AFIRM OUR SCIENCE FOR THEIR HEALING

Armed Forces 

Institute of 

Regenerative 

Medicine

Annual Report 2013

Armed Forces Institute of Regenerative Medicine

Annual Report 2013

This report contains nontechnical summaries of all currently funded Armed Forces 

Institute of Regenerative Medicine research projects. The technical progress reports 

for these projects are contained in the AFIRM Annual Report 2013 – Technical 

Progress Reports.

Ms. Kristy S. Pottol

Program Director

Armed Forces Institute of Regenerative Medicine (AFIRM) 

Project Management Office (PMO) 

Kristy.s.pottol.civ@mail.mil
AFIRM Annual Report 2013

Table of Contents

ii

Executive Summary...................................................................................................................................................v

I: Introduction

Background..............................................................................................................................................................I-1

Research Goals........................................................................................................................................................I-2

The Five Major Research Programs of the AFIRM............................................................................................I-2

History......................................................................................................................................................................I-3

Funding: A Six-Way Partnership..........................................................................................................................I-4

Structure ..................................................................................................................................................................I-5

Management and Oversight..................................................................................................................................I-9

II: Limb and Digit Salvage

Background.............................................................................................................................................................II-1

Unmet Needs......................................................................................................................................................... II-2

Areas of Emphasis ............................................................................................................................................... II-3

Bone Repair and Regeneration ...........................................................................................................................II-4

Soft Tissue Repair and Regeneration (Excluding Nerve)................................................................................II-6

Nerve Repair and Regeneration.......................................................................................................................... II-9

Composite Tissue Injury Repair........................................................................................................................II-12

Epimorphic Regeneration...................................................................................................................................II-12

Clinical Trials.......................................................................................................................................................II-13

III: Craniofacial Reconstruction

Background...........................................................................................................................................................III-1

Unmet Needs........................................................................................................................................................III-2

Areas of Emphasis ...............................................................................................................................................III-2

Bone Regeneration...............................................................................................................................................III-2

Soft Tissue Regeneration.....................................................................................................................................III-6

Cartilage Regeneration (Focus: Ear).................................................................................................................III-9

Clinical Trials.....................................................................................................................................................III-10

IV: Scarless Wound Healing

Background...........................................................................................................................................................IV-1

Unmet Needs........................................................................................................................................................IV-2

Areas of Emphasis ...............................................................................................................................................IV-2

Control of Wound Environment and Mechanics ...........................................................................................IV-3

Therapeutic Delivery to Wounds.......................................................................................................................IV-3

Attenuation of Wound Inflammatory Response.............................................................................................IV-5

Clinical Trials.......................................................................................................................................................IV-6
our science for their healing

Table of Contents iii

V: Burn Repair

Background.............................................................................................................................................................V-1

Unmet Needs..........................................................................................................................................................V-2

Areas of Emphasis .................................................................................................................................................V-3

Intravenous Treatment of Burn Injury ...............................................................................................................V-3

Topical Treatment of Burn Injury ...................................................................................................................... V-4

Wound Healing and Scar Prevention .................................................................................................................V-5

Skin Products/Substitutes.................................................................................................................................... V-6

Clinical Trials........................................................................................................................................................ V-8

VI: Compartment Syndrome

Background...........................................................................................................................................................VI-1

Unmet Needs........................................................................................................................................................VI-2

Areas of Emphasis ...............................................................................................................................................VI-2

Cellular Therapy of CS........................................................................................................................................VI-2

Biological Scaffold-Based Treatment of CS......................................................................................................VI-4

VII: AFIRM Statistics

Introduction ....................................................................................................................................................... VII-1

Personnel............................................................................................................................................................. VII-2

Honors and Achievements ............................................................................................................................... VII-3

Publications and Presentations........................................................................................................................ VII-5

Inventions, Patent Applications, and Patents................................................................................................VII-6

Developmental Accomplishments and Milestones.......................................................................................VII-6

Appendices

Appendix A: Honors and Awards to AFIRM Faculty......................................................................................A-1

Appendix B: Publications and Presentations.....................................................................................................B-1

Appendix C: Patent Applications and Invention Disclosures ........................................................................C-1

Appendix D: Descriptions of Technology Readiness Levels and Clinical Study Phases ........................... D-1

Appendix E: Acronyms.........................................................................................................................................E-1

AFIRM OUR SCIENCE FOR THEIR HEALING

Regenerative medicine is a rapidly growing discipline that aims 

to provide hope for restoring the structure and function of damaged tissues and organs, and curing previously untreatable injuries and diseases. The concept of regenerative medicine—in its 

simplest form—is to replace or regenerate human cells, tissues, 

or organs to restore or establish normal function. Advanced 

technologies, such as tissue regeneration, novel biomaterials scaffolding, and stem cell-enabled treatments, are 

needed to revolutionize the clinical rehabilitation of 

individuals with severe injuries. 

Executive 

Summary
AFIRM Annual Report 2013

Executive Summary

vi

In 2008, the Department of Defense established the 

Armed Forces Institute of Regenerative Medicine 

(AFIRM) to help treat injured warfighters who 

have survived serious injury (potentially due to 

advances in body armor, battlefield evacuation, and/

or military medical care) only to face the challenge 

of overcoming severe limb, head, face, and burn 

wounds caused by the use of improvised explosive 

devices. As a multi-institutional, interdisciplinary network of scientists, the AFIRM’s mission is 

to accelerate the development of new regenerative 

medicine-based products and therapies to treat the 

severe injuries suffered by U.S. Service members. 

Utilizing a team of well established, proven research 

investigators, the AFIRM has expanded the regenerative medicine knowledge base, developed models 

of injury, and tested advanced technology products 

in an effort to propel the field forward.

The AFIRM has exceeded the U.S. Army’s expectations regarding the quickness of translating new 

therapies from the research laboratory into clinical trials. These advances were made possible by a 

cultural transformation among the participating 

laboratories. Usually, academic laboratories receive 

competitive but rather small, short-term research 

grants that foster innovation but do not necessarily allow translational research or the formation of 

collaborative networks. The AFIRM changed this 

culture by (1) fostering an understanding among its 

researchers that clinical impact is the ultimate goal, 

and (2) focusing its mission on synergy through collaboration among the laboratories. This understanding permeates all levels of the AFIRM program 

including its leadership. 

Creating Partnerships and 

Collaborations 

Over the past five years, the AFIRM has achieved 

success through a six-member partnership that 

includes the U.S. Army, Navy, and Air Force; the 

Veterans Health Administration; the Defense 

Health Program; and the National Institutes of 

Health. This effective collaboration has yielded more 

than 85 funded projects to date, with research activities being organized into five primary focus areas 

that include Limb and Digit Salvage, Craniofacial 

Reconstruction, Scarless Wound Healing, Burn 

Repair, and Compartment Syndrome. A Program 

Synergy Group was established early on to identify 

collaborative opportunities and to build bridges 

between the focus areas and projects.

Dr. Krista Niece, a research associate at USAISR, 

measures fluoride levels in media from cells cultured 

with the antifungal drug voriconazole. Elevated 

serum fluoride levels have been reported in patients 

taking voriconazole.

Limb and Digit Salvage 

The Limb and Digit Salvage focus area 

seeks to develop novel solutions using 

regenerative medicine that will allow 

victims of severe extremity trauma to 

recover rapidly, reliably, and completely 

so they can return to productive lives. 

In total, 22 projects received funding 

in Year 5. Projects span the following 

clinical challenge areas: Bone, Soft 

Tissue, and Nerve Repair/Regeneration; 

Composite Tissue Injury Repair; and 

Epimorphic Regeneration.
our science for their healing

Executive Summary vii

Research under the AFIRM is conducted 

through two independent research consortia 

working with the U.S. Army Institute of Surgical 

Research (USAISR). One research consortium is led by Rutgers, the State University of 

New Jersey, and the Cleveland Clinic (RCCC 

[Rutgers–Cleveland Clinic Consortium]), while 

the other is led by Wake Forest University 

Baptist Medical Center and the McGowan 

Institute for Regenerative Medicine in 

Pittsburgh (WFPC [Wake Forest–Pittsburgh 

Consortium]). Each consortium is a multiinstitutional network, together comprising more 

than 35 members, which are primarily academic 

institutions. Notably, AFIRM member organizations have established collaborations/partnerships with more than 100 academic or industrial institutions located within and outside of 

the U.S. (including Australia, China, Finland, 

France, Germany, Italy, and the Netherlands). 

As the AFIRM consortia continue to exhibit a 

substantial level of collaboration and coordination, 

a web of new working relationships has evolved 

between the two academic consortia (RCCC and 

WFPC) and USAISR, and between academic and 

military scientists and clinicians. This type of successful collaboration is illustrated by a Craniofacial 

Reconstruction project that is focused on developing vascular tissue engineering treatments using 

bioactive scaffolds. Funded in 2010 by an AFIRM 

supplement, this project links the Longaker group 

at Stanford University (WFPC member) with 

the Anderson/Langer team at the Massachusetts 

Institute of Technology (RCCC member). Another 

example of successful collaborative activity within 

the AFIRM involves a number of strong working 

relationships that have developed over the past two 

years between RCCC and WFPC investigators and 

military clinicians at the Walter Reed National 

Military Medical Center (WRNMMC). For example, a WRNMMC patient who received a double 

hand transplant by WFPC researchers at Johns 

Hopkins University was recently transferred back to 

WRNMMC to continue to receive hand therapy and 

rehabilitation. 

The development of new partnerships with scientists at various academic institutions as well as with 

industry partners has led to the establishment of 7 

new AFIRM projects in the areas of Craniofacial 

Reconstruction, Burn Repair, and Limb and Digit 

Salvage since 2012. These projects are being led 

by the following individuals: Dr. Brian Barnes of 

Arteriocyte Medical Systems, Inc.; Dr. Stephen 

Feinberg of the University of Michigan; Dr. Bohdan 

Pomahac of Brigham and Women’s Hospital; 

Drs. David Sachs and Curtis Cetrulo, Jr., of 

Massachusetts General Hospital; Drs. Douglas 

Smith and D. Kacy Cullen of the University of 

Pennsylvania; Dr. Richard Clark of NeoMatrix 

Formulations, Inc.; and Dr. Thomas Tulenko of 

Cooper Medical School of Rowan University. 

Partnerships such as these will add new technologies to the existing research portfolio, helping to 

fulfill the mission of the AFIRM. 

Year 5 Program Highlights 

The AFIRM program involves the efforts of nearly 

500 individuals, which include faculty members, 

postdoctoral fellows, graduate students, scientific 

and technical staff, and undergraduates. AFIRM 

faculty members are highly accomplished scientists: During the fifth year of the program, AFIRM 

faculty received 43 honors or awards, including 

selection to membership or leadership positions 

in professional societies, invited presentations and 

lectureships, receipt of honorary degrees, awards 

from private foundations, recognition of excellence 

at conferences, and faculty teaching awards. 

