Percutaneous Autologous Bone Marrow-Derived Mesenchymal Stromal Cell Implantation Is Safe for Reconstruction of Human Lower Limb Long Bone Atrophic Nonunion

Mohsen Emadedin, Narges Labibzadeh, Roghayeh Fazeli, Fatemeh Mohseni, Seyedeh Esmat Hosseini, Reza Moghadasali, Soura Mardpour, Vajiheh Azimian, Alireza Goodarzi, Maede Ghorbani Liastani, Ali Mirazimi Bafghi, Mohamadreza Baghaban Eslaminejad, Nasser Aghdami, Mohsen Emadedin, Narges Labibzadeh, Roghayeh Fazeli, Fatemeh Mohseni, Seyedeh Esmat Hosseini, Reza Moghadasali, Soura Mardpour, Vajiheh Azimian, Alireza Goodarzi, Maede Ghorbani Liastani, Ali Mirazimi Bafghi, Mohamadreza Baghaban Eslaminejad, Nasser Aghdami

Abstract

Objective: Nonunion is defined as a minimum of a 9-month period of time since an injury with no visibly progressive signs of healing for 3 months. Recent studies show that application of mesenchymal stromal cells (MSCs) in the laboratory setting is effective for bone regeneration. Animal studies have shown that MSCs can be used to treat nonunions. For the first time in an Iranian population, the present study investigated the safety of MSC implantation to treat human lower limb long bone nonunion.

Materials and methods: It is a prospective clinical trial for evaluating the safety of using autologus bone marrow derived mesenchymal stromal cells for treating nonunion. Orthopedic surgeons evaluated 12 patients with lower limb long bone nonunion for participation in this study. From these, 5 complied with the eligibility criteria and received MSCs. Under fluoroscopic guidance, patients received a one-time implantation of 20-50×106 MSCs into the nonunion site. All patients were followed by anterior-posterior and lateral X-rays from the affected limb, in addition to hematological, biochemical, and serological laboratory tests obtained before and 1, 3, 6, and 12 months after the implantation. Possible adverse effects that included local or systemic, serious or non-serious, and related or unrelated effects were recorded during this time period.

Results: From a safety perspective, all patients tolerated the MSCs implantation during the 12 months of the trial. Three patients had evidence of bony union based on the after implantation Xrays.

Conclusion: The results have suggested that implantation of bone marrow-derived MSCs is a safe treatment for nonunion. A double-blind, controlled clinical trial is required to assess the efficacy of this treatment (Registration Number: NCT01206179).

Keywords: Autologous; Bone Marrow; Mesenchymal Stromal Cells; Nonunion.

Figures

Fig.1
Fig.1
Flowchart of patients. HDL; High density lipoprotein, LDL; Low density lipoprotein, ALT; Alanin aminotransferase, AST; Aspartate aminoternsferase, BUN; Blood urea nitrogen, TSH; Thyroid stimulating hormone, T4; Thyroxine, PT; Prothrombine time, PTT; Partial thromboplastine time, INR; International ration, HBS Ag; Hepatitis B surface Ag, HIV; Human immunodeficiency virus, HTLV; Human T lymphtropic virus, BM; Bone marrow, and MSCs; Mesenchymal stromal cells.
Fig.2
Fig.2
Characterization of passage-1 human bone marrow mesenchymal stromal cells (MSCs). A. Phenotypic appearance of fibroblast-like MSCs after one passage in MSCs injected in patients with nonunion and B. Representative flow cytometric analysis using WinMDI software confirmed the expressions of CD90, CD105, CD73, CD44, and CD45/CD34 surface markers (red lines) on MSCs compared to isotype controls (black lines).
Fig.3
Fig.3
Patients radiographies. A. Anteroposterior and lateral radiographs of a non-united open tibial and fibular fracture of a 32-year-old patient, B. 2 months after using mesenchymal stromal cells (MSCs) with demonstrated radiological signs of healing, C. Lateral radiograph of a non-united femural fracture of a 23-year-old patient before implantation of mesenchymal stromal cells, and D. 6 months after transcutaneous implantation of MSCs with radiological signs of healing.

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