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Perspectives on Modern Orthopaedics

Regenerative Medicine for

the Musculoskeletal System
Based on Muscle-derived
Stem Cells

Charley B. Gates, MD
Tharun Karthikeyan, MD
Freddie Fu, MD
Johnny Huard, PhD
Dr. Gates is Resident, Department of
Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Dr. Karthikeyan is Resident, Department
of Orthopaedic Surgery, University of
Pittsburgh Medical Center. Dr. Fu is
David Silver Professor and Chair, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center. Dr.
Huard is Henry J. Mankin Professor of
Orthopaedic Surgery, Department of
Orthopaedic Surgery, Molecular Genetics Biochemistry, and Bioengineering,
University of Pittsburgh, and Director,
Stem Cell Research Center, Childrens
Hospital of Pittsburgh.
Dr. Huard or a member of his immediate
family has received research or
institutional support from CookMyoSite,
Inc. None of the following authors or a
member of their immediate families has
received anything of value from or owns
stock in a commercial company or
institution related directly or indirectly to
the subject of this article: Dr. Gates, Dr.
Karthikeyan, and Dr. Fu.
Reprint requests: Dr. Huard, Department
of Orthopaedic Surgery, University of
Pittsburgh Medical Center, Kaufmann
Building, Suite 1011, 3471 Fifth
Avenue, Pittsburgh, PA 15213.
J Am Acad Orthop Surg 2008;16:
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.


The identification and characterization of stem cells is introducing
a paradigm shift in the field of orthopaedic surgery. Whereas in the
past, diseased tissue was replaced with allograft material, current
trends in research revolve around regenerating damaged tissue.
Muscle-derived stem cells have an application in regeneration of
articular cartilage, bone, and skeletal muscle. These postnatal (ie,
adult) stem cells can be readily isolated via muscle biopsy. They
can display long-term proliferation, high self-renewal, and multipotent differentiation. They also can be genetically modified to
secrete growth factors important to tissue healing, thereby functioning as implantable, long-lasting reservoirs for these molecules.
Taken together, this evidence suggests that muscle-derived stem
cells are well suited for gene therapy and tissue engineering applications for the musculoskeletal system. Effective implementation
of even just a few applications of muscle-derived stem cellbased
tissue engineering has the potential to revolutionize the way certain musculoskeletal diseases are managed.

quiet revolution is taking place

in many fields of medicine, including orthopaedic surgery. The
stem cell is the focus of this revolution. Applications of stem cell technology have the potential to alter
the natural history of musculoskeletal damage and disease processes that, at present, have no attractive therapeutic options. The
etiologies of these conditions vary,
but ultimately, each condition disrupts the ability of the body to completely heal certain tissues of the
musculoskeletal system. Current
treatment regimens for many disabling orthopaedic afflictions delays
rather than arrests the progression

of symptoms, but stem cell technology offers the opportunity to alter

their otherwise debilitating course
and substantially improve patient
outcomes. Although stem cell research is in its early stages, its potential for healing diseased and damaged tissue is both real and vast. An
understanding of the fundamental
characteristics and processes of
stem cell biology will permit the orthopaedic surgeon to be actively involved in the development and critique of future clinical applications
of this technology and will help each
surgeon determine which patients
may benefit from stem cell treatment.

Journal of the American Academy of Orthopaedic Surgeons

Charley B. Gates, MD, et al

What is a Stem Cell?

At present, there is no unifying definition of what exactly constitutes a
stem cell.1 Stem cells are generally
considered to possess certain properties that distinguish them from normal, fully differentiated cells. These
properties include the capacity to
remain in a quiescent, undifferentiated state until an appropriate stimulus causes them to divide (asymmetrically) and differentiate along
multiple tissue lineages, and the
ability to undergo many more replicative cycles than normal, fully differentiated cells.1,2 Asymmetric division refers to cellular division that
produces a daughter stem cell with
all of the properties of the parent
stem cell and a second cell that is
committed to a tissue lineage. In
this way, stem cells both differentiate and self-perpetuate, creating a
pool of cells with the ability to selfrenew and to produce cells of the
host tissue type. This property has
significant implications for the regeneration of old and diseased musculoskeletal tissues. Stem cells also
express unique cell surface proteins
that differ from those of committed
cells and are commonly used as
markers to identify stem cells for
scientific experiments.
Variation in the methods and procedures for stem cell research sometimes results in findings that are difficult to interpret. Differences in
isolation technique, in vitro culture
conditions, and methods of characterization of stem cell properties are
widespread. There are also differences in the species, age, sex, and location within the body from which different research groups harvest stem
cells. Additionally, there is no consensus regarding the panel of surface
marker proteins that defines a stem
cell. Thus, it becomes difficult to
identify tissue-committed progenitor cells from true multipotent stem
The two general types of stem
cells are those that exist in fetuses
Volume 16, Number 2, February 2008

