A new device to control mechanical environment in bone defect healing in rats

A comprehensive molecular profiling approach reveals metabolic alterations that steer bone tissue regeneration

Bone regeneration after fracture is a complex process with high and dynamic energy demands. The impact of metabolism on bone healing progression and outcome, however, is so far understudied. Our comprehensive molecular profiling reveals that central metabolic pathways, such as glycolysis and the citric acid cycle, are differentially activated between rats with successful or compromised bone regeneration (young versus aged female Sprague-Dawley rats) early in the inflammatory phase of bone healing. We also found that the citric acid cycle intermediate succinate mediates individual cellular responses and plays a central role in successful bone healing. Succinate induces IL-1β in macrophages, enhances vessel formation, increases mesenchymal stromal cell migration, and potentiates osteogenic differentiation and matrix formation in vitro. Taken together, metabolites-here particularly succinate-are shown to play central roles as signaling molecules during the onset of healing and in steering bone tissue regeneration.

Biomechanical validation of a modified genioplasty distractor

PURPOSE

Genioplasty is a surgical procedure that is used to enhance the shape and appearance of the chin. It can be performed alone or in combination with other jaw-related surgeries either for medical or cosmetic purposes. Recently many studies have been reported for mandibular reconstruction with distraction osteogenesis. However, these distractors can cause some complications such as incorrect prolongation of hard tissues due to the lack of guiding section. The purpose of this study is to manufacture a novel genioplasty distractor and measure its biomechanical stability and reliability for different activation lengths in mandibular bone.

METHODS

The modified genioplasty distractor was manufactured from grade 2 and grade 5 (Ti6AI4V) titanium alpha + beta alloy which was biocompatible and adequately rigid for possible in situ application in the future and a sample holder was manufactured for compressive strength testing.

RESULTS

Test results showed that our modified genioplasty distractors withstood 300 N compression force for activation lengths from 0 to 11 mm. Recorded stress values were in the range of 0.110 MPa to 0.389 MPa.

CONCLUSION

The modified genioplasty distractor developed and tested here is a promising surgical tool that has the potential to reduce genioplasty related complications especially in demanding cases.

Compromised Bone Healing in Aged Rats Is Associated With Impaired M2 Macrophage Function

Fracture repair is initiated by a multitude of immune cells and induction of an inflammatory cascade. Alterations in the early healing response due to an aged adaptive immune system leads to impaired bone repair, delayed healing or even formation of non-union. However, immuno-senescence is not limited to the adaptive immunity, but is also described for macrophages, main effector cells from the innate immune system. Beside regulation of pro- and anti-inflammatory signaling, macrophages contribute to angiogenesis and granulation tissue maturation. Thus, it seems likely that an altered macrophage function due to aging may affect bone repair at various stages and contribute to age related deficiencies in bone regeneration. To prove this hypothesis, we analyzed the expression of macrophage markers and angiogenic factors in the early bone hematoma derived from young and aged osteotomized Spraque Dawley rats. We detected an overall reduced expression of the monocyte/pan-macrophage markers CD14 and CD68 in aged rats. Furthermore, the analysis revealed an impaired expression of anti-inflammatory M2 macrophage markers in hematoma from aged animals that was connected to a diminished revascularization of the bone callus. To verify that the age related disturbed bone regeneration was due to a compromised macrophage function, CD14+ macrophage precursors were transplanted locally into the osteotomy gap of aged rats. Transplantation rescued bone regeneration partially after 6 weeks, demonstrated by a significantly induced deposition of new bone tissue, reduced fibrosis and significantly improved callus vascularization.

The influence of gap size on the development of fracture union with a micro external fixator

Increasingly, the rat femoral fracture model is being used for preclinical investigations of fracture healing, however, the effect of gap size and its influence on mechanobiology is not well understood. We aimed to evaluate the influence of osteotomy gap on osteotomy healing between the previously published extremes of guaranteed union (0.5 mm) and non-union (3 mm) using this model.

