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Le Baron M, Maman P, Volpi R, Flecher X. External fixation as definitive treatment or external fixation followed by early fixation in open fractures of the tibial shaft: A descriptive study. Injury 2024; 55 Suppl 1:111477. [PMID: 39069345 DOI: 10.1016/j.injury.2024.111477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/08/2024] [Accepted: 02/25/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Treatment options for open tibial shaft fractures include external fixation with or without early conversion to internal fixation. OBJECTIVES The aim of this study was to describe 1) early conversion to internal fixation and definitive external fixation and 2) in case of conversion, to identify risk factors for complications. METHODS Seventy-two external fixations of open fractures of the tibial shaft (Gustilo classification, 7 fractures (9.7 %) grade I, 25 fractures (34.7 %) grade II, 40 fractures (55.6 %) grade III (31 grade IIIA and 9 grade IIIB)) were included in a continuous non-randomised study. Thirty-three fractures without infection signs were converted to internal fixation at a mean time of 40.5 +/-15 days (IF group). External fixation was maintened in the remaining 39 fractures (EF group). RESULTS In the "IF" group, the union rate was 69.7 % at 6.3 +/-3.6 months (3-16). All patients had complete union at 16 months, requiring 2.8 +/-0.8 reoperations. Fixation with external fixation only ("EF" group) showed a union rate of 51.3 % at 8.9 +/-4 (5-22) months and 96 % at 16 months after 3.7 +/-0.9 reoperations. Superficial infection (12.1 %; p = 0.011) and numerous surgeries (2.76; p = 0.004) were found to be risk factors for deep infection. Time to wound closure >7 days (p = 0.049), time to reoperation >28 days (p = 0.00), numerous surgeries (2.76; p = 0.004) and deep infection (6.1 %; p = 0.027) were found to be union failure factors. CONCLUSION Early conversion of external fixation to internal fixation is an effective option to achieve bone union of open tibial fractures in selected patients.
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Affiliation(s)
- Marie Le Baron
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France.
| | - Pascal Maman
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
| | - Richard Volpi
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
| | - Xavier Flecher
- Centre de Chirurgie orthopédique et traumatologie, Centre Hospitalo-Universitaire Nord, Marseille, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, France
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Alam MA, Shirazi AF, Alaradi H. Association of Fracture Location and Pattern With Nonunion or Malunion in Tibia Fractures Managed With Intramedullary Nailing: A Retrospective Study. Cureus 2023; 15:e49156. [PMID: 38130567 PMCID: PMC10733781 DOI: 10.7759/cureus.49156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Background and objective Extra-articular fractures of the tibia are common orthopedic injuries that are frequently treated with rigid intramedullary nailing. Fracture location and pattern may increase the risk of nonunion or malunion in fractures managed with intramedullary nails. This study aimed to assess the relationship between fracture pattern and location with malunion and nonunion. The primary objective was to evaluate the influence of fracture location and pattern on adverse clinical outcomes such as nonunion, delayed union, and malunion in tibial shaft fractures that are treated operatively with rigid intramedullary nails. Methodology This was a retrospective cross-sectional study conducted on patients operated in a tertiary care center in the Kingdom of Bahrain. The study included patients who sustained tibia shaft fractures and were subsequently operated with intramedullary of the tibia. The primary endpoint was the rate of adverse outcomes associated with fracture patterns. Fracture characteristics were to determine which fracture patterns healed well with intramedullary nailing and which fractures ended up with malunion or nonunion and would likely benefit from additional measures to augment the nail fixation and help encourage union. Results One hundred and eighty-nine patients were included in the study. The level of associated fibula fracture was significantly associated with an increased risk of nonunion and malunion (P = 0.0034, P = 0.001). The presence of a concomitant distal fibula fracture in association with tibia fractures increased the odds of nonunion (odds ratio [OR] = 4.871, P = 0.033, confidence interval [CI] = 1.133-20.948). Conclusions The level and pattern of some tibia and fibula fractures were associated with nonunion, malunion, and delayed union. Further studies with more robust follow-up are needed to examine these findings in greater detail.
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Affiliation(s)
- Mahmood A Alam
- Orthopaedics and Trauma, Salmaniya Medical Complex, Manama, BHR
| | - Ahmed F Shirazi
- Orthopaedics and Trauma, Salmaniya Medical Complex, Manama, BHR
| | - Hasan Alaradi
- Orthopaedics and Trauma, Salmaniya Medical Complex, Manama, BHR
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Kuroda R, Niikura T, Matsumoto T, Fukui T, Oe K, Mifune Y, Minami H, Matsuoka H, Yakushijin K, Miyata Y, Kawamoto S, Kagimura T, Fujita Y, Kawamoto A. Phase III clinical trial of autologous CD34 + cell transplantation to accelerate fracture nonunion repair. BMC Med 2023; 21:386. [PMID: 37798633 PMCID: PMC10557317 DOI: 10.1186/s12916-023-03088-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND We previously demonstrated that CD34 + cell transplantation in animals healed intractable fractures via osteogenesis and vasculogenesis; we also demonstrated the safety and efficacy of this cell therapy in an earlier phase I/II clinical trial conducted on seven patients with fracture nonunion. Herein, we present the results of a phase III clinical trial conducted to confirm the results of the previous phase studies using a larger cohort of patients. METHODS CD34 + cells were mobilized via administration of granulocyte colony-stimulating factor, harvested using leukapheresis, and isolated using magnetic cell sorting. Autologous CD34 + cells were transplanted in 15 patients with tibia nonunion and 10 patients with femur nonunion, who were followed up for 52 weeks post transplantation. The main outcome was a reduction in time to heal the tibia in nonunion patients compared with that in historical control patients. We calculated the required number of patients as 15 based on the results of the phase I/II study. An independent data monitoring committee performed the radiographic assessments. Adverse events and medical device failures were recorded. RESULTS All fractures healed during the study period. The time to radiological fracture healing was 2.8 times shorter in patients with CD34 + cell transplantation than in the historical control group (hazard ratio: 2.81 and 95% confidence interval 1.16-6.85); moreover, no safety concerns were observed. CONCLUSIONS Our findings strongly suggest that autologous CD34 + cell transplantation is a novel treatment option for fracture nonunion. TRIAL REGISTRATION UMIN-CTR, UMIN000022814. Registered on 22 June 2016.
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Affiliation(s)
- Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan.
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yutaka Mifune
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hiroshi Matsuoka
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yoshiharu Miyata
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Hospital and Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Shinichiro Kawamoto
- Department of Transfusion Medicine and Cell Therapy, Kobe University Hospital, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tatsuo Kagimura
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-Ku, Kobe, 650-0047, Japan
| | - Yasuyuki Fujita
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-Ku, Kobe, 650-0047, Japan
| | - Atsuhiko Kawamoto
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Chuo-Ku, Kobe, 650-0047, Japan
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Xu W, Yang Y, Li N, Hua J. Interaction between Mesenchymal Stem Cells and Immune Cells during Bone Injury Repair. Int J Mol Sci 2023; 24:14484. [PMID: 37833933 PMCID: PMC10572976 DOI: 10.3390/ijms241914484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/13/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Fractures are the most common large organ trauma in humans. The initial inflammatory response promotes bone healing during the initial post-fracture phase, but chronic and persistent inflammation due to infection or other factors does not contribute to the healing process. The precise mechanisms by which immune cells and their cytokines are regulated in bone healing remain unclear. The use of mesenchymal stem cells (MSCs) for cellular therapy of bone injuries is a novel clinical treatment approach. Bone progenitor MSCs not only differentiate into bone, but also interact with the immune system to promote the healing process. We review in vitro and in vivo studies on the role of the immune system and bone marrow MSCs in bone healing and their interactions. A deeper understanding of this paradigm may provide clues to potential therapeutic targets in the healing process, thereby improving the reliability and safety of clinical applications of MSCs to promote bone healing.
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Affiliation(s)
| | | | - Na Li
- Shaanxi Centre of Stem Cells Engineering & Technology, College of Veterinary Medicine, Northwest A&F University, Yangling, Xianyang 712100, China; (W.X.); (Y.Y.)
| | - Jinlian Hua
- Shaanxi Centre of Stem Cells Engineering & Technology, College of Veterinary Medicine, Northwest A&F University, Yangling, Xianyang 712100, China; (W.X.); (Y.Y.)
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Ozden Akkaya O, Dikmen T, Nawaz S, Kibria AG, Altunbaş K, Yağci A, Erdoğan M, Yaprakci MV. Comparison of proliferation and osteogenic differentiation potential of bovine adipose tissue and bone marrow derived stem cells. Biotech Histochem 2023; 98:267-279. [PMID: 36815431 DOI: 10.1080/10520295.2023.2177347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Bone marrow derived stem cells (BMSC) are the most utilized cell type in the field of bone regeneration. Although BMSC are both safe and efficacious, the search for alternative sources for stem cells continues. We investigated bovine BMSC and adipose tissue derived mesenchymal stem cells (ATSC) using immunofluorescence and PCR. We further compared the osteogenic differentiation potentials of both sources of stem cells. We assessed alkaline phosphatase (ALP) enzyme levels and calcium deposition in differentiating cells at days 7, 14 and 21 to compare the osteogenic differentiation capability of both cell types. We found that ATSC expressed significantly higher ALP levels compared to BMSC throughout osteogenic differentiation. Calcium deposition was greater in ATSC than BMSC at days 7 and 14. By the end of day 21, BMSC produced greater calcium deposition. We found that ATSC undergo osteogenic differentiation more rapidly than BMSC, but BMSC provide greater mineralization over longer periods.
