An acellular biologic scaffold treatment for volumetric muscle loss: results of a 13-patient cohort study

Jenna Dziki, Stephen Badylak, Mohammad Yabroudi, Brian Sicari, Fabrisia Ambrosio, Kristen Stearns, Neill Turner, Aaron Wyse, Michael L Boninger, Elke H P Brown, J Peter Rubin, Jenna Dziki, Stephen Badylak, Mohammad Yabroudi, Brian Sicari, Fabrisia Ambrosio, Kristen Stearns, Neill Turner, Aaron Wyse, Michael L Boninger, Elke H P Brown, J Peter Rubin

Abstract

Volumetric muscle loss (VML) is a severe and debilitating clinical problem. Current standard of care includes physical therapy or orthotics, which do not correct underlying strength deficits, and surgical tendon transfers or muscle transfers, which involve donor site morbidity and fall short of restoring function. The results of a 13-patient cohort study are described herein and involve a regenerative medicine approach for VML treatment. Acellular bioscaffolds composed of mammalian extracellular matrix (ECM) were implanted and combined with aggressive and early physical therapy following treatment. Immunolabeling of ultrasound-guided biopsies, and magnetic resonance imaging and computed tomography imaging were performed to analyse the presence of stem/progenitor cells and formation of new skeletal muscle. Force production, range-of-motion and functional task performance were analysed by physical therapists. Electrodiagnostic evaluation was used to analyse presence of innervated skeletal muscle. This study is registered with ClinicalTrials.gov, numbers NCT01292876. In vivo remodelling of ECM bioscaffolds was associated with mobilisation of perivascular stem cells; formation of new, vascularised, innervated islands of skeletal muscle within the implantation site; increased force production; and improved functional task performance when compared with pre-operative performance. Compared with pre-operative performance, by 6 months after ECM implantation, patients showed an average improvement of 37.3% (P<0.05) in strength and 27.1% improvement in range-of-motion tasks (P<0.05). Implantation of acellular bioscaffolds derived from ECM can improve strength and function, and promotes site-appropriate remodelling of VML defects. These findings provide early evidence of bioscaffolding as a viable treatment of VML.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Functional task performance. Functional measures as assessed by task/exercise completion from each patient. Data represent per cent change from pre-surgical maximum. NT, not tested.
Figure 2
Figure 2
Site-appropriate tissue remodelling by ECM bioscaffolds. (a–c) Massons trichrome staining of human muscle biopsies shows islands of skeletal muscle present at 6–8 weeks, 10–12 weeks and 24–28 weeks post surgery, respectively. (d–f) Human muscle biopsies are characterised by desmin expression at all time points, indicating new muscle formation within the site of implantation. (g–i) ECM bioscaffold implantation is associated with the presence of CD146+NG2+ perivascular stem cells. (j–l) PVSCs were shown to migrate away from their normal vessel-associated anatomic location at all time points. Arrows indicate CD146+ PVSCs migrating away from vessels. (m, n) Migrating PVSCs and vascularity was quantified using CellProfiler image analysis software. (o) At 24–28 weeks post surgery, ECM bioscaffold implantation was associated with the presence of β-III tubulin+ cells, implicating innervated skeletal muscle. (Scale bars=50 μm).
Figure 3
Figure 3
Ultrasound imaging shows that ECM bioscaffolds degrade on implantation. (a) Grayscale ultrasound image 1 month after surgery in the posterior shoulder demonstrates a thin, sheet-like hyperechoic structure representing SIS-ECM (yellow arrows) overlying the posterior deltoid muscle. The posterior deltoid muscle is increased in echogenicity due to underlying fatty infiltration. (b) Ultrasound imaging 7 months after surgery shows that surgically-placed SIS-ECM is not longer identifiable superficial to the posterior deltoid. (c). Ultrasound image 1 month after surgery in the medial mid thigh demonstrates an ill-defined hypoechoic structure representing SIS-ECM (yellow arrows) adjacent to the sartorius muscle. (d) Ultrasound image 7 months after surgery shows that surgically-placed SIS-ECM is no longer identifiable and the sartorius muscle appears to have enlarged. (e) Ultrasound imaging 1 month after surgery in the posterior mid thigh demonstrates a sheet-like echogenic structure representing dermal ECM (yellow arrows) with surrounding complex anechoic material (dashed-blue line) likely representing post-operative fluid collection. (f) Ultrasound imaging 7 months after surgery shows dermal ECM (yellow arrows) has decreased in echogenicity and now has a tubular or ‘rolled-up’ appearance as opposed to a sheet-like appearance. The previously identified post-operative fluid collection has essentially resolved.
Figure 4
Figure 4
Representative CT imaging shows ECM bioscaffold implantation increases post-operative bulk muscle content. Overall area of the treated muscle was measured at three representative sites (proximal, middle and distal) both prior to surgery and 7 months after surgery in multiple anatomic locations.