Craniofacial 

Reconstruction 

The Craniofacial Reconstruction focus 

area aims to generate both soft and hard 

tissues through novel regenerative medicine 

approaches to reduce the impact to wounded 

warriors of devastating, disfiguring facial 

injuries. In total, 18 projects received funding 

in Year 5. Projects span the following 

clinical challenge areas: Bone Regeneration, 

Soft Tissue Regeneration, and Cartilage 

Regeneration (with a focus on the ear).
AFIRM Annual Report 2013

Executive Summary

viii

AFIRM-sponsored researchers are making substantial contributions to the scientific literature: In the 

fifth year of the program, the group published 85 

articles in peer-reviewed journals and produced 70 

presentations and non-peer-reviewed publications. 

AFIRM scientists also have been making novel 

patentable discoveries in the field of regenerative 

medicine: During the fifth year of the program, the 

researchers filed 8 invention disclosures and 8 U.S. 

Government patent applications. 

The Technology Readiness Levels (TRLs) of products generated by AFIRM-funded researchers have 

been steadily rising. At the start of the program, 58 

of 63 research and development products (92%) were 

nearly evenly distributed across TRLs 1, 2, and 3. 

By the end of the fifth year of the program, approximately one-third of the products were at TRLs 2 

and 3, one-third at TRL 4, and one-third at TRL 5 

or greater. The shift to higher TRL numbers demonstrates the increasing translation of products into 

preclinical studies and human clinical studies. 

The AFIRM has recruited a substantial number of 

talented young scientists into the field of regenerative medicine. During the fifth year of the program, 

more than 100 graduate and undergraduate students received practical scientific training through 

AFIRM-sponsored research projects. The number 

of advanced degrees (master’s or doctoral) awarded 

to students who received training through AFIRMsponsored projects has risen from 3 in the first year 

of the program to 24 in the fifth year.

Year 5 Research Highlights 

Research efforts over the past 5 years have led to 

dozens of noteworthy accomplishments, including 

the following: 

Dr. Matthew Tirrell and colleagues at the University 

of California, Berkeley, and the University of 

Chicago (Limb and Digit Salvage, Project 4.4.5, 

WFPC), are pursuing an approach to induce peripheral nerve growth following traumatic amputation 

by modulating components of the naturally occurring extracellular matrix (ECM). The researchers 

have developed a peptide-based hydrogel system as 

injectable ECMs with nanofibrous structures. They 

can incorporate bioactive peptide sequences and/or 

growth factors into the hydrogels. The concentration 

of the hydrogels, which is directly linked to stiffness, 

can be tuned to promote the spreading, proliferation, and migration of a model cell type, Schwann 

cells. The researchers will choose the hydrogel 

concentration that performs best in their in vitro 

Scarless Wound 

Healing 

The Scarless Wound Healing focus area 

encompasses technologies aimed at 

the various stages of wound healing to 

find new treatment options to prevent 

and manage scars. In total, 9 projects 

received funding in Year 5. Projects 

span the following clinical challenge 

areas: Control of Wound Environment 

and Mechanics, Therapeutic Delivery 

to Wounds, and Attenuation of Wound 

Inflammatory Response.

WFPC postdoctoral fellows prepare a glass pipette 

for sterile technique.
our science for their healing

Executive Summary ix

models, and they will use this concentration in 

animal studies.

Dr. Scott Guelcher and colleagues at Vanderbilt 

University (Craniofacial Reconstruction, 

Projects 4.5.1a/4.5.7, RCCC) are developing and 

evaluating allograft bone/polymer composites 

for treating trauma-related bone defects. The 

researchers are pursuing two related projects in 

collaboration with researchers at the USAISR 

and Medtronic. In Project 4.5.1a, they are developing injectable, settable LV® bone grafts for the 

repair of long bone defects. In Project 4.5.7, they 

are developing injectable, settable LV bone grafts 

augmented with recombinant human bone morphogenetic protein-2 (rhBMP-2) for the repair of 

craniofacial and long bone defects. The researchers have demonstrated that their LV grafts support bone remodeling and healing in rabbit and 

sheep leg bone defect models. They also found that 

delivery of rhBMP-2 from LV grafts enhanced new 

bone formation in a rat skull defect model. Pending 

510(k) regulatory clearance of the LV bone graft 

and successful completion of the preclinical studies, 

preparation for a clinical trial in patients requiring 

ridge augmentation will begin.

Dr. Sang Jin Lee and colleagues at Wake Forest 

University (Compartment Syndrome, Project 4.3.5, 

WFPC) are focused on developing an approach to 

enhance the recruitment of endogenous stem and 

progenitor cells to the site of compartment syndrome injury to increase the regenerative response. 

The researchers are using biomaterials containing 

myogenic (muscle cell)-inducing factors that can be 

implanted within the injured muscle compartment. 

They have demonstrated that host muscle stem cells 

can be recruited into implanted biomaterials in situ, 

and that these cells can be transformed into muscle 

cells using myogenic-inducing factors. They have 

developed novel injectable and implantable scaffolding systems using heparin-conjugated gelatin microparticles and heparin-conjugated cell-free muscle 

matrix, respectively. The researchers demonstrated 

the mobilization of host stem and progenitor cells, 

as well as new muscle tissue regeneration in vivo in 

rats, using these scaffolding systems. 

Dr. Thomas Mustoe and colleagues at Northwestern 

University (Scarless Wound Healing, Project 4.6.3, 

RCCC) are investigating the wound-healing capability of curcumin (a yellow-colored component of 

the Indian spice turmeric). The researchers found 

that the intravenous delivery of curcumin accelerated healing and reduced scarring in a rabbit ear 

ischemia/reperfusion (I/R) model. They also found 

that they could apply curcumin via tiny nanospheres to the wound site in the rabbit I/R model 

with no apparent toxicity. They recently confirmed 

the effectiveness of curcumin in reducing necrosis and supporting the survival of skin flaps in 

a porcine model. They expect the transition to 

Good Manufacturing Practices to be straightforward based on discussions with manufacturers of 

curcumin.

Dr. Robert Christy and colleagues at USAISR (Burn 

Repair, Project 4.6.8, USAISR) isolated human adipose-derived stem cells (ASCs) using a point-of-care 

device. They developed the technology to differentiate ASCs into epithelial cells for use on patients so 

severely burned that they do not have an autologous 

source of epithelial cells. They also demonstrated 

that stem cells can be isolated in adequate quantities from the adipose layer of discarded burn skin. 

They recently developed the technology to remove 

the cells from the amniotic membrane for epithelial differentiated ASC sheets and epithelial wound 

covering. They also developed a porcine model to 

determine the validity of skin constructs in deep 

partial thickness burns. The researchers plan to 

Burn Repair 

The Burn Repair focus area seeks 

to leverage regenerative medicine 

technologies to reduce morbidity and 

mortality in victims of severe burns, both 

military and civilian. In total, 15 projects 

received funding in Year 5. Projects span 

the following clinical challenge areas: 

Intravenous Treatment of Burn Injury, 

Topical Treatment of Burn Injury, Wound 

Healing and Scar Prevention, and Skin 

Products/Substitutes.
AFIRM Annual Report 2013

Executive Summary

x

continue to use and optimize the InGeneron, Inc. 

point-of-care device for the isolation of ASCs. They 

will also develop a more clinically relevant porcine 

burn model, and use this model for the development 

of a large (up to 20%) total body surface area burn, 

which will provide a stringent test for their, and 

other AFIRM-related, skin equivalent products.

From the Laboratory to the 

Battlefield 

AFIRM-funded researchers share a strong commitment to bringing therapies as quickly as possible 

to wounded warriors and the civilian sector. The 

conduction of clinical trials is the ultimate goal of 

many AFIRM-sponsored projects. Through Year 

5, AFIRM investigators have advanced numerous 

products through clinical study planning, approval, 

and execution stages. Ten (10) clinical trials were 

open to patient enrollment during the fifth year 

of the program, including six Phase I or I/II, three 

Phase III, and one diagnostic study. Another three 

clinical protocols for Phase I or I/II studies were 

submitted to Institutional Review Boards or Human 

Research Protection offices. 

Nontechnical summaries of the AFIRM clinical trials can be found at the end of each focus area-related 

chapter, and full progress reports of the clinical 

trials (when available) are located in the AFIRM 

Annual Report 2013 – Technical Progress Reports. 

The following are a few examples of promising 

translational research projects: 

In Project 4.7.3 (Scarless Wound Healing, RCCC/

USAISR), researchers at the University of Florida 

(UF) are conducting a Phase I/IIa clinical trial 

designed to test the safety and efficacy of using 

autologous fat transfer (AFT) for scar prevention 

and remodeling. Patient enrollment began in July 

2010. To date, the researchers have enrolled and 

treated 10 patients. The key 

accomplishments for the 

past year were the successful transition of the 

clinical trial to UF, and the 

finalization of all administrative and protocolrelated logistics at both UF 

and USAISR/Brooke Army 

Medical Center, such that 

the trial is open to enrollment at two new sites. 

There are multiple companies that currently market 

fat tissue transplantation 

devices and systems. If the 

evidence from this trial 

supports the use of AFT Hulan Shang prepares adipose-derived cells for flow cytometry.

Compartment 

Syndrome 

The Compartment Syndrome focus area 

addresses secondary sequelae of trauma. 

Projects in this program seek to prevent, repair, 

or regenerate tissue damaged by compartment 

syndrome, thereby enhancing the healing 

process for a quicker return to functionality. 

In total, 6 projects received funding in Year 5. 

Projects span the following clinical challenge 

areas: Cellular Therapy of Compartment 

Syndrome and Biological Scaffold-Based 

Treatment of Compartment Syndrome.
our science for their healing

Executive Summary xi

for scar remodeling, the researchers do not expect 

any problems regarding commercialization.

In Project 4.4.2 (Limb and Digit Salvage, WFPC), 

researchers at the Johns Hopkins University School 

of Medicine and the University of Pittsburgh are 

developing a protocol for hand transplantation 

using donor bone marrow stromal cells in combination with novel fusion proteins (the “Pittsburgh 

Protocol”) that will minimize maintenance immunosuppressive therapy. The researchers have performed 10 successful hand/forearm transplants in 

six patients, including the first bilateral and first 

above elbow arm transplant in the U.S. All compliant transplant patients to date are being maintained 

on a single immunosuppressive drug at low doses, 

and they continue to have increased motor and 

sensory function of their transplanted hands, which 

correlates with their severity of amputation, time 

after transplant, and participation in hand therapy. 

In Project 4.5.2 (Craniofacial Reconstruction, 

RCCC), researchers at the University of Michigan 

are using a tissue-engineering/regenerative medicine approach, in conjunction with the surgical 

technique of prelamination, to create a prevascularized composite soft tissue flap. More specifically, 

the researchers are using an ex vivo-produced oral 

mucosa equivalent for major areas of intra-oral 

reconstruction, and as a platform technology for 

the tissue engineering of a set of human lips. The 

technology in development is similar to the development of orphan drugs, in that the target market area 

is very specific: post-traumatic (explosives, burns, 

gunshot and motor vehicle accidents) and postoncologic surgery.
Executive Summary

xii AFIRM Annual Report 2013
AFIRM OUR SCIENCE FOR THEIR HEALING

Background

Nearly 6,800 U.S. military fatalities and more than 51,000 injuries have resulted from the wars in Iraq and Afghanistan.1

 The 

use of improvised explosive devices in these conflicts has led to 

a substantial increase in severe blast trauma; explosive injury 

mechanisms have accounted for approximately three-quarters 

of all combat-related injuries.2 Scientific advances in body armor 

to protect the torso and vital organs, faster evacuation from the 

battlefield after injury, and major advances in trauma resuscitation save wounded warriors who would have died of 

their injuries in previous conflicts. However, those who 

survive often have seriously debilitating injuries to 

unprotected areas of the face, neck, head, and 

limbs, causing massive trauma and tissue loss.

