Use of Placental Tissue for Orthopedic
Injuries: Potentials and Pitfalls Daniel Kuebler, PhD
Franciscan University of Steubenville
Placental and Extra-embryonic Membrane
Tissue: The Tissue Engineering Triad
Create a microenvironment that is hospitable to healing
Scaffolding
Cells
Bioactive molecules
Benjamin D. Smith & Daniel A. Grande. The current
state of scaffolds for musculoskeletal regenerative
applications Nature Reviews Rheumatology 11, 213–
222 (2015)
Placental Tissues: Options
Chorionic Plate
Chorionic Villi
Amnion/Chorion
Umbilical Cord
Decidua
Stem Cells in Placental Tissue
Stem Cells
Amniotic epithelial cells (hAEC)
Amnion
Reduced immunogenicity
Mesenchymal stem cells
Amnion, Chorion, Decidua, Umbilical cord
Maternal and fetal origin
Reduced immunogenicity
Hematopoietic stem cells
Chorion plate/villi and decidua
Tabatabaei et al. AJMB 6, (2014).
MSCs in Placental Tissue
Mesenchymal stem cells
Amnion, Chorion, Decidua, Umbilical cord, Amniotic Fluid, Chord Blood
In culture
CD73+, CD90+, CD105+
CD45-, CD34-
Relative abundance?
Amnion/Chorion
Chorion Plate
Umbilical cord
Placental Membranes as Scaffolds:
Amnion or Chorion Membranes
Amnion
Chorion
Collagen based matrix
~25-35% collagen by dry
weight
Laminins
Fibronectins
Hyaluranic acid
Niknejad et al. Eur Cells and Materials 15, (2008).
Placental Membranes: Bioactive
molecules Growth Factors
EGF, FGF, PDGF, TGF-beta
Tissue remodeling enzymes
TIMPs
Immunomodulators
IL-4, IL-10
Fortunato et al., AM J OF REPRO IMMUNO
VOL. 40, 1998.
TIMP-4 Expression
IL-4 Expression
Moreas-Pinto et al., Immunology. 1997 Jan; 90(1): 87–94.
Preparations of Fresh Membranes
Separate amnion from chorion
Wash membrane(s)
Sterilize using antibiotics
Screen for pathogens
Ready for use
Storage issues
4oC: stability
-80oC: Freeze/thaw cycles Tabatabaei et al. AJMB 6 (2014).
Commercially Available Membranes
Do They Maintain Structural Integrity? Preserved tissues
Dehydration, lyophilization, chemical cross-linking, cryopreservation, sterile solution
Products
HRT
Dehydrated membranes
(HydraTek® Process)
Amnion/Chorion-based
Room temp
Amniox
Cryopreserved and RT
Amnion and Umbilical Cord
Some layered with additional particulates
MiMedx
Dehydrated
Amnion, Amnion/Chorion
NuTech
AlloFresh®
Amnion
ActiveBarrier®45
Amnion
ActiveBarrier®200
Chorion-Based
EpiFix®, Koob et al., J Biomed Mater Res B
Appl Biomater 102 (2014)
Injectable Products: Fluid and Membrane Particles
NuTech
NuCel®
Bioactive amnion suspension
Amnion and amniotic fluid
MiMedx
OrthoFlow® (amniotic fluid)
Amniox
Neox® and Clarix®: amnion + umbilical cord product
Particulate, no fluid
HRT
ActiveMatrix®, CryoMatrix® and RX Flow®
Placental tissue matrix with fluid
Cryo and room temp
Do They Maintain Bio-active
Molecules?
Growth Factors
EGF, FGF, PDGF
Tissue remodeling enzymes
TIMPs
Immunomodulators
IL-4, IL-10
EpiFix®, Koob et al., Int J of Wound Heal. 10 (2013)
Do They Maintain Bioactivity?
Immuno-modulatory
ability
Chemo-attractant
Do They Maintain Bioactivity?
Adipose-derived Stem Cells (ASCs)
Bind to placental tissue matrix of
RXFlow® and ActiveMatrix® (HRT)
Increase in proliferation in response to
certain concentrations of EpiFix®
(MiMedix)
Koob et al., Int J of Wound Heal. 10 (2013)
Do They Maintain Live Cells?
Advertising claims vs. Reality
Cryopreservation and dehydration
likely destroy all viable cells
Based on FDA regulations and
guidance
Regulated as a drug, device, and/or
biological product (section 351)
Potential Orthopedic Uses
Packing bone defects
Covering damaged articular
cartilage
Wrapping damaged tendons
(ActiveBarrier®, tendon)
(ActiveBarrier®
metatarsal head)
Potential Orthopedic Uses
Packing bone defects
Covering damaged articular
cartilage
Wrapping damaged tendons
Injections
(Willett et al. Arthritis Research & Therapy 16 (2014).
Orthopedic Studies With Placental
Tissue Very few studies
Injectable amnion/chorion mix for plantar fasciitis
Zelen, et al., Foot and Ankle International 34: 1332-1339.
Orthopedic Studies With Placental
Tissue Very few studies
Injectable amnion/chorion mix for tendonitis
Werber, J of Sports Medicine. (2015) 219896. Lullove, Cureus. (2015) 7(6): e275.
Orthopedic Studies With Placental
Tissue Very few studies
Injectables of human amnion and amniotic fluid for spine
fusions
Nunley et al., Inter J of Spine Surgery. (2016) 10: 12.
Current Studies: @ClinicalTrials.gov
Active, not recruiting Amniotic Membrane as an Adjunct Treatment for Hallux Rigidus
Condition:Hallux Rigidus Interventions:Procedure: Dorsal Cheilectomy without Amniotic Membrane Tissue Implantation; Procedure: Dorsal Cheilectomy with Amniotic Membrane Tissue Implantation ]
Active, not recruiting Evaluation of Amniotic Fluid Product in Knee Osteoarthritis
Condition: Osteoarthritis of the Knee Interventions: Other: Amniotic Fluid 4.0ml dose; Other: Amniotic Fluid 2.0ml dose; Other: Placebo Control
Recruiting Peroneal and Achilles Tendon Repair Indications With CLARIX® CORD 1K
Condition:Peroneal and Achilles Tendon Tears Intervention:Biological: CLARIX® CORD 1K graft
Recruiting ReNu™ vs. Corticosteroids for the Treatment of Plantar Fasciitis
Condition:Fasciitis, Plantar Interventions:Device: ReNu Injection; Device: Corticosteroid Injection
Recruiting NuTech Affinity™ for the Treatment of Chondral Defects
Conditions:Chondral Lesions; Cartilage Intervention:Other: NuTech Affinity™ Membrane
Recruiting Study of Nucel for One and Two Level Lumbar Interbody Fusion
Conditions:Degenerative Disc Disease;Spondylolisthesis;Spondylosis Interventions:Procedure: One or two level lumbar interbody fusion surgery; Other: Nucel
Recruiting An Investigation of ReNu™ Knee Injection in Patients With Osteoarthritis
Condition:Osteoarthritis Interventions:Procedure: Knee injection; Device: ReNu amniotic allograft; Device: placebo saline; Device: Hyaluronic Acid
Summary
Placenta tissues contain a variety of factors that can be of benefit in orthopedic applications
Matrix: collagen
Growth factors
Anti-inflammatory cytokines
TIMPs
Mesencymal stem cells
Key in evaluation products is to ensure maintenance of bioactivity, and structure
Promising but preliminary results in a variety of orthopedic applications