Abstract
Bone is an organ with high natural regenerative capacity and most fractures heal spontaneously when appropriate fracture fixation is provided. However, additional treatment is required for patients with large segmental defects exceeding the endogenous healing potential and for patients suffering from fracture non-unions. These cases are often associated with insufficient vascularization. Transplantation of CD34+ endothelial progenitor cells (EPCs) has been successfully applied to promote neovascularization of bone defects, however including extensive ex vivo manipulation of cells. Here, we hypothesized, that treatment with granulocyte colony-stimulating factor (G-CSF) may improve bone healing by mobilization of CD34+ progenitor cells into the circulation, which in turn may facilitate vascularization at the defect site. In this pilot study, we aimed to characterize the different cell populations mobilized by G-CSF and investigate the influence of cell mobilization on the healing of a critical size femoral defect in rats. Cell mobilization was investigated by flow cytometry at different time points after five consecutive daily G-CSF injections. In a pilot study, bone healing of a 4.5-mm critical femoral defect in F344 rats was compared between a saline-treated control group and a G-CSF treatment group. In vivo microcomputed tomography and histology were applied to compare bone formation in both treatment groups. Our data revealed that leukocyte counts show a peak increase at the first day after the last G-CSF injection. In addition, we found that CD34+ progenitor cells, including EPCs, were significantly enriched at day 1, and further increased at day 5 and day 11. Upregulation of monocytes, granulocytes and macrophages peaked at day 1. G-CSF treatment significantly increased bone volume and bone density in the defect, which was confirmed by histology. Our data show that different cell populations are mobilized by G-CSF treatment in cell specific patterns. Although in this pilot study no bridging of the critical defect was observed, significantly improved bone formation by G-CSF treatment was clearly shown.
Highlights
While the majority of bone fractures and bone defects heal, nonunion is a common complication of a fracture; it indicates that fracture healing is not happening in a timely fashion
granulocyte colony-stimulating factor (G-CSF) induced an elevation of blood leukocytes
In another study, observing mononuclear cells (MNCs) as well as CD34+ cells during 5 days of daily G-CSF injections, the highest values were detected on the last day of intramuscular injections (Deng et al, 2015)
Summary
While the majority of bone fractures and bone defects heal, nonunion is a common complication of a fracture; it indicates that fracture healing is not happening in a timely fashion. The gold standard is still autogenous or allogenic bone grafting, but these come with obvious drawbacks such as comorbidities and limited material availability (Giannoudis et al, 2011) Bone transport methods such as Ilizarov have proven popular for some time but they require extensive care and are not exempt from complications (Catagni et al, 2011). Pharmacologic options such as BMP2 and PTH can improve bone healing to a certain degree, but it has been shown that bone regenerates better in presence of a mechanical support, such as a scaffold, for the cells to migrate on (Lichte et al, 2011). The research community is massively investigating into tissue engineered constructs with successes and failures (Keating et al, 2005; Hulsart-Billstrom et al, 2016)
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