Endochondral ossification in vitro is influenced by mechanical bending

Clinical and Research Approaches to Treat Non-union Fracture

PURPOSE OF REVIEW

Impaired healing outcomes or even non-unions after bone injury are still a highly relevant problem in the daily clinical life. Especially within an aging population, the occurrence of bone fractures increases and thus novel treatment approaches to overcome compromised bone regeneration are needed.

RECENT FINDINGS

The gold standard to treat delayed or non-healing bone injuries is still the use of autologous bone grafts to foster regeneration. Besides its successful treatment outcome, it also has disadvantages: a second surgery is needed in order to harvest the bone material and the material is highly limited. Looking into the recent literature, a multitude of different research approaches were already conducted to identify new possible strategies to treat impaired bone regeneration: application of mesenchymal stromal cells, platelet lysates, growth factors, interference in the immune system, or bone formation stimulation by ultrasound. This review gives an overview of the treatment approaches actually performed in the clinic as well as at the bench in the context of compromised bone healing. It clearly highlights the complexity of the nature of non-healing bone fractures as well as patient-dependent factors influencing the healing process.

Biomaterial delivery of morphogens to mimic the natural healing cascade in bone

Complications in treatment of large bone defects using bone grafting still remain. Our understanding of the endogenous bone regeneration cascade has inspired the exploration of a wide variety of growth factors (GFs) in an effort to mimic the natural signaling that controls bone healing. Biomaterial-based delivery of single exogenous GFs has shown therapeutic efficacy, and this likely relates to its ability to recruit and promote replication of cells involved in tissue development and the healing process. However, as the natural bone healing cascade involves the action of multiple factors, each acting in a specific spatiotemporal pattern, strategies aiming to mimic the critical aspects of this process will likely benefit from the usage of multiple therapeutic agents. This article reviews the current status of approaches to deliver single GFs, as well as ongoing efforts to develop sophisticated delivery platforms to deliver multiple lineage-directing morphogens (multiple GFs) during bone healing.

In vitro models for bone mechanobiology: Applications in bone regeneration and tissue engineering

Healthy bone healing is a remarkable, mechanically sensitive, scar-free process that leads rapidly to repair tissue of high mechanical quality and functionality, and knowledge of this process is essential for driving advances in bone tissue engineering and regeneration. Gaining this knowledge requires the use of models to probe and understand the detailed mechanisms of healing, and the tight coupling of biology and mechanics make it essential that both of these aspects are controlled and analysed together, using a mechanobiological approach. This article reviews the literature on in vitro models used for this purpose, beginning with two-dimensional (2D) cell culture models used for applying controlled mechanical stimuli to relevant cells, and detailing the analysis techniques required for understanding both substrate strain and fluid flow stimuli in sufficient detail to relate them to biological response. The additional complexity of three-dimensional (3D) models, enabling more faithful representation of the healing situation, can require correspondingly more sophisticated tools for mechanical and biological analysis, but has recently uncovered exciting evidence for the mechanical sensitivity of angiogenesis, essential for successful healing. Studies using explanted tissue continue to be vital in informing these approaches, providing additional evidence for the relevance of effects in biological and mechanical environments close to those in the living organism. Mechanobiology is essential for the proper analysis of models for bone regeneration, and has an exciting integrative role to play not only in advancing knowledge in this area, but also in ensuring successful translation of new tissue engineering and regenerative therapies to the clinic.

Superelastic cage implantation: a new technique for treating osteonecrosis of the femoral head with mid-term follow-ups

We developed a device for the treatment of Ficat and Arlet stage II and III osteonecrosis of the femoral head. This device, which we named the "super-elastic cage," was designed to provide mechanical support for the necrotic weight-bearing area of the femoral head to prevent its collapse. The cage was used in combination with surgical removal of necrotic bone, insertion of vascularized pedical bone graft, or impacted autologous cancellous bone graft. A total of 93 hips in 62 patients at Ficat stage II to III were included in a 8-year study. Implantations were performed by 2 different approaches: Smith-Peterson approach and minimal invasive approach by the lateral side of great trochanter. The follow-up period was between 72 and 107 months. Of the femoral heads in this study, 82.7% survived. The superelastic cage implantation technique may offer an alternative treatment to the early and middle stages of osteonecrosis of the femoral head.

