Downloaded from http://rstb.royalsocietypublishing.org/ on June 18, 2017
rstb.royalsocietypublishing.org
From gristle to chondrocyte
transplantation: treatment
of cartilage injuries
Anders Lindahl
Research
Cite this article: Lindahl A. 2015 From gristle
to chondrocyte transplantation: treatment
of cartilage injuries. Phil. Trans. R. Soc. B 370:
20140369.
http://dx.doi.org/10.1098/rstb.2014.0369
Accepted: 29 April 2015
One contribution of 13 to a discussion meeting
issue ‘Cells: from Robert Hooke to cell
therapy—a 350 year journey’.
Subject Areas:
cellular biology
Keywords:
cartilage, stem cells, cell therapy
Author for correspondence:
Anders Lindahl
e-mail: [email protected]
Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, and Institute of Biomedicine,
Department of Clinical Chemistry and Transfusion Medicine, Sahlgrenska University Hospital,
SE413 45 Gothenburg, Sweden
This review addresses the progress in cartilage repair technology over the
decades with an emphasis on cartilage regeneration with cell therapy. The
most abundant cartilage is the hyaline cartilage that covers the surface of
our joints and, due to avascularity, this tissue is unable to repair itself. The
cartilage degeneration seen in osteoarthritis causes patient suffering and is a
huge burden to society. The surgical approach to cartilage repair was nonexisting until the 1950s when new surgical techniques emerged. The use of
cultured cells for cell therapy started as experimental studies in the 1970s
that developed over the years to a clinical application in 1994 with the introduction of the autologous chondrocyte transplantation technique (ACT).
The technology is now spread worldwide and has been further refined by
combining arthroscopic techniques with cells cultured on matrix (MACI technology). The non-regenerating hypothesis of cartilage has been revisited and
we are now able to demonstrate cell divisions and presence of stem-cell
niches in the joint. Furthermore, cartilage derived from human embryonic
stem cells and induced pluripotent stem cells could be the base for new
broader cell treatments for cartilage injuries and the future technology base
for prevention and cure of osteoarthritis.
1. Introduction
Cartilage can be found of three different phenotypes in the body—hyaline, elastic and fibrous, and the dominating cell in cartilage is the chondrocyte which
comprise only a fraction of the cartilage volume. The most abundant cartilage
is hyaline cartilage that covers the surfaces in our joints and comprises the
rib cartilage and part of the airways structure (trachea, larynx and nose). Hyaline cartilage is the precursor of bone during fetal development and the
epiphyseal cartilage present in the ends of long bones is a specialized form of
hyaline cartilage that is the cellular structure for longitudinal bone growth. Elastic cartilage is found in the external ears and part of the airways (epiglottis and
larynx). Fibrous cartilage is found in the intervertebral discs, joint capsule and
ligaments. The different phenotypes of cartilage are the result of the extracellular matrix composition with large proteoglycan molecules combined with
fibrillary components.
Cartilage on bone was described in old rhymes as gristle (AD 700) according to the Oxford Dictionary Thesaurus and in the sixteenth century the word
cartilage emerged in written texts: ‘A structure or formation consisting of cartilage, a gristly part; as the cartilages of the ribs’ (AD 1540). Chemical analysis of
cartilage in the 1870s describes a structure with gelating properties and that it
contains sugar in part. The concept of repairing damaged cartilage in humans
has been considered futile, as elegantly stated by the Scottish surgeon William
Hunter 1718–1783: ‘If we consult the standard Chirurgical Writers from Hippocrates down to the present age, we shall find that an ulcerated Cartilage is
universally allowed to be a troublesome Disease; that it admits of a Cure
with more difficulty than carious Bone; and that, when destroyed, it is never
recovered’ [1, p. 520].
& 2015 The Author(s) Published by the Royal Society. All rights reserved.
Downloaded from http://rstb.royalsocietypublishing.org/ on June 18, 2017
territorial
Matrilins 1 and 3
Biglycan and
decorin
SS
Collagen II and XI
PRELP
Matrilin-3
NC-4
Decorin
Syndecan
Collagen VI
Integrin
Chondroadherin
Asporin
Fibromodulin
Aggrecan
Chondrocyte
Hyaluronan
CILP-1
KS
CD44
Hyaluronan
Fibulin
Link
protein
Figure 1. The molecular arrangement of extracellular matrix in cartilage. SS, disulfide bond; KS, keratan sulfate. Adapted with permission from [3]. Copyright &
2011 Macmillan Publishers Ltd.
2. The chondrocyte and hyaline cartilage
The word chondrocyte emerged in Dorlands Illustrated
Dictionary in 1903. The chondrocyte is the main cell in cartilage
and is the producer of the matrix components of cartilage [2].
The chondrocyte is surrounded by a territorial and interterritorial matrix where the molecular constituents of the cartilage
matrix are laid down into large multimolecular assemblies
(for review see [3]; figure 1).
The most abundant proteins in extracellular matrix of hyaline cartilage are the fibril forming collagens where type II
collagen is the main component, while type I is prominent in
most other tissues, with elastin abundant in elastic cartilage.
