Fphys 07-00180

ORIGINAL RESEARCH
published: 24 May 2016
doi: 10.3389/fphys.2016.00180
Frontiers in Physiology | www.frontiersin.org 1 May 2016 | Volume 7 | Article 180
Edited by:
Mario Diaz,
Universidad de La Laguna, Spain
Reviewed by:
Nick Robert Forsyth,
Keele University, UK
Roman Krawetz,
University of Calgary, Canada
Yolande Ramos,
Leiden University Medical Center,
Netherlands
*Correspondence:
Mohammed Abbas
mmabbas@kau.edu.sa;
Ali Mobasheri
a.mobasheri@surrey.ac.uk
Specialty section:
This article was submitted to
Membrane Physiology and Membrane
Biophysics,
a section of the journal
Frontiers in Physiology
Received: 18 January 2016
Accepted: 05 May 2016
Published: 24 May 2016
Citation:
Kalamegam G, Abbas M, Gari M,
Alsehli H, Kadam R, Alkaff M,
Chaudhary A, Al-Qahtani M,
Abuzenadah A, Kafienah W and
Mobasheri A (2016) Pelleted Bone
Marrow Derived Mesenchymal Stem
Cells Are Better Protected from the
Deleterious Effects of Arthroscopic
Heat Shock. Front. Physiol. 7:180.
doi: 10.3389/fphys.2016.00180
Pelleted Bone Marrow Derived
Mesenchymal Stem Cells Are Better
Protected from the Deleterious
Effects of Arthroscopic Heat Shock
Gauthaman Kalamegam1, 2
, Mohammed Abbas2, 3
*, Mamdooh Gari1, 2, 4
, Haneen Alsehli5
,
Roaa Kadam1
, Mohammed Alkaff2, 3
, Adeel Chaudhary1
, Mohammed Al-Qahtani1
,
Adel Abuzenadah1, 5
, Wael Kafienah6
and Ali Mobasheri1, 7, 8
*
1
Center of Excellence in Genomic Medicine Research, King Abdulaziz University, Jeddah, Saudi Arabia, 2
Sheik Salem Bin
Mahfouz Scientific Chair for Treatment of Osteoarthritis by Stem Cells, King Abdulaziz University, Jeddah, Saudi Arabia,
3
Department of Orthopedic Surgery, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia,
4
Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah,
Saudi Arabia, 5
Faculty of Applied Medical Sciences, Center of Innovation in Personalized Medicine, King Abdulaziz University,
Jeddah, Saudi Arabia, 6
School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK, 7
The D-BOARD
European Consortium for Biomarker Discovery, The APPROACH Innovative Medicines Initiative Consortium, Faculty of Health
and Medical Sciences, University of Surrey, Surrey, UK, 8
Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis,
Arthritis Research UK Pain Centre, Medical Research Council and Arthritis Research UK Centre for Musculoskeletal Aging
Research, University of Nottingham, Queen’s Medical Centre, Nottingham, UK
Introduction: The impact of arthroscopic temperature on joint tissues is poorly
understood and it is not known how mesenchymal stem cells (MSCs) respond to
the effects of heat generated by the device during the process of arthroscopy
assisted experimental cell-based therapy. In the present study, we isolated and
phenotypically characterized human bone marrow mesenchymal stem cells (hBMMSCs)
from osteoarthritis (OA) patients, and evaluated the effect of arthroscopic heat on cells
in suspension and pellet cultures.
Methods: Primary cultures of hBMMSCs were isolated from bone marrow aspirates of
OA patients and cultured using DMEM supplemented with 10% FBS and characterized
for their stemness. hBMMSCs (1 6× 10 cells) cultured as single cell suspensions or
cell pellets were exposed to an illuminated arthroscope for 10, 20, or 30 min. This was
followed by analysis of cellular proliferation and heat shock related gene expression.
Results: hBMMSCs were viable and exhibited population doubling, short spindle
morphology, MSC related CD surface markers expression and tri-lineage differentiation
into adipocytes, chondrocytes and osteoblasts. Chondrogenic and osteogenic
differentiation increased collagen production and alkaline phosphatase activity. Exposure
of hBMMSCs to an illuminated arthroscope for 10, 20, or 30 min for 72 h decreased
metabolic activity of the cells in suspensions (63.27% at 30 min) and increased metabolic
activity in cell pellets (62.86% at 10 min and 68.57% at 20 min). hBMMSCs exposed to
37, 45, and 55◦C for 120 s demonstrated significant upregulation of BAX, P53, Cyclin
A2, Cyclin E1, TNF-α, and HSP70 in cell suspensions compared to cell pellets.

Kalamegam et al. Heat Shock and MSC Viability
Conclusions: hBMMSC cell pellets are better protected from temperature alterations
compared to cell suspensions. Transplantation of hBMMSCs as pellets rather than as
cell suspensions to the cartilage defect site would therefore support their viability and
may aid enhanced cartilage regeneration.
Keywords: mesenchymal stem cells, osteoarthritis (OA), cell viability, population doubling, fluorescence activated
cell sorting (FACS), differentiation, heat shock
INTRODUCTION
Osteoarthritis (OA) is a chronic degenerative disease of load-
bearing synovial joints that commonly affects a significant and
ever increasing proportion of the aging population. OA is the
most common joint disorder in the elderly. Its incidence has
been rising steadily and is expected to escalate further with the
projected world-wide increase in the aging population, impacting
on the existing socio-economic burden (Arden and Nevitt, 2006).
