Original Full Length ArticleInduced periosteum a complex cellular scaffold for the treatment of large bone defects
Introduction
Bone regeneration for the treatment of large bone defects is challenging and several factors are thought to affect treatment outcome, including the location and length of the defect, the condition of the soft tissue envelope, the mechanical environment, as well as patient related factors such as age, metabolic and systemic disorders and related co-morbidities [1], [2], [3]. For small bone defects with healthy surrounding soft tissues, the bone gap can usually be bridged with conventional cancellous bone grafting or bone substitutes [4]. However, when the defect exceeds a ‘critical size’ more specialised treatment modalities are essential to augment tissue repair [5]. Indeed the treatment of large size defects represents a substantial challenge and many consider that elaborate tissue engineering strategies including the use of exogenous stem cells, growth factors and bioactive scaffolds will be required [6].
Recently the novel concept of Guided Bone Regeneration with the use of bioactive induced membranes, pioneered by Masquelet et al. has received attention [7], [8]. When a cement spacer is placed in critical sized defects a biological membrane is induced around it. At a later date the cement is removed with the induced membrane (IM) serving as a conduit to contain cells or bone graft [9]. Animal studies have shown the IM to have osteogenic, osteoinductive and angiogenic properties [10], [11], but to date there have been no studies addressing the functional properties and characteristics of the IM in a clinical setting.
The periosteum is widely recognised to be of critical importance in bone formation and regeneration [12], [13], [14]. Structurally it is divided into two distinct layers an outer fibrous layer and a inner cambium layer [15], [16], this has been shown to be a reservoir of progenitor cells with an osteogenic potential comparable to bone marrow derived mesenchymal stromal cells (BM-MSCs) and superior to synovial MSCs [12], [17], [18], [19]. The periosteum is highly vascularised, provides the cortical blood supply [15], [16], [18] and has been demonstrated to be an important factor in healing long bone fractures [20], [21]. The anatomical location of IM in relation to the cement spacer implant closely resembles that of the diaphyseal periosteum in relation to underlying bone, suggesting that these tissues may be analogous.
The purpose of this study was to investigate the morphology, molecular properties and gene expression patterns of the IM harvested from a series of patients undergoing reconstruction for the treatment of large diaphyseal bone defects. The tissue architecture and location of cell types were compared to normal diaphyseal periosteum in order to identify any characteristics of the IM that may facilitate bone regeneration. Of particular interest was whether IMs were enriched for MSCs; highly proliferative multipotential cells that can form bone, cartilage and other stromal lineages [22]. The presence of pericytes was also investigated, a cell type known to share many proliferative and differentiation characteristics with MSCs [23], as well as being important contributors to blood vessel maturation [24]. The distribution of molecules critical to bone repair and vascularisation including bone morphogenic protein—(BMP) 2, vascular endothelial growth factor (VEGF) and stromal derived factor 1 (SDF-1) expression was also investigated.
Our aim was to investigate if a comparatively simple surgical technique was associated with the generation of a periosteum like structure, containing MSCs and molecules needed for bone repair. This would support the concept that the skeleton has remarkable intrinsic repair capabilities that may not necessarily depend on elaborate and expensive tissue engineering strategies for optimal repair.
Section snippets
Inclusion criteria
Patients admitted to our institution for treatment of either the upper or the lower extremity with bone loss (critical size bone defect) using the IM technique were invited to participate in this study; all patients gave informed consent and research was carried out in compliance with the Helsinki Declaration. Ethics committee approval was obtained from the local National Health Service Research & Development Department, National Research Ethics Service, Leeds East Research Ethics Committee for
Tissue morphology and cellular composition
The IM shared a number of morphological features with periosteum including the presence of 2 distinct layers, analogous to the inner cellular cambium layer and outer fibroblastic/collagenous periosteal layer observed in periosteum [13], [16]. However, in IM both of these layers were thicker and the total median thickness was significantly greater 1422 μm (range: 981–2126) compared to 860 μm (range: 468–1019) in periosteum (p = 0.032) (Fig. 2A). The presence of blood vessels was confirmed by CD31
Discussion
The purpose of this work was to investigate the cellular and molecular basis for the excellent fracture healing noted in man following the use of the so called Masquelet or IM technique [7], [8]. Whilst previous experimental studies have shown some important characteristics of the biological composition and activity of the IM, no human studies had been performed thus far. The IM and periosteum shared strong architectural similarities, vascular features and growth factor expression. This
Funding
United Kingdom National Health Service: National Institute for Health Research, Leeds Musculoskeletal Biomedical Research Unit. This work was partially funded through WELMEC, a Centre of Excellence in Medical Engineering funded by the Wellcome Trust and EPSRC, under grant number WT 088908/Z/09/Z.
Conflicts of interest
The authors declare that they have no conflicts of interest.
Acknowledgments
This work was funded by the NIHR/LMBRU and WELMEC, a Centre of Excellence in Medical Engineering funded by the Wellcome Trust and EPSRC, under grant number WT 088908/Z/09/Z. We gratefully acknowledge the help of Dr Thomas Baboolal, Dr. Dimitrios Kouroupis, Mr Nick Kanakaris and Mr Paul Harwood for recruiting patients and collecting samples as well as all the staff at Leeds General Infirmary Trauma Unit.
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