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Affiliation(s)
- Ozlem Ozden Akkaya
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Afyon Kocatepe University, Afyonkarahisar, Türkiye
| | - Tayfun Dikmen
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Afyon Kocatepe University, Afyonkarahisar, Türkiye
| | - Shah Nawaz
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Afyon Kocatepe University, Afyonkarahisar, Türkiye.,Department of Anatomy, Faculty of Veterinary Science, University of Agriculture, Faisalabad, Pakistan
| | - Asm Golam Kibria
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Afyon Kocatepe University, Afyonkarahisar, Türkiye.,Department of Anatomy and Histology, Chattogram University of Veterinary and Animal Sciences, Chattogram, Bangladesh
| | - Korhan Altunbaş
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Afyon Kocatepe University, Afyonkarahisar, Türkiye
| | - Artay Yağci
- Department of Histology and Embryology, Milas Veterinary Faculty, Mugla Sıtkı Kocman University, Mugla, Türkiye
| | - Metin Erdoğan
- Department of Veterinary Biology and Genetics, Faculty of Veterinary Medicine, Afyon Kocatepe University, Afyonkarahisar, Türkiye
| | - Mustafa Volkan Yaprakci
- Department of Surgery, Faculty of Veterinary Medicine, Afyon Kocatepe University, Afyonkarahisar, Türkiye
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Xie C, Wang C, Huang W, Huang Y, Li Q, Yu C, Yin D. Recombinant human bone morphogenetic protein is a valid alternative to autologous bone graft for long bone non-unions: a systematic review and meta-analysis. Surgeon 2023:S1479-666X(22)00134-2. [PMID: 36682906 DOI: 10.1016/j.surge.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 06/23/2022] [Accepted: 11/14/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To compare the efficacy of recombinant human bone morphogenetic proteins (rhBMPs) and autologous bone graft (ABG) on the healing of long bone non-union. METHODS A systematic literature search was conducted on PubMed, Web of Science, Cochrane Library, and CNKI up to December 2021. Two authors independently screened the studies, extracted data, and assessed the quality of the trials. A Meta-analysis was performed using state software (version 12.0). RESULTS A total of 14 studies were included in this meta-analysis. Overall, there was no significant difference between the rhBMPs group and the ABG group in terms of healing rate (RR = 1.04, 95% CI = 0.96-1.12, p = 0.365) and healing time (SMD = -0.31, 95% CI = -0.76-0.14, p = 0.175). Subgroup analysis showed rhBMPs lead to higher healing rates (RR = 1.35, 95% CI = 1.17-1.56, p < 0.001), and shorter healing time (SMD = -0.65, 95% CI = -1.08 to -0.22, p = 0.003) in the subgroup of moderate-quality studies. Sensitivity analysis proved that our conclusions were relatively robust. No significant publication bias was recognized in all studies (Begg's test, p = 0.193; Egger's test, p = 0.307). CONCLUSIONS RhBMPs or combined with allografts bone, inorganic bone was a valid alternative to ABG for the treatment of long bone non-union.
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Affiliation(s)
- Chengxin Xie
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Chenglong Wang
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Wenwen Huang
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Yu Huang
- Department of Traumatic Surgery & Microsurgery & Hand Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Qinglong Li
- Department of Traumatic Surgery & Microsurgery & Hand Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Chengqiang Yu
- Department of Spine Surgery, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
| | - Dong Yin
- Department of Joint Surgery and Sports Medicine, The People's Hospital of Guangxi Zhuang Autonomous Region & Guangxi Academy of Medical Sciences, 530021 Nanning, China.
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Abstract
Physiologic bone healing involves numerous parameters, such as microstability, fracture morphology, or tissue perfusion, to name just a few. Slight imbalances or a severe impairment of even one of these factors may, as the figurative weakest link in the chain, crucially or completely inhibit the regenerative potential of a fractured bone. This review revisits the physiology and pathophysiology of fracture healing and provides an insight into predispositions, subtypes, diagnostic tools, and therapeutic principles involved with delayed fracture healing and nonunions. Depending on the patients individual risk factors, nonunions may develop in a variety of subtypes, each of which may require a slightly or fundamentally different therapeutical approach. After a detailed analysis of these individual factors, additional diagnostic tools, such as magnetic resonance imaging (MRI), dynamic contrast-enhanced MRI, sonography, or contrast-enhanced ultrasonography, may be indicated to narrow down the most likely cause for the development of the nonunion and therefore help find and optimize the ideal treatment strategy.
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Affiliation(s)
- Paul Mick
- Center for Orthopedics, Heidelberg University Hospital, Heidelberg, Germany
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8
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Stolberg-Stolberg J, Fuchs T, Lodde MF, Roßlenbroich S, Garcia P, Raschke M, Everding J. Addition of shock wave therapy to nail dynamization increases the chance of long-bone non-union healing. J Orthop Traumatol 2022; 23:4. [PMID: 34997869 PMCID: PMC8742797 DOI: 10.1186/s10195-021-00620-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/26/2021] [Indexed: 01/15/2023] Open
Abstract
Background Long-bone non-unions after intramedullary nailing can be treated by nail dynamization or focused high-energy extracorporal shock wave therapy (fESWT). The objective of this study was to assess the effect of the combination therapy of nail dynamization and fESWT on long-bone non-unions. Materials and methods 49 patients with long-bone non-unions (femur and tibia) after nailing were treated with nail dynamization (group D, n = 15), fESWT (group S, n = 17) or nail dynamization in addition to fESWT (group DS, n = 17). Patients were followed up for 6 months retrospectively. Furthermore, age, sex, Non-Union Scoring System (NUSS) score, time intervals from primary and last surgery until intervention and smoking status were analysed for their correlations to bone union. Results Union rates were 60% for group D, 64.7% for group S and 88.2% for group DS, with a significant difference between group D and DS (p = 0.024). Successful treatment was correlated with high age (OR 1.131; 95% CI 1.009–1.268; p = 0.034), female gender (OR 0.009; 95% CI 0.000–0.89; p = 0.039), low NUSS score (OR 0.839; 95% CI 0.717–0.081; p = 0.028) and negative smoking status (OR 86.018; 95% CI 3.051–2425.038; p = 0.009). Conclusions Data from the present study indicate that the combination therapy of nail dynamization and fESWT leads to a higher union rate than dynamization or fESWT alone. Level of evidence Level 3.
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Affiliation(s)
- Josef Stolberg-Stolberg
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Thomas Fuchs
- Department of Trauma and Reconstructive Surgery, Vivantes Hospital Friedrichshain, Landsberger Allee 49, 10249, Berlin, Germany
| | - Moritz F Lodde
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Steffen Roßlenbroich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Patric Garcia
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
| | - Michael Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany.
| | - Jens Everding
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149, Muenster, Germany
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Wagner JM, Steubing Y, Dadras M, Wallner C, Lotzien S, Huber J, Sogorski A, Sacher M, Reinkemeier F, Dittfeld S, Becerikli M, Lehnhardt M, Behr B. Wnt3a and ASCs are capable of restoring mineralization in staph aureus-infected primary murine osteoblasts. J Bone Miner Metab 2022; 40:20-28. [PMID: 34562154 DOI: 10.1007/s00774-021-01269-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 08/23/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Bone infections are one of the main reasons for impaired bone regeneration and non-union formation. In previous experimental animal studies we could already demonstrate that bone defects due to prior infections showed a markedly reduced healing capacity, which could effectively be enhanced via application of Wnt3a and Adipose-derived stromal cells (ASCs). For a more in-depth analysis, we investigated proliferation and mineralization of cultured osteoblasts infected with staph aureus and sought to investigate effects of Wnt3a and ASCs on infected osteoblasts. MATERIALS AND METHODS Primary murine osteoblasts were isolated from calvariae and infected with staph aureus. Infected osteoblasts received treatment via application of recombinant Wnt3a, ASC conditioned medium and were furthermore cocultured with ASCs. Osteoblasts were evaluated by Alamar blue assay for metabolic activity, TUNEL-assay for apoptosis, ALP and Alizarin Red staining for mineralization. In addition, immunoflourescent staining (IF) and qRT-PCR analyses were performed. RESULTS Infected osteoblasts showed a markedly reduced ability for mineralization and increased apoptosis, which could be restored to physiological levels by Wnt3a and ASC treatment. Interestingly, metabolic activity of osteoblasts seemed to be unaffected by staph aureus infection. Additional analyses of Wnt-pathway activity revealed effective enhancement of canonical Wnt-pathway activity in Wnt3a-treated osteoblasts. CONCLUSIONS In summary, we gained further osteoblast-related insights into pathomechanisms of reduced bone healing capacity upon infections.
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Affiliation(s)
| | - Yonca Steubing
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Mehran Dadras
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Christoph Wallner
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Sebastian Lotzien
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Julika Huber
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Alexander Sogorski
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Maxi Sacher
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Felix Reinkemeier
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Stephanie Dittfeld
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Mustafa Becerikli
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Marcus Lehnhardt
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Björn Behr
- University Hospital BG Bergmannsheil Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
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Effect of Bone Morphogenetic Protein-2 in the Treatment of Long Bone Non-Unions. J Clin Med 2021; 10:jcm10194597. [PMID: 34640615 PMCID: PMC8509770 DOI: 10.3390/jcm10194597] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 01/15/2023] Open
Abstract
Background: Delayed fracture healing continues to cause significant patient morbidity and an economic burden to society. Biological stimulation of non-unions includes application of recombinant bone morphogenetic protein-2 (rhBMP-2). However, rhBMP-2 use continues to be a matter of controversy as literature shows scarce evidence for treatment effectiveness. Questions: The objective of this study was to evaluate the effectiveness of rhBMP-2 treatment on long bone non-unions measuring union rate and time to union. Furthermore, we assess risk factors for treatment failure. Methods and patients: A total of 91 patients with non-unions of long bones were treated with rhBMP-2 (n = 72) or standard care without BMP (n = 19) at our institution. Patient characteristics, comorbidities, nicotine consumption, and complications were recorded. Bone healing was assessed by plane X-rays and clinical examination. Patients were followed up with for 24 months. Results: Overall, there was significantly faster bone healing after rhBMP-2 application compared to the no-BMP group (p < 0.001; HR = 2.78; 95% CI 1.4–5.6). Union rates differed significantly between rhBMP-2 compared to the no-BMP group (89% vs. 47%; p < 0.001). At the humerus, there was neither a significantly higher union rate in the rhBMP-2 (83%) compared to the no-BMP group (50%) (p = 0.26; n = 12) nor a faster bone healing with a median time of 9 months in both groups (HR = 2.01; 95% CI 0.49–8.61; p = 0.315). The 33 femora treated using rhBMP-2 healed significantly faster than 9 femora in the no-BMP group (HR = 2.93; 95% CI 1.00–8.4; p = 0.023) with significant differences in union rate with 85% and 44%, respectively (p = 0.022). Regarding tibia non-unions, 25 out of 27 (93%) healed with a median of 9 months after rhBMP-2 application with no significant difference in the no-BMP group (33%) in time to union (p = 0.097) but a significantly higher union rate (p = 0.039). There was no effect of comorbidities, age, sex, soft tissue damage, or nicotine use on time to union, union rate, or secondary interventions. Conclusion: Consistent with the literature, overall, significantly higher union rates with reduced time to union were achieved after rhBMP-2 application. Femoral and tibial non-unions in particular seem to profit from rhBMP-2 application.