A femoral osteotomy in 12–14 week old female Wistar rats was stabilised with a micro fixator (titanium blocks, carbon fiber bars) with an osteotomy gap of 1.0 mm (n = 5), 1.5 mm (n = 7), 2.0 mm (n = 6). After five weeks, the left femur was retrieved. The osteotomy gap was scanned using X-ray microtomography and then histologically evaluated. The radiographic union rate (complete mineralised bone bridging across the osteotomy) was three times higher for the 1.0 mm than the 2.0 mm gap. The 1.0 mm gap had the largest callus (0.069μm³) and bone volume (0.035μm³). Callus and bone volume were approximately 50% smaller within the 2.0 mm gap.

Using cadaveric rat femurs stabilised with the external fixator, day 0 mechanical assessment of construct stiffness was calculated on materials testing machine displacement vs load output. The construct stiffness for the 1.0, 1.5 and 2.0 mm gaps was 32.6 ± 5.4, 32.5 ± 2.4, and 32.4 ± 8.3 N/mm (p = 0.779). Interfragmentary strain (IFS) was calculated using the change in osteotomy gap displacement as measured using microstrain miniature differential reluctance transducer spanning the osteotomy gap. Increasing the gap size significantly reduced the IFS (p = 0.013). The mean ‘day 0’ IFS for the 1.0, 1.5 and 2.0 mm gaps were 11.2 ± 1.3, 8.4 ± 1.5 and 6.1 ± 1.2% respectively.

A 1.5 mm gap resulted in a delayed fracture healing by 5 weeks and may represent a useful test environment for fracture healing therapy. Increasing gap size did not affect construct stiffness, but did reduce the ‘day 0’ IFS, with a doubling of non-union and halving of bone volume measured between 1.0 and 2.0 mm gaps.

Biomechanics of two external fixator devices used in rat femoral fractures

The use of external fixators allows for the direct investigation of newly formed interfragmentary bone, and the radiographic evaluation of the fracture. We validated the results of a finite element (FE) model with the in vitro stiffness' of two widely used external fixator devices used for in vivo analysis of fracture healing in rat femoral fractures with differing construction (Ti alloy ExFix1 and PEEK ExFix2). Rat femoral fracture fixation was modeled using two external fixators. For both constructs an osteotomy of 2.75 mm was used, and offset maintained at 5 mm. Tufnol, served as standardized substitutes for rat femora. Constructs were loaded under axial compression and torsion. Overall axial and torsional stiffness were compared between the in vitro models and FE results. FE models were also used to compare the fracture movement and overall pattern of von Mises stress across the external fixators. In vitro axial stiffness of ExFix1 was 29.26 N/mm ± 3.83 compared to ExFix2 6.31 N/mm ± 0.67 (p* < 0.05). Torsional stiffness of ExFix1 was 47.5 Nmm/° ± 2.71 compared to ExFix2 at 19.1 Nmm/° ±1.18 (p* < 0.05). FE results predicted similar comparative ratios between the ExFix1 and 2 as the in vitro studies. FE results predicted considerably larger interfragmentary motion in the ExFix2 comparing to ExFix1. We demonstrated significant differences in the stiffness' of the two external fixators as one would expect from such variable designs; yet, importantly we validated the utility of an FE model for the analysis and prediction of changes in fracture mechanics dependent on fixator choice. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:293-298, 2019.

Novel standardized massive bone defect model in rats employing an internal eight-hole stainless steel plate for bone tissue engineering

Massive bone defects are a challenge in orthopaedic research. Defective regeneration leads to bone atrophy, non-union of bone, and physical morbidity. Large animals are important models, however, production costs are high, nursing is complex, and evaluation methods are limited. A suitable laboratory animal model is required to explore the underlying molecular mechanism and cellular process of bone tissue engineering. We designed a stainless steel plate with 8 holes; the middle 2 holes were used as a guide to create a standardized critical size defect in the femur of anaesthetized rats. The plate was fixed to the bone using 6 screws, serving as an inner fixed bracket to secure a tricalcium phosphate implant seeded with green fluorescent protein-positive rat bone marrow mesenchymal stem cells within the defect. In some animals, we also grafted a vessel bundle into the lateral side of the implant, to promote vascularized bone tissue engineering. X-ray, microcomputed tomography, and histological analyses demonstrated the stainless steel plate resulted in a stable large segmental defect model in the rat femur. Vascularization significantly increased bone formation and implant degradation. Moreover, survival and expansion of green fluorescent protein-positive seeded cells could be clearly monitored in vivo at 1, 4, and 8 weeks postoperation via fluorescent microscopy. This standardized large segmental defect model in a small animal may help to advance the study of bone tissue engineering. Furthermore, availability of antibodies and genetically modified rats could help to dissect the precise cellular and molecular mechanisms of bone repair.