The fibrillary assembly of collagen is fine-tuned by other fibrillary collagens, e.g. type XI with type II collagen and molecules
from the small leucin rich repeat protein family, i.e. decorine,
fibomoduline, as well as the matrillins and thrombospondins.
The major non-protein components of hyaline cartilage are
the proteoglycans that are also present in high loading structures like the aorta. The major proteoglycan in cartilage is
aggrecan that is aided in its assembly into large molecules by
the polysaccaride hyaluronan [4]. It is generally appreciated
that the cartilage matrix proteoglycan is constantly turned
over with a long half-life for the collagen fibres (decades) and
for a long time it was an established fact in the textbooks
(e.g. in the 1937 Textbook of Histology by E. E. Hewer) that in
the mature state the chondrocytes do not divide and thus are
unable to regenerate themselves and, even more unlikely,
repair a damaged tissue. Furthermore, the chondrocytes have
a very low metabolism and cartilage is unable to respond by
the usual inflammatory responses as the tissue is not vascularized and not innervated. These facts laid the foundation of the
wear and tear hypothesis of cartilage, which has dominated the
view of the arthritis disease for decades, but progress in cell
and molecular biology has now challenged the hypothesis [5].
3. The treatment of osteoarthritis and
cartilage defects
Osteoarthritis (OA) is an increasingly common degenerative
joint condition, estimated to affect several hundred million
patients worldwide and more than 40% of people over 70
years of age [6]. Primary osteoarthritis is generally associated
with ageing and the ‘wear and tear’ of life but not everyone
gets it—not even the very old—which means that OA is a disease
and not a result of ageing. The disease is characterized by cartilage degradation, formation of osteophytes and subchondral
sclerosis that leads to joint destruction and severe impairment
of mobility. The OA disease causes a burden to society and the
healthcare system (30% of healthcare costs in the USA), but
despite the increase in knowledge in medical science no drugbased disease modifying therapy exists [7], basically because
of the facts that (i) the disease process stretches over decades,
(ii) no biological markers able to monitor the early stages and
the progression of OA exist and (iii) no specific drug target
and disease mechanism have been identified.
Secondary osteoarthritis, caused by joint trauma, tends to
develop relatively early in life, typically 10 or more years
after a specific cause and approximately 5% of the population
Phil. Trans. R. Soc. B 370: 20140369
Collagen IX
Discoidin
2
Collagen II and XI
COMP
Procollagen II
Fibronectin
SS
interterritorial
rstb.royalsocietypublishing.org
Collagen XIII
pericellular
Downloaded from http://rstb.royalsocietypublishing.org/ on June 18, 2017
3
periosteal flap
sutured over lesion
lesion
biopsy of healthy
cartilage
enzymatic digestion
cultivation for 11–21 days
(10-fold increase in number of cells)
trypsin treatment
Figure 2. Autologous chondrocyte transplantation technique. Adapted with permission from [17]. Copyright
between 35 and 54 years have radiographic signs of OA [8,9]
probably due to trauma.
The concept regarding the chondrocyte as a non-dividing
cell has underpinned the view of the degenerating cartilage in
arthritis as a consequence of wear and tear of the tissue. The clinical paradigm in the early- and mid-1900s was that cartilage
damage was to be left unattended as no repair was possible,
although single cases were reported where complete debridement of cartilage or transplantation of skin flaps with adipose
tissue were used to operate on the cartilage defect. In the
1950s, the tibia osteotomy technique was introduced by Jackson
where the weight bearing on the afflicted condyle—most commonly the medial condyle—was released by a correction of the
load axis [10]. The introduction of the Pridie drilling technique
was a later improvement based on the thought that by introducing bleeding and subsequent scar tissue into the joint the
cartilage would repair [11]. Partial-thickness cartilage defects,
even very small ones, do not heal spontaneously whereas fullthickness osteochondral lesions below a critical size do, although
with fibrous cartilage tissue of inferior functional quality. When
cartilage is wounded, the tissue at the wound edge is damaged
and cells die, resulting in debris similar to wounds in other
tissues. However, this damaged and avital cartilage tissue
will not be removed. Wound healing is prevented by avascularity in combination with an impaired migration capacity of
cartilage cells through the dense extracellular matrix. If a fullthickness defect is penetrating the subchondral bone, bleeding
from the underlying bone marrow will trigger a wound healing
reaction although the resulting fibrocartilaginous repair tissue
will gradually degenerate over time. Besides the Pridie drilling
or the more gentle marrow stimulation techniques, there was
no other regenerative treatment option for symptomatic joint
surface defects available.
(a) The cell-therapy approach
Cell therapy for treatment of cartilage defects emerged in the
1960s with the pioneering work of the British Cryobiologist
suspension of
2.6 × 106 – 5 × 106 cells
& 1994 Massachusetts Medical Society.
