Bone Marrow Implantation Research Articles

Bone Disease among Children with Sickle Cell Disease: A Scoping Review of Incidence and Interventions.

Children with sickle cell disease (SCD) are more likely to have deficient serum levels of vitamin D for bone metabolism. However, appropriate interventions are essential to prevent its progression and alleviate symptoms. The aim of this study is to determine interventions for managing bone disease in children with SCD. This study uses a scoping review. A literature review was conducted using PubMed, CINAHL, ScienceDirect, Scopus, and Google Scholar search engines. The study was eligible for inclusion if it included articles published from 2013 to 2023, full-text, and original study design. Study quality was assessed using the Joanna Briggs Institute (JBI) appraisal tool. This review identified six studies and 114 children with SCD, including 57 boys (50%) and 57 girls (50%). The majority of SCD types experienced were HbSS (86.84%), HbS-B0 Thal (7.01%), HbSC (5.27%), and the HbSS Arab-Indian haplotype (0.88%). Bone disease problems that often arise in children with SCD include Avascular Necrosis (AVN) (78.08%), Osteonecrosis of the Femoral Head (ONFH) (18.42%), and other bone problems (3.50%). Meanwhile, four types of intervention findings were used in managing bone disease among children with SCD: 1). Surgical procedures 53 (41.09%) included total hip arthroplasty (THA), Osteotomy, and Multiple epiphyseal drilling with Autologous Bone Marrow Implantation (AMBI); 2). Invasive procedures 67 (51.93%) included intravenous bisphosphonates, hydroxyurea (HU), and core decompression (CD) with bone marrow aspirate concentrate injection: 3). Oral pharmacological or Vitamin D3 (cholecalciferol) 4 (3.10%); 4). Non-pharmacology or physical therapy 5 (3.88%). Our findings highlight that surgical, invasive, pharmacological, and physical therapy interventions positively impact increasing bone mineral density (BMD) and functional improvement of bone disease among children with SCD. The interventions provided excellent functional outcomes with minimal complications and no life-threatening side effects.

Implantation of Culture-Expanded Bone Marrow Derived Mesenchymal Stromal Cells for Treatment of Osteonecrosis of the Femoral Head.

Although core decompression (CD) with stem cell for the treatment of osteonecrosis of the femoral head (ONFH) showed promising results in many reports, the efficacy remains uncertain. We aimed to evaluate the efficacy of CD with culture-expanded autologous bone marrow-derived mesenchymal stem cell (BM-MSC) implantation in early stage ONFH. A total of 18 patients (22 hips) with ONFH who underwent CD with culture-expanded BM-MSC implantation from September 2013 to July 2020 were retrospectively reviewed. The median age was 35.0years [interquartile range (IQR), 28.5-42.0], and the median follow-up period was 4.0years (IQR, 2.0-5.3). The median number of MSCs was 1.06 × 108. To evaluate radiographic and clinical outcomes, Association Research Circulation Osseous (ARCO) classifications, Japanese Investigation Committee classification, combined necrotic angle (CNA) visual analogue scale (VAS) and Harris Hip Score (HHS) were checked at each follow-up. The preoperative stage of ONFH was ARCO 2 in 14 hips and ARCO 3a in 8 hips. The ARCO staging was maintained in 7 hips in ARCO 2 and 4 hips in ARCO 3a. The radiographic failure rate of ARCO 2 and 3a was 14.3 and 50%, respectively. Furthermore, CNA decreased to more than 20° in 6 hips (four were ARCO 2 and two were ARCO 3a).There was no significant difference in the VAS and HHS (P = 0.052 and P = 0.535, respectively). Total hip arthroplasty was performed in 4 hips. CD with culture-expanded autologous BM-MSCs showed promising results for the treatment of early stage ONFH.

Expansion strategies for umbilical cord blood haematopoietic stem cells in vitro.

Haematopoietic stem cell transplantation (HSCT) is considered an effective treatment for some haematopoietic malignancies, haematopoietic failure and immunodeficiency. Compared with bone marrow and mobilized peripheral blood, cord blood has the advantages of easy access, being harmless to donors and low requirement for HLA matching. In addition, umbilical cord blood transplantation (UCBT) has achieved remarkable clinical success in the past 30 years due to the low recurrence rate of malignancies treated by UCBT, mild degree of chronic graft-versus-host disease (GVHD) and good quality of life for patients after transplantation. However, the number of cells in a single cord blood is too small for rapid bone marrow implantation. We summarize the various factors involved that need to be considered in the expansion of haematopoietic stem cells (HSCs) in vitro, which all avoid complex operations, such as vector construction and virus transfection. We also found it necessary to identify a new molecule as the carrier of HSCs cultured in vitro, which not only would provide a three-dimensional structure conducive to the self-renewal of HSCs but also prevent their differentiation.

