The gold standard in the repair of bony defects is autologous bone grafting, even though it has drawbacks in terms of availability and morbidity at the harvesting site. Bone-tissue engineering, in which osteogenic cells and scaffolds are combined, is considered as a potential bone graft substitute strategy. Proof-of-principle for bone tissue engineering using mesenchymal stromal cells (MSCs) has been demonstrated in various animal models. In addition, 7 human clinical studies have so far been conducted. Because the experimental design and evaluation parameters of the studies are rather heterogeneous, it is difficult to draw conclusive evidence on the performance of one approach over the other. However, it seems that bone apposition by the grafted MSCs in these studies is observed but not sufficient to bridge large bone defects. In this paper, we discuss the published human clinical studies performed so far for bone-tissue regeneration, using culture-expanded, nongenetically modified MSCs from various sources and extract from it points of consideration for future clinical studies.

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The surface marker profile of mesenchymal stromal cells (MSCs) suggests that they can escape detection by the immune system of an allogeneic host. This could be an optimal strategy for bone regeneration applications, where off-the-shelf cells could be implanted to heal bone defects. However, it is unknown how pre-differentiation of MSCs to an osteogenic lineage, a means of improving bone formation, affects their immunogenicity. Using immunohistological techniques in a rat ectopic implantation model, we demonstrate that allogeneic osteoprogenitors mount a T cell- and B cell-mediated immune response resulting in an absence of in vivo bone formation. Suppression of the host immune response with daily administration of an immunosuppressant, FK506, is effective in preventing the immune attack on the allogeneic osteoprogenitors. In the immunosuppressed environment, the allogeneic osteoprogenitors are capable of generating bone in amounts similar to those of syngeneic cells. However, using osteoprogenitors from one of the allogeneic donors led to newly deposited bone that was attacked by the host immune system, despite the continued administration of the immunosuppressant. This suggests that, although using an immunosuppressant can potentially suppress the immune attack on the allogeneic cells, optimizing the dose of the immunosuppressant may be crucial to ensure bone formation within the allogeneic environment. Overall, allografts comprising osteoprogenitors derived from allogeneic MSCs have the potential to be used in bone regeneration applications.

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In the present study, two open porous calcium phosphate ceramics, β-tricalcium phosphate (β-TCP), and hydroxyapatite (HA) were compared in a critical-sized femoral defect in rats. Previous comparisons of these two ceramics showed significantly greater osteoinductive potential of β-TCP upon intramuscular implantation and a better performance in a spinal fusion model in dogs. Results of the current study also showed significantly more bone formation in defects grafted with β-TCP compared to HA; however, both the ceramics were not capable of increasing bone formation to such extend that it bridges the defect. Furthermore, a more pronounced degradation of β-TCP was observed as compared to HA. Progression of inflammation and initiation of new bone formation were assessed for both materials at multiple time points by histological and fluorochrome-based analyses. Until 12 days postimplantation, a strong inflammatory response in absence of new bone formation was observed in both ceramics, without obvious differences between the two materials. Four weeks postimplantation, signs of new bone formation were found in both β-TCP and HA. At 6 weeks, inflammation had subsided in both ceramics while bone deposition continued. In conclusion, the two ceramics differed in the amount of bone formed after 8 weeks of implantation, whereas no differences were found in the duration of the inflammatory phase after implantation or initiation of new bone formation.

The aim of this study was to evaluate the accuracy of percutaneous pedicle screw placement using augmented reality surgical navigation during minimally invasive transforaminal lumbar interbody fusion (TLIF).Summary of Background Data: Augmented reality-based navigation is a new type of computer-assisted navigation where video cameras are used instead of infrared cameras to track the operated patients and surgical instruments. This technology has not so far been clinically evaluated for percutaneous pedicle screw placement. Materials and Methods:The study assessed percutaneous pedicle screw placement in 20 consecutive patients who underwent single-level minimally invasive TLIF using augmented reality surgical navigation. Facet joint violation and depression by the inserted pedicle screws were evaluated. Secondary outcome such as radiation dose exposure, fluoroscopy time, and operative time were collected for 3 phases of surgery: preparation phase, pedicle screw placement, and decompression with cage placement.Results: A clinical accuracy for screw placement within the pedicle (Gertzbein 0 or 1) of 94% was achieved. One screw violated the facet joint with a transarticular pathway. The screw head did not depress the facet in 54%. The use of fluoroscopy during navigation correlated with patient body-mass index (r = 0.68, P < 0.0001). The pedicle screw placement time corresponded to 36 ± 5% of the total operative time of 117 ± 11 minutes. A statistically significant decrease of 10 minutes in operative time was observed between the first and last 10 procedures which corresponded to the pedicle screw placement time decrease (48 ± 9 vs. 38 ± 7 min, P = 0.0142). The learning curve model suggests an ultimate operative time decrease to 97 minutes. Conclusion:Augmented reality surgical navigation can be clinically used to place percutaneous screws during minimally invasive TLIF. However, the lack of tracking of the location of the device requires intraoperative fluoroscopy to monitor screw insertion depth especially in obese patients.

Tissue Engineering Part A eering new bone via a minimally invasive route using human bone marrow derived stromal cell aggregates, micro ceramic particles and human platelet rich plasma gel (doi: 10.1089(doi: 10. /ten.TEA.2012 This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof. 2 AbstractThere is a rise in the popularity of arthroscopic procedures in orthopedics. However, the majority of cell based bone tissue engineered constructs rely on solid pre-formed scaffolding materials, which require large incisions and extensive dissections for placement at the defect site. Thus, they are not suitable for minimally invasive techniques.The aim of this study was to develop a clinically relevant, easily moldable, bone tissue engineered construct (TEC), amenable to minimally invasive techniques, using human mesenchymal stromal cells (hMSC) and calcium phosphate micro particles in combination with an in-situ forming platelet rich plasma (PRP) gel obtained from human platelets. Most conventional TECs rely on seeding and culturing single cell suspensions of hMSCs on scaffolds. However, for generating TECs amenable to the minimally invasive approach, it was essential to aggregate the hMSCs in vitro prior to seeding them on the scaffolds as unaggregated MSCs did not generate any bone. 24 hours of in vitro aggregation was determined to be optimal for maintaining cell viability in vitro and bone formation in vivo. Moreover, no statistically significant difference was observed in the amount of bone formed when the TECs were implanted via an open approach or a minimally invasive route. TECs generated using MSCs from three different human donors generated new bone through the minimally invasive route in a reproducible manner, suggesting that these TECs could be a viable alternative to pre-formed scaffoldsemployed through an open surgery for treating bone defects. Page 2 of 35Tissue Engineering Part A eering new bone via a minimally invasive route using human bone marrow derived stromal cell aggregates, micro ceramic particles and human platelet rich plasma gel