Audrey Smith (1915–1981) who pioneered the freezing technique for blood cells and was also the first to demonstrate
successful freezing and thawing of chondrocytes [12]. Furthermore, frozen cartilage and chondrocytes for treatment
of cartilage defects were tried in rabbit models [13] as well
as endochondral allografts and chondrocytes [14]. A cellular
approach to cartilage repair was re-addressed in rabbits by
Grande et al. in the early 1980s [15]. In 1984, a collaborative
work started between this author, involved as a PhD student
in a research programme studying growth hormone effects
on chondrocytes [16], and the orthopaedic surgeon Lars
Peterson with the aim to establish a human treatment
model based on autologous chondrocyte transplantation.
Mats Brittberg also joined the group as a PhD student and
the first human autologous chondrocyte transplantation
(ACT) took place in 1987 based on the earlier rabbit studies
and with a culture technology adapted to human chondrocytes. The culture technique is based on autologous
chondrocyte culture using autologous serum; the first pilot
trial was published in 1994 and the technology subsequently
found its way into the clinic ([17]; figure 2).
(b) Cell therapy and cartilage regeneration: state
of the art
The ACT technology [17] has in the last decades emerged as
the first disease modifying treatment with long-term excellent
clinical result in patients with isolated cartilage injuries
[18 –22] and osteochondral lesions in the knee and ankle
[23,24]. The ACT technique for the treatment of cartilage injuries has been spread worldwide with over 45 000 patients
treated (estimation 2012); among those were 1800 treated by
our group over the last 20 years and the treatment has been
approved by the Food and Drug Administration since 1997
and by the European Medicines Agency since 2010. Four randomized controlled clinical trials have demonstrated
treatment superiority for ACT over conventional treatment
Phil. Trans. R. Soc. B 370: 20140369
injection of
cultured chondrocytes
under flap into lesion
rstb.royalsocietypublishing.org
periosteal flap
taken from
medial tibia
Downloaded from http://rstb.royalsocietypublishing.org/ on June 18, 2017
The OA patients and younger patients with small injuries are
not subjected to ACT treatments due to the limited source of
‘normal’ cartilage in an OA joint and the high costs of good
manufacturing practice-produced cells or grafts. Chondrocytes
isolated from human articular cartilage are pluripotent with a
unique differentiation capacity towards cartilage, bone and fat
cells while mesenchymal stem cells (MSCs) have a default
differentiation towards bone and not hyaline cartilage in vivo
[30] making them less suitable for ACT. Furthermore, MSCs
and articular chondrocytes also differ in several bHLH genes
[31] partly explaining the different cartilage phenotypes.
Articular cartilage is generally thought to have poor
self-renewal capacity but articular cartilage lesions undergo
perfect regeneration in fetal life [32]. In articular cartilage,
there are cells with progenitor phenotype distinguishable from
resident chondrocytes by their migratory behaviour, multidifferentiation capacity and clonogenicity [33,34] that could
potentially be used for cartilage regeneration. Furthermore,
OA cells could potentially be used for ACT as proteoglycan
synthesis in OA cells was found in comparable amounts to
normal cartilage from ACT donors although collagen synthesis
was significantly lower [35]. When OA cells were cultured in a
hyaluronan scaffold only a few genes were differentially
expressed between OA and normal hyaline cartilage, and the
risk of differentiation into hypertrophic cartilage was not
increased. OA chondrocytes could thus fulfil the requirements
for matrix-associated cartilage ACT and OA patients could
likely benefit from the treatment [36]. However, OA cells are
not used clinically since knees with damaged cartilage are
not healthy and the cartilage harvest for ACT is thus affected
by the joint pathology.
The ultimate goal for human cartilage cell-based repair
would be an off-the-shelf arthroscopic product based on a universal donor cell line combined with a suitable scaffold. For
proof of concept, we derived chondroprogenitor cells from
human embryonic stem cells (hES cells) [37] and hES cells cocultured with irradiated human chondrocytes induced the
best chondrogenic differentiation so far in hES cells [38].
An alternative to hES cells is to induce patient-specific
induced pluripotent stem (iPS) cells. The cellular reprogramming technique for adult cells was first demonstrated in
mouse fibroblasts by Yamanaka and co-worker [39] followed
by human fibroblasts using four pivotal genes: Oct3/4, Sox2,
(d) Stem-cell niches and molecular control mechanisms
in the knee joint: implications for cartilage repair
and osteoarthritis
The basic concept of the non-dividing chondrocyte has been
challenged over the last decades and the culture of chondrocytes and subsequent treatment with ACT has demonstrated
that cell cultures of chondrocytes and transplantation is an
effective treatment for cartilage with a long-term result and
even combined defect of bone and cartilage has been successfully treated with a long-term clinical result [45]. The
treatment concepts have been improved but also basic research
on chondrocyte biology with translational implication has
emerged as a result of our publication in 1994 [17]. Interestingly,
the concept of cartilage stem cells was almost non-existent in the
literature before 1994, but today there are several hundred publications each year (nine publications in 1993 and 533 in 2014,
PubMed search term: cartilage stem cells).