Nearly 50 million Americans are already afflicted with OA, with
50% of the individuals affected being more than 65 years of age
(Center for Disease Control Prevention (CDC), 2010). By 2030,
it is estimated that about 20% of the European and American
populations will suffer from OA (De Bari et al., 2010). In the same
period in the Middle East, the indicators of aging, namely the
standardized prospective median age and the average age of the
population are projected to increase from 20.9 and 26.0 in 2010 to
23.5 and 31.4 (Lutz et al., 2008). Furthermore, the cultural prayer
position and increased obesity in the Middle Eastern population
pose additional risks for the development of OA in the aging
population.
OA is characterized by progressive joint degeneration, pain,
effusion and limitation of mobility with eventual loss of function
(Buckwalter and Lane, 1997). The entire articulating joint
together with its constituent peri-articular tissues including bone,
ligaments, joint capsule and synovium and are involved in the
progression of OA, highlighting the complex nature of this
disease (Loeser et al., 2012).
Although multiple factors are implicated in the
aetiopathogenesis of OA, the underlying molecular mechanisms
still remain unclear. Several hypotheses have been proposed
to account for the development of OA including age-related
“wear and tear,” chondrocytes’ poor response to growth factors,
increased sensitivity to pro-inflammatory stimuli, excessive
cross-linking and structural modification of collagens leading
to alterations in the bio-mechanical properties of articular
cartilage, mitochondrial dysfunction, oxidative stress and low-
level inflammation (Mobasheri et al., 2013). Fundamentally, the
number of chondrocytes in articular cartilage decreases with age
resulting in impaired extracellular matrix repair and reduced
production of new matrix proteins. In addition the absence of
blood vessels and stem cells within the cartilage limits the natural
healing capacity (Henrotin and Reginster, 1999; Mobasheri
et al., 2013) although evidence suggests that innervation and
vascularization increases in the late stages of disease progression.
Non-steroidal anti-inflammatory drugs, opioids, topical
formulations, intra-articular injections and nutraceuticals are all
used in OA treatment, but they are largely symptom modifying
agents and there is little evidence to suggest that any of them
have the capacity to act as disease modifying osteoarthritis drugs
(DMOADs). Pharmacological management with DMOADs may
relieve pain to some degree, but does not offer any structure
modification (Reid et al., 2012). Various surgical methods have
been developed to restore damaged cartilage and improve joint
function. These include microfracture, subchondral drilling,
abrasion arthroplasty and autologus chondrocyte implantation
(ACI). The aim of these techniques is to promote intrinsic
healing by promoting vascular invasion, fibrin clot formation
and recruitment of stem cells (Brittberg et al., 1994; Vinatier
et al., 2009; Orth et al., 2014). However, the poor biomechanical
properties of the new scar tissue in microfracture, as well as
donor site morbidity, low cellularity and surrounding cartilage
damage at the transplantation site in ACI limit their clinical
utility and surgical outcomes (Brittberg et al., 1994; Vinatier et al.,
2009; Orth et al., 2014). When pharmacological and surgical
management fail, which is so often the case in the clinical
setting, the disease progresses to end stage OA, where total joint
replacement becomes the only option. However, the life span of
currently available prostheses is limited and there is increasing
demand for safer and more effective surgical treatments and
therapeutic strategies (Kurtz et al., 2007).
Regenerative medicine offers great potential for therapeutic
intervention in OA and could provide an excellent alternative
to total joint replacement. The use of autologus matrix induced
chondrogenesis (AMIC) in OA (Gille et al., 2013) and intra-
articular injection of meniscal stem/progenitors cells (Shen et al.,
2014) are some recent advances in this area. Autologus and
allogeneic stem cells derived from various sources (viz. bone
marrow, synovium, adipose tissue etc.) have been used for
treatment of OA with variable success (Garcia-Alvarez et al.,
2011; Mobasheri et al., 2014). These are either directly injected
into the damaged site or differentiated into cartilage together with
tissue engineered scaffolds or following treatment with growth
factors.
The introduction of biological agents such as stem cells
into the joint normally requires arthroscopic techniques.
Temperature increases of 52.0 and 49.5◦C following monopolar
and bioplar radiofrequency application with irrigation have been
reported during wrist arthroscopy in cadaveric models (Huber
et al., 2013). Animal studies have demonstrated ultrastructural
changes in the size and cross-sectional diameter of the joint
capsular collagen fibrils ranging from 22.5 to 50.4% following
increased temperatures of 45 and 85◦C (Lopez et al., 1998).
Bone drilling, a common treatment for operative fracture also
generates heat and temperatures above 47◦C are known to cause

osteonecrosis (Augustin et al., 2012). The aim of this study
was to investigate the impact of temperature changes associated
with arthroscopic procedures on cellular activity and/or survival
in suspension and pellet cultures of human bone marrow
mesenchymal stem cells (hBMMSCs), which are increasingly
studied as a promising cell source for cartilage regeneration.
MATERIALS AND METHODS
Derivation and Propagation of hBMMSCs
Bone marrow aspirates were harvested from the iliac crest of
OA patients undergoing surgical treatment in the Department
of Orthopedics, King Abdulaziz University Hospital, Jeddah,
Kingdom of Saudi Arabia. Prior to sample collection informed
patient consent was obtained and the research study was carried
out following Institutional Research Ethics Committee approval
[11–557]. hBMMSCs were isolated using earlier published
protocols (Brady et al., 2014). Briefly, the bone marrow aspirate
(5–6 ml) was collected in heparinized tubes (Becton Dickinson,
BD) and directly plated into tissue culture flasks (∼2 ml of
aspirate/T175 cm2 flask; Greiner) and cultured using Dulbeccos’s
modified Eagle’s medium (Sigma), supplemented with 10% fetal
bovine serum (Sigma), 2 mM Gluta-Max (Life Technologies)
and antibiotic solution (penicillin, 100 u/mL; streptomycin
100 µg/mL - Sigma) under standard culture conditions of 37◦C
and 5% carbon dioxide (CO2) in atmospheric air for 5–7 days.
