatory processes. Therefore, the bovine membrane showed a special integration pattern as the fragments were found to be overlapping, providing secondary porosity in combination with a transmembraneous vascularization. Altogether, the bovine membrane showed comparable results to the porcine control group in terms of biocompatibility and standing time. Moreover, blood vessels were found within the bovine membranes, which can potentially serve as an additional functionality of barrier membranes that conventional barrier membranes do not provide.

Thermal treatment at 500 °C significantly reduces the reaction to irregular tricalcium phosphate granules as foreign bodies: An in vivo study

Evaporation of phosphate species during thermal treatment (> 400 °C) of calcium phosphates leads to the formation of an alkaline layer on their surface. The aim of this study was to evaluate the hypothesis that the biological response of thermally treated calcium phosphates is modified by the presence of such an alkaline layer on their surface. For this purpose, 0.125-0.180 mm α- and β-tricalcium phosphate (TCP) granules were obtained by crushing and size classification, with some being subjected to thermal treatment at 500 °C. The four types of granules (α-TCP, β-TCP, α-TCP-500 °C, and β-TCP-500 °C) were implanted subcutaneously and orthotopically in rats. Sham operations served as control. Subcutaneously, α-TCP and β-TCP induced significantly more multinucleated giant cells (MNGCs) than calcined granules. Most of the induced MNGCs were TRAP-negative, CD-68 positive and cathepsin K-negative, reflecting a typical indication of a reaction with a foreign body. The vessel density was significantly higher in the α-TCP and β-TCP groups than it was in the α-TCP-500 °C and β-TCP-500 °C groups. In the femur model, β-TCP-500 °C induced significantly more new bone formation than that induced by β-TCP. The granule size was also significantly larger in the β-TCP-500 °C group, making it more resistant to degradation than β-TCP. The MNGC density was higher in the α-TCP and β-TCP groups than in the α-TCP-500 °C and β-TCP-500 °C groups, including cathepsin-positive, CD-68 positive, TRAP-positive and TRAP-negative MNGCs. In conclusion, this study confirms that the biological response of calcium phosphates was affected by the presence of an alkaline layer on their surface. Thermally-treated α-TCP and β-TCP granules produced significantly fewer MNGCs and were significantly less degraded than non-thermally-treated α-TCP and β-TCP granules. Thermally treating α-TCP and β-TCP granules shifts the reaction from a foreign body reaction towards a physiological reaction by downregulating the number of induced MNGCs and enhancing degradation resistance.

Implantation of an Injectable Bone Substitute Material Enables Integration Following the Principles of Guided Bone Regeneration

BACKGROUND/AIM

The present study investigates the in vivo tissue reaction and the integration behavior of an injectable bone substitute material (IBS) composed of a water-based gel combined with nano hydroxyapatite particles and biphasic calcium phosphate granules. The results of the IBS were compared to biphasic bone substitute granules (BBSM) of the same chemical composition.

MATERIALS AND METHODS

The subcutaneous implantation model in 40 female 5-week-old CD-1 mice up to 60 days after implantation was used for conduction of the in vivo experiments. Moreover, established histological, histopathological and histomorphometrical methods were applied.

RESULTS

The results showed that the IBS was gradually invaded by cells and complex tissue elements. Thus, the implant bed could be distinguished in two areas, i.e. an outer and inner region. While the outer region started to interact with the peri-implant tissue by evoking multinucleated giant cells and at earlier time points by undergoing a continuous high vascularization, the inner part was free of peri-implant cells for at least 30 days, starting to undergo a similar tissue reaction at a later time point. The bone substitute granules allowed for a fast tissue influx between the interspaces of the granules starting at day 10. While the vessel density did not differ in both groups up to the end of the study, the amount of vascularization was significantly higher over the entire observation period in the BBSM group. Moreover, the amount of biomaterial-associated multinucleated giant cells (BMGCs) was significantly higher in the IBS group in the period of between 15 to 30 days after implantation, while comparable BMGC numbers were found in both groups towards the end of the study.

CONCLUSION

IBS can build a barrier-like structure that is able to control the soft tissue influx into the central regions of the implantation bed, which could not be observed in other bone substitute granules of the same chemical composition. This directed integration behavior is assumed to be in accordance with the concept of Guided Bone Regeneration (GBR). Furthermore, BMGCs can significantly influence the process of angiogenesis within an implant bed of a biomaterial but not the maturity of blood vessels.

Effect of zoledronic acid and graphene oxide on the physical and in vitro properties of injectable bone substitutes

The aim of this work was to develop injectable bone substitutes (IBS) consisting of zoledronic acid (ZOL) and graphene oxide (GO) for the treatment of osteoporosis and metastasis. The powder phase was consisting of tetra calcium phosphate (TTCP), dicalcium phosphate dihyrate (DCPD) and calcium sulfate dihyrate (CSD), while the liquid phase comprised of methylcellulose (MC), gelatin and sodium citrate dihyrate (SC), ZOL and GO. The structural analysis of IBS samples was performed by Fourier Transform Infrared Spectroscopy (FTIR). Injectability, setting time and mechanical strength were investigated. Additionally, in vitro properties of synthesized IBS were analyzed by means of bioactivity, ZOL release, degradation, pH variation, PO₄^3- ion release and cell studies. Overall, all IBS exhibited excellent injectability results with no phase separation. The setting time of the IBS was prolonged with ZOL incorporation while the prolonging effect decreased with GO incorporation. The mechanical properties decreased with ZOL addition and increased with the incorporation of GO. The maximum compressive strength was found as 25.73 MPa for 1.5GO0ZOL incorporated IBS. In vitro results showed that ZOL and GO loaded IBS also revealed clinically suitable properties with controlled release of ZOL, pH value and PO₄^3- ions. In in vitro cell studies, both the inhibitory effect of ZOL and GO loaded IBS on MCF-7 cells and proliferative effect on osteoblast cells were observed. Moreover, the prepared IBS led to proliferation, differentiation and mineralization of osteoblasts. The results are encouraging and support the conclusion that developed IBS have promising physical and in vitro properties which needs to be further validated by gene expression and in vivo studies.