Comparison of Effects of Pulsed Electromagnetic Field Stimulation on Platelet-Rich Plasma and Bone Marrow Stromal Stem Cell Using Rat Zygomatic Bone Defect Model

BACKGROUND

Reconstruction of bone defects that occur because of certain reasons has an important place in plastic and reconstructive surgery. The objective of the treatments of these defects was to reinstate the continuity of tissues placed in the area in which the defect has occurred. In this experimental study, the effect of pulsed electromagnetic field stimulation on platelet-rich plasma (PRP) and bone marrow stromal cell, which propounded that they have positive impact on bone regeneration, was evaluated with the bone healing rate in the zygomatic bone defect model enwrapped with superficial temporal fascia.

METHODS

After creating a 4-mm defect on the zygomatic bone of the experiments, the defect was encompassed with a superficial temporal fascial flap and a nonunion model was created. After surgery, different combinations of the PRP, bone marrow stromal cell, and electromagnetic field applications were implemented on the defective area. All the experiments were subjected to bone density measurement.

RESULTS

The result revealed that the PRP and pulsed electromagnetic field implementation were rather a beneficial and an effective combination in terms of bone regeneration.

CONCLUSIONS

It was observed that the superficial temporal fascial flap used in the experiment was a good scaffold choice, providing an ideal bone regeneration area because of its autogenous, vascular, and 3-dimensional structures. As a result, it is presumed that this combination in the nonhealing bone defects is a rather useful treatment choice and can be used in a reliable way in clinical applications.

Temporal delimitation of the healing phases via monitoring of fracture callus stiffness in rats

The healing process consists of at least three phases: inflammatory, repair, and remodeling phase. Because callus stiffness correlates with the healing phases, it is suitable for evaluating the fracture healing process. Our aim was to develop a method which allows determination of callus stiffness in vivo, the healing time and the duration of the repair phase. The right femurs of 16 Wistar rats were osteotomized and stabilized with either more rigid or more flexible external fixation. Fixator deformation was measured using strain gauges during gait analysis. The strains were recalculated as the callus stiffness over the time course of healing, and the healing phases were identified based on stiffness thresholds. Our hypothesis was that stabilization with more flexible external fixation prolongs the repair phase, therefore resulting in an extended healing time. Confirming our hypothesis, the duration of the repair phase (rigid: approximately 15 days, flexible: approximately 41 days) and the healing time (rigid: approximately 27 days, flexible: approximately 62 days) were significantly longer for more flexible external fixation. Our method allows the quantitative detection of differences in the healing time and duration of the repair phase without multiple time-point sacrifices, which reduces the number of animals in experimental studies.

Interaction of age and mechanical stability on bone defect healing: an early transcriptional analysis of fracture hematoma in rat

Among other stressors, age and mechanical constraints significantly influence regeneration cascades in bone healing. Here, our aim was to identify genes and, through their functional annotation, related biological processes that are influenced by an interaction between the effects of mechanical fixation stability and age. Therefore, at day three post-osteotomy, chip-based whole-genome gene expression analyses of fracture hematoma tissue were performed for four groups of Sprague-Dawley rats with a 1.5-mm osteotomy gap in the femora with varying age (12 vs. 52 weeks - biologically challenging) and external fixator stiffness (mechanically challenging). From 31099 analysed genes, 1103 genes were differentially expressed between the six possible combinations of the four groups and from those 144 genes were identified as statistically significantly influenced by the interaction between age and fixation stability. Functional annotation of these differentially expressed genes revealed an association with extracellular space, cell migration or vasculature development. The chip-based whole-genome gene expression data was validated by q-RT-PCR at days three and seven post-osteotomy for MMP-9 and MMP-13, members of the mechanosensitive matrix metalloproteinase family and key players in cell migration and angiogenesis. Furthermore, we observed an interaction of age and mechanical stimuli in vitro on cell migration of mesenchymal stromal cells. These cells are a subpopulation of the fracture hematoma and are known to be key players in bone regeneration. In summary, these data correspond to and might explain our previously described biomechanical healing outcome after six weeks in response to fixation stiffness variation. In conclusion, our data highlight the importance of analysing the influence of risk factors of fracture healing (e.g. advanced age, suboptimal fixator stability) in combination rather than alone.

