Effect of Use of Slow Release of Bone Morphogenetic Protein-2 and Transforming Growth Factor-Beta-2 in a Chitosan Gel Matrix on Cranial Bone Graft Survival in Experimental Cranial Critical Size Defect Model

The Influence of rhBMP-7 Associated with Nanometric Hydroxyapatite Coatings Titanium Implant on the Osseointegration: A Pre-Clinical Study

Background: Bioceramic nanometer coatings have been regarded as potential substitutes for plasma-sprayed hydroxyapatite coatings, and the association with bone morphogenetic protein (BMP) is an attempt to achieve faster osseointegration to hasten oral rehabilitation. Objective: This study aimed to investigate the effect of recombinant human bone morphogenetic protein-7 (rhBMP-7) on the osseointegration of titanium implants coated with a thin film surface of hydroxyapatite (HA). Methods: Two implants (n = 24) were placed in each white New Zealand rabbits’ femur (n = 6). Implants were placed in the right femur after standard instrumentation (A and B) and in the left femur after an over-instrumentation (C and D), preventing bone-implant contact. The distal implants were installed associated with rhBMP-7 (groups B [regular instrumentation] and D [over-instrumentation]) and, also, in the absence of without BMP (control groups A [regular instrumentation] and C [over-instrumentation]). After 4 weeks, the animals were euthanized. The bone blocks containing the implants were embedded in methyl methacrylate and sectioned parallel to the long axis of the implant, which were analyzed by image segmentation. The data were analyzed using a nonparametric statistical method. Results: We observed that Group A had a mean bone formation of 35.6% compared to Group B, which had 48.6% (p > 0.05). Moreover, this group showed 28.3% of connective tissue compared to Group A, with 39.3%. In the over-instrumented groups, rhBMP-7 (Group D) showed an enhanced and significant increase in bone formation when compared with the group without rhBMP-7 (Group C). Conclusion: We concluded that the association of rhBMP-7 to thin nanostructure HA-coated implants promoted greater new bone area than the same implants in the absence of rhBMP-7, mainly in cases of over-instrumented implant sites.

BMP and TGFβ use and release in bone regeneration

A fracture that does not unite in nine months is defined as nonunion. Nonunion is common in fragmented fractures and large bone defects where vascularization is impaired. The distal third of the tibia, the scaphoid bone or the talus fractures are furthermore prone to nonunion. Open fractures and spinal fusion cases also need special monitoring for healing. Bone tissue regeneration can be attained by autografts, allografts, xenografts and synthetic materials, however their limited availability and the increased surgical time as well as the donor site morbidity of autograft use, and lower probability of success, increased costs and disease transmission and immunological reaction probability of allografts oblige us to find better solutions and new grafts to overcome the cons. A proper biomaterial for regeneration should be osteoinductive, osteoconductive, biocompatible and mechanically suitable. Cytokine therapy, where growth factors are introduced either exogenously or triggered endogenously, is one of the commonly used method in bone tissue engineering. Transforming growth factor β (TGFβ) superfamily, which can be divided structurally into two groups as bone morphogenetic proteins (BMPs), growth differentiation factors (GDFs) and TGFβ, activin, Nodal branch, Mullerian hormone, are known to be produced by osteoblasts and other bone cells and present already in bone matrix abundantly, to take roles in bone homeostasis. BMP family, as the biggest subfamily of TGFβ superfamily, is also reported to be the most effective growth factors in bone and development, which makes them one of the most popular cytokines used in bone regeneration. Complications depending on the excess use of growth factors, and pleiotropic functions of BMPs are however the main reasons of why they should be approached with care. In this review, the Smad dependent signaling pathways of TGFβ and BMP families and their relations and the applications in preclinical and clinical studies will be briefly summarized.

