ISTITUTO ORTOPEDICO G. PINI
UNIVERSITA’ DEGLI STUDI DI MILANO
Classificazione e indicazione all’uso dei
fattori di crescita in Traumatologia
G.M. Calori
Biella, 5 Giugno 2009
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Clinical Evidence
vs
Clinical Experience
Levels of evidence
○ PRCT (14%)
○ Cohort studies (20%)
○ Case control (10%)
○ Retrospective case series
(56%)
○ Experience/Opinion (0%)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Dott. Marshall R. Urist
Bone: Formation by Autoinduction. Science. 1965 Nov 12;150(698):893-9.
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
OSTEOINDUCTION
Is the ability to stimulate bone tissue
formation in a non-bone site and can be
distinguished in:
1) CELL-MEDIATED
2) GF-MEDIATED
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
OSTEOINDUCTION
CELL-MEDIATED
In cell-mediated osteogenesis cell precursors
are harvested from bone marrow,
concentrated and grafted
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
OSTEOINDUCTION
GF-MEDIATED
In GF-mediated osteoinduction growth
factors stimulate resident mesenchimal
cells to differentiate in a chondro and
osteblastic lineage
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
GROWTH FACTORS
TGF-ß (1-5) and BMPs (1-16) belong
to a family of proteins with similar
amino-acidic sequences called TGF-ß
superfamily
They are the main regulators of
osteoblastic feedback
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
GROWTH FACTORS
TGF- ß
TGF-ß controls the
repairing process
throughtout deposition of
extracellular matrix with a
mitogenic and chemotactic
action
Joyce ME et al. J Cell Biol 110:2195-2207, 1990
Noda M, Camilliere JJ. Endocrinology 124:2991-2994, 1989
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
GROWTH FACTORS
TGF- ß
Concentration of TGF- ß in
bone tissue and in platelets
is 100 times greater than in
the other tissues
Joyce ME et al. J Cell Biol 110:2195-2207, 1990
Noda M, Camilliere JJ. Endocrinology 124:2991-2994, 1989
Classificazione e indicazione all’uso dei fattori di crescita
G.M. CALORI
GROWTH FACTORS
Mesenchymal
stem cell
Osteo-
Pre-osteoblast
progenitor cell
Transitionosteoblast
Secreting
osteoblast
Osteozytic
osteoblast
Osteocyte
• IGF-I / IGF-II
Growth Factors have a combined, sequencial
and stadium-specific action
• aFGF / bFGF
• TGF-B1 / TGF-B2
• LIF
• BMP-2 / BMP-3

PDGF

BMP-7

Osteonectin

BDGF

Collagen type I

Vitamin D
sialoprotein

Osteocalcin
Classificazione e indicazione all’uso dei fattori di crescita
G.M. CALORI
GROWTH FACTORS
Proliferative
effect
Mesenchimal stem cell
Differentiative
effect
TGF-ß
BMP
TGF-ß
BMP
TGF-ß
IGF
PDGF
FGF
Cellula osteoprogenitrice
BMP
TGF-ß
Osteoblast
Mohan S, Baylink DJ. Clin Orthop 263:30-48, 1991
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
The meeting between biotechnologies
and the muscoloscheletal system
involves many fields:
 scaffolds for bone defects treatment
 scaffolds for cartilage defects treatment
 synthetic growth factors
 platelets concentration systems
 marrow inhaled concentration and adsorbment systems
 stem cells in vitro expansion systems (?)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
The meeting between biotechnologies
and the muscoloscheletal system
involves many fields:
 scaffolds for bone defects treatment
 scaffolds for cartilage defects treatment
 synthetic growth factors
 platelets concentration systems
 marrow inhaled concentration and adsorbment systems
 stem cells in vitro expansion systems (?)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
1980 - 2000




BMP genes identified
Sampath & Reddi
Commercial rights to molecules established
– Creative Biomolecules (later Stryker Orthobiologics)
get OP1 (BMP-7) for bone
– Wyeth get BMP-2 for bone
Both Boston - based Companies
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
1980 - 2000