I: Introduction

1 Http://www.defense.gov/news/casualty.pdf as of January 15, 2014. 2 Belmont, et al. J Trauma Acute Care Surg. 2012 Jul;73(1):3-12.
AFIRM Annual Report 2013

I: Introduction

I-2

The emerging field of regenerative medicine holds 

great potential for healing military personnel with 

debilitating, disfiguring, and disabling injuries. 

Regenerative medicine focuses on (1) restoring the 

structure and function of tissues and organs that 

have been damaged, and (2) finding methods of 

curing previously untreatable injuries and diseases. 

Scientists are applying a variety of approaches to 

prompt the body to regenerate cells and tissues, 

often using the patient’s own cells combined with 

degradable biomaterials. Use of a patient’s own cells 

eliminates the possibility of tissue rejection. Recent 

years have seen the rapid development of technologies for engineering tissues. Scientists ultimately 

hope to deliver advanced therapies, such as whole 

organs and engineered fingers and limbs, to injured 

members of the military as well as civilians. 

Research Goals 

The AFIRM is a multi-institutional, interdisciplinary network of leading universities, hospitals, and 

private companies working to develop advanced 

treatment options for severely wounded warfighters. 

The AFIRM was designed to accelerate the delivery 

of regenerative medicine therapies to treat our most 

severely injured Service members, but in particular those coming from our theaters of operation in 

Iraq and Afghanistan. Clinical trials have begun for 

several AFIRM products, including advanced transplantation strategies and engineered skin replacement applications. The inclusion of military patients 

in these trials is the first step in delivering advanced 

technologies to wounded warriors. 

The Five Major Research 

Programs of the AFIRM 

Limb and Digit Salvage 

Saving the limb, also referred to as “limb salvage,” 

at a minimum requires (1) bridging large bony 

defects to restore skeletal integrity; (2) bridging soft 

tissues, such as muscle, nerves, tendons, and ligaments, to lend stability and enable movement; and 

(3) covering the injured area with healthy skin. The 

AFIRM Limb and Digit Salvage program is focused 

on developing regenerative medicine therapies to 

help healthcare providers save and rebuild injured 

limbs. The ultimate goal of this program is to enable 

victims of severe extremity trauma to recover rapidly, reliably, and completely so they can return to 

productive lives. 

Craniofacial Reconstruction 

Massive bone and soft tissue loss to the face and 

head due to blast forces 

is a devastating injury. 

Researchers funded by 

the AFIRM Craniofacial 

Reconstruction program 

are designing and developing therapies that healthcare providers can use to 

return form and function 

of the face, head, and neck 

to warfighters with severe 

craniofacial injuries. These 

therapies are expected to 

(1) regenerate functional 

bone and cartilage to levels 

of the face; (2) restore 

motor and sensate competencies through muscle, 

vascular, and nerve 

regeneration; (3) mitigate 

scar formation; (4) prevent 

infection; and (5) eliminate RCCC researcher Glenda Evans analyzes images on bone regeneration. 
our science for their healing

Introduction I-3

skin coverage deficits through tissue engineering. 

The creation and delivery of new polymers and 

tissues will preserve and regenerate bone and soft 

tissue capable of administering stem cells, growth 

factors, bone derivatives, and therapeutic drugs. 

Scarless Wound Healing 

Severe military trauma burns often heal with large 

scars that may impair normal function and cause 

significant disfigurement. Scars are the result of the 

body’s complex series of wound-healing processes 

that begin at the onset of injury and can continue 

for months. The AFIRM Scarless Wound Healing 

program is focused on investigating all phases of 

wound healing and scar formation to find new 

treatment strategies to prevent and mitigate scars.

Burn Repair

Although there have been many advances in medical care, severe burns are still associated with substantial morbidity and mortality. The AFIRM Burn 

Repair program is leveraging regenerative medicine 

technology to (1) prevent wound infection, (2) prevent burn inflammation and injury progression, 

(3) speed the generation of a viable wound bed and 

reduce the reharvest time of autograft donor sites, 

(4) improve skin substitutes for burn wound grafting when autografts are not immediately available, 

and (5) prevent and manage scars. 

Compartment Syndrome

Compartment syndrome is often a secondary 

sequela resultant from blast injuries, severe blunt or 

penetrating trauma, fractures, and vascular injuries. 

Muscles are encased in compartments of nonyielding tissue called fascia. Bleeding or tissue swelling 

within a muscle compartment raises the pressure 

in the compartment and, if unchecked, this pressure can become high enough that blood flow into 

the compartment is reduced or completely stopped. 

Prolonged interruption of blood flow can destroy 

the nerves and muscles within the compartment. 

Restoration of these damaged or destroyed tissues 

has no satisfactory solution with current surgical options. The AFIRM Compartment Syndrome 

program focuses on advancing effective therapies to 

stabilize tissue and reduce the onset of late effects of 

nerve and muscle damage. 

History

In 2005, Dr. Anthony Atala presented some of the 

latest advances in the field of regenerative medicine at the Advanced Technology Applications in 

Combat Casualty Care Conference. This talk alerted 

the combat casualty care research community to 

the near-term potential for regenerative medicine 

products that could make a substantial difference 

in the care of our wounded warriors. In 2006, the 

Army’s Director of the Combat Casualty Care 

Research Program, COL Bob Vandre, developed the 

idea of a regenerative medicine institute similar to 

the Department of Defense (DoD) Multidisciplinary 

University Research Initiative, but aimed at 

near-term, translational research. Soon thereafter, COL Vandre received approval from the U.S. 

Army Medical Research and Materiel Command 

(USAMRMC) to pursue funding for this project. 

He briefed the DoD Technology Area Review and 

Analysis panel, which reviews medical research 

and development for the DoD, and the panel highly 

approved the concept. 

Rutgers graduate student Koustubh Dube works in 

the walk-in hood used for kilogram-scale polymer 

synthesis at the New Jersey Center for Biomaterials.
AFIRM Annual Report 2013

I: Introduction

I-4

In 2007, USAMRMC, the 

Office of Naval Research 

(ONR), the U.S. Air Force 

Office of the Surgeon 

General, the National 

Institutes of Health (NIH), 

and the Veterans Health 

Administration of the U.S. 

Department of Veterans 

Affairs (VA) agreed to 

co-fund the new institute. 

These funds, along with 

$10 million (M) from the 

2007 War Supplemental bill, 

provided $8.5M per year 

in funding for the AFIRM, 

which was deemed sufficient to proceed. A Program 

Announcement was released 

in August 2007, and seven 

proposals were received in 

October 2007. Two finalists were selected for oral 

presentations in December 2007. Both received 

scores of “excellent,” and one was selected for funding. White House staffers learned of the AFIRM 

and invited representatives from USAMRMC to 

meet and discuss the new institute.

After two meetings, and upon hearing that funding was available for only one AFIRM finalist, the 

DoD was tasked to provide funding for the second AFIRM finalist. Within 1 week, an additional 

$8.5M per year was transferred to USAMRMC’s 

budget lines. Both AFIRM finalists signed 

USAMRMC cooperative agreements in March 2008. 

Funding: A Six-Way Partnership 

The AFIRM is financed with basic research through 

exploratory development funds and is expected to 

make major advances in the ability to understand 

and control cellular responses in wound repair and 

organ/tissue regeneration. The program is managed 

and funded through USAMRMC with funding 

from the following organizations: 

•	 U.S. Army

•	 U.S. Navy, ONR

•	 U.S. Air Force, Office of the Surgeon General

•	 Veterans Health Administration

•	 Defense Health Program

•	 NIH

Total funding for the first 5 years of the AFIRM 

amounts to more than $300M: 

•	 $100M from U.S. government funding (Army,

Navy, Air Force, VA, and NIH). 

•	 $80M from matching funds received from state

governments and participating universities. 

•	 $109M from pre-existing research projects

directly related to deliverables of the AFIRM 

from the NIH, Defense Advanced Research 

Projects Agency, congressional special programs, the National Science Foundation, and 

philanthropy. 

• $25M in additional funds provided by the

Defense Health Program. 

AFIRM was recently extended for a sixth year with 

no additional funds. A new effort, referred to as 

AFIRM II, will build on the success of the AFIRM. 

Following an open competition, the Wake Forest 

University School of Medicine (Wake Forest Baptist 

Medical Center) was selected to lead AFIRM II. 

Funded through a cooperative agreement with 

USAMRMC, ONR, NIH, Air Force Medical 

Service, VA Office of Research and Development, 

and Office of the Assistant Secretary of Defense for 

Cell Therapy technicians at Lonza Walkersville, Inc. perform cell culture in a 

Lonza current Good Manufacturing Practices-compliant facility.
our science for their healing

Introduction I-5

Health Affairs, AFIRM II is scheduled to begin in 

fiscal year 2013. AFIRM II will encompass five key 

research areas, including extremity regeneration, 

craniomaxillofacial regeneration, skin regeneration, 

composite tissue allotransplantation and immunomodulation, and genitourinary/lower abdomen 

reconstruction. 

Structure 

The AFIRM is composed of two independent 

civilian research consortia working with the U.S. 

Army Institute of Surgical Research (USAISR) at 

Fort Sam Houston, Texas. USAISR, which includes 

the San Antonio Military Medical Center – North 

(formerly Brooke Army Medical Center), serves 

as the AFIRM’s primary government component 

and is home to the DoD’s only burn unit. The two 

AFIRM research consortia are responsible for 

executing the management of overall therapeutic 

programs and individual projects within their consortia. One consortium is led by Rutgers, the State 

University of New Jersey, and the Cleveland Clinic, 

and the other is led by the Wake Forest Institute for 

Regenerative Medicine and the McGowan Institute 

for Regenerative Medicine in Pittsburgh. Each of 

these civilian consortia is itself a multi-institutional 

network, as described below. 

Rutgers–Cleveland Clinic Consortium 

The Rutgers–Cleveland Clinic Consortium (RCCC) 

is directed by Joachim Kohn, PhD, Director of 

the New Jersey Center for Biomaterials and Board 

of Governors Professor of Chemistry at Rutgers 

University, and co-directed by Linda Graham, MD, 

Staff Vascular Surgeon at the Cleveland Clinic 

and Professor in the Department of Biomedical 

Engineering at the Lerner Research Institute at Case 

Western Reserve University. 