Failure and progression to total hip arthroplasty among the treatments for femoral head osteonecrosis: a Bayesian network meta-analysis.

Osteonecrosis of the femoral head (ONFH) often leads to secondary osteoarthritis and total hip arthroplasty. Recent published literatures. There has been increasing focus on the early intervention in ONFH patients to preserve the native hip articulation, reduce pain and improve function. Efficacy of surgical strategies for ONFH is debated. Several clinical studies showed controversial results, and the best treatment has not yet been clarified. To provide an overview over current treatment options for ONFH compares their failure rates and conversion to total hip arthroplasty (THA) rates. Core decompression (CD) augmented with autologous bone grafting plus the implantation of bone marrow concentrate can decrease the rate of failure and progression to THA rates compared to CD alone.

Role of Scaffolds, Subchondral, Intra-Articular Injections of Fresh Autologous Bone Marrow Concentrate Regenerative Cells in Treating Human Knee Cartilage Lesions: Different Approaches and Different Results.

The value of bone marrow aspirate concentrates for treatment of human knee cartilage lesions is unclear. Most of the studies were performed with intra-articular injections. However, subchondral bone plays an important role in the progression of osteoarthritis. We investigated by a literature review whether joint, subchondral bone, or/and scaffolds implantation of fresh autologous bone marrow aspirate concentrated (BMAC) containing mesenchymal stem cells (MSCs) would improve osteoarthritis (OA). There is in vivo evidence that suggests that all these different approaches (intra-articular injections, subchondral implantation, scaffolds loaded with BMAC) can improve the patient. This review analyzes the evidence for each different approach to treat OA. We found that the use of intra-articular injections resulted in a significant relief of pain symptoms in the short term and was maintained in 12 months. However, the clinical trials indicate that the application of autologous bone marrow concentrates in combination with scaffolds or in injection in the subchondral bone was superior to intra-articular injection for long-term results. The tendency of MSCs to differentiate into fibrocartilage affecting the outcome was a common issue faced by all the studies when biopsies were performed, except for scaffolds implantation in which some hyaline cartilage was found. The review suggests also that both implantation of subchondral BMAC and scaffolds loaded with BMAC could reduce the need for further surgery.

Early injection of autologous bone marrow concentrates decreases infection risk and improves healing of acute severe open tibial fractures

IntroductionOpen fractures are at risk of nonunion; surgeons are reluctant to propose early standard bone grafting after open fractures, preferring to wait in order to adequately assess the facture status of infection. Bone marrow contains mesenchymal stem cells (MSCs) and granulocyte and macrophage precursors identified in vitro as colony forming units-granulocyte macrophage (CFU-GM), both of which have a prophylactic action against infection. We therefore tested the hypothesis that early injection of bone marrow concentrate would be useful in these fractures. MethodsWe evaluated a series of 231 patients who had received early percutaneous implantation of bone marrow concentrate (BMC) to treat open fractures (with gap less than 10 mm) that were Gustilo-Anderson Type II or III. The results were compared with those of 67 control (no early graft) patients and with those of 76 patients treated with an early, standard of care, iliac bone graft. All patients were treated with external fixation and were considered to have an aseptic fracture at the time of early grafting, but the actual status of infection was re-assessed at the time of grafting by histology and/or analysis of the aspirate. The bone marrow graft contained after concentration 49,758 ± 21,642 CFU-GM-derived colonies/cc and 9400 ± 1435 MSCs/cc which represents an important increase compared to the level of CFU-GM cells and MSCs present in a standard auto-graft. Healing was evaluated at 9 months. ResultsThe rate of unsuspected infections was higher than 15% in the 3 groups. Bone union and removal of external fixation was achieved at 9 months by 50.7% of patients in the Control Group, by 86.8% of patients in the group with a standard bone graft, and by 87.4% of patients in the bone marrow group. A 90% risk reduction (p = 0.005) in the need for an invasive standard bone graft to treat a nonunion and in the risk of infection was observed when bone marrow was proposed as early injection to the treatment of type II or type-III tibial fractures. ConclusionBone marrow concentrate for early grafting in open fractures with limited gap was efficient for healing while decreasing infection.

