Masahiko Takahata

Accuracy analysis of pedicle screw placement in posterior scoliosis surgery: comparison between conventional fluoroscopic and computer-assisted technique.

Study Design. The accuracy of pedicle screw placement was evaluated in posterior scoliosis surgeries with or without the use of computer-assisted surgical techniques. Objective. In this retrospective cohort study, the pedicle screw placement accuracy in posterior scoliosis surgery was compared between conventional fluoroscopic and computer-assisted surgical techniques. Summary of Background Data. There has been no study systemically analyzing the perforation pattern and comparative accuracy of pedicle screw placement in posterior scoliosis surgery. Methods. The 45 patients who received posterior correction surgeries were divided into 2 groups: Group C, manual control (25 patients); and Group N, navigation surgery (20 patients). The average Cobb angles were 73.7° and 73.1° before surgery in Group C and Group N, respectively. Using CT images, vertebral rotation, pedicle axes as measured to anteroposterior sacral axis and vertebral axis, and insertion angle error were measured. In perforation cases, the angular tendency, insertion point, and length abnormality were evaluated. Results. The perforation was observed in 11% of Group C and 1.8% in Group N. In Group C, medial perforations of left screws were demonstrated in 8 of 9 perforated screws and 55% were distributed either in L1 or T12. The perforation consistently occurred in pedicles in which those axes approached anteroposterior sacral axis within 5°. The average insertion errors were 8.4° and 5.0° in Group C and Group N, respectively, which were significantly different (P < 0.02). Conclusion. The medial perforation in Group C occurred around L1, especially when pedicle axis approached anteroposterior sacral axis. This consistent tendency was considered as the limitation of fluoroscopic screw insertion in which horizontal vertebral image was not visible. The use of surgical navigation system successfully reduced the perforation rate and insertion angle errors, demonstrating the clear advantage in safe and accurate pedicle screw placement of scoliosis surgery.

Tumor necrosis factor inhibits mesenchymal stem cell differentiation into osteoblasts via the ubiquitin E3 ligase Wwp1

Patients with chronic inflammatory disorders, such as rheumatoid arthritis, often have osteoporosis due to a combination of Tumor necrosis factor‐induced increased bone resorption and reduced bone formation. To test if TNF inhibits bone formation by affecting the commitment and differentiation of mesenchymal stem cells (MSCs) into osteoblasts, we examined the osteogenic potential of MSCs from TNF transgenic (TNF‐Tg) mice, a model of chronic inflammatory arthritis. MSC‐enriched cells were isolated from bone marrow stromal cells using negative selection with anti‐CD45 antibody coated magnetic beads. The expression profile of MSC surface markers the osteogenic, chondrogenic, and adipogenic properties of CD45− cells were confirmed by FACS and cell differentiation assays. MSC‐enriched CD45− cells from TNF‐Tg mice formed significantly decreased numbers of fibroblast and ALP+ colonies and had a decreased expression of osteoblast marker genes. As TNF may upregulate ubiquitin ligases, which negatively regulate osteoblast differentiation, we examined the expression levels of several ubiquitin ligases and found that Wwp1 expression was significantly increased in MSC‐enriched CD45− cells of TNF‐Tg mice. Wwp1 knockdown rescued impaired osteoblast differentiation of TNF‐Tg CD45− cells. Wwp1 promotes ubiquitination and degradation of JunB, an AP‐1 transcription factor that positively regulates osteoblast differentiation. Injection of TNF into wild‐type mice resulted in decreased osteoblast differentiation of MSCs and increased JunB ubiquitination, which was completely blocked in Wwp1−/− mice. Thus, Wwp1 targets JunB for ubiquitination and degradation in MSCs after chronic exposure to TNF, and inhibition of Wwp1 in MSCs could be a new mechanism to limit inflammation‐mediated osteoporosis by promoting their differentiation into osteoblasts. STEM CELLS 2011;29:1601–1610

Regulation of Human Osteoclast Development by Dendritic Cell-Specific Transmembrane Protein (DC-STAMP)