(ie, embryonic stem cells) and in

adults (ie, postnatal stem cells). Each
type of stem cell has advantages and
disadvantages, both in terms of its
use in research and its potential clinical application.

Embryonic Stem Cells

Embryonic stem cells have many attractive features, including the ability to proliferate indefinitely in vitro
without loss of differentiation potential and the ability to produce all tissue types when reimplanted.1 This
suggests that they have a broader potential for differentiation and a longer
period of viability than do their adult
counterparts. However, when used
therapeutically, embryonic stem
cells function as allografts that incite
an immune response, and they can be
tumorigenic.1 There are substantial
ethical concerns regarding the harvesting and use of embryonic stem
cells, since they are derived from embryos. At this time, federal funding in
the United States is available only for
research using embryonic stem cell
lines that were already in existence
before August 9, 2001.1

Adult Stem Cells

Advantages of adult stem cells include ease of isolation from multiple
tissue types present within patients
of any age, their autologous nature,
their decreased tumorigenicity, and
the minimal ethical concerns regarding their use. However, their capacity for differentiation into various
tissue types may be more limited
than that of embryonic stem cells.3,4
Multiple tissue types have been
identified as harboring adult stem
cells. These include, but are not limited to, adipose tissue,3 periosteum,4 synovial membrane,5 pericytes,6 blood,7 bone marrow,8 and
skeletal muscle.9,10 The relationship
between these groups of stem cells is
not clear. The question remains
whether each pool of stem cells is a
separate entity or whether they are

all descendents of one common

true stem cell that circulates and
homes to tissues as needed. Currently, there is no clear consensus on
this;1 however, evidence seems to
suggest that the source of these postnatal adult stem cells is the blood
vessel and that the number of cells
correlates with the degree of angiogenesis within a given tissue.11
Bone marrow is the most extensively studied source of adult stem
cells for use in orthopaedic applications. Marrow-derived adult stem
cells are readily isolated via aspiration. Once expanded in culture in
vitro, they are a natural choice for
gene therapy applications designed
to alleviate musculoskeletal conditions. This is especially true for therapies intended for enhancing bone
regeneration because marrow is the
primary source of osteoprogenitor
cells in vivo. Additionally, marrowderived stem cells have been shown
to be capable of differentiating into
osteoblasts, adipocytes, chondrocytes, and myoblasts in vitro.8
Recently, considerable attention
has been focused on fat as a source of
adult stem cells. Adipose tissue,
such as bone marrow, derives from
the embryonic mesenchyme and has
been shown to contain cells capable
of differentiating toward adipogenic,
myogenic, osteogenic, and chondrogenic lineages.3
Although these and other tissues
have demonstrated multipotent
adult stem cell populations both in
vitro and in vivo, the use of some of
them for regenerative applications is
hampered by practical and technical
difficulties. For example, even
though adult stem cells derived from
bone marrow show a vigorous capacity for differentiation into multiple
tissue lineages, harvesting these
cells entails a fairly invasive process
(ie, bone marrow biopsy), and the
yield of stem cells from any given
sample is fairly low. Peripheral blood
and adipose tissue are readily available and easily harvested, but their
potential for differentiation into

Regenerative Medicine for the Musculoskeletal System Based on Muscle-derived Stem Cells

Figure 1

Muscle-derived stem cells (MDSCs) are multipotent cells that can be induced to
differentiate into multiple types of tissues depending on the stimulus provided.
Stimuli include nutrient medium, growth factors, plating density, hypoxia, mechanical
stimuli (eg, pressure), and other factors. The local environment must be controlled
in order to control the ultimate fate of MDSCs. bFGF = basic fibroblast growth
factor, BMP = bone morphogenetic protein, IGF-1 = insulin-like growth factor-1,
NGF = nerve growth factor, TGF- = transforming growth factor

multiple tissue types appears to be

more limited.12
In our laboratory, much of our efforts have been focused on musclederived stem cells (MDSCs), which
appear to be ideal for orthopaedic applications. These stem cells can be
clinically harvested with ease, are
amenable to in vitro and in vivo manipulation, and provide a multitude
of potential clinical applications.