The RCCC consists of the following member 

institutions: 

•	 Rutgers, the State University of New Jersey/New

Jersey Center for Biomaterials

•	 Cleveland Clinic

•	 Brigham and Women’s Hospital

•	 Carnegie Mellon University

•	 Case Western Reserve University

•	 Cooper Medical School of Rowan University

•	 Dartmouth Hitchcock Medical Center/Thayer

School of Engineering

•	 Massachusetts General Hospital/Harvard

Medical School

•	 Massachusetts Institute of Technology

•	 Minnesota Medical Research Foundation

•	 Mayo Clinic College of Medicine

•	 Northwestern University

•	 Stony Brook University

•	 University of Cincinnati

•	 University of Florida

•	 University of Medicine and Dentistry of

New Jersey

•	 University of Minnesota

•	 University of Michigan

•	 University of Pennsylvania

•	 University of Virginia

•	 Vanderbilt University

Wake Forest–Pittsburgh Consortium 

The Wake Forest–Pittsburgh Consortium (WFPC) 

is directed by Anthony Atala, MD, Director of the 

Wake Forest Institute for Regenerative Medicine 

and Professor and Chair of the Department of 

Urology at Wake Forest University, and co-directed 

by Rocky Tuan, PhD, Director of the Center 

for Cellular and Molecular Engineering at the 

University of Pittsburgh. 

The WFPC consists of the following member 

institutions:

•	 Wake Forest Institute for Regenerative

Medicine/Wake Forest University

•	 McGowan Institute for Regenerative Medicine/

University of Pittsburgh

•	 Allegheny-Singer Research Institute

•	 Carnegie Mellon University

•	 Georgia Institute of Technology

•	 Institute for Collaborative Biotechnologies

(includes University of California, Santa 

Barbara; Massachusetts Institute of 

Technology; and California Institute 

of Technology)
AFIRM Annual Report 2013

I: Introduction

I-6

•	 Johns Hopkins University School of Medicine

•	 Oregon Health and Science University

•	 Rice University

•	 Sanford-Burnham Medical Research Institute/

University of California, Santa Barbara

•	 Stanford University

•	 Tufts University

•	 University of California, Berkeley

•	 University of Chicago

•	 University of Texas Health Science Center

at Houston

•	 University of Wisconsin

•	 Vanderbilt University

Additional Collaborators to the AFIRM 

AFIRM researchers have established a wide variety 

of both national and international partnerships 

with academia and industry, which has contributed 

to the success of the program to date. These have 

included collaborations with:

•	 Allegheny-Singer Research Institute

•	 Armand Trousseau Hospital (France)

•	 Arizona Burn Center

•	 Arteriocyte Medical Systems, Inc.

•	 Avita Medical, LLC

•	 Axonia Medical

•	 Baylor All Saints Medical Center

•	 Baylor College of Medicine

•	 Baylor University Medical Center

•	 Biogeneral, Inc.

•	 Biologics Consulting Group

•	 Biosafe-America

•	 BioStat International, Inc.

•	 BonWrx, Inc.

•	 Buffalo General Hospital

•	 CVPath Institute, Inc.

•	 Cynvenio Biosystems

•	 Emory University

•	 Evonics

•	 Fidia Advanced Biopolymers (Italy)

•	 GID Group, Inc.

•	 Glycosan BioSystems, Inc.

•	 Healthpoint Biotherapeutics, Ltd./

DFB Bioscience

•	 ImageIQ, Inc.

•	 InGeneron, Inc.

•	 Integra Spine/Integra LifeSciences

•	 Intercytex Ltd.

•	 Intrinsix Corp.

•	 Jefferson University Hospital

•	 Johann Wolfgang University (Germany)

•	 Kensey Nash Corporation

•	 KeraNetics, LLC

•	 Kinetic Concepts, Inc.

•	 Lexmark, Inc.

•	 LifeCell Corporation

•	 LifeNet Health

•	 Lonza Walkersville, Inc.

•	 Louisiana State University

RCCC researcher Jarred Nesbitt performs postoperative care in the animal care facility.
our science for their healing

Introduction I-7

•	 Loyola University Medical Center

•	 Maricopa Integrated Health Systems

•	 Massachusetts Eye and Ear Infirmary

•	 MedDRA Assistance, Inc.

•	 Medical University of South Carolina

•	 Medtronic, Inc.

•	 Montefiore Medical Center

•	 Morgridge Institute for Research

•	 Neodyne Biosciences

•	 NeoMatrix Formulations, Inc.

•	 New York University

•	 Nitinol Development Corporation

•	 Norman Noble, Inc.

•	 North Carolina State University

•	 NOVOTEC

•	 NovoPedics, Inc.

•	 Numia Medical

•	 Ohio State University

•	 Oregon Biomedical Engineering Institute

•	 Oregon Medical Laser Center

•	 Organogenesis, Inc.

•	 Orlando Regional Medical Center

•	 Osteotech, Inc.

•	 Pennington Biomedical Research Center,

Louisiana State University 

•	 PeriTec Biosciences, Ltd.

•	 Philadelphia University

•	 Proxy Biomedical

•	 Queensland University of Technology

(Australia) 

•	 Radboud University of Nijmegen Medical

Centre (The Netherlands) 

•	 ResearchPoint Global

•	 Resonetics

•	 Rockefeller University

•	 Royal Perth Hospital (Australia)

•	 St. Barnabas Medical Center

•	 San Antonio Military Medical Center – North

(formerly Brooke Army Medical Center) 

•	 Shanghai 9th People’s Hospital (China)

•	 SimQuest, LLC

•	 Spaulding Rehabilitation Hospital

•	 Special Operations Medical

Command-Fort Bragg 

•	 Stratatech Corporation

•	 Stryker Corporation

•	 Texas Tech University

•	 Tolera Therapeutics, Inc.

•	 Trident Biomedical, Inc.

•	 University Hospitals, Cleveland

•	 University of Alabama at Birmingham

•	 University of California, Davis

•	 University of California, Los Angeles

•	 University of Colorado Hospital

Christine Miller, a National Research Council 

postdoctoral fellow at the U.S. Army Institute of 

Surgical Research, prepares Ribonucleic acid (RNA) 

samples for sequencing to identify RNA-based 

therapeutics for the treatment of drug-resistant 

biofilm pathogens commonly associated with 

chronic wounds.
AFIRM Annual Report 2013

I: Introduction

I-8

•	 University of Indiana

•	 University of Kentucky

•	 University of Massachusetts, Lowell

•	 University of Michigan

•	 University of North Carolina at Chapel Hill

•	 University of South Florida/Tampa

General Hospital 

•	 University of Tampere (Finland)

•	 University of Tennessee Health Science Center

•	 University of Texas at Arlington

•	 University of Texas at Austin

•	 University of Texas, San Antonio

•	 University of Texas Southwestern

Medical Center 

•	 University of Utah

•	 University of Washington-Harborview

Medical Center 

•	 University of Wisconsin–Madison

•	 Virginia Commonwealth University

•	 Washington Hospital

Center (Washington, 

DC)

Programs and 

Projects 

Research activities are 

organized into programs 

within each consortium. While some of 

the con-sortia programs 

are directly comparable to the AFIRM’s 

major research programs (e.g., RCCC’s 

CranioMaxilloFacial 

Program), other consortia programs consolidate expertise (e.g., 

WFPC’s Extremity 

Injury Program, which 

integrates experts in the 

areas of limb and digit 

salvage and compartment 

syndrome). A scientist or clinician Program Leader 

coordinates each program, which consists of multiple projects. One or more Project Leaders directs 

each project, which can vary in size from a single 

laboratory to a collaboration spanning multiple 

institutions. 

Consortium members evaluate all levels of the 

operation on an annual basis to monitor progress 

and guide the consortium’s activities. Active project 

management by each consortium has reshaped the 

programs, leading to the termination or reduced 

funding of some projects and the addition of projects that are more promising for accelerated development. The consortia also engage external scientific program and product development consultants 

who provide advice regarding clinical trials, product 

development plans, and other recommendations for 

commercialization. Additionally, information for 

the public, including clinical trial opportunities, has 

been made available through websites developed 

and maintained by the consortia.

In addition to the three core groups (RCCC, WFPC, 

and USAISR), intramural researchers from the NIH 

RCCC researcher Joseph Morand performs peripheral nerve microsurgery under a 

microscope at the University of Pennsylvania.
our science for their healing

Introduction I-9

and/or the Veterans Health Administration can 

participate in the AFIRM program, although none 

have chosen to do so as of yet. With the approval of 

a program leader, these intramural researchers can 

lead projects.

Management and Oversight

The day-to-day execution of the AFIRM’s research 

portfolio is managed by the AFIRM Project 

Management Office (PMO), which is located within 

the U.S. Army Medical Materiel Development 

Activity at Fort Detrick, Maryland. The AFIRM 

PMO works as part of an integrated project management team, across the AFIRM consortia, to 

incorporate the strategic, developmental, and tactical aspects of product management. The AFIRM 

PMO also functions as an accountability model to 

ensure execution of the AFIRM portfolio. 

The AFIRM is guided by a Board of Directors 

(BOD) and an Integrated Project Team (IPT), which 

contains a Steering Group. A Program Synergy 

Group is responsible for research coordination and 

communication between the three components of 

the AFIRM. The roles and membership of each of 

these entities are described below.

Board of Directors

The AFIRM’s BOD 

is chaired by the 

Commanding General 

of USAMRMC, and its 

members are flag-level 

representatives from the 

Army, Navy, Air Force, 

NIH, VA, Office of the 

Assistant Secretary 

of Defense for Health 

Affairs, TRICARE 

Management Activity, 

and the Uniformed 

Services University of 

the Health Sciences. The 

Principal Assistant for 

Research and Technology 

of USAMRMC serves as 

the Deputy Chair of the 

BOD. The main purpose 

of the BOD is to provide high-level guidance 

for the AFIRM by presiding over the IPT and the 

Program Synergy Group.

Integrated Project Team

The AFIRM’s IPT is chaired by the Director of the 

USAMRMC’s Clinical and Rehabilitative Medicine 

Research Program (CRMRP). IPT membership 

consists of a group of experts who represent the 

interests of the funding agencies, experts in military 

needs, external scientists knowledgeable in regenerative medicine, and specialists in contracting and 

product development. The overall function of the 

IPT is to ensure that the AFIRM meets military 

needs, funds superior science, and is well managed. 

The specific responsibilities of the IPT are to: 

•	 Approve the annual report and program plans

that are presented to the BOD. 

•	 Ensure that all AFIRM research projects are

aligned with military requirements. 

•	 Monitor and evaluate the activities and progress of the AFIRM programs and management, 

and provide recommendations based on their 

expertise. 

Bridget Ford, a postdoctoral fellow in the Extremity Trauma and Regenerative 

Medicine task area at USAISR, prepares adipose-derived stem cells for use in tissue 

engineered scaffolds for wound-healing applications.
I: Introduction

I-10 AFIRM Annual Report 2013

•	 Facilitate the military’s evaluation and purchasing of products developed by the AFIRM. 

•	 Assist consortia directors and management

teams in internal communication within the 

DoD, and in understanding and meeting DoD 

regulation and reporting requirements relative 

to AFIRM performance. 

•	 Facilitate the leveraging of AFIRM resources by

coordinating with other funding agencies that 

support closely related research. 

The IPT’s Steering Group has day-to-day decisionmaking authority over the AFIRM and recommends major changes in research direction or 

funding to the voting members of the IPT. This 

group is chaired by the AFIRM Project Director and 

also includes the USAISR Commander, the Combat 

Casualty Care Senior Scientist, the Contracting 

Officer, and the Directors and Co-Directors of the 

RCCC and the WFPC. Among other activities, the 

Steering Group ensures that all AFIRM research 

projects are aligned with military requirements, 

reviews AFIRM research allocation, establishes 

decision points and continuation criteria, assesses 

project and program achievements in relation to 

milestones and timelines, and recommends continuation or termination of programs and individual 

projects to the IPT. 