Osteoclasts (OC) are bone‐resorbing, multinucleated cells that are generated via fusion of OC precursors (OCP). The frequency of OCP is elevated in patients with erosive inflammatory arthritis and metabolic bone diseases. Although many cytokines and cell surface receptors are known to participate in osteoclastogenesis, the molecular mechanisms underlying the regulation of this cellular transformation are poorly understood. Herein, we focused our studies on the dendritic cell‐specific transmembrane protein (DC‐STAMP), a seven‐pass transmembrane receptor‐like protein known to be essential for cell‐to‐cell fusion during osteoclastogenesis. We identified an immunoreceptor tyrosine‐based inhibitory motif (ITIM) in the cytoplasmic tail of DC‐STAMP, and developed an anti‐DC‐STAMP monoclonal antibody 1A2 that detected DC‐STAMP expression on human tumor giant cells, blocked OC formation in vitro, and distinguished four patterns of human PBMC with a positive correlation to OC potential. In freshly isolated monocytes, DC‐STAMPhigh cells produced a higher number of OC in culture than DC‐STAMPlow cells and the surface expression of DC‐STAMP gradually declined during osteoclastogenesis. Importantly, we showed that DC‐STAMP is phosphorylated on its tyrosine residues and physically interacts with SHP‐1 and CD16, an SH2‐domain‐containing tyrosine phosphatase and an ITAM‐associated protein, respectively. Taken together, these data show that DC‐STAMP is a potential OCP biomarker in inflammatory arthritis. Moreover, in addition to its effect on cell fusion, DC‐STAMP dynamically regulates cell signaling during osteoclastogenesis.

Self-complementary AAV2.5-BMP2-coated Femoral Allografts Mediated Superior Bone Healing Versus Live Autografts in Mice With Equivalent Biomechanics to Unfractured Femur

Structural allografts used for critical bone defects have limited osteogenic properties for biointegration. Although ex vivo tissue-engineered constructs expressing bone morphogenetic protein-2 (BMP2) have demonstrated efficacy in critical defect models, similar success has not been achieved with off-the-shelf acellular approaches, including allografts coated with freeze-dried single-stranded adeno-associated virus (ssAAV-BMP2). To see whether the self-complementary AAV serotype 2.5 vector (scAAV2.5-BMP2) could overcome this, we performed side-by-side comparisons in vitro and in the murine femoral allograft model. Although ssAAV-BMP2 was unable to induce BMP2 expression and differentiation of C3H10T1/2 cells in culture, scAAV2.5-BMP2 transduction led to dose-dependent BMP2 expression and alkaline phosphatase activity, and displayed a 25-fold increased transduction efficiency in vivo. After 6 weeks, the ssAAV-BMP2 coating failed to demonstrate any significant effects. However, all allografts coated with 10(10) scAAV2.5-BMP2 formed a new cortical shell that was indistinguishable to that formed by live autografts. Additionally, coated allografts experienced reduced resorption resulting in a threefold increase in graft bone volume versus autograft. This led to biomechanical superiority versus both allografts and autografts, and equivalent torsional rigidity to unfractured femur. Collectively, these results demonstrate that scAAV2.5-BMP2 coating overcomes the major limitations of structural allografts, which can be used to heal critical defects of any size.

Clinical results and complications of circumferential spinal cord decompression through a single posterior approach for thoracic myelopathy caused by ossification of posterior longitudinal ligament.

Study Design. A retrospective review. Objective. This study examined the clinical outcomes of circumferential spinal cord decompression through a posterior approach for thoracic ossification of posterior longitudinal ligament (OPLL), to determine the efficacy of this procedure and the incidence of complications. Summary of Background Data. Since posterior decompressive laminectomy is not always effective in the treatment of thoracic myelopathy caused by OPLL, circumferential spinal cord decompression through a single posterior approach seems to offer an effective treatment option. However, this procedure is technically demanding and has a high risk of postoperative neurologic deterioration. Long-term clinical outcome data and complication rates of this procedure are not well covered in the literature. Methods. Medical records of sequentially treated 30 patients, who had undergone circumferential spinal cord decompression through a single posterior approach, were reviewed to determine demographic data, neurologic examination, imaging findings, surgical procedure, and follow-up data. The Japanese Orthopedic Association (JOA) score was used to assess physical dysfunction and neurologic impairment. Results. The mean follow-up period was 8 years; the average operative time was 389 minutes; the mean blood loss was 1883 mL. An average of 4-level spinal cord decompression was performed on all 30 patients. Posterior spinal fusion was performed on 26 of the 30 patients. The mean preoperative JOA score was 3.4/11, and it improved to an average of 7.1/11 at final evaluation. Clinical symptoms and the JOA score improved in 24 patients, but were unchanged or worsened in the other 6 patients compared to the preoperative conditions. Surgical complications included dural tear in 12 patients (40%), deep infection in 3 (10%), and postoperative neurologic deterioration in 10 (33%). Statistical analysis showed that a risk factor associated with the unfavorable surgical outcomes was multiple level circumferential spinal cord decompression of 5 or more vertebral levels. Conclusion. Despite circumferential spinal cord decompression through posterior approach for thoracic OPLL providing effective neurologic recovery, there was a high rate of complications such as postoperative neurologic deterioration. Risk factor analysis shows that multiple level circumferential decompression of 5 or more vertebral levels to be associated with unfavorable surgical outcome.