Natural Polymeric Scaffolds in Bone Regeneration

Despite considerable advances in microsurgical techniques over the past decades, bone tissue remains a challenging arena to obtain a satisfying functional and structural restoration after damage. Through the production of substituting materials mimicking the physical and biological properties of the healthy tissue, tissue engineering strategies address an urgent clinical need for therapeutic alternatives to bone autografts. By virtue of their structural versatility, polymers have a predominant role in generating the biodegradable matrices that hold the cells in situ to sustain the growth of new tissue until integration into the transplantation area (i.e., scaffolds). As compared to synthetic ones, polymers of natural origin generally present superior biocompatibility and bioactivity. Their assembly and further engineering give rise to a wide plethora of advanced supporting materials, accounting for systems based on hydrogels or scaffolds with either fibrous or porous architecture. The present review offers an overview of the various types of natural polymers currently adopted in bone tissue engineering, describing their manufacturing techniques and procedures of functionalization with active biomolecules, and listing the advantages and disadvantages in their respective use in order to critically compare their actual applicability potential. Their combination to other classes of materials (such as micro and nanomaterials) and other innovative strategies to reproduce physiological bone microenvironments in a more faithful way are also illustrated. The regeneration outcomes achieved in vitro and in vivo when the scaffolds are enriched with different cell types, as well as the preliminary clinical applications are presented, before the prospects in this research field are finally discussed. The collection of studies herein considered confirms that advances in natural polymer research will be determinant in designing translatable materials for efficient tissue regeneration with forthcoming impact expected in the treatment of bone defects.

The Investigation of LRP5-Loaded Composite with Sustained Release Behavior and Its Application in Bone Repair

Low-density lipoprotein receptor-related protein 5 (LRP5) plays a vital role in bone formation and regeneration. In this study, we developed an injectable and sustained-release composite loading LRP5 which could gelatinize in situ. The sustained release of the composite and its efficacy in bone regeneration were evaluated. Sodium alginate, collagen, hydroxyapatite, and LRP5 formed the composite LRP5-Alg/Col/HA. It was found that the initial setting time and final setting time of LRP5-Alg/Col/HA containing 4% alginate were suitable for surgical operation. When the composite was loaded with 40 μg/mL LRP5, LRP5-Alg/Col/HA did not exhibit a burst-release behavior and could sustainably release LRP5 up to 21 days. Up to 18 days, LRP5 released from LRP5-Alg/Col/HA still present the binding activity with DKK1 (Wnt signaling pathway antagonist) and could increase the downstream β-catenin mRNA in bone marrow mesenchymal stem cells. Moreover, LRP5-Alg/Col/HA was found to significantly increase bone mineral density in the defect area after 6 weeks’ implantation of LRP5-Alg/Col/HA into the rats’ calvarial defect area. H&E staining detection demonstrated that LRP5-Alg/Col/HA could mediate the formation of a new bone tissue. Therefore, we concluded that Alg/Col/HA was a suitable sustained-release carrier for LRP5 and LRP5-Alg/Col/HA had a significant effect on repairing bone defects and could be a good bone regeneration material.

Materials Science and Design Principles of Growth Factor Delivery Systems in Tissue Engineering and Regenerative Medicine

Growth factors (GFs) are signaling molecules that direct cell development by providing biochemical cues for stem cell proliferation, migration, and differentiation. GFs play a key role in tissue regeneration, but one major limitation of GF-based therapies is dosage-related adverse effects. Additionally, the clinical applications and efficacy of GFs are significantly affected by the efficiency of delivery systems and other pharmacokinetic factors. Hence, it is crucial to design delivery systems that provide optimal activity, stability, and tunable delivery for GFs. Understanding the physicochemical properties of the GFs and the biomaterials utilized for the development of biomimetic GF delivery systems is critical for GF-based regeneration. Many different delivery systems have been developed to achieve tunable delivery kinetics for single or multiple GFs. The identification of ideal biomaterials with tunable properties for spatiotemporal delivery of GFs is still challenging. This review characterizes the types, properties, and functions of GFs, the materials science of widely used biomaterials, and various GF loading strategies to comprehensively summarize the current delivery systems for tunable spatiotemporal delivery of GFs aimed for tissue regeneration applications. This review concludes by discussing fundamental design principles for GF delivery vehicles based on the interactive physicochemical properties of the proteins and biomaterials.