Core Decompression Combined with Implantation of Autologous Bone Marrow Concentrate with Tricalcium Phosphate Does Not Prevent Radiographic Progression in Early Stage Osteonecrosis of the Hip.

BackgroudUntreated osteonecrosis of the femoral head ultimately leads to secondary coxarthrosis. The aim of this study was to determinate if the core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate could be used to prevent radiographic progression of early stage osteonecrosis of the hip. We also sought to determine whether this treatment improved clinical outcomes and reduced the need for total hip arthroplasty.MethodsEighteen hips were included in the present study. All of them underwent core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate between 2007 and 2012. The cell concentrate was obtained from the posterior iliac crest and processed and implanted during the same surgical procedure. Patient demographic data, clinical data including modified Harris hip score, and radiological data were collected preoperatively, postoperatively, and during the follow-up period. Also, survival endpoints were analyzed: time of femoral head collapse and need for total hip arthroplasty.ResultsThe mean age of patients was 37.8 years (standard deviation [SD], 9.31 years). The mean follow-up was 68.9 months (SD, 15.0 months). In most cases (70.6%), the etiology of the osteonecrosis of the femoral head was corticosteroid use; in the remaining cases, secondary to alcohol use. Core decompression of the femoral head combined with implantation of autologous bone marrow concentrate with tricalcium phosphate did not prevent progression to collapse (< 80% at 5 years) although modified Harris hip scores improved. Overall median survival with the total hip arthroplasty as endpoint was 23 months (95% confidence interval [CI], 14.9 to 31.1 months). Overall median survival time with any degree of collapse as endpoint was 7 months (95% CI, 2.0 to 12.0 months).ConclusionsThe results obtained in this study suggest that core decompression combined with implantation of autologous bone marrow concentrate and tricalcium phosphate will not prevent radiographic progression of early stage osteonecrosis of the hip. These finding also suggest that the absence of indications for hip replacement alone is not an indicator of good response to the treatment, and it is important to note the radiological results.

218. Randomized prospective clinical trial to evaluate efficacy and safety in lumbar fusion surgery of implantation of autologous bone marrow mesenchymal cells expanded ex vivo and combined with allogeneic bone tissue, compared with autologous iliac crest graft: part I: radiological findings

BACKGROUND CONTEXT Spinal fusion is a widely used surgical technique for a great variety of spine pathologies. Spinal fusion using the patient's iliac crest is the standard surgical technique, although it is associated with a relevant percentage of failures and local morbidity of the bone donor area. PURPOSE The main objective of this clinical trial was to evaluate the feasibility, safety, and efficacy of implantation of a scaffold of heterologous human cancellous bone tissue seeded with autologous bone marrow mesenchymal cells expanded ex vivo (XCEL-MT-OSTEO-ALPHA) and to compare the resulting intervertebral fusion as evaluated by radiography and computed tomography (CT) with that obtained in patients who received autologous iliac crest graft. STUDY DESIGN/SETTING Multicenter, prospective, open-label, randomized, parallel and single-dose phase I-II study (EudraCT No.2010-023999-12; NCT01552707). PATIENT SAMPLE Sixty-five patients from 5 centers (mean age, 61.05 years; 65.6% female) with degenerative spondylolisthesis (79.4%) and/or disc disease at L4-L5. OUTCOME MEASURES Adverse events were recorded and fusion was assessed by radiography (3, 6, and 12 months) and CT (6 and 12 months). Bone fusion status was evaluated according to previously established qualitative criteria by a radiologist who was blind to treatment allocation. METHODS Patients underwent instrumented circumferential fusion at L4-L5; transforaminal lumbar interbody fusion (TLIF) was performed using an intersomatic cage filled with autologous iliac crest graft, and intertransverse fusion consisted of local bone graft on the TLIF side and randomly assigned XCEL-MT-OSTEO-ALPHA (Group A, treatment) or autologous iliac crest graft (Group B, control) on the contralateral side.Patients underwent follow-up for 1 year. RESULTS Groups A and B comprised 31 and 34 patients, respectively. There were no significant differences in preoperative variables between groups, and no serious adverse reactions were associated with the product. Compared with controls the treatment group showed a significantly higher rate of intertransverse fusion as determined by radiography at 3 (85.7% vs 56.3%), 6 (81.5% vs 48.3%), and 12 months (96.3% vs 51.7%) and by CT at 6 months (96.3% vs 54.8%). One year after surgery the intertransverse fusion rate was higher in the treatment than the control group (86.2% vs 66.7%), although this difference was not significant. CONCLUSIONS XCEL-MT-OSTEO-ALPHA is a viable and safe product for use in lumbar fusion surgery. Radiological fusion rates in the area in which the product was applied were significantly higher than those obtained with autologous iliac crest graft. FDA DEVICE/DRUG STATUS XCEL-MT-OSTEO-ALPHA (Not approved for this indication)

