Autologous regenerative stimulants for bone allograft implantation

Abstract

There are many different surgical techniques for bone reconstruction. However, biological reconstruction methods are being increasingly developed. The main purpose is not only to fill up defects, but to stimulate the processes of reconstruction and regeneration of bone as a complete organ. In this report, we describe the basic principles of orthobiology and the essential orthobiological materials. A clinical case is presented where a combination of allogeneic osteoplastic materials with autologous platelet-rich plasma is used to reconstruct a cavity defect in the tibia.

Full text

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REGENERATIVE MEDICINE AND CELL TECHNOLOGIES
DOI: 10.15825/1995-1191-2020-4-133-139
    
 
K.A.Vorobyov1,T.O.Skipenko1, N.V.Zagorodniy1, D.V.Smolentsev1,A.R. Zakirova1,
V.I.Sevastianov2
1 Priorov National Medical Research Center for Traumatology and Orthopedics, Moscow,
Russian Federation
2 Shumakov National Medical Research Center of Transplantology and Artificial Organs, Moscow,
Russian Federation
There are many different surgical techniques for bone reconstruction. However, biological reconstruction methods
are being increasingly developed. The main purpose is not only to ll up defects, but to stimulate the processes
of reconstruction and regeneration of bone as a complete organ. In this report, we describe the basic principles of
orthobiology and the essential orthobiological materials. A clinical case is presented where a combination of allo-
geneic osteoplastic materials with autologous platelet-rich plasma is used to reconstruct a cavity defect in the tibia.
Keywords:orthobiology,boneregeneration,bone defect, bonegraft, allogeneic bonegraftmaterial, bone
marrowaspirate,platelet-rich plasma.
Corresponding author: Konstantin Vorobyov. Adress: 10, Priorova str., Moscow, 127299, Russian Federation.
Phone: (905) 222-10-00. E-mail: vorobyov_doc@mail.ru

Orthobiology is a conceptual concept, which includes
a group of biological materials and substrates promoting
bone regeneration. Such include bone grafts, osteoplastic
materials, growth factors, regulatory protein, and cellular
biomedical products [1, 2]. The role of orthobiology in
bone healing lies in osteoconduction, osteoinduction and
osteogenesis, which are part of the “diamond concept”
proposed by Giannoudis et al. [3], where the authors
identied four basic conditions for successful bone
healing: potent osteogenic cell populations, osteocon-
ductive matrix scaffolds, osteoinductive stimulus, and
mechanical stability.
 
Bone transplantation in the classical concept is pos-
sible only if the bone tissue is preserved in its native
form and is applicable only for two types of materials –
autologous bone and allograft. Autografts have three
functional properties (osteoconductivity, osteoinduction
and osteogenicity) and demonstrate the highest ability
for osseointegration and remodeling; therefore, they are
rightfully considered the ‘gold standard’ for bone graf-
ting. However, their use is limited because they can be
used in a small volume and there is a need to form an
additional access for collection of donor fragments [4].
Spongy bone autografts are the most commonly used
type of materials because they contain a small number of
osteoblasts and osteocytes, with a high content of living
multipotent mesenchymal stromal cells (MSCs) and they
create an osteogenic potential for neoosteogenesis from
the graft. Moreover, proteins contained in the autograft
allow maintaining the natural osteoinductive potential
[2]. In the early post-autograft period, at the stage of
hematoma and inammation, the contained MSCs allow
quick formation of granulation tissue; necrotic tissues are
removed by macrophages, and graft neovascularization
occurs [3].
  
Unlike autografts, allografts are immunogenic and
exhibit rejection reactions, which are caused by antigens
of the major histocompatibility complex (MHC) [5]. The
initial osseointegration phase is accompanied by severe
inammation due to immune response, causing necrosis
of osteoprogenitor cells [6]. The necessary conditions for
the use of allografts should be considered a decrease in
immunogenicity and the conduct of donor/recipient com-
patibility studies, by analogy with organ transplantation
[7]. Another problem is the risk of infection transmission,
which has been resolved in most countries in the world
thanks to the widespread development of a network of
tissue banks and advanced processing technologies [4].
Due to immune response, puried decellularized and
delipidized bone grafting materials (DDBGM) are very
popular in clinical practice [8]. Purication of bone tissue
of bone marrow cells and lipids and then of mineral-
collagen matrix signicantly reduces the degree of in-
ammatory response during DDBGM implantation, but
does not prevent it. According to various literary sources,
the probability of an immune response after implanta-
tion of such materials is about 10% [9]. Demineralized

