classificazione e indicazione all’uso dei fattori di crescita in traumatologia g.m. calori

Classificazione e indicazione all’uso dei Classificazione e indicazione all’uso dei fattori di crescita in Traumatologia fattori di crescita in Traumatologia

G.M. CaloriG.M. Calori

Biella, 5 Giugno 2009Biella, 5 Giugno 2009

ISTITUTO ORTOPEDICO G. PINIISTITUTO ORTOPEDICO G. PINI

UNIVERSITA’ DEGLI STUDI DI MILANOUNIVERSITA’ DEGLI STUDI DI MILANO

Clinical Evidence Clinical Evidence vsvs Clinical Experience Clinical Experience

Levels of evidenceLevels of evidence○ PRCT (14%)PRCT (14%)○ Cohort studies (20%)Cohort studies (20%)○ Case control (10%) Case control (10%) ○ Retrospective case series Retrospective case series

(56%)(56%)○ Experience/Opinion (0%)Experience/Opinion (0%)

G.M. CALORI G.M. CALORI Classificazione e indicazione all’uso dei fattori di crescitaClassificazione e indicazione all’uso dei fattori di crescita

Dott. Marshall R. Urist Bone: Formation by Autoinduction. Bone: Formation by Autoinduction. Science. 1965 Nov 12;150(698):893-9.Science. 1965 Nov 12;150(698):893-9.


Is the ability to Is the ability to stimulate bone tissue stimulate bone tissue

formation in a non-bone siteformation in a non-bone site and can be and can be distinguished in:distinguished in:

1) CELL-MEDIATED1) CELL-MEDIATED

2) GF-MEDIATED2) GF-MEDIATED

OSTEOINDUCTIONOSTEOINDUCTION


In cell-mediated osteogenesis In cell-mediated osteogenesis cell precursorscell precursors are harvested from are harvested from bone marrowbone marrow, ,

concentrated and graftedconcentrated and grafted

OSTEOINDUCTIONOSTEOINDUCTIONCELL-MEDIATEDCELL-MEDIATED


In GF-mediated osteoinduction In GF-mediated osteoinduction growth growth factorsfactors stimulate stimulate resident mesenchimal resident mesenchimal cellscells to differentiate in a chondro and to differentiate in a chondro and

osteblastic lineageosteblastic lineage

OSTEOINDUCTIONOSTEOINDUCTIONGF-MEDIATEDGF-MEDIATED


TGF-ßTGF-ß (1-5)(1-5) and and BMPsBMPs (1-16) belong (1-16) belong

to a family of proteins with similar to a family of proteins with similar amino-acidic sequences called amino-acidic sequences called TGF-TGF-ßß

superfamilysuperfamily

They are the main They are the main regulators of regulators of osteoblastic feedbackosteoblastic feedback

GROWTH FACTORSGROWTH FACTORS


TGF-ßTGF-ß controls the controls the repairingrepairing process process

throughtout deposition of throughtout deposition of extracellular matrix with a extracellular matrix with a

mitogenic and chemotactic mitogenic and chemotactic actionaction

Joyce ME et al. J Cell Biol 110:2195-2207, 1990Noda M, Camilliere JJ. Endocrinology 124:2991-2994, 1989

GROWTH FACTORSGROWTH FACTORSTGF- TGF- ßß


Concentration of TGF- ß in Concentration of TGF- ß in bone tissuebone tissue and in and in plateletsplatelets is 100 times greater than in is 100 times greater than in

the other tissuesthe other tissues

Joyce ME et al. J Cell Biol 110:2195-2207, 1990Noda M, Camilliere JJ. Endocrinology 124:2991-2994, 1989

GROWTH FACTORSGROWTH FACTORSTGF- TGF- ßß



PDGF

BMP-7

Osteonectin

BDGF

Collagen type I

Vitamin D

sialoprotein

Osteocalcin

Mesenchymal stem cell

Osteo-

progenitor cell

Pre-osteoblast Transition- osteoblast

Secreting osteoblast

Osteozytic osteoblast Osteocyte

• IGF-I / IGF-II

• aFGF / bFGF

• TGF-B1 / TGF-B2

• LIF

• BMP-2 / BMP-3

Growth Factors have a combined, sequencial and stadium-specific action



Mohan S, Baylink DJ. Clin Orthop 263:30-48, 1991

Mesenchimal stem cellMesenchimal stem cell

Cellula osteoprogenitriceCellula osteoprogenitrice

OsteoblastOsteoblast

Proliferative Proliferative effecteffect

DifferentiativeDifferentiative effecteffect

TGF-ß

TGF-ß

TGF-ßIGFPDGFFGF

BMPTGF-ß

BMP

BMP


The meeting between biotechnologies The meeting between biotechnologies and the muscoloscheletal system and the muscoloscheletal system involves involves manymany fields: fields:

scaffolds for bone defects treatmentscaffolds for bone defects treatment scaffolds for cartilage defects treatmentscaffolds for cartilage defects treatment synthetic growth factorssynthetic growth factors platelets concentration systemsplatelets concentration systems marrow inhaled concentration and adsorbment systemsmarrow inhaled concentration and adsorbment systems stem cells in vitro expansion systems (?)stem cells in vitro expansion systems (?)