Equivalent 10-Year Outcomes After Implantation of Autologous Bone Marrow–Derived Mesenchymal Stem Cells Versus Autologous Chondrocyte Implantation for Chondral Defects of the Knee

Background: The use of bone marrow–derived mesenchymal stem cells (BMSCs) in cartilage repair procedures circumvents some of the limitations of autologous chondrocyte implantation (ACI), but long-term outcomes for this newer procedure are lacking. The authors previously reported comparable outcomes for the 2 procedures at 2-year follow-up. Purpose/Hypothesis: The purpose was to compare the long-term clinical outcomes of ACI versus BMSCs. It was hypothesized that there would be no significant difference between the groups in terms of patient-reported outcome scores and safety outcomes at 10-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Seventy-two patients who underwent either ACI or BMSC implantation—matched in terms of age and lesion site— were followed up to a median of at least 10 years. Patients were assessed with the 36-item Short Form Health Survey (SF-36), the International Knee Documentation Committee knee evaluation form, the Lysholm Knee Score, and the Tegner Activity Scale. In addition, information was obtained regarding any additional surgical procedures as well as safety data, with particular attention to infection and tumor formation. Results: There was an improvement in all patient-reported outcomes scores apart from the Mental Component Summary of the SF-36 after cartilage repair surgery. There was no significant difference in any of the patient-reported outcomes between cohorts at any time point. Six and 5 patients in the ACI and BMSC groups, respectively, underwent subsequent surgical procedures, including 1 total knee replacement in the BMSC group. None of the patients in either group developed any deep infection or tumor within the follow-up period. Conclusion: BMSC implantation used for the treatment of chondral defects of the knee appears to result in equivalent clinical outcomes to first-generation ACI at up to 10 years, with no apparent increased tumor formation risk.

Osteonecrosis in Pediatric Patients with Acute Lymphoblastic Leukemia (ALL): A Single-Center Cohort Analysis

Introduction: Osteonecrosis (ON) is one of the most debilitating sequelae in pediatric patients with ALL, related with front-line, second-line chemotherapy or HSCT. Many studies reported ON incidence and risk factors, but results differ substantially. Clinical significance of radiological findings is not fully established, due to deficiencies in available radiological classifications and a consensus regarding therapeutic approach is still lacking. Recently Niinimäki proposed a new scoring system for ON in oncologic patients (Niinimäki et al., 2015).Materials and methods: 270 consecutive patients enrolled in the AIEOP-BFM ALL 2009 protocol from October 2010 to December 2016 in our institution have been prospectively analysed. Patients were tested with MRI in case of clinical suspicion of ON; a subgroup of 19 out of 39 transplanted patients underwent MRI as screening before HSCT. 168 MRI (average 4 per patient) were reviewed and 318 ON lesions classified according to the Niinimäki score. Steinberg classification was used to evaluate femoral head and specially adapted for convex surfaces of the major joints involved. Surgery mainly consisted of core-decompression +/- bone marrow concentrate autografting. Surgical outcome was assessed by means of quality of life assessment questionnaires (SF-36) and joint specific questionnaires before and 6 months after surgery.Results: Out of 270, 43 patients developed ON (16%); 62% of them were male (p-value 0.42), 63% ≥10 years and 26% ≥15 years (p-value <0.001), 26% T-ALL (p-value 0.01) and 58% high risk (p-value <0.001). 3 out of 4 Ph+ ALL patients, who received additional TKI, developed ON: 1 was younger than 6 years, 2 of 3 underwent surgery for severe ON. A multivariate analysis assess that the risk of ON is 6-fold higher in high risk patients, compared with standard and intermediate risk (HR 6.3; p-value <0.0001), 12-fold higher in patients ≥10 years-old (HR 11.983; p-value <0.0001), while no significant impact of immunophenotype could be demonstrated. Considering ON diagnosis also after relapse and transplant, the risk of ON remains significantly higher in high risk patients (HR 3.2; p-value 0.0005) and in patients ≥10 years-old (HR 9.8; p-value <0.0001), while a significant impact of transplant couldn't be assessed (p-value 0.16). Cumulative incidence of ON at 5-years was 18.9% (SE 2.7) and after censoring patients at relapse and transplant was 14.2% (SE 2.3). At first MRI, knees were involved in 25 patients (58%), hips in 15 (35%), ankles in 22 (52%), shoulders in 3 patients (with available upper limbs MRI), tibial diaphyses in 28 patients (67%). The total number of affected joints was 138, with a median of 3 per patient; the total amount of lesions detected anytime was 399 (median 8 lesions per patient; range 1-22, IQ 5-12). The bilateral involvement of the same joint was found in 8 of the 17 patients with ON of the hip, 26/35 for the knee (74%) and 23/25 (92%) for the ankle, 26/29 (90%) for the tibial diaphysis. The Niinimäki classification allowed to compare different type of ON lesions: convex surface, concave surface, diaphysis. Diaphyseal lesions had virtually no clinical significance, with around 25% of tibial lesions disappearing. Lesions involving concave surfaces had scarce clinical significance, with almost half lesions resolved or improving during follow-up. The lesions of the convex surface were the most severely affected causing the worst disabilities. Niinimaki and Steinberg classifications were not consistent with each other for convex surfaces and the Steinberg scoring better predictive of subsequent disabilities. Seventeen over 43 patients (39%) underwent core decompression, in 10 patients implemented by autologous implantation of bone marrow concentrate. In 9 patients multiple sites underwent surgery during the same procedure (range 1 - 6), the knee was the most involved (19 joints operated). Quality of life and performance status questionnaires, assessed in 10 patients, demonstrated pain reduction and improvement of joint activity after surgery, especially for the knee.Conclusions: ON has a high prevalence in ALL pediatric patients, who generally present with multiple lesions. The most relevant lesions involved convex surfaces, for which the Niinimäki classification lacked in specificity for clinical outcome and a new score system is under evaluation. Core decompression appears as a promising approach also in pediatric patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Combination of High Tibial Osteotomy and Autologous Bone Marrow Derived Cell Implantation in Early Osteoarthritis of Knee: A Preliminary Study.

