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Liu H, Chen H, Han Q, Sun B, Liu Y, Zhang A, Fan D, Xia P, Wang J. Recent advancement in vascularized tissue-engineered bone based on materials design and modification. Mater Today Bio 2023; 23:100858. [PMID: 38024843 PMCID: PMC10679779 DOI: 10.1016/j.mtbio.2023.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/03/2023] [Accepted: 11/06/2023] [Indexed: 12/01/2023] Open
Abstract
Bone is one of the most vascular network-rich tissues in the body and the vascular system is essential for the development, homeostasis, and regeneration of bone. When segmental irreversible damage occurs to the bone, restoring its vascular system by means other than autogenous bone grafts with vascular pedicles is a therapeutic challenge. By pre-generating the vascular network of the scaffold in vivo or in vitro, the pre-vascularization technique enables an abundant blood supply in the scaffold after implantation. However, pre-vascularization techniques are time-consuming, and in vivo pre-vascularization techniques can be damaging to the body. Critical bone deficiencies may be filled quickly with immediate implantation of a supporting bone tissue engineered scaffold. However, bone tissue engineered scaffolds generally lack vascularization, which requires modification of the scaffold to aid in enhancing internal vascularization. In this review, we summarize the relationship between the vascular system and osteogenesis and use it as a basis to further discuss surgical and cytotechnology-based pre-vascularization strategies and to describe the preparation of vascularized bone tissue engineered scaffolds that can be implanted immediately. We anticipate that this study will serve as inspiration for future vascularized bone tissue engineered scaffold construction and will aid in the achievement of clinical vascularized bone.
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Affiliation(s)
- Hao Liu
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Hao Chen
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Qin Han
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Bin Sun
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Yang Liu
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Aobo Zhang
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Danyang Fan
- Department of Dermatology, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Peng Xia
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
| | - Jincheng Wang
- Department of Orthopedic Surgery, The Second Hospital of Jilin University, Changchun 130000, Jilin, China
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Watson E, Mikos AG. Advances in In Vitro and In Vivo Bioreactor-Based Bone Generation for Craniofacial Tissue Engineering. BME FRONTIERS 2023; 4:0004. [PMID: 37849672 PMCID: PMC10521661 DOI: 10.34133/bmef.0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/17/2022] [Indexed: 10/19/2023] Open
Abstract
Craniofacial reconstruction requires robust bone of specified geometry for the repair to be both functional and aesthetic. While native bone from elsewhere in the body can be harvested, shaped, and implanted within a defect, using either an in vitro or in vivo bioreactors eliminates donor site morbidity while increasing the customizability of the generated tissue. In vitro bioreactors utilize cells harvested from the patient, a scaffold, and a device to increase mass transfer of nutrients, oxygen, and waste, allowing for generation of larger viable tissues. In vivo bioreactors utilize the patient's own body as a source of cells and of nutrient transfer and involve the implantation of a scaffold with or without growth factors adjacent to vasculature, followed by the eventual transfer of vascularized, mineralized tissue to the defect site. Several different models of in vitro bioreactors exist, and several different implantation sites have been successfully utilized for in vivo tissue generation and defect repair in humans. In this review, we discuss the specifics of each bioreactor strategy, as well as the advantages and disadvantages of each and the future directions for the engineering of bony tissues for craniofacial defect repair.
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Affiliation(s)
- Emma Watson
- Department of Bioengineering, Rice University, Houston, TX 77030, USA
| | - Antonios G. Mikos
- Department of Bioengineering, Rice University, Houston, TX 77030, USA
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Shi J, Dai W, Gupta A, Zhang B, Wu Z, Zhang Y, Pan L, Wang L. Frontiers of Hydroxyapatite Composites in Bionic Bone Tissue Engineering. MATERIALS (BASEL, SWITZERLAND) 2022; 15:ma15238475. [PMID: 36499970 PMCID: PMC9738134 DOI: 10.3390/ma15238475] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 05/31/2023]
Abstract
Bone defects caused by various factors may cause morphological and functional disorders that can seriously affect patient's quality of life. Autologous bone grafting is morbid, involves numerous complications, and provides limited volume at donor site. Hence, tissue-engineered bone is a better alternative for repair of bone defects and for promoting a patient's functional recovery. Besides good biocompatibility, scaffolding materials represented by hydroxyapatite (HA) composites in tissue-engineered bone also have strong ability to guide bone regeneration. The development of manufacturing technology and advances in material science have made HA composite scaffolding more closely related to the composition and mechanical properties of natural bone. The surface morphology and pore diameter of the scaffold material are more important for cell proliferation, differentiation, and nutrient exchange. The degradation rate of the composite scaffold should match the rate of osteogenesis, and the loading of cells/cytokine is beneficial to promote the formation of new bone. In conclusion, there is no doubt that a breakthrough has been made in composition, mechanical properties, and degradation of HA composites. Biomimetic tissue-engineered bone based on vascularization and innervation show a promising future.