The first media change was carried out on day 5 and subsequently
every 2 or 3 days until subculture. Dead/suspended cells and
cellular debris were washed away with media changes and the
hBMMSCs were retained as a consequence of their plastic
adherence. Basic fibroblast growth factor (bFGF; Peprotech) at
5 ng/mL was added to the culture medium to facilitate hBMMSCs
expansion and early passages of the derived hBMMSCs (<P5)
were used in the experiment Expanded cells were frozen using
ProFreeze (Lonza) in liquid nitrogen and stored for subsequent
use.
Effect of Arthroscope Temperature on Cell
Morphology and Metabolic Activity
Baseline characterization included assessment of cell morphology
and survival. The hBMMSCs were seeded in 24 well tissue
culture plates at 2 × 104 cells/well. Cell morphology and their
metabolic activity were analyzed using phase contrast microscopy
and MTT assay respectively. To study the effect of temperature
related changes that may result with use of the arthroscope in
a clinical setting hBMMSCs (1 × 106 cells) were used either as
cell suspensions or cell pellets. The arthroscope was sterilized
and suspended vertically down using a stand with fixed clamp
and placed within the biosafety cabinet. The suspension height
of the arthroscope from the clamp was kept constant and the
illuminated end was placed into the medium (10 mL) containing
cell suspensions or cell pellets in 50 mL graduated Falcon tubes.
The samples from both cell suspension and cell pellet groups
were exposed for 10 min (Group A), 20 min (Group B), or 30 min
(Group C). The cell suspensions and pellets were then gently
mixed and 2 × 104 cells/well were seeded in a 24 well plate
and cultured under standard culture conditions of 37◦C in 5%
atmospheric air for 72 h and both cell morphology and metabolic
activity were assessed.
Cellular activity assays were also performed on cells from
all the groups using the MTT kit (3-(4,5-dimethylthiazolyl-
2)-2,5-diphenyltetrazolium bromide; Sigma). Briefly,
10 µL MTT reagent (0.5 mg/mL) was added to cultures,
incubated for 4 h followed by medium removal and
addition of 200 µL solubilization reagent. Culture plates
were further incubated for 2 h and absorbance at 570 nm
(ref 650 nm) was measured using a spectrophotometer
(µQuant; BioTek).
CD Marker Analysis
Cultures of hBMMSCs were analyzed for expression of
MSC related cluster of differentiation (CD) markers. Briefly,
monolayer cultures of hBMMSCs were dissociated using 0.25%
Trypsin-EDTA (Life Technologies) for 3 min. Trypsin activity
was inhibited by addition of culture medium containing 10%
fetal bovine serum (FBS). The cell suspension was centrifuged
at 300 g × 5 min and the cell pellet was then resuspended
in phosphate buffered saline without calcium and magnesium
(PBS-) containing 3% FBS to obtain single cell suspension.
Separate aliquots (2 × 105 cells) were used for MSC isotype
cocktail (Miltenyi Biotec), MSC phenotyping cocktail (Miltenyi
Biotec) or in combination with other primary monoclonal
antibodies (CD44, CD29—BD Pharmingen) to avoid interference
with same fluorochromes. The MSC isotype cocktail comprised
of fluorochrome conjugated monoclonal antibodies, namely
mouse IgG1-FITC, mouse IgG1-PE, mouse IgG1-APC, mouse
IgG1-PerCp and mouse IG2a-PerCp. The MSC phenotyping
cocktail comprised of both positive (CD73-APC, CD90-FITC,
CD105-PE) and negative (CD34/CD45/CD14/CD20-PerCp)
fluorochrome conjugated monoclonal antibodies. The cells
were incubated with respective antibodies at 1:10 dilution
for 15 min at 4◦C; then washed with 1 mL of 3% FBS
and centrifuged at 300 g × 5 min. The supernatant was
discarded and the cells were resuspended in 500 µl of 3%
FBS before analysis using a FACS Aria III instrument (BD
BioSciences), which is equipped with a 488 nM (blue) laser
and a 561-nM (yellow-green) laser for uncoupled excitation
and detection of FITC and PE fluorochromes. In addition to
increasing the sensitivity of PE detection, this set-up eliminated
the PE-FITC spill over, thereby eliminating the need for
compensation. As an additional measure, single-stained control
tubes for each color was analyzed to rule out the need for
compensation as well as set up the detection range for each
fluorochrome.
Trypan Blue Viability/Population Doubling
Time
The hBMMSCs were seeded at 2 × 104 cells/well in a 24 well
plate and cultured for up to 3 days to determine cell viability
and population doubling time (PDT). The cells were trypsinized
daily at the same time and the live/dead cell counts were obtained
following trypan blue vital staining. Three replicates were carried
out for each sample. PDT (http://www.doubling-time.com) was

calculated using the formula:
Doubling time =
Duration ∗ log(2)
Log(final concentration) − Log(initial concentration)
hBMMSCs Differentiation into Adipocytes
The hBMMSCs (2 × 104 cells/well) were seeded into 24 well
plates and allowed to reach confluence before being stimulated
to differentiate using the StemPro adipocyte differentiation
kit (A10070-01, ThermoFisher Scientific). Control cells were
cultured using the differentiation basal medium alone while cells
stimulated to undergo adipocyte differentiation were cultured in
basal medium fortified with adipocytic supplement (StemPro R
)
for up to 21 days with fresh media change every 3–4 days.
