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Vascularization is crucial for the induction of bone formation. In this study, we investigated the application of two subtypes of peripheral blood-derived endothelial progenitor cells (EPCs) to stimulate vessel formation in ectopic bone constructs. Early and late outgrowth EPCs (E-EPC and L-EPC, respectively) were characterized for their ability to form network structures in vitro and perfused vessels subcutaneously in mice. Only L-EPCs showed the formation of fully connected networks on Matrigel two-dimensional (2D) angiogenesis assays. The presence of multipotent stromal cells (MSCs) inhibited network formation in 2D assays, but stimulated network formation in three-dimensional plugs. In vivo studies revealed that at 2 weeks, the highest incidence of formed perfused vessels was reached by implanted E-EPC/MSC constructs and this could be attributed to the presence of E-EPCs. L-EPCs displayed a significantly lower frequency of blood vessel formation than E-EPCs and this was accompanied by a lowering of total luminal area densities. Nevertheless, combined E-EPC/L-EPC application somewhat increased the percentage incidence of perfused vessels. After 6 weeks, differences in vascularization were still obvious as all three EPC-based constructs contained higher numbers of perfused vessels than constructs containing MSCs alone. Bone was formed in all constructs at an incidence that coincided with high density of perfused vessels after 2 weeks. Altogether, our findings suggest the differential establishment of vascular networks by E-EPCs and L-EPCs and suggest the importance of early vasculogenesis in ectopic bone formation.

Bioprinting of chondrocyte-laden hydrogels facilitates the fabrication of constructs with controlled organization and shape e.g. for articular cartilage implants. Gelatin-methacryloyl (gelMA) supplemented with gellan gum is a promising bio-ink. However, the rheological properties governing the printing process, and the influence of gellan gum on the mechanical properties and chondrogenesis of the blend, are still unknown. Here, we investigated the suitability of gelMA/gellan for cartilage bioprinting. Multiple concentrations, ranging from 3% to 20% gelMA with 0%-1.5% gellan gum, were evaluated for their printability, defined as the ability to form filaments and to incorporate cells at 15 °C-37 °C. To support the printability assessment, yield stress and viscosity of the hydrogels were measured. Stiffness of UV-cured constructs, as well as cartilage-like tissue formation by embedded chondrocytes, were determined in vitro. A large range of gelMA/gellan concentrations were printable with inclusion of cells and formed the bioprinting window. The addition of gellan gum improved filament deposition by inducing yielding behavior, increased construct stiffness and supported chondrogenesis. High gellan gum concentrations, however, did compromise cartilage matrix production and distribution, and even higher concentrations resulted in too high yield stresses to allow cell encapsulation. This study demonstrates the high potential of gelMA/gellan blends for cartilage bioprinting and identifies yield stress as a dominant factor for bioprintability.

Despite intensive research, hydrogels currently available for tissue repair in the musculoskeletal system are unable to meet the mechanical, as well as the biological, requirements for successful outcomes. Here we reinforce soft hydrogels with highly organized, high-porosity microfibre networks that are 3D-printed with a technique termed as melt electrospinning writing. We show that the stiffness of the gel/scaffold composites increases synergistically (up to 54-fold), compared with hydrogels or microfibre scaffolds alone. Modelling affirms that reinforcement with defined microscale structures is applicable to numerous hydrogels. The stiffness and elasticity of the composites approach that of articular cartilage tissue. Human chondrocytes embedded in the composites are viable, retain their round morphology and are responsive to an in vitro physiological loading regime in terms of gene expression and matrix production. The current approach of reinforcing hydrogels with 3D-printed microfibres offers a fundament for producing tissue constructs with biological and mechanical compatibility.

Background and purpose - Autologous conditioned serum (ACS) is a disease-modifying drug for treatment of knee osteoarthritis, and modest superiority over placebo was reported in an earlier randomized controlled trial (RCT). We hypothesized that when given the opportunity, placebo-treated patients from that RCT would now opt for ACS treatment, which would result in a greater clinical improvement than placebo. Methods - Of 74 patients treated with placebo in the previous trial, 20 opted for ACS treatment. Patients who did not choose further treatment were interviewed about their reasons. Clinical improvement of the 20 ACS-treated patients was measured using knee-specific clinical scores, as was "response shift" at 3 and 12 months. Results - In the 20 patients who did opt for ACS, the visual analog scale (VAS) score for pain improved; but after 12 months, clinical results were similar to those after placebo treatment. Response shift measurement demonstrated that the 20 patients had adapted to their disabilities during treatment. Interpretation - Placebo-treated patients from an earlier trial were reluctant to undergo ACS treatment, in part due to the laborious nature of the therapy. In a subset of patients who opted for treatment, ACS treatment after placebo did not result in greater clinical improvement than placebo treatment only. However, due to the limited power of the current study and possible selection bias, definite advice on using or refraining from ACS cannot be given.