Preclinical therapies to prevent or treat fracture non-union: A systematic review

Background

Non-union affects up to 10% of fractures and is associated with substantial morbidity. There is currently no single effective therapy for the treatment or prevention of non-union. Potential treatments are currently selected for clinical trials based on results from limited animal studies, with no attempt to compare results between therapies to determine which have the greatest potential to treat non-union.

Aim

The aim of this systematic review was to define the range of therapies under investigation at the preclinical stage for the prevention or treatment of fracture non-union. Additionally, through meta-analysis, it aimed to identify the most promising therapies for progression to clinical investigation.

Methods

MEDLINE and Embase were searched from 1^St January 2004 to 10^th April 2017 for controlled trials evaluating an intervention to prevent or treat fracture non-union. Data regarding the model used, study intervention and outcome measures were extracted, and risk of bias assessed.

Results

Of 5,171 records identified, 197 papers describing 204 therapies were included. Of these, the majority were only evaluated once (179/204, 88%), with chitosan tested most commonly (6/204, 3%). Substantial variation existed in model design, length of survival and duration of treatment, with results poorly reported. These factors, as well as a lack of consistently used objective outcome measures, precluded meta-analysis.

Conclusion

This review highlights the variability and poor methodological reporting of current non-union research. The authors call for a consensus on the standardisation of animal models investigating non-union, and suggest journals apply stringent criteria when considering animal work for publication.

Chitosan as a vehicle for growth factor delivery: Various preparations and their applications in bone tissue regeneration

The replacement of conventional autografts and allografts by bone fragments constructed from alternate materials, cells, and molecules (growth factors, drugs, etc.) is an exciting prospect in the field of bone tissue engineering. Bone morphogenetic protein-2 (BMP-2) is a growth factor that has been extensively studied from this point of view. This review analyzes the relevance of chitosan and its derivatives and composites with various materials such as ceramics, heparin, silica, stem cells, titanium implants, etc., in terms of delivering BMP-2 for the purpose of bone regeneration. Chitosan offers the versatility to be modified into any shapes or sizes including conversion to nanoparticles, microspheres, nanofibers, porous scaffolds, and films. The results presented in this review clearly demonstrate that chitosan-based materials are biocompatible and have the potential to systematically and sustainably release BMP-2 where required. This release results in enhanced cell proliferation levels, enhancement of alkaline phosphatase activity, increased differentiation as well as increased mineralization under in vitro and in vivo conditions. This review also shines a spotlight on the currently developed chitosan-based products that are being used for BMP-2 delivery.

Effects of local delivery of BMP2, zoledronate and their combination on bone microarchitecture, biomechanics and bone turnover in osteoporotic rabbits

The hip fracture is one major clinical challenge associated with osteoporosis, resulting in heavy socioeconomic burdens and high mortality. Systemic therapies of anti-osteoporosis drugs are expensive, time-consuming and also evoke substantial side effects, which fails to provide early protection from fractures. Accumulating evidence demonstrates the high bioavailability and therapeutic efficacy of local drug delivery in accelerating facture healing and bone defect repair. This study aims at investigating the effects of local delivery of BMP2 and zoledronate (two promising anabolic/anti-catobolic reagents) encapsulated by fibrin sealants into femoral necks on regulating bone quality and remodeling in osteoporotic rabbits subjected to combined ovariectomy and glucocorticoid injection. We show that 6-week BMP2 delivery exhibited more prominent effect on mitigating trabecular bone microarchitecture deterioration and mechanical strength reduction of femoral necks than local zoledronate treatment. BMP2 plus zoledronate showed more significant improvement of bone microstructure, mechanical strength and bone formation rate at 12 weeks post injection than single BMP2 or zoledronate delivery via μCT, biomechanical, histomorphometric and serum biochemical analyses. This study enriches our knowledge for understanding the availability of local drug delivery for improving bone quantity and quality, which may lead to earlier, safer and more efficient protection from osteoporosis-induced fractures in clinics.