In serum veritas-in serum sanitas? Cell non-autonomous aging compromises differentiation and survival of mesenchymal stromal cells via the oxidative stress pathway

Even tissues capable of complete regeneration, such as bone, show an age-related reduction in their healing capacity. Here, we hypothesized that this decline is primarily due to cell non-autonomous (extrinsic) aging mediated by the systemic environment. We demonstrate that culture of mesenchymal stromal cells (MSCs) in serum from aged Sprague-Dawley rats negatively affects their survival and differentiation ability. Proteome analysis and further cellular investigations strongly suggest that serum from aged animals not only changes expression of proteins related to mitochondria, unfolded protein binding or involved in stress responses, it also significantly enhances intracellular reactive oxygen species production and leads to the accumulation of oxidatively damaged proteins. Conversely, reduction of oxidative stress levels in vitro markedly improved MSC function. These results were validated in an in vivo model of compromised bone healing, which demonstrated significant increase regeneration in aged animals following oral antioxidant administration. These observations indicate the high impact of extrinsic aging on cellular functions and the process of endogenous (bone) regeneration. Thus, addressing the cell environment by, for example, systemic antioxidant treatment is a promising approach to enhance tissue regeneration and to regain cellular function especially in elderly patients.

Study on osteogenesis promoted by low sound pressure level infrasound in vivo and some underlying mechanisms

To clarify the effects of low sound pressure level (LSPL) infrasound on local bone turnover and explore its underlying mechanisms, femoral defected rats were stabilized with a single-side external fixator. After exposure to LSPL infrasound for 30min twice everyday for 6 weeks, the pertinent features of bone healing were assessed by radiography, peripheral quantitative computerized tomography (pQCT), histology and immunofluorescence assay. Infrasound group showed a more consecutive and smoother process of fracture healing and modeling in radiographs and histomorphology. It also showed significantly higher average bone mineral content (BMC) and bone mineral density (BMD). Immunofluorescence showed increased expression of calcitonin gene related peptide (CGRP) and decreased Neuropeptide Y (NPY) innervation in microenvironment. The results suggested the osteogenesis promotion effects of LSPL infrasound in vivo. Neuro-osteogenic network in local microenvironment was probably one target mediating infrasonic osteogenesis, which might provide new strategy to accelerate bone healing and remodeling.

External fixation of femoral defects in athymic rats: Applications for human stem cell implantation and bone regeneration

An appropriate animal model is critical for the research of stem/progenitor cell therapy and tissue engineering for bone regeneration in vivo. This study reports the design of an external fixator and its application to critical-sized femoral defects in athymic rats. The external fixator consists of clamps and screws that are readily available from hardware stores as well as Kirschner wires. A total of 35 rats underwent application of the external fixator with creation of a 6-mm bone defect in one femur of each animal. This model had been used in several separate studies, including implantation of collagen gel, umbilical cord blood mesenchymal stem cells, endothelial progenitor cells, or bone morphogenetic protein-2. One rat developed fracture at the proximal pin site and two rats developed deep tissue infection. Pin loosening was found in nine rats, but it only led to the failure of external fixation in two animals. In 8 to 10 weeks, various degrees of bone growth in the femoral defects were observed in different study groups, from full repair of the bone defect with bone morphogenetic protein-2 implantation to fibrous nonunion with collagen gel implantation. The external fixator used in these studies provided sufficient mechanical stability to the bone defects and had a comparable complication rate in athymic rats as in immunocompetent rats. The external fixator does not interfere with the natural environment of a bone defect. This model is particularly valuable for investigation of osteogenesis of human stem/progenitor cells in vivo.