Many BMPs are recognised (?up to 40)
Related by cysteine knot structure
High amino acid sequence homology
Share property of producing bone in non-osseous sites
Genes found on different chromosomes
Little difference between species (so human molecules
can ligitimately and effectively be used on different lab
animals)
All members of TGFbeta superfamily of proteins
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
1980 - 2000



Human genome identified
Plasmids manufactured containing gene sequences for
BMPs
Development of technology to produce rhBMP in
cultured CHO cells
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
2000 - present



Animal and human studies
Large scale commercial production
Commercial licences granted
– rhBMP7 (OP1/ Osigraft) for long-bone non-union
– rhBMP2 (Inductos) for open fractures of the tibia
– rhBMP2 (Infuse) for spinal fusion
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Animal Studies since 2001








Salkeld, Cook et al 2001 – dog ulna defect
Mizumoto et al 2003– augmented callotasis with BMP7
Cook et al 2003– improved cartilage repair in dogs
Improved tendon integration
Dose ranging studies
Seeherman (Wyeth – BMP2) – acceleration of fracture
healing
Blokhuis – (BMP7) acceleration of fracture healing
Saito et al 2006 (BMP-2) - repair rabbit radial bone
defect – 2009 induced periodontal regeneration in dogs
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Animal Studies since 2001








Salkeld, Cook et al 2001 – dog ulna defect
Mizumoto et al 2003– augmented callotasis with BMP7
Cook et al 2003– improved cartilage repair in dogs
Improved tendon integration
Dose ranging studies
Seeherman (Wyeth – BMP2) – acceleration of fracture
healing
Blokhuis – (BMP7) acceleration of fracture healing
Saito et al 2006 (BMP-2) - repair rabbit radial bone
defect – 2009 induced periodontal regeneration in dogs
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Repair of Articular Cartilage Defects with Osteogenic
Protein-1 (BMP-7) in Dogs – Cook et al
OP-1
After 6 weeks
Control
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Repair of Articular Cartilage Defects with Osteogenic
Protein-1 (BMP-7) in Dogs
OP-1
Control
After 52 weeks
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Human Studies for Trauma




Friedlaender 2001
BESTT 2003
Australian Limb Salvage Series
Others - ongoing
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
BMP-7 in Non Union - Friedlander et al.

JBJS (Am) 2001;83 Suppl 1(Pt1):s151-62
»PRCT (Part blinded, multi-center)
»124 Tibial Non unions

Excluded: Unreliable, Infected, envelope problems etc
2
groups
– Autograft + IM Nail (Control)
– BMP-7 + IM nail
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Summary of Safety*:
% of Patients
1 00
80
60
44
44
40
21
20
20
3
0
0
Serious
Adverse
Events
Osteomyelitis
OP-1 (n=61)
Chronic
Donor Site
Pain
Autograft (n=61)
*Friedlaender et. al, JBJS, Vol. 83-A, No. 4, April 2001.
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Friedlander results

More “atrophic” (p=0.048) in OP-1 (randomisation)

Comparable union rates at 9 months

Concluded BMP-7 comparable to autograft

20% chronic donor pain in autograft group

Osteomyelitis higher in control group
– (21% vs 3%) p=0.002

Potential Criticisms:
– 1/3 loss to follow up at 2 years
– Heterogenous group (50% prev IMN, 40% prev autograft)
– Non stratified
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Evidence for BMPs in
Acute Fracture Care
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
BMP-2 Evaluation in Surgery for Tibial
Trauma Trial (BESTT) - Govender et al
» BMP-2 for treatment of Open Tibial fractures: PRCT (450
Patients)
JBJS(A) 2002 84-A(12):2123-34.




