Bone morphogenetic proteins in musculoskeletal medicine

TRPV4 Activator-Containing CMT-Hy Hydrogel Enhances Bone Tissue Regeneration In Vivo by Enhancing Mitochondrial Health

Treating different types of bone defects is difficult, complicated, time-consuming, and expensive. Here, we demonstrate that transient receptor potential cation channel subfamily V member 4 (TRPV4), a mechanosensitive, thermogated, and nonselective cation channel, is endogenously present in the mesenchymal stem cells (MSCs). TRPV4 regulates both cytosolic Ca2+ levels and mitochondrial health. Accordingly, the hydrogel made from a natural modified biopolymer carboxymethyl tamarind CMT-Hy and encapsulated with TRPV4-modulatory agents affects different parameters of MSCs, such as cell morphology, focal adhesion points, intracellular Ca2+, and reactive oxygen species- and NO-levels. TRPV4 also regulates cell differentiation and biomineralization in vitro. We demonstrate that 4α-10-CMT-Hy and 4α-50-CMT-Hy (the hydrogel encapsulated with 4αPDD, 10 and 50 nM, TRPV4 activator) surfaces upregulate mitochondrial health, i.e., an increase in ATP- and cardiolipin-levels, and improve the mitochondrial membrane potential. The same scaffold turned out to be nontoxic in vivo. 4α-50-CMT-Hy enhances the repair of the bone-drill hole in rat femur, both qualitatively and quantitatively in vivo. We conclude that 4α-50-CMT-Hy as a scaffold is suitable for treating large-scale bone defects at low cost and can be tested for clinical trials.

Role of Traditional Chinese Medicine in Bone Regeneration and Osteoporosis

According to World Health Organization (WHO), osteoporosis is a systematic bone disability marked by reduced bone mass and microarchitectural degeneration of osseous cells, which leads to increased bones feebleness and fractures vulnerability. It is a polygenetic, physiological bone deformity that frequently leads to osteoporotic fractures and raises the risk of fractures in minimal trauma. Additionally, the molecular changes that cause osteoporosis are linked to decreased fracture repair and delayed bone regeneration. Bones have the ability to regenerate as part of the healing mechanism after an accident or trauma, including musculoskeletal growth and ongoing remodeling throughout adulthood. The principal treatment approaches for bone loss illnesses, such as osteoporosis, are hormone replacement therapy (HRT) and bisphosphonates. In this review, we searched literature regarding the Traditional Chinese medicines (TCM) in osteoporosis and bone regeneration. The literature results are summarized in this review for osteoporosis and bone regeneration. Traditional Chinese medicines (TCM) have grown in popularity as a result of its success in curing ailments while causing minimal adverse effects. Natural Chinese medicine has already been utilized to cure various types of orthopedic illnesses, notably osteoporosis, bone fractures and rheumatism with great success. TCM is a discipline of conventional remedy that encompasses herbal medication, massage (tui na), acupuncture, food, and exercise (qigong) therapy. It is based on more than 2,500 years of Chinese healthcare profession. This article serves as a comprehensive review summarizing the osteoporosis, bone regeneration and the traditional Chinese medicines used since ancient times for the management of osteoporosis and bone regeneration.

Reconstruction of Traumatic Bone Defect With In Situ Implantation of Dropped Traumatic Segmental Bone Fragments

This study was conducted to determine whether in situ implantation of a dropped traumatic segmental bone fragment is safe and whether the authors' method would reduce the incidence of infectious and related complications. The authors retrospectively reviewed 16 patients with open fractures, including 11 with Gustilo-Anderson type IIIA fractures and 5 with Gustilo-Anderson type IIIB fractures who had a dropped traumatic segmental bone fragment between January 2002 and January 2012. Mean patient age was 35.4 years (range, 19-47 years). There were 10 femurs and 6 tibias. Average postoperative follow-up was 26.8 months (range, 12-60 months). The dropped traumatic segmental bone fragments were cleaned with 3% hydrogen peroxide, placed in separate sterile cups, and soaked in 1% iodophor for 30 minutes. Initial treatment included surgical debridement, wound irrigation, in situ implantation of the dropped traumatic segmental bone fragment, and temporary external fixation. Approximately 4 to 8 weeks later, after successful reconstruction of the soft tissue envelope, minimally invasive plate osteosynthesis was performed. Mean duration of treatment was 8 weeks (range, 6-14 weeks). All patients had fracture union at final follow-up. Mean healing time was 21.8 weeks (range, 14-48 weeks). One patient did not achieve primary union and required bone grafting. One patient with a Gustilo-Anderson type IIIB fracture had deep infection and removal of the dropped traumatic segmental bone fragment and bone grafting. According to the Klemm and Börner classification, 11 patients had excellent results, 3 had good results, and 2 had poor results. With adequate soft tissue coverage, this method was acceptable for the management of open fractures with bone defects.