The IPT has additional members from the Army, 

Navy, Air Force, and VA (one representative from 

each of these organizations), three representatives 

from the NIH (sharing one vote), and four external scientists. The IPT also has ex officio advisors 

from the Judge Advocate General, the DoD Human 

Research Protection Office, a commercialization 

expert, and a regulatory expert appointed by the 

CRMRP. 

The Steering Group and the additional IPT members are voting members of the IPT. They are 

assisted by the ex officio members of the IPT and 

the Program Synergy Group to ensure that the 

AFIRM is progressing toward solutions for militarily relevant injuries. 

Program Synergy Group 

The Program Synergy Group includes representatives from each of the major programs in each of 

the consortia, members of the NIH or VA intramural research programs (as deemed appropriate), and USAISR. The Program Synergy Group is 

chaired by one of the consortia Co-Directors. It 

serves as a conduit for information exchange among 

the cores and seeks to build bridges between the 

programs and projects. It identifies and promotes 

opportunities to share or combine best practices 

and to accelerate existing projects or initiate new 

projects to bring therapies to our wounded Service 

members. The Program Synergy Group reports its 

findings and recommendations twice a year to the 

Steering Group.
AFIRM OUR SCIENCE FOR THEIR HEALING

Background

Warfighters in combat often suffer severe trauma to the extremities, and these injuries can result in large areas of tissue loss, 

disrupting function of the distal limb and interfering with 

wound healing. The primary goals of AFIRM’s Limb and 

Digit Salvage Program are to preserve and restore damaged or missing tissue following injury, reduce 

amputation rates, reduce the time and risks involved 

in recovery, and enable the warrior’s return to an 

independent, fully functional life and, ideally, 

return to duty. 

II: Limb and 

Digit Salvage
AFIRM Annual Report 2013

II: Limb and Digit Salvage

II-2

In light of this, researchers at Rutgers–Cleveland 

Clinic Consortium (RCCC) are working on integrated projects to develop tissue-engineering 

solutions for bone, nerve, blood vessels, menisci, 

and skeletal muscle. These researchers are collaborating with investigators in AFIRM’s Craniofacial 

Reconstruction Program to minimize immunosuppression in limb and face transplantation for those 

cases when salvage is not possible. RCCC researchers are also aligned with ongoing work in AFIRM’s 

Burn Repair Program to develop therapies for 

restoration of massive partial to full thickness skin 

loss in limbs following burn injury. 

Concurrently, Wake Forest–Pittsburgh Consortium 

(WFPC) researchers are pursuing an interdisciplinary, multipronged approach to the functional 

reconstruction/replacement of limb and digit tissue, including transplantation (composite tissue 

allografts), epimorphic regeneration, tissue regeneration by traditional tissue-engineering approaches, 

and enabling technologies that may be applied 

broadly across many types of defects in limb and 

digit reconstruction.

To help expedite these medical products and procedures, AFIRM researchers have established numerous industry partnerships in anticipation of commercialization, which is a critical step in delivering 

products to wounded warriors. 

Unmet Needs 

Today’s modern battlefield medicine is helping to 

save wounded warfighters who would not have 

survived in previous wars. As severe injuries to 

extremities are almost never limited to one tissue, 

failure to address any one tissue can result in functional or actual loss of the limb. Therefore, projects 

in the Limb and Digit Salvage Program are targeted 

to make specific advances in these areas of critical 

unmet needs, which include bone, nerve, artery, and 

soft tissue, as well as composite tissue injury repair 

and transplantation. 

Bone loss presents a significant challenge for restoration of limb function. Current techniques of bone 

restoration most often employ autogenous (patient’s 

own) cancellous bone graft, which provides a 

bone matrix, along with autogenous osteogenic 

(bone-forming) cells; however, the use of autogenous bone causes additional pain, bleeding, and 

scars as a result of the multiple surgeries required 

to both harvest and implant the bone material. 

Furthermore, the amount of bone that can be harvested from a patient is limited in cases of severe 

critical-size defects. As an alternative to autogenous 

bone, recombinant bone morphogenetic protein-2 

(BMP-2) has been used in combination with scaffolds to regenerate bone. Unfortunately, while innovative, none of these strategies has achieved rapid 

and predictable bone regeneration. 

The loss of soft tissue presents a significant challenge in the care of a severely damaged limb. These 

areas of soft tissue, which include muscle, tendon, 

ligament, fascia and cartilage, have limited restorative capabilities, yet are critical to the function of 

the salvaged limb. Blood vessel repair for hemorrhage control and rapid restoration of blood supply 

to an injured extremity remain critical factors in the 

survival of a wounded warrior and the preservation 

of limb function. Additionally, restoring vascular 

function is critical as the previous restorative strategies are dependent on restoring blood flow to the 

injury site.

Severe extremity injuries may involve extensive 

nerve loss. Nerve allografts (the use of cadaveric 

nerve tissue from another individual) represent 

a promising option for restoration or regeneration of lost nerves; however, allografting requires 

the patient to endure approximately 18 months 

of immunosuppressive therapy as endogenous 

nerves grow across the allogeneic conduit. Due to 

this extended duration of healing, the patient may 

be placed at risk of developing infections or other 

complications. Therefore, a need exists to develop 

allografts that can repair nerve defects in injured 

soldiers without the need for long-term immunosuppression. An added critical need exists for 

synthetic nerve scaffolds that can support consistent 

regeneration across large nerve gaps. 

Limb salvage is possible for many injured warriors; 

however, when the salvage attempt fails, it is critical that an identically functional replacement is 

provided through engineering or transplantation. 

Accurate control of the recipient’s immune response 

poses a significant challenge to the more widespread 

use of limb transplantation. Therefore, improving 

immunomodulation techniques to reduce the obstacles to composite tissue transplantation remains a 

critical unmet need.
our science for their healing

Limb and Digit Salvage II-3

Areas of Emphasis 

AFIRM researchers are pursuing a complementary 

mix of research projects focused on various aspects 

of limb and digit salvage. As shown in Table II-1, 

projects are grouped into five “clinical challenge” 

topic areas: Bone Repair and Regeneration, Soft 

Tissue Repair and Regeneration (excluding nerve), 

Nerve Repair and Regeneration, Composite Tissue 

Injury Repair, and Epimorphic Regeneration. 

Table II-1. Projects funded by RCCC and WFPC per clinical challenge topic area. 

Clinical Challenge Consortium/ 

Institution

Project 

No. Project Title

Bone Repair and 

Regeneration RCCC

4.2.1a Advanced 3-D Scaffolds for Large Segmental Bone Defects: NonLoad Bearing Tyrosine-Derived Polycarbonate Scaffolds

4.2.1b Advanced 3-D Scaffolds for Large Segmental Bone Defects: Partial 

Load Bearing Poly(Propylene Fumarate) Scaffolds

4.2.2 Optimizing Cell Sources for Repair of Bone Defects

4.2.2a Point of Care Autologous Stem Cell Concentrate for Bone Defect 

Repair

4.2.3 Advancing Bone Repair Using Molecular Surface Design (MSD): 

Biodegradable Scaffolds with Tethered Osteoinductive Biomolecules

4.8.1 Improved Preclinical Model for Orthopedic Trauma

Soft Tissue Repair 

and Regeneration 

(excluding nerve)

RCCC

4.3.2 Development of Tissue (Peritoneum) Lined Bioabsorbable and 

Fracture-Resistant Stent Graft for Vessel Trauma

4.3.2a Construction of Tissue Engineered Blood Vessels

4.4.3a Functional Scaffolds for Musculoskeletal Repair and Delivery of 

Therapeutic Agents 

4.4.3b Functional Scaffolds for Soft Tissue Repair and Joint Preservation

WFPC

4.4.6 Oxygen-Generating Biomaterials for Large Tissue Salvage

4.5.8 Isolation and Expansion of Native Vascular Networks for Organ Level 

Tissue Engineering

Nerve Repair and 

Regeneration

RCCC

4.4.1 Repair of Segmental Nerve Defects: A Theragnostic System Solution 

for Optimal Nerve Repair – Prevention of Muscle Atrophy

4.4.2 Repair of Segmental Nerve Defects

4.4.2a Cells and Bioactive Molecules Delivery in Peripheral Nerve 

Restoration

4.4.2b Repair of Peripheral Nerve Injury Using Tissue-Engineered Nerve 

Grafts Encased in Biodegradable Nerve Guidance Tubes

WFPC

4.4.4 Peripheral Nerve Repair for Limb and Digit Salvage

4.4.5 Modular, Switchable, Synthetic Extracellular Matrices for 

Regenerative Medicine

Composite Tissue 

Injury Repair WFPC 4.4.3 Spatial and Temporal Control of Vascularization and Innervation of 

Composite Tissue Grafts

Epimorphic 

Regeneration WFPC 4.4.1 Epimorphic, Non-Blastemal Approach to Digit Reconstruction
AFIRM Annual Report 2013

II: Limb and Digit Salvage

II-4

Nontechnical summaries of the projects are presented after the summary table, and technical 

progress reports for each project can be found 

in the AFIRM Annual Report 2013 – Technical 

Progress Reports. 

Bone Repair and Regeneration 

Studies at RCCC 

RCCC’s Limb Salvage and Transplantation Program 

aims to provide injured warriors with new clinical methods that significantly improve the regeneration of bone non-unions or large bone defects 

(more than 3 cm) in a reliable and timely manner. 

In Project 4.2.1a, the Ortiz and Kohn group at 

the New Jersey Center for Biomaterials at Rutgers 

University is developing advanced scaffolds to 

treat large segmental bone defects. The researchers 

synthesized four calcium phosphates (CaPs) with 

varying solubilities and then produced composite 

scaffolds by incorporating the CaPs into a tyrosinederived polycarbonate (TyrPC) polymer. They tested 

the CaP-containing scaffolds in rabbit skull and 

radius (forearm) defect models and found that several of the composite scaffolds regenerated bone as 

well as or better than a commercially available bone 

scaffold. All treatment groups had demonstrated the 

formation of a direct interface between native bone 

and scaffold. The researchers found that the scaffolds containing octacalcium phosphate performed 

better than any of the others. They also found that 

the addition of bone marrow aspirate (BMA) to 

their TyrPC/CaP scaffolds enhanced bone regeneration. The researchers plan to pursue a pivotal 

large animal goat skull defect model study in the 

upcoming year. They have designed a Phase I clinical trial. They plan to file a 510(k) application for 

the first-generation bone regeneration scaffold. The 

researchers have an exclusive license with Trident 

Biomedical, Inc. for the library of TyrPCs, and work 

with a separate industrial partner for the large-scale 

current Good Manufacturing Practices (cGMP) 

synthesis of TyrPCs.

