Injury, Int. J.

Care Injured (2005) 36S, S34—S37

www.elsevier.com/locate/injury

Biological activity of bone morphogenetic

proteins (BMP’s)
S.J.E. Matthews

The Oxford Trauma Unit, The John Radcliffe Hospital, Oxford OX3 9DU, UK

Accepted 25 July 2005

KEYWORDS Summary Bone morphogenetic proteins are multifunctional molecules having

Bone morphogenetic
protein;
Biological activity;
Fracture healing;
Pattern of expression
effects in many tissue types. They are members of the transforming growth fac-
tor-b superfamily. At least 40 different types have been described to date. Their
potential use in tissue regeneration has led to extensive research leading to a plethora
of articles being published. This article provides a brief overview of the biological
activity of different BMP’s involved in the fracture healing process.
# 2005 Elsevier Ltd. All rights reserved.

Introduction is OP-1, BMP-8 is OP-2, BMP-12 is Growth and Differ-

Bone morphogenic protein (BMP) was first described
by Dr. Marshall Urist in 1965.17 Since then, their
importance in bone regeneration has been illustrated
by a plethora of scientific studies.
BMP are multifunctional autocoids which have
effects on many tissue types in the body and mod-
ulate embryological growth and differentiation as
well as cellular function. They are members of the
transformation growth factor-b (TGF-b) superfam-
ily except for BMP-1, which does not have the C-
terminal sequence of the TGF-b family.
BMPs are misleadingly named, as their actions
have been implicated in the development of many
tissues, including heart, gut and kidney. Because
BMPs have been isolated from different species, and
due to the lack of standardisation of these purifica-
tions, several of the BMPs have alternate names that
are often used interchangeably. For instance, BMP-7
E-mail address: Stuart.Matthews@orh.nhs.uk.
entiation Factor 7 (GDF-7), and BMP-13 is both GDF-
6 and CDMP-2. The Cartilage Derived Morphogenic
Proteins (CDMP) are also TGF-b family members.1
At least 40 different sub-types have been des-
cribed to date and these have been divided into
groups according to their primary amino acid
sequence as below
 BMP 2/4: BMP-2 and BMP-4 (BMP-2b)
 BMP 7/OP1: BMP-5, -6 (Vgr-1), -7(OP1), -8(OP2), -
8b(OP3)
 BMP 3: BMP-3 (osteogenin) and BMP-3b (GDF-10)
 CDMP: BMP-12, -13, -14 (CDMP1-3)
 Others: Growth/Differentiation (GDF) 5, 6 and 7,
BMP-15, BMP-16
Their role in inducing differentiation of fibro-
blasts to convert to osteoblasts and so to form bone
has been established in vivo.14 However, there is
an ongoing debate and research activity to clearly
define the biological activity of each of these mole-
cules on an individual basis.

