The potential of stem cells in orthopaedic
surgery
E H Lee, J H P Hui. Journal of Bone & Joint Surgery. (British
volume). London: Jul 2006.Vol.88, Iss. 7; pg. 841, 11 pgs
Stem cell therapy holds great promise for the repair &
regeneration of musculoskeletal tissues
 challenges need to be overcome
 generate adequate numbers of the correct
phenotypes of cells under animal-free culture.
 appropriate three-dimensional structure
 production of extracellular matrix
 structurally & biomechanically compliant with the
demands of native tissue
 fully integrated & immunologically compatible,
with the host tissue
Definitions
 Stem cells
 Able to self-renew giving rise to more stem cells
 ability to differentiate into tissues of various
lineages under appropriate conditions
 Pluripotent:
 Embryonic stem cells (ESCs)
 able to differentiate into most cell types
 Multipotent
 can give rise to several other cell types, but
those types are limited in number
 Totipotent
 embryo
 ability of a single cell, usually a stem cell, to
divide and produce all the differentiated cells in
an organism
 Embryonic stem cells (ESCs)
 Pluripotent
 capable of differentiating into many tissue types,
 Adult stem cells
 Differentiate to the tissue in which they reside
 hepatocytes – liver
 haemopoietic stem cells - blood
 under appropriate conditions some can
differentiate into multilineages, becoming
multipotent.
 mesenchymal stem cells (MSCs)
 found in bone marrow, skin, adipose
tissue,
 capable of differentiating into bone,
cartilage, tendon, ligament, fat
 multipotent adult progenitor cell (MAPC)3
 more pluripotent stem cell
 bone marrow
 Transdifferentiation
 cells from one lineage dedifferentiate
 giving rise to an intermediate cell type, before
redifferentiating into cells of another lineage.
 heart, liver & brain
Derivation of ESCs
 pluripotent ESC
 fertilised oocyte, zygote & morula
 inner cell mass (ICM)
 main source of ESC
 5-6 day old human blastocyst
  two distinct cell layers  found post-natally in the nonhaemopoietic
 hypoblast bone marrow stroma,
 yolk sac  also be derived from periosteum, fat & skin.
 epiblast  multipotent cells capable of differentiating
 differentiates three layers, into cartilage, bone, muscle, tendon,
 ectoderm, mesoderm & ligament & fat
endoderm.  great potential
 repair & regeneration of bone &
cartilage.
 appropriate growth factors & scaffold
technology
 ? possible to repair large defects in
bone & cartilage biologically
 progenitor cells, injected directly into
tissues to enhance the process of repair
 using them as a vehicle for gene
delivery.

Mesenchymal stem cells

 multipotent progenitor cells
 capable of differentiating into several connective
tissue cell types, including osteocytes,
chondrocytes, adipocytes, tenocytes & myocytes
 characterised by cell surface markers
 MSCs from bone marrow share the following
features.
 No expression of HSC markers, such as CD34 &
CD14.
 Expression of matrix receptors such as CD44,
CD29 & CD71.
 Expression of MSC markers, SH2 (CD105) &
SH3 (CD71).12
 Extracellular matrix components: collagen,
proteoglycans & fibronectin.
 Growth factors & cytokine receptors for TGF-β
Cell lineages from the Inner Cell Mass (ICM) of human group.
blastocysts. TE, trophectoderm; hESC, human
embryonic stem cell; GI, gastrointestinal. Articular cartilage
 Articular cartilage
 autologous chondrocyte implantation (ACI).
Differentiation of human stem cells  Chondrocytes stem cells
 Controlled differentiation  periosteum containing stem cells,
 growth factors  chondrocyte precursors
 direct contact with companion cells  Bone
 specific gene construct transfected into ESCs  bone marrow osteoprogenitors
 autologous human stromal progenitors in
Overcoming problems with ESCs the regeneration of large bone defects
 significant hurdles: cell-based therapy from hESCs.  requirements
 forming a more stable progenitor stage to avoid the  osteoproduction,
formation of teratomas  osteoinduction,
 ideal serum & xeno-free feeder cell culture media  osteoconduction
 mechanical stimulation.
Adult stem cells  Osteoproduction
 more limited in their ability to differentiate into many  ability of the cell to secrete bone material.
tissue types  muscle-derived stem cells
 present fewer ethical problems  Osteoinduction
 autologous cells: no problems with immunogenicity.  growth factors that attract osteogenic cells
 problem of control of differentiation to the site of the defect
 propensity to form teratomas is much slighter.  TGF-β, bone morphogenetic proteins
 haemopoietic stem cells (HSCs) & MSCs. (BMPs), BMP-2 & BMP-7,
 HSCs  Osteoconduction
 already in use clinically  incorporation of a structure bearing bone
 leukaemia, thalassaemia & multiple cells into a recipient site.
myeloma  Scaffold
 MSCs
 BMP regulates chemotaxis, mitosis & differentiation,
  fundamental in initiating fracture repair
 TGF-β & IGF
 stimulate fracture repair & minimise the rate of
nonunion.
 Requirements
 dose must be of sufficient concentration for a
sustained period
 short biological half-lives
 must be maintained at therapeutic
concentrations at the fracture site to be effective.