Osteogenic/angiogenic dual growth factor delivery microcapsules for regeneration of vascularized bone tissue

Growth factors (GFs) are major biochemical cues for tissue regeneration. Herein, a novel dual GF delivery system is designed composed of poly(lactic-co-glycolic acid) (PLGA) nanoparticles (NPs) and alginate microcapsules (MCs) via an electrodropping method. While bone morphogenetic protein (BMP)-2 is encapsulated in the PLGA NPs, vascular endothelial growth factor (VEGF) is included in the alginate MCs, where BMP-2-loaded PLGA NPs are entrapped together in the fabrication process. The initial loading efficiencies of BMP-2 and VEGF are 78% ± 3.6% and 43% ± 1.7%, respectively. When our dual GF-loaded MCs are assessed for in vitro osteogenesis of umbilical cord blood-derived mesenchymal stem cells (UCB-MSCs) on 2D and 3D environment, MCs contribute to much better UCB-MSCs osteogenesis as confirmed by von Kossa staining, immunofluorescence (osteocalcin, collagen 1), calcium content measurement, and osteogenic markers expression. In addition, when dual GF-encapsulated MCs are combined with collagen and then applied to 8 mm diameter rat calvarial defect model, the positive effects on vascularized bone regeneration are much more pronounced; micro computed tomography (CT) and histology analyses exhibit 82.3% bone healing coupled with 12.6% vessel occupied area. Put together, current study indicates a synergistic effect of BMP-2/VEGF and highlights the great potential of dual GF delivery modality (PLGA NPs-in-MC) for regeneration of vascularized bone.

Protein growth factors loaded highly porous chitosan scaffold: a comparison of bone healing properties

Present study aimed to investigate and compare effectiveness of porous chitosan alone and in combination with insulin like growth factor-1 (IGF-1) and bone morphogenetic protein-2 (BMP-2) in bone healing. Highly porous (85±2%) with wide distribution of macroporous (70-900 μm) chitosan scaffolds were fabricated as bone substitutes by employing a simple liquid hardening method using 2% (w/v) chitosan suspension. IGF-1 and BMP-2 were infiltrated using vacuum infiltration with freeze drying method. Adsorption efficiency was found to be 87±2 and 90±2% for BMP-2 and IGF-1 respectively. After thorough material characterization (pore details, FTIR and SEM), samples were used for subsequent in vivo animal trial. Eighteen rabbit models were used to evaluate and compare control (chitosan) (group A), chitosan with IGF-1 (group B) and chitosan with BMP-2 (group C) in the repair of critical size bone defect in tibia. Radiologically, there was evidence of radiodensity in defect area from 60th day (initiated on 30th day) in groups B and C as compared to group A and attaining nearly bony density in most of the part at day 90. Histological results depicted well developed osteoblastic proliferation around haversian canal along with proliferating fibroblast, vascularization and reticular network which was more pronounced in group B followed by groups C and A. Fluorochrome labeling and SEM studies in all groups showed similar outcome. Hence, porous chitosan alone and in combination with growth factors (GFs) can be successfully used for bone defect healing with slight advantage of IGF-1 in chitosan samples.

Effects of different growth factors and carriers on bone regeneration: a systematic review

OBJECTIVE

The application and subsequent investigations in the use of varied osteogenic growth factors in bone regeneration procedures have grown dramatically over the past several years. Owing to this rapid gain in popularity and documentation, a review was undertaken to evaluate the in vivo effects of growth factors on bone regeneration.

STUDY DESIGN

Using related key words, electronic databases (Medline, Embase, and Cochrane) were searched for articles published from 1999 to April 2010 to find growth factor application in bone regeneration in human or animal models.

RESULTS

A total of 63 articles were matched with the inclusion criteria of this study. Bone morphogenetic protein 2 (BMP-2) was the most studied growth factor. Carriers for the delivery, experimental sites, and methods of evaluation were different, and therefore articles did not come to a general agreement.

CONCLUSIONS

Within the limitations of this review, BMP-2 may be an appropriate growth factor for osteogenesis.

