Repair and remodeling of bone during healing and fusion require a combination of bone resorption and formation to successfully restore the bone to its previous strength. The healing process is highly responsive to the mechanical conditions of the construct, where excessive loading can cause high strains that delay healing, but moderate loading can be beneficial. Maintaining compression at the site of fracture can benefit healing by maintaining bone congruency and increasing the stability of the bone-implant construct to prevent excessive shifting. For these reasons, compressive mechanisms are employed in many orthopaedic devices, including both intramedullary (IM) nails and external fixators for ankle arthrodesis applications. Tibiotalocalcaneal (TTC) arthrodesis is a salvage procedure that fuses both the ankle and the subtalar joints. It has become the standard of care in ankle degeneration, which can be brought on by posttraumatic arthritis, failed total ankle arthroplasty, or diabetic conditions such as Charcot arthropathy. While current devices are effective in many cases, TTC arthrodesis procedures still incur failure rates as high as 22%, where failure of the bones to successfully fuse can result in amputation. Because bone healing relies upon bone resorption, the initial compression applied to the implanted constructs can be quickly lost, which may sacrifice the stability of the structure and delay or inhibit further healing. By employing a mechanism that can sustain compression during the bone healing process, it was possible to increase the stability of the construct even during bone resorption, minimizing the failures that still occur. The focus of this study was to determine the effects of compression on the mechanical stability of the implant-bone construct found in TTC arthrodesis. A comparison was made between the torsional stability of two currently marketed intramedullary devices, as well as a prototype IM device comprised of a nickel titanium core, designed to hold constant compression for up to 9mm of resorption. Additionally, the stability of each construct over time was evaluated by correlating bone resorption to a loss in compressive force.

Large bone defects pose a significant clinical challenge currently lacking an adequate therapeutic solution. Bone tissue engineering (BTE) therapies aim to provide that solution by combining structural scaffolds, bioactive factors, and/or osteogenic cells. Cellular therapies are likely vital to repair severe defects in patients lacking sufficient endogenous cells. Stem cells are attractive cell choices due to their osteogenic differentiation and extensive proliferation abilities, but their therapeutic potential is still uncertain, as studies comparing stem cell sources and delivery methods have produced inconsistent results. In this thesis, we developed a challenging in vivo large bone defect model for quantitative comparison of human stem cell-based therapies and then evaluated the abilities of adult or fetal stem cell-seeded constructs to enhance defect repair, with or without added osteogenic cues. First, we showed that cellular construct treatment enhanced defect healing over acellular construct treatment, although there were no differences between adult or fetal cell sources. We next labeled stem cells with a fluorescent tracking agent, the quantum dot, to determine biodistribution of implanted cells during the repair process. While quantum dots effectively labeled cells in vitro, they were ineffective in vivo tracking agents due to false positive signals and detrimental effects on stem cell-mediated repair. Finally, we developed a novel gene therapy technique using virus-coated scaffolds to deliver the osteogenic factor bone morphogenetic protein 2 (BMP2) to defect sites, either by in vitro (BMP2 transduction of seeded stem cells pre-implantation) or in vivo (BMP2 transduction of defect-site host cells) means. While defect-site BMP2 delivery through gene therapy methods improved repair, in vivo therapy enhanced healing more than stem cell-based in vitro therapy. This finding does not rule out the potential of stem cell-based in vitro gene therapy treatment for functional bone repair, as increases in viral dose may improve stem cell-mediated healing, but it does present evidence of a novel acellular BTE therapy with potential off-the-shelf clinical application in large bone defect repair, as scaffolds could be virally coated with the gene for BMP2 expression and frozen until implantation.