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Jayankura M, Schulz AP, Delahaut O, Witvrouw R, Seefried L, Berg BV, Heynen G, Sonnet W. Percutaneous administration of allogeneic bone-forming cells for the treatment of delayed unions of fractures: a pilot study. Stem Cell Res Ther 2021; 12:363. [PMID: 34174963 PMCID: PMC8235864 DOI: 10.1186/s13287-021-02432-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/06/2021] [Indexed: 01/15/2023] Open
Abstract
Background Overall, 5–10% of fractures result in delayed unions or non-unions, causing major disabilities and a huge socioeconomic burden. Since rescue surgery with autologous bone grafts can cause additional challenges, alternative treatment options have been developed to stimulate a deficient healing process. This study assessed the technical feasibility, safety and preliminary efficacy of local percutaneous implantation of allogeneic bone-forming cells in delayed unions of long bone fractures. Methods In this phase I/IIA open-label pilot trial, 22 adult patients with non-infected delayed unions of long bone fractures, which failed to consolidate after 3 to 7 months, received a percutaneous implantation of allogeneic bone-forming cells derived from bone marrow mesenchymal stem cells (ALLOB; Bone Therapeutics) into the fracture site (50 × 106 to 100 × 106 cells). Patients were monitored for adverse events and need for rescue surgery for 30 months. Fracture healing was monitored by Tomographic Union Score (TUS) and modified Radiographic Union Score. The health status was evaluated using the Global Disease Evaluation (GDE) score and pain at palpation using a visual analogue scale. The presence of reactive anti-human leukocyte antigen (HLA) antibodies was evaluated. Results During the 6-month follow-up, three serious treatment-emergent adverse events were reported in two patients, of which two were considered as possibly treatment-related. None of the 21 patients in the per-protocol efficacy population needed rescue surgery within 6 months, but 2/21 (9.5%) patients had rescue surgery within 30 months post-treatment. At 6 months post-treatment, an improvement of at least 2 points in TUS was reached in 76.2% of patients, the GDE score improved by a mean of 48%, and pain at palpation at the fracture site was reduced by an average of 61% compared to baseline. The proportion of blood samples containing donor-specific anti-HLA antibodies increased from 8/22 (36.4%) before treatment to 13/22 (59.1%) at 6 months post-treatment, but no treatment-mediated allogeneic immune reactions were observed. Conclusion This pilot study showed that the percutaneous implantation of allogeneic bone-forming cells was technically feasible and well tolerated in patients with delayed unions of long bone fractures. Preliminary efficacy evidence is supporting the further development of this treatment. Trial registration NCT02020590. Registered on 25 December 2013. ALLOB-DU1, A pilot Phase I/IIa, multicentre, open proof-of-concept study on the efficacy and safetyof allogeneic osteoblastic cells (ALLOB®) implantation in non-infected delayed-union fractures. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-021-02432-4.
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Affiliation(s)
- Marc Jayankura
- Service d'Orthopédie - Traumatologie, Cliniques Universitaires de Bruxelles - Université Libre de Bruxelles, Hôpital Erasme, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Arndt Peter Schulz
- Klinik für Orthopädie und Unfallchirurgie, Universität zu Lübeck, Ratzeburger Allee 160, 23568, Lübeck, Germany.,Labor für Biomechanik, BG Klinikum Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany.,Fraunhofer Research Institution for Individualized and Cell-Based Medical Engineering, Mönkhofer Weg 239 a, 23562, Lübeck, Germany
| | - Olivier Delahaut
- Service d'Orthopédie, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Richard Witvrouw
- Department of Traumatology and Orthopaedics, Oost-Limburg Hospital, Schiepse Bos 2, Genk, Belgium
| | - Lothar Seefried
- Orthopedic Department, University of Wuerzburg, Wuerzburg, Germany
| | - Bruno Vande Berg
- Service de Radiologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Guy Heynen
- Bone Therapeutics S.A., Gosselies, Belgium
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12
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Heinks T, Hettwer A, Hiepen C, Weise C, Gorka M, Knaus P, Mueller TD, Loidl-Stahlhofen A. Optimized expression and purification of a soluble BMP2 variant based on in-silico design. Protein Expr Purif 2021; 186:105918. [PMID: 34044133 DOI: 10.1016/j.pep.2021.105918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 04/11/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
Bone morphogenetic protein 2 (BMP21) is a highly interesting therapeutic growth factor due to its strong osteogenic/osteoinductive potential. However, its pronounced aggregation tendency renders recombinant and soluble production troublesome and complex. While prokaryotic expression systems can provide BMP2 in large amounts, the typically insoluble protein requires complex denaturation-renaturation procedures with medically hazardous reagents to obtain natively folded homodimeric BMP2. Based on a detailed aggregation analysis of wildtype BMP2, we designed a hydrophilic variant of BMP2 additionally containing an improved heparin binding site (BMP2-2Hep-7M). Consecutive optimization of BMP2-2Hep-7M expression and purification enabled production of soluble dimeric BMP2-2Hep-7M in high yield in E. coli. This was achieved by a) increasing protein hydrophilicity via introducing seven point mutations within aggregation hot spots of wildtype BMP2 and a longer N-terminus resulting in higher affinity for heparin, b) by employing E. coli strain SHuffle® T7, which enables the structurally essential disulfide-bond formation in BMP2 in the cytoplasm, c) by using BMP2 variant characteristic soluble expression conditions and application of l-arginine as solubility enhancer. The BMP2 variant BMP2-2Hep-7M shows strongly attenuated although not completely eliminated aggregation tendency.
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Affiliation(s)
- Tobias Heinks
- Westfälische Hochschule Recklinghausen, 45665, Recklinghausen, Germany.
| | - Anette Hettwer
- Westfälische Hochschule Recklinghausen, 45665, Recklinghausen, Germany; Universität Würzburg, Department for Molecular Plant Physiology and Biophysics - Botany I, Julius-von-Sachs Institute, 97082, Würzburg, Germany
| | - Christian Hiepen
- Freie Universität Berlin, Institute of Chemistry and Biochemistry, 14195, Berlin, Germany
| | - Christoph Weise
- Freie Universität Berlin, Institute of Chemistry and Biochemistry, 14195, Berlin, Germany
| | - Marcel Gorka
- Westfälische Hochschule Recklinghausen, 45665, Recklinghausen, Germany
| | - Petra Knaus
- Freie Universität Berlin, Institute of Chemistry and Biochemistry, 14195, Berlin, Germany
| | - Thomas D Mueller
- Universität Würzburg, Department for Molecular Plant Physiology and Biophysics - Botany I, Julius-von-Sachs Institute, 97082, Würzburg, Germany
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13
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Doll J, Streblow J, Weber MA, Schmidmaier G, Fischer C. The AMANDUS Project PART II-Advanced Microperfusion Assessed Non-Union Diagnostics with Contrast-Enhanced Ultrasound (CEUS): A Reliable Diagnostic Tool for the Management and Pre-operative Detection of Infected Upper-Limb Non-unions. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:478-487. [PMID: 33342619 DOI: 10.1016/j.ultrasmedbio.2020.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
Abstract
The management of upper-limb non-unions can be challenging, especially when infection is existent. Thus, pre-operative detection of infection plays a relevant role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for differentiating between aseptic and infected upper-limb non-unions. Osseous perfusion of 50 upper-extremity non-unions (radius/ulna, n = 20; humerus, n = 22; clavicle, n = 8) was prospectively assessed with CEUS before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (in arbitrary units). Significant perfusion differences between aseptic and infected non-unions could be detected (peak enhancement, p < 0.001). The sensitivity and specificity for the detection of infected upper-limb non-unions were 80% and 94.3% (cutoff peak enhancement: 130.8 arbitrary units). CEUS reliably differentiates between aseptic and infected upper-limb non-unions. Consequently, CEUS should be integrated into the daily diagnostic routine algorithm to plan non-union revision surgery more precisely as a single- or multi-step procedure.
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Affiliation(s)
- Julian Doll
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, HTRG-Heidelberg Trauma Research Group, Ultrasound Center, Heidelberg University Hospital, Heidelberg, Germany.
| | - Jan Streblow
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, HTRG-Heidelberg Trauma Research Group, Ultrasound Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany; Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerhard Schmidmaier
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, HTRG-Heidelberg Trauma Research Group, Ultrasound Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Fischer
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, HTRG-Heidelberg Trauma Research Group, Ultrasound Center, Heidelberg University Hospital, Heidelberg, Germany
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14
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Yousefi AM, Powers J, Sampson K, Wood K, Gadola C, Zhang J, James PF. In vitro characterization of hierarchical 3D scaffolds produced by combining additive manufacturing and thermally induced phase separation. JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 2021; 32:454-476. [PMID: 33091329 PMCID: PMC7965350 DOI: 10.1080/09205063.2020.1841535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Abstract
This paper reports on the hybrid process we have used for producing hierarchical scaffolds made of poly(lactic-co-glycolic) acid (PLGA) and nanohydroxyapatite (nHA), analyzes their internal structures via scanning electron microscopy, and presents the results of our in vitro proliferation of MC3T3-E1 cells and alkaline phosphatase activity (ALP) for 0 and 21 days. These scaffolds were produced by combining additive manufacturing (AM) and thermally induced phase separation (TIPS) techniques. Slow cooling at a rate of 1.5 °C/min during the TIPS process was used to enable a uniform temperature throughout the scaffolds, and therefore, a relatively uniform pore size range. We produced ten different scaffold compositions and topologies in this study. These scaffolds had macrochannels with diameters of ∼300 µm, ∼380 µm, and ∼460 µm, generated by the extraction of embedded porous 3D-plotted polyethylene glycol (PEG) matrices. The other experimental factors included different TIPS temperatures (-20 °C, -10 °C, and 0 °C), as well as varying PLGA concentrations (8%, 10%, and 12% w/v) and nHA content (0%, 10%, and 20% w/w). Our results indicated that almost all these macro/microporous scaffolds supported cell growth over the period of 21 days. Nevertheless, significant differences were observed among some scaffolds in terms of their support of cell proliferation and differentiation. This paper presents the results of our in vitro cell culture for 0 and 21 days. Our optimal scaffold with a porosity of ∼90%, a modulus of ∼5.2 MPa, and a nHA content of 20% showed a cell adhesion of ∼29% on day 0 and maintained cell proliferation and ALP activity over the 21-day in vitro culture. Hence, the use of additive manufacturing and designed experiments to optimize the scaffold fabrication parameters resulted in superior mechanical properties that most other studies using TIPS.
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Affiliation(s)
- Azizeh-Mitra Yousefi
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH 45056
| | - Joseph Powers
- Department of Biology, Miami University, Oxford, OH 45056
| | - Kaylie Sampson
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH 45056
| | - Katherine Wood
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH 45056
| | - Carter Gadola
- Department of Biology, Miami University, Oxford, OH 45056
| | - Jing Zhang
- Department of Statistics, Miami University, Oxford, OH 45056
| | - Paul F. James
- Department of Biology, Miami University, Oxford, OH 45056
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15
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Dai K, Shen T, Yu Y, Deng S, Mao L, Wang J, Liu C. Generation of rhBMP-2-induced juvenile ossicles in aged mice. Biomaterials 2020; 258:120284. [DOI: 10.1016/j.biomaterials.2020.120284] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/26/2020] [Accepted: 08/01/2020] [Indexed: 12/20/2022]
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16
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Zhou YQ, Tu HL, Duan YJ, Chen X. Comparison of bone morphogenetic protein and autologous grafting in the treatment of limb long bone nonunion: a systematic review and meta-analysis. J Orthop Surg Res 2020; 15:288. [PMID: 32727538 PMCID: PMC7391588 DOI: 10.1186/s13018-020-01805-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/16/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Bone morphogenetic proteins (BMPs) have strong bone induction properties and can promote healing of fractures and other defects. However, BMP treatment efficacy for long bone nonunion remains controversial. The aim of this meta-analysis was to synthetically evaluate the advantages and disadvantages of BMP plus bone grafting (observation group) versus autologous bone grafting (control group) for limb long bone nonunion. METHODS PubMed, Embase, Web of Science, Cochrane Library, OVID, CNKI, Weipu Journal, Chinese Biomedical Literature, and WanFang were searched for randomized and non-randomized controlled trials published before November 2019. A meta-analysis of outcome indicators was performed using RevMan 5.3 and Stata 12.0. RESULTS Five randomized and four non-randomized controlled trials involving 30-124 cases were included, with a total of 655 nonunion cases. There were no significant group differences in postoperative healing rate, infection, and secondary operation rates (P > 0.05), but the study group demonstrated significantly shorter mean healing time (WMD = - 1.27, 95%CI - 1.67 to - 0.88, P < 0.00001), a greater frequency of excellent/good post-treatment limb function (RR = 1.18, 95%CI 1.01-1.39, P = 0.04), and lower intraoperative blood loss (P < 0.05). Alternatively, the hospitalization cost was significantly higher in the study group (P < 0.01). CONCLUSIONS Bone morphogenetic protein is a viable alternative to autologous bone grafting, with potential advantages of accelerated fracture healing and improved postoperative function.