Following differentiation, the cells were fixed in 4% formaldehyde
solution for 30 min, rinsed twice with PBS and stained with oil
Red O (Sigma) to visualize lipid vacuoles.
hBMMSCs Differentiation into Osteoblasts
The hBMMSCs (2×104 cells/ well) were seeded into 24 well plates
and stimulated to differentiate along the osteoblastic lineage
using (StemPro R
) osteoblast differentiation kit (A10072-01,
ThermoFisher Scientific). The control cells were cultured using
the differentiation basal medium alone while the cells stimulated
to undergo osteoblastic differentiation were cultured in basal
medium fortified with osteogenic supplement (StemPro R
) for up
to 21 days with fresh media change every 3–4 days. Following
differentiation, the cells were fixed in 4% formaldehyde solution
for 30 min, rinsed twice with PBS and stained with Alizarin red
(Sigma) solution, washed and analyzed by light microscopy.
hBMMSCs Differentiation into
Chondrocytes
The hBMMSCs (2×104 cells/ well) were seeded into 24 well plates
and stimulated to differentiate along the chondrocytic lineage
using (StemPro R
) chondrocyte differentiation kit (A10071-01,
ThermoFisher Scientific). The control cells were cultured using
the differentiation basal medium alone while the cells stimulated
to undergo chondrocyte differentiation were cultured in basal
medium with chondrogenic supplement (StemPro R
) for up to
21 days with fresh media change every 3–4 days. Following
differentiation, the cells were fixed in 4% formaldehyde solution
for 30 min, rinsed twice with PBS and stained with Alcian blue
solution prepared in 0.1 N HCl, washed and analyzed by light
microscopy.
Collagen (Sircol) Assay
The secreted total collagen levels from both chondrocyte
control and differentiation cultures were evaluated using the
SircolTM
(chemical collagen assay) kit (Bioclor) according to the
manufacturer’s instructions. Briefly, 1 ml of the Sircol reagent was
added to the 100 µl of the standards and samples (1:20, diluted
in distilled water) in 1.5 ml microcentrifuge tubes (Eppendorf);
mixed well and placed on a mechanical shaker for 30 min to
enable collagen-dye complex precipitation. The contents were
then centrifuged at 12,000 rpm for 10 min and the supernatant
was carefully decanted taking care to avoid loss of cell pellets.
The unbound dye was removed by layering 750 µl of ice-cold
acid-salt wash reagent (Kit content) followed by centrifugation at
12,000 rpm for 10 min. The supernatant was carefully removed
and 250 µl of alkali reagent (kit content) was added and
vortexed to dissolve the bound dye. Absorbance at 555 nm
was spectrophotometrically measured using a microplate ELISA
reader (µQuant-BioTek) and the collagen concentration was
determined.
Alkaline Phosphatase Assay
Alkaline phosphatase (ALP) activity levels from both control
and differentiated osteoblast cultures were evaluated by
measuring the release of p-nitrophenylphosphate (Sigma)
as reported earlier (Gauthaman et al., 2011). Absorbance at
555 nm was spectrophotometrically measured using a microplate
ELISA reader (µQuant-BioTek) and ALP concentration was
determined.
Quantitative Real-Time Polymerase Chain
Reaction (QRTPCR)
The hBMMSCs (2×106 cells) either as pellets or cell suspensions
in 500 µl PBS, were subjected to heat shock for various
temperatures (37, 45, and 55◦C) for 120 s using the hotplate
method as reported earlier (Dolan et al., 2012) as the temperature
was identified to be more accurate. Total RNA was then
extracted from the heat shock treated cells using QiagenTM
RNA extraction kit reagent (Invitrogen, Life Technologies).
RNA quality and quantity were measured using a NanodropTM
spectrophotometer (Nanodrop technologies, Wilmington, DW)
and all samples were treated with DNase-I prior to first strand
cDNA synthesis with random hexamers using the SuperScriptTM
first strand synthesis system (Invitrogen). Primer sequences were
taken from earlier published studies (Alekseenko et al., 2014;
Liang et al., 2015) and the details are given in Table 1. QRT-
PCR analysis was performed with the ABI StepOne Plus Real-
Time PCR System (Applied Biosystems, Foster City, CA) using
SYBR green and relative quantitation was performed using the
comparative CT (2- CT) method.
Statistical Analysis
The differences observed between treated and control cell
numbers, collagen content, alkaline phosphatase and gene
expression assays were analyzed using the Students t-test with
the statistical package for Social Sciences (SPSS 13). The results
were expressed as mean ± standard error of the mean (SEM)
from three different replicates for individual assays and a value
of p < 0.05 was considered to be statistically significant.
RESULTS
Morphology and Growth Characteristics of
hBMMSCs
In primary cultures by day 5–7 the hBMMSCs adhered to the
culture surface as multiple colony forming units (CFU) and the
cell numbers continued to expand by day 7–9 reaching up to
60–70% confluence. The non-adherent cells that were present

TABLE 1 | The genes and primer sequences used for quantitative real time
PCR.