49 centres, 11 countries
450 Patients, Stratified (1, 2 and 3A) and (3B)
Excluded patients in whom “bone grafting anticipated”
3 groups
– IM Nailing
– Low concentration BMP-2 (0.75mg/ml)
– High concentration BMP-2 (1.5mg/ml)
» Outcome measure

2y intervention within 12 months due to delayed or non union.
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
3B Open Tibia Subgroup

No significant difference % reamed and unreamed (p=0.14)

Outcome measures :
» Need for bone graft


Control 13/65 (20%)
BMP-2 1/66 (2%) p0.0005, relative risk reduction 90%
» Invasive secondary procedures


Control 18/65 (28%)
BMP-2 6/66 (9%) p=0.0065, relative risk reduction 68%
» Infection


Control 26/65 (40%)
BMP-2 13/66 (21%) p=0.02, relative risk reduction 48%
» Faster clinical healing 95 v 126 days in BMP-2 group
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Results
6 weeks
* BESTT Study Group
14 weeks
26 weeks
52 weeks
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
“Son of BESTT” - Swiontowski et al

rhBMP-2 in open tibial fractures. A subgroup analysis of data
combined from two prospective randomized studies.
J Bone Joint Surg Am. 2006 Jun;88(6):1258-65.
– 450 BESTT patients plus 60 US centre patients
– Sub group analysis
» 3A/3B fractures (n=131)
» Reamed Nailing (n=113)
– Only analysed 1.5mg/ml (High dose/concentration) treatment
group
– Trial not set up or powered for subgroup analysis.
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Results BESTT

Secondary Intervention
– Control 46%
– 0.75mg/ml BMP-2 37%
– 1.5mg/ml BMP-2 26%
» dose/response relationship (p=0.0004)
» 44% reduction in 2y intervention between Control and High dose

Greater overall success in BMP groups esp High
– Faster wound healing at 6/52 p=0.001
– More healed P=0.0008
– Faster Healing P=0.002
– Lower infection in severe fractures (3B) in BMP groups.
P=0.02
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
BMP-2 + Allograft vs AICBG - Jones et al

rhBMP-2 and allograft compared with Autogenous bone graft for
reconstruction of diaphyseal tibial fractures with cortical defects.
(BESTT ALL) Study Group 2006 JBJS (A)July 2006
– RCT N=30 (2/3 IM nail), (1/3 Ex fix)
» 2 Groups of 15


15 Secondary autologous graft at 6-12 weeks
15 Allograft chips with BMP-2
» 1-7cm defects, 20% drop out rate/loss to follow up,15% violated protocol
(LISS 2/IMN 1) or Demineralised Bone Matrix (1)
– “Success” rate in BMP-2 87%, Control 67%.
» (p>0.05)
» 13% of failures in control were broken cross screws!
– Suggested equivalence of Auto vs Allo+BMP-2
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
BMP-7 in Tibial fractures – Maniscalco et al

Healing of Fresh tibial fractures with OP-1 a preliminary report.
Acta Biomed Ateneo Parmenese 2002;73:27-32.
– Ex fix +BMP-7 vs Ex fix +
Autologous graft
– 2 randomised groups
» BMP-7 (n=7) control (n=7).
– No statistical difference
» They all healed!
» Involved opening closed fractures
» Undersized study
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
BMP-7 in Open Tibial Fractures – McKee et al
 BMP-7 on healing of open tibial fractures results of multicenter PRCT
OTA 2002, AAOS 2003




N=62 per group
Favoured early weight bearing in BMP-7 group
Less pain with activity P=0.04
Reduced secondary intervention in BMP-7
group (13% vs 27%) p=0.02
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
BMP-7 in Distal Tibial Fractures + EF – Ristinemi et al
 rhBMP-7 accelerates the healing in distal tibial fractures treated by
external fixation.
JBJS Br 2007 Feb 89(2):265-72.
–
–
–
–
–
–
20 in each group,
case control study
Faster healing p<0.03
Faster return to work p<0.018
Shorter time in external fixator p<0.037
Lower secondary intervention in BMP-7 group
» 10% vs 35%
– CONCLUDED BMP-7 ACCELERATES ACUTE FRACTURE
UNION
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Spinal Fusion Evidence
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
12 RCTs of BMPs in Spinal Fusion

9 USA, 1 Sweden,1 Canada, 1 Japan/USA

Ecosse 1 France 0 (Full Time)

4 Anterior, 7 Posterolateral, 1 Neck.

BMP-2 n=631
– More effective than autograft for radiographic fusion p<0.05
– 95% vs 89% Burkus 2002
– 99% vs 76% in Burkus 2005

BMP-7 n=56
– No significant difference to autograft in fusion
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Australian Limb Salvage