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Affiliation(s)
- Jingcun Shi
- Department of Oral and Maxillofacial Surgery—Head & Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, National Center for Stomatology, Shanghai 200011, China
| | - Wufei Dai
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- Shanghai Tissue Engineering Key Laboratory, Shanghai Research Institute of Plastic and Reconstructive Surgey, Shanghai 200011, China
| | - Anand Gupta
- Department of Dentistry, Government Medical College & Hospital, Chandigarh 160017, India
| | - Bingqing Zhang
- Department of Oral and Maxillofacial Surgery—Head & Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, National Center for Stomatology, Shanghai 200011, China
| | - Ziqian Wu
- Department of Oral and Maxillofacial Surgery—Head & Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, National Center for Stomatology, Shanghai 200011, China
| | - Yuhan Zhang
- Department of Oral and Maxillofacial Surgery—Head & Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, National Center for Stomatology, Shanghai 200011, China
| | - Lisha Pan
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, National Center for Stomatology, Shanghai 200011, China
| | - Lei Wang
- Department of Oral and Maxillofacial Surgery—Head & Neck Oncology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, National Center for Stomatology, Shanghai 200011, China
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Techniques and Innovations in Flap Engineering: A Review. Plast Reconstr Surg Glob Open 2022; 10:e4523. [PMID: 36168612 PMCID: PMC9509183 DOI: 10.1097/gox.0000000000004523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/19/2022] [Indexed: 11/26/2022]
Abstract
Currently, the gold standard for complex defect reconstruction is autologous tissue flaps, with vascularized composite allografts as its highest level. Good clinical results are obtained despite considerable obstacles, such as limited donor sites, donor site morbidity, and complex operations. Researchers in the field of tissue engineering are trying to generate novel tissue flaps requiring small or no donor site sacrifice. At the base of existing technologies is the tissue’s potential for regeneration and neovascularization.
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Studenova EA. IS A BIG OMENTUM THE SURGEON'S BEST FRIEND OR WORST ENEMY? REVIEW. SURGICAL PRACTICE 2021. [DOI: 10.38181/2223-2427-2021-4-15-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The interest of surgeons in the greater omentum is associated with a unique combination of such functions as plasticity, immune defense, barrier, hormonal, angiogenesis and regeneration for adjacent tissues, reabsorption, hemostatic, thermoregulation. The purpose of this review was to track the historically changing position of operations with the use of the greater omentum in abdominal, thoracic surgery, reconstructive plastic surgery, analyze the aspects of the use and controversial issues of omentization of the anastomoses line and omentoplasty in modern conditions, as well as highlight promising directions for the use of the greater omentum in medicine. in the sources of domestic and foreign databases until July 2021. Information about the negative consequences of omentectomy is given – a decrease in local and general immunoresistance, the development of adhesive disease, an increase in the number of postoperative purulent-inflammatory complications. It is useful for the surgeon to use a large omentum in non-standard and technically difficult cases. Situations are described in which a radical attitude to the greater omentum is justified – torsion of the omentum strand, metastasis, adhesions, omentitis, entrapment in hernias, complications from the pedicle flap. Analysis of the literature revealed ambiguous results of omentization and omentoplasty, which indicates the need for randomized studies in this area, the development of clinical recommendations for these operations with a description of clear indications and methods of carrying out.
