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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:
68-76
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.
68
Abstract
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.
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
Muscle-derived Stem
Cells
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
70
Tissue Engineering in
Musculoskeletal
Tissues Using MDSCs
In general, tissue engineering involves three primary components:
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.
Regenerative Medicine for the Musculoskeletal System Based on Muscle-derived Stem Cells
Figure 3
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
72
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.)
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
process.
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,
74
Tissue Engineering in
Other Tissues Using
MDSCs
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
Summary
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
References
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.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Tuan RS, Boland G, Tuli R: Adult mesenchymal stem cells and cell-based
tissue engineering. Arthritis Res
Ther 2003;5:32-45.
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
Res 1992;276:291-298.
De Bari C, DellAccio F, Tylzanowski
P, Luyten FP: Multipotent mesenchymal stem cells from adult human synovial membrane. Arthritis Rheum
2001;44:1928-1942.
Diefenderfer DL, Brighton CT: Microvascular perictyes express aggrecan
message which is regulated by BMP-2.
Biochem Biophys Res Commun
2000;269:172-178.
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
human mesenchymal stem cells.
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.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
75
Regenerative Medicine for the Musculoskeletal System Based on Muscle-derived Stem Cells
34.
35.
36.
37.
38.
39.
76
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.