163 cases
1997-1999
FU 15 mo ave.
Heterogeneous group – OP1 + AutoG, AlloG, Fillers. OP1
alone: 36 cases.
40 had previous AutoG.
39 failures overall
30% failure for non union group (28/113)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Bone loss - THA revision
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
July 2006 - Impaction grafting review
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
July 2006 - Impaction grafting review
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
GFs vs infection
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
July 2006 – Chen et al
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
July 2006 – Chen et al
Conclusions
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PRP
PRP is a source of aspecific
autologous GFs able to stimulate the
repairing process in the application
site.
It has the same effects of the
haematoma, empowered by high
concentration of trombocites.
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PRP
PPP
(Platelet Poor
Plasma)
PRP
(Platelet Rich Plasma)
Red blood cell
Throughout centrifugation
PRP is divided from the
other blood fractions
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PRP
Activated platelets
degranulate and
release various GF
and cytokines:
Platelet Derived Growth Factor
Transforming Growth Factor beta
Vascular Endothelial Growth Factor
Epithelial Growth Factor
Insuline Growth Factor
PDGF-ßß
PDGF-aa
PDGF-aß
TGF-ß1
TGF-ß2
VEGF
EGF
IGF1-2
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PRP
Activated platelets
degranulate and
release various GF
and cytokines:
Platelet Derived Growth Factor
INDUCE
OSTEOGENESIS
Vascular
Endothelial Growth Factor
Transforming Growth Factor beta
Epithelial Growth Factor
Insuline Growth Factor
PDGF-ßß
PDGF-aa
PDGF-aß
TGF-ß1
TGF-ß2
VEGF
EGF
IGF1-2
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PRP
Activated platelets
degranulate and
release various GF
and cytokines:
Platelet Derived Growth Factor
INDUCES
ANGIOGENESIS
Vascular
Endothelial Growth Factor
Transforming Growth Factor beta
Epithelial Growth Factor
Insuline Growth Factor
PDGF-ßß
PDGF-aa
PDGF-aß
TGF-ß1
TGF-ß2
VEGF
EGF
IGF1-2
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
DBM
Bae et al.Spine. 2006 20;31:1299-306
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
WHAT GFs ?
 BMP-2
 PRP
 BMP-7
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
WHAT GFs ?
 BMP-2
 PRP
 BMP-7
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
WHAT GFs ?
Mesenchimal
cells
Mesenchimal
cells
Osteoblast
Mesenchimal cells, in
presence of BMP-2 only
(not charachterized by a
powerful mitogenic
effect), differentiate but
not multiply
Osteoblasts
Mesenchimal cells in presence of DBM
(BMP + TGF-  and other GFs) differentiate
and multiply themselves
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
WHAT GFs ?
 BMP-2
 PRP
 BMP-7
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PRP
It does not exist any controlled