High tibial osteotomy (HTO) is a recommended treatment for medial compartment knee osteoarthritis. Newer cartilage regenerative procedures may add benefits to the results of HTO. In this prospective study we have investigated the safety and also results of HTO associated with autologous bone marrow derived cells (BMDC) implantation in relatively young and middle aged active individuals with early osteoarthritis of the knee. A total of 24 patients (mean age of 47.9 years) with varus knee and symptomatic medial compartment osteoarthritis were treated with medial opening-wedge high tibial osteotomy in conjunction with implantation of bone marrow derived cells into the chondral lesions. The clinical outcomes were assessed by IKDC, KOOS, VAS, and Tegner scores. The radiographic studies were performed preoperatively and at follow-ups. No major complications were seen during the operations and postoperative follow-ups. All clinical scores were significantly improved for the IKDC score (from 32.7±15 to 64±21) (P<0.005), KOOS score (from30±11 to 68±19) (P<0.005), VAS (from 7.5 to 3) and Tegner score (from 1.2 to 2.1) (P<0.004). HTO in conjunction with BMDC implantation is a safe and feasible treatment and is associated with good results in short term follow up for early medial compartment osteoarthritis in varus knees.Level of evidence: IV.

Intra-articular knee implantation of autologous bone marrow–derived mesenchymal stromal cells in rheumatoid arthritis patients with knee involvement: Results of a randomized, triple-blind, placebo-controlled phase 1/2 clinical trial

BackgroundIn this study, we intend to assess the safety and tolerability of intra-articular knee implantation of autologous bone marrow–derived mesenchymal stromal cells (MSCs) in patients with rheumatoid arthritis (RA) and to determine the preliminary clinical efficacy data in this population. The trial registration numbers are as follows: Royan Institute Ethics Committee: AC/91/1133; NCT01873625. MethodsThis single-center, randomized, triple-blind, placebo-controlled phase 1/2 clinical trial randomized RA patients with knee involvement to receive either an intra-articular knee implantation of 40 million autologous bone marrow–derived MSCs per joint or normal saline (placebo). Patients were followed up for 12 months to assess therapy outcomes. ResultsA total of 30 patients, 15 in the MSC group and 15 in the placebo group, enrolled in this study. There were no adverse effects reported after MSC administration or during follow-up. Patients who received MSCs had superior findings according to the Western Ontario and McMaster Universities Arthritis Index (WOMAC), visual analogue scale (VAS), time to jelling and pain-free walking distance. However, this improvement could not be significantly sustained beyond 12 months. The MSC group exhibited improved standing time (P = 0.01). In addition, the MSCs appeared to contribute to reductions in methotrexate and prednisolone use. ConclusionIntra-articular knee implantation of MSCs appeared to be safe and well tolerated. In addition, we observed a trend toward clinical efficacy. These results, in our opinion, have justified the need for further investigations over an extended assessment period with larger numbers of RA patients who have knee involvement.