Modifications of biomaterial surface properties are employed to increase osteoblast differentiation and bone formation. Microtextured metallic surfaces promote osteoblast differentiation and high surface energy- achieved by controlling surface hydrocarbon contamination- increases osteoblast differentiation and peri-implant bone formation. Recombinant human bone morphogenic protein 2 (BMP2) is approved to induce bone formation in a number of applications. It is used clinically in combination with biomaterials to improve peri-implant bone formation and osseointegration. The amount of BMP2 that is required is large and inflammatory (swelling/seroma) and bone-related (ectopic bone/bone resorption) complications have been reported after BMP2 treatment. The aim of this study was to examine potential deleterious effects of BMP2 on the inflammatory environment and apoptosis of osteoblasts. Surface roughness and energy decreased pro-inflammatory interleukins and increased anti-inflammatory interleukins. In contrast, BMP2 abolished the surface effect, increasing pro-inflammatory interleukin (IL) 6, IL8, and IL17 in a surface roughness-dependent fashion and decreasing anti-inflammatory IL10 on rough surfaces. 5Z-7-Oxozeaenol and Dorsomorphin, but not H-8, blocked the effect of BMP2 on IL1A expression. There was an increase in expression of IL6 when treated with BMP2 for the control and H-8 groups, but both 5Z-7-Oxozeaenol and Dorsomorphin blocked the effect. Both 5Z-7-Oxozeaenol and H-8 blocked the effect of BMP2 on IL10 expression. BMP2 treatment had little effect on apoptosis in human mesenchymal stem cells (MSCs). Exogenous BMP2 had no effect on TUNEL. Caspase-3 activity was increased only at 200ng/ml BMP2. BAX/BCL2 decreased in MSCs treated with 50 and 100ng/ml BMP2. In contrast, BMP2 increased caspase-3 activity and TUNEL at all doses in normal human osteoblasts (NHOst). BAX/BCL2 increased in NHOst treated with BMP2 in a dose-dependent manner. Cells treated with 200 ng/ml BMP2 had an 8-fold increase in BAX/BCL2 expression in comparison with untreated cells. Similarly, BMP2 increased DNA fragmentation in NHOst cells. The BMP2-induced increase in DNA fragmentation was eliminated by 5-Z7-Oxozeaenol and Dorsomorphin. The results suggest that while surface features modulate an initial controlled inflammatory response, the addition of BMP2 induces a pro-inflammatory response. The effect of BMP2 on apoptosis depends on cell maturation state, inducing apoptosis in committed osteoblasts. BMP2 together with microtextured orthopaedic and dental implants may increase inflammation and possibly delay bone formation. Dose, location, and delivery strategies are important considerations in BMP2 as a therapeutic and must be optimized to minimize complications.

The work presented in this thesis focuses on the development of strategies and smart bioactive materials for the treatment of osteoporosis. High and low molecular weight soluble hyaluronic acid-bisphosphonate (HA-BP) derivatives were investigated for their ability to inhibit osteoclasts. Low molecular weight HA-BP (L-HA-BP) was most effective in inhibiting active resorption of both murine and human osteoclasts (without affecting osteoblasts) compared to free bisphosphonate (BP). Precursor monocytes were unaffected, suggesting the specificity of HA-BP towards osteoclasts. This new class of functionalized hyaluronic acid could lead to rapid development of tailor-made pro-drugs for targeted treatment of osteoporosis. Polyphosphoesters (PEP) have been widely studied for their pro-osteoblast effects, primarily due to their involvement in cellular energy production pathway leading to the formation of inorganic phosphates that contribute to mineralized bone. Given that the effect of PEP on human osteoclasts is little studied, this work on poly(ethylene sodium phosphate) (PEP.Na) explores the potential to use PEP.Na as an inhibitor of osteoclast activity for the first time. PEP.Na exposure led to a dose-dependent toxicity of osteoclasts with reduction in their capacity to form resorption pits over 24h. Currently, there is a dearth of in vitro cell-culture systems that can study osteoclast-related resorption and osteoblast-related mineralization in a single co-culture system, and to simultaneously quantify the effects of soluble factors on these processes. Described here, is the development of a novel and simple two-sided co-culture system that can overcome these limitations with reliable and quantifiable readouts. In comparison with traditional one-sided co-culture systems, the two-sided co-culture was able to generate similar readouts for alkaline phosphatase (ALP) and tartrate-resistant acid phosphatase (TRAP) markers. There is also the advantage of distinctly separate and quantifiable readouts for mineralization and resorption, which has been demonstrated using Pamidronate. Finally, HA-BP was synthesized with pre-determined amounts of BP groups. The BP groups attached to HA allowed the tunable incorporation of BMP-2 in hydrogels. The charge-based affinity of BMP-2 and BP allowed stable incorporation of specific amounts of BMP-2, which could be tuned by the ratio of BP groups. 125I-labelled BMP-2 was loaded into hydrogels and their release was studied. Radioactive measurements revealed the tunable sequestration and controlled release of protein over time. This result was corroborated by ALP measurements of cells exposed to released BMP-2. ALP production was found to be almost 5-fold higher in HA-BP hydrogels loaded with BMP-2 which suggested that the sequestered BMP-2 is not only available to cells but also remains highly potent, even in entrapped form, The release of BMP-2 is dependent upon the rate of diffusion, swelling in hydrogels and degradation pattern of the gels and may assist in the long-term and rapid regeneration of osteoblasts in vitro.

