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Background: Nontraumatic osteonecrosis of the femoral head (NONFH) is a debilitating disease that represents a significant financial burden for both individuals and healthcare systems. Despite its significance, however, its prevalence in the Chinese general population remains unknown. This study aimed to investigate the prevalence of NONFH and its associated risk factors in the Chinese population.
Methods: A nationally representative survey of 30,030 respondents was undertaken from June 2012 to August 2013. All participants underwent a questionnaire investigation, physical examination of hip, and bilateral hip joint X-ray and/or magnetic resonance imaging examination. Blood samples were taken after overnight fasting to test serum total cholesterol, triglyceride, and high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels. We then used multivariate logistic regression analysis to investigate the associations between various metabolic, demographic, and lifestyle-related variables and NONFH.
Results: NONFH was diagnosed in 218 subjects (0.725%) and the estimated NONFH cases were 8.12 million among Chinese people aged 15 years and over. The prevalence of NONFH was significantly higher in males than in females (1.02% vs. 0.51%, \(\chi^2\) = 24.997, P < 0.001). Among NONFH patients, North residents were subjected to higher prevalence of NONFH than that of South residents (0.85% vs. 0.61%, \(\chi^2\) = 5.847, P = 0.016). Our multivariate regression analysis showed that high blood levels of triglycerides, total cholesterol, LDL-cholesterol, and non-HDL-cholesterol, male, urban residence, family history of osteonecrosis of the femoral head, heavy smoking, alcohol abuse and glucocorticoid intake, overweight, and obesity were all significantly associated with an increased risk of NONFH.
Conclusions: Our findings highlight that NONFH is a significant public health challenge in China and underscore the need for policy measures on the national level. Furthermore, NONFH shares a number of risk factors with atherosclerosis.
The key hypothesis of this work represented the question, if mimicking the zonal composition and structural porosity of musculoskeletal tissues influences invading cells positively and leads to advantageous results for tissue engineering. Conventional approaches in tissue engineering are limited in producing monolithic “scaffolds” that provide locally variating biological key signals and pore architectures, imitating the alignment of collagenous fibres in bone and cartilage tissues, respectively. In order to fill this gap in available tissue engineering strategies, a new fabrication technique was evolved for the production of scaffolds to validate the hypothesis.
Therefore, a new solidification based platform procedure was developed. This process comprises the directional solidification of multiple flowable precursors that are “cryostructured” to prepare a controlled anisotropic pore structure. Porous scaffolds are attained through ice crystal removal by lyophilisation. Optionally, electrostatic spinning of polymers may be applied to provide an external mesh on top or around the scaffolds. A consolidation step generates monolithic matrices from multi zonal structures. To serve as matrix for tissue engineering approaches or direct implantation as medical device, the scaffold is sterilized.
An Adjustable Cryostructuring Device (ACD) was successively developed; individual parts were conceptualized by computer aided design (CAD) and assembled. During optimisation, a significant performance improvement of the ACDs accessible external temperature gradient was achieved, from (1.3 ± 0.1) K/mm to (9.0 ± 0.1) K/mm. Additionally, four different configurations of the device were made available that enabled the directional solidification of collagenous precursors in a highly controlled manner with various sample sizes and shapes.
By using alginate as a model substance the process was systematically evaluated. Cryostructuring diagraphs were analysed yielding solidification parameters, which were associated to pore sizes and alignments that were determined by image processing. Thereby, a precise control over pore size and alignment through electrical regulation of the ACD could be demonstrated.
To obtain tissue mimetic scaffolds for the musculoskeletal system, collagens and calcium phosphates had to be prepared to serve as raw materials. Extraction and purification protocols were established to generate collagen I and collagen II, while the calcium phosphates brushite and hydroxyapatite were produced by precipitation reactions.
Besides the successive augmentation of the ACD also an optimization of the processing steps was crucial. Firstly, the concentrations and the individual behaviour of respective precursor components had to be screened. Together with the insights gained by videographic examination of solidifying collagen solutions, essential knowledge was gained that facilitated the production of more complex scaffolds. Phenomena of ice crystal growth during cryostructuring were discussed. By evolutionary steps, a cryostructuring of multi-layered precursors with consecutive anisotropic pores could be achieved and successfully transferred from alginate to collagenous precursors. Finally, very smooth interfaces that were hardly detectable by scanning electron microscopy (SEM) could be attained. For the used collagenous systems, a dependency relation between adjustable processing parameters and different resulting solidification morphologies was created.
