ORTHOPEDIC TISSUE ENGINEERING BASIC SCIENCE AND PRACTICE EDlTED BY VICTORM. GOLDBERG ARNOLD I. CAPLAN ORTHOPEDIC TISSUE ENGINEERING BASIC SCIENCE AND PRACTICE EDITED BY VICTOR M. GOLDBERG ARNOLD I. CAPLAN Case Western Reserve University Cleveland, Ohio, U.S.A. ~ MARCEL DEKKER, INC. ~ DEKKER NEW YORK· BASEL Although great care has been taken to provide accurate and current information, neither the author(s) nor the publisher, nor anyone else associated with this publi- cation, shall be liable for any loss, damage, or liability directly or indirectly caused or alleged to be caused by this book. The material contained herein is not intended to provide specific advice or recommendations for any specific situation. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress. ISBN: 0-8247-4749-6 This book is printed on acid-free paper. Headquarters Marcel Dekker, Inc., 270 Madison Avenue, New York, NY 10016, U.S.A. tel: 212-696-9000; fax: 212-685-4540 Distribution and Customer Service Marcel Dekker, Inc., Cimarron Road, Monticello, New York 12701, U.S.A. tel: 800-228-1160; fax: 845-796-1772 Eastern Hemisphere Distribution Marcel Dekker AG, Hutgasse 4, Postfach 812, CH-4001 Basel, Switzerland tel: 41-61-260-6300; fax: 41-61-260-6333 World Wide Web http://www.dekker.com The publisher offers discounts on this book when ordered in bulk quantities. For more information, write to Special Sales/Professional Marketing at the headquarters address above. Copyright © 2004 by Marcel Dekker, Inc. All Rights Reserved. Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher. Current printing (last digit): 10 9 8 7 6 5 4 3 2 1 PRINTED IN THE UNITED STATES OF AMERICA Preface During the last three decades, important advances have been made in the available treatments for the loss of skeletal tissue as a result of trauma or disease. The application of large skeletal allografts and total joint replace- ment have become successful and reproducible treatment options. Unfortu- nately there still is a significant incidence of failure because of mechanical or biological complications. A new discipline known as tissue engineering has developed that integrates the concepts of the life sciences, such as biology, chemistry, and engineering, with surgical techniques to develop strategies for the regeneration of musculoskeletal tissue. The basic components of any tissue-engineered treatment strategy requires viable cells, biomatrices, and bioactive factors. The cells are central to the regenerative process of any musculoskeletal tissue. They must be responsive to their environment and ultimately capable of integrating into the host tissue and synthesizing appropriate extracellular matrix. The biomatrix may have several functions, including a delivery vehicle for the cells or bioactive factors, or it may func- tion as a scaffolding to conduct the host cells and inductive molecules. Because the musculoskeletal system demands the capability of withstanding functional loads, scaffolds must be capable of temporary supportive activ- ities when used in highly loaded environments such as bone. The matrix also may act as an organizing guiding component for the morphogenesis of the engineered tissue. The integration of the biomatrix and cells requires a defi- nition of the optimal number density and distribution of the ceJl component relative to the scaffold. Bioactive factors may function as mitogens, morphogens, or growth factors. These molecules have been shown iii MARCEL DEKKER, INC. ~ 270 Madison Avenue. New York. New York 10016 lI!!JI? iv Preface experimentally and clinically to be important inducers of the regeneration of musculoskeletal tissue. Orthopedic Tissue Engineering: Basic Science and Practice is a timely publication that provides a basis of both the basic science and the clinical application of this emerging discipline. The book provides a strong basis for the concepts of principles of tissue engineering and regeneration of mus- culoskeletal tissue and the application of these principles to specific clinical problems. The publication is directed toward a wide audience of both basic scientists and clinicians involved in the experimental and clinical applica- tions of these new treatments. Medical students and graduate students as well as established investigators and clinicians in many discipbnes of surgery will use this book in their activities. The books is divided into sections on basic science and clinical applica- tions. The chapters in the basic science section address the issues of princi- ples