Improved osseointegration using porcine xenograft compared to demineralized bone matrix for the treatment of critical defects in a small animal model
Corresponding Author
Alexander H. Jinnah
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Correspondence
Alexander H. Jinnah, Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA.
Email: [email protected]
Search for more papers by this authorPatrick Whitlock
Division of Pediatric Orthopaedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
Search for more papers by this authorJeffrey S. Willey
Department of Radiation/Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorKerry Danelson
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorBethany A. Kerr
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorOmer A. Hassan
Department of Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorCynthia L. Emory
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorThomas L. Smith
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorDaniel N. Bracey
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorCorresponding Author
Alexander H. Jinnah
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Correspondence
Alexander H. Jinnah, Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA.
Email: [email protected]
Search for more papers by this authorPatrick Whitlock
Division of Pediatric Orthopaedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
Search for more papers by this authorJeffrey S. Willey
Department of Radiation/Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorKerry Danelson
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorBethany A. Kerr
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorOmer A. Hassan
Department of Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorCynthia L. Emory
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorThomas L. Smith
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorDaniel N. Bracey
Division of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
Search for more papers by this authorAbstract
Background
Autograft (AG) is the gold standard bone graft due to biocompatibility, osteoconductivity, osteogenicity, and osteoinductivity. Alternatives include allografts and xenografts (XG).
Methods
We investigated the osseointegration and biocompatibility of a decellularized porcine XG within a critical defect animal model. We hypothesized that the XG will result in superior osseointegration compared to demineralized bone matrix (DBM) and equivalent immune response to AG. Critical defects were created in rat femurs and treated with XG, XG plus bone morphogenetic protein (BMP)-2, DBM, or AG. Interleukin (IL)-2 and IFN-gamma levels (inflammatory markers) were measured from animal blood draws at 1 week and 1 month post-operatively. At 1 month, samples underwent micro-positron-emission tomography (microPET) scans following 18-NaF injection. At 16 weeks, femurs were retrieved and sent for micro-computerized tomography (microCT) scans for blinded grading of osseointegration or were processed for histologic analysis with tartrate resistant acid phosphatase (TRAP) and pentachrome.
Results
Enzyme linked immunosorbent assay testing demonstrated greater IL-2 levels in the XG vs. AG 1 week post-op; which normalized by 28 days post-op. MicroPET scans showed increased uptake within the AG compared to all groups. XG and XG + BMP-2 showed a trend toward increased uptake compared with DBM. MicroCT scans demonstrated increased osseointegration in XG and XG + BMP groups compared to DBM. Pentachrome staining demonstrated angiogenesis and endochondral bone formation. Furthermore, positive TRAP staining in samples from all groups indicated bone remodeling.
Conclusions
These data suggest that decellularized and oxidized porcine XG is biocompatible and at least equivalent to DBM in the treatment of a critical defect in a rat femur model.
REFERENCES
- 1Janicki P, Schmidmaier G. What should be the characteristics of the ideal bone graft substitute? Combining scaffolds with growth factors and/or stem cells. Injury. 2011; 42(Suppl 2): S77-S81.
- 2Gulick DT. Effects of various treatment techniques on the signs and symptoms of delayed onset muscle soreness. Eugene, Ore: Microform Publications, Int'l Inst for Sport & Human Performance, University of Oregon; 1995.
- 3Amini AR, Laurencin CT, Nukavarapu SP. Bone tissue engineering: recent advances and challenges. Crit Rev Biomed Eng. 2012; 40(5): 363-408.
- 4Nauth A, Schemitsch E, Norris B, Nollin Z, Watson JT. Critical-size bone defects: is there a consensus for diagnosis and treatment? J Orthop Trauma. 2018; 32(Suppl 1): S7-S11.
- 5Calori GM, Mazza E, Colombo M, Ripamonti C. The use of bone-graft substitutes in large bone defects: any specific needs? Injury. 2011; 42(Suppl 2): S56-S63.
- 6Aloise AC, Pelegrine AA, Zimmermann A, de Mello EOR, Ferreira LM. Repair of critical-size bone defects using bone marrow stem cells or autogenous bone with or without collagen membrane: a histomorphometric study in rabbit calvaria. Int J Oral Maxillofac Implants. 2015; 30(1): 208-215.
- 7Issa JP, Gonzaga M, Kotake BG, de Lucia C, Ervolino E, Iyomasa M. Bone repair of critical size defects treated with autogenic, allogenic, or xenogenic bone grafts alone or in combination with rhBMP-2. Clin Oral Implants Res. 2015; 27: 558-566.