Muscle-derived Stem
MDSCs are postnatal stem cells that
reside in and can be isolated from
skeletal muscle. Several characteristics of skeletal muscle make it an
optimal source of adult stem cells.
In adults, skeletal muscle comprises
the largest proportion of total body
mass of any tissue, making it readily
available from almost any part of the
body and requiring only a minimally

invasive biopsy. Also, skeletal muscle possesses an inherent ability to

regenerate, as evidenced by the
nearly constant cycle of muscle micro-injury and repair that occurs
with routine activity, such as
MDSCs represent only one of several different types of progenitor
cells that reside within skeletal
muscle. One such cell that is often
cited in related literature is the satellite cell, which has long been recognized as a quiescent muscle progenitor cell that lies beneath the
basal lamina. Following skeletal
muscle injury, it divides and fuses
with other progenitors to form myofibers.14 When stimulated with the
appropriate growth factors in vitro,
satellite cells also have the capacity
to differentiate down other lineages,
such as osteoblastic, adipogenic, and
chondrogenic cell lines.15 Although
satellite cells have some of the prop-

erties of stem cells, MDSCs are considered to be a population of cells

distinct from satellite cells. The difference between these two cell types
is reflected by the surface marker expression of MDSCs, their degree of
pluripotency, and other behavioral
characteristics.2 Satellite cells express proteins, such as MyoD and
Pax7, which indicate their commitment to the myogenic lineage, and
satellite cells display a limited capacity for differentiation. However,
MDSCs express surface markers (eg,
CD34, Sca-1) that are consistent
with other known stem cells.14
MDSCs display a vigorous capacity for differentiation into tissue
types from all three primary germ
layers, including neural, hepatocytic, myogenic, hematopoietic, osteogenic, adipogenic, chondrogenic,
and endothelial cell types2,16 (Figure
1). Most importantly, MDSCs exhibit long-term proliferation, high
self-renewal, and multipotent differentiation. As a research tool, they
have a high capacity for viral transduction and subsequent protein
production.9,10 Such attributes render MDSCs vital elements of any approach to regenerative medicine for
the musculoskeletal system.
After harvesting MDSCs via muscle biopsy, the tissue is enzymatically digested into its cellular components. Isolation of the myogenic
precursors, including MDSCs, is performed via serial plating of the digested muscle tissue onto collagencoated flasks (pre-plate technique).
This technique relies on the differential adhesion characteristics of
cellular components of muscle tissue. Committed cells (eg, fibroblasts)
tend to adhere early, whereas progenitor cells (eg, MDSCs) tend to adhere late.9,17

Tissue Engineering in
Tissues Using MDSCs
In general, tissue engineering involves three primary components:

Journal of the American Academy of Orthopaedic Surgeons

Charley B. Gates, MD, et al

cells, a scaffold on which the cells

can attach and proliferate, and signaling molecules, which encourage
the native and implanted cells to behave in a particular manner. Genes
encoding the proteins of interest
must be introduced into the host cell
nucleus, usually by some type of viral vector. Transcription and translation of the transferred DNA subsequently occur, resulting in the
expression of the desired gene product (ie, protein). With tissue engineering in musculoskeletal tissues,
the genes of interest usually code for
growth factors, which can alter the
local cellular milieu and induce
multipotent stem cells to differentiate down different tissue lineages.
Articular Cartilage
Articular cartilage is a target in
several injury and disease processes,
including trauma, septic arthritis,
osteoarthritis, and osteochondritis
dissecans. Articular cartilage has a
limited capacity to heal itself, due in
part to its poor vascular supply. Current modes of therapy for cartilage
injury include abrasion arthroplasty,
microfracture, autologous chondrocyte implantation, and meniscal or
osteochondral allografts.18,19 None of
these treatments fully restores the
articular cartilage defect. Even in a
best-case scenario, they delay rather
than prevent the subsequent progression of degenerative joint disease.
Regenerating articular cartilage
may help to prevent the degenerative joint changes that follow articular cartilage injury. Ideal cells for
articular cartilage repair would act
directly as chondrogenic progenitor
cells and function as gene delivery
vehicles for proteins that direct the
actions of such cells in vivo. Autologous chondrocytes are a natural
choice for cartilage repair, but their
use is limited by several major drawbacks, including donor site morbidity, low cell number upon harvest,
and loss of chondrocyte phenotype
Volume 16, Number 2, February 2008