1980 - 20001980 - 2000

BMP genes identifiedBMP genes identified Sampath & ReddiSampath & Reddi Commercial rights to molecules establishedCommercial rights to molecules established

– Creative Biomolecules (later Stryker Orthobiologics) Creative Biomolecules (later Stryker Orthobiologics) get OP1 (BMP-7) for boneget OP1 (BMP-7) for bone

– Wyeth get BMP-2 for boneWyeth get BMP-2 for bone Both Boston - based CompaniesBoth Boston - based Companies


1980 - 20001980 - 2000

Many BMPs are recognised (?up to 40)Many BMPs are recognised (?up to 40) Related by cysteine knot structureRelated by cysteine knot structure High amino acid sequence homologyHigh amino acid sequence homology Share property of producing bone in non-osseous sitesShare property of producing bone in non-osseous sites Genes found on different chromosomesGenes found on different chromosomes Little difference between species (so human molecules Little difference between species (so human molecules

can ligitimately and effectively be used on different lab can ligitimately and effectively be used on different lab animals)animals)

All members of TGFbeta superfamily of proteinsAll members of TGFbeta superfamily of proteins


1980 - 20001980 - 2000

Human genome identifiedHuman genome identified Plasmids manufactured containing gene sequences for Plasmids manufactured containing gene sequences for

BMPsBMPs Development of technology to produce rhBMP in Development of technology to produce rhBMP in

cultured CHO cellscultured CHO cells


2000 - present2000 - present

Animal and human studiesAnimal and human studies Large scale commercial productionLarge scale commercial production Commercial licences grantedCommercial licences granted

– rhBMP7 (OP1/ Osigraft) for long-bone non-unionrhBMP7 (OP1/ Osigraft) for long-bone non-union

– rhBMP2 (Inductos) for open fractures of the tibiarhBMP2 (Inductos) for open fractures of the tibia

– rhBMP2 (Infuse) for spinal fusionrhBMP2 (Infuse) for spinal fusion


Animal Studies since 2001Animal Studies since 2001

Salkeld, Cook et al 2001 – dog ulna defectSalkeld, Cook et al 2001 – dog ulna defect Mizumoto et al 2003– augmented callotasis with BMP7Mizumoto et al 2003– augmented callotasis with BMP7 Cook et al 2003– improved cartilage repair in dogsCook et al 2003– improved cartilage repair in dogs Improved tendon integrationImproved tendon integration Dose ranging studiesDose ranging studies Seeherman (Wyeth – BMP2) – acceleration of fracture Seeherman (Wyeth – BMP2) – acceleration of fracture

healinghealing Blokhuis – (BMP7) acceleration of fracture healingBlokhuis – (BMP7) acceleration of fracture healing Saito et al 2006 (BMP-2) - repair rabbit radial bone Saito et al 2006 (BMP-2) - repair rabbit radial bone

defect – 2009 induced periodontal regeneration in dogsdefect – 2009 induced periodontal regeneration in dogs


Animal Studies since 2001Animal Studies since 2001

Salkeld, Cook et al 2001 – dog ulna defectSalkeld, Cook et al 2001 – dog ulna defect Mizumoto et al 2003– augmented callotasis with BMP7Mizumoto et al 2003– augmented callotasis with BMP7 Cook et al 2003– improved cartilage repair in dogsCook et al 2003– improved cartilage repair in dogs Improved tendon integrationImproved tendon integration Dose ranging studiesDose ranging studies Seeherman (Wyeth – BMP2) – acceleration of fracture Seeherman (Wyeth – BMP2) – acceleration of fracture

healinghealing Blokhuis – (BMP7) acceleration of fracture healingBlokhuis – (BMP7) acceleration of fracture healing Saito et al 2006 (BMP-2) - repair rabbit radial bone Saito et al 2006 (BMP-2) - repair rabbit radial bone

defect – 2009 induced periodontal regeneration in dogs defect – 2009 induced periodontal regeneration in dogs


Repair of Articular Cartilage Defects with Osteogenic Repair of Articular Cartilage Defects with Osteogenic Protein-1 (BMP-7) in Dogs – Protein-1 (BMP-7) in Dogs – Cook et alCook et al

After 6 weeks

OP-1

Control


Repair of Articular Cartilage Defects with Osteogenic Repair of Articular Cartilage Defects with Osteogenic Protein-1 (BMP-7) in DogsProtein-1 (BMP-7) in Dogs

After 52 weeks

OP-1 Control


Human Studies for TraumaHuman Studies for Trauma

Friedlaender 2001Friedlaender 2001 BESTT 2003BESTT 2003 Australian Limb Salvage SeriesAustralian Limb Salvage Series Others - ongoingOthers - ongoing


BMP-7 in Non Union - BMP-7 in Non Union - Friedlander et al. Friedlander et al.

JBJS (Am) 2001;83 Suppl 1(Pt1):s151-62 JBJS (Am) 2001;83 Suppl 1(Pt1):s151-62

»PRCT PRCT (Part blinded, multi-center) (Part blinded, multi-center)

»124 Tibial Non unions124 Tibial Non unions Excluded: Unreliable, Infected, envelope problems etcExcluded: Unreliable, Infected, envelope problems etc

2 groups2 groups – Autograft + IM Nail (Control)Autograft + IM Nail (Control)

– BMP-7 + IM nail BMP-7 + IM nail


Summary of Safety*:Summary of Safety*:

44

3 0

44

21 20

0

20

40

60

80

100

SeriousAdverseEvents

Osteomyelitis ChronicDonor Site

Pain

% o

f P

ati

en

ts

OP-1 (n=61) Autograft (n=61)

*Friedlaender et. al, JBJS, Vol. 83-A, No. 4, April 2001.


Friedlander resultsFriedlander results More “atrophic” (p=0.048) in OP-1 (randomisation) More “atrophic” (p=0.048) in OP-1 (randomisation)

Comparable union rates at 9 monthsComparable union rates at 9 months

Concluded BMP-7 comparable to autograftConcluded BMP-7 comparable to autograft

20% chronic donor pain in autograft group20% chronic donor pain in autograft group

Osteomyelitis higher in control groupOsteomyelitis higher in control group

– (21% vs 3%) p=0.002(21% vs 3%) p=0.002

Potential Criticisms:Potential Criticisms:– 1/3 loss to follow up at 2 years1/3 loss to follow up at 2 years– Heterogenous group (50% prev IMN, 40% prev autograft) Heterogenous group (50% prev IMN, 40% prev autograft) – Non stratifiedNon stratified


Evidence for BMPs in Evidence for BMPs in Acute Fracture Care Acute Fracture Care


BMP-2 Evaluation in Surgery for Tibial BMP-2 Evaluation in Surgery for Tibial Trauma Trial (BESTT) - Trauma Trial (BESTT) - Govender et alGovender et al

» BMP-2 for treatment of BMP-2 for treatment of Open Tibial fracturesOpen Tibial fractures: PRCT (450 : PRCT (450 Patients) Patients)

JBJS(A) 2002 84-A(12):2123-34. JBJS(A) 2002 84-A(12):2123-34.