randomised study pro PRP. Its
efficacy, based on shared
phisyopathologic remarks, has to be
demonstrated in the
muscoloscheletal field.
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Tissue-Engineering: PRP
PRP = osteopromotive agent
 It promotes the cellular division (mitogenesis)
 Not specific for the bone cell
 Only partially involved in the cascade of events
that leads to bone neoformation and that follows
the osteoblast differentiation
 Unable to induce by the bone neoformation
 Unable to promote the differentiation of stromal
cells
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
WHAT GFs ?
 BMP-2
 PRP
 BMP-7
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Tissue-Engineering: BMP-7
BMP-7 = osteoinductive agent
 It stimulates
bonegrowtgh
neoformation
BMP
are the only
factors with a
recognized ability to induce the differentiation
of of osteoprogenitor cells in a prechondroblastic and pre-osteoblastic lineage
Urist MR. Science 159:893-899, 1965
Wozney JM. Mol Reprod Devel 32:160-167, 1992
Chen D. Growth Factors 22(4):233, 2004
Chaudhary LR. Bone 34(3):402, 2004
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Only recombinant BMPs have level A grade
of raccomandation according EBM criteria
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PRP vs BMP-7
End-point: evaluation of osteoinduction in rats
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Bone formation after 50gg of 20mm3 at Bio0ss
or
20 mm3 at rib
10 µl of rhBMP-7
+
or
20 µl PRP
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
ISTITUTO ORTOPEDICO G. PINI
UNIVERSITA’ DEGLI STUDI DI MILANO
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
STUDY PURPOSE
 Compare the efficacy of BMP-7 and PRP as
bone stimulating agents in the treatment of NU
 Establish a real alternative to autograft,
golden standard for this treatment
G.M. CALORI
L’utilizzo dei fattori di crescita nelle Pseudoartrosi
When in the atrophic non-union there was a bone loss that needed a
scaffold to correct the deformity
This gap was classified in 3 groups:
Group A: gap < 1 cm
55 patients (45.83%)
Group B: gap from 1 to 3 cm
47 patients (39.16%)
Group C: gap > 3 cm
18 patients (15.0%)
RESULTS
L’utilizzo dei fattori di crescita nelle Pseudoartrosi
G.M. CALORI
rh BMP-7
PRP
N evaluable patients (9 months Follow up)
60
60
Age (y) mean ± SD
46,4±1,98
42,5±1,76
15 Tibia
10 Femur
15 Humerus
12 Ulna
8 Radius
19 Tibia
8 Femur
16 Humerus
8 Ulna
9 Radius
NU duration (months) - mean ± SD
20,2±1,34
19,4±1,45
N° Praevius surgery - mean ± SD
2,6±0,62
2,8±0,74
Synthesis Change
40/60 (66,6%)
48/60 (80 %)
RX Healing rate *1
52/60 (86,6%)
41/60 ( 68,3%)
RX Healing time ( months ) - mean ± SD
8±0,48
9±0,52
Clinical Healing rate *1
52/60 (86,6%)
41/60 ( 68,3%)
Clinical Healing time (months)- mean ±
SD
Failures *1
3,5±0,48
4±0,61
8/60 (13,4 %)
19/60 (31,7%)
Previous autografts
23/60 (38,3%)
21/60 (35%)
Re-interventions *2
4/60 (6,6%)
12/60 (20%)
Site NU
*1