of tissue engineering and the role of each component, namely, morphogenic proteins, cells, and biomatrices. Important areas of bioreac- tors and clinically applicable animal models in tissue engineering are dis- cussed for a broad background in tissue engineering/basic science. The clinical application section addresses each type of musculoskeletal tissue, including bone, cartilage, meniscus, intervertebral disc, and liga- ment/tendon. The area of gene therapy to enhance both bone and cartilage repair is discussed. The integration of the two sections will provide the reader with a broad background in tissue engineering science and clinical application. Further, it will serve as a source of material for investigators in each of the areas and provide a platform for important future develop- ments in this emerging clinical discipline. Finally, this publication has defined the state of the science and art and, most important, the future direc- tions and issues that must be solved for the ultimate successful application of regeneration of musculoskeletal tissue. Victor A1. Goldberg Arnold I. Caplan MARCEL DEKKER, INC. ~ 270 Madison Avenue. New York. New York 10016 ~ Foreword The application of tissue engineering III orthopedics has immense possibilities yet to be realized. The discipline of tissue engineering was identified and generally defined less than 15 years ago, but the recognition of its potential to impact patient treatment has resulted in a dramatic refo- cusing of research activities into areas of unmet or unsatisfactory clinical needs. Already there are tissue-engineered products available in the wound care field to treat burns and chronic wounds, demonstrating the validity of this approach. This has been a dramatic success story for such a new field, and has been the catalyst for a massive focus on basic and applied research, particularly in orthopedics, where the many potential applications are clear and necessary. The field of tissue engineering, particularly when applied to ortho- pedics where tissues often function in a mechanically demanding environ- ment, requires a collaboration of excellence in cell and molecular biology, biochemistry, material sciences, bioengineering, and clinical research. For success in tissue engineering it is necessary that researchers with expertise in one area have an appreciation of the knowledge and challenges of the other areas. At the same time, the influx of researchers into tissue engi- neering requires a rapid learning curve of the many facets of this field to bring them into a productive mode as soon as possible. Therefore there is an obvious need for a text that brings to the researcher the critical and salient points of these areas. This book provides an up-to-date knowledge base for experts and novices alike in tissue engineering, providing a guide and resource to this rapidly expanding fields. v MARCEL DEKKER, INC. ~ 270 Madison Avenue. New York. New York 10016 ~ vi Foreword The topics in the book comprehensively cover the basic science (cell and molecular biology) and engineering (biomatrices, bioreactors, biomech- anics) aspects that are important in tissue engineering, and considers the in vitro an in vivo growth environments. It also provides insight into the phy- siology and developmental biology that can help guide the researcher. Of particular importance, Chapter 9 describes the animal models that are being used in translational research, where the efficacy of tissue-engineered products will be determined. Success in an animal model is generally a prere- quisite for moving into clinical trials, yet the models used often are not well understood and unfortunately the interpretation of the results are often overextrapolated. The book also describes the different tissues and the clin- ical applications that tissue engineering can target. These chapters therefore cover the breadth of tissue engineering in orthopedics, and can educate all of us. Tissue engineering applications can be considered to act in one of several general ways. The most simple is for the product to assist, or facili- tate, the body to repair itself. The second is to induce the body to repair itself. The third is to introduce a tissue that can remodel in vivo to become functional over time. The fourth is to provide a frank replacement that can function at the time of, or soon after, implantation. While the last type of application is the one most commonly thought of as tissue engineering, it is by far the most difficult to develop. The first