49 centres, 11 countries49 centres, 11 countries 450 Patients, Stratified (1, 2 and 3A) and (3B) 450 Patients, Stratified (1, 2 and 3A) and (3B) Excluded patients in whom “Excluded patients in whom “bone grafting anticipatedbone grafting anticipated”” 3 groups3 groups

– IM NailingIM Nailing

– Low concentration BMP-2 (0.75mg/ml)Low concentration BMP-2 (0.75mg/ml)

– High concentration BMP-2 (1.5mg/ml)High concentration BMP-2 (1.5mg/ml)

» Outcome measureOutcome measure 2y intervention within 12 months due to delayed or non union.2y intervention within 12 months due to delayed or non union.


3B Open Tibia Subgroup3B Open Tibia Subgroup

No significant difference % reamed and unreamed (p=0.14)No significant difference % reamed and unreamed (p=0.14)

Outcome measures : Outcome measures :

» Need for bone graftNeed for bone graft Control 13/65 (20%)Control 13/65 (20%) BMP-2 1/66 (2%) p0.0005, relative risk reduction 90%BMP-2 1/66 (2%) p0.0005, relative risk reduction 90%

» Invasive secondary proceduresInvasive secondary procedures Control 18/65 (28%)Control 18/65 (28%) BMP-2 6/66 (9%) p=0.0065, relative risk reduction 68%BMP-2 6/66 (9%) p=0.0065, relative risk reduction 68%

» InfectionInfection Control 26/65 (40%)Control 26/65 (40%) BMP-2 13/66 (21%) p=0.02, relative risk reduction 48%BMP-2 13/66 (21%) p=0.02, relative risk reduction 48%

» Faster clinical healing 95 v 126 days in BMP-2 groupFaster clinical healing 95 v 126 days in BMP-2 group


* BESTT Study Group

6 weeks 14 weeks

ResultsResults G.M. CALORI G.M. CALORI Classificazione e indicazione all’uso dei fattori di crescitaClassificazione e indicazione all’uso dei fattori di crescita

26 weeks 52 weeks

““Son of BESTT” - Son of BESTT” - Swiontowski et alSwiontowski et al

rhBMP-2 inrhBMP-2 in open tibial fracturesopen tibial fractures. . A subgroup analysis of data combined A subgroup analysis of data combined from two prospective randomized studies.from two prospective randomized studies.

J Bone Joint Surg Am. 2006 Jun;88(6):1258-65. J Bone Joint Surg Am. 2006 Jun;88(6):1258-65.

– 450 BESTT patients plus 60 US centre patients450 BESTT patients plus 60 US centre patients

– Sub group analysis Sub group analysis » 3A/3B fractures (n=131) 3A/3B fractures (n=131)

» Reamed Nailing (n=113)Reamed Nailing (n=113)

– Only analysed 1.5mg/ml (High dose/concentration) treatment Only analysed 1.5mg/ml (High dose/concentration) treatment groupgroup

– Trial not set up or powered for subgroup analysisTrial not set up or powered for subgroup analysis.


Results BESTTResults BESTT Secondary InterventionSecondary Intervention

– Control 46%Control 46%

– 0.75mg/ml BMP-2 37%0.75mg/ml BMP-2 37%

– 1.5mg/ml BMP-2 26% 1.5mg/ml BMP-2 26% » dose/response relationship (p=0.0004)dose/response relationship (p=0.0004)

» 44% reduction in 2y intervention between Control and High dose44% reduction in 2y intervention between Control and High dose

Greater overall success in BMP groups esp HighGreater overall success in BMP groups esp High

– Faster wound healing at 6/52 p=0.001Faster wound healing at 6/52 p=0.001

– More healed P=0.0008More healed P=0.0008

– Faster Healing P=0.002Faster Healing P=0.002

– Lower infection in severe fractures (3B) in BMP groups. P=0.02Lower infection in severe fractures (3B) in BMP groups. P=0.02


BMP-2 + Allograft vs AICBG - BMP-2 + Allograft vs AICBG - Jones et al Jones et al

rhBMP-2 and allograft compared with Autogenous bone graft for rhBMP-2 and allograft compared with Autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. reconstruction of diaphyseal tibial fractures with cortical defects. (BESTT ALL) Study Group 2006 JBJS (A)July 2006(BESTT ALL) Study Group 2006 JBJS (A)July 2006

– RCT N=30 (2/3 IM nail), (1/3 Ex fix)RCT N=30 (2/3 IM nail), (1/3 Ex fix)» 2 Groups of 152 Groups of 15

15 Secondary autologous graft at 6-12 weeks15 Secondary autologous graft at 6-12 weeks 15 Allograft chips with BMP-215 Allograft chips with BMP-2

» 1-7cm defects, 20% drop out rate/loss to follow up,15% violated protocol 1-7cm defects, 20% drop out rate/loss to follow up,15% violated protocol (LISS 2/IMN 1) or Demineralised Bone Matrix (1)(LISS 2/IMN 1) or Demineralised Bone Matrix (1)

– “ “Success” rate in BMP-2 87%, Control 67%.Success” rate in BMP-2 87%, Control 67%. » (p>0.05)(p>0.05)

» 13% of failures in control were broken cross screws!13% of failures in control were broken cross screws!