In Project 4.2.1b, the Yaszemski team at the Mayo 

Clinic fabricated poly(propylene fumarate) (PPF) 

scaffolds for analysis in various bone defect animal models. The researchers loaded the scaffolds 

with recombinant human BMP-2 (rhBMP-2) via 

a collagen-based hydrogel for controlled delivery, 

and quantified the delivery kinetics of the rhBMP-2 

from the hydrogels in the scaffold pores. The 

research team increased bone formation in a rabbit 

skull defect model via a combination of CaP surface 

coating on the scaffold and rhBMP-2-controlled 

delivery from the scaffold. Their histology results 

indicated that bone is formed inside the pores 

of the scaffold and is distributed throughout the 

defect. During the upcoming year, the researchers 

plan to evaluate the CaP-coated PPF scaffolds with 

controlled rhBMP-2 delivery in a rat femoral (leg) 

defect model. Following the completion of these 

studies, the researchers will test the composite scaffolds in the minipig mandible (jaw) and goat tibia 

(lower leg) segmental defect models (in collaboration with Project 4.8.1). If these preclinical animal 

studies are successful, the researchers will proceed 

to a first-in-human pilot safety study of the scaffold 

implant, and perform cGMP scale-up, fabrication, 

sterilization, and pre-commercialization work for 

an Investigational Device Exemption (IDE)/510(k) 

submission. 

Bone-forming stem/progenitor cells are severely 

depleted in the region of a large bone defect. The 

Muschler group (Project 4.2.2) at the Cleveland RCCC graduate student Koustubh Dube prepares 

solution in the laboratory.
our science for their healing

Limb and Digit Salvage II-5

Clinic is addressing the need to define and competitively assess promising methods for harvesting, processing, and transplanting osteogenic 

(bone-forming) connective tissue progenitor cells 

(CTP-O). The researchers are exploring three basic 

methods for cell processing: Density separation 

(DS) (using a centrifuge to remove red blood cells 

and serum), selective retention (SR) (regarding the 

fact that CTP-O attach very readily to some surfaces as a means for concentration and selection), 

and magnetic separation (magnetically labeling 

CTP-O and then preferentially collecting them 

with a magnet). The researchers have determined 

that magnetic separation based on hyaluronan, as 

a marker for CTP-O, increased bone regeneration 

in the canine femoral multi-defect model. They 

attempted to validate the chronic caprine (goat) 

tibial defect (CCTD) model as a viable tool for 

advanced assessment of cell harvest and processing 

strategies, but found large differences in the yield 

and quality of cells between the proximal humerus, 

pelvis and sternum. Only the sternum proved to be 

a suitable model approximating the harvest of bone 

and marrow from human or canine bone. During 

the upcoming year, the researchers will complete a 

comparison of SR processing and DS using mineralized cancellous bone allograft in the canine femoral 

multi-defect model. The most effective sourcing and 

processing methods will be advanced into appropriate assessment in the CCTD model. The researchers 

are working with the Project 4.8.1 team to develop 

a more stringent CCTD model. The researchers will 

evaluate the most effective methods for cell sourcing 

alone and in combination with advanced scaffolds, 

surgical methods, and/or drug delivery systems to 

identify the most promising therapies to advance 

into clinical trials.

Due to the limitations of the currently available 

therapies, there remains an unmet need for a therapy that can regenerate bone in large gap defects. 

The Barnes team (Project 4.2.2a) at Arteriocyte, 

Inc. is investigating the effects of concentrated 

versus non-concentrated BMA on the regeneration 

of long bone. They are testing whether the concentrated BMA (cBMA) produced with the Magellan® 

MAR01TM system results in superior defect repair 

when combined with graft materials in a rabbit 

segmental defect model. This therapy is expected 

to accelerate fracture healing while reducing the 

likelihood of serious complications (e.g., non-union 

and osteomyelitis). The researchers successfully 

accomplished graft implantation on all 60 treatment 

animals and assessed the ability of the Magellan® 

System to concentrate BMA-derived nucleated cells 

and mesenchymal stem cells (MSCs). Preliminary 

data demonstrated that the Magellan® MAR01TM system could significantly enhance the concentration 

of MSCs and cBMA-derived nucleated cells. During 

the upcoming year, the researchers will conduct a 

variety of assessments to determine the efficacy of 

cBMA in improving bone repair. 

The Bushman and Kohn group (Project 4.2.3) at 

Rutgers University is using molecular surface design 

(MSD) to enhance the survival and performance of 

transplanted cells. MSD is a biomaterials strategy 

that involves tethering a growth factor or signaling 

molecule onto the surface of an implant to change 

the way that cells interact with the material. This 

can change cell attachment, migration, proliferation, differentiation, or survival in a controlled 

manner. During the past year, the researchers tested 

the efficacy of scaffolds tethered with rhBMP-2 in 

RCCC researcher Dr. Zheng Zhang holds a biphasic 

scaffold composed of a soft cartilage-forming layer 

overlaying a rigid bone-forming layer for use in the 

treatment of osteochondral defects.
AFIRM Annual Report 2013

II: Limb and Digit Salvage

II-6

the rabbit skull defect model. They recently harvested scaffolds from the rabbits and will use several 

methods to gauge the efficacy of the MSD method 

for tethering. The researchers also focused in Year 5 

on osteochondral (bone/cartilage) regeneration. 

They synthesized a small library of candidate polymers that induce adult stem cells to form cartilage 

and then conducted assays to select the best one(s). 

They found one polymer to be superior to all of the 

others. The researchers then developed a fabrication 

technique to mesh a bone-generating polymer scaffold with their newly identified cartilage-generating 

polymer. This technique allowed them to produce a 

“biphasic” scaffold capable of generating both bone 

and cartilage. The researchers next hope to obtain 

proof-of-principle data on their biphasic scaffold 

in a relevant animal model. With respect to the 

researchers’ bone regeneration scaffolds with tethered rhBMP-2, they hope to confirm efficacy in the 

rabbit skull defect model. Positive indications would 

lead to expansion of the technology and testing in 

larger animal models.

In Project 4.8.1, the Pluhar team at the University 

of Minnesota, the Bechtold team at Minnesota 

Medical Research Foundation, and the Muschler 

team at the Cleveland Clinic are seeking to develop 

a large animal model that is sensitive enough 

to allow for the testing of novel bone regeneration technologies before moving into Phase I or II 

human trials. The researchers created a bone defect 

in the tibia (lower leg) of Spanish-Boer goats. They 

performed surgeries on 30 goats with 12 weeks of 

radiographic follow-up that demonstrated little to 

no bone formation in the defects treated with the 

current standards of practice, fresh autograft, or 

morsellized allograft bone. The addition of fresh 

bone marrow aspirate to the allograft did not 

result in improved healing. However, there was a 

significant enhancement of new bone formation 

when the researchers added rhBMP-2 to allograft 

with or without bone marrow aspirate. Overall, the 

researchers have shown that this model may be sensitive enough to detect differences in healing among 

current bone grafting technologies. All procedures 

are well tolerated by the goats, and researchers at 

other institutions can perform the surgeries by following the standard operating procedure developed 

by the research team. During the upcoming year, 

the researchers will use the model to test new bone 

regenerative technologies that are being developed 

by other AFIRM research teams. 

Soft Tissue Repair and 

Regeneration (Excluding Nerve)

Studies at RCCC

Current metal stents are designed for the treatment 

of late-stage peripheral vascular disease, leave young 

patients at risk for graft failure due to fracture or 

the recurrence of stenosis (narrowing of a blood 

vessel), and are not designed to last the lifetime of 

the individual. The Sarac group (Project 4.3.2) at 

the Cleveland Clinic is developing bioabsorbable 

and fracture-resistant, tissue-lined stent grafts that 

contain either polylactic acid or polydioxanone 

for minimally invasive treatment of arterial and 

venous trauma in young patients. In October 2012, 

the researchers held a successful pre-IDE meeting 

with the U.S. Food and Drug Administration (FDA) 

for the fracture-resistant stent design; a follow-up 

meeting was held in March 2013. The researchers 

chose Resonetics, Inc. to cut their stents with an 

athermal laser. They found that the thickness of the 

material did not allow for enough radial force, and 

was also too thin to be able to be sewn to tissue. The 

RCCC Postdoc Dr. Divya Bhatnagar operates the 

extruder instrument in the laboratory to prepare 

filaments that can be used in braided nerve 

regeneration conduits.
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Limb and Digit Salvage II-7

researchers subsequently identified and manufactured appropriate dimensions for the stent graft that 

included a thickness that allowed for enough radial 

force and could support sewn tissue. They were also 

able to successfully crimp the stent. In conjunction 

with Peritec Biosciences, the researchers are now 

progressing to design verification and freeze. The 

research team has obtained Institutional Animal 

Care and Use Committee and Animal Care and Use 

Review Office approval for the evaluation of their 

stent design in the dog model, which will occur during the upcoming year.

The Tulenko team (Project 4.3.2a) at Cooper 

University Hospital is using a human “endothelial 

progenitor-like” cell line, derived from human adipose tissue, to seed the inner surface of a biological 

tubular scaffold for segmental vascular repairs. This 

technology could potentially reduce the long-term 

risk of vascular repair failures due to infection, 

re-stenosis, and re-injuries. During the past year, 

the researchers developed a method of activating endothelial nitric-oxide synthase (eNOS) (an 

essential endothelial gene) in adipose-derived stem 

cells that had been differentiated into an endothelial 

phenotype in cell culture. They also developed two 

types of tissue-engineered blood vessels (TEBVs) 

for arterial segmental repair: cell-free TEBVs and 

cell-lined TEBVs. The cell-free TEBVs were coated 

with a small molecule that is believed to encourage 

autogenous (one’s own) cells to differentiate into 

endothelium (though the induction of eNOS). The 

researchers implanted these scaffolds into a dog 

carotid artery model. Preliminary analysis at 28 

days post-implantation suggests that the cell-free 

TEBV is patent and functioning as a competent 

arterial segment. They will complete the in vivo 

evaluation of the cell-free TEBV in the dog carotid 

model during the upcoming year. If results following testing in a second animal species (rabbit) are 

positive, the researchers will file an FDA application for testing this device in humans, and will 

submit a clinical protocol for approval by the local 

Institutional Review Board (IRB).

Dermal (skin) grafts are commonly used in clinical practice to repair abdominal wall defects and 

hernias. However, the implanted grafts tend to lose 

their integrity and strength over time, which results 

in complications such as bulging and hernia recurrence. Engineered improvements to biologic grafts 

are therefore needed to make them more suitable 

for abdominal wall repair and reconstruction. The 

Derwin group (Project 4.4.3a) at the Cleveland 

Clinic seeks to provide 

injured warriors with 

biological materials 

for reconstruction of 

large abdominal defects 

through the generation 

of a fiber-reinforced 

biological graft. The 

researchers have developed biological dermal 

grafts using a proprietary fiber reinforcement 

technique that are significantly stronger and 

stiffer than native dermis 

grafts. During the past 

year, the research team 

downselected scaffold 

design and transitioned 

to a semi-automated 

scaffold manufacturing process to scale up RCCC researchers are developing a TEBV. From left to right: Drs. Shaohua Chang and 

Thomas Tulenko, Ben Jones, Drs. Ping Zhang and Zhengyu Wei
AFIRM Annual Report 2013

II: Limb and Digit Salvage

II-8

scaffold generation. They established a clinically relevant large animal (pig) model for abdominal wall 

repair and initiated a pilot study using two pigs. 