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RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS Vol. XXII № 4–2020
bone matrix (DBM) is a highly puried, allogeneic bone
derivative, a material devoid (by more than 40%) of the
mineral component, while preserving collagenous and
non-collagenous inducer proteins [10] that determine
osteoinductivity. Having plasticity and high degree of
biodegradation, the process of osseointegration and re-
modeling of the implanted DBM is more intensive than
with non-demineralized bone materials [4].
The clinical outcome of a reconstructive-restorative
surgery depends on the patient’s health status, the tis-
sues surrounding the recipient bed, and the quality and
functional characteristics of the implanted materials. To
improve the functional properties of bone grafting mate-
rials, they are used in combination with autologous bone
marrow aspirate and/or autologous platelet-rich plasma
[2, 11, 12]. The use of such combinations is a simple, af-
fordable and effective way to reduce the risk of immune
reactions after implantation, increase the osteoinductive
potential and impart osteogenic properties to materials.
   
Autologous bone marrow aspirate (ABMA) contains
2 types of adult stem cells: hematopoietic stem cells
(HSCs) and MSCs. The main mechanism of ABMA
as a stimulator of bone regeneration, is realized due to
MSCs content, which differentiate into osteoblasts in the
presence of specic growth factors and cytokines. The
mediated mechanism of action of ABMA is the effect
of cytokines derived from MSCs on endothelial cells,
which promote angiogenesis.
  
The use of autologous platelet-rich plasma (aPRP) as
a biogenic stimulator of regeneration is a fairly popular
and widespread method in orthopedics. Regenerative
potential is achieved through a cascade of reactions and
release of growth factors contained in platelet-rich plas-
ma [13]. Besides, plasma platelets are able to release
over 300 molecules that are responsible for complex
intercellular and extracellular interactions [14]. Unlike
soft tissue, bone regeneration is a long process. In this
regard, many researchers suggest the use of thrombin-
activated aPRP in the form of a dense brin clot to create
conditions for slow release of the factors contained in
it [16].
The main orthobiological materials and their compa-
rative characteristics are presented in Table.
CASE
PatientM.,bornin 1979, medicalrecordcardNo.
Н2019-10342,wastreatedatthe12thdepartmentofthe
PriorovaNationalMedicalResearchCenterof Trau-
matologyandOrthopedicsfromDecember18,2019to
December24,2019forpost-traumaticdeformityofthe
proximalthirdoftherighttibia.PosttraumatictypeII
medialright-sidedgonarthrosis.Cystoftheupperthird
ofthecentral-medialrighttibia.Olddamagetothe
bodyandanteriorhornofthemedialmeniscus,partial
damagetotheanteriorcruciateligament of the right
kneejoint.Moderaterightknee synovitis. Thepatient
complainedofswellingandpaininhisrightkneeduring
physicalexercise,impairedlowerlimbfunction.Exami-
nationrevealedadeformityoftheproximalmetaphysis
oftheright tibiaalongtheanteriorsurfaceandava-
rusdeformityofthetibia.Therightkneecontourswere
unchanged,andedemawasmoderate.Therightthigh
musclesweresatisfactorilydeveloped.Onpalpation,the
internalarticularcavitywaspainful.PositiveBaykov’s
symptoms.Capsularligamentapparatus:anteriordra-
wertest(–/+),Lachmantest(–),posteriordrawertest
(–),Varusstresstest(–),Valgusstresstest(–).Joint
movementwasfull,painfulwhenexingmainlyalongthe
innersurface.Patellamovementswerepainless.Novas-
cularorneurologicaldisordersinthelimbwererevealed
atthetimeofexamination.ThepatientunderwentX-ray
andmultispiralcomputedtomography(MRI),whichdia-
gnosedacystoftheproximalcentral-medialmetaphysis
oftherighttibia(Fig.1).
Punchtrephinebiopsyofthecystwasperformed;
cytologicalexaminationrevealednoatypicalcells.Given
theclinicalanddiagnosticdata,adecisionwastakento
surgicallyreconstructtheabnormalfocus–combined
Table
Comparative biological properties of bone grafts and autologous regenerative stimulants
Autologous and allogenic orthobiological materials
Material type/functional properties Osteoconduction Osteoinduction Osteogenicity Osseointegration
Cortical autograft + + + +
Spongy autograft +++ +++ +++ +++
Cortical allo-implant + +/– – +
Spongy allo-implant + +/– – ++
Demineralized bone matrix + ++ – ++
Autologous bone marrow aspirate – ++ +++ +++1
Autologous platelet-rich plasma – +++ + ++2
Note.1 – effect on the osseointegration process is achieved due to the content bone marrow-derived multipotent mesenchymal
stromal cells; 2 – effect on the osseointegration process is achieved due to the content of growth factors.