 ? role of Gene therapy to solve this
 Gene therapy
 ex vivo
 gene encoding for a given growth factor is
isolated & transferred to a recipient cell
using viral or non-viral vectors.
 genetically modified cells both secrete the
BMP protein & respond to it, thereby
potentially magnifying the clinial response
 muscle-derived stem cells
 capable of producing sufficient levels of
osteoinductive proteins, such as BMP-2,
after transduction with viral vectors.
 ? can heal critically sized bony defects
 no clinical trials of gene therapy for
tissue repair.
 Tendons & ligaments
 MSCs in rabbit
 Repair
 larger cross-sectional area
 collagen fibres better aligned
 higher maximum stresses & moduli at
12 & 26
 ACL
 normal anatomy of the insertion site of the ACL
is fibrocartilaginous
 four distinct zones:
 ligament substance,
 unmineralised fibrocartilage,
 mineralised fibrocartilage
 bone
 improve tendon-to-bone healing
 BMP-2 can augment tendon healing in a
bone tunnel
 rat model that tendons treated with BMP-12
form a fibrocartilaginous insertion after four
weeks
 Rabbit
 tendon-bone junction results in a zone
of fibrocartilage at the junction which
more closely resembled that of the
normal ACL.
 improved biomechanical properties
 rapid & significant increase in load to
failure & stiffness in the first eight weeks
after reconstruction of the ACL
 Meniscus
 isolated chondrocytes seeded on to meniscal
matrices were able to bond separate pieces
together.
 strength of the adhesion increased over time by
the formation of a newly synthesised
cartilaginous matrix.
 meniscal lesion involving the inner, avascular,
one-third of the meniscus benefitted from the
bonding capabilities of the transplant.
 Intervertebral disc
 discogenic back pain
 transplantation to the intervertebral disc of
mature autologous disc cells, chondrocytes or
stem cells.
 Cell transplantation can potentially increase
proteoglycan production, induce disc
regeneration or slow the process of
degeneration.
 transplantation of autologous disc cells &
chondrocytes derived from costal cartilage
 MSCs can maintain viability & proliferate within
the intervertebral disc of the rat.
 introduction of appropriate genes into disc cells
by gene transduction using adenoviral vectors or
'gene-gun' delivery systems
 Spinal fusion.
 hybrid graft by combining cultured MSCs with a
ceramic scaffold
 Spinal cord injuries
 pluripotential cells to differentiate into neural
tissue.
 repair of the spinal cord is very complex
 restoring or enhancing local spinal reflex
arcs
 reconnecting regenerating axons from
above.
 Gliosis may block the outgrowth of axons.
 MSCs isolated in culture from the
mononuclear layer of bone marrow can
remyelinate demyelinatecl spinal cord axons
after direct injection into the lesion.
 Future strategies for repair of the human spinal
cord
 multifaceted,
 enhancement of axonal growth &
reconnection,
 replacement of cellular elements
 reversal of demyelination
 Physeal injuries
 cultured chondrocytes have been transferred
into physeal defects for the correction of
established growth arrest in animal models
 Rat: transplantation of autologous chondrocytes
cultured in atelocollagen gel reduced the
angular deformity & length discrepancy of the
leg with the injured physis
 Rabbit: implantation of MSCs into growth-plate
defects resulted in a significant reduction in
growth arrest
 ? donor MSCs differentiated into chondrocytes
as well as the host bone marrow cells from the
metaphyseal subchondral region, thereby
generating the repair of the physis.
 Muscular dystrophy
 a heterogeneous group of neuromuscular
disorders that produce progressive muscle
weakness, muscle wasting
 Duchenne muscular dystrophy (DMD),
 in vitro bone marrow differentiates into
contractile myotubes.
 myoblasts could be transplanted into dystrophic
muscle & repaired a small proportion of
damaged myofibres.
 delivery of dystrophin by in vivo gene transfer
using viral vectors
 Osteogenesis imperfecta
  Pre-clinical studies
 whole bone marrow contains cells that can
engraft & become competent osteoblasts
after transplantation.
 because collagen is a secreted product,
even a low level of osteoblast engraftment
might be beneficial to patients with OI
 allogenic bone marrow transplantation in
patients with OI
 2% of the osteoblasts were of donor origin,
suggesting that donor-derived MSC
precursors in the marrow were capable of
homing to the bone marrow & of
differentiation into osteoblasts, or that
residual osteoblasts in the bone marrow
graft were able to establish in the bone
marrow.88
 genetic engineering of the individual's own bone
marrow with ex vivo genetic modification,
 Juvenile rheumatoid arthritis
 autologous stem cell transplantation (ASCT).
 high-dose therapy supported by autologous
stem cell transplantation may induce a good
response in such disease
 Immune ablation followed by reconstitution of
autologous haemopoiesis might allow 'resetting'
of the immune system through the induction of
peripheral tolerance.
 harvesting the patient's own HSCs
 aggressive treatment with irradiation &/or
high-dose chemotherapy to destroy the cells
that are responsible for the inflammatory
disease
 patient's stem cells are then subjected to
cycles of T-cell depletion before being
infused back into the patient
 T cells are removed because of their
potential to reintroduce the autoreactive
state.
 the use of ASCT for the treatment of human
autoimmune disorders, including various
rheumatic diseases, is in its infancy.