Co‑delivery and controlled release of stromal cell‑derived factor‑1α chemically conjugated on collagen scaffolds enhances bone morphogenetic protein‑2‑driven osteogenesis in rats

There has been considerable focus in investigations on the delivery systems and clinical applications of bone morphogenetic protein-2 (BMP-2) for novel bone formation. However, current delivery systems require high levels of BMP-2 to exert a biological function. There are several concerns in using of high levels of BMP-2, including safety and the high cost of treatment. Therefore, the development of strategies to decrease the levels of BMP-2 required in these delivery systems is required. In our previous studies, a controlled-release system was developed, which used Traut's reagent and the cross-linker, 4-(N-maleimi-domethyl) cyclohexane-1-carboxylic acid 3-sulfo-N-hydroxysuccinimide ester sodium salt (Sulfo-SMCC), to chemically conjugate BMP-2 directly on collagen discs. In the current study, retention efficiency and release kinetics of stromal cell-derived factor-1α (SDF-1α) cross-linked on collagen scaffolds were detected. In addition, the osteogenic activity of SDF-1α and suboptimal doses of BMP-2 cross-linked on collagen discs following subcutaneous implantation in rats were evaluated. Independent two-tailed t-tests and one-way analysis of variance were used for analysis. In the present study, the controlled release of SDF-1α chemically conjugated on collagen scaffolds was demonstrated. By optimizing the concentrations of Traut's reagent and the Sulfo-SMCC cross-linker, a significantly higher level of SDF-1α was covalently retained on the collagen scaffold, compared with that retained using a physical adsorption method. Mesenchymal stem cell homing indicated that the biological function of the SDF-1α cross-linked on the collagen scaffolds remained intact. In rats, co-treatment with SDF-1α and a suboptimal dose of BMP-2 cross-linked on collagen scaffolds using this chemically conjugated method induced higher levels of ectopic bone formation, compared with the physical adsorption method. No ectopic bone formation was observed following treatment with a suboptimal dose of BMP-2 alone. Therefore, the co-delivery of SDF-1α and a suboptimal dose of BMP-2 chemically conjugated on collagen scaffolds for the treatment of bone injuries reduced the level of BMP-2 required, reducing the risks of side effects.

Deletion of BMP receptor type IB decreased bone mass in association with compromised osteoblastic differentiation of bone marrow mesenchymal progenitors

We previously found that disruption of two type I BMP receptors, Bmpr1a and Acvr1, respectively, in an osteoblast-specific manner, increased bone mass in mice. BMPR1B, another BMP type I receptor, is also capable of binding to BMP ligands and transduce BMP signaling. However, little is known about the function of BMPR1B in bone. In this study, we investigated the bone phenotype in Bmpr1b null mice and the impacts of loss of Bmpr1b on osteoblasts and osteoclasts. We found that deletion of Bmpr1b resulted in osteopenia in 8-week-old male mice, and the phenotype was transient and gender specific. The decreased bone mass was neither due to the changes in osteoblastic bone formation activity nor osteoclastic bone resorption activity in vivo. In vitro differentiation of Bmpr1b null osteoclasts was increased but resorption activity was decreased. Calvarial pre-osteoblasts from Bmpr1b mutant showed comparable differentiation capability in vitro, while they showed increased BMP-SMAD signaling in culture. Different from calvarial pre-osteoblasts, Bmpr1b mutant bone marrow mesenchymal progenitors showed compromised differentiation in vitro, which may be a reason for the osteopenic phenotype in the mutant mice. In conclusion, our results suggested that BMPR1B plays distinct roles from BMPR1A and ACVR1 in maintaining bone mass and transducing BMP signaling.

Innovative strategies for the management of long bone infection: a review of the Masquelet technique

Post-traumatic long bone osteomyelitis (PTOM) is a relatively frequent occurrence in patients with severe open fractures and requires treatment to prevent limb-threatening complications. The Masquelet technique represents a length-independent, two-staged reconstruction that involves the induction of a periosteal membrane and use of an antibiotic-impregnated cement spacer for the treatment of segmental bone loss that result from bone infection. In this review, we summarize recent developments regarding the diagnosis and treatment of long bone PTOM, with a special emphasis on the use of the Masquelet technique for reconstruction of wide diaphyseal defects.