Cartilage stem cells and growth was poorly understood
until the work of Archer where appositional growth was
demonstrated in articular cartilage in the knee joints of the marsupial Monodelphis [46]. Interestingly, the surface layer of the
synovial joint, the lamina splendence, expresses the Notch receptor and thus could be the location of stem cells of the cartilage
[47]. We have studied the Notch signalling pathway due to its
role in regulation of joint development and growth [48] and
demonstrated that the Notch receptor is expressed in the surface layer of human articular cartilage—laminae splendence
[49]. We were also able to demonstrate that Notch1, its ligand
4
Phil. Trans. R. Soc. B 370: 20140369
(c) Improvements in autologous chondrocyte
transplantation cell technology: scaffolds
and alternative cell sources
Klf4 and c-Myc with a retroviral system [40]. Although the
cells have similar properties as hES cells with potential to
differentiate to most adult tissue cells, c-Myc is an oncogene
and 10% of the cell lines developed tumours in SCID mice.
Furthermore, as the virus stably integrates into the iPS cell
genome cells would be unsuitable for human treatment.
Recent protocols using mRNA, proteins or drugs have overcome part of the problem of transformed cells. We have
established an iPS cell line from human cartilage with a chondrogenic differentiation capacity using mRNA reprogramming
thus resulting in a genetic footprint-free cell line [41].
Other cell sources for cartilage regeneration are using bone
marrow stromal cells or MSCs where several papers have been
published (for an extensive review see [42]). However, the bone
marrow stimulating techniques or drilling all aim at getting
more bleeding and thus stem cells into the injured area and randomized trials using cultured MSCs are limited. Other cell
sources that have been considered are fat stromal cells and
umbilical cord cells although no clinical trial has been published so far. An interesting approach using nasal septal
cartilage that is derived from the neural ridge has been demonstrated to have good cartilage regenerating capacity in vitro and
there are ongoing clinical trials with promising results [43].
The original two-step technology of ACT has been gradually
modified and the periosteum has been replaced by synthetic
collagen membranes and further developed into an
arthroscopic procedure using Matrix-Assisted Chondrocyte
Implantation (MACI) techniques. In the latter case, the chondrocytes are cultured expanded and subsequently cultured on a
three-dimensional matrix thus forming a primitive cartilage
that could be manipulated and implanted arthroscopically—for
an extensive review see [44].
rstb.royalsocietypublishing.org
[25 –27] while one showed no difference, although ACT produced a better hyaline repair tissue [28]. However, the latter
study does not take into account that inclusion criterias for
ACT treatment in our hands are repeated failed previous conventional treatments as one-third of patients with cartilage
injuries diagnosed for the first time improve spontaneously
after debridement [29]. Recent reports from our group with
15-year follow-up gives further support for the hypothesis
that the ACT technology is a local disease modifying treatment where the chondrocyte graft has contributed to local
cartilage regeneration [20]. Furthermore, long-term followup using delayed gadolinium-enhanced magnetic resonance
imaging demonstrated a hyaline repair tissue similar to surrounding cartilage [21].
Downloaded from http://rstb.royalsocietypublishing.org/ on June 18, 2017
5
C
A
transit
amplifying cells
stem cells
A
illustrations: Portus Andersson
Figure 3. Illustration and visualization of a stem cell niche in the rabbit knee. A, perichondrial groove of Ranvier; B, growth plate; C, articular cartilage. Adapted
with permission from [55].
Jagged1 and downstream suppressor gene HES5 were only
expressed in a few cells localized within the uppermost cell
layers of the surface zone lamina splendence in normal cartilage,
in sharp contrast to the abundant expression of these markers
detected in OA biopsies [50]. The presences of Notch receptors
in this area suggest a more important role of the surface layer in
cartilage regeneration although the functional mechanisms
need to be elucidated.
An additional important contribution to the understanding
of cartilage regeneration and repair has been the work on cartilage MSCs. Cartilage MSC niches reside in the synovial tissue
and based on double labelling techniques the cells were demonstrated to undergo proliferation and chondrogenic differentiation
following injury in vivo [51]. The basic understanding of the
MSCs was founded on the pioneering work of Friedenstein
and co-workers in 1988 by the presentation of the concept that
bone, cartilage, marrow adipocytes and haematopoiesis-supporting stroma could originate from a common progenitor and
potential stem cell [52]. However, the definite proof of the concept has not been fully explored until recently when the
combined technology of rigorous single-cell analysis and lineage
tracing revealed the riddle of the skeletal stem cell. A skeletal
stem cell was identified and downstream clones were linked to
several phenotypes in the skeletal tissue. Interestingly, adipose
cells were not connected with the skeletal stem cell [53,54].
We have demonstrated the presence of a stem-cell niche in
the zone of Ranvier close to the knee joint (figure 3) as well as
in the intervertebrate disc region by means of long-term labelling
and co-expression of stem-cell niche markers, i.e. b-catenin,
Notch1, Noggin and c-kit [55,56]. With specific labelling of
cells in the niche we were also able to demonstrate that cells
from the niche migrate and support joint structures, e.g. meniscus, ligament and cartilage [57]. The niche cells could thus
potentially be involved in human cartilage regeneration—a finding that would mean a paradigm shift for the concept of cellular
treatment for cartilage defects and the OA disease mechanism.