Figure 2

Muscle-derived stem cells (MDSCs) may play a role in articular cartilage tissue
engineering. After isolation, MDSCs are transduced to express bone
morphogenetic protein-4 (BMP-4). The MDSCs are then expanded in vitro and
induced to undergo chondrogenesis. These cells can then be autotransplanted with
a scaffold into the articular cartilage defect.

during long-term culturing in vitro.19,20

MDSCs are an attractive alternative for articular cartilage repair for
several important reasons. They are
easy to isolate, and they display
long-term proliferation, high selfrenewal, multipotent differentiation, and efficient transduction and
protein secretion9 (Figure 2). Recently, Kuroda et al21 investigated
whether MDSCs could serve as a
source of progenitor cells for cartilage repair and as gene delivery vehicles for bone morphogenetic
protein-4 (BMP-4), a growth factor
that stimulates chondrogenesis.
MDSCs isolated from skeletal muscle in 3-week-old mice were cultured in vitro for 2 weeks, mixed
with fibrin glue, and applied to fresh
full-thickness defects in the trochlear groove of the femurs of 12-weekold rats. The authors found that
BMP-4 was an essential component
for in vitro expansion and resulted in
the production of significantly (P <
0.05) more type II collagenpositive
colonies compared with controls.
Also, MDSCs exposed to BMP-4

(MDSC-B4) produced smooth cartilage with integrated margins that

was macroscopically and histologically superior in comparison with
controls (Figure 3). Further, the
transplanted MDSCs were present in
vivo for 12 weeks and were colocalized with type II collagen production, indicating that the MDSCs
displayed prolonged survival, acquired a phenotype resembling host
chondrocytes, and participated in
the repair of articular cartilage.
Potential limitations of this study
include the possibility of late ossification (no ossification was observed
during the 24-week healing period
following transplantation). Another
point to consider is that the MDSCs
came from 3-week-old mice but
were transplanted into rats; the ideal source of MDSCs may, in fact, be
the patients themselves. Nonetheless, this study serves as proof of the
concept for performing MDSC implantation in articular cartilage in
adult humans.21
Other researchers have attempted
to engineer articular cartilage using
different cell types, in vitro expan71

Regenerative Medicine for the Musculoskeletal System Based on Muscle-derived Stem Cells

Figure 3

Gross appearance of cartilage defect healing following implantation with either

muscle-derived stem cells (MDSCs) (A), MDSCs transduced with bone
morphogenetic protein (BMP)-4 gene (B), or no treatment (C), 24 weeks after
injury. Only the repaired cartilage defects in the MDSC+BMP-4 treatment group
exhibited white, glossy, smooth surfaces throughout the 24-week healing period.
(Adapted with permission from Kuroda R, Usas A, Kubo S, et al: Cartilage repair
using bone morphogenetic protein 4 and muscle-derived stem cells. Arthritis
Rheum 2006;54:433-442.)

sion conditions, and scaffolds. Adultderived adipose stem cells and bone
marrowderived stem cells have both
been shown to undergo chondrogenesis following exposure to appropriate growth factors.20 A direct comparison of chondrogenic potential in
progenitor cells derived from bone
marrow and adipose tissue was conducted.12 Bone marrow aspirates and
matching adipose tissue overlying
the posterior superior iliac crest were
obtained from patients undergoing
elective spine surgery, and chondrogenesis was induced. Based on histology and reverse-transcription-polymerase chain reaction (RT-PCR) for
type II collagen, the bone marrowderived cells were more cartilaginous,
suggesting that bone marrowderived
cells may be a better choice than
adipose-derived stem cells for cartilage repair.12 No such direct comparisons exist between MDSCs and
bone marrowderived stem cells, or
between MDSCs and adipose-derived
stem cells, but such comparative research is needed as the field of stem
cell research expands and multiple
cell types with potential for cartilage
tissue engineering are identified.
The implantation of uncommitted cells often leads to formation of

