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中华老年骨科与康复电子杂志 ›› 2023, Vol. 09 ›› Issue (06) : 373 -378. doi: 10.3877/cma.j.issn.2096-0263.2023.06.007

综述

含生长因子骨移植材料的研究进展和监管现状
郭晓磊, 李晓云, 孙嘉怿, 金乐, 郭亚娟, 史新立()   
  1. 100081 北京,国家药品监督管理局医疗器械技术审评中心
  • 收稿日期:2023-11-06 出版日期:2023-12-05
  • 通信作者: 史新立
  • 基金资助:
    国家药监局中国药品监管科学行动计划第二批重点项目:新型生物材料安全性有效性评价研究

The research development and regulatory state-of-art of bone grafts with growth factors

Xiaolei Guo, Xiaoyun Li, Jiayi Sun, Le Jin, Yajuan Guo, Xinli Shi()   

  1. Center for Medical Device Evaluation, Beijing, China
  • Received:2023-11-06 Published:2023-12-05
  • Corresponding author: Xinli Shi
引用本文:

郭晓磊, 李晓云, 孙嘉怿, 金乐, 郭亚娟, 史新立. 含生长因子骨移植材料的研究进展和监管现状[J]. 中华老年骨科与康复电子杂志, 2023, 09(06): 373-378.

Xiaolei Guo, Xiaoyun Li, Jiayi Sun, Le Jin, Yajuan Guo, Xinli Shi. The research development and regulatory state-of-art of bone grafts with growth factors[J]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2023, 09(06): 373-378.

骨移植材料接受食品药品监督管理局(FDA)不同路径的监管审批,其预期的安全性和有效性可能只有FDA审评者清楚,临床医生有必要对监管过程有所了解。FDA的审批路径主要包括4个监管途径:510K批准、研究器械豁免/上市前批准(IDE/PMA)、人细胞、组织和细胞基产品(HTC/P)和再生医学先进治疗(RMAT)。骨再生修复过程中涉及到多种生长因子,如骨形态发生蛋白-2、4(BMP-2,4)、成纤维细胞生长因子、血管内皮生长因子、血小板源性生长因子(PDGF)和胰岛素样生长因子-1等。Infuse (BMP-2)是重组骨形态蛋白-2(rhBMP-2)与可吸收胶原海绵结合的骨移植材料。骨形成蛋白-1(OP-1)材料2001年获得FDA批准用于替代自体骨移植治疗长骨顽固性骨不愈合。PDGF-BB材料是rhPDGF与β-磷酸三钙结合制成,2015年获得FDA批准用于踝关节融合术。iFactorTM是P-15吸附在无机矿物物质上在水凝胶载体中制成的肽增强骨移植材料,2005年FDA批准可用于单节段颈椎前路椎间融合术。我国已有4家公司含生长因子的骨移植材料获得国家药品监督管理局批准,所含的生长因子均为rhBMP-2,与国外相比产品的种类还有很大的差距。组织工程骨材料是组织工程三要素即支架、细胞、生长因子的有效结合,将使骨移植材料的科技含量、有效性得到进一步提高。国家药品监督管理局对骨移植材料应根据产品组成进行分类细化,增加审批路径,提高监管水平,促进科研成果的转化。

Bone graft materials are subject to various regulatory approval pathways by the FDA (Food and Drug Administration). The expected safety and efficacy of bone grafts may only be clear to FDA reviewers, but difficult for clinical physicians to anticipate. The FDA's regulatory pathways mainly include of four pathways: 510K approval, IDE/PMA (Investigational Device Exemption/Premarket Approval), HTC/P (human cells, tissues, and cellular and tissue-based products), and RMAT (Regenerative Medicine Advanced Therapy). The bone regeneration process involves various growth factors, such as bone morphogenetic proteins-2, 4(BMP-2, 4), fibroblast growth factors, vascular endothelial growth factors, platelet-derived growth factors (PDGF), and insulin-like growth factor-1, etc. Infuse (BMP-2) is a graft material that combines rh-BMP-2 with an absorbable collagen sponge. OP-1 (BMP-7) was approved by the FDA in 2001 to replace autograft in treating recalcitrant long bone nonunions. PDGF-BB materials are made by combining rhPDGF with β-tricalcium phosphate, and were approved by the FDA in 2015 for surgical fusion of ankle. iFactorTM is a peptide-enhanced bone graft material manufactured by adsorbing P-15 onto inorganic mineral matter and hydrogel carriers, which was approved by the FDA in 2005 for anterior cervical discectomy and fusion in single-level procedures. Four products of rhBMP-2 enhanced bone grafts are approved in China. In comparison with foreign countries, there is a significant gap in the variety of products containing growth factors and bioactive factors in China. The medical device of tissue engineering consist of three basic elements of tissue engineering such as carrier, cell, and growth factors, which were combined effectively, and enhance the scientific content and effectiveness and bone grafts and bone graft substitutes.The National Medical Products Administration should refine the approval pathways for bone graft materials containing growth factors and bioactive molecules based on product composition, improve the timeliness of the regulatory process, and enhance translational scientific level.