- 8Giannoudis PV, Chris Arts JJ, Schmidmaier G, Larsson S. What should be the characteristics of the ideal bone graft substitute? Injury. 2011; 42(Suppl 2): S1-S2.
- 9Khan SN, Cammisa FP Jr, Sandhu HS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am Acad Orthop Surg. 2005; 13(1): 77-86.
- 10Albrektsson T, Johansson C. Osteoinduction, osteoconduction and osseointegration. Eur Spine J. 2001; 10(Suppl 2): S96-S101.
- 11Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity. A statistical evaluation. Spine. 1995; 20(9): 1055-1060.
- 12Sasso RC, LeHuec JC, Shaffrey C, Spine Interbody Research Group. Iliac crest bone graft donor site pain after anterior lumbar interbody fusion: a prospective patient satisfaction outcome assessment. J Spinal Disord Tech. 2005; 18(Suppl): S77-S81.
- 13Kim DH, Rhim R, Li L, et al. Prospective study of iliac crest bone graft harvest site pain and morbidity. Spine J. 2009; 9(11): 886-892.
- 14Sohn HS, Oh JK. Review of bone graft and bone substitutes with an emphasis on fracture surgeries. Biomater Res. 2019; 23: 9.
- 15Campana V, Milano G, Pagano E, et al. Bone substitutes in orthopaedic surgery: from basic science to clinical practice. J Mater Sci Mater Med. 2014; 25(10): 2445-2461.
- 16De Long WG Jr, Einhorn TA, Koval K, et al. Bone grafts and bone graft substitutes in orthopaedic trauma surgery. A critical analysis. J Bone Joint Surg Am. 2007; 89(3): 649-658.
- 17Shibuya N, Jupiter DC. Bone graft substitute: allograft and xenograft. Clin Podiatr Med Surg. 2015; 32(1): 21-34.
- 18Mather C, Treuting P. Onchocerca armillata contamination of a bovine pericardial xenograft in a human patient with repaired tetralogy of Fallot. Cardiovasc Pathol. 2012; 21(3): e35-e38.
- 19Boneva RS, Folks TM, Chapman LE. Infectious disease issues in xenotransplantation. Clin Microbiol Rev. 2001; 14(1): 1-14.
- 20Galili U. Evolution of alpha 1,3galactosyltransferase and of the alpha-Gal epitope. Subcell Biochem. 1999; 32: 1-23.
- 21Galili U. The alpha-Gal epitope (Galalpha1-3Galbeta1-4GlcNAc-R) in xenotransplantation. Biochimie. 2001; 83(7): 557-563.
- 22Cooper DKC, Ekser B, Tector AJ. Immunobiological barriers to xenotransplantation. Int J Surg. 2015; 23(Pt B): 211-216.
- 23Galili U, Wang L, LaTemple DC, Radic MZ. The natural anti-Gal antibody. Subcell Biochem. 1999; 32: 79-106.
- 24Bracey DN, Seyler TM, Jinnah AH, et al. A porcine xenograft-derived bone scaffold is a biocompatible bone graft substitute: an assessment of cytocompatability and the alpha-gal epitope. Xenotransplantation. 2019; 26:e12534.
- 25Seyler TM, Bracey DN, Plate JF, et al. The development of a xenograft-derived scaffold for tendon and ligament reconstruction using a decellularization and oxidation protocol. Arthroscopy. 2017; 33(2): 374-386.
- 26Whitlock PW, Smith TL, Poehling GG, Shilt JS, Van Dyke M. A naturally derived, cytocompatible, and architecturally optimized scaffold for tendon and ligament regeneration. Biomaterials. 2007; 28(29): 4321-4329.
- 27Bracey DN, Jinnah AH, Willey JS, et al. Investigating the Osteoinductive potential of a decellularized xenograft bone substitute. Cells Tissues Organs. 2019; 207(2): 97-113.
- 28de Guzman RC, Saul JM, Ellenburg MD, et al. Bone regeneration with BMP-2 delivered from keratose scaffolds. Biomaterials. 2013; 34(6): 1644-1656.
- 29Whitlock PW, Seyler TM, Parks GD, et al. A novel process for optimizing musculoskeletal allograft tissue to improve safety, ultrastructural properties, and cell infiltration. J Bone Joint Surg Am. 2012; 94(16): 1458-1467.
- 30Cheng C, Alt V, Pan L, et al. Application of F-18-sodium fluoride (NaF) dynamic PET-CT (dPET-CT) for defect healing: a comparison of biomaterials in an experimental osteoporotic rat model. Med Sci Monit. 2014; 20: 1942-1949.