Dehydrothermal-, diisocyanate-, and carbodiimide- based cross linking methods were evaluated, whereby the “zero length” cross linking by carbodiimide was found to be most suitable. Afterwards, a formulation for the cross linking solution was elaborated, which generated favourable outcomes by application inside a reduced pressure apparatus. As a consequence, a pore collapse during wet chemical cross linking could be avoided.
Complex monolithic scaffolds featuring continuous pores were fabricated that mimicked structure and respective composition of different areas of native tissues by the presence of biochemical key stimulants. At first, three types of bone scaffolds were produced from collagen I and hydroxyapatite with appropriate sizes to fit critical sized defects in rat femurs. They either featured an isotropic or anisotropic porosity and partly also contained glycosaminoglycans (GAGs). Furthermore, meniscus scaffolds were prepared by processing two precursors with biomimetic contents of collagen I, collagen II and GAGs. Here, the pore structures were created under boundary conditions, which allowed an ice crystal growth that was nearly orthogonal to the external temperature gradient. Thereby, the preferential alignment of collagen fibres in the natural meniscus tissue could be mimicked. Those scaffolds owned appropriate sizes for cell culture in well plates or even an authentic meniscus shape and size. Finally, osteochondral scaffolds, sized to either fit well plates or perfusion reactors for cell culture, were fabricated to mimic the composition of subchondral bone and different cartilage zones. Collagen I and the resorbable calcium phosphate brushite were used for the subchondral zone, whereas the cartilage zones were composed out of collagen I, collagen II and tissue mimetic contents of GAGs. The pore structure corresponded to the one that is dominating the volume of natural osteochondral tissue.
Energy dispersive X-ray spectroscopy (EDX) and SEM were used to analyse the composition and pore structure of the individual scaffold zones, respectively. The cross section pore diameters were determined to (65 ± 25) µm, (88 ± 35) µm and(93 ± 42) µm for the anisotropic, the isotropic and GAG containing isotropic bone scaffolds. Furthermore, the meniscus scaffolds showed pore diameters of (93 ± 21) µm in the inner meniscus zone and (248 ± 63) µm inside the outer meniscus zone. Pore sizes of (82 ± 25) µm, (83 ± 29) µm and (85 ± 39) µm were present inside the subchondral, the lower chondral and the upper chondral zone of osteochondral scaffolds. Depending on the fabrication parameters, the respective scaffold zones were also found to feature a specific micro- and nanostructure at their inner surfaces.
Degradation studies were carried out under physiological conditions and resulted in a mean mass loss of (0.52 ± 0.13) %, (1.56 ± 0.10) % and (0.80 ± 0.10) % per day for bone, meniscus and osteochondral scaffolds, respectively. Rheological measurements were used to determine the viscosity changes upon cooling of different precursors. Micro computer tomography (µ-CT) investigations were applied to characterize the 3D microstructure of osteochondral scaffolds. To obtain an osteochondral scaffold with four zones of tissue mimetic microstructure alignment, a poly (D, L-lactide-co-glycolide) mesh was deposited on the upper chondral zone by electrostatic spinning. In case of the bone scaffolds, the retention / release capacity of bone morphogenetic protein 2 (BMP-2) was evaluated by an enzyme linked immunosorbent assay (ELISA). Due to the high presence of attractive BMP binding sites, only less than 0.1 % of the initially loaded cytokine was released. The suitability of combining the cryostructuring process with 3D powder printed calcium phosphate substrates was evaluated with osteochondral scaffolds, but did not appear to yield more preferable results than the non-combined approach.