Specialized Histological and Histomorphometrical Analytical Methods for Biocompatibility Testing of Biomaterials for Maxillofacial Surgery in (Pre-) Clinical Studies

Both preclinical in vivo experiments and clinical trials are indispensable for analysis of tissue reactions in evaluating the compatibility of biomaterials or medical devices, i.e. the cell types interacting with the material, integration or degradation behavior, implant bed vascularization and immunological response. In particular, both the histological workup (including the processes such as embedding, cutting, histochemical and immunohistochemical staining methods), as well as qualitative and quantitative analysis are crucial steps enabling the final evaluation of biocompatibility. We present a short overview of the most important steps of the different workup and analytical methods used in preclinical and clinical biopsies for both novice and experienced researchers in the field of biomaterial science.

The Biomaterial-Induced Cellular Reaction Allows a Novel Classification System Regardless of the Biomaterials Origin

Several different biomaterials are being introduced for clinical applications. However, no current material-specific systematic studies define parameters for evaluating these materials. The aim of this retrospective animal study is to classify biomaterials according to the in vivo induced cellular reaction and outline the clinical consequence of the biomaterial-specific cellular reaction for the regeneration process. A retrospective histologic analysis was performed for 13 polymeric biomaterials and 19 bone substitute materials (BSMs) (of various compositions and origins) that were previously implanted in a standardized subcutaneous model. Semiquantitative analyses were performed at days 3, 15, and 30 after implantation according to a standardized score for the induction of multinucleated giant cells (MNGCs) and vascularization rate. The induced cellular reaction in response to different polymeric materials allowed their classification according to the MNGC score in the following groups: class I induced no MNGCs at any time point, class II induced and maintained a constant number of MNGCs over 30 days, and class III induced MNGCs and provided an increasing number over 30 days. All BSMs induced MNGCs to varying extents. Therefore, the resultant BSM classifications are as follows: class I induced MNGCs with a decreasing number, class II induced and maintained constant MNGCs over 30 days, and class III induced MNGCs with increasing number over 30 days. These observations were mostly related to the biomaterial physicochemical properties and were independent of the biomaterial origin. Consequently, the induction of MNGCs and their increase over 30 days resulted in disintegration of the biomaterial. By contrast, the absence of MNGCs resulted in an integration of the biomaterial within the host tissue. This novel classification provides clinicians a tool to assess the capacity and suitability of biomaterials in the intended clinical indication for bone and soft tissue implantations.

In Vivo Analysis of the Biocompatibility and Immune Response of Jellyfish Collagen Scaffolds and its Suitability for Bone Regeneration

Jellyfish collagen, which can be defined as "collagen type 0" due to its homogeneity to the mammalian types I, II, III, V, and IX and its batch-to-batch consistent producibility, is of special interest for different medical applications related to (bone) tissue regeneration as an alternative to mammalian collagen-based biomaterials. However, no in vivo studies regarding the induction of M1- and M2-macrophages and their time-dependent ration as well as the analysis of the bone regeneration capacity of jellyfish collagen scaffolds have been conducted until now. Thus, the goal of this study was to determine the nature of the immune response to jellyfish collagen scaffolds and their bone healing capacities. Two in vivo studies using established implantation models, i.e., the subcutaneous and the calvarian implantation model in Wistar rats, were conducted. Furthermore, specialized histological, histopathological, and histomorphometrical methods have been used. As a control biomaterial, a collagen scaffold, originating from porcine pericardium, which has already been stated as biocompatible, was used for the subcutaneous study. The results of the present study show that jellyfish collagen scaffolds are nearly completely resorbed until day 60 post implantation by stepwise integration within the subcutaneous connective tissue mediated mainly by macrophages and single multinucleated giant cells. Interestingly, the degradation process ended in a vessel rich connective tissue that is understood to be an optimal basis for tissue regeneration. The study results showed an overall weaker immune response to jellyfish collagen than to porcine pericardium matrices by the induction of significantly lower numbers of macrophages together with a more balanced occurrence of M1- and M2-macrophages. However, both collagen-based biomaterials induced balanced numbers of both macrophage subtypes, which supports their good biocompatibility. Moreover, the histomorphometrical results for the calvarial implantation of the jellyfish scaffolds revealed an average of 46.20% de novo bone formation at day 60, which was significantly higher compared to the control group. Thereby, the jellyfish collagen scaffolds induced also significantly higher numbers of anti-inflammatory macrophages within the bony implantation beds. Altogether, the results show that the jellyfish collagen scaffolds allowed for a directed integration behavior, which is assumed to be in accordance with the concept of Guided Bone Regeneration (GBR). Furthermore, the jellyfish collagen scaffolds induced a long-term anti-inflammatory macrophage response and an optimal vascularization pattern within their implant beds, thus showing excellent biocompatibility and (bone) tissue healing properties.