- 31Lieberman JR, Daluiski A, Stevenson S, et al. The effect of regional gene therapy with bone morphogenetic protein-2-producing bone-marrow cells on the repair of segmental femoral defects in rats. J Bone Joint Surg Am. 1999; 81(7): 905-917.
- 32Strom TB, Roy-Chaudhury P, Manfro R, et al. The Th1/Th2 paradigm and the allograft response. Curr Opin Immunol. 1996; 8(5): 688-693.
- 33Chen N, Gao Q, Field EH. Prevention of Th1 response is critical for tolerance. Transplantation. 1996; 61(7): 1076-1083.
- 34Badylak SF, Gilbert TW. Immune response to biologic scaffold materials. Semin Immunol. 2008; 20(2): 109-116.
- 35Pensak M, Hong SH, Dukas A, et al. Combination therapy with PTH and DBM cannot heal a critical sized murine femoral defect. J Orthop Res. 2015; 33(8): 1242-1249.
- 36Alaee F, Hong SH, Dukas AG, Pensak MJ, Rowe DW, Lieberman JR. Evaluation of osteogenic cell differentiation in response to bone morphogenetic protein or demineralized bone matrix in a critical sized defect model using GFP reporter mice. J Orthop Res. 2014; 32(9): 1120-1128.
- 37Rentsch C, Schneiders W, Manthey S, Rentsch B, Rammelt S. Comprehensive histological evaluation of bone implants. Biomatter. 2014; 4:e27993. [Epub ahead of print].
- 38Zhang H, Yang L, Yang XG, et al. Demineralized bone matrix carriers and their clinical applications: an overview. Orthopaedic surgery. 2019; 11(5): 725-737.
- 39Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury. 2007; 38(Suppl 4): S3-S6.
- 40Julius W. Das Gesetz der. Transformation der Knochen. Berlin, Germany: Verlag von August Hirschwald; 1892.
- 41Matsuo Y, Ogawa T, Yamamoto M, et al. Evaluation of peri-implant bone metabolism under immediate loading using high-resolution Na(18)F-PET. Clin Oral Invest. 2017; 21(6): 2029-2037.
- 42Fragogeorgi EA, Rouchota M, Georgiou M, Velez M, Bouziotis P, Loudos G. In vivo imaging techniques for bone tissue engineering. J Tissue Eng. 2019; 10. https://doi.org/10.1177/2041731419854586. [Epub ahead of print].
- 43Lohmann P, Willuweit A, Neffe AT, et al. Bone regeneration induced by a 3D architectured hydrogel in a rat critical-size calvarial defect. Biomaterials. 2017; 113: 158-169.
- 44Bernhardsson M, Sandberg O, Ressner M, Koziorowski J, Malmquist J, Aspenberg P. Shining dead bone-cause for cautious interpretation of [(18)F]NaF PET scans. Acta Orthop. 2018; 89(1): 124-127.
- 45Muschler GF, Nakamoto C, Griffith LG. Engineering principles of clinical cell-based tissue engineering. J Bone Joint Surg Am. 2004; 86-A(7): 1541-1558.
- 46Giannoni P, Scaglione S, Daga A, Ilengo C, Cilli M, Quarto R. Short-time survival and engraftment of bone marrow stromal cells in an ectopic model of bone regeneration. Tissue Eng Part A. 2010; 16(2): 489-499.
- 47Saran U, Gemini Piperni S, Chatterjee S. Role of angiogenesis in bone repair. Arch Biochem Biophys. 2014; 561: 109-117.
- 48Issa JP, Gonzaga M, Kotake BG, de Lucia C, Ervolino E, Iyomasa M. Bone repair of critical size defects treated with autogenic, allogenic, or xenogenic bone grafts alone or in combination with rhBMP-2. Clin Oral Implant Res. 2016; 27(5): 558-566.
- 49Delaisse JM. The reversal phase of the bone-remodeling cycle: cellular prerequisites for coupling resorption and formation. Bonekey Rep. 2014; 3: 561.
- 50Gotz W, Gerber T, Michel B, Lossdorfer S, Henkel KO, Heinemann F. Immunohistochemical characterization of nanocrystalline hydroxyapatite silica gel (NanoBone(r)) osteogenesis: a study on biopsies from human jaws. Clin Oral Implant Res. 2008; 19(10): 1016-1026.
- 51Allman AJ, McPherson TB, Merrill LC, Badylak SF, Metzger DW. The Th2-restricted immune response to xenogeneic small intestinal submucosa does not influence systemic protective immunity to viral and bacterial pathogens. Tissue Eng. 2002; 8(1): 53-62.