Furthermore, the niche area could potentially be the source for
osteophyte formation in late OA.
Primary OA has an estimated heritability of 40% for the
knee, 60% for the hip and 65% for the hand [6]. Although
genome-wide association scans have uncovered novel genetic
associations OA is a highly polygenic disease with susceptibility alleles of only moderate-to-low individual effect. The
general belief before large-scale sequencing techniques and
the publication of the human genome was that the genes connected to the OA disease are found in the extracellular
matrix, as monogenetic mutations in the collagen type II gene
will cause osteoarthritis in early adolescence. But recent reviews
of mega data has revealed that several of the loci associated with
OA contain genes encoding key regulators of skeletal growth
and endochondral ossification instead of genes encoding structural proteins of the cartilage extracellular matrix. Furthermore,
direct and indirect regulation of gene transcription is highlighted as an important factor in this disease. This paradigm
shift from the regulatory rather than a structural level is important and could be the base for new therapies in the future [58].
Interestingly, two genes have been found to be consistently
associated with OA in Caucasians: the growth differentiation
factor 5 (GDF5) and 50 -iodothyronine deiodinase enzyme type
II (DIO2), both associated with stem-cell niche growth control
[59,60]. Furthermore, hip OA in females is associated with the
frizzle-related protein B (FRZB) that is an inhibitor of the Wnt
signalling pathway [60].
We have focused our interest on GDF5 which participates
in the development, maintenance and repair of bone, cartilage
and other tissues of the synovial joint and demonstrated that
GDF5 is downregulating one of the main degrading enzymes
in OA—MMP13—via the WNT inhibitor DKK1 [61]. The
known polymorphism site SNP rs143383, a T-to-C transition
located in the 50 untranslated region of the GDF5 gene, is
associated with osteoarthritis at genome-wide significance
level. The T-allele seems to result in a reduced level of GDF5
because of the elimination of a methylation site compared to
the C-allele and it supports the hypothesis that normal joint
maintenance requires an adequate GDF5 level.
4. Future perspectives
The future of cartilage regeneration therapy in humans will be
based on a deeper knowledge of cartilage developmental
biology and an understanding of the regenerative potential of
normal hyaline cartilage. The cell-therapy approach to cartilage
Phil. Trans. R. Soc. B 370: 20140369
B
rstb.royalsocietypublishing.org
differentiated
cells
Downloaded from http://rstb.royalsocietypublishing.org/ on June 18, 2017
A more functional understanding of the genes involved in
OA disease is needed in the future as well as better diagnostic markers for early OA in order to find a more precise
pharmacological treatment. This will probably be achieved
by combining iPS technology with modern gene editing
technology where the complicated interaction between the cellular regulatory system of regeneration and inflammation
could be studied in detail.
Competing interests. I declare I have no competing interests.
Funding. This study was funded by the Swedish Research Council
References
1.
Hunter W. 1742 Of the structure and diseases of
articulating cartilages. Phil. Trans. R. Soc. Lond. 42,
514–521. (doi:10.1098/rstl.1742.0079)
2. Muir H. 1995 The chondrocyte, architect of cartilage.
Biomechanics, structure, function and molecular
biology of cartilage matrix macromolecules.
BioEssays 17, 1039–1048. (doi:10.1002/bies.
950171208)
3. Heinegard D, Saxne T. 2011 The role of the cartilage
matrix in osteoarthritis. Nat. Rev. Rheumatol. 7,
50 –56. (doi:10.1038/nrrheum.2010.198)
4. Hardingham TE, Muir H. 1972 The specific
interaction of hyaluronic acid with cartillage
proteoglycans. Biochim. Biophys. Acta 279,
401–405. (doi:10.1016/0304-4165(72)90160-2)
5. Berenbaum F. 2013 Osteoarthritis as an
inflammatory disease (osteoarthritis is not
osteoarthrosis!). Osteoarthrit. Cartilage 21, 16 –21.
(doi:10.1016/j.joca.2012.11.012)
6. Chard J, Lohmander S, Smith C, Scott D. 2005
Osteoarthritis of the knee. Clin. Evid. 14, 1506–1522.
7. Wieland HA, Michaelis M, Kirschbaum BJ, Rudolphi
KA. 2005 Osteoarthritis—an untreatable disease?
Nat. Rev. Drug Discov. 4, 331 –344. (doi:10.1038/
nrd1693)
8. Petersson IF, Boegard T, Saxne T, Silman AJ, Svensson
B. 1997 Radiographic osteoarthritis of the knee
classified by the Ahlback and Kellgren & Lawrence
systems for the tibiofemoral joint in people aged
35–54 years with chronic knee pain. Ann. Rheum.
Dis. 56, 493–496. (doi:10.1136/ard.56.8.493)
9. Gelber AC, Hochberg MC, Mead LA, Wang NY,
Wigley FM, Klag MJ. 2000 Joint injury in young
adults and risk for subsequent knee and hip
osteoarthritis. Ann. Intern. Med. 133, 321 –328.