Multilevel instrumented posterolateral lumbar spine fusion with an allogeneic cellular bone graft

Background

Low back pain (LBP) is the leading cause of absence from work, disability, and impaired quality of life. Fusion surgery may be indicated when non-operative treatments have failed to provide relief. Surgery may include the use of fusion-enhancing implants, such as cellular bone allografts (CBAs). The purpose of this retrospective study was to evaluate efficacy and safety of one CBA (V-CBA) in patients who underwent instrumented posterolateral fusion (IPLF).

Methods

Retrospective data were collected from 150 consecutive patients who had undergone IPLF surgery between January 1, 2015, and March 31, 2018, in which V-CBA was used. All surgeries were performed by one surgeon. V-CBA was mixed with local autograft bone. Patient diagnoses included degenerative disc disease, spondylosis, spondylolisthesis, or spondylolysis with or without stenosis. Standing anteroposterior (AP) and lateral images were collected prior to surgery and again at the terminal visit, which took place between 6 and 33 months post-operatively. De-identified images were assessed radiologically. Adverse events were documented. The primary composite endpoint of fusion status was dependent upon two main criteria: bridging bone per the Lenke scale (classified as “A” definitely solid or “B” possibly solid) and posterior hardware status (intact). Lenke scale C or D were categorized as pseudarthrosis.

Results

Eighty-seven male and 63 female patients (613 levels total) underwent IPLF in which V-CBA was implanted. An average of 4.1 levels was treated, with 59.3% of patients having undergone treatment for more than 3 levels. Twenty-nine percent of patients had diabetes. Fifty-two percent of patients had previously used nicotine products, and 12% were current smokers. Sixteen serious adverse events were recorded and included lumbar seroma, cerebrospinal fluid leak, wound dehiscence, pneumonia, urinary tract infection, and myocardial infarction. Successful fusion (Lenke scale “A” or “B”) was recorded in 148 out of 150 patients (98.7%), or 608 out of 613 levels. The total pseudarthrosis rate was 0.8%.

Conclusions

The use of V-CBA combined with local autograft in multilevel IPLF resulted in successful fusions in 98.7% of patients. These results are particularly robust given the complex nature of many of these cases: 89 patients had 4 or more surgical levels, and many patients had multiple comorbidities.

Level of evidence

IV

The Addition of High Doses of Hyaluronic Acid to a Biphasic Bone Substitute Decreases the Proinflammatory Tissue Response

Biphasic bone substitutes (BBS) are currently well-established biomaterials. Through their constant development, even natural components like hyaluronic acid (HY) have been added to improve both their handling and also their regenerative properties. However, little knowledge exists regarding the consequences of the addition of HY to their biocompatibility and the inflammatory tissue reactions. Thus, the present study was conducted, aiming to analyze the influence of two different amounts of high molecular weight HY (HMWHY), combined with a BBS, on in vitro biocompatibility and in vivo tissue reaction. Established in vitro procedures, using L929 cells, were used for cytocompatibility analyses under the test conditions of DIN EN:ISO 10993-5. For the in vivo part of the study, calvarial defects were created in 20 Wistar rats and subsequently filled with BBS, and BBS combined with two different HMWHY amounts, i.e., BBS + HY(L) and BBS + HY(H). As controls, empty defects were used. Established histological, immunohistochemical, and histomorphometrical methods were applied to analyze the tissue reactions to the three different materials, including the induction of pro- and anti-inflammatory macrophages and multinucleated giant cells (BMGCs). The in vitro results showed that none of the materials or compositions caused biological damage to the L929 cells and can be considered to be non-toxic. The in vivo results showed that only the addition of high doses of HY to a biphasic bone substitute significantly decreases the occurrence of pro-inflammatory macrophages (* p < 0.05), comparable to the numbers found in the control group, while no significant differences within the three study groups for M2-macrophages nor BMGCs were detected. In conclusion, the addition of different amounts of HMWHY does not seem to affect the inflammation response to BBS, while improving the material handling properties.

Biopolymers - Calcium phosphates composites with inclusions of magnetic nanoparticles for bone tissue engineering

Composites based on combination of biopolymers (chitosan, hyaluronic acid and bovine serum albumin or gelatin), calcium phosphates (CP) and magnetic nanoparticles have been prepared by a biomimetic co-precipitation method. The biomimetic strategy is inspired by natural mineralization processes, where the synthesized minerals are usually combined with proteins, polysaccharides or other mineral forms to form composite, in physiological conditions of temperature and pH. The morphology of the magnetic composites, studied using scanning electron microscopy (SEM) indicated a macroporous structure, which influenced the retention of simulated biological fluids. Fourier transformed infrared spectroscopy and X-ray diffraction and Energy-dispersive X-ray spectroscopy (EDX) confirmed the composition of the scaffolds and the formation of various types of calcium phosphates with amorphous nature. The in vitro degradation studies showed a slow degradation process for magnetic composites that confirmed the tightly connection of the polymeric matrix with calcium phosphates, which limits the enzyme access to the degradable components and material disintegration. The magnetic scaffolds exhibited no negative effect on osteoblasts cell, emphasizing a good biocompatibility. Considering the scaffolds properties, some compositions based on calcium phosphates, chitosan, Hya/Bsa and more than 3% of MNPs are recommended for further optimization and in vivo tests.