– Suggested equivalence of Auto vs Allo+BMP-2Suggested equivalence of Auto vs Allo+BMP-2


Healing of Fresh tibial fractures with OP-1 a preliminary report.Healing of Fresh tibial fractures with OP-1 a preliminary report. Acta Biomed Ateneo Parmenese 2002;73:27-32. Acta Biomed Ateneo Parmenese 2002;73:27-32.

– Ex fix +BMP-7 vs Ex fix + Ex fix +BMP-7 vs Ex fix + Autologous graftAutologous graft

– 2 randomised groups 2 randomised groups » BMP-7 (n=7) control (n=7).BMP-7 (n=7) control (n=7).

– No statistical differenceNo statistical difference» They all healed!They all healed!

» Involved opening closed fracturesInvolved opening closed fractures

» Undersized studyUndersized study

BMP-7 in Tibial fractures – BMP-7 in Tibial fractures – Maniscalco et alManiscalco et al


BMP-7 on healing of open tibial fractures results of multicenter BMP-7 on healing of open tibial fractures results of multicenter PRCTPRCT OTA 2002, AAOS 2003 OTA 2002, AAOS 2003

N=62 per group N=62 per group Favoured early weight bearing in BMP-7 groupFavoured early weight bearing in BMP-7 group Less painLess pain with activity P=0.04with activity P=0.04 Reduced secondary interventionReduced secondary intervention in BMP-7 in BMP-7

group (13% vs 27%) p=0.02group (13% vs 27%) p=0.02

BMP-7 in Open Tibial Fractures – BMP-7 in Open Tibial Fractures – McKee et alMcKee et al


rhBMP-7 accelerates the healing in distal tibial fractures treated byrhBMP-7 accelerates the healing in distal tibial fractures treated by external fixation. external fixation. JBJS Br 2007 Feb 89(2):265-72. JBJS Br 2007 Feb 89(2):265-72.

– 20 in each group, 20 in each group,

– case control studycase control study

– Faster healing p<0.03Faster healing p<0.03

– Faster return to work p<0.018Faster return to work p<0.018

– Shorter time in external fixator p<0.037Shorter time in external fixator p<0.037

– Lower secondary intervention in BMP-7 groupLower secondary intervention in BMP-7 group» 10% vs 35%10% vs 35%

– CONCLUDED BMP-7 ACCELERATES ACUTE FRACTURE CONCLUDED BMP-7 ACCELERATES ACUTE FRACTURE UNION UNION

BMP-7 in Distal Tibial Fractures + EF – BMP-7 in Distal Tibial Fractures + EF – Ristinemi et alRistinemi et al


Spinal Fusion EvidenceSpinal Fusion Evidence


12 RCTs of BMPs in Spinal Fusion12 RCTs of BMPs in Spinal Fusion

9 USA, 1 Sweden,1 Canada, 1 Japan/USA9 USA, 1 Sweden,1 Canada, 1 Japan/USA

Ecosse 1 France 0 (Full Time)Ecosse 1 France 0 (Full Time)

4 Anterior, 7 Posterolateral, 1 Neck.4 Anterior, 7 Posterolateral, 1 Neck.

BMP-2 n=631BMP-2 n=631

– More effective than autograft for radiographic fusion p<0.05More effective than autograft for radiographic fusion p<0.05– 95% vs 89% Burkus 200295% vs 89% Burkus 2002– 99% vs 76% in Burkus 200599% vs 76% in Burkus 2005

BMP-7 n=56BMP-7 n=56

– No significant difference to autograft in fusionNo significant difference to autograft in fusion


Australian Limb SalvageAustralian Limb Salvage

163 cases163 cases 1997-19991997-1999 FU 15 mo ave.FU 15 mo ave. Heterogeneous group – OP1 + AutoG, AlloG, Fillers. OP1 Heterogeneous group – OP1 + AutoG, AlloG, Fillers. OP1

alone: 36 cases.alone: 36 cases. 40 had previous AutoG.40 had previous AutoG. 39 failures overall39 failures overall 30% failure for non union group (28/113)30% failure for non union group (28/113)


Bone loss - THA revisionBone loss - THA revision


July 2006 - Impaction grafting reviewJuly 2006 - Impaction grafting review


GFs vs infectionGFs vs infection


July 2006 – Chen et alJuly 2006 – Chen et al


July 2006 – Chen et alJuly 2006 – Chen et alConclusionsConclusions


PRP is a source of PRP is a source of aspecific aspecific autologous GFsautologous GFs able to stimulate the able to stimulate the

repairing process in the application repairing process in the application site.site.

It has the same It has the same effects of the effects of the haematomahaematoma, empowered by high , empowered by high

concentration of trombocites.concentration of trombocites.

PRPPRP


ThroughoutThroughout centrifugationcentrifugation PRP is divided from the PRP is divided from the other blood fractionsother blood fractions

Red blood cellRed blood cell

PRPPRP(Platelet Rich Plasma)(Platelet Rich Plasma)

PPPPPP(Platelet Poor (Platelet Poor

Plasma)Plasma)

PRPPRP


Activated platelets Activated platelets degranulate and degranulate and release various release various GF GF and cytokines:and cytokines:

Platelet Derived Growth FactorPlatelet Derived Growth Factor PDGF-ßßPDGF-ßß PDGF-aaPDGF-aa

PDGF-aßPDGF-aßTransforming Growth Factor betaTransforming Growth Factor beta TGF-ß1TGF-ß1

TGF-ß2TGF-ß2Vascular Endothelial Growth FactorVascular Endothelial Growth Factor VEGFVEGFEpithelial Growth FactorEpithelial Growth Factor EGFEGFInsuline Growth FactorInsuline Growth Factor IGF1-2IGF1-2

