Validation of Laboratory Test for Predicting Bone Tissue Regeneration (Rebone-test)

• Assessment of the pro-osteogenic properties of serum over time. [ Time Frame: 1 day before surgery; 1 month postoperatively; 12 month postoperatively ] [ Designated as safety issue: No ]

  In order to determine whether the pro-osteogenic properties are maintained over time, we planned to collect other serum samples, namely preoperatively, 1 day before the surgery, and postoperatively, after 1 and 12 months.

  The pro-osteogenic activity will be evaluated as previously described.

• Correlation between laboratory testing and timing of healing. [ Time Frame: 1, 3, 6, and 9 months postoperatively ] [ Designated as safety issue: No ]
  Clinical and radiographic results will be assessed at intermediate end points, as previously described.

The aim of the study is to determine whether the evaluation of pro-osteogenic activity of autologous serum may predict the effectiveness of platelet gel in regenerating bone tissue in patients with nonunions of long bones.

Serum samples will be collected 1 month before the surgery, and their pro-osteogenic activity will be evaluated by using a bioactivity test (mineralization assay).

In order to determine whether the pro-osteogenic activity of the serum is able to discriminate between individuals who will achieve or will not achieve bone consolidation, the laboratory results will be correlated with clinical and radiographic results at 12 months, when patients will be considered as healed or not healed.

Pseudarthrosis (or 'nonunions') is defined as a bone movement which occurs after about 6 months from the traumatic event as consequence of the inadequate healing of a fracture. The use of regenerative medicine for treating recalcitrant pseudarthrosis is considered a promising strategy to promote bone consolidation. Among the various approaches used, the local cell therapy based on autologous mesenchymal stromal cells (MSC), combined with or without growth factors, has been extensively used. MSC reside within the stromal compartment of bone marrow which may be obtained from the iliac crest. Growth factors may be discharged from platelet gel (PG) which is obtained after activation of autologous platelet concentrates. Nevertheless, the results of recent clinical studies show that the above mentioned regenerative approach shows a failure rate of approximately 30% (Calori et al, 2008). The availability of a laboratory test which may predict the regenerative capacity of the PG may help the orthopaedic surgeon in addressing the decisions regarding the regenerative approach, e.g. to use or non use autologous platelet concentrates or to enhance the use of autologous derivatives with recombinant factors.The rationale for the use of platelet concentrates in pseudarthrosis is the significant reduction of osteoinductive growth factors observed at the lesion site (Gandhi et al., 2005). Platelet gel mimics what happens physiologically after any bone injury, when platelets are entrapped in a clot within a fibrin matrix. Platelet activation determines the release of various growth factors promoting bone healing. The optimal level and ratio of growth factors and their synergistic effects should be more efficient than single recombinant molecules, even though no data are available on the most relevant molecules and on their optimal amount. In this context, the in vitro mineralization assay could be a valid tool to assess the pro-osteogenic activity of platelet gel, thus obviating the measurement of the myriad of platelet-derived substances.

The aim of the study is to determine whether the evaluation of pro-osteogenic activity of autologous serum may predict the effectiveness of PG in the regeneration of bone tissue in patients with nonunions of long bones. The rationale is based on the following issues:

• in 30% of long bone nonunions treated with PG, bone consolidation is not obtained (Calori et al, 2008);
• the proportion of growth factors in serum is comparable to that observed in platelet gel after activation, even if the concentration is lower;
• the autologous serum is able to support the 'in vitro' osteogenic differentiation of MSCs and the formation of mineral nodules (mineralization assay) (Granchi et al, 2010);
• the correlation between 'in vitro' mineralization and regenerative capacity has been demonstrated in various experimental models (De Bari et al, 2008);
• preliminary data obtained in our lab showed that in patients affected by congenital pseudarthrosis of the tibia the presence of osteoinductive growth factors in serum is an essential requirement to warrant the effectiveness of the local cell therapy with MSC and PG (submitted paper).

In order to evaluate the ability of the autologous serum in inducing the mineralization in vitro the investigators will use a bioactivity test (mineralization assay). For this purpose serum samples of patients candidates to the treatment with MSC and PG will be collected 1 month before the surgery and used for cultivating normal MSC, whose ability to mineralize in vitro will be previously verified in standard culture conditions.

Further analysis will be conducted in order to determine whether the pro-osteogenic properties are maintained over time, and serum samples will be collected the day before the surgery and postoperatively (after 1 and 12 months).

In order to determine whether the pro-osteogenic activity of the serum is able to predict and discriminate between individuals who achieve or not achieve bone consolidation, the laboratory results will be correlated with clinical and radiographic results at 12 months, when patients will be considered as healed or not healed.

primary care clinic

• Gandhi A, Bibbo C, Pinzur M, Lin SS. The role of platelet-rich plasma in foot and ankle surgery. Foot Ankle Clin. 2005 Dec;10(4):621-37, viii. Review.
• Calori GM, Tagliabue L, Gala L, d'Imporzano M, Peretti G, Albisetti W. Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non-unions: a prospective randomised clinical study on 120 patients. Injury. 2008 Dec;39(12):1391-402. Epub 2008 Nov 22.
• Cenni E, Savarino L, Perut F, Fotia C, Avnet S, Sabbioni G. Background and rationale of platelet gel in orthopaedic surgery. Musculoskelet Surg. 2010 May;94(1):1-8. Epub 2009 Nov 24. Review.
• Arvidson K, Abdallah BM, Applegate LA, Baldini N, Cenni E, Gomez-Barrena E, Granchi D, Kassem M, Konttinen YT, Mustafa K, Pioletti DP, Sillat T, Finne-Wistrand A. Bone regeneration and stem cells. J Cell Mol Med. 2011 Apr;15(4):718-746.
• De Bari C, Dell'Accio F, Karystinou A, Guillot PV, Fisk NM, Jones EA, McGonagle D, Khan IM, Archer CW, Mitsiadis TA, Donaldson AN, Luyten FP, Pitzalis C. A biomarker-based mathematical model to predict bone-forming potency of human synovial and periosteal mesenchymal stem cells. Arthritis Rheum. 2008 Jan;58(1):240-50.
• Granchi D, Devescovi V, Baglìo SR, Leonardi E, Donzelli O, Magnani M, Stilli S, Giunti A, Baldini N. Biological basis for the use of autologous bone marrow stromal cells in the treatment of congenital pseudarthrosis of the tibia. Bone. 2010 Mar;46(3):780-8. Epub 2009 Nov 10.

Eligible patients will be identified according to the following criteria.

Inclusion criteria:

• patients with aseptic nonunion of long bones and candidates for treatment with platelet gel and MSC in addition to fixation devices and bone grafting;
• patients who have given their written consent to participate in the study.

Exclusion criteria:

• patients with bone infections;
• patients with congenital disorders involving the skeletal development;
• patients treated with corticosteroids or other immunosuppressive agents;
• patients suffering from mental or psychiatric disorders that preclude the possibility of correctly adhering to the protocol.