0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2005.07.032
Biological activity of bone morphogenetic proteins
Biological activity
Extensive research has burgeoned in the last decade
due to their potential use in tissue engineering and
bone healing as they play an important role in the
development and repair of both cartilage and bone.
BMPs bind to receptors in the cell membrane of
their target cell. There are two receptor types
(BMPR type I and II) and also type IA and type IB,
the latter differing in their spatial as well as tem-
poral distribution. This may explain in part why the
same molecule has different effects on different
cell types and even cell age may initiate different
responses from the same BMP.
Once BMPs bind to the BMPR the latter phosphor-
ylate transcription factors which ultimately activate
the expression of target genes in the cell nucleus, in
conjunction with other co-activators. These tran-
scription factors are called Smads, of which type 1, 5
and 8 are the active types3 which form a complex
with type 4 inside the cell nucleus before activating
the relevant gene. Regulation of the action of BMPs
is carried by Noggin and Chordin which act as
antagonists.
Smad proteins, of which 8 types are found in
vertebrates, are the first responsive transcription
factors that were found using a screen for genes that
repress mutations in a Drosophila melanogaster
TGF-b like gene named MAD (this stands for Mothers
Against Decapentaplegic gene). The same gene has
also been found in the nematode Caenorhabditis
elegans–—the spinal muscular atrophy protein pro-
ducing gene, namely Sma. The derivation of Smad is
thus from Sma and Mad. These proteins are ubiqui-
tous cellular proteins that have been preserved
through evolution and mediate responses to the
TGF-b/Activin/BMP family.
The clinical effects of BMPs affect different parts
of the pathway from chemotaxis and mitogenesis,
cellular differentiation and up regulation of cellular
proliferation and vascularisation. Many BMPs, either
alone or in tandem have been implicated in chon-
drogenesis as well as bone formation and they also
affect calcification and remodelling of callus.
At the cellular level Shukunami et al.15 have
shown that BMP-2 initiates chondrogenesis in ATDC5
cells (a mouse chondrogenic cell line). BMP-2 and
BMP-7 on the other hand have been shown to cause
apoptosis (cell death) of undifferentiated chick
chondrocytes but to support them if already differ-
entiated; an example of differences in temporal
BMP receptor status.
Onishi et al.13 used immunostaining of a rat frac-
ture model to determine the locations of BMP-2/-4,
BMP-7 and the BMP type 2 receptor (BMPR-II)
in membranous and endochondral ossification.
S35
They found that in the early stages of fracture repair,
BMPs-2/-4 and 7 were strongly induced in the thick-
ened periosteum near the fracture ends and that
this coincided with enhanced expression of BMPR-II.
By day 7 following fracture, BMP-2/-4 and 7 immu-
nostaining was increased in various chondrocytes
including proliferating chondrocytes in endochon-
dral bone, as well as fibroblast like spindle cells. By
day 14, BMP-7 was no longer expressed in prolifer-
ating and mature chondrocytes whilst BMP-2 and 4
continued to be expressed in various chondrocytes
until the late stage. They also found that in newly
formed trabecular bone, BMPs-2/-4 and 7 were
present at various levels and were observed on
multinucleated osteoclast like cells on newly
formed trabecular bone. They noted that BMPR-II
was actively expressed in both intramembranous
and endochondral ossification. Taking into account
their previous work on BMPR-I receptors they con-
cluded that BMP-7 may act predominantly in the
initial phase of endochondral ossification while BMP-
2/-4 acts throughout the process.
In contrast, Cheng et al.2 attempted to identify
the BMPs that may possess the most osteoinductive
activity analysing BMP activity in mesenchymal pro-
genitor and osteoblastic cells by infecting them with
recombinant adenoviruses expressing the 14 human
BMPs (2—15). They used alkaline phosphatase activ-
ity, osteoclastin and matrix stimulation as outcome
measures. They interpreted their findings as
showing an osteogenic hierarchical model in which
BMP-2, 6 and 9 played an important role in inducing
osteoblastic differentiation of mesenchymal stem
cells and in contrast most BMPs being able to sti-
mulate osteogenesis in mature osteoblasts.
Cho et al.3 examined the temporal patterns of
messenger RNA (mRNA) expression for members of
the TGF-b superfamily over a 28 day period in
healing mouse tibias. They found that BMP-2 and
growth differentiation factor 8 (GDF-8) showed max-
imal expression on day one after fracture whilst,
amongst other things, BMPs-3, 4, 7 and 8 showed a
restricted period of activity from days 14 to 21.
BMP-2 and BMP-7 have been evaluated in animal
models and in human clinical trials and are available
for clinical use. Much of the clinical application has
