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