Genes Primer sequences
GAPDH F: 5′-ACCACAGTCCATGCCATCAC-3′
R: 5′-TCCACCACCCTGTTGCTGTA-3′
BAX F: 5′- TGGAGCTGCAGAGGATGATTG -3′
R: 5′- GCTGCCACTCGGAAAAAGAC -3′
BCL2 F: 5′- GGCTGGGATGCCTTTGTG -3′
R: 5′- CAGCCAGGAGAAATCAAACAGA -3′
P53 F: 5′- GCGCACAGAGGAAGAGAATC -3′
R: 5′- CTCTCGGAACATCTCGAAGC -3′
TNF-α 5′-GGT-GCTTGT-TCC-TCA-GCC-TC-3′
5′-CAG-GCA-GAAGAG-CGT-GGT-G-3′
Cyclin A2 5′-CCT CTC CTC CAT GTC TGT
GTT-AAG-3′
5′-GTG CTC CAT TCT CAG AAC CTG
CTT-3′
Cyclin E1 5′-TGC AGA TCG CAG AGC TTC TA-3′
5′-CTT TCT TTG CTT GGG CTT TG-3′
HSP70 5′-TCTTGGCACCACCTACTCTTG-3′
5′-CATCACCGATCAACCGTTCAG-3′
F, Forward primer; R, Reverse primer.
in early cultures were washed away with media changes leaving
behind only adherent hBMMSCs. The hBMMSCs derived from
the bone marrow aspirate of OA patients showed epitheloid and
short spindle shaped cells in early passages (Figure 1). The initial
number of cells in primary monolayer cultures varied from 1.4 ±
0.4×106 to 1.9 ± 0.6×106 cells (from 5 mL bone marrow aspirate
cultured in three T175 cm2 flasks). However, with subsequent
passages where uniform monolayer cultures were obtained, the
cell numbers could be expanded to 2.1 ± 0.4 × 106 cells per
T175 cm2 flask.
Surface Marker Characterization of
hBMMSCs
The derived cells analyzed for CD markers expression
demonstrated high percentages of positive MSC related CD
markers, namely CD73 (95.7%), CD90 (99.0%), CD105 (98.2%),
CD44 (99.0%), and CD29 (83.2%) compared with respective
isotype matched controls (Figure 2). These cells were negative
for CD34 and CD45, the haematopoietic stem cell related CD
markers (Figure 2).
hBMMSCs Population Doubling and Cell
Viability
The hBMMSCs demonstrated a mean increase in cell numbers
from 24 to 72 h. There was a mean increase of 72.73 and 127.27%
at 48 and 72 h respectively (Figure 3A). These mean increases in
cell numbers were statistically significant (P < 0.05).
The hBMMSCs showed an increasing linear growth profile
over time with every passage and the PDT was 24.33–29.56 h
with growth rate 0.0285 and 0.0234 (Growth rate = number of
doublings that occur per unit of time) at P1 and P5 respectively.
Cell growth were slower with increase in passage number. The
trypan blue viability showed that most of the cultured hBMMSCs
remained viable in culture platforms that could be used for
in vitro assays. The percentage of viable cells were 94.57, 94.33,
and 94.77% at 24, 48, and 72 h respectively (Figure 3B).
Differentiation Potential of hBMMSCs
The hBMMSCs showed differentiation into adipocytes,
chondrocytes and osteoblasts with culture in respective
differentiation medium (StemPro R
). The cells differentiated
along the adipocyte lineage demonstrated lipid vacuolation
starting as early as day 14 and the number of cells with lipid
vacuoles increased when cultured until 21 days and these cells
demonstrated positive staining with oil red O (Figure 4A).
hBMMSCs cultured in chondrogenic differentiation medium
demonstrated aggregation of cells when cultured for up to 21
days and they included chondrocyte like cells that demonstrated
positive staining with Alcian blue compared to the control
(Figure 4B). Osteogenic differentiation potential of hBMMSCs
cultured in osteogenic differentiation medium showed positive
staining with Alizarin red indicative of calcium mineralization
(Figure 4C).
Collagen Secretion and Alkaline
Phosphatase Activity of Differentiated
hBMMSCs
The amount of secreted collagen measured using the Sircol assay
confirmed that chondrocytic differentiating cells secreted large
amounts of collagen at various culture periods compared to
undifferentiated control cells (Figure 5A). The mean percentage
increases in collagen levels were 923.53, 1078.96, and 1550.00% at
7, 14, and 21 days compared to their respective controls and these
increases were statistically significant (P < 0.05).
The culture media analyzed for alkaline phosphatase
activity from control and osteocytic differentiated cells showed
increase in alkaline phosphatase levels compared to control
undifferentiated cells (Figure 5B). The mean percentage
increases in alkaline phosphatase levels were 17.65, 200.10, and
131.25% at 7, 14, and 21 days compared to their respective
controls and only those increases at 14 and 21 days were
statistically significant (P < 0.05).
Effect of Arthroscope Temperature on the
Metabolic Activity of hBMMSCs
The cells that were exposed to the illuminated arthroscope for
10 min (Group A), 20 min (Group B), and 30 min (Group C)
demonstrated differences in metabolic activity rates for both
cell suspension group and cell pellet group when subsequently
cultured and assayed for 72 h. There were no changes in cell
morphology between suspensions and cell pellets. However, there
was a decrease in metabolically active cell numbers in the cell
suspensions (Figure 6A) compared to cell pellets (Figure 6B).
The cell suspensions displayed a minimal increase of 6.12% and
a minimal decrease of 2.04% at 10 and 20 min, respectively,
compared to controls (Figure 6C). Maximum mean decrease in
cell numbers were observed at 30 min (by 63.27%) compared
to the control (Figure 6C) and this was statistically significant
(P < 0.05). The cell pellet showed mean increases in cell numbers

FIGURE 1 | Phase contrast microscopic images showing primary cultures of human bone marrow derived mesenchymal stem cells (hBMMSCs) at
passages P0 (A) and P1 (B). Non-adherent cells are indicated by black arrows in P0 (A). The hBM-MSCs at P1 exhibited epitheloid and short spindle shaped and
morphology. (Magnification 10X).
by 62.86, 68.57, and 5.71% at 10, 20, and 30 min respectively,
compared to controls (Figure 6D). However, only those increases
observed at 10 and 20 min were statistically significant (P <
0.05).