Stem cell therapy in early post-traumatic talus osteonecrosis.

Avascular necrosis of the talus is one of the most notable complications associated with talar neck fractures with frequent evolution of the osteonecrosis into a difficult arthrodesis. We tested whether the injection of bone marrow mesenchymal stem cells (MSCs) could improve the repair process of the osteonecrosis. Forty-five early (without collapse) post-traumatic talus osteonecroses (group 1; study group) were treated between 1995 and 2012 with percutaneous injection of progenitor cells (autologous bone marrow concentrate from the iliac crest). The number of MSCs transplanted in each ankle of group 1 was 124 × 103 cells (range 101 × 103 to 164 × 103 cells). The evolution of these osteonecroses treated with autologous bone marrow implantation was compared with the evolution of a control group of 34 talar osteonecroses without collapse and treated with only core decompression (group 2; control group) between 1985 and 1995. The outcome was determined by progression in radiographic stages to collapse, by the need of arthrodesis, and by the time to successfully achieve fusion for patients who needed arthrodesis. For the 45 ankles with autologous concentrate bone marrow grafting, collapse frequency was lower (27%, 12 among 45 versus 71%, 24 among 34; odds ratio 0.1515, 95% CI 0.0563-0.4079; P = 0.0002) and follow-up showed longer duration of survival before collapse or arthrodesis, compared to 34 ankles of the control patients with core decompression alone. Furthermore, the time to successfully achieve fusion after arthrodesis was significantly shorter in patients treated with bone marrow progenitors as compared with the other ankles, which had core decompression alone. In our study the early conservative surgical treatment with autologous bone marrow grafting improved the natural course of the disease as compared with core decompression alone.

Autologous osteoblastic cells (PREOBy) versus concentrated bone marrow implantation in osteonecrosis of the femoral head: A randomized study

Background In non-traumatic osteonecrosis of the femoral head (ONFH), implantation of bone marrow concentrate (BMC) containing mesenchymal stem cells (MSC) could delay ONFH progression and improve symptoms (Hernigou 2002, Gangji 2004). The next step was to assess the hypothesis that a population of autologous osteoblastic cells (OB) consisting in a more differentiated cell than MSC, could be more efficacious than BMC in early stages ON. Objectives To evaluate the efficacy of OB cells implantation in a randomized comparison with BMC implantation in precollapse ARCO stages ONFH. Methods In a randomized controlled single blind trial, hips were treated by a core decompression procedure followed by BMC or OB cells implantation. In the BMC group, 410.6 ± 84.9 mL of BM was concentrated to 41.8 ± 10.9 mL. In the OB group, MSC were isolated from BM aspirate (48.8 ± 17.7 mL), expanded and differentiated ex vivo under autologous conditions to obtain OB cells (18.6 ± 4.3 106 cells). Hip pain, WOMAC score and x-rays were assessed at 24 and 36 months. The primary endpoint was the absence of progression to fractural stages and a significant pain improvement (responder). Results From 72 hips randomized, 60 hips (30 group) were analyzed as the ITT efficacy cohort (50.6 ± 11.8 years). Baseline demographic data, risk factors, location and size of ON and symptoms were not statistically different between groups. At 24 months, 70% versus 40% of hips (P Discussion OB cells seems able to improve ONFH better than BMC implantation. No difference was observed in the safety profiles of OB cells and BMC. Conclusions OB cells (PREOBy) treatment seems to be more efficacious than BMC treatment to delay the evolution to subchondral fracture and to reduce pain in ONFH.