CD133: enhancement of bone healing by local transplantation of peripheral blood cells in a biologically delayed rat osteotomy model

Sufficient angiogenesis is crucial during tissue regeneration and therefore also pivotal in bone defect healing. Recently, peripheral blood derived progenitor cells have been identified to have in addition to their angiogenic potential also osteogenic characteristics, leading to the hypothesis that bone regeneration could be stimulated by local administration of these cells. The aim of this study was to evaluate the angiogenic potential of locally administered progenitor cells to improve bone defect healing. Cells were separated from the peripheral blood of donor animals using the markers CD34 and CD133. Results of the in vitro experiments confirmed high angiogenic potential in the CD133(+) cell group. CD34(+) and CD133(+) cells were tested in an in vivo rat femoral defect model of delayed healing for their positive effect on the healing outcome. An increased callus formation and higher bone mineral density of callus tissue was found after the CD133(+) cell treatment compared to the group treated with CD34(+) cells and the control group without cells. Histological findings confirmed an increase in vessel formation and mineralization at day 42 in the osteotomy gap after CD133(+) cell transplantation. The higher angiogenic potential of CD133(+) cells from the in vitro experients therefore correlates with the in vivo data. This study demonstrates the suitability of angiogenic precursors to further bone healing and gives an indication that peripheral blood is a promising source for progenitor cells circumventing the problems associated with bone marrow extraction.

Influence of gender and fixation stability on bone defect healing in middle-aged rats: a pilot study

BACKGROUND

Gender and stability of fixation independently influence bone regeneration but their combined effects are unclear.

QUESTIONS/PURPOSES

In a pilot study we determined the combined influence of gender and fixation stability on the callus of middle-aged rats regarding (1) biomechanical properties; (2) bridging over time; (3) callus formation; and (4) callus size, geometry, mineralization, and microstructure.

METHODS

We osteotomized the left femur of 32 Sprague-Dawley rats (12 months old). Femurs were externally fixed with a gap of 1.5 mm in four groups of eight animals each: female semirigid, male semirigid, female rigid, and male rigid. Qualitative and quantitative in vivo radiographic analyses were performed twice weekly. Six weeks postoperatively, harvested femora were evaluated using micro-CT and biomechanical testing.

RESULTS

Torsional stiffness and maximum torque at failure were higher in male and in semirigidly fixed fractures. Radiographic analysis revealed earlier bridging and callus formation in both male groups. Micro-CT analysis showed a larger callus size, altered geometry, and microstructure in males and semirigidly fixed animals, whereas mineralization was similar in all animals.

CONCLUSION

Our data suggest female gender represents an independent risk factor for bone healing in middle-aged rats. Although healing in females was delayed compared with males, they exhibited a similar response (superior callus properties) to a more semirigid fixation.

CLINICAL RELEVANCE

While female gender appears to reflect a risk for impaired bone healing in middle-aged female rats, clinical studies would be required to confirm the finding in humans.

Temporal variation in fixation stiffness affects healing by differential cartilage formation in a rat osteotomy model

BACKGROUND

Dynamization involves a reduction in fixation construct stiffness during bone healing, allowing increased interfragmentary movement of the fracture through physiologic weightbearing and muscle contraction. Within some optimal range, interfragmentary movement stimulates healing, but this range likely varies across stages of bone healing.

QUESTIONS/PURPOSES

How does the time of dynamization affect the cartilage formation, bony bridging, and bone resorption in a rat fracture-healing model?

METHODS

Unilateral external fixators, stabilizing a 1-mm gap, were dynamized at 1 (D1 group, n = 10), 3 (D3 group, n = 11), or 4 (D4 group, n = 11) weeks postoperatively. Continuously 5 weeks stiff (S group, n = 10) and flexible (F group, n = 11) fixation were included for comparison. After 5 weeks, healing was evaluated by histomorphometric methods.

RESULTS

Advanced healing, indicated by less cartilage and a greater rate of bony bridging, was observed in the S group compared to the D1 or F group. In contrast, the D3 and D4 groups had less cartilage and more bridging compared to the S group. Also, the S group had less cortical resorption than the F and D1 groups.