A living thick nanofibrous implant bifunctionalized with active growth factor and stem cells for bone regeneration

New-generation implants focus on robust, durable, and rapid tissue regeneration to shorten recovery times and decrease risks of postoperative complications for patients. Herein, we describe a new-generation thick nanofibrous implant functionalized with active containers of growth factors and stem cells for regenerative nanomedicine. A thick electrospun poly(ε-caprolactone) nanofibrous implant (from 700 μm to 1 cm thick) was functionalized with chitosan and bone morphogenetic protein BMP-7 as growth factor using layer-by-layer technology, producing fish scale-like chitosan/BMP-7 nanoreservoirs. This extracellular matrix-mimicking scaffold enabled in vitro colonization and bone regeneration by human primary osteoblasts, as shown by expression of osteocalcin, osteopontin, and bone sialoprotein (BSPII), 21 days after seeding. In vivo implantation in mouse calvaria defects showed significantly more newly mineralized extracellular matrix in the functionalized implant compared to a bare scaffold after 30 days' implantation, as shown by histological scanning electron microscopy/energy dispersive X-ray microscopy study and calcein injection. We have as well bifunctionalized our BMP-7 therapeutic implant by adding human mesenchymal stem cells (hMSCs). The activity of this BMP-7-functionalized implant was again further enhanced by the addition of hMSCs to the implant (living materials), in vivo, as demonstrated by the analysis of new bone formation and calcification after 30 days' implantation in mice with calvaria defects. Therefore, implants functionalized with BMP-7 nanocontainers associated with hMSCs can act as an accelerator of in vivo bone mineralization and regeneration.

The role of barrier membranes for guided bone regeneration and restoration of large bone defects: current experimental and clinical evidence

Treatment of large bone defects represents a great challenge in orthopedic and craniomaxillofacial surgery. Although there are several methods for bone reconstruction, they all have specific indications and limitations. The concept of using barrier membranes for restoration of bone defects has been developed in an effort to simplify their treatment by offering a single-staged procedure. Research on this field of bone regeneration is ongoing, with evidence being mainly attained from preclinical studies. The purpose of this review is to summarize the current experimental and clinical evidence on the use of barrier membranes for restoration of bone defects in maxillofacial and orthopedic surgery. Although there are a few promising preliminary human studies, before clinical applications can be recommended, future research should aim to establish the 'ideal' barrier membrane and delineate the need for additional bone grafting materials aiming to 'mimic' or even accelerate the normal process of bone formation. Reproducible results and long-term observations with barrier membranes in animal studies, and particularly in large animal models, are required as well as well-designed clinical studies to evaluate their safety, efficacy and cost-effectiveness.

Bone graft substitutes: What are the options?

Currently, a number of bone grafting materials are available in the clinical setting to enhance bone regeneration, varying from autologous bone to several bone graft substitutes. Although autologous bone remains the "gold standard" for stimulating bone repair and regeneration, the morbidity from its harvesting and its restricted availability generated the need for the development of other materials or strategies either to substitute autologous bone graft or expand its limited supply. Bone graft substitutes can possess one or more components: an osteoconductive matrix, acting as a scaffold; osteoinductive proteins and other growth factors to induce differentiation and proliferation of bone-forming cells; and osteogenic cells for bone formation. Based on their distinct properties, all these bone grafting alternatives have specific indications, and can be used either alone or in combination. In this review, we summarise the available bone grafting materials, focussing mainly on the various bone substitutes and their characteristics, in an effort to specify the indications for their use.

Enhancement of fracture healing with the diamond concept: the role of the biological chamber

Bone regeneration presents a unique challenge to both clinicians and scientists. Recently, a vast amount of knowledge has been attained with regard to the molecular mediators, cell populations and the overall cascade of events participating in the bone repair processes. For the treatment of bone non-unions or bone defects, the 'diamond concept' for biological enhancement supports the implantation of mesenchymal stem cells, a scaffold and a growth factor. Prior to the implantation of any or all of these materials however, the surgeon must develop the ideal biological environment (non-union bed) where molecular and physiological processes will evolve facilitating an early and successful osteogenesis leading to bone continuity and functional restoration of the affected limb. At the end of the surgical procedure the non-union bed should have been transformed to a 'biological chamber' active enough to support efficiently all the necessary physiological processes for a successful outcome. The notion of creating the optimum 'biological chamber' represents the centre of the highest biological activity and in a sense the heart of the diamond concept.

Masquelet technique for the treatment of bone defects: tips-tricks and future directions

Reconstruction of diaphyseal bone defects still represents a major clinical challenge. Several approaches are used with the common objective to regenerate bone loss and restore function. The methods most commonly used are the vascularised fibula autograft and the Ilizarov bone transfer technique. Recently, Masquelet proposed a procedure combining induced membranes and cancellous autografts. The aim of this article was to briefly describe the technique, to review the current evidence and to discuss the tips and tricks that could help the surgeons to improve outcome. Future directions to increase its effectiveness and expand its application are also being discussed. However, predicting the outcome of reconstruction of bone defects remains difficult; and the patient should always be informed that, although potential complications are mostly predictable, in most of the cases the reconstruction process is long and difficult.

Growth factors and bone regeneration: how much bone can we expect?