Rheological and Mechanical Properties of Thermoresponsive Methylcellulose/Calcium Phosphate-Based Injectable Bone Substitutes

In this study, a novel injectable bone substitute (IBS) was prepared by incorporating a bioceramic powder in a polymeric solution comprising of methylcellulose (MC), gelatin and citric acid. Methylcellulose was utilized as the polymeric matrix due to its thermoresponsive properties and biocompatibility. 2.5 wt % gelatin and 3 wt % citric acid were added to the MC to adjust the rheological properties of the prepared IBS. Then, 0, 20, 30 and 50 wt % of the bioceramic component comprising tetracalcium phosphate/hydroxyapatite (TTCP/HA), dicalcium phosphate dehydrate (DCPD) and calcium sulfate dehydrate (CSD) were added into the prepared polymeric component. The prepared IBS samples had a chewing gum-like consistency. IBS samples were investigated in terms of their chemical structure, rheological characteristics, and mechanical properties. After that, in vitro degradation studies were carried out by measurement of pH and % remaining weight. Viscoelastic characteristics of the samples indicated that all of the prepared IBS were injectable and they hardened at approximately 37 °C. Moreover, with increasing wt % of the bioceramic component, the degradation rate of the samples significantly reduced and the mechanical properties were improved. Therefore, the experimental results indicated that the P50 mix may be a promising candidates to fill bone defects and assist bone recovery for non-load bearing applications.

Analysis of the in vitro degradation and the in vivo tissue response to bi-layered 3D-printed scaffolds combining PLA and biphasic PLA/bioglass components - Guidance of the inflammatory response as basis for osteochondral regeneration

The aim of the present study was the in vitro and in vivo analysis of a bi-layered 3D-printed scaffold combining a PLA layer and a biphasic PLA/bioglass G5 layer for regeneration of osteochondral defects in vivo Focus of the in vitro analysis was on the (molecular) weight loss and the morphological and mechanical variations after immersion in SBF. The in vivo study focused on analysis of the tissue reactions and differences in the implant bed vascularization using an established subcutaneous implantation model in CD-1 mice and established histological and histomorphometrical methods. Both scaffold parts kept their structural integrity, while changes in morphology were observed, especially for the PLA/G5 scaffold. Mechanical properties decreased with progressive degradation, while the PLA/G5 scaffolds presented higher compressive modulus than PLA scaffolds. The tissue reaction to PLA included low numbers of BMGCs and minimal vascularization of its implant beds, while the addition of G5 lead to higher numbers of BMGCs and a higher implant bed vascularization. Analysis revealed that the use of a bi-layered scaffold shows the ability to observe distinct in vivo response despite the physical proximity of PLA and PLA/G5 layers. Altogether, the results showed that the addition of G5 enables to reduce scaffold weight loss and to increase mechanical strength. Furthermore, the addition of G5 lead to a higher vascularization of the implant bed required as basis for bone tissue regeneration mediated by higher numbers of BMGCs, while within the PLA parts a significantly lower vascularization was found optimally for chondral regeneration. Thus, this data show that the analyzed bi-layered scaffold may serve as an ideal basis for the regeneration of osteochondral tissue defects. Additionally, the results show that it might be able to reduce the number of experimental animals required as it may be possible to analyze the tissue response to more than one implant in one experimental animal.

Antibacterial-nanocomposite bone filler based on silver nanoparticles and polysaccharides

Injectable bone fillers represent an attractive strategy for the treatment of bone defects. These injectable materials should be biocompatible, capable of supporting cell growth and possibly able to exert antibacterial effects. In this work, nanocomposite microbeads based on alginate, chitlac, hydroxyapatite and silver nanoparticles were prepared and characterized. The dried microbeads displayed a rapid swelling in contact with simulated body fluid and maintained their integrity for more than 30 days. The evaluation of silver leakage from the microbeads showed that the antibacterial metal is slowly released in saline solution, with less than 6% of silver released after 1 week. Antibacterial tests proved that the microbeads displayed bactericidal effects toward Staphylococcus aureus, Pseudomonas aeruginosa and Staphylococcus epidermidis, and were also able to damage pre-formed bacterial biofilms. On the other hand, the microbeads did not exert any cytotoxic effect towards osteoblast-like cells. After characterization of the microbeads bioactivity, a possible means to embed them in a fluid medium was explored in order to obtain an injectable paste. Upon suspension of the particles in alginate solution or alginate/hyaluronic acid mixtures, a homogenous and time-stable paste was obtained. Mechanical tests enabled to quantify the extrusion forces from surgical syringes, pointing out the proper injectability of the material. This novel antibacterial bone filler appears as a promising material for the treatment of bone defects, in particular when possible infections could compromise the bone-healing process. Copyright © 2016 John Wiley & Sons, Ltd.

Multinucleated giant cells in the implant bed of bone substitutes are foreign body giant cells-New insights into the material-mediated healing process

In addition to macrophages, multinucleated giant cells (MNGCs) are involved in the tissue reaction to a variety of biomaterials. Especially in the case of bone substitute materials it has been assumed that the MNGCs are osteoclasts, based on the chemical and physical similarity of many materials to the calcified matrix and the bony environment in which they are used. However, many studies indicate that these cells belong to the cell line of the foreign body giant cells (FBGCs), which are of "inflammatory origin", although they have been shown to possess both a pro- and also anti-inflammatory phenotype. Moreover, no information is available about their role in the tissue reaction to bone substitute materials. The present study was conducted to analyze the origin of MNGCs in the implant beds of a synthetic and a xenogeneic bone substitute and focused on the application of immunohistochemical methods. Two antibodies against integrin molecules specific for osteoclasts (β-3 integrin) or FBGCs (β-2 integrin) were used to distinguish both giant cell types. The results of the present study indicate that the MNGCs induced by both kinds of bone substitutes are FBGCs, as they express only β-2 integrin in contrast to the osteoclasts outside of the immediate implantation areas, which only demonstrate β-3 integrin expression. These data give new insight into the tissue reaction to both xenogeneic and synthetic bone substitutes. Based on this new knowledge further research concerning the proteomic profile of the FBGCs especially based on the different physicochemical properties of bone substitutes is necessary. This may show that specific characteristics of bone substitutes may exhibit a substantial influence on the regeneration process via the expression of anti-inflammatory molecules by FBGCs. Based on this information it may be possible to formulate and choose bone substitutes that can guide the process of bone tissue regeneration on the molecular level. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 1105-1111, 2017.