Several inflammatory processes underlie excessive bone formation, including chronic inflammation of the spine, acute infections, or periarticular ossifications after trauma. This suggests that local factors in these conditions have osteogenic properties. Mesenchymal stem cells (MSCs) and their differentiated progeny contribute to bone healing by synthesizing extracellular matrix and inducing mineralization. Due to the variation in experimental designs used in vitro, there is controversy about the osteogenic potential of proinflammatory factors on MSCs. Our goal was to determine the specific conditions allowing the pro-osteogenic effects of distinct inflammatory stimuli. Human bone marrow MSCs were exposed to tumor necrosis factor alpha (TNF-α) and lipopolysaccharide (LPS). Cells were cultured in growth medium or osteogenic differentiation medium. Alternatively, bone morphogenetic protein 2 (BMP-2) was used as osteogenic supplement to simulate the conditions in vivo. Alkaline phosphatase activity and calcium deposition were indicators of osteogenicity. To elucidate lineage commitment-dependent effects, MSCs were pre-differentiated prior treatment. Our results show that TNF-α and LPS do not affect the expression of osteogenic markers by MSCs in the absence of an osteogenic supplement. In osteogenic differentiation medium or together with BMP-2 however, these mediators highly stimulated their alkaline phosphatase activity and subsequent matrix mineralization. In pre-osteoblasts, matrix mineralization was significantly increased by these mediators, but irrespective of the culture conditions. Our study shows that inflammatory factors potently enhance the osteogenic capacity of MSCs. These properties may be harnessed in bone regenerative strategies. Importantly, the commitment of MSCs to the osteogenic lineage greatly enhances their responsiveness to inflammatory signals.

Flow-perfusion is being promoted as a way to grow tissue-engineered cartilage in vitro. Yet, there is a concern that flow-perfusion may induce unwanted mechanical effects on chondrogenesis and terminal differentiation. Therefore, the aim of this study is to evaluate the effect of fluid flow on chondrogenesis and chondrocyte hypertrophy of MSCs in a well-established pellet culture model.Human MSC pellets were mounted into 3D-printed porous scaffolds in basic chondrogenic differentiation medium, containing TGF-ß2. Constructs were then allowed to form cartilaginous matrix for 18 days, before they were transferred to a custom-built flow-perfusion system. A continuous flow of 1.22mlmin-1 was applied to the constructs for 10 days. Controls were maintained under static culture conditions. To evaluate chondrogenic and hypertrophic differentiation, RNA was isolated at day 20 and 28 and histology, immunohistochemistry and western blot analyses were performed after 28 days of culture.Abundant matrix was formed in the constructs, but production of chondrogenic and hypertrophic matrix components was affected by flow-perfusion. Although gene expression levels of the (late) hypertrophic and osteogenic marker osteocalcin increased by flow-perfusion, this did not result in more collagen type X protein deposition. Decreased GAG release, in combination with diminished collagen II staining, indicates reduced chondrogenesis in response to flow-perfusion.Caution should thus be taken when applying flow-perfusion to cultures to improve nutrient diffusion. Although we show that it is possible to influence the differentiation of chondrogenic differentiated MSCs by flow-perfusion, effects are inconsistent and strongly donor-dependent. © 2013 Elsevier Ltd.

OBJECTIVE: This study aimed to investigate the regenerative capacity of chondrocytes derived from debrided defect cartilage and healthy cartilage from different regions in the joint to determine the best cell source for regenerative cartilage therapies. METHODS: Articular cartilage was obtained from Outerbridge grade III and IV cartilage lesions and from macroscopically healthy weight-bearing and nonweight-bearing (NWB) locations in the knee. Chondrocytes isolated from all locations were either pelleted directly (P0 pellets) or after expansion (P2 pellets) and analyzed for glycosaminoglycan (GAG), DNA, and cartilage-specific gene expression. Harvested cartilage samples and cultured pellets were also analyzed by Safranin O histology and immunohistochemistry for collagen I, II, and X. Immunohistochemical stainings were quantified using a computerized pixel-intensity staining segmentation method. RESULTS: After 4 weeks of culture, the P0 pellets derived from grade III or healthy weight-bearing chondrocytes contained more (p

The use of growth factors in osteogenic constructs to promote recruitment of bone forming endogenous cells is not clear, while the advantage of circumventing cell seeding techniques before implantation is highly recognized. Therefore, the additive effect of the chemokine stromal cell-derived factor-1α (SDF-1α) on endogenous cell recruitment and vascularization was investigated in a hybrid construct, consisting of a ceramic biomaterial, hydrogel, and SDF-1α, in an ectopic mouse model. We demonstrated in vivo that local presence of low concentrations of SDF-1α resulted in a significant increase in recruited endogenous cells, which remained present for several weeks. SDF-1α stimulated vascularization in these hybrid constructs, as shown by the enhanced formation of erythrocyte-filled vessels. The presence of CD31-positive capillaries/small vessels after 6 weeks in vivo substantiated this finding. The SDF-1α treatment showed increased number of cells that could differentiate to the osteogenic lineage after 6 weeks of implantation, demonstrated by expression of collagen I and osteocalcin. Altogether, we show here the beneficial effects of the local application of a single growth factor in a hybrid construct on angiogenesis and osteogenic differentiation, which might contribute to the development of cell-free bone substitutes.