Effect of Heat Shock on hBMMSCs Gene
Expression (QRTPCR)
Gene expression analysis of hBMMSCs exposed to 37, 45, and
55◦C for 120 s either as cell suspension or cell pellet demonstrated
significant upregulation of the anti-apoptotic, cell cycle and heat
shock genes in the cell suspension group compared to the cell
pellet group (Figures 7A,B). In the cell suspension group the
increase in BAX expression was 12.37-, 23.86-, and 25.18-fold at
37, 45, and 55◦C respectively (Figure 7B), while the increase in
P53 was 21.24-, 35.77-, 57.36-fold at 37, 45, and 55◦C respectively
(Figure 7B). Cyclin A2 showed increases of 116.07-, 165.27-,
and 179.43-fold in the cell suspension group (Figure 7B), while
Cyclin E2 showed increases of 85.13-, 150.51-, and 185.63-fold
at 37, 45, and 55◦C respectively (Figure 7B). TNF-α expression
increased by 3.95-, 7.51-, and 9.41-fold in the cell suspension
group (Figure 7B), while the HSP70 expression increased by
53.61-, 75.25-, and 98.11-fold at 37, 45, and 55◦C respectively
(Figure 7B). In the cell pellet group only P53 showed a significant
upregulation and showed increased expression by 2.91-, 3.56-,
and 6.16-fold at 37, 45, and 55◦C respectively (Figure 7A).
DISCUSSION
Current pharmacological and surgical therapies for OA provide
pain relief and some degree of functional restoration, but
a complete cure yet remains elusive. Epidemiological data
from the Middle East indicate an increase in the aging and
overweight/obese population, both of which are strong risk
factors for the development of OA (Loeser et al., 2012). Therefore,
it is predicted that OA will grow into a significant health problem
in the Middle East as it has become in the West.
Damaged cartilage has a limited self-healing capacity dues
to the limited numbers of chondrocytes in mature tissue, poor
responses to anabolic factors, impaired extracellular matrix
production and lack of blood vessels (Henrotin and Reginster,
1999). Attempts to stimulate intrinsic cartilage repair by bone
drilling or microfracturing can promote recruitment of stem
cells into the defect area. The presence of MSCs in synovial
membrane/fluid is another indication of the potential reparative
role that stem cells may play in damaged joint tissue regeneration
(Harvanová et al., 2011; Miller et al., 2015). Mesenchymal stem
cells from bone marrow, adipose tissue, synovium, umbilical cord
and peripheral blood have been used in the management of OA
(Richardson et al., 2010; Orth et al., 2014). However, a robust cell
type that can be easily harvested and display a high proliferative
capacity and chondrogenic potential will be offer significant
advantageous for the development of cellular therapies. A
recent comparative study on hBMMSCs and adipose tissue
derived MSCs (ADMSCs) seeded on Chondro-Gide scaffolds and
exposed to chondrogenic medium, identified good proliferation
and cartilaginous extracellular matrix deposition with hBMMSCs
compared to ADMSCs (Kohli et al., 2015), highlighting the
advantage of the former cell type for the development of
regenerative medicine approaches.
hBMMSCs derived from OA patients have shown variations
with respect to cell proliferation; in some cases cell yields and
proliferative indices are high whereas in others they are very
poor. Effective expansion of isolated cells is another challenge as
the major problem with autologus therapy is the availability of
adequate numbers of stem cells. The inoculum density of cells for
use in a single 3 mm-4 mm deep subchondral bone drilling site
is approximately 2 × 106 cells (Haleem et al., 2010). Therefore, a
minimum of 10–12 × 106 cells may be needed for use in 4-6 drill
defects. Moreover, these numbers must be achieved in less than
3–4 subcultures to avoid cellular de-differentiation. In the present
study, we were able to successfully achieve increased cell yields
(approximately about 12 × 106 cells in three to four passages
from an initial number of 2×106 cells from 5 ml of bone marrow
aspirate). Most cells in culture remained viable as shown by the

FIGURE 2 | Representative Fluorescent activated cell-sorting (FACS) analysis showing the CD marker expression pattern in human bone marrow
mesenchymal stem cells (hBMMSCs). Top panel: Respective isotype controls; Middle panel: MSC positive CD markers; Bottom panel: MSC Negative CD
markers.
trypan blue viability assay (Figure 4D) and these cells exhibited
a short PDT. However, as expected, the target cell expansion was
not achieved in some elderly patients. This could be due to the
intrinsic senescent nature of the cells as, there appears to be an
inverse relationship with cell numbers and aging (Choumerianou
et al., 2010).
The derived and expanded hBMMSCs from OA patients
were identified to satisfy the minimal criteria set by ISCT.
The cells were plastic adherent; showed expression of CD73,
CD90, CD105, and CD29 and lacked expression of CD34
and CD45 (Figure 3). These cells also demonstrated tri-lineage
differentiation into adipocytes, chondrocytes and osteoblasts
(Figure 5). However, in our previous studies of hBMMSCs
and human Wharton’s Jelly stem cells (hWJSCs) we have
demonstrated expression of both osteogenic and chondrogenic
related gene and protein expression (Baksh et al., 2007;
Gauthaman et al., 2011). In addition, we have shown increased
production and secretion of collagen and alkaline phosphatase
activity following chondrocytic and osteocytic differentiation
respectively, similar to earlier studies obtained by our group and
by other investigators (Baksh et al., 2007; Gauthaman et al., 2011;
Fong et al., 2012; Brady et al., 2014).