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Affiliation(s)
- Yong-Qiang Zhou
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China
| | - Hong-Liang Tu
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China
| | - Yan-Ji Duan
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China
| | - Xiao Chen
- The Department of Orthopedic Surgery, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China. .,The Department of Neonatology, The First People's Hospital of Neijiang, Neijiang, 641000, Sichuan, China.
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17
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Hong SJ, Oh SH, Lee SL, Kim NH, Choe YH, Yim HJ, Lee JH. Bone regeneration by bone morphogenetic protein-2 from porous beads with leaf-stacked structure for critical-sized femur defect model in dogs. J Biomater Appl 2020; 34:1437-1448. [PMID: 32122178 DOI: 10.1177/0885328220910033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Sung Jin Hong
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Se Heang Oh
- Department of nanobiomedical science, Dankook University, Yongin, Republic of Korea
| | - Sung Lim Lee
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Na-Hyun Kim
- Gyeongnam Department of Environment & Toxicology, Korea Institute of Toxicology, Munsan, Republic of Korea
| | - Yong Ho Choe
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Hyeong Jun Yim
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Jae-Hoon Lee
- Institute of Animal Medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
- Department of Veterinary medicine, College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
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18
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Wojda SJ, Marozas IA, Anseth KS, Yaszemski MJ, Donahue SW. Thiol-ene Hydrogels for Local Delivery of PTH for Bone Regeneration in Critical Size defects. J Orthop Res 2020; 38:536-544. [PMID: 31709588 DOI: 10.1002/jor.24502] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/14/2019] [Indexed: 02/04/2023]
Abstract
Neither allograft nor commercially available bone graft substitutes provide the same quality of bone healing as autograft. Incorporation of bioactive molecules like parathyroid hormone (PTH) within bone graft substitute materials may provide similar, if not better treatment options to grafting. The goal of this work was to develop a biomaterial system for the local delivery of PTH to large bone defects for promoting bone regeneration. PTH was loaded in a thiol-ene hydrogel at several concentrations and polymerized in and around an osteoconductive poly(propylene fumarate) (PPF) scaffold. PTH was shown to be bioactive when released from the hydrogel for up to 21 days. Eighty percent of the PTH was released by day 3 with the remaining 20% released by day 14. Bone healing was quantified in rat critical size femoral defects that were treated with hydrogel/PPF and 0, 1, 3, 10, or 30 µg of PTH. Although complete osseous healing was not observed in all samples in any one treatment group, all samples in the 10 µg PTH group were bridged fully by bone or a combination of bone and cartilage containing hypertrophic chondrocytes and endochondral ossification. Outcome measures indicated improved defect bridging by a combination of bony and cartilaginous tissue in the 10 μg treatment group compared with empty bone defects and defects treated with only hydrogel/PPF (i.e., without PTH). Given the tailorability of the hydrogel, future studies will investigate the effects of prolonged gradual PTH release on bone healing. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:536-544, 2020.
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Affiliation(s)
- Samantha J Wojda
- Department of Biomedical Engineering, University of Massachusetts Amherst, Amherst, Massachusetts
| | - Ian A Marozas
- Department of Chemical and Biological Engineering and the BioFrontiers Institute, University of Colorado, Boulder, Colorado
| | - Kristi S Anseth
- Department of Chemical and Biological Engineering and the BioFrontiers Institute, University of Colorado, Boulder, Colorado
| | | | - Seth W Donahue
- Department of Biomedical Engineering, University of Massachusetts Amherst, Amherst, Massachusetts
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19
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Doll J, Gross S, Weber MA, Schmidmaier G, Fischer C. The AMANDUS Project-Advanced Microperfusion Assessed Non-Union Diagnostics With Contrast-Enhanced Ultrasound (CEUS) for the Detection of Infected Lower Extremity Non-Unions. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2281-2288. [PMID: 31155406 DOI: 10.1016/j.ultrasmedbio.2019.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 06/09/2023]
Abstract
The pre-operative determination of infection plays a decisive role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for the differentiation between aseptic and infected non-unions. Of 109 patients with lower extremity non-unions (tibia n = 78, femur n = 31) osseous perfusion with CEUS was prospectively assessed before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (PE) (arbitrary unit [au]). Significant perfusion differences between aseptic and infected non-unions were evident (PE, p < 0.001). The sensitivity and specificity for the detection of infected tibial and femoral non-unions could be determined with 85.1% and 88.7% (cutoff PE: 81.2 au). CEUS illustrates tibial and femoral non-union perfusion in real time and discriminates reliably between aseptic and infected non-unions. Consequently, when CEUS is integrated into the diagnostic routine algorithm, non-union revision surgery can be planned more accurately as a single or multistep procedure.
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Affiliation(s)
- Julian Doll
- Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Ultrasound Center, HTRG - Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany
| | - Sascha Gross
- Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Ultrasound Center, HTRG - Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany; Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerhard Schmidmaier
- Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Ultrasound Center, HTRG - Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Fischer
- Center for Orthopaedics, Trauma Surgery and Spinal Cord Injury, Ultrasound Center, HTRG - Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany.
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20
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Bone allografts combined with adipose-derived stem cells in an optimized cell/volume ratio showed enhanced osteogenesis and angiogenesis in a murine femur defect model. J Mol Med (Berl) 2019; 97:1439-1450. [PMID: 31367858 DOI: 10.1007/s00109-019-01822-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/02/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023]
Abstract
Critical sized defects, especially in long bones, pose one of the biggest problems in orthopedic surgery. By definition, these defects do not heal without further treatment. Different therapeutic options range from autologous bone grafts, for example, free vascularized bone grafts, to commercially available bone allografts. Disadvantages of these bone allografts are related to reduced osteogenesis, since they are solely composed of cell-free bone matrix. The purpose of this study was to investigate the cell seeding efficiency of human adipose-derived stem cells (hASCs) on human bone allografts in vitro and furthermore analyze these optimized seeded allografts in a critical sized defect model in vivo. Cancellous human bone allografts were colonized with human ASCs in vitro. Cell seeding efficiency was evaluated by Cell Counting Kit-8 assay. Thereafter, optimized hASC-seeded bone scaffolds were examined in a murine femur defect model, stabilized with the MouseExFix system. Subsequently, x-ray analysis and histology were performed. Examination of cell seeding efficiency revealed an optimum starting population of 84,600 cells per 100 mm3 scaffold. In addition, scaffolds seeded with hASCs showed increased osteogenesis compared with controls. Histological analysis revealed increased remodeling and elevated new bone formation within hASC-seeded scaffolds. Moreover, immunohistochemical stainings revealed increased proliferation, osteogenesis, and angiogenesis. In this study, we systemically optimized cell/volume ratio of two promising components of tissue engineering: hASCs and human bone allografts. These findings may serve as a basis for future translational studies. KEY MESSAGES: Bone tissue engineering. Mesenchymal stem cells derived from human adipose tissue (hASCs). Optimal cell/volume ratio of cell-seeded scaffolds. Increased osteogenesis and angiogenesis in vivo.
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21
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A review of materials for managing bone loss in revision total knee arthroplasty. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 104:109941. [PMID: 31500053 DOI: 10.1016/j.msec.2019.109941] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/14/2019] [Accepted: 07/02/2019] [Indexed: 12/25/2022]
Abstract
In 2014-2015, 61,421 total knee arthroplasties (TKAs) were performed in Canada; an increase of about 20% over 2000-2001. Revision total knee arthroplasties (rTKAs) accounted for 6.8% of TKAs performed between 2014 and 2015, and this is estimated to grow another 12% by 2025. rTKAs are typically more complicated than primary TKAs due to the significant loss of femoral and tibial bone stock. The escalating demand and limitations associated with total knee arthroplasty and their revision drives the development of novel treatments. A variety of materials have been utilized to facilitate regeneration of healthy bone around the site of a knee arthroplasty. The selection of these materials is based on the bone defect size and includes bone grafts, graft substitutes and cements. However, all these materials have certain disadvantages such as blood loss, disease transmission (bone grafts), inflammatory response, insufficient mechanical properties (bone graft substitutes) thermal necrosis and stress shielding (bone cement). Recently, the use of metal augments for large bone defects has attracted attention, however they can undergo fretting, corrosion, and stress shielding. All things considered, this review indicates the necessity of developing augments that have structural integrities and biodegradation rates similar to that of human bone. Therefore, the future of bone loss management may lie in fabricating novel bioactive glass augments as they can promote bone healing and implant stability and can degrade with time.
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22
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Abstract
Non-union of bone following fracture is an orthopaedic condition with a high morbidity and clinical burden. Despite its estimated global prevalence of nine million annually, the limit of bone regeneration therapy still results in patients living with pain, a reduced quality of life and associated psychological, social and financial repercussions. This review provides an overview of the current epidemiological and aetiological data, and highlights where the clinical challenges in treating non-union lie. Current treatment strategies are discussed as well as promising future research foci. Development in biotechnologies to treat non-union provides exciting scope for more effective treatment for this debilitating condition.
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Affiliation(s)
- S K Stewart
- Department of Bioengineering, Imperial College London, United Kingdom
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23
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Morris R, Pallister I, Trickett RW. Measuring outcomes following tibial fracture. Injury 2019; 50:521-533. [PMID: 30482409 DOI: 10.1016/j.injury.2018.11.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023]
Abstract
AIM The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes. METHODS A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards. RESULTS A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture. CONCLUSION We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.
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Affiliation(s)
- R Morris
- Department of Trauma & Orthopaedics, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, SA6 6NL, UK
| | - I Pallister
- Department of Trauma & Orthopaedics, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, SA6 6NL, UK
| | - R W Trickett
- Department of Trauma & Orthopaedics, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, SA6 6NL, UK.