The application of RNA interference (RNAi) has great therapeutic potential for degenerative diseases of cartilaginous tissues by means of fine tuning the phenotype of cells used for regeneration. However, possible non-specific effects of transfection per se might be relevant for future clinical application. In the current study, we selected two synthetic transfection reagents, a cationic lipid-based commercial reagent Lipofectamine RNAiMAX and polyethylenimine (PEI), and two naturally-derived transfection reagents, namely the polysaccharides chitosan (98% deacetylation) and hyaluronic acid (20% amidation), for siRNA delivery into primary mesenchymal cells including nucleus pulposus cells, articular chondrocytes and mesenchymal stem cells (MSCs). Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was used as an endogenous model gene to evaluate the extent of silencing by 20 nM or 200 nM siRNA at day 3 and day 6 post-transfection. In addition to silencing efficiency, non-specific effects such as cytotoxicity, change in DNA content and differentiation potential of cells were evaluated. Among the four transfection reagents, the commercial liposome-based agent was the most efficient reagent for siRNA delivery at 20 nM siRNA, followed by chitosan. Transfection using cationic liposomes, chitosan and PEI showed some decrease in viability and DNA content to varying degrees that was dependent on the siRNA dose and cell type evaluated, but independent of GAPDH knockdown. Some effects on DNA content were not accompanied by concomitant changes in viability. However, changes in expression of marker genes for cell cycle inhibition or progression, such as p21 and PCNA, could not explain the changes in DNA content. Interestingly, aspecific upregulation of GAPDH activity was found, which was limited to cartilaginous cells. In conclusion, non-specific effects should not be overlooked in the application of RNAi for mesenchymal cell transfection and may need to be overcome for its effective therapeutic application.

Additive manufacturing forms a potential route towards economically viable production of cellular constructs for tissue engineering. Hydrogels are a suitable class of materials for cell delivery and 3D culture, but are generally unsuitable as construction materials. Gelatine-methacrylamide is an example of such a hydrogel system widely used in the field of tissue engineering, e.g. for cartilage and cardiovascular applications. Here we show that by the addition of gellan gum to gelatine-methacrylamide and tailoring salt concentrations, rheological properties such as pseudo-plasticity and yield stress can be optimised towards gel dispensing for additive manufacturing processes. In the hydrogel formulation, salt is partly substituted by mannose to obtain isotonicity and prevent a reduction in cell viability. With this, the potential of this new bioink for additive tissue manufacturing purposes is demonstrated. This journal is © the Partner Organisations 2014.

Gelatin-methacrylamide (gelMA) hydrogels are shown to support chondrocyte viability and differentiation and give wide ranging mechanical properties depending on several cross-linking parameters. Polymer concentration, UV exposure time, and thermal gelation prior to UV exposure allow for control over hydrogel stiffness and swelling properties. GelMA solutions have a low viscosity at 37 °C, which is incompatible with most biofabrication approaches. However, incorporation of hyaluronic acid (HA) and/or co-deposition with thermoplastics allows gelMA to be used in biofabrication processes. These attributes may allow engineered constructs to match the natural functional variations in cartilage mechanical and geometrical properties.

Background context Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed condition relating to ossification of spinal ligaments that can cause compression of the esophagus and trachea. According to case reports, dysphagia or airway obstruction resulting from DISH is a rare occurrence. Purpose This study was intended to identify all published cases of dysphagia and/or airway obstruction resulting from DISH to increase the epidemiologic/clinical knowledge of these related conditions. Study design A systematic review of the literature was performed. Methods The articles resulting from the systematic PubMed/EMBASE search of the literature were closely read, and predefined parameters were scored. Results The search yielded a total of 118 articles (95 case reports and 23 case series) describing 204 patients with dysphagia and/or airway obstruction resulting from DISH. The number of cases demonstrated a steady increase from 1980 to 2009. This might be a real effect not ascribable to publication bias or expansion of the medical literature alone. Conclusions Diffuse idiopathic skeletal hyperostosis as a cause of dysphagia and/or airway obstruction may be an increasing and underappreciated phenomenon. Diffuse idiopathic skeletal hyperostosis should be included in the differential diagnosis of dysphagia and airway obstruction.