A large body of research has investigated the use of growth factors for bone regeneration, as a potential alternative to autogenous bone grafting. The bone morphogenetic proteins (BMPs) represent the most extensively investigated growth factors to date, as potential therapeutic agents for bone regeneration. Despite decades of research, the ideal growth factor or combination of growth factors for bone regeneration remains undefined. This article reviews the current available evidence for the application of growth factors for bone regeneration, with a focus on the clinical evidence for BMP use. Emerging pre-clinical and clinical evidence for growth factors other than the BMPs is also discussed.

Bone regeneration: current concepts and future directions

Bone regeneration is a complex, well-orchestrated physiological process of bone formation, which can be seen during normal fracture healing, and is involved in continuous remodelling throughout adult life. However, there are complex clinical conditions in which bone regeneration is required in large quantity, such as for skeletal reconstruction of large bone defects created by trauma, infection, tumour resection and skeletal abnormalities, or cases in which the regenerative process is compromised, including avascular necrosis, atrophic non-unions and osteoporosis. Currently, there is a plethora of different strategies to augment the impaired or 'insufficient' bone-regeneration process, including the 'gold standard' autologous bone graft, free fibula vascularised graft, allograft implantation, and use of growth factors, osteoconductive scaffolds, osteoprogenitor cells and distraction osteogenesis. Improved 'local' strategies in terms of tissue engineering and gene therapy, or even 'systemic' enhancement of bone repair, are under intense investigation, in an effort to overcome the limitations of the current methods, to produce bone-graft substitutes with biomechanical properties that are as identical to normal bone as possible, to accelerate the overall regeneration process, or even to address systemic conditions, such as skeletal disorders and osteoporosis.

High-throughput screening of a small molecule library for promoters and inhibitors of mesenchymal stem cell osteogenic differentiation

The use of high-throughput screening (HTS) techniques has long been employed by the pharmaceutical industry to increase discovery rates for new drugs that could be useful for disease treatment, yet this technology has only been minimally applied in other applications such as in tissue regeneration. In this work, an assay for the osteogenic differentiation of human mesenchymal stem cells (hMSCs) was developed and used to screen a library of small molecules for their potential as either promoters or inhibitors of osteogenesis, based on levels of alkaline phosphatase activity and cellular viability. From a library of 1,040 molecules, 36 promoters, and 20 inhibitors were identified as hits based on statistical criteria. Osteopromoters from this library were further investigated using standard culture techniques and a wider range of outcomes to verify that these compounds drive cellular differentiation. Several hits led to some improvement in the expression of alkaline phosphatase, osteogenic gene expression, and matrix mineralization by hMSCs when compared to the standard dexamethasone supplemented media and one molecule was investigated in combination with a recently identified biodegradable and osteoconductive polymer. This work illustrates the ability of HTS to more rapidly identify potential molecules to control stem cell differentiation.

The biology of intramedullary reaming

In this review we focus on the local biologic and physiologic effects of intramedullary reaming of long bones. Among the topics discussed are the consequences for vascularity, as well as the pathophysiology of intramedullary pressure generation and temperature increase. Reaming techniques and their suggested effects on bone formation are outlined. Moreover, techniques for avoiding local and systemic complications are summarized.

Cartilage repair evolution in post-traumatic osteochondral lesions of the talus: from open field autologous chondrocyte to bone-marrow-derived cells transplantation

The aims of this study are to describe evolution in cartilage repair from open field autologous chondrocyte implantation to regeneration by arthroscopic bone-marrow-derived cells (BMDCs) "one step" technique; to present the results of a series of patients consecutively treated and to compare in detail the different techniques used in order to establish the advantages obtained with the evolution in cartilage regenerative methods. 81 patients (mean age 30±8 years) were evaluated in this study. Patient assessment included clinical AOFAS score, X-rays and MRI preoperatively and at different established follow-ups. All the lesions were >1.5 cm(2) and received open autologous chondrocyte implantation (10 cases), arthroscopic autologous chondrocyte implantation (46 cases), and "one step" arthroscopic repair by BMDC transplantation (25 cases). For arthroscopic repair techniques a hyaluronic acid membrane was used to support cells and specifically designed instrumentation was developed. Patients of all the three groups underwent a second arthroscopy with a bioptic cartilage harvest at 1 year follow-up. Mean AOFAS score before surgery was 57.1±17.2 and 92.6±10.5 (P<0.0005) at mean 59.5±26.5 months. A similar pattern of AOFAS improvement in results was found in the three different techniques. Histological evaluations highlighted collagen type II and proteoglycan expression. The cartilage repair techniques described were able to provide a repair tissue which closely approximates the characteristics of the naive hyaline cartilage. Evolution in surgical technique, new biomaterials and more recently the use of BMDCs permitted a marked reduction in procedure morbidity and costs up to a "one step" technique able to overcome all the drawbacks of previous repair techniques.