fibrocartilage rather than true articular cartilage;20 thus, identification

of the optimal in vitro conditions
for chondrogenesis is critical to successful cartilage tissue engineering.
Growth factors reported to stimulate
chondrogenesis include insulin-like
growth factor-1 (IGF-1), transforming
growth factor (TGF-), BMPs, platelet-derived growth factor (PDGF),
and basic fibroblast growth factor
(bFGF).12,22-25 At present, most research is focused on BMPs and
TGF-. Kuroda et al21 found that
when TGF- was added to MDSCs
exposed to BMP-4, the number of
type II collagenpositive colonies actually decreased slightly. The mechanism of this interaction is unknown
but not necessarily surprising, given
the wide range of effects of each
growth factor. Other factors postulated to affect chondrogenesis in
vitro include plating density and period of expansion, hypoxia,26 and hydrostatic pressure.27 Thus, the optimal in vitro conditions and growth
factor milieu used to produce and expand chondrogenic cells is critical
but remains to be defined.
There is controversy regarding
which scaffold is ideal for articular
cartilage tissue engineering. Fibrin

glue and collagen gel have been used

as scaffolds.21,22 Those who support
the use of fibrin glue report that cells
settle into the suspension with minimal initial displacement, an undiminished cell viability, and enhanced
cell-matrix and matrix-matrix interactions.28,29 Others have criticized fibrin glue for being too mechanically
fragile, which may limit its clinical
usefulness. These critics have proposed using synthetic scaffolds (eg,
polyglycolic acid), which can be engineered with more uniform and
modifiable structural properties than
fibrin glue.30
Debate continues regarding all
three components of tissue engineering for articular cartilage, and more
research is needed to precisely define
the optimal conditions for articular
cartilage regeneration.
Among musculoskeletal tissues,
bone is unique in that, depending on
its location, its absence or presence
can create clinically significant problems. Nonunion represents a failure
of bone formation, whereas heterotopic ossification (HO) is excess bone
production in an undesired location.
Bone healing generally proceeds
well. However, the rate of nonunion
or delayed union following trauma
may be as high as 10%.31 Currently
available bone substitutes, such as
demineralized bone matrix, do not
behave physiologically or mechanically like true bone, creating a need
for an adequate bone substitute. Purified BMPs, such as BMP-2, -4, and
-7, can induce bone formation when
implanted at ectopic sites.14 In a
large prospective randomized controlled clinical trial, recombinant
human BMP-2 has been shown to be
safe and superior to the standard of
care of open tibia fractures, as it accelerates fracture and wound healing
and reduces both the infection rate
and the frequency of secondary interventions.32 MDSCs transduced to
express BMP-4 are effective gene delivery vehicles for this growth factor

Journal of the American Academy of Orthopaedic Surgeons

Charley B. Gates, MD, et al

Figure 4

Radiographic evidence of healing of segmental bone defects in rat femurs after implantation of MDSCs expressing either LacZ
(control) or BMP-4. The MDSC group exhibited nonunion at 6 (A) and 12 (B) weeks. The MDSC-BMP4 group exhibited some
healing by 6 weeks (C) and complete union by 12 weeks (D). (Adapted with permission from Shen HC, Peng H, Usas A,
Gearhart B, Fu FH, Huard J: Structural and functional healing of critical-size segmental bone defects by transduced musclederived cells expressing BMP4. J Gene Med 2004;6:984-991.)

and have been shown to heal

critical-sized long bone defects in
immunocompetent animals (Figure
4).33 Moreover, the functionality of
this healing has been demonstrated
by experiments that show no significant difference in torsional stiffness
or energy-to-failure between healed
and intact bones.33
Vascular supply to the fracture
site is absolutely critical to fracture
healing. Thus, vascular endothelial
growth factor (VEGF), the most essential mediator of angiogenesis, has
been shown to play a critical role in
fracture healing.34 Inactivation of
VEGF reduces the bone formation
induced by BMP-4.35 Therefore,
combining BMP and VEGF delivery
could accelerate bone healing
through improved angiogenesis. In
Volume 16, Number 2, February 2008