Signaling networks and transcription factors regulating mechanotransduction in bone

Mechanical stimulation has a critical role in the development and maintenance of the skeleton. This function requires the perception of extracellular stimuli as well as their conversion into intracellular biochemical responses. This process is called mechanotransduction and is mediated by a plethora of molecular events that regulate bone metabolism. Indeed, mechanoreceptors, such as integrins, G protein-coupled receptors, receptor protein tyrosine kinases, and stretch-activated Ca(2+) channels, together with their downstream effectors coordinate the transmission of load-induced signals to the nucleus and the expression of bone-related genes. During the past decade, scientists have gained increasing insight into the molecular networks implicated in bone mechanotransduction. In the present paper, we consider the major signaling cascades and transcription factors that control bone and cartilage mechanobiology and discuss the influence of the mechanical microenvironment on the determination of skeletal morphology.

Engineering endochondral bone: in vivo studies

The use of biomaterials to replace lost bone has been a common practice for decades. More recently, the demands for bone repair and regeneration have pushed research into the use of cultured cells and growth factors in association with these materials. Here we report a novel approach to engineer new bone using a transient cartilage scaffold to induce endochondral ossification. Chondrocyte/chitosan scaffolds (both a transient cartilage scaffold-experimental-and a permanent cartilage scaffold-control) were prepared and implanted subcutaneously in nude mice. Bone formation was evaluated over a period of 5 months. Mineralization was assessed by Faxitron, micro computed tomography, backscatter electrons, and Fourier transform infrared spectroscopy analyses. Histological analysis provided further information on tissue changes in and around the implanted scaffolds. The deposition of ectopic bone was detected in the surface of the experimental implants as early as 1 month after implantation. After 3 months, bone trabeculae and bone marrow cavities were formed inside the scaffolds. The bone deposited was similar to the bone of the mice vertebra. Interestingly, no bone formation was observed in control implants. In conclusion, an engineered transient cartilage template carries all the signals necessary to induce endochondral bone formation in vivo.

Mechanically induced osteogenic differentiation--the role of RhoA, ROCKII and cytoskeletal dynamics

Many biochemical factors regulating progenitor cell differentiation have been examined in detail; however, the role of the local mechanical environment on stem cell fate has only recently been investigated. In this study, we examined whether oscillatory fluid flow, an exogenous mechanical signal within bone, regulates osteogenic, adipogenic or chondrogenic differentiation of C3H10T1/2 murine mesenchymal stem cells by measuring Runx2, PPARgamma and SOX9 gene expression, respectively. Furthermore, we hypothesized that the small GTPase RhoA and isometric tension within the actin cytoskeleton are essential in flow-induced differentiation. We found that oscillatory fluid flow induces the upregulation of Runx2, Sox9 and PPARgamma, indicating that it has the potential to regulate transcription factors involved in multiple unique lineage pathways. Furthermore, we demonstrate that the small GTPase RhoA and its effector protein ROCKII regulate fluid-flow-induced osteogenic differentiation. Additionally, activated RhoA and fluid flow have an additive effect on Runx2 expression. Finally, we show RhoA activation and actin tension are negative regulators of both adipogenic and chondrogenic differentiation. However, an intact, dynamic actin cytoskeleton under tension is necessary for flow-induced gene expression.

Mechanobiological bone growth: comparative analysis of two biomechanical modeling approaches

Mechanobiological growth is the process whereby bone growth is modulated by mechanical loading. Analytical formulations of mechanobiological growth have been developed by Stokes et al. (J Orthop Res 17(5):646-653, 1990) and Carter et al. (J Orthop Res 6:804-816, 1988). The purpose of this study was to compare these two modeling approaches in a finite element model of a vertebra to investigate whether growth pattern induced by these models were equivalent. A finite element model of a thoracic vertebra, integrating a conceptual model of the growth plate, was developed and combined with the mechanobiological growth models. This model was further used to simulate vertebral growth modulation resulting from different physiological loading conditions. Different growth magnitudes were obtained under compression and combined tension/shear loading, whereas dissimilar growth patterns were triggered by shear forces and combined compression/shear. These two models represent mechanobiological bone growth under limited mechanical environment. Carter's model takes into account three-dimensional stress stimuli, but does not intrinsically incorporate the resulting growth orientation. Stokes' model adequately represents the mechanobiological contribution of axial stresses but does not take into account the contribution of non-axial stresses, which can occur in complex mechanical environment.