Intravitreal implantation of TPP1-transduced stem cells delays retinal degeneration in canine CLN2 neuronal ceroid lipofuscinosis

The CLN2 form of neuronal ceroid lipofuscinosis is a neurodegenerative disease that results from mutations in the TPP1 gene. Affected children exhibit progressive declines in most neurological functions including vision. Functional declines are accompanied by progressive brain and retinal atrophy. TPP1 encodes the soluble lysosomal enzyme tripeptidyl peptidase-1 (TPP1). Dachshunds with a TPP1 null mutation exhibit a disorder very similar to human CLN2 disease. Periodic infusion of recombinant TPP1 protein or a single injection of a TPP1 gene therapy vector into the cerebrospinal fluid of affected dogs significantly delays the onset and progression of neurological signs but does not slow vision loss or retinal degeneration. Studies were conducted to determine whether intravitreal implantation of autologous bone marrow derived stem cells transduced with a TPP1 expression construct would inhibit retinal degeneration in the canine model. A single injection of the transduced cells at an early stage in the disease progression substantially inhibited the development of disease-related retinal function deficits and structural changes. No adverse effects of the treatment were detected. These findings indicate that ex vivo gene therapy using autologous stem cells is an effective means of achieving sustained delivery of therapeutic compounds to tissues such as the retina for which systemic administration would be ineffective.

Clonal characteristics of mesenchymal stem cells able to transfer microenvironment

Mesenchymal stem cells (MSCs) can transfer hematopoietic microenvironment in vivo. After implantation of murine femur bone marrow (BM) plug or adherent cell layer (ACL) of long-term bone marrow culture (LTBMC) established from the same BM equivalent, ectopic hematopoietic focus is formed under the renal capsule of syngeneic recipient. Stromal cells in those foci are derived from donor MSCs, while hematopoietic cells are of recipient origin. Cellularity of individual foci is proportional to the number of transplanted femur equivalents. Consequently, this assay can be used to quantitatively assess the number of MSCs in BM. Based on the self-renewal potential of MSCs, ectopic foci can be serially retransplanted. The aim of this study was to characterize the clonal structure of MSC populations. LTBMCs were obtained from F1 (CBA x C57Black/J6) mice. Cultures were transduced 2 weeks after establishment with a lentiviral library containing genetic barcodes (32 variable nucleotides). After additional 2 weeks, the proportion of marked stromal clonogenic cells (colony forming units fibroblast /CFU-F/) in ACLs was 73.7±5.1%. ACLs were implanted under the renal capsules of syngeneic recipients. Six weeks later the developed ectopic foci were partially retransplanted. DNA was isolated from LTBMCs, initial and secondary ectopic foci. Barcode sequences were determined on Illumina platform. In initial ectopic foci 278±40 (n = 7) individual barcodes were identified. The secondary ectopic foci contained 247±23 (n = 4) barcodes. Only 12±1 common barcodes were found in both initial and secondary foci. Since the secondary were descendants of the initial foci, we calculated that the initial foci contained about 500 barcoded MSCs, meaning that at least 2.3% of MSCs took part in the formation of hematopoietic microenvironment in the initial and the secondary foci. All other MSCs formed microenvironment only once. Taking into account the proportion of marked stromal clonogenic cells in ACLs, initial foci contained at least 600 MSCs. As each LTBMC was established from one femur, a femur contains no less than 600 MSCs. Presuming a linear relationship between the number of implanted MSCs and the size of ectopic foci, our data suggest that not all MSCs, but only part of them is involved in formation of hematopoietic microenvironment.

Preliminary Results of Multiple Epiphyseal Drilling and Autologous Bone Marrow Implantation for Osteonecrosis of the Femoral Head Secondary to Sickle Cell Disease in Children.

Sickle cell disease (SCD) is the most common cause of osteonecrosis of the femoral head (ONFH) during childhood. The natural history of ONFH in SCD is poor with progression to femoral head collapse and deformity that ultimately may lead to hip osteoarthritis. Multiple epiphyseal drilling with autologous bone marrow implantation may enhance the mechanism of osteogenic repair. The purpose of this study was to describe early clinical and radiographic outcomes in pediatric patients with ONFH secondary to SCD after multiple epiphyseal drilling and AMBI. Nine boys and 2 girls (14 hips) with a mean age of 12.7 years (range, 9.7-18 y) at the time of surgery were evaluated. All patients were followed for at least 1 year after surgery and the mean duration of follow-up was 25 months (range, 12-47 mo). Clinical outcome was assessed by the pain domain from the Children's Hospital Oakland Hip Evaluation Scale and by hip range of motion. The extent of femoral head involvement was assessed by measuring the arc of necrosis and the amount of collapse on anteroposterior and frog lateral radiographs. The University of Pennsylvania system was used to assess the osteonecrosis stage. Wilcoxon signed-rank tests were used to compare radiographic and clinical variables. Compared with preoperative measures, multiple epiphyseal drilling with AMBI resulted in significant improvement in pain (P=0.0010), internal hip rotation (P=0.0005), external hip rotation (P=0.0010), and flexion (P=0.0015). The amount of lateral collapse (P=0.4609), anterior collapse (P=0.4258), and the arc of necrosis (P=0.2251) were not significant after surgery. The majority of the hips had either improvement in the Steinberg stage of disease (4/14 hips) or no further progression (7/14 hips) at the latest follow-up. There were no surgical complications. Multiple epiphyseal drilling with autologous bone marrow cell implantation allows for short-term clinical improvement and limits radiographic progression of ONFH associated with SCD in children with minimal morbidity.