Bone loss from the cranio-maxillofacial region is a major clinical problem affecting patients worldwide. Conventional treatment strategy includes the use of autogenous or allogeneic bone, biomaterials, and osteogenic growth factors. However, there has been no effective therapy for most cases so far. Stem cell-based gene therapy is the latest research method with possible applications in humans. The present study aims to (1) characterize rabbit mesenchymal stem cells (MSCs) relating to growth pattern, surface antigens, and the potential for multi-differentiation; (2) determine the transduction efficiency and duration of recombinant adeno-associated virus2 carrying enhanced green fluorescent protein (rAAV2EGFP) reporter gene in rabbit MSCs and study the effects of rAAV2EGFP transduction on stem cells’ phenotype and capacity of multi-differentiation; (3) evaluate the differentiation characteristics of rabbit MSCs following recombinant adeno-associated virus 2 carrying bone morphogenetic protein 2 gene (rAAV2BMP2) transduction; (4) investigate whether MSCs transduced by rAAV2BMP2 could successfully induce bone regeneration in rabbit critical-size cranial defects. MSCs were isolated from bone marrows of rabbit tibias and cultured. Cell counting and colony-forming assays demonstrated that growth rates of MSCs dropped substantially with increasing passages. Flow cytometry on MSCs at passage 1 showed that cells expressed high level of CD49a and low level of CD44 as well as stage-specific embryonic antigen 4 (SSEA4). Multi-differentiation and reverse transcriptase-polymerase chain reaction (RTPCR) tests demonstrated that rabbit MSCs were capable to differentiate into osteocytes, chondrocytes and adipocytes. Immunofluorescence microscopy showed that rabbit MSCs produced a series of hematopoietic growth factors, including stem cell factor (SCF), vascular endothelial growth factor-A (VEGFA) and granulocyte macrophage colony-stimulating factor (GMCSF). Subsequently, rabbit MSCs were transduced with rAAV2EGFP in vitro. By comparing the transduction efficiency with different doses of rAAV2EGFP particles, multiplicity of infection (MOI) of 1 x 10 4 was identified as an optimal parameter for the transduction of rAAV2 in rabbit MSCs. Fluorescent microscopy demonstrated long-term expression of EGFP in rabbit MSCs after transduction both in vitro and in vivo. In addition, cell proliferation assay, adipogenic induction test and flow cytometry showed that rAAV2EGFP transduced MSCs exhibited a similar pattern with non-transduced cells on the cell growth, capacity of adipogenic differentiation and expression of surface antigens, indicating that rabbit MSCs maintain their stem cell properties after rAAV2EGFP transduction. / published_or_final_version / Dentistry / Doctoral / Doctor of Philosophy

M. Tech. Biomedical Technology. / Aims to gain more insights into the effect of a specific human derived BMP-complex, standardised according to the human BMP-2 content, by loading it at concentrations higher than the concentration of the morphogen found in human (hDBM), in order to determine changes in the osteogenic response.