two mechanisms are easier to apply, and are likely in the short to medium term to be the way that tissue engineering products will have an impact on clinical treatment. Considera- tion of this relatively pragmatic approach may be the way to maintain for- ward progress of this field, while continuing to work toward the ultimate applications. Orthopedic applications of tissue engineering have the potential to revolutionize the field. Balancing this with reality-since the technical, regulatory, and commercial challenges may be substantial-means that the introduction of new products is likely to be slow. Hopefully researchers will use the experience already gained in tissue engineering to target applica- tions that minimize the challenges and allow progress to be made. Aiming for the ultimate goals (for example, frank replacement of mechanically func- tional tissues such as articular cartilage and meniscus, etc.) is essential, but at the same time applications that are less challenging will almost certainly lead to more rapid development of products that can help patients. Replace- ment of tissues with a mechanically demanding function such as cartilage, meniscus, and ligament is likely to be much more difficult with subsequently long development time. Induction of a repair process, already shown to be successful in wound care tissue engineering, may lead to rapid development of products in orthopedics. Every field needs its share of success! MARCEL DEKKER, INC. ~ 270 Madison Avenue. New York. New York 10016 ~ Foreword vii The use of tissue engineering in orthopedics inevitably requires that the product be commercially viable. The lengthy process times for develop- ment and regulatory approval, and the high cost of production, must be weighted. It seems likely that a strategy that encourages the development of relatively simple products with shorter time to market and lower cost of production will only serve to enhance the field. While these products may not be as technically challenging or attractive to the basic research scientists and engineers, for those who focus on translational or clinical research, these potential applications can be just as rewarding. A broad approach is, therefore, necessary. Tissue engineering is still in its infancy, but is moving into a more rigorous, science-driven field. This is welcomed and should be encouraged, and progress will surely be made not only in the areas that are already tar- geted, but by new researchers not burdened by history and dogma. There is therefore a need for both the safe and incremental, as well as the high-risk entrepreneurial approaches. The visionary leadership shown by those who introduced the field of tissue engineering, and by those who early on recognized its immense poten- tial in orthopedics, must now be enhanced by a new group of scientists and engineers with new vision. These researchers will need to work at the fore- front of their own technical discipline as well as in a multi-disciplinary envir- onment, having an advanced appreciation of technical fields not their own. This high-level collaboration among researchers in different fields will surely result in the development of new methods and products that can address the clinical challenges in orthopedics. The future is very bright! Anthony Ratcliffe Gail Naughton San Diego, California, U. S. A. MARCEL DEKKER, INC. ~ 270 Madison Avenue. New York. New York 10016 ~ MARCEL DEKKER, INC. ~ 270 Madison Avenue, New York. New York 10016 ~ Contents Preface Foreword Contributors PART I BASIC SCIENCE I. Principles of Tissue Engineering and Regeneration of Skeletal Tissues Victor M. Goldberg and Arnold I. Caplan III V X III 2. Tissue Engineering and Morphogenesis: Role of Morphogenetic Proteins 11 A. H. Reddi 3. Cell-Based Approaches to Orthopedic Tissue Engineering 21 E. J. Caterson, Rocky S. Tuan, and Scott P. Bruder 4. Intraoperative Harvest and Concentration of Human Bone Marrow Osteoprogenitors for Enhancement of Spinal Fusion James E. Fleming, Jr., George F. Muschler, Cynthia Boehm, fsador H. Lieberman, and Robert F. McLain 5. Molecular Genetic Methods for Evaluating Engineered Tissue Matthew L. Warman 51 67 ix MARCEL DEKKER, INC. ~ 270 Madison Avenue. New York. New York 10016 ~ [...]