PRPPRP


PRPPRP

Platelet Derived Growth FactorPlatelet Derived Growth Factor PDGF-ßßPDGF-ßß PDGF-aaPDGF-aa

PDGF-aßPDGF-aßTransforming Growth Factor betaTransforming Growth Factor beta TGF-ß1TGF-ß1

TGF-ß2TGF-ß2Vascular Endothelial Growth FactorVascular Endothelial Growth Factor VEGFVEGFEpithelial Growth FactorEpithelial Growth Factor EGFEGFInsuline Growth FactorInsuline Growth Factor IGF1-2IGF1-2

INDUCEINDUCEOSTEOGENESISOSTEOGENESIS

Activated platelets Activated platelets degranulate and degranulate and release various release various GF GF and cytokines:and cytokines:


Platelet Derived Growth Factor PDGF-ßß PDGF-aa

PDGF-aßTransforming Growth Factor beta TGF-ß1

TGF-ß2Vascular Endothelial Growth Factor VEGFEpithelial Growth Factor EGFInsuline Growth Factor IGF1-2

INDUCESINDUCESANGIOGENESISANGIOGENESIS

PRPPRPActivated platelets Activated platelets degranulate and degranulate and release various release various GF GF and cytokines:and cytokines:


Bae et al.Spine. 2006 20;31:1299-306

DBMDBMDBMDBM G.M. CALORI G.M. CALORI Classificazione e indicazione all’uso dei fattori di crescitaClassificazione e indicazione all’uso dei fattori di crescita

WHAT GFs ?WHAT GFs ?

BMP-2BMP-2

PRPPRP

BMP-7BMP-7


Mesenchimal Mesenchimal cellscells

Mesenchimal Mesenchimal cellscells

Mesenchimal cells, in Mesenchimal cells, in presence of BMP-2 only presence of BMP-2 only (not charachterized by a (not charachterized by a

powerful mitogenic powerful mitogenic effect), differentiate but effect), differentiate but

not multiplynot multiply


OsteoblastsOsteoblasts

Mesenchimal cells in presence of DBM Mesenchimal cells in presence of DBM (BMP + TGF- (BMP + TGF- and other GFs) differentiate and other GFs) differentiate

and and multiply themselvesmultiply themselves




BMP-2BMP-2

PRPPRP

BMP-7BMP-7


It does not exist any controlled It does not exist any controlled randomised study randomised study pro PRP. Its pro PRP. Its

efficacy, based on shared efficacy, based on shared phisyopathologic remarks, has to be phisyopathologic remarks, has to be

demonstrated in the demonstrated in the muscoloscheletal field. muscoloscheletal field.

PRPPRP


PRP =PRP = osteopromotive agentosteopromotive agent It promotes the cellular division (mitogenesismitogenesis)

Not specific for the bone cellNot 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 neoformationUnable to induce by the bone neoformation

Unable to promote the differentiation of stromal Unable to promote the differentiation of stromal cellscells

Tissue-Engineering: PRPTissue-Engineering: PRP



BMP-2BMP-2

PRPPRP

BMP-7BMP-7


It stimulates bone neoformationIt stimulates bone neoformation

BMP-7 = osteoinductive agentBMP-7 = osteoinductive agent

Tissue-Engineering: BMP-7Tissue-Engineering: BMP-7

Urist MR. Science 159:893-899, 1965Urist MR. Science 159:893-899, 1965Wozney JM. Mol Reprod Devel 32:160-167, 1992Wozney JM. Mol Reprod Devel 32:160-167, 1992

Chen D. Growth Factors 22(4):233, 2004Chen D. Growth Factors 22(4):233, 2004Chaudhary LR. Bone 34(3):402, 2004Chaudhary LR. Bone 34(3):402, 2004

BMP are the only growtgh factors with a BMP are the only growtgh factors with a

recognized ability to induce the differentiation recognized ability to induce the differentiation

of of of of osteoprogenitor cellsosteoprogenitor cells in a in a pre-pre-

chondroblasticchondroblastic and and pre-osteoblasticpre-osteoblastic lineage lineage


Only recombinant BMPs have level A grade Only recombinant BMPs have level A grade of raccomandation according EBM criteriaof raccomandation according EBM criteria


End-point: evaluation of osteoinduction in rats


PRP vs BMP-7PRP vs BMP-7

Bone formation after 50gg of 20mm3 at Bio0ss

or + 20 mm3 at rib

10 µl of rhBMP-7

or

20 µl PRP


STUDY PURPOSESTUDY PURPOSE

Compare the efficacyCompare the efficacy of BMP-7BMP-7 and PRPPRP as bone stimulating agents in the treatment of NU

Establish a real alternative to autograftalternative to autograft, golden standard for this treatment


When in the atrophic non-union there was a bone loss that needed a When in the atrophic non-union there was a bone loss that needed a scaffold to correct the deformityscaffold to correct the deformity

This gap was classified in 3 groups:This gap was classified in 3 groups:

Group A: gap < 1 cm 55 patients (45.83%) Group A: gap < 1 cm 55 patients (45.83%)

Group B: gap from 1 to 3 cm 47 patients (39.16%) Group B: gap from 1 to 3 cm 47 patients (39.16%)

Group C: gap > 3 cm 18 patients (15.0%)Group C: gap > 3 cm 18 patients (15.0%)

G.M. CALORI G.M. CALORI L’utilizzo dei fattori di crescita nelle L’utilizzo dei fattori di crescita nelle PseudoartrosiPseudoartrosi