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REGENERATIVE MEDICINE AND CELL TECHNOLOGIES
Fig. 1. Magnetic resonance imaging (MRI) of the knee. Tibial cyst. a) sagittal plane. b) frontal plane
аb
Fig. 2. Multispiral computed tomography (MSCT) of the knee joint. Tibial cyst after bone grafting. a) axial projection; b) fron-
tal projection; c) sagittal projection
аb c
bonegraftingwithallogeneiccancellousimplantsim-
pregnatedwithaPRP.Allogeneiccancellouschipsand
PerfoostblocksfromtheTkanevoyBankofthePriorova
NationalMedicalResearchCenterofTraumatologyand
Orthopedics(RU#FSR2009/05682datedDecember17,
2018)andasetsforpreparationofaPRPandactivation
platelet-richplasmaRegenBCT-SP(R-BCT-SP)and
RegenATS-SP(R-ATS-SP)producedbyRegenLabSA,
Switzerlandwereusedtoperformthesurgicalprocedure.
Thepermissionoftheethicscommitteewasnotre-
quiredforthesurgicalinterventionsincethematerials
usedhaveregistrationcerticates.Bloodsamplingand
preparationofautologousplasmaweredonepriorto
surgery,accordingtothemanufacturer’sinstructions.
Surgery process.Theoperationwasperformedunder
spinalanesthesia,withthepatientinthesupineposition,
withreoperativeantibioticprophylaxis.Therightlower
limbwasxedinakneebraceinthemiddlethirdofthe
thigh.Aftertreatingtheoperatingsitethreetimeswith
antisepticsolutions,ablood-squeezingtourniquetwas
appliedfromthelowerthirdofthelegtothelowerthird
ofthethigh, thenapneumatictourniquetwasinated
intheupperthirdofthethigh.Underthecontrolofan
electronicopticaltransducer, belowandlateraltothe
supercialgoosefoot,a5cmlongitudinalskinincision
wasmade,skin-subcutaneousapsweremobilized,and
accesstothebonewasmade.Anosteotomywasperfor-
medalongtheneedleinsertedintothecystcavityofthe
central-medialmetaphysisoftherighttibia,thenacanal
wasformedusingadrill.Thedefectcavitywasrepea-
tedlywashedwithasepticsolutions,andthewallswere
treated.Bone-graftingmaterialswerefragmentedtothe
requiredsize,thenautologousplasmawasaddedtothem
andplasmaactivationusingthrombinwasperformed.
Theresultingcombinedbone-graftingmaterialwas
placedinthedefectcavity,anditwasimpactedforuni-
formdistributioninthecavity.Forthepurposeofint-
raoperativecontrol,apicturewastakenwithanelect-
ronicopticalconverter.Woundsuturingwasperformed
inlayers.
CTmultiscanwasperformedthenextdayaftersur-
gery.Accordingtovisualdataobtainedinthreeplanes–
axial,frontal,sagittal(Fig.2)–therewasauniform
llingofthedefectwithbone-graftingmaterial.