They developed a non-invasive method for postoperative monitoring of repair of bulging/hernia 

recurrence in the pigs. The researchers also established the protocol for retrieval, mechanical testing 

and analysis of the pig abdominal wall. They will 

continue technology validation and product development together with prospective industrial collaborators during the upcoming year. As the device 

moves into product development and a regulatory 

path is defined, the FDA will be engaged to enable 

the execution of a clinical trial.

Due to limited healing capabilities, injuries to the 

meniscus (internal cartilage) of the knee are often 

treated with surgical removal of the damaged tissue. While this treatment generally leads to early 

symptom relief, it frequently leads to the development of degenerative arthritis of the knee. The Gatt/

Dunn group (Project 4.4.3b) at the University of 

Medicine and Dentistry of New Jersey is developing 

an off-the-shelf, tissue-engineered meniscus scaffold 

that can be used to replace a moderately to severely 

damaged meniscus in an injured service member. The scaffold is composed of an anatomically 

designed, fiber-reinforced scaffold and a collagenbased extracellular matrix (ECM) similar to the 

native meniscus. The research team implanted 

their second-generation meniscus scaffolds in a 

functional sheep model and recovered all 16- and 

32-week implants. All implants were found fully 

intact with no ruptures or fixation failures, which 

was a problem with the first generation scaffold. The 

researchers found that the tensile strength of the 

second generation implants at both 16 and 32 weeks 

was five times higher than the normal functional 

loads of the native meniscus. The implants exhibited 

excellent tissue adherence and incorporation at both 

time points, and blood vessels were found throughout them. Importantly, the meniscus scaffold was 

found to protect the articular (joint) surface. The 

researchers made minor modifications to the second 

generation scaffold before beginning a 52-week 

sheep implantation study, which they will complete 

in the upcoming year. Transition to clinical trials will be dependent on the results of the 52-week 

implantation study and planned longer term studies 

through 2 years post-implantation. The research 

team is in discussions with several companies who 

have expressed interest in partnering or co-developing the technology.

Studies at WFPC 

The Harrison group (Project 4.4.6) at Wake Forest 

University is developing an injectable biomaterial 

capable of generating oxygen—a particulate oxygen 

generator (POG)—that would allow the delivery of 

oxygen in controlled amounts to engineered tissue scaffolds or pre-existing tissue. The researchers 

have established an in vivo model for evaluating 

the applicability of the POGs. This model involved 

the creation of ischemia (oxygen starvation) to 

the rat hind limb via arterial ligation (tying up a 

key artery). The researchers demonstrated that 

the POGs can preserve skeletal muscle structure 

and function in vivo in an ischemic environment. 

Overall, the research team’s results suggest that its 

oxygen delivery system could be used as a readily 

available treatment to delay the onset of additional 

tissue damage resulting from compromised blood 

flow. The team’s primary focus in Year 5 will be to 

optimize the model and delivery protocol for POGs 

WFPC graduate student John McQuilling working 

with oxygen regenerating biomaterials.
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Limb and Digit Salvage II-9

to demonstrate physiologically relevant improvement in skeletal muscle structure and function 

under clinically relevant experimental conditions. 

Because organs are composed of multiple cell types, 

the researchers will continue to analyze several 

different tissues systems, including skeletal muscle, 

bone, nerve, and skin. 

Numerous tissue-engineering strategies begin with 

the implantation of cells onto matrices followed by 

the attempt to create a de novo vascular system. 

However, researchers have fallen short in creating a 

viable vascular network outside of the body due to 

the complexities of blood vessel network formation 

in the living organism. The Gurtner team (Project 

4.5.8) at Stanford University has developed novel 

strategies that utilize preformed native circulatory networks that can be supported outside the 

body during organ fabrication, matured using stem 

cell-based techniques, and then readily integrated 

into the systemic circulation. The researchers have 

successfully validated and optimized their protocol for the isolation and maintenance of explantable microvascular beds (EMBs) based on the rat 

superficial inferior epigastric vessels on an ex vivo 

bioreactor system. They have developed a decellularization protocol that achieves tissue decellularization while preserving matrix architecture and 

macroscopic vascular structure. The group successfully re-anastomosed the EMB into the native 

vascular circulation and established the ability to 

track the biomass non-invasively long-term. They 

have also successfully seeded decellularized rat tissue flaps with human and rat adipose-derived stem 

cells. Going forward, the researchers will seek to 

further improve long term engraftment and functional cellular differentiation for organ-level tissue 

engineering.

Nerve Repair and Regeneration

Studies at RCCC

A muscle that loses its nerve supply quickly 

undergoes atrophy, which can significantly affect 

functional recovery. The Langer/Anderson group

(Project 4.4.1) at the Massachusetts Institute of 

Technology has developed an implantable, organic, 

stretchable microelectrode array (termed “OSMEA”) 

that can electrically stimulate injured muscles in 

real time to keep them from degenerating. The 

researchers developed the OSMEA using biocompatible materials so that FDA approval can be 

obtained in the future. The researchers also set up 

a new animal experiment platform using electrical 

stimulation for treating muscle atrophy following 

loss of nerve supply. Data from up-to-date evaluations on the materials and the OSMEA has been 

very encouraging for the intended application. 

During the past year, the researchers synthesized 

a conducting polymer for the OSMEA, and conducted electrical and mechanical testing using this 

polymer. Their results confirmed the electrical and 

mechanical advantages of using this polymer in 

the OSMEA. The researchers are currently focusing on conducting preclinical animal studies that 

are aimed at proving the safety and efficacy of the 

proposed approach. These studies are expected to 

take at least 3 years to complete. Once proof-ofconcept is demonstrated in a defined animal model, 

the researchers will submit an IDE application and 

design a human clinical trial. The researchers note 

that the OSMEA is a platform technology that is 

also applicable to many other neural interfacing 

applications, including spinal cord surface stimulation, electrocorticogram-based brain-computer 

interfaces, and retinal prostheses.

WFPC researcher Dr. Zuhaib Ibrahim evaluating 

protocol skin biopsies after swine hind limb 

transplantation.
AFIRM Annual Report 2013

II: Limb and Digit Salvage

II-10

In Project 4.4.2, the Windebank/Yaszemski 

team at the Mayo Clinic and Rutgers University 

is developing braided biodegradable polycaprolactone fumarate (PCLF) conduits that promote 

improved nerve regeneration over current commercially available tubes both in motor function 

recovery and in gap length. During the past year, 

the researchers identified electrophysiologic, histologic, and molecular parameters of muscles that 

can potentially serve as sensitive prognostic markers 

for functional outcomes after nerve reconstruction, 

and as targets of intervention for enhancing regeneration. They also delineated the time course and 

characteristics of muscle atrophy due to denervation. The researchers developed and optimized the 

protocols for isolation and expansion of Schwann 

cells from adult nerve sources. They also optimized 

the coating method to reduce the pore size of their 

braided conduits. This was accomplished by applying a secondary hydrogel and fibrin glue coating 

as well as an airbrushed polymer coating to the 

conduits. They found that the braided conduits 

could be effectively sterilized by a validated ethylene 

oxide sterilization method. They tested the braided 

conduits for endotoxins, and found endotoxin levels 

to be within the limits specified by the FDA. During 

the upcoming year, the researchers will complete 

the additional preclinical testing requested by the 

FDA in response to the prior IDE submission. They 

will prepare and file an investigator-initiated IDE 

with the FDA. They will also obtain IRB approval 

to conduct a Phase I clinical trial to assess the safety 

of the PCLF conduits in patients with a 6 cm nerve 

defect resulting from a sural nerve biopsy (see 

Project 4.4.1a in “Clinical Trials”).

Bone marrow stromal cells (BMSC) comprise a 

mixed population of cells that contribute to the 

regeneration of multiple body tissues. Notably, 

BMSC can be placed in an individual without the 

need for suppression of the immune system. The 

Siemionow group (Project 4.4.2a) at the Cleveland 

Clinic seeks to improve nerve regeneration by 

enhancing the performance of epineural nerve 

sheath conduits with the addition of BMSC. Briefly, 

the researchers create empty epineural tubes from 

sheep median nerves. They fill the tubes with fluorescently labeled BMSC (isolated from sheep bone 

marrow using a protocol 

developed in their laboratory) to create a conduit, 

which is then transplanted 

into recipient animals that 

have a 6 cm median nerve 

gap. The conduit creates an 

ideal microenvironment for 

nerve regeneration as it not 

only protects against local 

fibrotic and inflammatory 

insults, but it also provides a 

source of growth factors crucial to effective nerve regeneration. Nine sheep were 

euthanized six months after 

transplantation of an epineural conduit. The researchers 

did not observe any signs of 

inflammation, rejection, or 

conduit leakage. The integrity and shape of the crosssection of the conduits were 

preserved. Good functional 

results were obtained (as 

RCCC researcher Laura Struzyna checks a custom-built mechano-bioreacter in 

a tissue culture incubator. These mechano-bioreactors are used to generate 

“stretch-grown” axonal constructs that are used as living aligned scaffolds to 

promote nerve regeneration.
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Limb and Digit Salvage II-11

determined by somatosensory evoked potential 

analyses prior to euthanization). During the upcoming year, the researchers plan to investigate different 

methods for the long-term storage of the epineural 

conduits. They will also perform human cadaver 

studies to optimize the best method for collecting 

and preparing the conduits for human studies. Their 

ultimate goal is to characterize, optimize and make 

a clinically applicable bio-conduit built of naturally occurring human epineural sheath filled with 

human MSCs, and to test its regenerative potential 

in the clinical setting. This application may be used 

in patients with motor neuron disease, cerebral 

infarct, degenerative nerve disease and peripheral 

nerve injury.

Tissue-engineered nerve grafts (TENGs) are transplantable living nervous tissues generated in culture 

that contain two separate neuron populations connected by long integrated tracts of axons. TENGs 

recapitulate one of the most favorable environments for robust and long-distance axon growth 

and regeneration. TENGs represent a potentially 

transformative solution for the functional repair of 

substantive nerve trauma, as well as an option for 

reconstruction of entire nerve branches following 

massive tissue loss. The Smith/Cullen team 

(Project 4.4.2b) at the University of Pennsylvania is 

using advanced biomaterials and three-dimensional 

(3D) fabrication methods (made available through 

other AFIRM projects) to select and optimize 

custom nerve guidance tubes (NGTs) in which to 

encase TENGs in order to repair segmental nerve 

defects. During the past year, the researchers demonstrated accelerated axonal regeneration across 

TENGs encased in NGTs compared to experimental AFIRM NGTs alone or commercially available 

(FDA-approved) NGTs alone. They also determined 

that TENGs possess a novel, and in many ways 

superior, mechanism of action compared to NGTs 

and autografts. Electrophysiological assessments 

and behavioral assessments revealed that functional recovery (based on stimulated foot twitch, 

compound nerve action potential, and compound 

muscle action potential) was observed in some 

animals as early as 10 weeks following repair with 

TENGs or autografts, but not with NGTs alone. The 

mechanism of action and early-stage results support 

the premise that TENGs may enable regeneration 

of nerves across critical, 5 cm or larger, peripheral 

nerve lesions. In conjunction with Axonia Medical, 

the researchers have initiated testing of TENGs 

encased in commercially available and custom 

NGTs in a clinically relevant large animal model of 

peripheral nerve injury.