RESULTSRESULTS

12/60 (20%)4/60 (6,6%)Re-interventions *2

21/60 (35%)23/60 (38,3%)Previous autografts

19/60 (31,7%) 8/60 (13,4 %) Failures *1

4±0,613,5±0,48Clinical Healing time (months)- mean ± SD

41/60 ( 68,3%)52/60 (86,6%)Clinical Healing rate *1

9±0,528±0,48RX Healing time ( months ) - mean ± SD

41/60 ( 68,3%)52/60 (86,6%)RX Healing rate *1

48/60 (80 %)40/60 (66,6%)Synthesis Change

2,8±0,742,6±0,62N° Praevius surgery - mean ± SD

19,4±1,4520,2±1,34NU duration (months) - mean ± SD

19 Tibia 8 Femur16 Humerus 8 Ulna 9 Radius

15 Tibia10 Femur15 Humerus12 Ulna 8 Radius

Site NU

42,5±1,7646,4±1,98Age (y) mean ± SD

6060N evaluable patients (9 months Follow up)

PRPPRPrh BMP-7rh BMP-7

*1*1 Χ2 test = 5.78 with 1 degree of freedom, p = 0.0162; test = 5.78 with 1 degree of freedom, p = 0.0162; significantsignificant

*2*2 Χ2 test = 4.62 with 1 degree of freedom, p = 0.0317; test = 4.62 with 1 degree of freedom, p = 0.0317; significantsignificant


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 41 grade II 2 grade IIIa1 grade IIIb

5

1 grade I 1 grade II

2 grade IIIa1 grade IIIb

Duration of non-union (months, median ± SD ) 20,2±2,35 19,2±2,86

Number of previous surgeries (median + range)

2 (1-5) 2 (1-5)

Prior autograft implementation 23/60 (38,3%) 21/60 (35%)


rhBMP-7 Group

n

PRP Group

Fixation treatment

prior to our intervention Fixation revision

during our interventio

n

Summary of fixation

treatment

Fixation treatmentprior to our intervention Fixation

revision during our interventio

n

Summary of

fixation treatmen

t

Non union

siten

Initial fixation after injury (preserved during our

intervention)

Fixation revision

after non union

Initial fixation after injury (preserved during our

intervention)

Fixation revision

after non union

tibia 151 IMN2 ORIF

1 EF

2 IMN2 ORIF

4 IMN5 IMN8 ORIF

2 EF

1 ORIF1 EF

192 IMN2ORIF1 EF

3 IMN2 ORIF

5 IMN7 IMN

10 ORIF2 EF

2 IMN4 ORIF

6 ORIF2 IMN6 ORIF

8 ORIF

1 IMN 1 EF 1 EF 1 EF

femur 102 IMN1 EF

1 EF2 IMN

3 IMN

2 ORIF 8 1 IMN

1 IMN1 EF

2 IMN

3 IMN3 ORIF

2 EF4 ORIF 4 ORIF

3 ORIF

2 EF

humerus

152 IMN3 ORIF

1 EF

2 IMN 2 IMN

4 IMN8 ORIF

3 EF16

1 IMN 1 ORIF

1 EF

3 IMN 3 IMN

4 IMN7 ORIF

5 EF

3 ORIF1 EF

1 IMN5 ORIF 6 ORIF

2 EF 2 EF 4 EF

ulna 124 ORIF

1 EF

3 ORIF2 K-W1 IMN

6 ORIF10 ORIF

2 EF8 2 ORIF

2 ORIF1 K-W

4 ORIF6 ORIF

2 EF1 EF 1 EF 2 EF

radius 81 ORIF

1 EF

3 ORIF2 K-W

5 ORIF7 ORIF

1 EF9 1 ORIF

4 ORIF2 K-W

6 ORIF7 ORIF

2 EF1 EF 1 EF 2 EF

FAILURESFAILURESBMP-7 (8/60)

1 case: new trauma with Ex Fix failure and re-fracture

4 cases: sepsis

2 case: absence of callus formation

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

1

4

1

2

1

5

4

9

0

1

2

3

4

5

6

7

8

9

10

NEWTRAUMA

SEPSIS POORCALLUS

ABSENCEOF CALLUS

CA

SE

S

rhBMP-7

PRP


Radiographic and clinical failure rateRadiographic and clinical failure rate

rhBMP-7HEALING RATE FAILURES

PRPHEALING RATE FAILURES

52 (86,7%)

8 (13,3%)

41 (68,3%)

19 (31,7%)P = 0,016 SIGNIFICANTP = 0,016 SIGNIFICANT

86,7% = NU healing rate86,7% = NU healing rate


NU NU Re - InterventionRe - InterventionrhBMP-7

NO RE-INTERVENTION RE-INTERVENTION

PRP

NO RE-INTERVENTION RE-INTERVENTION

3

57

13

47

• rhBMP-7: 5% VS PRP: 21%rhBMP-7: 5% VS PRP: 21%

• p= 0.0317p= 0.0317 SIGNIFICANTSIGNIFICANT


89,7% = NU healing rate89,7% = NU healing rate


SUMMARYSUMMARYMinibattle: PROsMinibattle: PROs

GFs Vs BMPs pros & consGFs Vs BMPs pros & cons

AGF (PRP)AGF (PRP)

Contains many GFs Contains many GFs (FGF, (FGF, TGFbeta,ILF,PDGF,VEGF) TGFbeta,ILF,PDGF,VEGF) that could act that could act sinergisticallysinergistically

Well documented in soft Well documented in soft tissue reconstruction and tissue reconstruction and CMF surgeryCMF surgery

Good handling, diffused Good handling, diffused techniquetechnique

Rh-BMPsRh-BMPs

The The only GFs with proven only GFs with proven efficacy in trauma efficacy in trauma conditionsconditions (EBM-criteria) (EBM-criteria)

Standardized dose: Standardized dose: reproducibility of resultsreproducibility of results

Drugs Drugs =scrutined by Health =scrutined by Health authorities for quality, authorities for quality, efficacy, safetyefficacy, safety


AGF (PRP)AGF (PRP) No BMPs contained No BMPs contained = = not not

osteoinductiveosteoinductive Sistem’s Variability Sistem’s Variability = =

concentration/activity PLT concentration/activity PLT variability = variability = conflicting conflicting literature evidenceliterature evidence

