Rameshwar R. Rao

Delivery of mesenchymal stem cells in chitosan/collagen microbeads for orthopedic tissue repair.

Microencapsulation and delivery of stem cells in biomaterials is a promising approach to repairing damaged tissue in a minimally invasive manner. An appropriate biomaterial niche can protect the embedded cells from the challenging environment in the host tissue, while also directing stem cell differentiation toward the desired lineage. In this study, adult human mesenchymal stem cells (MSC) were embedded in hydrogel microbeads consisting of chitosan and type I collagen using an emulsification process. Glyoxal and β-glycerophosphate were used as chemical and physical crosslinkers to initiate copolymerization of the matrix materials. The average size and size distribution of the microbeads could be varied by controlling the emulsification conditions. Spheroidal microbeads ranging in diameter from 82 ± 19 to 290 ± 78 µm were produced. Viability staining showed that MSC survived the encapsulation process (>90% viability) and spread inside the matrix over a period of 9 days in culture. Induced osteogenic differentiation using medium supplements showed that MSC increased gene expression of osterix and osteocalcin over time in culture, and also deposited calcium mineral. Bone sialoprotein and type I collagen gene expression were not affected. Delivery of microbeads through standard needles at practically relevant flow rates did not adversely affect cell viability, and microbeads could also be easily molded into prescribed geometries for delivery. Such protein-based microbeads may have utility in orthopedic tissue regeneration by allowing minimally invasive delivery of progenitor cells in microenvironments that are both protective and instructive.

Effects of hydroxyapatite on endothelial network formation in collagen/fibrin composite hydrogels in vitro and in vivo

Co-culture of endothelial cells (EC) and mesenchymal stem cells (MSC) results in robust vascular network formation in constrained 3-D collagen/fibrin (COL/FIB) composite hydrogels. However, the ability to form endothelial networks is lost when such gels are allowed to compact via cell-mediated remodeling. In this study, we created co-cultures of human EC and human MSC in both constrained and unconstrained COL/FIB matrices and systematically added nanoparticulate hydroxyapatite (HA, 0-20 mg ml(-1)), a bone-like mineral that has been shown to have pro-vasculogenic effects. Constructs cultured for 7 days were assayed for gel compaction, vascular network formation, and mechanical properties. In vitro, robust endothelial network formation was observed in constrained COL/FIB constructs without HA, but this response was significantly inhibited by addition of 5, 10, or 20 mg ml(-1) HA. In unconstrained matrices, network formation was abolished in pure COL/FIB constructs but was rescued by 1.25 or 2.5 mg ml(-1) HA, while higher levels again inhibited vasculogenesis. HA inhibited gel compaction in a dose-dependent manner, which was not correlated to endothelial network formation. HA affected initial stiffness of the gels, but gel remodeling abrogated this effect. Subcutaneous implantation of COL/FIB with 0, 2.5 or 2 0mg ml(-1) HA in the mouse resulted in increased perfusion at the implant site, with no significant differences between materials. Histology at day 7 showed both host and human CD31-stained vasculature infiltrating the implants. These findings are relevant to the design of materials and scaffolds for orthopedic tissue engineering, where both vasculogenesis and formation of a mineral phase are required for regeneration.

Vasculogenesis and angiogenesis in modular collagen–fibrin microtissues

The process of new blood vessel formation is critical in tissue development, remodeling and regeneration. Modular tissue engineering approaches have been developed to enable the bottom-up assembly of more complex tissues, including vascular networks. In this study, collagen-fibrin composite microbeads (100-300 μm in diameter) were fabricated using a water-in-oil emulsion technique. Human endothelial cells and human fibroblasts were embedded directly in the microbead matrix at the time of fabrication. Microbead populations were characterized and cultured for 14 days either as free-floating populations or embedded in a surrounding fibrin gel. The collagen-fibrin matrix efficiently entrapped cells and supported their viability and spreading. By 7 days in culture, endothelial cell networks were evident within microbeads, and these structures became more prominent by day 14. Fibroblasts co-localized with endothelial cells, suggesting a pericyte-like function, and laminin deposition indicated maturation of the vessel networks over time. Microbeads embedded in a fibrin gel immediately after fabrication showed the emergence of cells and the coalescence of vessel structures in the surrounding matrix by day 7. By day 14, inosculation of neighboring cords and prominent vessel structures were observed. Microbeads pre-cultured for 7 days prior to embedding in fibrin gave rise to vessel networks that emanated radially from the microbead by day 7, and developed into connected networks by day 14. Lumen formation in endothelial cell networks was confirmed using confocal sectioning. These data show that collagen-fibrin composite microbeads support vascular network formation. Microbeads embedded directly after fabrication emulated the process of vasculogenesis, while the branching and joining of vessels from pre-cultured microbeads resembled angiogenesis. This modular microtissue system has utility in studying the processes involved in new vessel formation, and may be developed into a therapy for the treatment of ischemic conditions.