Χ2 test = 5.78 with 1 degree of freedom, p = 0.0162; significant
*2
Χ2 test = 4.62 with 1 degree of freedom, p = 0.0317; significant
L’utilizzo dei fattori di crescita nelle Pseudoartrosi
G.M. CALORI
rhBMP-7
PRP
Number of patients
60
60
Gender (Male/Female)
32 / 28
35 / 25
Age (years,median + range)
44 (19-65)*
41 (21-62)*
Nicotine use %
33.3%
28.3%
Open fracture at injury
Duration of non-union
(months, median ± SD )
Number of previous surgeries
(median + range)
Prior autograft
implementation
4
1 grade II
2 grade IIIa
1 grade IIIb
5
1 grade I
1 grade II
2 grade IIIa
1 grade IIIb
20,2±2,35
19,2±2,86
2 (1-5)
2 (1-5)
23/60 (38,3%)
21/60 (35%)
PRP Group
rhBMP-7 Group
Fixation treatment
prior to our intervention
Non
union
site
tibia
femur
n
15
10
Initial fixation
after injury
(preserved
during our
intervention)
1 IMN
2 ORIF
1 EF
Fixation
revision
after non
union
Fixation
revision
during our
interventio
n
2 IMN
2 ORIF
4 IMN
2 IMN
4 ORIF
6 ORIF
1 IMN
1 EF
2 IMN
Fixation treatment
prior to our intervention
Summary of
fixation
treatment
n
Fixation
revision
after non
union
3 IMN
2 ORIF
5 IMN
2 IMN
6 ORIF
8 ORIF
1 EF
1 EF
1 EF
3 IMN
1 IMN
1 EF
2 IMN
2 IMN
1 EF
5 IMN
8 ORIF
2 EF
19
8
2 ORIF
4 ORIF
Initial fixation
after injury
(preserved
during our
intervention)
Fixation
revision
during our
interventio
n
2 IMN
2ORIF
1 EF
1 IMN
Summar
y of
fixation
treatmen
t
7 IMN
10 ORIF
2 EF
3 IMN
3 ORIF
2 EF
3 ORIF
4 ORIF
2 EF
2 IMN
humer
us
ulna
radius
15
12
8
2 IMN
3 ORIF
1 EF
4 ORIF
1 EF
1 ORIF
1 EF
2 IMN
3 IMN
1 ORIF
1 EF
3 ORIF
1 EF
1 IMN
5 ORIF
2 EF
2 EF
3 ORIF
2 K-W
1 IMN
6 ORIF
1 EF
1 EF
2 EF
3 ORIF
2 K-W
5 ORIF
4 ORIF
2 K-W
1 EF
1 EF
4 IMN
8 ORIF
3 EF
16
1 IMN
1 ORIF
1 EF
3 IMN
4 IMN
7 ORIF
5 EF
6 ORIF
4 EF
10 ORIF
2 EF
7 ORIF
1 EF
8
9
2 ORIF
2 ORIF
1 K-W
1 ORIF
2 EF
4 ORIF
6 ORIF
6 ORIF
2 EF
7 ORIF
2 EF
L’utilizzo dei fattori di crescita nelle Pseudoartrosi
G.M. CALORI
FAILURES
BMP-7 (8/60)
 1 case: new trauma with Ex Fix failure and re-fracture
 4 cases: sepsis
10
9
8
 1 case: poor callus at the 9th month
PRP (19/60)
 5 cases: sepsis
 9 cases: absence of callus formation
 1 case: new fracture in severe osteopenia
 4 cases: poor callus at the 9th month
CASES
 2 case: absence of callus formation
9
7
6
5
4
3
2
1
0
5
4
rhBMP-7
PRP
4
2
1
NEW
TRAUMA
1
SEPSIS
POOR
CALLUS
ABSENCE
OF CALLUS
L’utilizzo dei fattori di crescita nelle Pseudoartrosi
G.M. CALORI
Radiographic and clinical failure rate
rhBMP-7
HEALING RATE
FAILURES
52 (86,7%)
86,7% = NU healing rate
PRP
8 (13,3%)
HEALING RATE
FAILURES
41 (68,3%)
P = 0,016
SIGNIFICANT
19 (31,7%)
L’utilizzo dei fattori di crescita nelle Pseudoartrosi
G.M. CALORI
NU Re - Intervention
rhBMP-7
NO RE-INTERVENTION RE-INTERVENTION
3
PRP
57
NO RE-INTERVENTION RE-INTERVENTION
13
• rhBMP-7: 5% VS PRP: 21%
• p= 0.0317
SIGNIFICANT
47
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
89,7% = NU healing rate
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
SUMMARY
Minibattle: PROs
GFs Vs BMPs pros & cons
AGF (PRP)