been in encouraging and enhancing spinal fusion
surgery6,18 but has also been shown to have a role
in the treatment of fracture non unions10 and the
healing of critical sized diaphyseal bone defects.
They have also been used to encourage osteointe-
gration of orthopaedic implants and to help in the
incorporation of bone grafts. Work has also been in
progress with regards to their role in cartilage16 and
even tendon/ligament repair. BMP-7 has also been
S36
Figure 1 Overview of the role of different BMPs in osteocytic differentiation.
demonstrated by Mizumoto et al.12 to generate bone
in an animal model of distraction osteogenesis.
Clinical usage however has not proved to be a
panacea although a role has been established in
enhancing bone formation in unfavourable circum-
stances. Research into the action of the different
BMPs at cellular level suggests that the different
BMPs act at different stages in the transformation of
pluripotential cells to osteoblast formation with
subsequent bone formation and remodelling.13
Gutierrez et al.7 reported that BMP-2 has the
capacity to specifically convert the differentiation
pathway of the mouse myoblast cell line C2C12 into
that of osteoblast lineage cells, acting on the synth-
esis of proteoglycan during that conversion. On the
other hand, Gerstenfeld et al.4 showed that carti-
lage formation, which always precedes that of bone
during endochondral ossification, is initiated by
BMP-7 which appears to induce an ordered progres-
sion of cell differentiation via chondrogenic differ-
entiation through to osteogenesis the former
preceding the latter over 2—4 days.
However, Gerstenfeld et al.5 also showed that
whilst the progression of cartilage formation pre-
cedes that of bone in endochondral ossification,
BMP-7 may not be the conductor of the orchestra
for the whole process and it seems that chondro-
cytes will selectively promote osteogenesis by
expressing soluble Morphogenic factors of their
own, this effect not being induced by BMP-7.
Whilst BMP-2 and BMP-7 have been shown to
induce bone formation to the extent that they have
found applications in clinical practice, it is not clear
whether the other BMPs may have equal or indeed
greater clinical applications in this regards. This has
been due to the fact that recombinant proteins for
the others are either not biologically active or as yet
not available for the other BMPs. However, Kang
et al.9 from the University of Chicago Medical Centre
have used recombinant adenoviruses expressing the
14 types of BMPs (AdBMPs) and have found that BMP-
6 and BMP-9 effectively induced orthotopic ossifica-
tion when either the AdBMP transduced osteoblast
progenitors or the viral vectors were injected into
the quadriceps muscles of athymic mice. They
further showed that BMP-3 effectively inhibited
the orthotopic ossification induced by BMPs 2, 6
and 7. BMP-3 however failed to inhibit BMP-9
S.J.E. Matthews
induced bone formation. They concluded that
BMP-6 and BMP-9 may represent more effective
osteogenic factors for bone regeneration.
The same unit also used AdBMPs to analyse the
effects on both mesenchymal progenitor cells, pro-
osteoblastic and osteoblastic cells using alkaline
phosphatase activity, osteocalcin and matrix miner-
alisation as outcomes measures of osteoinductive
activity. They concluded, amongst other things, that
BMPs 2, 6 and 9 may play an important role in inducing
osteoblastic differentiation of mesenchymal stem
cells whereas most BMPs were able to stimulate
osteogenesis in mature osteoblasts (Fig. 1).6
It is clear that the way forwards in the therapeu-
tic application of BMP is to use them either in
combination or as adjuncts to cellular culture.11
Furthermore, whilst homodimeric BMPs are effec-
tive in clinical practice, evidence is emerging that
heterodimeric BMPs may have a greater clinical
effect than homodimers alone. Zhu et al.19 used
an A549 producer cell line co-transfected with ade-
novirus vectors encoding BMP-2 and BMP-7 (AdBMP2,
AdBMP7) and as controls each vector alone or with
no virus. This method was applied to a rat poster-
olateral spinal fusion model. At 8 weeks they were
assessed radiographically, mechanically and for
bone mineralisation and formation. They concluded
that Combined BMP-2 and BMP-7 gene transfer is
significantly more effective in inducing osteoblastic
differentiation and spine fusion than individual BMP
gene transfer.
Clinical trials are ongoing and results are
encouraging with meta-analysis revealing better
rates of healing than treatment with autologous
bone graft.9 BMPs-2 and -7 may in time be super-
seded by other BMPs in the clinical setting but
despite their effects on the development of many
tissue types and their ability to cross the placenta
making pregnancy an absolute contraindication,
clinical trials have revealed little evidence of toxic
effects but careful monitoring for potential long
term effects would seem sensible.8
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