Exposing hBMMSCs to an illuminated arthroscope resulted
in decreased metabolic activity of the cells maintained in
suspension. However, cell pellets exposed to an illuminated
arthroscope demonstrated increased numbers of metabolically
active cells (Figures 4B,C). Initially the metabolically active cell
numbers increased and remained stable in suspension cultures
that were exposed to the illuminated arthroscope for 10 and
20 min. This could be due to the free floating individual cell
movements within the medium resulting in a shorter duration
of close range exposure of single cells to the illuminated source
unlike the outer layer of cells in the pellet, which remained in
the same position for the entire duration of exposure. This was
reflected initially as lower metabolic activity and/or survival in
the cell pellets compared to the cell in suspensions. In contrast,
longer exposure of the illuminated arthroscope and the resultant
rise in temperature would have affected the suspended cells more
adversely compared to most cells in the pellets, expect those that
were present in the outer layer. Earlier studies have identified
that heat-shock generated by orthopedic procedures leads to
death of the transplanted cells. Cell recovery following immediate
exposure to 60◦C for 30 s to 1 min and subsequent evaluation of
proliferation after 12, 24, and 96 h has identified that proliferation
decreases and death results almost immediately (mostly by
necrosis) (Dolan et al., 2012). However, mild heat shock and
exposure of cells to temperatures up to 47◦C result in positive
osteointegration by osteoprogenitors (Zaffagnini et al., 1996).

FIGURE 3 | Mitochondrial activity (MTT) and cell viability (trypan blue) assay of the human bone marrow mesenchymal stem cells (hBMMSCs). (A)
Cellular activity of the hBMMSCs by MTT assay at 24, 48, and 72 h showing increase in cell numbers with increase in time. (B) Trypan blue viability assay showing the
percentage of live and dead cells at 24, 48, and 72 h. All values are expressed as mean ± standard error of the mean (SEM) from three different samples. Asterisks (*)
indicate statistical significance at p < 0.05 compared to respective controls.
FIGURE 4 | Histological images of the human bone marrow mesenchymal stem cells (hBMMSCs) differentiated into adipocytes, chondrocytes and
osteoblasts and stained with oil red O, Alcian blue and Alizarin red stains respectively. (A–C) are the magnified images of the boxed areas from the treated
images of adipocytes, chondrocytes and osteoblasts respectively. Arrows in (A) indicate cell vacuolation, and arrows in (B) indicate the chondrocyte like cells.
Magnification 10X.
In contrast to the above studies, the temperature ranged from
27.6 to 37.3◦C, indicating that sub-physiological temperature
changes or cold-shock can also adversely affect the metabolic
activity of transplanted cells. Previous studies have also reported
that arthroscopic procedures may be involved with either supra-
physiologic or sub-physiologic changes in temperature following
low-flow irrigation or cryotherapy (Zaffagnini et al., 1996;
Horstman and McLaughlin, 2006). Moreover, the cell aggregates
(pellets) were better protected against cold-shock than the cell
suspensions.
Differentiation of the BMMSCs following heat shock was not
undertaken in the present study, which becomes a constraint to
support our other findings. This would have provided additional
insights into the functional ability of these cells. Although more
in depth studies are needed to understand the mechanisms
behind the cold/heat shock related decrease in metabolic activity
and/or cell survival, our preliminary findings indicate that
in autologous settings the use of hBMMSCs together with
chondrocytes may have a protective effect on the transplanted
stem cells.
Gene expression studies confirmed that hBMMSCs exposed
to increased temperatures resulted in significant upregulation
of apoptotic (BAX, P53), cell cycle (Cylcin A2, Cyclin E2) as
well as injury and heat shock related (TNF-α, HSP70) genes

FIGURE 5 | Collagen secretion (A) and alkaline phosphatase induction (B) increased with time following chondrocytic and osteoblastic differentiation
of hBMMSCs compared to control, reflecting the increase in commitment of progenitor cells toward the respective phenotype. Values are expressed as
mean ± standard error of the mean (SEM) from three different samples. Asterisks (*) indicate statistical significance at p < 0.05 compared to respective controls.
FIGURE 6 | Phase contrast microscopic images of human bone marrow mesenchymal stem cells (hBMMSCs) following exposure either as cell
suspension arm (A) or cell pellet arm (B) to illuminated arthroscopic temperature and cultured for 72 h. Decrease in cell density was observed in cell
suspension arm (A) compared to cell pellet arm (B). (Magnification 10X). (C,D) Cellular activity assay of the hBMMSCs exposed to an illuminated arthroscope at 72 h,
either as cell suspension (C) or cell pellet (D). Values are expressed as mean ± standard error of the mean (SEM) from three different samples. Asterisks (*) indicate
statistical significance at p < 0.05 compared to respective controls.
in cell suspensions compared to cell pellets. Previous studies
have reported that increases in temperature ranging from 47 to
70◦C as a result of surgical procedures may impair the survival
of MSCs (Gill et al., 2007). Thermal stress is known to induce
profound changes in protein function and gene expression which
in turn activate cellular adaptive mechanisms that help to protect
the organism (Leppä and Sistonen, 1997; Hettler et al., 2013).