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Wojda SJ, Donahue SW. Parathyroid hormone for bone regeneration. J Orthop Res 2018; 36:2586-2594. [PMID: 29926970 DOI: 10.1002/jor.24075] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/18/2018] [Indexed: 02/04/2023]
Abstract
Delayed healing and/or non-union occur in approximately 5-10% of the fractures that occur annually in the United States. Segmental bone loss increases the probability of non-union. Though grafting can be an effective treatment for segmental bone loss, autografting is limited for large defects since a limited amount of bone is available for harvest. Parathyroid hormone (PTH) is a key regulator of calcium homeostasis in the body and plays an important role in bone metabolism. Presently PTH is FDA approved for use as an anabolic treatment for osteoporosis. The anabolic effect PTH has on bone has led to research on its use for bone regeneration applications. Numerous studies in animal models have indicated enhanced fracture healing as a result of once daily injections of PTH. Similarly, in a human case study, non-union persisted despite treatment attempts with internal fixation, external fixation, and autograft in combination with BMP-7, until off label use of PTH1-84 was utilized. Use of a biomaterial scaffold to locally deliver PTH to a defect site has also been shown to improve bone formation and healing around dental implants in dogs and drill defects in sheep. Thus, PTH may be used to promote bone regeneration and provide an alternative to autograft and BMP for the treatment of large segmental defects and non-unions. This review briefly summarizes the unmet clinical need for improved bone regeneration techniques and how PTH may help fill that void by both systemically and locally delivered PTH for bone regeneration applications. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2586-2594, 2018.
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Affiliation(s)
- Samantha J Wojda
- Department of Mechanical Engineering, Colorado State University, Fort Collins, Colorado
| | - Seth W Donahue
- Department of Biomedical Engineering, University of Massachusetts, Amherst, Massachusetts
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Abstract
PURPOSE OF REVIEW The development of therapeutics that target anabolic pathways involved in skeletogenesis is of great importance with regard to disease resulting in bone loss, or in cases of impaired bone repair. This review aims to summarize recent developments in this area. RECENT FINDINGS A greater understanding of how drugs that modulate signaling pathways involved in skeletogenesis exert their efficacy, and the molecular mechanisms resulting in bone formation has led to novel pharmacological bone repair strategies. Furthermore, crosstalk between pathways and molecules has suggested signaling synergies that may be exploited for enhanced tissue formation. The sequential pharmacological stimulation of the molecular cascades resulting in tissue repair is a promising strategy for the treatment of bone fractures. It is proposed that a therapeutic strategy which mimics the natural cascade of events observed during fracture repair may be achieved through temporal targeting of tissue repair pathways.
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Affiliation(s)
- Scott J Roberts
- Bone Therapeutic Area, UCB Pharma, 208 Bath Road, Slough, Berkshire, SL1 3WE, UK.
| | - Hua Zhu Ke
- Bone Therapeutic Area, UCB Pharma, 208 Bath Road, Slough, Berkshire, SL1 3WE, UK
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Scarpa E, Janeczek AA, Hailes A, de Andrés MC, De Grazia A, Oreffo RO, Newman TA, Evans ND. Polymersome nanoparticles for delivery of Wnt-activating small molecules. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2018; 14:1267-1277. [PMID: 29555223 DOI: 10.1016/j.nano.2018.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 02/05/2018] [Accepted: 02/24/2018] [Indexed: 01/02/2023]
Abstract
Spatiotemporal control of drug delivery is important for a number of medical applications and may be achieved using polymersome nanoparticles (PMs). Wnt signalling is a molecular pathway activated in various physiological processes, including bone repair, that requires precise control of activation. Here, we hypothesise that PMs can be stably loaded with a small molecule Wnt agonist, 6-bromoindirubin-3'-oxime (BIO), and activate Wnt signalling promoting the osteogenic differentiation in human primary bone marrow stromal cells (BMSCs). We showed that BIO-PMs induced a 40% increase in Wnt signaling activation in reporter cell lines without cytotoxicity induced by free BIO. BMSCs incubated with BIO-PMs showed a significant up-regulation of the Wnt target gene AXIN2 (14 ± 4 fold increase, P < 0.001) and a prolonged activation of the osteogenic gene RUNX2. We conclude that BIO-PMs could represent an innovative approach for the controlled activation of Wnt signaling for promoting bone regeneration after fracture.
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Affiliation(s)
- Edoardo Scarpa
- Centre for Human Development, Stem Cells and Regeneration, Bone and Joint Research Group, University of Southampton Faculty of Medicine, Southampton, United Kingdom; Institute for Life Sciences, Centre for Biological Sciences, B85, University Road, University of Southampton, Southampton, United Kingdom
| | - Agnieszka A Janeczek
- Centre for Human Development, Stem Cells and Regeneration, Bone and Joint Research Group, University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Alethia Hailes
- Centre for Human Development, Stem Cells and Regeneration, Bone and Joint Research Group, University of Southampton Faculty of Medicine, Southampton, United Kingdom; Institute for Life Sciences, Centre for Biological Sciences, B85, University Road, University of Southampton, Southampton, United Kingdom
| | - Maria C de Andrés
- Centre for Human Development, Stem Cells and Regeneration, Bone and Joint Research Group, University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Antonio De Grazia
- Centre for Human Development, Stem Cells and Regeneration, Bone and Joint Research Group, University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Richard Oc Oreffo
- Centre for Human Development, Stem Cells and Regeneration, Bone and Joint Research Group, University of Southampton Faculty of Medicine, Southampton, United Kingdom; Institute for Life Sciences, Centre for Biological Sciences, B85, University Road, University of Southampton, Southampton, United Kingdom
| | - Tracey A Newman
- Institute for Life Sciences, Centre for Biological Sciences, B85, University Road, University of Southampton, Southampton, United Kingdom; Clinical and Experimental Sciences, Medicine, University of Southampton, Southampton, United Kingdom.
| | - Nicholas D Evans
- Centre for Human Development, Stem Cells and Regeneration, Bone and Joint Research Group, University of Southampton Faculty of Medicine, Southampton, United Kingdom; Institute for Life Sciences, Centre for Biological Sciences, B85, University Road, University of Southampton, Southampton, United Kingdom; Bioengineering Sciences Group, Faculty of Engineering and the Environment, University of Southampton, Highfield, Southampton, United Kingdom.
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Krishnakumar GS, Roffi A, Reale D, Kon E, Filardo G. Clinical application of bone morphogenetic proteins for bone healing: a systematic review. INTERNATIONAL ORTHOPAEDICS 2017; 41:1073-1083. [PMID: 28424852 DOI: 10.1007/s00264-017-3471-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/23/2017] [Indexed: 01/28/2023]
Abstract
PURPOSE This paper documents the existing evidence on bone morphogenetic proteins (BMPs) use for the treatment of bone fractures, non-union, and osteonecrosis, through a review of the clinical literature, underlying potential and limitations in terms of cost effectiveness and risk of complications. METHODS A systematic review was performed on the PubMed database using the following string: (bone morphogenetic proteins OR BMPs) and (bone repair OR bone regeneration) including papers from 2000 to 2016. The search focused on clinical trials dealing with BMPs application to favor bone regeneration in bone fractures, non-union, and osteonecrosis, in English language, with level of evidence I, II, III, and IV. Relevant data (type of study, number of patients, BMPs delivery material, dose, site, follow-up, outcome, and adverse events) were extracted and analyzed. RESULTS Forty-four articles met the inclusion criteria: 10 randomized controlled trials (RCTs), 7 comparative studies, 18 case series, and 9 case reports. rhBMP-2 was documented mainly for the treatment of fractures, and rhBMP-7 mainly for non-unions and osteonecrosis. Mixed results were found among RCTs and comparative papers: 11 reported positive results for BMPs augmentation, 3 obtained no significant effects, and 2 showed negative results. The only study comparing the two BMPs showed a better outcome with rhBMP-2 for non-union treatment. CONCLUSION Clinical evidence on BMPs use for the treatment of fractures, non-union, and osteonecrosis is still controversial, with the few available reports being mainly of low quality. While positive findings have been described in many studies, mixed results are still present in the literature in terms of efficacy and adverse events. The difficulties in drawing clear conclusions are also due to the studies heterogeneity, mainly in terms of different BMPs applied, with different concomitant treatments for each bone pathology. Therefore, further research with well-designed studies is needed in order to understand the real potential of this biological approach to favour bone healing.
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Affiliation(s)
- Gopal Shankar Krishnakumar
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136, Bologna, Italy
| | - Alice Roffi
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136, Bologna, Italy.
| | - Davide Reale
- I Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Pupilli 1, 40136, Bologna, Italy
| | - Elizaveta Kon
- Knee Joint Reconstruction Center - 3rd Orthopaedic Division, Humanitas Clinical Institute, Via Alessandro Manzoni 56, Rozzano, Italy
| | - Giuseppe Filardo
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136, Bologna, Italy
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Mesenchymal stem cells from reaming material possess high osteogenic potential and react sensitively to bone morphogenetic protein 7. J Appl Biomater Funct Mater 2017; 15:e54-e62. [PMID: 28009419 DOI: 10.5301/jabfm.5000333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Femoral material harvested using the Reamer-Irrigator-Aspirator (RIA) system is an alternative source for autogenous bone material in the treatment of non-unions, especially in combination with bone morphogenetic proteins (BMP). So far, there is no in vivo evidence of BMP-7 interacting with mesenchymal stem cells (MSCs) from RIA material (RIA-MSCs) and iliac crest autogenous bone (BMSCs). The aim of this study was to compare their osteogenic potential when stimulated with BMP-7 in vivo. METHODS RIA-MSC and BMSC from 11 donors were isolated and the character of MSCs was investigated in vitro. Constructs consisting of MSC, β-tricalcium phosphate and 2 concentrations of BMP-7 (0.1 µg/mL and 1 µg/mL) were implanted in mice for 8 weeks. Bone formation in the constructs was analyzed quantitatively and qualitatively. RESULTS All cell populations used were determined to be MSCs. The qualitative in vivo analysis showed formation of bone tissue. With regard to quantity, bone formation was significantly higher in RIA constructs without or with stimulation with 0.1 µg/mL BMP-7, compared with BMSC constructs. We found no significant differences between constructs stimulated with 1 µg/mL BMP-7. In the RIA group, we observed a significant increase in bone formation after stimulation with 0.1 µg/mL BMP-7. No significant change could be found using a higher concentration. In the BMSC group, we detected a significant increase when using 0.1 µg/mL and 1 µg/mL BMP-7. CONCLUSIONS RIA material is a source of MSCs with high osteogenic potential. Our results showed that stimulation by BMP-7 leads to an increased osteogenic potential of MSCs. In this respect, RIA-MSCs reacted more sensitively than BMSCs.