CONCLUSIONS

These data suggest late dynamization at the onset of bony bridging led to enhanced healing, whereas dynamization at the early stage of cartilage differentiation delayed healing.

CLINICAL RELEVANCE

Although our observations from this small-animal study cannot be directly transferred to humans, these data suggest, once bony bridging begins, dynamization may stimulate bone healing and accelerate remodeling.

Local BMP-2 application can rescue the delayed osteotomy healing in a rat model

Delayed healing is still a severe complication in the clinic. The aim of the present study was to investigate the effect of locally delivered BMP-2 incorporated in a poly(d,l-lactide) (PDLLA) implant coating in a rat model with delayed tibial healing. The healing delay in this model is not caused by mechanical instability or additional tissue manipulation and presents therefore a common and challenging clinical situation of impaired healing. Radiological, histological and biomechanical evaluations were performed at days 5, 10, 28, 42, and 84 after tibial osteotomy. The control group showed a delayed healing without complete bridging and without reaching the biomechanical stability of the contralateral tibiae after 84 days. The mechanical stability of the BMP-treated tibiae showed a significant increase at days 28 and 42 compared to the control group and exceeded the stability of the intact contralateral tibiae. Less cartilage was detected at day 28 and the mineralisation was significantly enhanced at day 42 due to the local BMP application. Looking at the early healing phase (day 10) a reduced vascularisation was seen in the BMP group. This reflects the situation seen during normal healing, whereas the delayed healing in the present model had an increased vascularisation. The present study clearly demonstrates that local BMP-2 application can stimulate delayed healing in a clinically relevant animal model.

Osteogenic Growth Peptide Accelerates Bone Healing during Distraction Osteogenesis in Rabbit Tibia

Distraction osteogenesis is a valuable treatment method that allows limb lengthening or reconstruction of large bone defects. However, its major disadvantage is the long period required for the consolidation of a distraction callus. Osteogenic growth peptide (OGP) stimulates endochondral bone formation in fracture callus, but its capacity to promote regenerate ossification during distraction osteogenesis has not been evaluated. This study investigated whether intravenously administered OGP accelerated bone healing during distraction osteogenesis in 36 male New Zealand White rabbits, randomized into two groups. The treatment group received OGP (200 ng/kg body weight) in phosphate-buffered saline (PBS), intravenously, each day; the control group received PBS alone. A 15-mm lengthening of the right lower leg was performed using the method of Ilizarov. Evidence from biomechanical, histological and radiographic evaluations demonstrated that systemic OGP treatment promoted optimal new bone formation during distraction osteogenesis in this rabbit model.

Inter-species investigation of the mechano-regulation of bone healing: comparison of secondary bone healing in sheep and rat

Inter-species differences in regeneration exist in various levels. One aspect is the dynamics of bone regeneration and healing, e.g. small animals show a faster healing response when compared to large animals. Mechanical as well as biological factors are known to play a key role in the process. However, it remains so far unknown whether different animals follow at all comparable mechano-biological rules during tissue regeneration, and in particular during bone healing. In this study, we investigated whether differences observed in vivo in the dynamics of bone healing between rat and sheep are only due to differences in the animal size or whether these animals have a different mechano-biological response during the healing process. Histological sections from in vivo experiments were compared to in silico predictions of a mechano-biological computer model for the simulation of bone healing. Investigations showed that the healing processes in both animal models occur under significantly different levels of mechanical stimuli within the callus region, which could explain histological observations of early intramembranous ossification at the endosteal side. A species-specific adaptation of a mechano-biological model allowed a qualitative match of model predictions with histological observations. Specifically, when keeping cell activity processes at the same rate, the amount of tissue straining defining favorable mechanical conditions for the formation of bone had to be increased in the large animal model, with respect to the small animal, to achieve a qualitative agreement of model predictions with histological data. These findings illustrate that geometrical (size) differences alone cannot explain the distinctions seen in the histological appearance of secondary bone healing in sheep and rat. It can be stated that significant differences in the mechano-biological regulation of the healing process exist between these species. Future investigations should aim towards understanding whether these differences are due to differences in cell behavior, material properties of the newly formed tissues within the callus and/or differences in response to the mechanical environment.