Contains many GFs (FGF,
TGFbeta,ILF,PDGF,VEGF)
that could act
sinergistically
Well documented in soft
tissue reconstruction and
CMF surgery
Good handling, diffused
technique
Rh-BMPs



The only GFs with proven
efficacy in trauma
conditions (EBM-criteria)
Standardized dose:
reproducibility of results
Drugs =scrutined by Health
authorities for quality,
efficacy, safety
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
SUMMARY
Minibattle: CONs
GFs Vs BMPs pros & cons
AGF (PRP)





No BMPs contained = not
osteoinductive
Sistem’s Variability =
concentration/activity PLT
variability = conflicting
literature evidence
Lack of randomized trials in
Ortho-trauma
“manpower” cost non
quantifiable
Legal problems (preparation to
be done by haematologists
only )
Rh-BMPs




Even present, still few
randomized CTs
Limited approved indications
High aquisition costs
Low adoption, scarce
confidence
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
C.A. 56 yrs
Forearm biosseus fracture
Therapeutic program
1st STEP:
• NU site resection
• cultural exams
• antibiotic therapy
• Axial external fixator (4 wks)
PREVIOUS TREATMENT
• ORIF SYNTHESIS
-> Failure
• BONE IMPLANT
-> Failure
• Synthesis and cast
-> Failure:
Necrotic settic NU
C.A. 56 yrs
Forearm biosseus fracture
PREVIOUS TREATMENT
• ORIF SYNTHESIS
-> Failure
• BONE IMPLANT
-> Failure
• Synthesis and cast
-> Failure:
Necrotic settic NU
Therapeutic program
2nd STEP:
• Fixator removal
• Vascolarized fibular grafting
• ORIF
C.A. 56 yrs
Forearm biosseus fracture
PREVIOUS TREATMENT
• ORIF SYNTHESIS
-> Failure
• BONE IMPLANT
-> Failure
• Synthesis and cast
-> Failure:
Necrotic settic NU
Therapeutic program
2nd STEP:
• Fixator removal
• Vascolarized fibular grafting
• ORIF
C.A. 56 yrs
Forearm biosseus fracture
PREVIOUS TREATMENT
• ORIF SYNTHESIS
-> Failure
• BONE IMPLANT
-> Failure
• Synthesis and cast
-> Failure:
Necrotic settic NU
Therapeutic program
2nd STEP:
• Fixator removal
• Vascolarized fibular grafting
• ORIF
C.A. 56 yrs
Forearm biosseus fracture
PREVIOUS TREATMENT
• ORIF SYNTHESIS
-> Failure
• BONE IMPLANT
-> Failure
• Synthesis and cast
-> Failure:
Necrotic settic NU
Therapeutic program
3rd STEP:
• R-U distal prosthesis acc. to Herbert
C.A. 56 yrs
Forearm biosseus fracture
PREVIOUS TREATMENT
• ORIF SYNTHESIS
-> Failure
• BONE IMPLANT
-> Failure
• Synthesis and cast
-> Failure:
Necrotic settic NU
Therapeutic program
3rd STEP:
• R-U distal prosthesis acc. to Herbert
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
WHAT’S MORE …
rh-BMP7 + MSC
EXPERIENCE
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
ISTITUTO ORTOPEDICO G. PINI
UNIVERSITA’ DEGLI STUDI DI MILANO
Protocollo di Studio:
STUDIO CLINICO INDIPENDENTE SULLA EFFICACIA E SICUREZZA
DELL’IMPIEGO DI rhBMP-7 (OP-1) IN ASSOCIAZIONE CON CELLULE
STAMINALI MESENCHIMALI NEL TRATTAMENTO DELLE
PSEUDOARTROSI COMPLESSE DELLE OSSA LUNGHE
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Osteogenic
cells
Osteoconductive
scaffolds
“The Diamond Concept”
T. Einhorn - P. Giannoudis - D. Marsh
Mechanical
environment
Growth
factors
G.M. CALORI
Mesenchimal stem cell
BMP
Classificazione e indicazione all’uso dei fattori di crescita
Growth factors and in particular BMPs
make their action on mesemchymal cells so
WHY NOT use both together?
TGF-B
Cellula osteoprogenitrice
BMP
TGF-B
Osteoblast