Lack of randomized trials in Lack of randomized trials in Ortho-traumaOrtho-trauma

““manpower” cost non manpower” cost non quantifiablequantifiable

Legal problems (preparation to Legal problems (preparation to be done by haematologists be done by haematologists only )only )

Rh-BMPsRh-BMPs

Even present, still few Even present, still few randomized CTsrandomized CTs

Limited approved indicationsLimited approved indications High aquisition costsHigh aquisition costs Low adoption, scarce Low adoption, scarce

confidenceconfidence

SUMMARYSUMMARYMinibattle: CONsMinibattle: CONs

GFs Vs BMPs pros & consGFs Vs BMPs pros & cons


C.A. 56 yrsC.A. 56 yrs

Forearm biosseus fractureForearm biosseus fracture

Therapeutic programTherapeutic program1st STEP:1st STEP:• NU site resectionNU site resection• cultural examscultural exams• antibiotic therapyantibiotic therapy• Axial external fixator (4 wks)Axial external fixator (4 wks)

PREVIOUS TREATMENTPREVIOUS TREATMENT• ORIF SYNTHESISORIF SYNTHESIS-> Failure-> Failure• BONE IMPLANTBONE IMPLANT-> Failure-> Failure• Synthesis and castSynthesis and cast -> Failure: -> Failure: Necrotic settic NUNecrotic settic NU

Therapeutic programTherapeutic program2nd STEP:2nd STEP:• Fixator removalFixator removal• Vascolarized fibular graftingVascolarized fibular grafting• ORIFORIF




Therapeutic programTherapeutic program3rd STEP:3rd STEP:• R-U distal prosthesis acc. to HerbertR-U distal prosthesis acc. to Herbert




rh-BMP7 + MSCrh-BMP7 + MSC

EXPERIENCEEXPERIENCE

WHAT’S MORE …WHAT’S MORE …


Protocollo di Studio:Protocollo di Studio:

STUDIO CLINICO INDIPENDENTE SULLA EFFICACIA E SICUREZZA STUDIO CLINICO INDIPENDENTE SULLA EFFICACIA E SICUREZZA DELL’IMPIEGO DI rhBMP-7 (OP-1) IN ASSOCIAZIONE CON CELLULE DELL’IMPIEGO DI rhBMP-7 (OP-1) IN ASSOCIAZIONE CON CELLULE

STAMINALI MESENCHIMALI NEL TRATTAMENTO DELLE STAMINALI MESENCHIMALI NEL TRATTAMENTO DELLE PSEUDOARTROSI COMPLESSE DELLE OSSA LUNGHEPSEUDOARTROSI COMPLESSE DELLE OSSA LUNGHE




Osteogenic Osteogenic cellscells

Osteoconductive Osteoconductive scaffoldsscaffolds

Growth Growth factorsfactors

Mechanical Mechanical environmentenvironment

““The Diamond The Diamond Concept”Concept”

T. Einhorn - P. Giannoudis - D. Marsh T. Einhorn - P. Giannoudis - D. Marsh


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 bone-marrow stromal cells into a rat's calf muscle


Growth factors and in particular BMPs Growth factors and in particular BMPs make their action on mesemchymal cells somake their action on mesemchymal cells so

WHY NOTWHY NOT use both together?use both together?

Mesenchimal stem cellMesenchimal stem cell

Cellula osteoprogenitriceCellula osteoprogenitrice


BMP

BMP TGF-B

TGF-B

NON UNION – C.A. Pre-opNON UNION – C.A. Pre-op

II.2007II.2007

Motorcycle accident Motorcycle accident

-> radial fracture -> radial fracture

-> plating + TEN-> plating + TEN

II.2008II.2008

--> > RADIAL ATROPHIC NURADIAL ATROPHIC NU


10.II.200910.II.2009

devices removal + PSA 3 cm devices removal + PSA 3 cm resectionresection

new synthesis with plate +new synthesis with plate +

allograft +allograft +

mesenchymal stem cells mesenchymal stem cells (CELLECT) + (CELLECT) +

OP-1 (1 vial)OP-1 (1 vial)

NON UNION – C.A. NON UNION – C.A.


NON UNION – C.A. 1 monthNON UNION – C.A. 1 month

1 Month1 Month

Clin. Eval. : no painClin. Eval. : no pain

ROM : completeROM : complete

Rx : initial callus formationRx : initial callus formation


NON UNION – N.A. pre-opNON UNION – N.A. pre-opII.2006II.2006

Car accident Car accident

-> forearm fracture (22 B)-> forearm fracture (22 B)

-> plating-> plating

II.2007II.2007

-> radial plate removed -> radial plate removed

--> > ULNAR ATROPHIC NUULNAR ATROPHIC NU(15 mm gap) (15 mm gap)


NON UNION – N.A. opNON UNION – N.A. op1.IV.20081.IV.2008

plate removal + PSA 3.5 plate removal + PSA 3.5 resectionresection


xenograft +xenograft +


OsigraftOsigraft


NON UNION – N.A. opNON UNION – N.A. opOctober 2008 New surgical

Change device + Allograft (fibula shaft)

Proximal Osteointegration


NON UNION – N.A. opNON UNION – N.A. op


NON UNION – N.A. Post-opNON UNION – N.A. Post-op

1.IV.20081.IV.2008

plate removal + PSA 3.5 plate removal + PSA 3.5 resectionresection


xenograft +xenograft +


OsigraftOsigraft


NON UNION – N.A. 1-3-6 monthsNON UNION – N.A. 1-3-6 months


NON UNION – N.A. 12 monthsNON UNION – N.A. 12 months

12 months12 months

Clinical ev:Clinical ev:No painNo painComplete ROMComplete ROM

Rx:Rx:Low bone integrationLow bone integration


NON UNION – D.G. Pre-opNON UNION – D.G. Pre-opII.2008II.2008M. 16 YrsM. 16 YrsMotorcycle accident Motorcycle accident