Teriparatide therapy enhances devitalized femoral allograft osseointegration and biomechanics in a murine model

Despite the remarkable healing potential of long bone fractures, traumatic injuries that result in critical defects require challenging reconstructive limb sparing surgery. While devitalized allografts are the gold standard for these procedures, they are prone to failure due to their limited osseointegration with the host. Thus, the quest for adjuvants to enhance allograft healing remains a priority for this unmet clinical need. To address this, we investigated the effects of daily systemic injections of 40 μg/kg teriparatide (recombinant human parathyroid hormone) on the healing of devitalized allografts used to reconstruct critical femoral defects (4mm) in C57Bl/6 mice. The femurs were evaluated at 4 and 6 weeks using micro CT, histology, and torsion testing. Our findings demonstrated that teriparatide induced prolonged cartilage formation at the graft-host junction at 4 weeks, which led to enhanced trabeculated bone callus formation and remarkable graft-host integration at 6-weeks. Moreover, we observed a significant 2-fold increase in normalized callus volume (1.04 ± 0.3 vs. 0.54 ± 0.14 mm³/mm; p < 0.005), and Union Ratio (0.28 ± 0.07 vs. 0.13 ± 0.09; p < 0.005), compared to saline treated controls at 6-weeks. Teriparatide treatment significantly increased the torsional rigidity (1175 ± 311 versus 585 ± 408 N.mm²) and yield torque (10.5 ± 4.2 versus 6.8 ± 5.5 N.mm) compared to controls. Interestingly, the Union Ratio correlated significantly with the yield torque and torsional rigidity (R²=0.59 and R²=0.77, p < 0.001, respectively). These results illustrate the remarkable potential of teriparatide as an adjuvant therapy for allograft repair in a mouse model of massive femoral defect reconstruction, and warrant further investigation in a larger animal model at longer time intervals to justify future clinical trials for PTH therapy in limb sparing reconstructive procedures.

A genome-wide association study identifies susceptibility loci for ossification of the posterior longitudinal ligament of the spine

Ossification of the posterior longitudinal ligament of the spine (OPLL) is a common spinal disorder among the elderly that causes myelopathy and radiculopathy. To identify genetic factors for OPLL, we performed a genome-wide association study (GWAS) in ∼8,000 individuals followed by a replication study using an additional ∼7,000 individuals. We identified six susceptibility loci for OPLL: 20p12.3 (rs2423294: P = 1.10 × 10−13), 8q23.1 (rs374810: P = 1.88 × 10−13), 12p11.22 (rs1979679: P = 4.34 × 10−12), 12p12.2 (rs11045000: P = 2.95 × 10−11), 8q23.3 (rs13279799: P = 1.28 × 10−10) and 6p21.1 (rs927485: P = 9.40 × 10−9). Analyses of gene expression in and around the loci suggested that several genes are involved in OPLL etiology through membranous and/or endochondral ossification processes. Our results bring new insight to the etiology of OPLL.

Aging periosteal progenitor cells have reduced regenerative responsiveness to bone injury and to the anabolic actions of PTH 1-34 treatment.