References

    1. Lin, C. H., Lin, Y. T., Yeh, J. T. & Chen, C. T. Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect. Plast. Reconstr. Surg. 119, 2118–2126 (2007).
    1. Moneim, M. S. & Omer, G. E. Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption. J. Hand Surg. 11, 135–139 (1986).
    1. Grogan, B. F. & Hsu, J. R.Skeletal Trauma Research C. Volumetric muscle loss. J. Am. Acad. Orthop. Surg. 19 Suppl 1, S35–S37 (2011).
    1. Tu, Y. K. et al. Soft-tissue injury management and flap reconstruction for mangled lower extremities. Injury 39 Suppl 4, 75–95 (2008).
    1. Urish, K. L. et al. Antioxidant levels represent a major determinant in the regenerative capacity of muscle stem cells. Mol. Biol. Cell 20, 509–520 (2009).
    1. Qu-Petersen, Z. et al. Identification of a novel population of muscle stem cells in mice: potential for muscle regeneration. J. Cell Biol. 157, 851–864 (2002).
    1. Lavasani, M., Lu, A., Peng, H., Cummins, J. & Huard, J. Nerve growth factor improves the muscle regeneration capacity of muscle stem cells in dystrophic muscle. Hum. Gene Ther. 17, 180–192 (2006).
    1. Huard, J. et al. Human myoblast transplantation: preliminary results of 4 cases. Muscle Nerve 15, 550–560 (1992).
    1. Skuk, D. Myoblast transplantation for inherited myopathies: a clinical approach. Exp. Opin. Biol. Ther. 4, 1871–1885 (2004).
    1. Skuk, D. et al. Dystrophin expression in myofibers of Duchenne muscular dystrophy patients following intramuscular injections of normal myogenic cells. Mol. Ther. 9, 475–482 (2004).
    1. Hardiman, O., Sklar, R. M. & Brown, R. H. Jr Direct effects of cyclosporin A and cyclophosphamide on differentiation of normal human myoblasts in culture. Neurology 43, 1432–1434 (1993).
    1. Riederer, I. et al. Slowing down differentiation of engrafted human myoblasts into immunodeficient mice correlates with increased proliferation and migration. Mol. Ther. 20, 146–154 (2012).
    1. Sicari, B. M., Dearth, C. L. & Badylak, S. F. Tissue engineering and regenerative medicine approaches to enhance the functional response to skeletal muscle injury. Anat. Rec. 297, 51–64 (2014).
    1. Sicari, B. M. et al. An acellular biologic scaffold promotes skeletal muscle formation in mice and humans with volumetric muscle loss. Sci. Transl. Med. 6, 234ra58 (2014).
    1. Sicari, B. M. et al. A murine model of volumetric muscle loss and a regenerative medicine approach for tissue replacement. Tissue Eng. A 18, 1941–1948 (2012).
    1. Turner, N. J. et al. Xenogeneic extracellular matrix as an inductive scaffold for regeneration of a functioning musculotendinous junction. Tissue Eng. A 16, 3309–3317 (2010).
    1. Valentin, J. E., Stewart-Akers, A. M., Gilbert, T. W. & Badylak, S. F. Macrophage participation in the degradation and remodelling of extracellular matrix scaffolds. Tissue Eng. A 15, 1687–1694 (2009).
    1. Agrawal, V. et al. Epimorphic regeneration approach to tissue replacement in adult mammals. Proc. Natl Acad. Sci. USA 107, 3351–3355 (2010).
    1. Agrawal, V. et al. Recruitment of progenitor cells by an extracellular matrix cryptic peptide in a mouse model of digit amputation. Tissue Eng. A 17, 2435–2443 (2011).
    1. Agrawal, V., Brown, B. N., Beattie, A. J., Gilbert, T. W. & Badylak, S. F. Evidence of innervation following extracellular matrix scaffold-mediated remodelling of muscular tissues. J. Tissue Eng. Regen. Med. 3, 590–600 (2009).
    1. Rana, D., Zreiqat, H., Benkirane-Jessel, N., Ramakrishna, S. & Ramalingam, M. Development of decellularized scaffolds for stem cell-driven tissue engineering. J. Tissue Eng. Regen. Med. (2015).
    1. Reing, J. E. et al. Degradation products of extracellular matrix affect cell migration and proliferation. Tissue Eng. A 15, 605–614 (2009).
    1. Sicari, B. M. et al. The promotion of a constructive macrophage phenotype by solubilized extracellular matrix. Biomaterials 35, 8605–8612 (2014).
    1. Gentile, N. E. et al. Targeted rehabilitation after extracellular matrix scaffold transplantation for the treatment of volumetric muscle loss. Am. J. Phys. Med. Rehabil. 93, S79–S87 (2014).
    1. Gilbert, T. W. et al. Gene expression by fibroblasts seeded on small intestinal submucosa and subjected to cyclic stretching. Tissue Eng. 13, 1313–1323 (2007).
    1. Ballotta, V., Driessen-Mol, A., Bouten, C. V. & Baaijens, F. P. Strain-dependent modulation of macrophage polarization within scaffolds. Biomaterials 35, 4919–4928 (2014).
    1. Turner, N. J., Badylak, J. S., Weber, D. J. & Badylak, S. F. Biologic scaffold remodelling in a dog model of complex musculoskeletal injury. J. Surg. Res. 176, 490–502 (2012).
    1. Aurora, A., Roe, J. L., Corona, B. T. & Walters, T. J. An acellular biologic scaffold does not regenerate appreciable de novo muscle tissue in rat models of volumetric muscle loss injury. Biomaterials 67, 393–407 (2015).
    1. Hudak, P. L., Amadio, P. C. & Bombardier, C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am. J. Ind. Med. 29, 602–608 (1996).
    1. Binkley, J. M., Stratford, P. W., Lott, S. A. & Riddle, D. L. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys. Ther. 79, 371–383 (1999).
    1. Crapo, P. M., Gilbert, T. W. & Badylak, S. F. An overview of tissue and whole organ decellularization processes. Biomaterials 32, 3233–3243 (2011).
    1. Cuthbert, S. C. & Goodheart, G. J. Jr On the reliability and validity of manual muscle testing: a literature review. Chiropr. Osteopat. 15, 4 (2007).
    1. Han, N. et al. Electrodiagnostic evaluation of individuals implanted with extracellular matrix for the treatment of volumetric muscle injury: case series. Phys Therp. 96, 540–549 (2016).

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