Mineralization potential of cellulose-nanofibrils reinforced gelatine scaffolds for promoted calcium deposition by mesenchymal stem cells

Cellulose-nanofibrils (CNFs) enriched gelatine (GEL) scaffolds were fabricated in-situ by the combined freeze-thawing process and carbodiimide crosslinking chemistry. The original- and variously surface anionised CNFs (carboxylated/CNF-COOH/, and phosphonated with 3-AminoPropylphosphoric Acid/CNF-COOH-ApA/) were used in order to tune the scaffolds' biomimetic structure towards a more intensive mineralization process. The pore size reduction (from 208±35μm to 91±35μm) after 50% v/v of CNFs addition to GEL was identified, while separated pore-walls' alignment vs. shorter, dense and elongated pores are observed when using 80% v/v of original-CNFs vs. anionised-CNFs, all of them possessed osteoid-like compressive strength (0.025-0.40MPa) and elasticity (0.04-0.15MPa). While randomly distributed Ca²⁺-deficient hydroxyapatite/HAp/(Ca/P≈1.4) aggregates were identified in the case of original-CNF prevalent scaffolds after four weeks of incubation in SBF, the more uniform and intensified deposition with HAp-like (Ca/P≈1.69) structures were established using CNF-COOH-Apa. The growth of Mesenchymal Stem Cells (MSCs) was observed on all CNF-containing scaffolds, resulting in more extensive Ca²⁺ deposition compared to the positive control or pure GEL scaffold. Among them, the scaffold prepared with the 50% v/v CNF-COOH-ApA showed significantly increased mineralization kinetic as well as the capacity for bone-like patterning in bone tissue regeneration.

Rheological evaluations and in vitro studies of injectable bioactive glass-polycaprolactone-sodium alginate composites

Composite pastes composed of various amounts of melt-derived bioactive glass 52S4 (MG5) and polycaprolactone (PCL) microspheres in sodium alginate solution were prepared. Rheological properties in both rotatory and oscillatory modes were evaluated. Injectability was measured as injection force versus piston displacement. In vitro calcium phosphate precipitation was also studied in simulated body fluid (SBF) and tracked using scanning electron microscopy, X-ray diffraction and FTIR analyses. All composite pastes were thixotropic in nature and exhibited shear thinning behavior. The magnitude of thixotropy decreased by adding 10-30 wt% PCL, while further amounts of PCL increased it again. Moreover, the composites were viscoelastic materials in which the elastic modulus was higher than viscous term. The pastes which were just made of MG5 or PCL had poor injectability, whereas the composites containing both of these constituents exhibited reasonable injectability. All pastes revealed adequate structural stability in contact with SBF solution. In vitro calcium phosphate precipitation was well observed on the paste made of MG5 and somewhat on the pastes with 10-40 wt% PCL, however the precipitated layer was amorphous in nature. Overall, the produced composites may be appropriate as injectable biomaterials for non-invasive surgeries but more biological evaluations are essential.

Small-sized granules of biphasic bone substitutes support fast implant bed vascularization

The present study investigated the influence of granule size of 2 biphasic bone substitutes (BoneCeramic® 400–700 μm and 500–1000 μm) on the induction of multinucleated giant cells (MNGCs) and implant bed vascularization in a subcutaneous implantation model in rats. Furthermore, degradation mechanisms and particle phagocytosis of both materials were examined by transmission electron microscopy (TEM). Both granule types induced tissue reactions involving primarily mononuclear cells and only small numbers of MNGCs. Higher numbers of MNGCs were detected in the group with small granules starting on day 30, while higher vascularization was observed only at day 10 in this group. TEM analysis revealed that both mono- and multinucleated cells were involved in the phagocytosis of the materials. Additionally, the results allowed recognition of the MNGCs as the foreign body giant cell phenotype. Histomorphometrical analysis of the size of phagocytosed particles showed no differences between the 2 granule types. The results indicate that granule size seems to have impact on early implant bed vascularization and also on the induction of MNGCs in the late phase of the tissue reaction. Furthermore, the results revealed that a synthetic bone substitute material can induce tissue reactions similar to those of some xenogeneic materials, thus pointing to a need to elucidate their “ideal” physical characteristics. The results also show that granule size in the range studied did not alter phagocytosis by mononuclear cells. Finally, the investigation substantiates the differentiation of material-induced MNGCs, which are of the foreign body giant cell type.