... Steinbis, and Antonios G Mikos 7 Biomechanical Factors in Tissue Engineering of Articular Cartilage Farshid Gui/ak 8 105 Bioreactors for Orthopedic Tissue Engineering G Vunjak-No vako vic, B Obradovic, H Madry, G Altman, and D L Kaplan 9 77 Clinically Applicable Animal Models in Tissue Engineering Ernst B Hunziker PART II 10 11 123 149 CLINICAL APPLICATION Bone Tissue Engineering: Basic Science and Clinical... II TISSUE ENGINEERING TRIAD Tissue engineering is based on inductive morphogenetic signals, responding stem cells, and the biomimetic entracellular matrix functioning as a scaffold (I) This triad ofcues, cells, and context constitutes the holy trinity for tissue engineering (2), and also governs morphogenesis and development The principles and molecular basis oftissue engineering ofmusculoskeletal tissues... Avenue New York New York 10016 ~ ~ Principles of Tissue Engineering 3 constraint imposes unusual demands on tissue engineering strategies for skeletal tissues II PRINCIPLES OF TISSUE ENGINEERING The basic component of any tissue engineering strategy is the use, either in combination or separately, of cells, biomatrices or scaffolds/delivery vehicles, and signaling molecules that provide the biological... Safdar N Khan and Joseph M Lane 161 Articular Cartilage: Overview Joseph A Buckwalter 179 12 Cartilage: Current Applications B Kinner and M Spector 201 13 Tissue Engineering of Meniscus Brian Johnstone, Jung Yoo, Victor Goldberg, and Peter Angele 237 14 Tissue Engineering of Intervertebral Disc Jung Yoo and Brian Johnstone 249 IS Clinical Applications of Orthopedic Tissue Engineering: Ligaments and Tendons... is the restoration of the morphology and function ofthe lost tissue The recent emergence ofa new discipline, defined as tissue engineering, combines aspects ofcell biology, engineering, materials science, and surgery with the outcome goal to regenerate functional skeletal tissues as opposed to replacing them (4,5,9,21,24,35,37) Repair and regeneration of skeletal tissues are fundamentally different... differentiation factors 5 and 6 (19) and may play a critical role in initiation and maintenance of articular cartilage and joint morphogenesis MARCEL DEKKER, INC 270 Madison Avenue New York New York 10016 ~ ~ 15 Tissue Engineering and Morphogenesis V BMP RECEPTOR KII\lASES Recombinant human BMP-4 binds to type I BMP receptors, BMPR-IA and BMPR-lB, called ALK-3 and ALK-6, respectively BMP-2, BMP-7, and CDMP-I (GDF-5)... approach to tissue engineering with vascularized muscle flap and BMPs yielded new bone with a defined shape (3 l) and is proof of principle and concept for further refinement and validation We indeed are in a brave new world of prefabricated biological spare parts for the human body based on tissue engineering and sound architectural rules of inductive signals for morphogenesis, responding stem cells, and. .. contributions of bone and BMPs to the more wide-ranging concepts of tissue engineering in orthopedic surgery and regenerative medicine (32) ACKNOWLEDGMENTS This work is supported by the Lawrence Ellison Chair in Musculoskeletal Molecular Biology and grants from the Department of Defense and the Shriners Hospital for Children I thank Rita Rowlands for her outstanding bibliographic assistance and enthusiastic... cell-based tissue engineering treatment strategies (7) MARCEL DEKKER, INC 270 Madison Avenue New York New York 10016 ~ ~ Principles of Tissue Engineering 5 Rule 1: Physically replace the excised tissue with biologically matched tissue This requires that precise and discrete boundaries be established to fit the volume required by the excised or damaged tissue Rule 2: Regenerate the engineered tissue as... Chichester, England, 1988: 3-21 Caplan AI Embryonic development and the principles of tissue engineering In: Tissue Engineering of Cartilage and Bone Novartis Foundation London: John Wiley & Sons Ltd., 2002 In press Caplan AI Mesenchymal stem cells J Orthop Res 1991; 9:641-650 Caplan AI Tissue engineering designs for the future: new logics, old molecules Tissue Eng 2000; 6: 1-8 Caplan AI, Elyaderani M, Mochizuki . ORTHOPEDIC TISSUE ENGINEERING BASIC SCIENCE AND PRACTICE EDlTED BY VICTORM. GOLDBERG ARNOLD I. CAPLAN ORTHOPEDIC TISSUE ENGINEERING BASIC SCIENCE AND PRACTICE EDITED BY VICTOR M. GOLDBERG ARNOLD I INC. ~ 270 Madison Avenue, New York. New York 10016 ~ Contents Preface Foreword Contributors PART I BASIC SCIENCE I. Principles of Tissue Engineering and Regeneration of Skeletal Tissues Victor M. Goldberg and Arnold I. Caplan III V X III 2. Tissue Engineering and Morphogenesis: Role of Morphogenetic. different tissues and the clin- ical applications that tissue engineering can target. These chapters therefore cover the breadth of tissue engineering in orthopedics, and can educate all of us. Tissue