published_or_final_version / Orthopaedic Surgery / Master / Master of Philosophy

Healing large bone defects remains a clinical challenge. While autografts are the gold standard treatment for large bone defects, they are limited by availability and donor site pain. Growth factor treatments such as BMP therapy provide a promising alternative but are expensive and present clinical safety concerns, primarily due to delivery of BMPs at supraphysiological doses. Integrins are ECM receptors which mediate crucial cell functions such as adhesion and differentiation. Therefore, understanding the role of integrins in bone formation and directing desired interactions may enable modulation of host cell functions for therapeutic applications. In this work, beta 1 integrins were deleted in osteolineage cells of transgenic mice at three different stages of differentiation to elucidate their role in bone development. We also engineered bioartificial PEG-based matrices which target the pro-osteogenic alpha 2 beta 1 integrin to promote bone healing. Conditional deletion of beta 1 integrins in osteochondroprogenitor cells under the Twist 2 promoter resulted in severe pre-natal skeletal mineralization defects and embryonic lethality. Targeted deletion of beta 1 integrins in osterix-expressing osteoprogenitors resulted in growth abnormalities, reduced calvarial mineralization, impaired femur development, and tooth defects. However, mice lacking beta 1 integrins in osteocalcin-expressing osteoblasts and osteocytes displayed only a mild skeletal phenotype, indicating that beta 1 integrins play an important role in early skeletal development, but are not required for mature osteoblast function. PEG hydrogels functionalized with the integrin-specific GFOGER ligand enhanced bone regeneration, induced defect bridging in combination with low doses of rhBMP-2 and stimulated improved bone healing compared collagen sponges, which are the clinical standard delivery vector for BMP-2 therapy. These results suggest that treatment with bioartificial integrin-specific PEG hydrogels may be a promising clinical strategy for bone regeneration in large bone defects.

Cell-based therapies have potential for tissue regeneration but poor delivery methods lead to low viability or dispersal of cells from target sites, limiting clinical utility. Here, we developed a degradable and injectable hydrogel to deliver stem cells for bone regeneration. Alginate microbeads <200µm are injectable, persist at implantation sites and contain viable cells, but do not readily degrade in-vivo. We hypothesized that controlled release of rat adipose-derived stem cells (ASCs) from alginate microbeads can be achieved by incorporating alginate-lyase in the hydrogel. Microbeads were formed using high electrostatic potential. Controlled degradation was achieved through direct combination of alginate-lyase and alginate at 4°C. Results showed that microbead degradation and cell release depended on the alginate-lyase to alginate ratio. Viability of released cells ranged from 87% on day 2 to 71% on day 12. Monolayer cultures of released ASCs grown in osteogenic medium produced higher levels of osteocalcin and similar levels of other soluble factors as ASCs that were neither previously encapsulated nor exposed to alginate-lyase. Bmp2, Fgf2, and Vegfa mRNA in released cells were also increased. Thus, this delivery system allows for controlled release of viable cells and can modulate their downstream osteogenic factor production.

Repair of bone defects is a major challenge in orthopaedic surgery. Current bone graft treatments, including autografts, allografts and xenografts, have many limitations making it necessary to develop a biomaterial to be a bone graft substitute. One such biomaterial is bioactive resorbable silica-calcium phosphate nanocomposite (SCPC). SCPC was processed using a 3D rapid prototyping technique and sintered at different temperatures to create porous scaffolds. SEM analyses and mercury intrusion porosimetry showed SCPC to be highly porous with micro- and nanopores. BET analysis indicated that SCPC had high surface area. Mechanical testing demonstrated that SCPC had a compressive strength similar to trabecular bone. Analysis of different thermal treatment temperatures indicated as the temperature was increased, the porosity decreased and the mechanical strength increased. When loaded with rhBMP-2 (SCPC-rhBMP-2), SCPC provided a sustained release profile of rhBMP-2 for 14 days. This was shown to be a greater release than hydroxyapatite (HA)-rhBMP-2. After immersion in SBF, ICP analyses showed the calcium concentration of SBF dropped drastically after one day of immersion. In conjunction, FTIR showed the formation of a hydroxyapatite layer on the SCPC surface and was confirmed by SEM. SCPC thermally treated at 850 ??C demonstrated the greatest dissolution/precipitation reactions when immersed in SBF. Processing the SCPC-rhBMP-2 hybrid using a rapid prototyping technique allowed for an exact replica of the rabbit ulna to be fabricated. This was implanted into a 10 mm segmental defect in the rabbit ulna. CT scans during the healing of the defect showed intimate union between SCPC-rhBMP-2 and the bone and about 65% healing of the defect after 4 weeks. Rabbits were euthanized after 12 and 16 weeks. Digital images show almost complete healing of the defect after 16 weeks. Torsional testing of the ulna after 12 weeks demonstrated restoration of maximum torque and angle at failure. Histological evaluation after 12 weeks showed the regenerated bone has all the morphological characteristics of mature bone. Through in-vitro and in-vivo testing, it can be recommended that the porous bioactive SCPC can serve as a successful delivery system for biological growth factors and serve as an alternative to autologous bone grafting.