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DISCUSSION
Analyzing the literature on this topic [1–3, 12, 15,
17], we should note the tendency that reconstructive and
grafting interventions on bone tissues are aimed not only
at addressing pain, restoring function, lling a defect or
eliminating deformity, but also at stimulating regenera-
tive processes. This explains the development of such
a conceptual approach in orthopedics as orthobiology,
since orthobiological products and their combinations
can create the necessary conditions for achieving this
goal.
Transplantation of frozen massive bone-cartilagi-
nous allografts for bone tumors was performed by M.V.
Volkov in 1960–70s [18]. The author described 145
cases, of which half of the results were unsatisfactory,
which was due to insufcient understanding, at that time,
of the mechanisms of transplant immunology. One of
the rst studies on the histocompatibility of cartilage
tissue was carried out by Langer and Gross [19], whe-
re it was shown that intact articular cartilage does not
cause humoral immune responses. This is due to the fact
that antibodies are unable to penetrate through the dense
cartilage matrix and reach the chondrocytes. This peculi-
arity of cartilage tissue allows transplantation without the
necessary HLA compatibility studies [20], making the
cartilage an “immune-privileged” tissue. Bone tissue, on
the contrary, has enough immunogen; its transplantation
in its native form requires the necessary compatibility
studies to reduce the rejection risks and degree of im-
mune response [20, 21]. Modern possibilities of labora-
tory screening and understanding of the mechanisms of
transplant immunology and immunosuppression create
the necessary conditions for the development of tissue
transplantation, which is conrmed by literature data. For
example, C. Krettek et al. [17] describes positive clini-
cal results after transplantation of allogeneic osteochon-
dral blocks and massive grafts. The use of allogeneic
grafts from femoral heads from living donors is very
popular among many orthopedic surgeons in the USA
and European countries [22, 23]. In Russia, due to gaps
and conicts in legal regulations on tissue donation and
transplantation, the lack of a network of regional tissue
banks and the complexity of interaction of specialists in
the sequence from donor to recipient patient, bone tissue
transplantation remains a difcult surgical procedure to
access [24].
Allogeneic bone grafting materials are the most po-
pular and often used method in reconstructive surgery.
The ability to process bone tissue to a mineral-collagen
or demineralized matrix reduces immunogenicity and
minimizes the likelihood of complications associated
with it. In Russia, the production of materials is not sub-
ject to uniform standards on which the tissue processing
and sterilization technology is based [8, 25]. As a result,
bone grafting materials differ in their properties. This
complicates the repeatability and predictability of clini-
cal outcomes, and sometimes leads to post-implantation
complications [9].
The efciency of autologous bone marrow aspirate
use to improve bone regeneration processes, both alone
and in combination with osteoplastic materials, has been
conrmed by many studies. Gianakos et al. [26] descri-
bed the results of 35 animal studies in which BMA was
used in long bone defects. Healing occurred in 100%
of cases, and 90% reported signicant improvement in
earlier bone healing on histologic/histomorphometric
assessment. Hernigou et al. [27] described the use of
concentrated BMA concentrate after centrifugation in
the pseudarthrosis of the tibia in 60 patients, of whom
fusion was achieved in 53. Desai et al. [28] described the
positive results of the use of BMA in combination with
osteoplastic materials in false tibial joints. Schotter and
Warner [29] published data indicating a positive effect
when using BMA in combination with allogeneic bone
grafting materials.
Sanchez [30] and Gallasso [31] published clinical
cases of the use of aPRP to accelerate fracture healing.
A positive effect was achieved in all cases. Kesyan G.A.
et al. [11] described a number of clinical cases, which
also noted the positive effect of the use of aPRP in com-
bination with osteoplastic materials for the treatment of
pseudoarthrosis. Despite the widespread use of aPRP to
stimulate bone regeneration, the data on the effective-
ness of its use remain controversial. Peerbooms et al.
[32] reported that there is no benecial effect of using
aPRP to stimulate bone regeneration. Chahla et al. [15]
published an analytical review of the literature, which
reected the analysis of 105 studies, of which 16% fully
describe the characteristics of the cellular composition
and the content of growth factors, and only 10% describe
in detail the protocol for preparing aPRP. The need to
standardize aPRP preparation protocols and guidelines
for its use is described by many authors [15, 16]. Re-
lying on recommendations from the same publications,
it should be noted that to stimulate bone regeneration,
thrombin-activated plasma in the form of a dense brin
clot, which is able to form and maintain the required
shape and slowly release the growth factors contained
in it, is necessary. For this reason, we used the Regen
BCT-SP (R-BCT-SP) and Regen ATS-SP (R-ATS-SP)
kits, described in our clinical case.
CONCLUSION
The use of bone grafts and bone grafting materials
in combination with bone marrow aspirate or platelet-
rich plasma reduces the degree of immune response,
promotes osseointegration and remodeling processes,
which expands the possibilities of using surgical me-
thods for biological reconstruction of bone tissues. To
stimulate bone regeneration, it is recommended to use
thrombin-activated platelet-rich plasma in the form of
a dense brin clot. Only in this case can one create and

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REGENERATIVE MEDICINE AND CELL TECHNOLOGIES
maintain the necessary shape of the material and ensure
slow release of growth factors.
Theauthorsdeclarenoconictofinterest.
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Thearticlewassubmittedtothejournalon21.09.2020