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Haubruck P, Kammerer A, Korff S, Apitz P, Xiao K, Büchler A, Biglari B, Zimmermann G, Daniel V, Schmidmaier G, Moghaddam A. The treatment of nonunions with application of BMP-7 increases the expression pattern for angiogenic and inflammable cytokines: a matched pair analysis. J Inflamm Res 2016; 9:155-165. [PMID: 27703392 PMCID: PMC5036623 DOI: 10.2147/jir.s110621] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The local application of bone morphogenetic protein-7 (BMP-7) in combination with the transplantation of autologous bone graft improves the outcome in nonunion treatment; however, the specific reasons remain unclear. In this study, we sought to determine if the local application of BMP-7 contributes to improved bone regeneration in nonunion therapy by modulation of the angiogenic and inflammable cytokine expression patterns of the early inflammation response. Therefore, we utilized the analysis of serological cytokine expression patterns. As a matched pair analysis, best-fitting patients who were treated with transplantation of autologous bone graft (G1, n=10) were compared with patients who were treated with additional application of BMP-7 (G2, n=10). The changes in the cytokine expression patterns were monitored and correlated to clinical data of bone healing. Significant differences in angiogenesis potential (vascular endothelial growth factor [VEGF] serum levels) could be found in the first days after surgery (P<0.05). Furthermore, the increase and absolute amount of VEGF levels in the BMP-7 group were considerably higher than in the control group during the first 2 weeks after surgery. The expression pattern of inflammable cytokines showed noticeable differences in the time point of significant elevated levels, in particular, inflammable cytokines showed an earlier peak in G2. Furthermore, interleukin-6 was significantly elevated within the first week only, comparing G2 to G1 (P<0.05). Our findings indicate that BMP-7 induces an early and more intense expression of VEGF via a direct and postulated indirect pathway, thereby providing a favorable environment for bone healing. Moreover, application of BMP-7 leads to an earlier expression of known proinflammatory cytokines. The results of this study show that application of BMP-7 leads to costimulatory effect on both angiogenic and inflammable cytokine expression patterns that may serve as a possible stimulus for bone regeneration.
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Affiliation(s)
- Patrick Haubruck
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, HTRG - Heidelberg Trauma Research Group, Heidelberg, Germany
| | - Andreas Kammerer
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, HTRG - Heidelberg Trauma Research Group, Heidelberg, Germany
| | - Sebastian Korff
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, HTRG - Heidelberg Trauma Research Group, Heidelberg, Germany
| | - Philipp Apitz
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, HTRG - Heidelberg Trauma Research Group, Heidelberg, Germany
| | - Kai Xiao
- Department of Orthopedics Wuhan, Wuhan Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Axel Büchler
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, HTRG - Heidelberg Trauma Research Group, Heidelberg, Germany
| | - Bahram Biglari
- Department of Paraplegiology, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Ludwigshafen
| | - Gerald Zimmermann
- Department for Trauma Surgery, Theresienkrankenhaus und St. Hedwigs-Klinik GmbH, Mannheim
| | - Volker Daniel
- Department of Transplantation Immunology, Institute of Immunology, University of Heidelberg, Heidelberg, Germany
| | - Gerhard Schmidmaier
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, HTRG - Heidelberg Trauma Research Group, Heidelberg, Germany
| | - Arash Moghaddam
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Trauma and Reconstructive Surgery, Heidelberg University Hospital, HTRG - Heidelberg Trauma Research Group, Heidelberg, Germany
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Influence of implant properties and local delivery systems on the outcome in operative fracture care. Injury 2016; 47:595-604. [PMID: 26847958 DOI: 10.1016/j.injury.2016.01.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 01/15/2016] [Indexed: 02/02/2023]
Abstract
Fracture fixation devices are implanted into a growing number of patients each year. This may be attributed to an increase in the popularity of operative fracture care and the development of ever more sophisticated implants, which may be used in even the most difficult clinical cases. Furthermore, as the general population ages, fragility fractures become more frequent. With the increase in number of surgical interventions, the absolute number of complications of these surgical treatments will inevitably rise. Implant-related infection and compromised fracture healing remain the most challenging and prevalent complications in operative fracture care. Any strategy that can help to reduce these complications will not only lead to a faster and more complete resumption of activities, but will also help to reduce the socio-economic impact. In this review we describe the influence of implant design and material choice on complication rates in trauma patients. Furthermore, we discuss the importance of local delivery systems, such as implant coatings and bone cement, and how these systems may have an impact on the prevalence, prevention and treatment outcome of these complications.
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Giannoudis PV, Gudipati S, Harwood P, Kanakaris NK. Long bone non-unions treated with the diamond concept: a case series of 64 patients. Injury 2015; 46 Suppl 8:S48-54. [PMID: 26747919 DOI: 10.1016/s0020-1383(15)30055-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the "diamond concept". Over a 4-year period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria were hypertrophic, pathological, and infected non-unions. Fixation was revised as it was indicated whilst biological enhancement included the implantation of RIA graft, BMP-7 and concentrated bone marrow aspirate. Data recorded included patient demographics, initial fracture pattern and type of stabilisation, number of previous interventions, time to reoperation, time to union and functional outcome. Painless full weight bearing defined clinical union. Radiological union was defined as the presence of mature callous bridging to at least 3 bone cortices. The minimum follow up was 12 months (range 12-32). In total 64 patients (34 males) with a mean age of 45 years (17-83) were evaluated. Anatomical distribution of non-unions included the femur (54.68%), tibia (34.38%), humerus (4.68%), radius (3.13%) and clavicle (3.13%). The median number of previous interventions was 1 (range 1-5). The majority of patients (82.62%) underwent revision of fixation whereas only bone grafting was performed 9.38% of patients. Three patients developed superficial wound infection (one was MRSA), 1 had deep vein thrombosis and 1 developed heterotopic bone formation. Union was successful in 63/64 (98.4%) non-unions at a mean time of 6 months (range 3-12). All patients were mobilising pain free and returned to their daily living activities at the final follow up. The application of the "diamond concept" in this cohort of patients was associated with a high union rate by providing an optimal mechanical and biological environment. Such an approach should be considered in the surgeon's armamentarium particularly in such cases where difficulty of bone repair is foreseen.
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Affiliation(s)
- Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK.
| | - Suri Gudipati
- Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK
| | - Paul Harwood
- Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK
| | - Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, Floor A, Clarendon Wing, LGI, University of Leeds, Leeds, UK
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Helbig L, Guehring T, Rosenberger S, Ivanova A, Kaeppler K, Fischer CA, Moghaddam A, Schmidmaier G. A new animal model for delayed osseous union secondary to osteitis. BMC Musculoskelet Disord 2015; 16:362. [PMID: 26585516 PMCID: PMC4653915 DOI: 10.1186/s12891-015-0816-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/12/2015] [Indexed: 12/03/2022] Open
Abstract
Background The treatment of infection-related delayed bone unions is still very challenging for the orthopedic surgeon. The prevalence of such infection-related types of osteitis is high in complex fractures, particularly in open fractures with extensive soft-tissue damage. The aim of this study was to develop a new animal model for delayed union due to osteitis. Methods After randomization to infected or non-infected groups 20 Sprague–Dawley rats underwent a transverse fracture of the midshaft tibia. After intramedullary inoculation with staphylococcus aureus (103 CFU) fracture stabilization was done by intramedullary titanium K-wires. After 5 weeks all rats were euthanized and underwent biomechanical testing to evaluate bone consolidation or delayed union, respectively. Micro-CT scans were additionally used to quantitatively evaluate the callus formation by the score of Lane and Sandhu. Blood samples were taken to analyze infectious disease markers (day 1, 14 and 35). Results Biomechanical testing showed a significant higher maximum torque in the non-infected group 5 weeks postoperatively compared with the infected group (p < 0.001). According to the Lane and Sandhu score a significantly higher callus formation was found in the non-infected group (p < 0.001). Similarly, the leucocyte count in the infected group was significantly higher than in the non-infected group (p < 0.05). Conclusions Here we have established a new animal model for delayed osseous union secondary to osteitis. The animal model appears to be appropriate for future experimental studies to test new therapeutic strategies in these difficult to treat bone healing complications.
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Affiliation(s)
- Lars Helbig
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Thorsten Guehring
- Klinik für Unfallchirurgie und Orthopädie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany.
| | - Svenja Rosenberger
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Adriana Ivanova
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Kathrin Kaeppler
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Christian Alexander Fischer
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Arash Moghaddam
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Gerhard Schmidmaier
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
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Bone Morphogenetic Protein for the Healing of Tibial Fracture: A Meta-Analysis of Randomized Controlled Trials. PLoS One 2015; 10:e0141670. [PMID: 26509264 PMCID: PMC4624800 DOI: 10.1371/journal.pone.0141670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 10/12/2015] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To review the evidence from RCTs on clinical outcomes and benefit of acute tibial fracture and nonunion treated with and without BMPs. MATERIAL We searched multiple databases (MEDLINE, EMABSE, BIOSIS and Cochrane central) as well as reference lists of articles and contacted authors. Evaluated outcomes included union rate, revision rate, hardware failure and infection. The weighted and standard mean difference (WMD and SMD) or the relative risk (RR) was calculated for continuous or dichotomous data respectively. The quality of the trial was assessed, and meta-analyses were performed with the Cochrane Collaboration's REVMAN 5.0 software. RESULTS Eight RCTs involving 1113 patients were included. For acute tibial fracture, BMP group was associated with a higher rate of union (RR, 1.16; 95% CI, 1.04 to 1.30) and a lower rate of revision (RR, 0.68; 95% CI, 0.54 to 0.85) compared with control group. No significant differences were found in rate of hardware failure and infection. The pooled RR for achieving union for tibial fracture nonunion was 0.98 (95% CI, 0.86 to 1.13). There was no significant difference between the two groups in the rate of revision (RR, 0.48; 95% CI, 0.13 to 1.85) and infection (RR, 0.61; 95% CI, 0.37 to 1.02). CONCLUSION Study on acute tibial fractures suggests that BMP is more effective that controls, for bone union and for decreasing the rate of surgical revision to achieve union. For the treatment of tibial fracture nonunion, BMP leads to similar results to as autogenous bone grafting. Finally, well-designed RCTs of BMP for tibial fracture treatment are also needed.
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Papanagiotou M, Dailiana ZH, Karachalios T, Varitimidis S, Vlychou M, Hantes M, Malizos KN. RhBMP-7 for the treatment of nonunion of fractures of long bones. Bone Joint J 2015; 97-B:997-1003. [PMID: 26130359 DOI: 10.1302/0301-620x.97b7.35089] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients' quality of life was estimated using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union.