Saito et al 2005 “Accelerated bone repair
with the use of a synthetic BMP-2-derived
peptide and bone-marrow stromal cells. “
J Biomed Mater Res A ,2005 Jan 1;72(1):77-82
A denser and earlier ectopic bone
formation was achieved when BMP were
coimplanted with syngeneic rat bonemarrow stromal cells into a rat's calf muscle
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – C.A. Pre-op
II.2007
Motorcycle accident
-> radial fracture
-> plating + TEN
II.2008
-> RADIAL ATROPHIC NU
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – C.A.
10.II.2009
devices removal + PSA 3 cm
resection
new synthesis with plate +
allograft +
mesenchymal stem cells
(CELLECT) +
OP-1 (1 vial)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – C.A. 1 month
1 Month
Clin. Eval. : no pain
ROM : complete
Rx : initial callus formation
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – N.A. pre-op
II.2006
Car accident
-> forearm fracture (22 B)
-> plating
II.2007
-> radial plate removed
-> ULNAR ATROPHIC NU
(15 mm gap)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – N.A. op
1.IV.2008
plate removal + PSA 3.5
resection
new synthesis with plate +
xenograft +
mesenchymal stem cells
(CELLECT) +
Osigraft
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – N.A. op
October 2008 New surgical
Change device + Allograft
(fibula shaft)
Proximal Osteointegration
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – N.A. op
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – N.A. Post-op
1.IV.2008
plate removal + PSA 3.5
resection
new synthesis with plate +
xenograft +
mesenchymal stem cells
(CELLECT) +
Osigraft
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – N.A. 1-3-6 months
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – N.A. 12 months
12 months
Clinical ev:
No pain
Complete ROM
Rx:
Low bone integration
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – D.G. Pre-op
II.2008
M. 16 Yrs
Motorcycle accident
-> Medial femoral neck fracture
-> screw fixation
-> Varus deformity + AVN
-> 6 cm of shortening
III.2009
-> FEMORAL NECK NU +
NECROSIS OF THE FEMORAL
HEAD
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – D.G. post-op
OP 2.XII.08
Femoral valgus
osteotomy sec. Pauwels
Plating using blade-plate
135° + trocantheric fixation
-> OP1 + mesenchymal stem
cells + synthetic graft (cellect)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – D.G. 1 month
At 1 month
Clinical ev:
No pain
Stability
ROM complete
No weightbearing allowed
2,5 cm of shortening
Rx:
No progression of the femoral
head necrosis
No callus formation
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – E.E. Pre-op
II.2008
Car accident
-> Pertrocantheric femoral
fracture
-> plating (in Egypt)
-> implant failure + cut out of
one screw
X.2008
-> ATROPHIC NU
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – E.E. Post-op
OP 3.XII.08
Devices removal +
NU cruentation +
Replating using AO plate with
trocantheric fixation +
Medial allograft of
neutralization +
-> OP1 + mesenchymal stem
cells + synthetic graft
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – Z.M. pre-op
XII.2007
F. 61 Yrs
Domestic accident
Severe osteoporosis
-> femoral neck and
sottotrocantheric fracture
-> No diagnosis
-> FEMORAL ATROPHIC NU
-> 1° op: IMN + cement
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NON UNION – Z.M. post-op
OP 5.V.09
Nail and cement removal
Bone loss (6x3x3)
Plating using blade-plate
135° +
Allograft to fill the gap
(femoral head) +
Anterior Allograft of
stabilization +
-> OP1 + mesenchymal stem
cells + synthetic graft (cellect)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
NEVER FORGET ….
 GOOD STABILITY AND BONE CONTINUITY ARE CRUCIAL

CONTACT OF OP-1 WITH VITAL BONE

DO NOT JUDGE TOO EARLY

DO NOT HOPE IN MIRACLE !!
RECALCITRANT AND COMPLICATED NU CASES HAVE VERY
LIMITED HEALING CHANCES AS REPORTED IN LITERATURE
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
CONCLUSION

The discovery of GFs and rh-BMPs in particular opened the way to the combined
Biological and mechanical approach in the traumatology field

Rh-BMPs, growth and differenziation agents have the unique properties to stimulate
new bone formation even in extraskeletal sites

BMPs use, differently from other GFs is reccomanded in trauma applications
(according to EBM criteria)

Their success is NU is obviously linked to :
An adeguate stabilization
An adeguate soft tissue coverage
Vascularity
Vitality of bone
Correct administration (adeguate haemostasis/containment, no drainage)





G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
CONCLUSION
FURTHER CHALLENGE REGARDING THE COMPLETE
CHARACTERISATION OF PRP AND THE OPTIMISATION
OF THEIR PREPARATION AND DELIVERY STILL NEED TO
BE ADDRESSED.
NOWADAYS THE BMP-7 RECOMBINANT TECHNOLOGY
HAS PROVEN ITS SUPERIORITY AND REPRODUCIBILITY
FURTHER STUDY ABOUT THE ASSOCIATION OF BMP-7
AND MESENCHYMAL CELLS ARE NECESSARY
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
PSA
fase di silenzio biologico
“... IL TESSUTO DI PSEUDOARTROSI NON E’ DEL TUTTO PATOLOGICO MA
POSSIEDE ANCORA LARGHE PROPRIETA’ EVOLUTIVE IN SENSO
OSTEOGENETICO SE CORRETTAMENTE STIMOLATO ...”
(Ruggeri F., Zinghi G.F., SIOT 1977)
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
G.M. CALORI
Classificazione e indicazione all’uso dei fattori di crescita
Biotecnologie