On the Ultrastructure and Function of Rhogocytes from the Pond Snail Lymnaea stagnalis

Rhogocytes, also termed "pore cells", occur as solitary or clustered cells in the connective tissue of gastropod molluscs. Rhogocytes possess an enveloping lamina of extracellular matrix and enigmatic extracellular lacunae bridged by cytoplasmic bars that form 20 nm diaphragmatic slits likely to act as a molecular sieve. Recent papers highlight the embryogenesis and ultrastructure of these cells, and their role in heavy metal detoxification. Rhogocytes are the site of hemocyanin or hemoglobin biosynthesis in gastropods. Based on electron microscopy, we recently proposed a possible pathway of hemoglobin exocytosis through the slit apparatus, and provided molecular evidence of a common phylogenetic origin of molluscan rhogocytes, insect nephrocytes and vertebrate podocytes. However, the previously proposed secretion mode of the respiratory proteins into the hemolymph is still rather hypothetical, and the possible role of rhogocytes in detoxification requires additional data. Although our previous study on rhogocytes of the red-blooded (hemoglobin-containing) freshwater snail Biomphalaria glabrata provided much new information, a disadvantage was that the hemoglobin molecules were not unequivocally defined in the electron microscope. This made it difficult to trace the exocytosis pathway of this protein. Therefore, we have now performed a similar study on the rhogocytes of the blue-blooded (hemocyanin-containing) freshwater snail Lymnaea stagnalis. The intracellular hemocyanin could be identified in the electron microscope, either as individual molecules or as pseudo-crystalline arrays. Based on 3D-electron microscopy, and supplemented by in situ hybridization, immunocytochemistry and stress response experiments, we provide here additional details on the structure and hemocyanin biosynthesis of rhogocytes, and on their response in animals under cadmium and starvation stress. Moreover, we present an advanced model on the release of synthesized hemocyanin molecules through the slit apparatus into the hemolymph, and the uptake of much smaller particles such as cadmium ions from the hemolymph through the slit apparatus into the cytoplasm.

Heterogeneity of biomaterial-induced multinucleated giant cells: Possible importance for the regeneration process?

Biomaterial-associated multinucleated giant cells (BMGCs) have been found within the implantation beds of many different biomaterials. However, their exact differentiation and their involvement in the inflammatory and healing events of the foreign body response still remain mostly unclear. Silk fibroin (SF) scaffolds, which induces a tissue reaction involving both macrophages and BMGCs, was implanted in the subcutaneous connective tissue of four CD-1 mice for 15 days using an established subcutaneous implantation model. Analysis of macrophage polarization and BMGCs was performed by immunohistochemcial detection of pro- (cyclooxygenase-2 (COX-2), C-C chemokine receptor type 7 (CCR7), nuclear factor "kappa-light-chain-enhancer" (NF-κB)) and anti-(heme oxygenase-1 (HO-1) and mannose receptor (MR, also known as CD206)). Furthermore, histochemical detection of tartrate-resistant acid phosphatase (TRAP) was conducted to test its predictive efficiency for the pro-inflammatory differentiation of cells. An established system for histomorphometrical analysis was used for counting of BMGCs expressing these molecules. The results show that BMGCs express both pro- and anti-inflammatory molecules within the implantation beds of SF scaffolds in comparable numbers, while only statistically significantly lower numbers of TRAP-positive BMGCs were measured in comparison to the BMGCs expressing the above-mentioned molecules. As these data substantiate the heterogeneity of BMGCs, the question arises to what extent BMGCs can "support" the process of tissue regeneration. Furthermore, the data prompt the question to what extent TRAP-expression within a biomaterial implantation bed can be seen as a predictive marker for an inflammatory condition, as in this study no obvious correlation between TRAP-expression and other pro-inflammatory markers could be observed.

Injectable Bone Substitute Based on β-TCP Combined With a Hyaluronan-Containing Hydrogel Contributes to Regeneration of a Critical Bone Size Defect Towards Restitutio ad Integrum

In the present in vivo study, the regenerative potential of a new injectable bone substitute (IBS) composed of beta-tricalcium phosphate (β-TCP) and hyaluronan was tested in a rabbit distal femoral condyle model. To achieve this, 2 defects of 6 mm in diameter and 10 mm in length were drilled into each femur condyle in a total of 12 animals. For each animal, 1 hole was filled with the substitute material, and the other was left empty to serve as the control. After 1, 3, and 6 months, the regenerative process was analyzed by radiography as well as by histological and histomorphometrical analysis. The results revealed that bone tissue formation took place through osteoconductive processes over time, starting from the defect borders to the center. Both the β-TCP content and the hydrogel support bone tissue growth. The histomorphometrical measurements showed that the amount of bone formation in the experimental group was significantly higher compared with that found in the control group after 3 months (19.51 ± 5.08% vs. 1.96 ± 0.77%, P < .05) and 6 months (4.57 ± 1.56% vs. 0.23 ± 0.21%, P < .05). The application of the IBS gave a restitutio ad integrum result after 6 months and was associated with its nearly complete degradation, in contrast to the results found in the control group. In conclusion, the results of the present study demonstrate that the IBS contributes to sufficient bone regeneration by serving as a scaffold-like structure, combined with its degradation within 6 months.

Nanostructured medical sutures with antibacterial properties

Bacterial repellence in suture materials is a desirable property that can potentially improve the healing process by preventing infection. We describe a method for generating nanostructures at the surface of commercial sutures of different composition, and their potential for preventing biofilm formation. We show how bacteria attachment is altered in the presence of nanosized topographies and identify optimum designs for preventing it without compromising biocompatibility and applicability in terms of nanostructure robustness or tissue friction. These studies open new possibilities for flexible and cost-effective realization of topography-based antibacterial coatings for absorbable biomedical textiles.

Induction of multinucleated giant cells in response to small sized bovine bone substitute (Bio-Oss™) results in an enhanced early implantation bed vascularization

Purpose:

The host tissue reaction to the xenogeneic bone substitute Bio-Oss™ (Geistlich Biomaterials, Wolhousen, Switzerland) was investigated focusing on the participating inflammatory cells and implantation bed vascularization.

Materials and Methods:

Bio-Oss™ was implanted subcutaneously into CD1 mice for up to 60 days and analyzed by means of specialized histological and histomorphometrical techniques after explantation.