fact, Peng et al35 found that coimplanting into a skeletal defect

MDSCs that expressed BMP-4 and
MDSCs that expressed VEGF resulted in an augmentation of bone healing. The ratio of VEGF to BMP-4 is
critically important in maximizing
outcome. Bone healing is hindered
when the concentration of VEGF in
this ratio is too high.35
HO of muscles, tendons, and ligaments can be a problem following
trauma, burns, and other orthopaedic procedures. Following total
hip arthroplasty, radiologic HO has
been reported in 15% to 90% of patients, with 1% to 27% of patients
reporting clinically important pain
and loss of motion.36 Hannallah et
al37 tested whether MDSCs transduced with Noggin, a growth factor

that antagonizes BMPs, could block

heterotopic bone formation. Noggin
is normally expressed by tissues
such as skeletal muscle and cartilage
during embryonic development, and
it is required for normal development of the skeleton. Noggin inhibits BMP by directly binding to it and
preventing BMP from binding to its
receptor. MDSCs expressing Noggin
were shown to successfully block
bone formation in three scenarios
that normally resulted in HO: following implantation of MDSCs expressing BMP-4, following insertion
of demineralized bone matrix, and
following trauma (Achilles tenotomy).37 Gene therapy using MDSCs
to deliver Noggin may become a
powerful technique to inhibit HO in
targeted areas of the body.

Regenerative Medicine for the Musculoskeletal System Based on Muscle-derived Stem Cells

Skeletal Muscle
Skeletal muscle injury may occur
under a variety of circumstances,
most commonly during participation in sports. Following injury, myofiber regeneration begins with the
activation of satellite cells, which
normally lie quiescent under the
basal lamina. On activation, these
satellite cells proliferate and differentiate into multinucleated myotubes and eventually into myofibers.
Myofiber regeneration is limited by
fibroblast proliferation and the deposition of excess extracellular matrix, a process known as fibrosis,
which ultimately leads to incomplete recovery of the skeletal muscle.38
The relationship between postinjury inflammation and regeneration and fibrosis remains controversial. However, recent evidence
suggests that inflammatory pathways
and signaling may be beneficial to
muscle healing. Traditionally, multiple anti-inflammatory modalities are
employed following injury. This includes the widespread use of nonsteroidal anti-inflammatory drugs
(NSAIDs), which are prescribed, at
least in part, for pain control. Several studies suggest, however, that
NSAIDs, including cyclooxygenase-2
(COX-2)specific inhibitors, increase
fibrosis, inhibit myogenic precursor
cells, and impair myofiber regeneration by specifically upregulating
TGF-1.39,40 Such findings consequently suggest exercising caution in
the liberal use of NSAIDs and COX-2
inhibitors following injury because
they may interfere with the healing
Techniques to enhance myofiber
regeneration and inhibit fibrosis
have been explored. Growth factors
play an important role in the balance
between regeneration and fibrosis
following skeletal muscle injury.
IGF-1 has been shown to augment
myofiber regeneration,41 while other
agents, such as gamma-interferon,42
decorin,43 and suramin,44 block fibrosis through inactivation of TGF-1,

the main cytokine involved in the fibrosis cascade.45

MDSCs can play a major role in
the healing processes following skeletal muscle injury. After implantation
into skeletal muscle, they exhibit
long-term survival that is superior to
myoblasts, and they directly participate in myofiber regeneration.9,13,46
One study suggests that MDSCs also
exhibit multipotential differentiation
into endothelial and neural lineages
in vivo that may enhance the neural
and vascular supply of the regenerating muscle.9 Furthermore, MDSCs
can be efficiently transduced to produce pro-regenerative (ie, IGF-1) and
antifibrotic (ie, decorin) agents that
tip the balance between regeneration
and fibrosis toward regeneration.
Because of their long-term survival,
direct participation in myofiber healing, differentiation into neural and
vascular lineages, and ability to act as
effective gene delivery vehicles of
growth factors, MDSCs may prove to
be of critical value in efforts to improve clinical outcomes following
skeletal muscle injury.