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Affiliation(s)
- M Papanagiotou
- University of Thessalia, 3 Panepistimiou Street, Biopolis 41500 Larissa, Greece
| | - Z H Dailiana
- University of Thessalia, 3 Panepistimiou Street, Biopolis 41500 Larissa, Greece
| | - T Karachalios
- University of Thessalia, 3 Panepistimiou Street, Biopolis 41500 Larissa, Greece
| | - S Varitimidis
- University of Thessalia, 3 Panepistimiou Street, Biopolis 41500 Larissa, Greece
| | - M Vlychou
- University of Thessalia, 3 Panepistimiou Street, Biopolis 41500 Larissa, Greece
| | - M Hantes
- University of Thessalia, 3 Panepistimiou Street, Biopolis 41500 Larissa, Greece
| | - K N Malizos
- University of Thessalia, 3 Panepistimiou Street, Biopolis 41500 Larissa, Greece
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Westhauser F, Zimmermann G, Moghaddam S, Bruckner T, Schmidmaier G, Biglari B, Moghaddam A. Reaming in treatment of non-unions in long bones: cytokine expression course as a tool for evaluation of non-union therapy. Arch Orthop Trauma Surg 2015; 135:1107-16. [PMID: 26085339 DOI: 10.1007/s00402-015-2253-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Indexed: 11/29/2022]
Abstract
UNLABELLED The analysis of peripheral serum cytokine expression patterns has been shown to be a possible method for demonstrating changes in bone metabolism. The aim of this study is to evaluate the effectiveness of this method within the treatment of long bone non-union with intramedullary reaming, a well-established non-union treatment concept. MATERIALS AND METHODS Three groups were added to this study: group one (G1) suffered from long bone non-unions, treated successfully with intramedullary reaming; group two (G2) consisted of long bone fractures with proper fracture healing; and group three (G3) included long bone fractures resulting in non-unions. We took blood samples on day 2, and after week 1, 4, 6, month 3 and 6 after initial treatment. Clinical and radiological follow-up were provided for 6 months. We measured transforming growth factor ß-1 (TGFß-1), platelet-derived growth factor (PDGF-AB), and insulin like growth factor-1 (IGF-1) at all-time points. RESULTS TGF-ß1 levels in G1 and G2 increased from day 2 to 6 weeks after surgery. In general, G1 and G2 showed parallel TGF-ß1 expression patterns, and G3 had a significant peak during first week compared to G1 (p = 0.023). PDGF peaked in G3 during first week after treatment, whereas G1 had its maximum after 4 weeks and G2 after 6 weeks. We were able to detect a significantly lower PDGF concentration at 3 months in G1 compared to G3 (p = 0.029). IGF-1 showed a peak concentration in G1 during the first 4 weeks. Afterwards, concentration levels in both G1 and G2 were higher. CONCLUSIONS Our study was able to show that the cytokine expression pattern in physiological bone healing is similar to that in successful non-union treatment with intramedullary reaming. Our results show that the effect of non-union therapy could be observed objectively by measuring cytokine expression patterns in peripheral blood even in a small group of patients.
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Affiliation(s)
- Fabian Westhauser
- Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, HTRG-Heidelberg Trauma Research Group, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
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Samorezov JE, Alsberg E. Spatial regulation of controlled bioactive factor delivery for bone tissue engineering. Adv Drug Deliv Rev 2015; 84:45-67. [PMID: 25445719 PMCID: PMC4428953 DOI: 10.1016/j.addr.2014.11.018] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 11/21/2014] [Accepted: 11/24/2014] [Indexed: 12/29/2022]
Abstract
Limitations of current treatment options for critical size bone defects create a significant clinical need for tissue engineered bone strategies. This review describes how control over the spatiotemporal delivery of growth factors, nucleic acids, and drugs and small molecules may aid in recapitulating signals present in bone development and healing, regenerating interfaces of bone with other connective tissues, and enhancing vascularization of tissue engineered bone. State-of-the-art technologies used to create spatially controlled patterns of bioactive factors on the surfaces of materials, to build up 3D materials with patterns of signal presentation within their bulk, and to pattern bioactive factor delivery after scaffold fabrication are presented, highlighting their applications in bone tissue engineering. As these techniques improve in areas such as spatial resolution and speed of patterning, they will continue to grow in value as model systems for understanding cell responses to spatially regulated bioactive factor signal presentation in vitro, and as strategies to investigate the capacity of the defined spatial arrangement of these signals to drive bone regeneration in vivo.
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Affiliation(s)
- Julia E Samorezov
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Eben Alsberg
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA; Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, OH, USA; National Center for Regenerative Medicine, Division of General Medical Sciences, Case Western Reserve University, Cleveland, OH, USA.
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Pountos I, Panteli M, Georgouli T, Giannoudis PV. Neoplasia following use of BMPs: is there an increased risk? Expert Opin Drug Saf 2014; 13:1525-34. [DOI: 10.1517/14740338.2014.968124] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Courvoisier A, Sailhan F, Laffenêtre O, Obert L. Bone morphogenetic protein and orthopaedic surgery: can we legitimate its off-label use? INTERNATIONAL ORTHOPAEDICS 2014; 38:2601-5. [PMID: 25267430 DOI: 10.1007/s00264-014-2534-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/09/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE Bone morphogenetic proteins (BMP) are recombinant osteoinductive proteins with their primary role being to promote bone formation. The off-label use of BMP in orthopaedic surgery has dramatically increased. However, reports of complications with BMP have emerged, and the safety of these proteins in orthopaedics is questioned. The purpose of this review was to evaluate safe situations in which BMP should be used and situations in which their use should be restricted. METHOD We recorded all studies from PubMed database from 2002 (date of first authorisation for both BMPs) until January 2014 using "BMP" or "bone morphogenetic protein". Then we screened and extracted all studies dealing with orthopaedic surgery. All situations in which BMP were used, even cases reports, were considered, and complications reported were then listed. RESULTS Situations in which it seems safe and efficient to use BMP are long-bone nonunions, or arthrodesis as an alternative or combined to autograft in small-bone loss. Surgeons and patients should be aware of transient aseptic wound swelling when BMP is located superficially. The use of BMP in spine surgery for intersomatic fusion is efficient but should be restricted to approaches that respect the vertebral canal to avoid neurological complications. CONCLUSION This review is an off-label map of BMP use in orthopaedics during the past 10 years. Our results could provide a useful tool to help decisions around when to use a BMP in a specific complex, and sometimes off-label, situation.
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Affiliation(s)
- Aurélien Courvoisier
- Pediatric Orthopedic Department. Grenoble University Hospital, Grenoble Alpes University, BP 217, 38043, Grenoble Cedex 09, France,
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Oryan A, Alidadi S, Moshiri A, Bigham-Sadegh A. Bone morphogenetic proteins: a powerful osteoinductive compound with non-negligible side effects and limitations. Biofactors 2014; 40:459-81. [PMID: 25283434 DOI: 10.1002/biof.1177] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/21/2014] [Accepted: 07/26/2014] [Indexed: 12/29/2022]
Abstract
Healing and regeneration of large bone defects leading to non-unions is a great concern in orthopedic surgery. Since auto- and allografts have limitations, bone tissue engineering and regenerative medicine (TERM) has attempted to solve this issue. In TERM, healing promotive factors are necessary to regulate the several important events during healing. An ideal treatment strategy should provide osteoconduction, osteoinduction, osteogenesis, and osteointegration of the graft or biomaterials within the healing bone. Since many materials have osteoconductive properties, only a few biomaterials have osteoinductive properties which are important for osteogenesis and osteointegration. Bone morphogenetic proteins (BMPs) are potent inductors of the osteogenic and angiogenic activities during bone repair. The BMPs can regulate the production and activity of some growth factors which are necessary for the osteogenesis. Since the introduction of BMP, it has added a valuable tool to the surgeon's possibilities and is most commonly used in bone defects. Despite significant evidences suggesting their potential benefit on bone healing, there are some evidences showing their side effects such as ectopic bone formation, osteolysis and problems related to cost effectiveness. Bone tissue engineering may create a local environment, using the delivery systems, which enables BMPs to carry out their activities and to lower cost and complication rate associated with BMPs. This review represented the most important concepts and evidences regarding the role of BMPs on bone healing and regeneration from basic to clinical application. The major advantages and disadvantages of such biologic compounds together with the BMPs substitutes are also discussed.
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Affiliation(s)
- Ahmad Oryan
- Department of Pathology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
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Ma J, Yang F, Both SK, Prins HJ, Helder MN, Pan J, Cui FZ, Jansen JA, van den Beucken JJ. Bone forming capacity of cell- and growth factor-based constructs at different ectopic implantation sites. J Biomed Mater Res A 2014; 103:439-50. [DOI: 10.1002/jbm.a.35192] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/14/2014] [Accepted: 04/04/2014] [Indexed: 12/29/2022]
Affiliation(s)
- Jinling Ma
- Department of Biomaterials; Radboud University Medical Centre; Nijmegen the Netherlands
- Department of VIP service; Beijing Stomatological Hospital, Capital Medical University; Beijing 100050 China
| | - Fang Yang
- Department of Biomaterials; Radboud University Medical Centre; Nijmegen the Netherlands
| | - Sanne K. Both
- Department of Biomaterials; Radboud University Medical Centre; Nijmegen the Netherlands
| | - Henk-Jan Prins
- Department of Oral Cell Biology; Academic Centre for Dentistry Amsterdam; University of Amsterdam and VU University Amsterdam; Amsterdam the Netherlands
- Department of Oral and Maxillofacial Surgery; VU University Medical Centre/ACTA; Amsterdam the Netherlands
| | - Marco N. Helder
- Department of Orthopedic Surgery; VU University Medical Centre; Amsterdam the Netherlands
| | - Juli Pan
- Department of VIP service; Beijing Stomatological Hospital, Capital Medical University; Beijing 100050 China
- Department of Oral and Maxillofacial Surgery; Beijing Stomatological Hospital, Capital Medical University; Beijing 100050 China
| | - Fu-Zhai Cui
- Department of Materials Science and Engineering; State Key Laboratory of New Ceramics and Fine Processing; Tsinghua University; Beijing 100084 China
| | - John A. Jansen
- Department of Biomaterials; Radboud University Medical Centre; Nijmegen the Netherlands
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Cost effectiveness of tibial nonunion treatment: A comparison between rhBMP-7 and autologous bone graft in two Italian centres. Injury 2013; 44:1871-9. [PMID: 24074829 DOI: 10.1016/j.injury.2013.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 08/05/2013] [Accepted: 08/10/2013] [Indexed: 02/02/2023]
Abstract
Current evidences show that recombinant human bone morphogenetic protein 7 (rhBMP-7, eptotermin alfa) can be considered an effective alternative to autologous bone graft (ABG) in the treatment of tibial nonunions. Few studies, so far, have analysed the costs of treating tibial nonunions with either rhBMP-7 or ABG and none of them has specifically considered the Italian situation. The aim of the present study was to capture, through observational retrospective methods, the direct medical costs associated with the treatment of tibial nonunions with rhBMP-7 or ABG in Italy and to compare the cost effectiveness of the two interventions. The secondary objective was to perform a cost-reimbursement analysis for hospitalisations associated with the two treatments. Data of 54 patients with indication for tibial nonunion were collected from existing data sources. Of these patients, 26 were treated with ABG and 28 with rhBMP-7. The study captured the direct medical costs for treating each tibial nonunion, considering both inpatient and outpatient care. The hospital reimbursement was calculated from discharge registries, based on diagnosis-related group (DRG) values. A subgroup of patients (n=30) was also interviewed to capture perceived health during the follow-up, and the quality-adjusted life years (QALYs) were subsequently computed. The two groups were similar for what concerns baseline characteristics. While the medical costs incurred during the hospitalisation associated with treatment were on average €3091.21 higher (P<0.001) in patients treated with rhBMP-7 (reflecting the product procurement costs), the costs incurred during the follow-up were on average €2344.45 higher (P=0.02) in patients treated with ABG. Considering all costs incurred from the treatment, there was a borderline statistical evidence (P=0.04) for a mean increase of €795.42, in the rhBMP-7 group. Furthermore, the study demonstrated that, without appropriate reimbursement, the hospital undergoes significant losses (P=0.003) when using rhBMP-7 instead of ABG. In contrast to these losses, in Italy, the average cost to achieve a successful outcome was €488.96 lower in patients treated with rhBMP-7 and, additionally, the cost per QALY gained was below the cost-utility threshold of $50,000.