(doi:10.7326/0003-4819-133-5-200009050-00007)
10. Jackson JP, Waugh W. 1960 Tibial osteotomy for
osteoarthritis of the knee. Proc. R. Soc. Med. 53, 888.
11. Insall JN. 1967 Intra-articular surgery for
degenerative arthritis of the knee. A report of the
work of the late K. H. Pridie. J. Bone Joint Surg. Br.
Vol. 49, 211–228.
12. Lowe C, Smith AU. 1975 Isolation, freezing and
storage of rabbit growth plate chondrocytes. Lab.
Pract. 24, 511–514.
13. Chesterman PJ, Smith AU. 1968
Homotransplantation of articular cartilage and
isolated chondrocytes. An experimental study in
rabbits. J. Bone Joint Surg. Br. Vol. 50, 184–197.
14. Bentley G, Smith AU, Mukerjhee R. 1978 Isolated
epiphyseal chondrocyte allografts into joint surfaces.
An experimental study in rabbits. Ann. Rheumatic
Dis. 37, 449 –458. (doi:10.1136/ard.37.5.449)
15. Grande DA, Pitman MI, Peterson L, Menche D, Klein
M. 1989 The repair of experimentally produced
defects in rabbit articular cartilage by autologous
chondrocyte transplantation. J. Orthopaed. Res. 7,
208 –218. (doi:10.1002/jor.1100070208)
16. Lindahl A, Isgaard J, Nilsson A, Isaksson OG. 1986
Growth hormone potentiates colony formation of
epiphyseal chondrocytes in suspension culture.
Endocrinology 118, 1843 –1848. (doi:10.1210/endo118-5-1843)
17. Brittberg M, Lindahl A, Nilsson A, Ohlsson C,
Isaksson O, Peterson L. 1994 Treatment of deep
cartilage defects in the knee with autologous
chondrocyte transplantation. N. Engl. J. Med. 331,
889 –895. (doi:10.1056/NEJM199410063311401)
18. Peterson L, Brittberg M, Kiviranta I, Akerlund EL,
Lindahl A. 2002 Autologous chondrocyte
transplantation. Biomechanics and long-term
durability. Am. J. Sports Med. 30, 2 –12.
19. Peterson L, Minas T, Brittberg M, Nilsson A, SjogrenJansson E, Lindahl A. 2000 Two- to 9-year outcome
after autologous chondrocyte transplantation of the
knee. Clin. Orthop. 374, 212–234. (doi:10.1097/
00003086-200005000-00020)
20. Peterson L, Vasiliadis HS, Brittberg M, Lindahl A.
2010 Autologous chondrocyte implantation: a longterm follow-up. Am. J. Sports Med. 38, 1117–1124.
(doi:10.1177/0363546509357915)
21. Vasiliadis HS, Danielson B, Ljungberg M, McKeon B,
Lindahl A, Peterson L. 2010 Autologous chondrocyte
implantation in cartilage lesions of the knee: longterm evaluation with magnetic resonance imaging
and delayed gadolinium-enhanced magnetic
resonance imaging technique. Am. J. Sports Med.
38, 943– 949. (doi:10.1177/0363546509358266)
22. Vasiliadis HS, Lindahl A, Georgoulis AD, Peterson L.
2011 Malalignment and cartilage lesions in the
23.
24.
25.
26.
27.
28.
29.
30.
patellofemoral joint treated with autologous
chondrocyte implantation. Knee Surg. Sports
Traumatol. Arthrosc. 19, 452 –457. (doi:10.1007/
s00167-010-1267-1)
Petersen L, Brittberg M, Lindahl A. 2003 Autologous
chondrocyte transplantation of the ankle. Foot Ankle
Clin. 8, 291–303. (doi:10.1016/S1083-7515(03)
00045-7)
Peterson L, Minas T, Brittberg M, Lindahl A. 2003
Treatment of osteochondritis dissecans of the knee
with autologous chondrocyte transplantation:
results at two to ten years. J. Bone Joint Surg. Am.
85-A(Suppl. 2), 17 –24.
Bentley G, Biant LC, Carrington RWJ, Akmal M,
Goldberg A, Williams AM, Skinner JA, Pringle J.
2003 A prospective, randomised comparison of
autologous chondrocyte implantation versus
mosaicplasty for osteochondral defects in the knee.
J. Bone Joint Surg. Br. 85, 223– 230. (doi:10.1302/
0301-620X.85B2.13543)
Visna P, Pasa L, Cizmar I, Hart R, Hoch J. 2004
Treatment of deep cartilage defects of the knee
using autologous chondrograft transplantation and
by abrasive techniques—a randomized controlled
study. Acta Chir. Belg. 104, 709 –714.
Saris DB et al. 2008 Characterized chondrocyte
implantation results in better structural repair when
treating symptomatic cartilage defects of the knee
in a randomized controlled trial versus
microfracture. Am. J. Sports Med. 36, 235 –246.
(doi:10.1177/0363546507311095)
Knutsen G et al. 2004 Autologous chondrocyte
implantation compared with microfracture in the
knee. A randomized trial. J. Bone Joint Surg. Am.