Tissue Engineering in
Other Tissues Using
Repair and regeneration of musculoskeletal tissues are natural and
promising applications for genetically engineered MDSCs, but more
wide-reaching possibilities for their
use exist. The prospect of using
MDSCs for cardiac repair is particularly intriguing. It has been demonstrated that transplanted MDSCs
can successfully repair both damaged47 and diseased48 myocardium.
Research is already underway that
uses MDSCs to introduce antifibrotic agents into injured cardiac muscle
to minimize the scarring that follows infarction.
The ability of MDSCs to regenerate muscle is also being employed to
treat urinary incontinence in women. This is perhaps the most immediately promising application of the

regenerative capacity of MDSCs. Because no genetic manipulation of the

MDSCs is required, safety issues regarding the use of viral transduction
vectors are not a concern. Clinical
trials that re-inject autologous, tissue cultureexpanded MDSCs into
the sphincter muscle of stressincontinent women are currently in
progress.49 The results of these early
clinical trials will almost certainly
aid in the development of other
treatments of orthopaedic ailments
and will help make the promise of
MDSC-based therapies a reality.

The field of stem cell research is
growing rapidly, and several important fundamental questions remain
unanswered. The lack of a unifying
definition of stem cells, conflicting
reports regarding their phenotype,
and the nature of the relationship between the different pools of adult
stem cells within various tissues all
warrant further investigation. As research accumulates, the techniques
and procedures for harvesting, isolating, and characterizing these cells
may become standardized, enabling
more meaningful comparisons and
discussion about the pluripotency,
use, and longevity of each type of
stem cell.
Among the groups of stem cells,
MDSCs stand out as readily available, easily accessible cells that have
demonstrated pluripotency both in
vivo and in vitro. They are amenable
to efficient transduction and are capable of long-term survival and
growth factor production following
transplantation, making them efficient gene delivery vehicles to the
musculoskeletal system. Identification of optimal in vitro expansion
conditions, including the growth factor milieu, and the most efficient
supporting scaffold will accelerate
the development of clinical applications for stem cell technology to improve healing of articular cartilage,
bone, and skeletal muscle. Evidence

Journal of the American Academy of Orthopaedic Surgeons

Charley B. Gates, MD, et al

to date suggests that MDSCs may

play a critical role in tissue engineering for the repair of musculoskeletal
damage and disease, which could
revolutionize the clinical management of a variety of debilitating musculoskeletal conditions.

Evidence-based Medicine: There is
one prospective level II study (reference 32), two level III/IV case reports
or cohort studies (references 19 and
31), and one level V expert opinion
reference (reference 36).
Citation numbers printed in bold
type indicate references published
within the past 5 years.









Tuan RS, Boland G, Tuli R: Adult mesenchymal stem cells and cell-based
tissue engineering. Arthritis Res
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Deasy BM, Jankowski RJ, Huard J:
Muscle-derived stem cells: Characterization and potential for cellmediated therapy. Blood Cells Mol
Dis 2001;27:924-933.
Zuk PA, Zhu M, Mizuno H, et al: Multilineage cells from human adipose tissue: Implications for cell-based therapies. Tissue Eng 2001;7:211-228.
Nakahara H, Goldberg VM, Caplan AI:
Culture-expanded periosteal-derived
cells exhibit osteochondrogenic potential in porous calcium phosphate ceramics in vivo. Clin Orthop Relat
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De Bari C, DellAccio F, Tylzanowski
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Diefenderfer DL, Brighton CT: Microvascular perictyes express aggrecan
message which is regulated by BMP-2.
Biochem Biophys Res Commun
Zvaifler NJ, Marinova-Mutafchieva
L, Adams G, et al: Mesenchymal precursor cells in the blood of normal individuals. Arthritis Res 2000;2:477488.
Pittenger MF, Mackay AM, Beck SC,
et al: Multilineage potential of adult
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Science 1999;284:143-147.
Qu-Petersen Z, Deasy B, Jankowski R,
et al: Identification of a novel population of muscle stem cells in mice: Potential for muscle regeneration.

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J Cell Biol 2002;157:851-864.

10. Gussoni E, Soneoka Y, Strickland CD,
et al: Dystrophin expression in the mdx
mouse restored by stem cell transplantation. Nature 1999;401:390-394.
11. Tavian M, Zheng B, Oberlin E, et al:
The vascular wall as a source of stem
cells. Ann N Y Acad Sci 2005;1044:
12. Huang JI, Kazmi N, Durbhakula MM,
Hering TM, Yoo JU, Johnstone B:
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13. Irintchev A, Wernig A: Muscle damage and repair in voluntarily running
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Cell Tissue Res 1987;249:509-521.
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15. Asakura A, Komaki M, Rudnicki M:
Muscle satellite cells are multipotential stem cells that exhibit myogenic,
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Journal of the American Academy of Orthopaedic Surgeons