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Affiliation(s)
- E. A. Studenova
- Private Institution of Healthcare "Russian Railways Medicine Clinical Hospital N.A. Semashko"
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Abu-Shahba AG, Wilkman T, Kornilov R, Adam M, Salla KM, Lindén J, Lappalainen AK, Björkstrand R, Seppänen-Kaijansinkko R, Mannerström B. Periosteal Flaps Enhance Prefabricated Engineered Bone Reparative Potential. J Dent Res 2021; 101:166-176. [PMID: 34514892 PMCID: PMC8808084 DOI: 10.1177/00220345211037247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The clinical translation of bone tissue engineering for reconstructing large bone defects has not advanced without hurdles. The in vivo bioreactor (IVB) concept may therefore bridge between bone tissue engineering and reconstructive surgery by employing the patient body for prefabricating new prevascularized tissues. Ideally, IVB should minimize the need for exogenous growth factors/cells. Periosteal tissues are promising for IVB approaches to prefabricate tissue-engineered bone (TEB) flaps. However, the significance of preserving the periosteal vascular supply has not been adequately investigated. This study assessed muscle IVB with and without periosteal/pericranial grafts and flaps for prefabricating TEB flaps to reconstruct mandibular defects in sheep. The sheep (n = 14) were allocated into 4 groups: muscle IVB (M group; nM = 3), muscle + periosteal graft (MP group; nMP = 4), muscle + periosteal flap (MVP group; nMVP = 4), and control group (nControl = 3). In the first surgery, alloplastic bone blocks were implanted in the brachiocephalic muscle (M) with a periosteal graft (MP) or with a vascularized periosteal flap (MVP). After 9 wk, the prefabricated TEB flaps were transplanted to reconstruct a mandibular angle defect. In the control group, the defects were reconstructed by non-prevascularized bone blocks. Computed tomography (CT) scans were performed after 13 wk and after 23 wk at termination, followed by micro-CT (µCT) and histological analyses. Both CT and µCT analysis revealed enhanced new bone formation and decreased residual biomaterial volume in the MVP group compared with control and MP groups, while the M group showed less new bone formation and more residual biomaterial. The histological analysis showed that most of the newly formed bone emerged from defect edges, but larger areas of new bone islands were found in MP and MVP groups. The MVP group showed enhanced vascularization and higher biomaterial remodeling rates. The periosteal flaps boosted the reconstructive potential of the prefabricated TEB flaps. The regenerative potential of the periosteum was manifested after the transplantation into the mechanically stimulated bony defect microenvironment.
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Affiliation(s)
- A G Abu-Shahba
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta, Egypt
| | - T Wilkman
- Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, Helsinki, Finland
| | - R Kornilov
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - M Adam
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - K M Salla
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - J Lindén
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland.,Finnish Centre for Laboratory Animal Pathology (FCLAP), HiLIFE, University of Helsinki, Helsinki, Finland
| | - A K Lappalainen
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - R Björkstrand
- Department of Mechanical Engineering, Aalto University, Espoo, Finland
| | - R Seppänen-Kaijansinkko
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, Helsinki, Finland
| | - B Mannerström
- Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Wang J, Wang X, Zhen P, Fan B. [Research progress of in vivo bioreactor for bone tissue engineering]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:627-635. [PMID: 33998218 DOI: 10.7507/1002-1892.202012083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress of in vivo bioreactor (IVB) for bone tissue engineering in order to provide reference for its future research direction. Methods The literature related to IVB used in bone tissue engineering in recent years was reviewed, and the principles of IVB construction, tissue types, sites, and methods of IVB construction, as well as the advantages of IVB used in bone tissue engineering were summarized. Results IVB takes advantage of the body's ability to regenerate itself, using the body as a bioreactor to regenerate new tissues or organs at injured sites or at ectopic sites that can support the regeneration of new tissues. IVB can be constructed by tissue flap (subcutaneous pocket, muscle flap/pocket, fascia flap, periosteum flap, omentum flap/abdominal cavity) and axial vascular pedicle (axial vascular bundle, arteriovenous loop) alone or jointly. IVB is used to prefabricate vascularized tissue engineered bone that matched the shape and size of the defect. The prefabricated vascularized tissue engineered bone can be used as bone graft, pedicled bone flap, or free bone flap to repair bone defect. IVB solves the problem of insufficient vascularization in traditional bone tissue engineering to a certain extent. Conclusion IVB is a promising method for vascularized tissue engineered bone prefabrication and subsequent bone defect reconstruction, with unique advantages in the repair of large complex bone defects. However, the complexity of IVB construction and surgical complications hinder the clinical application of IVB. Researchers should aim to develop a simple, safe, and efficient IVB.