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Steinhausen E, Glombitza M, Böhm HJ, Hax PM, Rixen D. Pseudarthrosen. Unfallchirurg 2013; 116:633-47; quiz 648-9. [DOI: 10.1007/s00113-013-2413-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Zimmer J, Degenkolbe E, Wildemann B, Seemann P. BMP Signaling in Regenerative Medicine. Bioinformatics 2013. [DOI: 10.4018/978-1-4666-3604-0.ch064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
More than 40 years after the discovery of Bone Morphogenetic Proteins (BMPs) as bone inducers, a whole protein family of growth factors connected to a wide variety of functions in embryonic development, homeostasis, and regeneration has been characterized. Today, BMP2 and BMP7 are already used in the clinic to promote vertebral fusions and restoration of non-union fractures. Besides describing present clinical applications, the authors review ongoing trials highlighting the future possibilities of BMPs in medicine. Apparently, the physiological roles of BMPs have expanded their range from bone growth induction and connective tissue regeneration to cancer diagnosis/treatment and cardiovascular disease prevention.
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Affiliation(s)
- Julia Zimmer
- Charité-Universitätsmedizin Berlin, Berlin-Brandenburg Center for Regenerative Therapies, Germany
| | - Elisa Degenkolbe
- Charité-Universitätsmedizin Berlin, Berlin-Brandenburg Center for Regenerative Therapies, Germany
| | - Britt Wildemann
- Charité-Universitätsmedizin Berlin, Berlin-Brandenburg Center for Regenerative Therapies, Germany
| | - Petra Seemann
- Charité-Universitätsmedizin Berlin, Berlin-Brandenburg Center for Regenerative Therapies, Germany
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Human endothelial-like differentiated precursor cells maintain their endothelial characteristics when cocultured with mesenchymal stem cell and seeded onto human cancellous bone. Mediators Inflamm 2013; 2013:364591. [PMID: 23476102 PMCID: PMC3588182 DOI: 10.1155/2013/364591] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 12/20/2012] [Accepted: 01/03/2013] [Indexed: 12/15/2022] Open
Abstract
Introduction. Cancellous bone is frequently used for filling bone defects in a clinical setting. It provides favourable conditions for regenerative cells such as MSC and early EPC. The combination of MSC and EPC results in superior bone healing in experimental bone healing models. Materials and Methods. We investigated the influence of osteogenic culture conditions on the endothelial properties of early EPC and the osteogenic properties of MSC when cocultured on cancellous bone. Additionally, cell adhesion, metabolic activity, and differentiation were assessed 2, 6, and 10 days after seeding. Results. The number of adhering EPC and MSC decreased over time; however the cells remained metabolically active over the 10-day measurement period. In spite of a decline of lineage specific markers, cells maintained their differentiation to a reduced level. Osteogenic stimulation of EPC caused a decline but not abolishment of endothelial characteristics and did not induce osteogenic gene expression. Osteogenic stimulation of MSC significantly increased their metabolic activity whereas collagen-1α and alkaline phosphatase gene expressions declined. When cocultured with EPC, MSC's collagen-1α gene expression increased significantly. Conclusion. EPC and MSC can be cocultured in vitro on cancellous bone under osteogenic conditions, and coculturing EPC with MSC stabilizes the latter's collagen-1α gene expression.
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Ronga M, Fagetti A, Canton G, Paiusco E, Surace MF, Cherubino P. Clinical applications of growth factors in bone injuries: experience with BMPs. Injury 2013; 44 Suppl 1:S34-9. [PMID: 23351868 DOI: 10.1016/s0020-1383(13)70008-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The management of open fractures and delayed or non unions continue to be complicated by high rates of treatment failure and significant patient disability and dissatisfaction. The use of bone morphogenetic proteins (BMPs) in the treatment of these injuries has been assessed by several authors. BMPs induce the process of bone healing by recruiting bone-forming cells to the area of lesion. The use of BMP currently has two FDA-approved indications: treatment of open tibial fractures treated with intramedullary fixation and treatment of tibia long bone non-union. Despite this limited target, off-label BMP use continues to push the spectrum for new applications. This review describes the current evidence for the use of BMPs in open fractures and non-unions.
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Affiliation(s)
- Mario Ronga
- Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy.
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Longo UG, Trovato U, Loppini M, Rizzello G, Khan WS, Maffulli N, Denaro V. Tissue engineered strategies for pseudoarthrosis. Open Orthop J 2012; 6:564-70. [PMID: 23248729 PMCID: PMC3522502 DOI: 10.2174/1874325001206010564] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 09/14/2012] [Accepted: 09/22/2012] [Indexed: 11/22/2022] Open
Abstract
Numerous classification systems of non-union have been proposed based on: presence or absence of infection, radiographic features, clinical findings, biologic activity, location and shape. The management of pseudarthrosis is strongly related to the type of non-union (infected versus uninfected, atrophic versus hypertrophic). Surgical management of pseudarthrosis is generally effective with a success rate ranging from 75 to 100%. Nevertheless, in a relatively high number of instances several combined treatments are required for the fracture healing. The current gold standard to stimulate the bone regeneration is represented by the revision surgery with the application of autologous bone grafts. However, several approaches have been described to promote and enhance the bone tissue regeneration, including extracorporeal shock wave therapy (ESWT), ultrasound, electromagnetic, bone morphogenic proteins (BMPs) and platelet-rich-plasma (PRP).The aim of the present study was to perform a systematic review of the literature evaluating the current therapies to promote and enhance the bone tissue healing. The systematic review was performed according to PRISMA guidelines with a PRISMA checklist and algorithm.Limitations of the present systematic review are mainly related to the scanty quality of the studies available in the literature. Although the therapies previously described for the management of patients with non-unions seems to be effective, the limitations of the included studies, especially the extensive clinical heterogeneity, make not possible to provide clear recommendations regarding the application of these approaches. The problems remain the need to better understand the most effective treatment options, subject to surgical stabilization as a first step.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery. Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128 Trigoria, Rome, Italy ; Centro Integrato di Ricerca (CIR) Campus Bio-Medico University, Via Alvaro del Portillo, 21, 00128, Rome, Italy
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Abstract
Autologous bone is used very often in the treatment of fresh fractures, delayed unions and non-unions. Alternatives have included allografts and in recent years also demineralized bone matrix. The growing availability of good synthetic bone grafts and their advantages in safety and avoiding donor-site morbidity are the reasons that these products are being used more and more. There are on the market a wide variety of substitutes with different capabilities. Nevertheless autologous bone graft is still considered as the gold standard and will be discussed here in that context. Osteoconductive, osteogenic and osteoinductive products will also be classified and their advantages and disadvantages described.
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Affiliation(s)
- Gerald Zimmermann
- Theresienkrankenhaus Mannheim, Department of Trauma and Orthopaedic Surgery, University of Heidelberg, Germany.
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Janicki P, Schmidmaier G. What should be the characteristics of the ideal bone graft substitute? Combining scaffolds with growth factors and/or stem cells. Injury 2011; 42 Suppl 2:S77-81. [PMID: 21724186 DOI: 10.1016/j.injury.2011.06.014] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Reconstruction of large bone defects or non-unions resulting from biochemical disorders, tumour resections or complicated fractures is still a challenge for orthopaedic and trauma surgery. On the one hand, autografts harbour most features of ideal bone graft substitutes but on the other hand, they have a lot insurmountable disadvantages. An ideal bone graft substitute should be biomechanically stable, able to degrade within an appropriate time frame, exhibit osteoconductive, osteogenic and osteoinductive properties and provide a favourable environment for invading blood vessels and bone forming cells. Whilst osteoconductivity of biomaterials for bone tissue engineering strategies can be directed by their composition, surface character and internal structure, osteoinductive and osteogenic features can be provided by growth factors originally participating in fracture healing and/or multipotent mesenchymal stromal/stem cells (MSC) capable of rebuilding bone and marrow structures. In this review, aspects of the clinical application of the most commonly used growth factors for bone repair, the bone morphogenetic proteins (BMPs), and the potential use of human MSC for clinical application will be discussed.
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Affiliation(s)
- Patricia Janicki
- Research Center for Experimental Orthopedics, Department of Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, Heidelberg, Germany
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Smith JO, Aarvold A, Tayton ER, Dunlop DG, Oreffo ROC. Skeletal tissue regeneration: current approaches, challenges, and novel reconstructive strategies for an aging population. TISSUE ENGINEERING PART B-REVIEWS 2011; 17:307-20. [PMID: 21615329 DOI: 10.1089/ten.teb.2011.0143] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Loss of skeletal tissue as a consequence of trauma, injury, or disease is a significant cause of morbidity with often wide-ranging socioeconomic impacts. Current approaches to replace or restore significant quantities of lost bone come with substantial limitations and inherent disadvantages that may in themselves cause further disability. In addition, the spontaneous repair capacity of articular cartilage is limited; thus, investigation into new cartilage replacement and regeneration techniques are warranted. Along with the challenges of an increasingly aging demographic, changing clinical scenarios and rising functional expectations provide the imperative for new, more reliable skeletal regeneration strategies. The science of tissue engineering has expanded dramatically in recent years, notably in orthopedic applications, and it is clear that new approaches for de novo skeletal tissue formation offer exciting opportunities to improve the quality of life for many, particularly in the face of increasing patient expectations. However, significant scientific, financial, industrial, and regulatory challenges should be overcome before the successful development of an emergent tissue engineering strategy can be realized. We outline current practice for replacement of lost skeletal tissue and the innovative approaches in tissue regeneration that have so far been translated to clinical use, along with a discussion of the significant hurdles that are presented in the process of translating research strategies to the clinic.
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Affiliation(s)
- James Oliver Smith
- Bone and Joint Research Group, Centre for Human Development, Stem Cells and Regeneration, Human Development and Health, Institute of Developmental Sciences, Southampton, United Kingdom
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