We observed that the heat shock protein HSP70 was increased
significantly, which is indicative of an adaptive response of the
cells to overcome heat stress and interestingly this was more
pronounced in the cell suspension group. Increased expression
HSP70 is one of the most important responses following physical
and chemical stresses including elevated temperature, exposure
to heavy metals, pharmacological agents and bacterial toxins
(Sonna et al., 2002; Dolan et al., 2015). Increasing temperatures
beyond the threshold limit for a given cell type is known to
either activate the apoptotic program or result in cellular necrosis
in extreme situations (Creagh et al., 2000; Sonna et al., 2002;

FIGURE 7 | Gene expression profile (QRT-PCR) of BCL2, BAX, P53,
HSP70, TNF-α, CYCLIN A2, and CYCLIN E2 of hBMMSCs exposed to
heat shock either as cell pellet (A) or cell suspension (B). Upregulation of
apoptotic, cell cycle, inflammation and heat shock related genes in hBM-MSCs
cell suspension (B) compared to cell pellet (A) indicate that individual cells (B)
were easily affected by heat shock compared to cell pellet (A). Data analysis
and relative quantitation were performed using the comparative Ct method
( Ct). The differences in gene expression levels were analyzed using
student’s t-test. Asterisks (*) indicate statistical significance at p < 0.05.
Dolan et al., 2015). We also observed that in cell suspensions
proapoptotic BAX was increased and the antiapoptotic BCL2
was decreased, indicating that the hBMMSCs were undergoing
cell death. Cyclin E2 is involved in G1/S phase of cell cycle
progression and cyclin A2 is involved in regulation of G2/M
phase of cell cycle. Heat stress following radiation upregulate
HSP which in turn augments cell cycle arrest at G1, S, and G2/M
phases (Nitta et al., 1997). The increased expression observed for
cyclin E2 and Cyclin A2 in cell suspensions may be indicative
of an attempt to overcome the heat stress and promote cell
survival. The expression level probably decreased as the heat
stressed cells in the suspension group underwent necrotic death
unlike the pellet group. In addition, P53 is known to influence
expression of numerous target genes that control cell cycle,
apoptosis, gene instability, senescence following stress (Morselli
et al., 2008). Increased expression of P53 was observed following
heat stress, and P53 is associated with negative regulation of cell
cycle progression (Reisman et al., 2012). If the gene expression of
cell cycle inhibitor p21 had been included in the study, it would
have provided additional information on the cell proliferation
ability following heat shock of hBMMSCs.
The introduction of MSCs into the joint can be achieved either
through injection as a cell suspension or through loading onto
a scaffold as an implant. Our findings offer caution when the
former approach is used since the cells are not encased by a
matrix that can protect them from external factors such as heat
from the arthroscope. This study suggests that improvizations
in surgical methods that avoid generating large amounts of
heat may result in more favorable outcomes when applying
MSCs in cell suspension to treat an arthritic joint. Alternatively,
administration of cells in combination with biodegradable
materials as pellets/encapsulations might enhance the survival of
transplanted cells.
CONCLUSIONS
hBMMSCs from OA patients have the capacity to expand and
actively differentiate. However, they are prone to damage if
the method of delivery to the joint is not optimal and is
accompanied by the generation of excess heat. Less invasive and
more cytoprotective surgical methods that do not generate excess
heat are needed to ensure successful therapeutic delivery of MSCs
to the joint.
AUTHOR CONTRIBUTIONS
MAb and MAl are the clinicians and were involved in
providing clinical materials/information and intellectual support.
GK and MG were involved in conceptualization, intellectual
contribution, statistical evaluation and manuscript writing. HA
and RK was involved in providing technical assistance with
experimental work, manuscript editing and intellectual help. AA,
AC, MAQ, and WK were involved in the overall co-ordination
of the work, and also reviewed and edited the manuscript. AM
contributed to the synthesis and editing of the manuscript.
ACKNOWLEDGMENTS
We acknowledge the financial support provided by the
“Sheik Salem Bin Mahfouz Scientific Chair for Treatment of
Osteoarthritis by Stem Cells” and the stem cell laboratory
facility at CEGMR and King Abdulaziz University Hospital’.
AM is the co-ordinator of the D-BOARD Consortium funded
by European Commission Framework 7 programme (EU
FP7; HEALTH.2012.2.4.5-2, project number 305815, Novel
Diagnostics and Biomarkers for Early Identification of Chronic
Inflammatory Joint Diseases). AM is a member of the
Applied Public-Private Research enabling OsteoArthritis Clinical
Headway (APPROACH) consortium, a 5-year project funded
by the European Commission’s Innovative Medicines Initiative
(IMI). APPROACH is a public-private partnership directed
toward osteoarthritis biomarker development through the
establishment of a heavily phenotyped and comprehensively
analyzed longitudinal cohort. The research leading to these
results has received partial support from the Innovative

Medicines Initiative (IMI) Joint Undertaking under grant
agreement no. 115770, resources of which are composed of
financial contribution from the European Union’s Seventh
Framework programme (FP7/2007-2013) and EFPIA companies’
in kind contribution. The funders had no role in study design,
data collection and analysis, decision to publish, or preparation
of the manuscript. We acknowledge Dr. Farid Ahmed for his
support with flow cytometry.
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Copyright © 2016 Kalamegam, Abbas, Gari, Alsehli, Kadam, Alkaff, Chaudhary,
Al-Qahtani, Abuzenadah, Kafienah and Mobasheri. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (CC BY).
The use, distribution or reproduction in other forums is permitted, provided the
original author(s) or licensor are credited and that the original publication in this
journal is cited, in accordance with accepted academic practice. No use, distribution
or reproduction is permitted which does not comply with these terms.

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