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Affiliation(s)
- Jian Wang
- First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou Gansu, 730000, P.R.China.,Orthopaedic Center, the 940th Hospital of PLA Joint Logistics Support Force, Lanzhou Gansu, 730000, P.R.China
| | - Xiao Wang
- School of Design and Art, Lanzhou University of Technology, Lanzhou Gansu, 730000, P.R.China
| | - Ping Zhen
- Orthopaedic Center, the 940th Hospital of PLA Joint Logistics Support Force, Lanzhou Gansu, 730000, P.R.China
| | - Bo Fan
- Orthopaedic Center, the 940th Hospital of PLA Joint Logistics Support Force, Lanzhou Gansu, 730000, P.R.China
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Naujokat H, Loger K, Schulz J, Açil Y, Wiltfang J. Bone tissue engineering in the greater omentum with computer-aided design/computer-aided manufacturing scaffolds is enhanced by a periosteum transplant. Regen Med 2020; 15:2297-2309. [PMID: 33355523 DOI: 10.2217/rme-2020-0115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Aim: This study aimed to evaluate two different vascularized bone flap scaffolds and the impact of two barrier membranes for the reconstruction of critical-size bone defects. Materials & methods: 3D-printed scaffolds of biodegradable calcium phosphate and bioinert titanium were loaded with rhBMP-2 bone marrow aspirate, wrapped by a collagen membrane or a periosteum transplant and implanted into the greater omentum of miniature pigs. Results: Histological evaluation demonstrated significant bone formation within the first 8 weeks in both scaffolds. The periosteum transplant led to enhanced bone formation and a homogenous distribution in the scaffolds. The omentum tissue grew out a robust vascular supply. Conclusion: Endocultivation using 3D-printed scaffolds in the greater omentum is a very promising approach in defect-specific bone tissue regeneration.
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Affiliation(s)
- Hendrik Naujokat
- Department of Oral & Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany
| | - Klaas Loger
- Department of Oral & Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany
| | - Juliane Schulz
- Department of Oral & Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany
| | - Yahya Açil
- Department of Oral & Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany
| | - Jörg Wiltfang
- Department of Oral & Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany
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Zheng W, Chen Q, Zhang Y, Xia R, Gu X, Hao Y, Yu Z, Sun X, Hu D. BMP9 promotes osteogenic differentiation of SMSCs by activating the JNK/Smad2/3 signaling pathway. J Cell Biochem 2019; 121:2851-2863. [PMID: 31680322 DOI: 10.1002/jcb.29519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/10/2019] [Indexed: 12/22/2022]
Abstract
Synovial mesenchymal stem cells (SMSCs) with high proliferation and multi differentiation ability, and low immunogenicity have attracted research attention for their potential application in tissue engineering. Once their ability of osteogenesis is strengthened, it will be of practical value to apply the SMSCs in the field of bone regeneration. The current study aimed to investigate the osteogenic characteristics of SMSCs induced by bone morphogenetic protein 9 (BMP9) both in vitro and in vivo and to elucidate the mechanism underlying these characteristics. Specifically, different BMPs were assessed to determine the protein that would be the most favorable for stimulating osteogenic differentiation of SMSCs following their separation. The BMP9-enhanced osteogenesis of SMSCs was fully investigated in vitro and in vivo, and the c-Jun N-terminal kinase (JNK)/Smad2/3 signaling pathway stimulated by BMP9 was further explored. Our data suggested that BMP9 could significantly promote gene and protein expression of runt-related transcription factor 2, alkaline phosphatase, osteopontin, and osteocalcin, and SP600125, a JNK-specific inhibitor, could effectively decrease this tendency. Similar results were also confirmed in rats with cranial defects. In conclusion, our study indicated that BMP9 promotes bone formation both in vitro and in vivo possibly by activating the JNK/Smad2/3 signaling pathway.
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Affiliation(s)
- Weiwei Zheng
- Department of Orthopaedics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Qian Chen
- Laboratory Center, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Yu Zhang
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Rui Xia
- Department of Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xueping Gu
- Department of Orthopaedics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Yuefeng Hao
- Department of Orthopaedics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
| | - Zepeng Yu
- Department of Intervention, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xingwei Sun
- Department of Intervention, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Dan Hu
- Department of Orthopaedics, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China
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