-> Medial femoral neck fracture -> Medial femoral neck fracture

-> screw fixation-> screw fixation

-> Varus deformity + AVN-> Varus deformity + AVN

-> 6 cm of shortening-> 6 cm of shortening

III.2009III.2009

--> > FEMORAL NECK NU + FEMORAL NECK NU + NECROSIS OF THE FEMORAL NECROSIS OF THE FEMORAL HEADHEAD


NON UNION – D.G. post-opNON UNION – D.G. post-op

OP 2.XII.08OP 2.XII.08

Femoral valgus Femoral valgus osteotomy sec. Pauwelsosteotomy sec. Pauwels

Plating using blade-plate Plating using blade-plate 135° + trocantheric fixation 135° + trocantheric fixation

--> > OP1 + mesenchymal stem OP1 + mesenchymal stem cells + synthetic graft cells + synthetic graft (cellect)(cellect)


NON UNION – D.G. 1 monthNON UNION – D.G. 1 month


At 1 monthAt 1 month

Clinical ev:Clinical ev:No painNo painStabilityStabilityROM completeROM completeNo weightbearing allowedNo weightbearing allowed2,5 cm of shortening2,5 cm of shortening

Rx:Rx:No progression of the No progression of the femoral head necrosisfemoral head necrosisNo callus formationNo callus formation

NON UNION – E.E. Pre-opNON UNION – E.E. Pre-op

II.2008II.2008

Car accident Car accident

-> Pertrocantheric femoral -> Pertrocantheric femoral fracture fracture

-> plating (in Egypt)-> plating (in Egypt)

-> implant failure + cut out of -> implant failure + cut out of one screwone screw

X.2008X.2008

--> > ATROPHIC NU ATROPHIC NU


NON UNION – E.E. Post-opNON UNION – E.E. Post-op

OP 3.XII.08OP 3.XII.08

Devices removal +Devices removal +

NU cruentation +NU cruentation +

Replating using AO plate with Replating using AO plate with trocantheric fixation +trocantheric fixation +

Medial allograft of Medial allograft of neutralization +neutralization +

--> > OP1 + mesenchymal stem OP1 + mesenchymal stem cells + synthetic graftcells + synthetic graft


NON UNION – Z.M. pre-opNON UNION – Z.M. pre-opXII.2007XII.2007F. 61 YrsF. 61 YrsDomestic accident Domestic accident Severe osteoporosisSevere osteoporosis

-> femoral neck and -> femoral neck and sottotrocantheric fracture sottotrocantheric fracture

-> No diagnosis -> No diagnosis

--> > FEMORAL ATROPHIC NUFEMORAL ATROPHIC NU

-> 1° op: IMN + cement-> 1° op: IMN + cement


NON UNION – Z.M. post-opNON UNION – Z.M. post-opOP 5.V.09OP 5.V.09

Nail and cement removal Nail and cement removal

Bone loss (6x3x3)Bone loss (6x3x3)

Plating using blade-plate Plating using blade-plate 135° + 135° +

Allograft to fill the gap Allograft to fill the gap (femoral head) +(femoral head) +

Anterior Allograft of Anterior Allograft of stabilization +stabilization + --> > OP1 + mesenchymal stem OP1 + mesenchymal stem cells + synthetic graft cells + synthetic graft (cellect)(cellect)


GOOD STABILITY AND BONE CONTINUITYGOOD STABILITY AND BONE CONTINUITY ARE CRUCIALARE CRUCIAL

CONTACT OF OP-1 WITH VITAL BONECONTACT OF OP-1 WITH VITAL BONE

DO NOT JUDGE TOO EARLYDO NOT JUDGE TOO EARLY

DO NOT HOPE IN MIRACLEDO NOT HOPE IN MIRACLE !!!!

RECALCITRANT AND COMPLICATED NU CASES HAVE VERY RECALCITRANT AND COMPLICATED NU CASES HAVE VERY LIMITED HEALING CHANCES AS REPORTED IN LITERATURELIMITED HEALING CHANCES AS REPORTED IN LITERATURE

NEVER FORGET ….NEVER FORGET ….


The discovery of GFs and rh-BMPs in particular opened the way to the combined The discovery of GFs and rh-BMPs in particular opened the way to the combined Biological and mechanical approach in the traumatology field Biological and mechanical approach in the traumatology field

Rh-BMPs, growth and differenziation agents have the unique properties to stimulate Rh-BMPs, growth and differenziation agents have the unique properties to stimulate new bone formation even in extraskeletal sitesnew bone formation even in extraskeletal sites

BMPs use, differently from other GFs is reccomanded in trauma applications BMPs use, differently from other GFs is reccomanded in trauma applications (according to EBM criteria)(according to EBM criteria)

Their success is NU is obviously linked to :Their success is NU is obviously linked to : An adeguate stabilizationAn adeguate stabilization An adeguate soft tissue coverageAn adeguate soft tissue coverage VascularityVascularity Vitality of bone Vitality of bone Correct administration (adeguate haemostasis/containment, no drainage)Correct administration (adeguate haemostasis/containment, no drainage)

CONCLUSIONCONCLUSION


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 FURTHER STUDY ABOUT THE ASSOCIATION OF BMP-7 AND MESENCHYMAL CELLS ARE NECESSARYAND MESENCHYMAL CELLS ARE NECESSARY

CONCLUSIONCONCLUSION


“... 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)(Ruggeri F., Zinghi G.F., SIOT 1977)

PSAPSAfase di silenzio biologicofase di silenzio biologico


BiotecnologieBiotecnologie


classificazione e indicazione all’uso dei fattori di crescita in traumatologia g.m. calori

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