A 5-mm femoral defect in female but not in male rats leads to a reproducible atrophic non-union

INTRODUCTION

The objectives of this study were to (1) establish a reproducible atrophic non-union model in rats by creation of a segmental femoral bone defect that allows, (2) in-depth characterization of impaired healing, and (3) contrast its healing patterns to the normal course. Hypothesis was that a 5-mm bone defect in male rats would deviate from uneventful healing patterns and result in an atrophic non-union.

MATERIALS AND METHODS

A femoral osteotomy was performed in two groups of 12-week-old male rats (1 vs. 5 mm gap) stabilized with an external fixator. Bone healing in these models was evaluated by radiology, biomechanics, and histology at 6 or 8 weeks. The evaluation of the 5-mm group revealed in some cases a delayed rather than a non-union, and therefore, a group of female counterparts was included.

RESULTS

The creation of a 5-mm defect in female rats resulted in a reproducible atrophic non-union characterized by sealing of the medullary canal, lack of cartilage formation, and negligible mechanical properties of the callus. In both gap size models, the male subjects showed advanced healing compared to females.

DISCUSSION AND CONCLUSION

This study showed that even under uneventful healing conditions in terms of age and bone defect size, there is a sex-specific advanced healing in male compared to female subjects. Contrary to our initial hypothesis, only the creation of a 5-mm segmental femoral defect in female rats led to a reproducible atrophic non-union. It has been shown that an atrophic non-union exhibits different healing patterns compared to uneventful healing. A total lack of endochondral bone formation, soft tissue prolapse into the defect, and bony closure of the medullary cavity have been shown to occur in the non-union model.

Influences of age and mechanical stability on volume, microstructure, and mineralization of the fracture callus during bone healing: is osteoclast activity the key to age-related impaired healing?

Earlier studies have shown that the influence of fixation stability on bone healing diminishes with advanced age. The goal of this study was to unravel the relationship between mechanical stimulus and age on callus competence at a tissue level. Using 3D in vitro micro-computed tomography derived metrics, 2D in vivo radiography, and histology, we investigated the influences of age and varying fixation stability on callus size, geometry, microstructure, composition, remodeling, and vascularity. Compared were four groups with a 1.5-mm osteotomy gap in the femora of Sprague-Dawley rats: Young rigid (YR), Young semirigid (YSR), Old rigid (OR), Old semirigid (OSR). Hypothesis was that calcified callus microstructure and composition is impaired due to the influence of advanced age, and these individuals would show a reduced response to fixation stabilities. Semirigid fixations resulted in a larger DeltaCSA (Callus cross-sectional area) compared to rigid groups. In vitro microCT analysis at 6 weeks postmortem showed callus bridging scores in younger animals to be superior than their older counterparts (p<0.01). Younger animals showed (i) larger callus strut thickness (p<0.001), (ii) lower perforation in struts (p<0.01), and (iii) higher mineralization of callus struts (p<0.001). Callus mineralization was reduced in young animals with semirigid fracture fixation but remained unaffected in the aged group. While stability had an influence, age showed none on callus size and geometry of callus. With no differences observed in relative osteoid areas in the callus ROI, old as well as semirigid fixated animals showed a higher osteoclast count (p<0.05). Blood vessel density was reduced in animals with semirigid fixation (p<0.05). In conclusion, in vivo monitoring indicated delayed callus maturation in aged individuals. Callus bridging and callus competence (microstructure and mineralization) were impaired in individuals with an advanced age. This matched with increased bone resorption due to higher osteoclast numbers. Varying fixator configurations in older individuals did not alter the dominant effect of advanced age on callus tissue mineralization, unlike in their younger counterparts. Age-associated influences appeared independent from stability. This study illustrates the dominating role of osteoclastic activity in age-related impaired healing, while demonstrating the optimization of fixation parameters such as stiffness appeared to be less effective in influencing healing in aged individuals.