86-A, 455 –464.
Dozin B, Malpeli M, Cancedda R, Bruzzi P, Calcagno S,
Molfetta L, Priano F, Kon E, Marcacci M. 2005
Comparative evaluation of autologous chondrocyte
implantation and mosaicplasty: a multicentered
randomized clinical trial. Clin. J. Sport Med. 15,
220–226. (doi:10.1097/01.jsm.0000171882.66432.80)
Tallheden T, Dennis JE, Lennon DP, Sjogren-Jansson
E, Caplan AI, Lindahl A. 2003 Phenotypic plasticity
of human articular chondrocytes. J. Bone Joint Surg.
Am. 85-A(Suppl. 2), 93 –100.
Phil. Trans. R. Soc. B 370: 20140369
grant no. 2012-2517 and Western Region ALF research grant no.
ALFGBG-432251.
6
rstb.royalsocietypublishing.org
injuries pioneered by our group has been spread worldwide and
has repaired dysfunctional knees in thousands of patients. The
further development of ACT to MACI technology has improved
the quality of life further by reducing the rehabilitation period
following surgery due to the replacement of open knee surgery
with arthroscopic techniques. The autologous technique for cartilage regeneration will remain for the foreseeable future
although alternative cell sources and modification of the methodology will find its way into clinical trials, i.e. nasal cartilage
source. However, a broader access to the therapy will need a universal donor cell line suitable for many patients. This will
probably be achieved with iPS technology and/or decellularized
cultured scaffolds.
Downloaded from http://rstb.royalsocietypublishing.org/ on June 18, 2017
41.
42.
44.
45.
46.
47.
48.
49.
50.
51. Kurth TB, Dell’Accio F, Crouch V, Augello A, Sharpe
PT, De Bari C. 2011 Functional mesenchymal stem
cell niches in adult mouse knee joint synovium in
vivo. Arthritis Rheum. 63, 1289 –1300. (doi:10.
1002/art.30234)
52. Owen M, Friedenstein AJ. 1988 Stromal stem cells:
marrow-derived osteogenic precursors. Ciba Found.
Symp. 136, 42 –60.
53. Worthley DL et al. 2015 Gremlin 1 identifies a
skeletal stem cell with bone, cartilage, and reticular
stromal potential. Cell 160, 269 –284. (doi:10.1016/
j.cell.2014.11.042)
54. Chan CK et al. 2015 Identification and specification
of the mouse skeletal stem cell. Cell 160, 285 –298.
(doi:10.1016/j.cell.2014.12.002)
55. Karlsson C, Thornemo M, Henriksson HB, Lindahl A.
2009 Identification of a stem cell niche in the zone
of Ranvier within the knee joint. J. Anat. 215,
355–363. (doi:10.1111/j.1469-7580.2009.01115.x)
56. Henriksson H, Thornemo M, Karlsson C, Hagg O,
Junevik K, Lindahl A, Brisby H. 2009 Identification
of cell proliferation zones, progenitor cells and a
potential stem cell niche in the intervertebral disc
region: a study in four species. Spine (Phila Pa
1976) 34, 2278– 2287. (doi:10.1097/BRS.0b013e3
181a95ad2)
57. Henriksson HB et al. 2013 Similar cellular migration
patterns from niches in intervertebral disc and in knee
joint regions detected by in situ labelling. An
experimental study in the New Zealand white rabbit.
Stem Cell Res. Ther. 4, 104. (doi:10.1186/scrt315)
58. Reynard LN, Loughlin J. 2013 Insights from human
genetic studies into the pathways involved in
osteoarthritis. Nat. Rev. Rheumatol. 9, 573– 583.
(doi:10.1038/nrrheum.2013.121)
59. Meulenbelt I et al. 2008 Identification of DIO2 as a
new susceptibility locus for symptomatic
osteoarthritis. Hum. Mol. Genet. 17, 1867–1875.
(doi:10.1093/hmg/ddn082)
60. Loughlin J et al. 2004 Functional variants within the
secreted frizzled-related protein 3 gene are
associated with hip osteoarthritis in females. Proc.
Natl Acad. Sci. USA 101, 9757–9762. (doi:10.1073/
pnas.0403456101)
61. Enochson L, Stenberg J, Brittberg M, Lindahl A. 2014
GDF5 reduces MMP13 expression in human chondrocytes
via DKK1 mediated canonical Wnt signaling inhibition.
Osteoarthrit. Cartilage 22, 566–577. (doi:10.1016/j.joca.
2014.02.004)
7
Phil. Trans. R. Soc. B 370: 20140369
43.
pluripotent stem cells from adult human fibroblasts
by defined factors. Cell 131, 861–872. (doi:10.
1016/j.cell.2007.11.019)
Borestrom C, Simonsson S, Enochson L, Bigdeli N,
Brantsing C, Ellerstrom C, Hyllner J, Lindahl A. 2014
Footprint-free human induced pluripotent stem cells
from articular cartilage with redifferentiation
capacity: a first step toward a clinical-grade cell
source. Stem Cells Transl. Med. 3, 433– 447. (doi:10.