Noninvasive quantification of in vitro osteoblastic differentiation in 3D engineered tissue constructs using spectral ultrasound imaging.

Non-destructive monitoring of engineered tissues is needed for translation of these products from the lab to the clinic. In this study, non-invasive, high resolution spectral ultrasound imaging (SUSI) was used to monitor the differentiation of MC3T3 pre-osteoblasts seeded within collagen hydrogels. SUSI was used to measure the diameter, concentration and acoustic attenuation of scatterers within such constructs cultured in either control or osteogenic medium over 21 days. Conventional biochemical assays were used on parallel samples to determine DNA content and calcium deposition. Construct volume and morphology were accurately imaged using ultrasound. Cell diameter was estimated to be approximately 12.5–15.5 µm using SUSI, which corresponded well to measurements of fluorescently stained cells. The total number of cells per construct assessed by quantitation of DNA content decreased from 5.6±2.4×104 at day 1 to 0.9±0.2×104 at day 21. SUSI estimation of the equivalent number of acoustic scatters showed a similar decreasing trend, except at day 21 in the osteogenic samples, which showed a marked increase in both scatterer number and acoustic impedance, suggestive of mineral deposition by the differentiating MC3T3 cells. Estimation of calcium content by SUSI was 41.7±11.4 µg/ml, which agreed well with the biochemical measurement of 38.7±16.7 µg/ml. Color coded maps of parameter values were overlaid on B-mode images to show spatiotemporal changes in cell diameter and calcium deposition. This study demonstrates the use of non-destructive ultrasound imaging to provide quantitative information on the number and differentiated state of cells embedded within 3D engineered constructs, and therefore presents a valuable tool for longitudinal monitoring of engineered tissue development.

Assembly of Discrete Collagen–Chitosan Microenvironments into Multiphase Tissue Constructs

Modular assembly of protein-polysaccharide microenvironments into 3D macroscale tissue constructs is reported. Rapid and simple centrifugation and vacuum molding methods are used to create cohesive multiphase constructs with prescribed geometries. Human fibroblasts are shown to survive in the microenvironments and in the macroscale constructs. Control of the spatial organization in engineered tissues is a key to recreating the complex tissue architectures needed for regenerative therapies.

Exogenous mineralization of cell-seeded and unseeded collagen-chitosan hydrogels using modified culture medium.

Induced biomineralization of materials has been employed as a strategy to increase integration with host tissue, and more recently as a method to control cell function in tissue engineering. However, mineralization is typically performed in the absence of cells, since hypertonic solutions that lack the nutrients and culture components required for the maintenance of cell viability are often used. In the present study, we exposed fibroblast-seeded three-dimensional collagen-chitosan hydrogels to a defined culture medium modified to have specific concentrations of ions involved in biomineralization. The modified medium caused a significant increase in calcium deposition in collagen-chitosan gels, relative to constructs incubated in a standard medium, though serum supplementation attenuated mineral deposition. Collagen-chitosan constructs became opaque over 3 days of mineralization in modified Dulbeccos modified Eagle medium (DMEM), in contrast to translucent control gels incubated in standard DMEM. Histological staining confirmed increased levels of mineral in the treated constructs. Rheological characterization showed that both the storage and loss moduli increased significantly in mineralized materials. Mineralization of fibroblast-seeded constructs resulted in decreased cell viability and proliferation rate over 3 days of incubation in modified medium, but the cell population remained over 75% viable and regained its proliferative potential after rescue in standard culture medium. The ability to mineralize protein matrices in the presence of cells could be useful in creating mechanically stable tissue constructs, as well as to study the effects of the tissue microenvironment on cell function.

Winner for outstanding research in the Ph.D. category for the 2013 Society for Biomaterials meeting and exposition, April 10-13, 2013, Boston, Massachusetts: Osteogenic differentiation of adipose-derived and marrow-derived mesenchymal stem cells in modular protein/ceramic microbeads.

Modular tissue engineering applies biomaterials-based approaches to create discrete cell-seeded microenvironments, which can be further assembled into larger constructs for the repair of injured tissues. In the current study, we embedded human bone marrow-derived mesenchymal stem cells (MSC) and human adipose-derived stem cells (ASC) in collagen/fibrin (COL/FIB) and collagen/fibrin/hydroxyapatite (COL/FIB/HA) microbeads, and evaluated their suitability for bone tissue engineering applications. Microbeads were fabricated using a water-in-oil emulsification process, resulting in an average microbead diameter of approximately 130 ± 25 μm. Microbeads supported both cell viability and cell spreading of MSC and ASC over 7 days in culture. The embedded cells also began to remodel and compact the microbead matrix as demonstrated by confocal reflectance microscopy imaging. After two weeks of culture in media containing osteogenic supplements, both MSC and ASC deposited calcium mineral in COL/FIB microbeads, but not in COL/FIB/HA microbeads. There were no significant differences between MSC and ASC in any of the assays examined, suggesting that either cell type may be an appropriate cell source for orthopedic applications. This study has implications in the creation of defined microenvironments for bone repair, and in developing a modular approach for delivery of pre-differentiated cells.