A new custom build confined compression setup was elaborated together with a suitable evaluation procedure for the mechanical characterisation under physiological conditions. For bone and cartilage scaffolds, apparent elastic moduli of (37.6 ± 6.9) kPa and (3.14 ± 0.85) kPa were measured. A similar behaviour of the scaffolds to natural cartilage and bone tissue was demonstrated in terms of elastic energy storage. Under physiological frequencies, less than 1.0 % and 0.8 % of the exerted energy was lost for bone and cartilage scaffolds, respectively. With average relaxation times of (0.613 ± 0.040) sec and (0.815 ± 0.077) sec, measured for the cartilage and bone scaffolds, they respond four orders of magnitude faster than the native tissues. Additionally, all kinds of produced scaffolds were able to withstand cyclic compression at un-physiological frequencies as high as 20 Hz without a loss in structural integrity.
With the presented new method, scaffolds could be fabricated whose extent in mimicking of native tissues exceeded the one of scaffolds producible by state of the art methods. This allowed a testing of the key hypothesis: The biological evaluation of an anisotropic pore structure in vivo revealed a higher functionality of immigrated cells and led finally to advantageous healing outcomes. Moreover, the mimicking of local compositions in combination with a consecutive anisotropic porosity that approaches native tissue structures could be demonstrated to induce zone specific matrix remodelling in stem cells in vitro. Additionally, clues for a zone specific chondrogenic stem cell differentiation were attained without the supplementation of growth factors.
Thereby, the hypothesis that an increased approximation of the hierarchically compositional and structurally anisotropic properties of musculoskeletal tissues would lead to an improved cellular response and a better healing quality, could be confirmed. With a special focus on cell free in situ tissue engineering approaches, the insights gained within this thesis may be directly transferred to clinical regenerative therapies.
Testosterone deficiency in males is linked to various pathological conditions, including muscle and bone loss. This study evaluated the potential of different training modalities to counteract these losses in hypogonadal male rats. A total of 54 male Wistar rats underwent either castration (ORX, n = 18) or sham castration (n = 18), with 18 castrated rats engaging in uphill, level, or downhill interval treadmill training. Analyses were conducted at 4, 8, and 12 weeks postsurgery. Muscle force of the soleus muscle, muscle tissue samples, and bone characteristics were analyzed. No significant differences were observed in cortical bone characteristics. Castrated rats experienced decreased trabecular bone mineral density compared to sham-operated rats. However, 12 weeks of training increased trabecular bone mineral density, with no significant differences among groups. Muscle force measurements revealed decreased tetanic force in castrated rats at week 12, while uphill and downhill interval training restored force to sham group levels and led to muscle hypertrophy compared to ORX animals. Linear regression analyses showed a positive correlation between bone biomechanical characteristics and muscle force. The findings suggest that running exercise can prevent bone loss in osteoporosis, with similar bone restoration effects observed across different training modalities.
Lower limb bone geometry in adult individuals with X-linked hypophosphatemia: an observational study
(2022)
Summary
We assessed lower-limb geometry in adults with X-linked hypophosphatemia (XLH) and controls. We found large differences in multiple measures including femoral and tibial torsion, bowing and cross-sectional area and acetabular version and coverage which may contribute to clinical problems such as osteoarthritis, fractures and altered gait common in XLH.
Purpose
Individuals with X-linked hypophosphatemia (XLH) are at risk of lower-limb deformities and early onset of osteoarthritis. These two factors may be linked, as altered biomechanics is a risk factor for osteoarthritis. This exploratory evaluation aims at providing clues and concepts for this association to facilitate future larger-scale and longitudinal studies on that aspect.
Methods
For this observational study, 13 patients with XLH, aged 18–65 years (6 female), were compared with sex-, age- and weight-matched healthy individuals at a single German research centre. Femoral and hip joint geometry, including femoral and tibial torsion and femoral and tibial shaft bowing, bone cross-sectional area (CSA) and acetabular version and coverage were measured from magnetic resonance imaging (MRI) scans.
Results
Total femoral torsion was 29° lower in individuals with XLH than in controls (p < 0.001), mainly resulting from lower intertrochanteric torsion (ITT) (p < 0.001). Femoral lateral and frontal bowing, tibial frontal bowing, mechanical axis, femoral mechanical–anatomical angle, acetabular version and acetabular coverage were all greater and tibial torsion lower in individuals with XLH as compared to controls (all p < 0.05). Greater femoral total and marrow cavity CSA, greater tibial marrow cavity CSA and lower cortical CSA were observed in XLH (all p < 0.05).