Comparative study of osteogenic potential of a composite scaffold incorporating either endogenous bone morphogenetic protein-2 or exogenous phytomolecule icaritin: an in vitro efficacy study

A local delivery system with sustained and efficient release of therapeutic agents from an appropriate carrier is desirable for orthopedic applications. Novel composite scaffolds made of poly (lactic-co-glycolic acid) with tricalcium phosphate (PLGA/TCP) were fabricated by an advanced low-temperature rapid prototyping technique, which incorporated either endogenous bone morphogenetic protein-2 (BMP-2) (PLGA/TCP/BMP-2) or phytomolecule icaritin (ICT) (PLGA/TCP/ICT) at low, middle and high doses. PLGA/TCP served as control. In vitro degradation, osteogenesis and release tests showed statistical differences among PLGA/TCP/ICT, PLGA/TCP and PLGA/TCP/BMP-2 groups, where PLGA/TCP/ICT had the desired slow release of bioactive icaritin in a dose-dependent manner, whereas there was almost no BMP-2 release from the PLGA/TCP/BMP-2 scaffolds. PLGA/TCP/ICT significantly increased more ALP activity, upregulated mRNA expression of osteogenic genes and enhanced calcium deposition and mineralization in rabbit bone marrow stem cells cultured on scaffolds compared with the other two groups. These results indicate the desired degradation rate, osteogenic capability and release property in PLGA/TCP/ICT composite scaffold, as icaritin preserved its bioactivity and structure after incorporation, while PLGA/TCP/BMP-2 did not show an initially expected osteogenic potential, owing to loss of the original bioactivity of BMP-2 during its incorporation and fabrication procedure. The results suggest that PLGA/TCP composite scaffolds incorporating osteogenic ICT might be a promising approach for bone tissue bioengineering and regeneration.

Rat bone marrow stromal cells-seeded porous gelatin/tricalcium phosphate/oligomeric proanthocyanidins composite scaffold for bone repair

Repair of bone defects remains a major challenge in orthopaedic surgery. Bone tissue engineering is an attractive approach for treating bone loss in various shapes and amounts. The aim of this study was to prepare and evaluate the feasibility of a porous scaffold, which was composed of oligomeric proanthocyanidin crosslinked gelatin mixed with β-tricalcium phosphate (GTP) and was seeded with bone marrow stromal cells (BMSCs) as a bone substitute. GTP scaffolds were made porous using a salt-leaching method. The physicochemical properties of the scaffold were evaluated to determine the optimal salt:composite weight ratio. The results indicated that the GTP scaffold had a favourable macroporous structure and higher porosity when the salt:composite weight ratio was 4:1. Cytotoxic tests demonstrated that extracts from the GTP scaffolds promoted the proliferation of BMSCs. Rat BMSCs were seeded on a GTP scaffold and cultured in a spinner flask. After 2 weeks of culture, scanning electron microscopy observation showed that the cells adhered well to the surfaces of the pores in the scaffold. Moreover, this study explored the biological response of rat calvarial bone to the scaffold to evaluate its potential in bone tissue engineering. Bone defects were filled with BMSC-seeded GTP scaffold and acellular GTP scaffold. After 8 weeks, the scaffold induced new bone formation at a bone defect, as was confirmed by X-ray microradiography and histology. The BMSC-seeded scaffold induced more new bone formation than did an acellular scaffold. These observations suggest that the BMSCs-seeded GTP scaffold can promote the regeneration of defective bone tissue.

The evaluation of ectopic bone formation induced by delivery systems for bone morphogenetic protein-9 or its derived peptide