Mapping the Road to Recovery: Shorter Stays and Satisfied Patients in Posterior Spinal Fusion

Background: Adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) experience variations in their hospital care, which may lead to differences in objective and patient-reported outcomes. The purpose of this study was to demonstrate that using plan of care—educating families preoperatively and standardizing some aspects of care—would decrease time to mobility and time to discharge while maintaining pain control and patient satisfaction. Methods: Chart review was conducted in 3 groups—preprotocol (December 2008 to December 2009, n=51), first protocol (December 2, 2009 to July 24, 2013, n=100), and second protocol (July 25, 2013 to June 1, 2014, n=39)—to track pain scores (0 to 10), time to regular diet, Foley catheter removal, epidural catheter removal, mobility, and discharge. Patient satisfaction surveys (0 to 10) were administered before discharge. Statistical analysis was performed using a 1-way analysis of variance test with Tukey post hoc analysis. Results: Average pain scores were similar in all groups. Time to sitting was significantly reduced in both first protocol (27.2±9.8 h, P=1×10−8) and second protocol (28.4±13.6 h, P=3×10−5) compared with preprotocol (40.2±15.4 h). Time to discharge was significantly lower in second protocol (84.3±27.2 h, P=0.036) compared with first protocol (98.4±27.8 h). Patient satisfaction with care was significantly higher in first protocol (9.1/10, P=2×10−6) and second protocol (8.6/10, P=5×10−4) compared with preprotocol (6.5/10). Conclusions: By educating families preoperatively and standardizing portions of postoperative care in PSF for AIS, pain scores were significantly reduced while overall satisfaction remained high. Specifically, by removing the epidural and Foley catheters on postoperative day 2, time to discharge was dramatically decreased by 15 hours. The application of a multidisciplinary, evidence-driven plan of care for AIS patients undergoing PSF improves throughput and has beneficial effects on objective and patient-reported outcomes. Level of Evidence: Level III—retrospective case series.

Treatment of Unicameral Bone Cysts of the Proximal Femur With Internal Fixation Lessens the Risk of Additional Surgery

Little data exist to guide the treatment of unicameral bone cysts in the proximal femur. Methods of treatment include corticosteroid injections, curettage and bone grafting, and internal fixation. The authors completed a multi-institutional, retrospective review to evaluate their experience with proximal femoral unicameral bone cysts. They posed the following questions: (1) Does internal fixation reduce the risk of further procedures for the treatment of a unicameral bone cyst? (2) Is radiographic healing faster with internal fixation? Following institutional review board approval, the authors conducted a retrospective review of 36 patients treated for a unicameral bone cyst of the proximal femur at their institutions between 1974 and 2014. Medical records and radiographs were reviewed to identify patient demographics and treatment outcomes. Tumor locations included femoral neck (n=13), intertrochanteric (n=16), and subtrochanteric (n=7). Initial treatment included steroid injection (n=2), curettage and bone grafting (n=9), and internal fixation with curettage and bone grafting (n=25). Mean time was 9 months to radiographic healing and 15 months to return to full activity. The number of patients requiring additional surgeries was increased among those who did not undergo internal fixation. There was no difference in time to radiographic healing. However, time to return to normal activities was reduced if patients had received internal fixation. A significant reduction in additional procedures was observed when patients had been treated with internal fixation. Although this did not influence time to radiographic healing, patients did return to normal activities sooner. Internal fixation should be considered in the treatment of proximal femoral unicameral bone cysts. [Orthopedics. 2017; 40(5):e862-e867.].

Vocal Cord Paresis After Posterior Spinal Fusion to Treat Adolescent Idiopathic Scoliosis: A Case Report

Case:A 15-year-old girl with adolescent idiopathic scoliosis with a 50° curve underwent posterior spinal fusion from T3 to T11. After discharge from the hospital, the patient reported dysphonia and dysphagia. Flexible nasendoscopy confirmed left vocal cord paresis. Stretch injury to the recurrent laryngeal nerve from the left T5 pedicle screw or intubation may have caused the vocal cord paresis. The pedicle screw was removed during revision surgery. Postsurgically, the patient demonstrated immediate and ultimately full recovery and no longer had any symptoms. Conclusion:To our knowledge, this is the first case report of vocal cord paresis most likely caused by pedicle screw position after posterior spinal fusion.