5966/sctm.2013-0138)
Bornes TD, Adesida AB, Jomha NM. 2014
Mesenchymal stem cells in the treatment of
traumatic articular cartilage defects: a
comprehensive review. Arthritis Res. Ther. 16, 432.
(doi:10.1186/s13075-014-0432-1)
Pelttari K et al. 2014 Adult human neural crestderived cells for articular cartilage repair. Sci. Transl.
Med. 6, 251ra119. (doi:10.1126/scitranslmed.
3009688)
Brittberg M. 2010 Cell carriers as the next
generation of cell therapy for cartilage repair: a
review of the matrix-induced autologous
chondrocyte implantation procedure. Am. J.
Sports Med. 38, 1259–1271. (doi:10.1177/
0363546509346395)
Bentley G, Bhamra JS, Gikas PD, Skinner JA,
Carrington R, Briggs TW. 2013 Repair of
osteochondral defects in joints—how to achieve
success. Injury 44(Suppl. 1), S3–S10. (doi:10.1016/
S0020-1383(13)70003-2)
Hayes AJ, MacPherson S, Morrison H, Dowthwaite G,
Archer CW. 2001 The development of articular
cartilage: evidence for an appositional growth
mechanism. Anat. Embryol. 203, 469–479. (doi:10.
1007/s004290100178)
Dowthwaite GP et al. 2004 The surface of articular
cartilage contains a progenitor cell population.
J. Cell Sci. 117, 889–897. (doi:10.1242/jcs.00912)
Watanabe N et al. 2003 Suppression of
differentiation and proliferation of early
chondrogenic cells by Notch. J. Bone Miner. Metab.
21, 344– 352. (doi:10.1007/s00774-003-0428-4)
Archer CW, Dowthwaite GP, Francis-West P. 2003
Development of synovial joints. Birth Defects Res. C
69, 144– 155. (doi:10.1002/bdrc.10015)
Karlsson C, Brantsing C, Egell S, Lindahl A. 2008
Notch1, Jagged1, and HES5 are abundantly
expressed in osteoarthritis. Cells Tissues Organs 188,
287 –298. (doi:10.1159/000121610)
rstb.royalsocietypublishing.org
31. Karlsson C, Brantsing C, Svensson T, Brisby H, Asp J,
Tallheden T, Lindahl A. 2007 Differentiation of
human mesenchymal stem cells and articular
chondrocytes: analysis of chondrogenic potential
and expression pattern of differentiation-related
transcription factors. J. Orthop. Res. 25, 152– 163.
(doi:10.1002/jor.20287)
32. Namba RS, Meuli M, Sullivan KM, Le AX, Adzick NS.
1998 Spontaneous repair of superficial defects in
articular cartilage in a fetal lamb model. J. Bone
Joint Surg. Am. 80, 4 –10.
33. Bos PK, Kops N, Verhaar JA, van Osch GJ. 2008
Cellular origin of neocartilage formed at wound
edges of articular cartilage in a tissue culture
experiment. Osteoarthrit. Cartilage 16, 204–211.
(doi:10.1016/j.joca.2007.06.007)
34. Thornemo M et al. 2005 Clonal populations of
chondrocytes with progenitor properties identified
within human articular cartilage. Cells Tissues
Organs 180, 141–150. (doi:10.1159/000088242)
35. Tallheden T, Bengtsson C, Brantsing C, SjogrenJansson E, Carlsson L, Peterson L, Brittberg M,
Lindahl A. 2005 Proliferation and differentiation
potential of chondrocytes from osteoarthritic
patients. Arthritis Res. Ther. 7, R560–R568. (doi:10.
1186/ar1709)
36. Dehne T, Karlsson C, Ringe J, Sittinger M, Lindahl A.
2009 Chondrogenic differentiation potential of
osteoarthritic chondrocytes and their possible use in
matrix-associated autologous chondrocyte
transplantation. Arthritis Res. Ther. 11, R133.
(doi:10.1186/ar2800)
37. Bigdeli N et al. 2008 Adaptation of human
embryonic stem cells to feeder-free and matrix-free
culture conditions directly on plastic surfaces.
J. Biotech. 133, 146–153. (doi:10.1016/j.jbiotec.
2007.08.045)
38. Bigdeli N, Karlsson C, Strehl R, Concaro S, Hyllner J,
Lindahl A. 2009 Coculture of human embryonic
stem cells and human articular chondrocytes results
in significantly altered phenotype and improved
chondrogenic differentiation. Stem Cells 27, 1812 –
1821. (doi:10.1002/stem.114)
39. Takahashi K, Yamanaka S. 2006 Induction of
pluripotent stem cells from mouse embryonic and
adult fibroblast cultures by defined factors. Cell 126,
663–676. (doi:10.1016/j.cell.2006.07.024)
40. Takahashi K, Tanabe K, Ohnuki M, Narita M, Ichisaka
T, Tomoda K, Yamanaka S. 2007 Induction of