We have earlier shown that a peptide derived from the bone morphogenetic protein-9 (pBMP-9) stimulates mouse preosteoblasts MC3T3-E1 differentiation in vitro. Here, we evaluated the effects of two delivery systems (DSs) for pBMP-9, one based on collagen and the other on chitosan. The release kinetics of BMP-9 (used as control) and pBMP-9 from these DSs were first determined in vitro by using enzyme-linked immunosorbent assay and high performance liquid chromatography assays, respectively. Micro-computerized tomography and histological analysis were then performed to study in vivo the ectopic ossification induced by both DSs containing these molecules in C57BL/6 mouse quadriceps. We found that collagen DS released in vitro about 35% of its BMP-9 within 1 h, whereas chitosan DS released 80%. The pBMP-9 was released from both DSs more slowly for up to 10 days. These release kinetics seemed to fit the Korsmeyer-Peppas model. Only chitosan DS containing BMP-9 induced strong bone formation in all mice quadriceps within 24 days. All mice quadriceps treated by pBMP-9 trapped in this DS also favored bone structures that started to mineralize. However, pBMP-9 in collagen DS failed to promote ectopic ossification within 24 days in vivo. This study highlights the importance to optimize carrier, thus improving the efficiency of pBMP-9 in vivo.

Repair of rat calvarial bone defects by controlled release of rhBMP-2 from an injectable bone regeneration composite

The objective of the present study was to enhance the regeneration ability of an injectable bone regeneration composite (IBRC) by the controlled release of recombinant human bone morphogenetic protein-2 (rhBMP-2). The IBRC comprised nano-hydroxyapatite/collagen (nHAC) particles in an alginate hydrogel carrier. First, bovine serum albumin (BSA) as a model protein was released from IBRC to evaluate its release rules. The results suggested that IBRC is a good controlled release carrier for BSA in the range 5-75 µg/ml. In the in vitro study the rhBMP-2 released from IBRC was determined by an enzyme-linked immunosorbent assay specific for rhBMP-2. The bioactivity of the released rhBMP-2 was evaluated through differentiated function of marrow mesenchymal stem cells (MSCs), as measured by alkaline phosphatase activity. The results of an in vitro study confirmed that rhBMP-2 released continuously for 21 days, and its bioactivity was well preserved during this period. The bone formation ability was assessed using a rat calvarial defect model of critical size. Micro-computed tomography (micro-CT) and histological analysis demonstrated that the IBRC had good bone formation ability, which was promoted through rhBMP-2 released from IBRC/rhBMP-2. In vitro and in vivo studies suggested that the present system is a potential bone critical defect repair material for clinical applications.

In vitro evaluation of an injectable chitosan gel for sustained local delivery of BMP-2 for osteoblastic differentiation

We investigated the effect of sustained release of bone morphogenetic protein-2 (BMP-2) from an injectable chitosan gel on osteoblastic differentiation in vitro. We first characterized the release profile of BMP-2 from the gels, and then examined the cellular responses of preosteoblast mouse stromal cells (W-20-17) and human embryonic palatal mesenchymal (HEPM) cells to BMP-2. The release profiles of different concentrations of BMP-2 exhibited sustained releases (41% for 2 ng/mL and 48% for 20 ng/mL, respectively) from the chitosan gels over a three-week period. Both cell types cultured in the chitosan gels were viable and significantly proliferated for 3 days (p < 0.05). Chitosan gels loaded with BMP-2 enhanced ALP activity of W-20-17 by 3.6-fold, and increased calcium mineral deposition of HEPM by 2.8-fold at 14 days of incubation, compared to control groups initially containing the same amount of BMP-2. In addition, schitosan gels loaded with BMP-2 exhibited significantly greater osteocalcin synthesis of W-20-17 at seven days, and of HEPM at both 7 and 14 days compared with the control groups (p<0.05). This study suggests that the enhanced effects of BMP-2 released from chitosan gels on cell differentiation and mineralization are species and cell type dependent.

Cranial bone defects: current and future strategies

Bony defects in the craniomaxillofacial skeleton remain a major and challenging health concern. Surgeons have been trying for centuries to restore functionality and aesthetic appearance using autografts, allografts, and even xenografts without entirely satisfactory results. As a result, physicians, scientists, and engineers have been trying for the past few decades to develop new techniques to improve bone growth and bone healing. In this review, the authors summarize the advantages and limitations of current animal models; describe current materials used as scaffolds, cell-based, and protein-based therapies; and lastly highlight areas for future investigation. The purpose of this review is to highlight the major scaffold-, cell-, and protein-based preclinical tools that are currently being developed to repair cranial defects.