Results:

Bio-Oss™ induced within the first 15 days an early high vascularization combined with a marked presence of multinucleated giant cells. The latter cells were associated mainly with the smaller sized granules within the implantation bed. Toward the end of the study the number of multinucleated giant cells decreased while the tissue reaction to the larger granules was mainly mononuclear.

Conclusion:

The results of the present study showed that smaller xenogeneic bone substitute granules induce multinucleated giant cells, whereas the larger-sized ones became integrated within the implantation bed by means of a mononuclear cell-triggered granulation tissue. Obviously, the presence of multinucleated giant cells within biomaterial implantation beds is not only related to the type of synthetic bone substitute material, but also to the granule size of the natural-based xenogeneic bone substitute material.

An Injectable Complex of β-tricalcium Phosphate Granules, Hyaluronate, and rhFGF-2 on Repair of Long-bone Fractures with Large Fragments

We evaluated the effects of an injectable complex of β-tricalcium phosphate (β-TCP) granules, hyaluronate, and recombinant human fibroblast growth factor-2 (rhFGF-2) on repair of unstable intertrochanteric fractures in elderly patients. Twenty-five patients (range, 76-91 years) having 31.A2 fractures (AO classification) were treated with injection of the complex followed by intramedullary nails. Bone regeneration and β-TCP resorption, unions of intertrochanteric fractures and displaced lesser trochanters to the shaft, and varus deformity of the femoral neck were assessed by X-ray and CT scans. Fracture union occurred in all cases and union of the displaced lesser trochanter to the shaft was obtained in 24 cases by 12 weeks. It is of interest that β-TCP granules were completely resorbed and marked new bone formation around the lesser trochanter was observed in all cases compared to cases not treated with the complex. Based on the results of intertrochanteric fractures, we applied this technique to two patients with subtrochanteric or humeral fractures in elderly patients, and obtained bone union. This complex is a paste-like material that is easy to handle, and it may be of considerable use in treatment of both unstable intertrochanteric fractures and other cortical bone defects with minimal surgical invasion.

High-Temperature Sintering of Xenogeneic Bone Substitutes Leads to Increased Multinucleated Giant Cell Formation: In Vivo and Preliminary Clinical Results

The present preclinical and clinical study assessed the inflammatory response to a high-temperature-treated xenogeneic material (Bego-Oss) and the effects of this material on the occurrence of multinucleated giant cells, implantation bed vascularization, and regenerative potential. After evaluation of the material characteristics via scanning electron microscopy, subcutaneous implantation in CD-1 mice was used to assess the inflammatory response to the material for up to 60 days. The clinical aspects of this study involved the use of human bone specimens 6 months after sinus augmentation. Established histologic and histomorphometric analysis methods were applied. After implantation, the material was well integrated into both species without any adverse reactions. Material-induced multinucleated giant cells were observed in both species and were associated with enhanced vascularization. These results revealed the high heat treatment led to an increase in the inflammatory tissue response to the biomaterial, and a combined increase in multinucleated giant cell formation. Further clarification of the differentiation of the multinucleated giant cells toward so-called osteoclast-like cells or foreign-body giant cells is needed to relate these cells to the physicochemical composition of the material.

3D-ultrastructure, functions and stress responses of gastropod (Biomphalaria glabrata) rhogocytes

Rhogocytes are pore cells scattered among the connective tissue of different body parts of gastropods and other molluscs, with great variation in their number, shape and size. They are enveloped by a lamina of extracellular matrix. Their most characteristic feature is the "slit apparatus", local invaginations of the plasma membrane bridged by cytoplasmic bars, forming slits of ca. 20 nm width. A slit diaphragm creates a molecular sieve with permeation holes of 20×20 nm. In blue-blooded gastropods, rhogocytes synthesize and secrete the respiratory protein hemocyanin, and it has been proposed-though not proven-that in the rare red-blooded snail species they might synthesize and secrete the hemoglobin. However, the cellular secretion pathway for respiratory proteins, and the functional role(s) of the enigmatic rhogocyte slit apparatus are still unclear. Additional functions for rhogocytes have been proposed, notably a role in protein uptake and degradation, and in heavy metal detoxification. Here we provide new structural and functional information on the rhogocytes of the red-blooded freshwater snail Biomphalaria glabrata. By in situ hybridization of mantle tissues, we prove that rhogocytes indeed synthesize hemoglobin. By electron tomography, the first three dimensional (3D) reconstructions of the slit apparatus are provided, showing detail of highly dense material in the cytoplasmic bars close to the slits. By immunogold labelling, we collected evidence that a major component of this material is actin. By genome databank mining, the complete sequence of a B. glabrata nephrin was obtained, and localized to the rhogocytes by immunofluorescence microscopy. The presence of both proteins fit the ultrastructure-based hypothesis that rhogocytes are related to mammalian podocytes and insect nephrocytes. Reactions of the rhogocytes to deprivation of food and cadmium toxification are also documented, and a possible secretion pathway of newly synthesized respiratory proteins through the slit apparatus is discussed.