Mini-invasive treatment for delayed or nonunion: the use of percutaneous autologous bone marrow injection

Delayed union or nonunion of bone fracture is becoming less frequent, but still remains a challenging clinical problem. Autologous cancellous bone grafting that is the gold standard method, often involves donor site morbidities and complications. Once these fractures have been mechanically stabilized, other local factors should be investigated to promote delayed healing. The purpose of this study was to evaluate the initial outcome of the percutaneous injection of autologous bone marrow after concentration for the treatment of delayed or nonunion. Our subjects included 10 patients of delayed or nonunion fracture (3 female, 7 male) with an average age of 28 years. All fractures were mechanically stabilized after accident. Delayed or nonunion affected the femur in 2 patients, the tibia in 5 patients, the humerus in 2 patients, and the ulna in 1 patient. Bone marrow aspirates were obtained from both the posterior superior iliac crest. Bone marrow aspiration concentrate was produced via density gradient centrifugation. Trocars were inserted in the delayed or nonunion gap under fluoroscopic guidance. The bone marrow aspiration concentrate was injected slowly. As results, all of 10 delayed or nonunion healed after treatment with percutaneous injection of autologous bone marrow. The mean time for new bone formation was 3.3 months, for clinical union was 5.2 months, and for radiological union was 11.8 months. The current study is encouraging in the initial outcome and percutaneous bone marrow implantation could be an effective and safe treatment for delayed or nonunion.

Influence of transcutaneous electrical stimulation on heterotopic ossification: an experimental study in Wistar rats.

Heterotopic ossification (HO) is a metaplastic biological process in which there is newly formed bone in soft tissues, resulting in joint mobility deficit and pain. Different treatment modalities have been tried to prevent HO development, but there is no consensus on a therapeutic approach. Since electrical stimulation is a widely used resource in physiotherapy practice to stimulate joint mobility, with analgesic and anti-inflammatory effects, its usefulness for HO treatment was investigated. We aimed to identify the influence of electrical stimulation on induced HO in Wistar rats. Thirty-six male rats (350-390 g) were used, and all animals were anesthetized for blood sampling before HO induction, to quantify the serum alkaline phosphatase. HO induction was performed by bone marrow implantation in both quadriceps of the animals, which were then divided into 3 groups: control (CG), transcutaneous electrical nerve stimulation (TENS) group (TG), and functional electrical stimulation (FES) group (FG) with 12 rats each. All animals were anesthetized and electrically stimulated twice per week, for 35 days from induction day. After this period, another blood sample was collected and quadriceps muscles were bilaterally removed for histological and calcium analysis and the rats were killed. Calcium levels in muscles showed significantly lower results when comparing TG and FG (P<0.001) and between TG and CG (P<0.001). Qualitative histological analyses confirmed 100% HO in FG and CG, while in TG the HO was detected in 54.5% of the animals. The effects of the muscle contractions caused by FES increased HO, while anti-inflammatory effects of TENS reduced HO.

Combining Concentrated Autologous Bone Marrow Stem Cells Injection With Core Decompression Improves Outcome for Patients with Early-Stage Osteonecrosis of the Femoral Head: A Comparative Study

The management of early-stage osteonecrosis of the femoral head (ONFH) remains challenging. This study aimed to evaluate the effects of core decompression and concentrated bone marrow implantation on ONFH. The study recruited 28 hips with early ONFH randomly assigned into two groups of core decompression with (group A) and without (group B) bone marrow injection. Patients were evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, Visual Analogue Scale (VAS) pain index, and MRI. The mean WOMAC and VAS scores in all patients improved significantly (P<0.001). MRI showed a significant improvement in group A (P=0.046) and significant worsening in group B (P<0.001). Bone marrow stem cell injection with core decompression can be effective in early ONFH.