表1 FDA监管骨再生修复材料的类型及优缺点
材料类型 优点 缺点
自体骨 有骨传导、骨诱导、骨形成,"金标准" 取骨手术增加感染风险,取材量有限
自体骨:松质骨 表面积大,有利于再血管化 机械强度差
自体骨:皮质骨 机械性能稳定 相对于松质骨移植,需要更长的时间进行重建
自体骨:带血管皮质骨 移植后愈合时间较短,并且保存了移植物中的骨细胞和成骨前体细胞 很难获取和移植
骨髓抽吸物 可以通过微创手术获取 移植物中的干细胞数量少于预想的数量
富血小板血浆 价格低,易于获取,能够直接刺激间充质干细胞迁移到对应部位,减少需要获取的自体移植物的数量 个体的富血小板血浆与制备方法具有异质性
同种异体骨 数量充足,加工处理容易 传播疾病,免疫排斥
同种异体骨:松质骨 冷冻干燥会使移植物具有低残余湿度,且保质期为4~5年 低的机械强度
同种异体骨:皮质骨 力学强度好,可结构移植 炎症反应导致愈合缓慢
同种异体骨:脱钙骨基质 暴露天然BMPs,具有骨诱导性 不同批次和制造商的产品生长因子含量具有差异
合成材料 种类多,可制成注射型,可3D打印 无生长因子,空隙连接不理想
磷酸钙陶瓷 与骨组织相似的组成 机械强度大,难以塑形
磷酸钙 具有与骨最相似组成,是合成移植物的"金标准" 降解不可预测,因此不适合于承重区域
双相磷酸钙 兼具磷酸钙与羟基磷灰石的优点,吸收速率和力学性能的范围依赖合成比例 移植物机械强度依赖于组成比例
羟基磷灰石 具有很好的生物相容性,与磷酸钙相比,具有更高的拉伸与压缩强度。 移植物吸收慢
磷酸钙骨水泥 沉淀与析出反应使其更容易塑形 机械强度差
硫酸钙 成本低,易塑形 吸收与成骨不平衡,伤口渗出裂开的风险,缺乏机械强度
生物活性玻璃 与骨和组织进行化学结合,激活基因促进骨生成 具有生物活性的SiO2含量不足
生长因子和生物活性分子材料 有骨传导、骨诱导 长期效果研究少,有超适应证使用并发症,价格高
Infuse(BMP-2) 与自体移植相比,可能有更好的成骨能力,在吸烟患者中具有好的骨再生能力 超适应证使用可能会造成患者呼吸障碍,还存在异位成骨的风险
OP-1(BMP-7) 在骨不愈合和脊柱融合术有很好的成骨性 异位成骨的风险
PDGF-BB 相比自体移植物,并发症更少,并具有相似的临床结果 价格昂贵
iFactor(P-15) 成骨与自体移植物具有相似的结果 移植物渗出水肿
图1 骨再生修复过程中生长因子作用级联流程图:多种生长因子通过相互作用的级联过程参与骨修复过程中的成骨、成软骨、成血管、骨修复注:VEGF表示血管内皮生长因子;PDGF表示血小板源性生长因子;TGF-β表示转化生长因子-β;BMP表示骨形态发生蛋白;FGF表示成纤维细胞生长因子
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