Discussion
We observed large differences in clinically relevant measures of tibia and particularly femur bone geometry in individuals with XLH compared to controls. These differences may plausibly contribute to clinical manifestations of XLH such as early-onset osteoarthritis, pseudofractures and altered gait and therefore should be considered when planning corrective surgeries.
The skeletal system forms the mechanical structure of the body and consists of bone, which is hard connective tissue. The tasks the skeleton and bones take over are of mechanical, metabolic and synthetic nature. Lastly, bones enable the production of blood cells by housing the bone marrow. Bone has a scarless self-healing capacity to a certain degree. Injuries exceeding this capacity caused by trauma, surgical removal of infected or tumoral bone or as a result from treatment-related osteonecrosis, will not heal. Critical size bone defects that will not heal by themselves are still object of comprehensive clinical investigation. The conventional treatments often result in therapies including burdening methods as for example the harvesting of autologous bone material. The aim of this thesis was the creation of a prevascularized bone implant employing minimally invasive methods in order to minimize inconvenience for patients and surgical site morbidity. The basis for the implant was a decellularized, naturally derived vascular scaffold (BioVaSc-TERM®) providing functional vessel structures after reseeding with autologous endothelial cells. The bone compartment was built by the combination of the aforementioned scaffold with synthetic β-tricalcium phosphate. In vitro culture for tissue maturation was performed using bioreactor technology before the testing of the regenerative potential of the implant in large animal experiments in sheep. A tibia defect was treated without the anastomosis of the implant’s innate vasculature to the host’s circulatory system and in a second study, with anastomosis of the vessel system in a mandibular defect. While the non-anastomosed implant revealed a mostly osteoconductive effect, the implants that were anastomosed achieved formation of bony islands evenly distributed over the defect.
In order to prepare preconditions for a rapid approval of an implant making use of this vascularization strategy, the manufacturing of the BioVaSc-TERM® as vascularizing scaffold was adjusted to GMP requirements.
Bioactive glass (BG) scaffolds are being investigated for bone tissue engineering applications because of their osteoconductive and angiogenic nature. However, to increase the in vivo performance of the scaffold, including enhancing the angiogenetic growth into the scaffolds, some researchers use different modifications of the scaffold including addition of inorganic ionic components to the basic BG composition. In this study, we investigated the in vitro biocompatibility and bioactivity of Cu2+-doped BG derived scaffolds in either BMSC (bone-marrow derived mesenchymal stem cells)-only culture or co-culture of BMSC and human dermal microvascular endothelial cells (HDMEC). In BMSC-only culture, cells were seeded either directly on the scaffolds (3D or direct culture) or were exposed to ionic dissolution products of the BG scaffolds, kept in permeable cell culture inserts (2D or indirect culture). Though we did not observe any direct osteoinduction of BMSCs by alkaline phosphatase (ALP) assay or by PCR, there was increased vascular endothelial growth factor (VEGF) expression, observed by PCR and ELISA assays. Additionally, the scaffolds showed no toxicity to BMSCs and there were healthy live cells found throughout the scaffold. To analyze further the reasons behind the increased VEGF expression and to exploit the benefits of the finding, we used the indirect method with HDMECs in culture plastic and Cu2+-doped BG scaffolds with or without BMSCs in cell culture inserts. There was clear observation of increased endothelial markers by both FACS analysis and acetylated LDL (acLDL) uptake assay. Only in presence of Cu2+-doped BG scaffolds with BMSCs, a high VEGF secretion was demonstrated by ELISA; and typical tubular structures were observed in culture plastics. We conclude that Cu2+-doped BG scaffolds release Cu2+, which in turn act on BMSCs to secrete VEGF. This result is of significance for the application of BG scaffolds in bone tissue engineering approaches.