Mechanical stimulation of the pro-angiogenic capacity of human fracture haematoma: involvement of VEGF mechano-regulation

Compromised angiogenesis appears to be a major limitation in various suboptimal bone healing situations. Appropriate mechanical stimuli support blood vessel formation in vivo and improve healing outcomes. However, the mechanisms responsible for this association are unclear. To address this question, the paracrine angiogenic potential of early human fracture haematoma and its responsiveness to mechanical loading, as well as angiogenic growth factors involved, were investigated in vitro. Human haematomas were collected from healthy patients undergoing surgery within 72 h after bone fracture. The haematomas were embedded in a fibrin matrix, and cultured in a bioreactor resembling the in vivo conditions of the early phase of bone healing (20% compression, 1 Hz) over 3 days. Conditioned medium (CM) from the bioreactor was then analyzed. The matrices were also incubated in fresh medium for a further 24 h to evaluate the persistence of the effects. Growth factor (GF) concentrations were measured in the CM by ELISAs. In vitro tube formation assays were conducted on Matrigel with the HMEC-1 cell line, with or without inhibition of vascular endothelial growth factor receptor 2 (VEGFR2). Cell numbers were quantified using an MTS test. In vitro endothelial tube formation was enhanced by CM from haematomas, compared to fibrin controls. The angiogenesis regulators, vascular endothelial growth factor (VEGF) and transforming growth factor beta1 (TGF-beta1), were released into the haematoma CM, but not angiopoietins 1 or 2 (Ang1, 2), basic fibroblast growth factor (bFGF) or platelet-derived growth factor (PDGF). Mechanical stimulation of haematomas, but not fibrin controls, further increased the induction of tube formation by their CM. The mechanically stimulated haematoma matrices retained their elevated pro-angiogenic capacity for 24 h. The pro-angiogenic effect was cancelled by inhibition of VEGFR2 signalling. VEGF concentrations in CM tended to be elevated by mechanical stimulation; this was significant in haematomas from younger, but not from older patients. Other GFs were not mechanically regulated. In conclusion, the paracrine pro-angiogenic capacity of early human haematomas is enhanced by mechanical stimulation. This effect lasts even after removing the mechanical stimulus and appears to be VEGFR2-dependent.

Sex-specific compromised bone healing in female rats might be associated with a decrease in mesenchymal stem cell quantity

INTRODUCTION

The clinically known importance of patient sex as a major risk factor for compromised bone healing is poorly reflected in animal models. Consequently, the underlying cellular mechanisms remain elusive. Because mesenchymal stem cells (MSCs) are postulated to regulate tissue regeneration and give rise to essential differentiated cell types, they may contribute to sex-specific differences in bone healing outcomes.

METHODS

We investigated sex-specific variations in bone healing and associated differences in MSC populations. A 1.5 mm osteotomy gap in the femora of 8 male and 8 female 12-month-old Sprague-Dawley rats was stabilized by an external fixator. Healing was analyzed in terms of biomechanical testing, bridging and callus size over time (radiography at 2, 4, and 6 weeks after surgery), and callus volume and geometry by microCT at final follow-up. MSCs were obtained from bone marrow samples of an age-matched group of 12 animals (6 per gender) and analyzed for numbers of colony-forming units (CFUs) and their capacity to differentiate and proliferate. The proportion of senescent cells was determined by beta-galactosidase staining.

RESULTS

Sex-specific differences were indicated by a compromised mechanical competence of the callus in females compared with males (maximum torque at failure, p=0.028). Throughout the follow-up, the cross-sectional area of callus relative to bone was reduced in females (p< or =0.01), and the bridging of callus was delayed (p(2weeks)=0.041). microCT revealed a reduced callus size (p=0.003), mineralization (p=0.003) and polar moment of inertia (p=0.003) in female animals. The female bone marrow contained significantly fewer MSCs, represented by low CFU numbers in both femora and tibiae (p(femur)=0.017, p(tibia)=0.010). Functional characteristics of male and female MSCs were similar.

CONCLUSION

Biomechanically compromised and radiographically delayed bone formation were distinctive in female rats. These differences were concomitant with a reduced number of MSCs, which may be causative for the suboptimal bone healing.