Effect of addition of hyaluronic acids on the osteoconductivity and biodegradability of synthetic octacalcium phosphate

The present study was designed to investigate whether three sodium hyaluronic acid (HyA) medical products, Artz(®), Suvenyl(®) and a chemically modified derivative of sodium HyA Synvisc(®), can be used as suitable vehicles for an osteoconductive octacalcium phosphate (OCP). OCP granules (300-500 μm diameter) were mixed with these sodium HyAs with molecular weights of 90 × 10(4) (Artz(®)), 190 × 10(4) (Suvenyl(®)) and 600 × 10(4) (Synvisc(®)) (referred to as HyA90, HyA190 and HyA600, respectively). OCP-HyA composites were injected using a syringe into a polytetrafluoroethylene ring, placed on the subperiosteal region of mouse calvaria for 3 and 6 weeks, and then bone formation was assessed by histomorphometry. The capacity of the HyAs for osteoclast formation from RAW264 cells with RANKL was examined by TRAP staining in vitro. Bone formation was enhanced by the OCP composites with HyA90 and HyA600, compared to OCP alone, through enhanced osteoclastic resorption of OCP. HyA90 and HyA600 facilitated in vitro osteoclast formation. The results suggest that the osteoconductive property of OCP was accelerated by the HyAs-associated osteoclastic resorption of OCP, and therefore that HyA/OCP composites are attractive bone substitutes which are injectable and bioactive materials.

β-TCP granules mixed with reticulated hyaluronic acid induce an increase in bone apposition

β beta-tricalcium phosphate (β-TCP) granules are suitable for repair of bone defects. They have an osteoconductive effect shortly after implantation. However, dry granules are difficult to handle in the surgical room because of low weight and lack of cohesion. Incorporation of granules in a hydrogel could be a satisfactory solution. We have investigated the use of hyaluronic acid (HyA) as an aqueous binder of the granules. β-TCP granules were prepared by the polyurethane foam technology. Commercially available linear (LHya) and reticulated hyaluronic acid (RHyA) in aqueous solution were used to prepare a pasty mixture that can be handled more easily than granules alone. Thirteen New Zealand White rabbits (3.5-3.75 kg) were used; a 4 mm hole was drilled in each femoral condyle. After flushing, holes were filled with either LHyA, RHyA, dry β-TCP granules alone, β-TCP granules + LHyA and β-TCP granules + RHyA. Rabbits were allowed to heal for one month, sacrificed and femurs were harvested and analysed by microCT and histomorphometry. The net amount of newly formed bone was derived from measurements done after thresholding the microCT images for the material and for the material+bone. LHyA and RHyA did not result in healing of the grafted area. LHyA was rapidly eluted from the grafted zone but allowed deposition of more granules, although the amount of formed bone was not significantly higher than with β-TCP granules alone. RHyA permitted the deposition of more granules which induced significantly more bone trabeculae without inducing an inflammatory reaction. RHyA appears to be a good vehicle to implant granules of β-TCP, since HyA does not interfere with bone remodeling.

Nanoscale chemical interaction enhances the physical properties of bioglass composites

Bioglasses are favorable biomaterials for bone tissue engineering; however, their applications are limited due to their brittleness. In addition, the early failure in the interface is a common problem of composites of bioglass and a polymer with high mechanical strength. This effect is due to the phase separation, nonhomogeneous mixture, nonuniform mechanical strength, and different degradation properties of two compounds. To address these issues, in this study a nanoscale interaction between poly(methyl methacrylate) (PMMA) and bioactive glass was formed via silane coupling agent (3-trimethoxysilyl)propyl methacrylate (MPMA). A monolith was produced at optimum composition from this hybrid by the sol-gel method at 50 °C with a rapid gelation time (<50 min) that possessed superior physicochemical properties compared to pure bioglass and physical mixture. For instance, the Young's modulus of bioglass was decreased 40-fold and the dissolution rate of silica was retarded 1.5-fold by integration of PMMA. Prolonged dissolution of silica fosters bone integration due to the continuous dissolution of bioactive silica. The primary osteoblast cells were well anchored and cell migration was observed on the surface of the hybrid. The in vivo studies in mice demonstrated that the integrity of the hybrids was maintained in subcutaneous implantation. They induced mainly a mononuclear phagocytic tissue reaction with a low level of inflammation, while bioglass provoked a tissue reaction with TRAP-positive multinucleated giant cells. These results demonstrated that the presence of a nanoscale interaction between bioglass and PMMA affects the properties of bioglass and broadens its potential applications for bone replacement.

Metaphyseal bone formation induced by a new injectable β-TCP-based bone substitute: a controlled study in rabbits

PURPOSE

Adequate filling of bone defects still poses a challenge in every day clinical work. As many bone defects are irregularly shaped the need for appropriate scaffolds reaching the complete defect surface are great. The purpose of this pre-clinical pilot study was to investigate the handling, biocompatibility, biodegradation and osteoconductivity of a new pasty bone substitute (pure phase β-TCP, hyaluronic acid, methylcellulose) in bone tissue.

METHODS

In an unilateral tibial defect model the peri-implant and bone tissue response to the new pasty bone substitute was tested in New Zealand white rabbits for up to 24 weeks compared to empty controls. Analysis included HR-pQCT scans, histomorphometric evaluation and quantification of vascularization of un-decalcified histological slices.

RESULTS

After 1 week the experimental group presented significantly higher new bone volume fraction (p = 0.021) primarily consisting of immature bone matrix and higher vessel density compared to controls (p = 0.013). After 4 weeks bone formation was not significantly different to controls but was distributed more evenly throughout the defect. Bone matrix was now mineralized and trabeculae were thicker than in controls (p = 0.002) indicating faster intramedullary bone maturation. Controls presented extensive periosteal bone formation, major fibrous tissue influx and high vascularization. After 12 and 24 weeks there was no new bone detectable. There were no severe signs of inflammation at all time points.

CONCLUSION

The substitute showed an early induction of bone formation. It promoted accelerated intramedullary bone repair and maturation and prevented periosteal bone formation indicating its potential use for reconstructive surgery of bone defects.