Approaches to mimic the complexity of the skeletal mesenchymal stem/stromal cell niche in vitro
(2019)
Mesenchymal stem/stromal cells (MSCs) are an essential element of most modern tissue engineering and regenerative medicine approaches due to their multipotency and immunoregulatory functions. Despite the prospective value of MSCs for the clinics, the stem cells community is questioning their developmental origin, in vivo localization, identification, and regenerative potential after several years of far-reaching research in the field. Although several major progresses have been made in mimicking the complexity of the MSC niche in vitro, there is need for comprehensive studies of fundamental mechanisms triggered by microenvironmental cues before moving to regenerative medicine cell therapy applications. The present comprehensive review extensively discusses the microenvironmental cues that influence MSC phenotype and function in health and disease – including cellular, chemical and physical interactions. The most recent and relevant illustrative examples of novel bioengineering approaches to mimic biological, chemical, and mechanical microenvironmental signals present in the native MSC niche are summarized, with special emphasis on the forefront techniques to achieve bio-chemical complexity and dynamic cultures. In particular, the skeletal MSC niche and applications focusing on the bone regenerative potential of MSC are addressed. The aim of the review was to recognize the limitations of the current MSC niche in vitro models and to identify potential opportunities to fill the bridge between fundamental science and clinical application of MSCs.
The MEK5/ERK5 mitogen-activated protein kinases (MAPK) cascade is a unique signaling module activated by both mitogens and stress stimuli, including cytokines, fluid shear stress, high osmolarity, and oxidative stress. Physiologically, it is mainly known as a mechanoreceptive pathway in the endothelium, where it transduces the various vasoprotective effects of laminar blood flow. However, it also maintains integrity in other tissues exposed to mechanical stress, including bone, cartilage, and muscle, where it exerts a key function as a survival and differentiation pathway. Beyond its diverse physiological roles, the MEK5/ERK5 pathway has also been implicated in various diseases, including cancer, where it has recently emerged as a major escape route, sustaining tumor cell survival and proliferation under drug stress. In addition, MEK5/ERK5 dysfunction may foster cardiovascular diseases such as atherosclerosis. Here, we highlight the importance of the MEK5/ERK5 pathway in health and disease, focusing on its role as a protective cascade in mechanical stress-exposed healthy tissues and its function as a therapy resistance pathway in cancers. We discuss the perspective of targeting this cascade for cancer treatment and weigh its chances and potential risks when considering its emerging role as a protective stress response pathway.
Photon-counting detector (PCD) CT allows for ultra-high-resolution (UHR) examinations of the shoulder without requiring an additional post-patient comb filter to narrow the detector aperture. This study was designed to compare the PCD performance with a high-end energy-integrating detector (EID) CT. Sixteen cadaveric shoulders were examined with both scanners using dose-matched 120 kVp acquisition protocols (low-dose/full-dose: CTDI\(_{vol}\) = 5.0/10.0 mGy). Specimens were scanned in UHR mode with the PCD-CT, whereas EID-CT examinations were conducted in accordance with the clinical standard as “non-UHR”. Reconstruction of EID data employed the sharpest kernel available for standard-resolution scans (ρ\(_{50}\) = 12.3 lp/cm), while PCD data were reconstructed with both a comparable kernel (11.8 lp/cm) and a sharper dedicated bone kernel (16.5 lp/cm). Six radiologists with 2–9 years of experience in musculoskeletal imaging rated image quality subjectively. Interrater agreement was analyzed by calculation of the intraclass correlation coefficient in a two-way random effects model. Quantitative analyses comprised noise recording and calculating signal-to-noise ratios based on attenuation measurements in bone and soft tissue. Subjective image quality was higher in UHR-PCD-CT than in EID-CT and non-UHR-PCD-CT datasets (all p < 0.001). While low-dose UHR-PCD-CT was considered superior to full-dose non-UHR studies on either scanner (all p < 0.001), ratings of low-dose non-UHR-PCD-CT and full-dose EID-CT examinations did not differ (p > 0.99). Interrater reliability was moderate, indicated by a single measures intraclass correlation coefficient of 0.66 (95% confidence interval: 0.58–0.73; p < 0.001). Image noise was lowest and signal-to-noise ratios were highest in non-UHR-PCD-CT reconstructions at either dose level (p < 0.001). This investigation demonstrates that superior depiction of trabecular microstructure and considerable denoising can be realized without additional radiation dose by employing a PCD for shoulder CT imaging. Allowing for UHR scans without dose penalty, PCD-CT appears as a promising alternative to EID-CT for shoulder trauma assessment in clinical routine.