A stabilized tibia fracture model was used in young (8-week old) and aged (1-year old) mice to define the relative bone regenerative potential and the relative responsiveness of the periosteal progenitor population with aging and PTH 1-34 (PTH) systemic therapy. Bone regeneration was assessed through gene expressions, radiographic imaging, histology/histomorphometry, and biomechanical testing. Radiographs and microCT showed increased calcified callus tissue and enhanced bone healing in young compared to aged mice. A key mechanism involved reduced proliferation, expansion, and differentiation of periosteal progenitor cell populations in aged mice. The experiments showed that PTH increased calcified callus tissue and torsional strength with a greater response in young mice. Histology and quantitative histomorphometry confirmed that PTH increased callus tissue area due primarily to an increase in bone formation, since minimal changes in cartilage and mesenchyme tissue area occurred. Periosteum examined at 3, 5, and 7 days showed that PTH increased cyclin D1 expression, the total number of cells in the periosteum, and width of the periosteal regenerative tissue. Gene expression showed that aging delayed differentiation of both bone and cartilage tissues during fracture healing. PTH resulted in sustained Col10a1 expression consistent with delayed chondrocyte maturation, but otherwise minimally altered cartilage gene expression. In contrast, PTH 1-34 stimulated expression of Runx2 and Osterix, but resulted in reduced Osteocalcin. β-Catenin staining was present in mesenchymal chondroprogenitors and chondrocytes in early fracture healing, but was most intense in osteoblastic cells at later times. PTH increased active β-catenin staining in the osteoblast populations of both young and aged mice, but had a lesser effect in cartilage. Altogether the findings show that reduced fracture healing in aging involves decreased proliferation and differentiation of stem cells lining the bone surface. While PTH 1-34 enhances the proliferation and expansion of the periosteal stem cell population and accelerates bone formation and fracture healing, the effects are proportionately reduced in aged mice compared to young mice. β-Catenin is induced by PTH in early and late fracture healing and is a potential target of PTH 1-34 effects.

Endogenous tissue engineering: PTH therapy for skeletal repair

Based on its proven anabolic effects on bone in osteoporosis patients, recombinant parathyroid hormone (PTH1-34) has been evaluated as a potential therapy for skeletal repair. In animals, the effect of PTH1-34 has been investigated in various skeletal repair models such as fractures, allografting, spinal arthrodesis and distraction osteogenesis. These studies have demonstrated that intermittent PTH1-34 treatment enhances and accelerates the skeletal repair process via a number of mechanisms, which include effects on mesenchymal stem cells, angiogenesis, chondrogenesis, bone formation and resorption. Furthermore, PTH1-34 has been shown to enhance bone repair in challenged animal models of aging, inflammatory arthritis and glucocorticoid-induced bone loss. This pre-clinical success has led to off-label clinical use and a number of case reports documenting PTH1-34 treatment of delayed-unions and non-unions have been published. Although a recently completed phase 2 clinical trial of PTH1-34 treatment of patients with radius fracture has failed to achieve its primary outcome, largely because of effective healing in the placebo group, several secondary outcomes are statistically significant, highlighting important issues concerning the appropriate patient population for PTH1-34 therapy in skeletal repair. Here, we review our current knowledge of the effects of PTH1-34 therapy for bone healing, enumerate several critical unresolved issues (e.g., appropriate dosing regimen and indications) and discuss the long-term potential of this drug as an adjuvant for endogenous tissue engineering.

Outcomes of fusion surgery for ossification of the posterior longitudinal ligament of the thoracic spine: a multicenter retrospective survey: clinical article.

OBJECT The aim of this study was to evaluate the outcomes of fusion surgery in patients with ossification of the posterior longitudinal ligament in the thoracic spine (T-OPLL) and to identify factors significantly related to surgical outcomes. METHODS The study included 76 patients (34 men and 42 women with a mean age of 56.3 years) who underwent fusion surgery for T-OPLL at 7 spine centers during the 5-year period from 2003 to 2007. The authors evaluated the patient demographic data, underlying disease, preoperative comorbidities, history of spinal surgery, radiological findings, surgical methods, surgical outcomes, and complications. Surgical outcomes were assessed using the Japanese Orthopaedic Association (JOA) scale score for thoracic myelopathy (11 points) and the recovery rate. RESULTS The mean JOA scale score was 4.6 ± 2.1 points preoperatively and 7.7 ± 2.5 points at the time of the final follow-up examination, yielding a mean recovery rate of 45.4% ± 39.1%. The recovery rates by surgical method were 38.5% ± 37.8% for posterior decompression and fusion, 65.0% ± 35.6% for anterior decompression and fusion via an anterior approach, 28.8% ± 41.2% for anterior decompression via a posterior approach, and 57.5% ± 41.1% for circumferential decompression and fusion. The recovery rate was significantly higher in patients without diabetes mellitus (DM) than in those with DM. One or more complications were experienced by 31 patients (40.8%), including 20 patients with postoperative neurological deterioration, 7 with dural tears, 5 with epidural hematomas, 4 with respiratory complications, and 10 with other complications. CONCLUSIONS The outcomes of fusion surgery for T-OPLL were favorable. The absence of DM correlated with better outcomes. However, a high rate of complications was associated with the fusion surgery.