Studies at WFPC 

Following trauma, incomplete nerve regeneration 

and permanent demyelination (damage to the protective sheath surrounding nerves) may lead to lifelong disability. In Project 4.4.4, the Marra group

at the University of Pittsburgh, the Kaplan group

at Tufts University, and the Smith group at Wake 

Forest University are developing biodegradable 

nerve conduits containing silk fibroin, polycaprolactone, or collagen that deliver chemical cues (e.g., 

growth factors) and biophysical cues (e.g., surface 

patterning) to regenerating peripheral nerves. They 

established a nonhuman primate (NHP) model of 

critical median nerve deficits (5 cm) using autograft 

and cell-free nerve grafts. They completed an NHP 

study of noncritical median nerve defects (1 cm) 

using keratin gel-filled collagen conduits. They completed the examination of polymer-based tubes containing glial cell-line derived neurotrophic factor 

RCCC researcher Dr. Huan Wang prepares for animal 

surgery to study the performance of novel nerve 

conduits on peripheral nerve regeneration.
AFIRM Annual Report 2013

II: Limb and Digit Salvage

II-12

embedded in double-wall microsphere, in a critical 

rat sciatic nerve defect model (1.5 cm). The researchers completed a quantitative characterization of the 

mechanical properties of their silk nerve conduits. 

They improved the gradient design and delivery of 

neurotrophic factors from both polymer conduits 

and silk conduits. They implanted silk nerve conduits including neurotrophic factors and enzymes 

into a critical rat sciatic nerve defect (1.5 cm). They 

submitted a pre-IND data package to FDA and held 

a pre-IND meeting with Center for Drug Evaluation 

and Research/FDA to review preclinical data and 

clinical trial study design for keratin gel filler. 

During the upcoming year, the research teams plan 

to complete the NHP median nerve gap (5 cm) studies and proceed into clinical trials. Additional silk 

conduits will continue to be tested in the rat sciatic 

nerve defect model, and a basic science pipeline will 

continue to provide innovative ideas to the project.

Functional limb and digit tissue restoration involves 

a hierarchically defined process that often requires 

precise spatial and temporal coordination among 

multiple biological systems and processes. The 

Tirrell group (Project 4.4.5) at the University of 

California, Berkeley, is pursuing an approach to 

induce peripheral nerve growth following traumatic amputation by modulating components of 

the naturally occurring ECM (e.g., fibronectin 

and laminin). The researchers have developed a 

peptide-based hydrogel system as injectable ECMs 

with nanofibrous structures. They can incorporate 

bioactive peptide sequences and/or growth factors 

into the hydrogels. The 3D matrix system of the 

hydrogels also allows for mammalian cell growth. 

The researchers’ data show that their hydrogels 

span a range of physiologically relevant stiffnesses 

and may be useful in many regenerative medicine 

applications due to their fibrous, ECM-mimicking 

structure. The concentration of the hydrogels, 

which is directly linked to stiffness, can be tuned to 

promote the spreading, proliferation, and migration 

of a model cell type, Schwann cells. In Year 5, the 

researchers will choose the hydrogel concentration 

that performs best in their in vitro models and will 

use that concentration in animal studies.

Composite Tissue Injury Repair

Studies at WFPC

The Guldberg group (Project 4.4.3) at the Georgia 

Institute of Technology seeks to develop and test 

technologies that will enable the restoration of limb 

function following composite tissue trauma. The 

researchers have established promising strategies 

using nanofiber mesh spatial guidance and sustained delivery of a clinically approved inductive 

protein, BMP-2, for regeneration of bone, nerve, 

and muscle. They have developed composite injury 

animal models that simulate bone/nerve, bone/

vascular, and bone/muscle injuries. They have used 

these models to test their nanofiber mesh/hydrogel BMP-2 delivery systems (patents pending), 

which provide spatial and temporal cues to guide 

improved bone and nerve regeneration. During 

the past year, the researchers completed a pivotal 

6-month sheep segmental defect study (initiated in 

AFIRM Year 4), which was conducted with leveraged funding from the Australia Research Council. 

They found that the hybrid BMP delivery system in 

the sheep could effectively regenerate human scale 

(3 cm) segmental bone defects. The researchers will 

next complete optimization studies of hydrogel 

composition and degradation characteristics. They 

will also focus on overcoming the challenges of 

chronic non-union with or without adjacent concomitant soft tissue injury or mechanical instability. 

When proof-of-concept has been fully demonstrated in the sheep model, the researchers plan to 

initiate a pilot human clinical trial. 

Epimorphic Regeneration 

Studies at WFPC 

The Badylak group (Project 4.4.1) at the University 

of Pittsburgh is investigating mechanisms for 

recruiting large populations of stem cells to the 

site of limb and digit injury, and then developing 

strategies to induce the formation of functional 

limb and digit tissue to replace the damaged or 

missing structures. The researchers have shown 

that injury sites in non-regenerating mammalian 

systems recruit endogenous multipotent stem 

cells, representing a step toward non-blastemal 

epimorphic regeneration. They developed a digit 
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Limb and Digit Salvage II-13

amputation mouse model and 

used it to definitively show that 

endogenous multipotent stem 

cells are recruited to the site 

of injury following injection 

of ECM. This accumulation of 

cells is termed a “multipotent 

cell cluster” or MCC. They have 

continued to further define the 

population of cells involved 

in the formation of the MCC, 

and to examine the ability of 

those cells to differentiate into 

different functional tissues. The 

researchers believe that control of the “microenvironment 

niche” is necessary to direct 

complex tissue regeneration; 

to that end, they are developing a Biomechanical Interface 

for Optimized Delivery of 

MEMS Orchestrated Mammalian Epimorphosis 

(BIODOME) device. They have completed several 

design improvements for the BIODOME, including better flexibility to allow for digit swelling, 

smaller profile for greater mouse mobility, and 

shape changes that allow for easier removal and 

re-use, as well as better preservation of the healing 

digit. Optimization of the mouse designs is ongoing and will inform future designs for a BIODOME 

device for large animal models and, eventually, a 

human pilot study. Studies in mice and canines will 

also continue as the researchers introduce different 

bioactive molecules in a controlled fashion to the 

injury site microenvironment.

Clinical Trials 

Several AFIRM Limb and Digit Salvage technologies have advanced to the human clinical trial stage. 

The status of each clinical trial is summarized in 

Table II-2, and additional details on these trials follow the table. Detailed clinical trial progress reports, 

when available, can be found in the AFIRM Annual 

Report 2013 – Technical Progress Reports. 

While composite tissue allografts (e.g., hand transplants) are now a clinical reality and have been 

performed in multiple centers worldwide, the 

procedure has not reached widespread clinical use 

because recipients require lifelong, high-dose multidrug immunosuppression to prevent graft rejection. The Lee group (Project 4.4.2, WFPC) at the 

Johns Hopkins University School of Medicine and 

the University of Pittsburgh is developing a protocol for hand transplantation using donor BMSCs 

in combination with novel fusion proteins (the 

“Pittsburgh Protocol”) that will minimize maintenance immunosuppressive therapy. The researchers 

WFPC researcher adding cells to a tissue scaffold.

Table II-2. AFIRM-funded Limb and Digit Salvage projects with pending or active clinical trials.

Project Title Consortium Project No. Trial Phase Current 

Status

Hand Transplantation for Reconstruction of Disabling Upper 

Limb Battlefield Trauma – Translational and Clinical Trials WFPC 4.4.2 Phase I Open

A Clinical Trial to Assess the Safety of a Novel Scaffold 

Biomaterial RCCC 4.4.1a Phase I Submitted IDE to FDA
II: Limb and Digit Salvage

have shown that their fusion protein can prolong 

the survival of allografts in a hind limb transplantation model in swine. They have performed ten 

successful hand/forearm transplants in six patients, 

including the first bilateral and first above elbow 

arm transplant in the United States. All compliant 

transplant patients to date are being maintained on 

a single immunosuppressive drug at low doses and 

continue to have increased motor and sensory function of their transplanted hands, which correlates 

with their severity of amputation, time after transplant, and participation in hand therapy. During 

the upcoming year, the researchers plan to optimize 

their strategy, combining targeted immunomodulation and BMSC/fusion protein induction to further 

reduce maintenance immunosuppression and allow 

weaning of systemic drug therapy. They note that 

this regimen might enable tolerance induction and 

reduce side effects related to high-dose immunosuppression, hopefully enabling widespread clinical 

application of hand transplantation for the reconstruction of upper extremity amputations.

In Project 4.4.1a (RCCC), the Yaszemski/

Windebank group at the Mayo Clinic is developing 

novel biodegradable polymer nerve conduits that 

are suitable to repair nerve defects longer than 3 cm. 

More specifically, their goal is to repair post-biopsy 

sural nerve defects with a PCLF synthetic nerve 

conduit. Since the sural nerve is located just below 

the skin, potential morbidity from the conduit will 

be readily identifiable, and the device can be easily 

removed and analyzed. This model will provide a 

platform for determining safety and an indication of 

efficacy of scaffolds for nerve repair. The researchers 

had been working with BonWrx, Inc., to complete 

this study. During the past year, they validated an 

FDA-approved sterilization method for their PCLF 

conduits that involves the use of ethylene oxide 

(EtO) with a 12-hour cycle and an 11-hour purge. 

The EtO-treated tubes supported nerve regrowth 

when used to bridge nerve gaps, and there was no 

observable cytotoxicity. The researchers obtained 

IRB approval to initiate a separate feasibility clinical 

trial and follow 10 patients with sural nerve biopsy 

but without repair. They completed procedures, 

product drawings and specifications, and production documentation for their PCLF conduits to be 

manufactured for clinical trial use. The researchers 

also completed and filed an IDE, which is currently 

under review by the FDA. They provided nerve conduits for testing by third parties to support a second 

IDE submission. They plan to conduct a Phase I 

clinical trial to assess the safety of the PCLF conduits in patients with a 6 cm nerve defect resulting 

from a sural nerve biopsy. The researchers will use 

leveraged funding from the Mayo Clinic to conduct the clinical trial, and results of the trial will be 

reported to the Department of Defense.

II-14 AFIRM Annual Report 2013
AFIRM OUR SCIENCE FOR THEIR HEALING

Background 

During the current conflicts, more than 25% of wounded warriors treated in U.S. military facilities have sustained maxillofacial 

injuries.1,2 Ranging from simple fractures to extensive bone defects, 

severe burns, and soft tissue avulsion, these wounds can greatly alter 

the life of the injured victim. A soldier with a significant craniofacial injury loses his/her interface with the world; when one’s face 

is gone, so goes one’s identity. A severe facial injury directly 

impacts the ability to communicate—speech may be difficult 

to understand and facial expressions nonexistent—and 

possibly the ability to eat. Unfortunately, a significant 

disfigurement often portrays a person as a mangled, 

contracted, or absent face, which typically leads 

to grave embarrassment and/or separation 

from society. As these soft tissue and bony 

injuries to the face and cranium are 

excruciatingly painful and may carry 

devastating psychological impact, 

restoring form and function 

to these traumatized warriors is critical to their 

rehabilitation.

III: Craniofacial 

Reconstruction

1 Lew TA, et al. J Oral Maxillofac Surg. 2010 Jan; 68(1):3-7. 2 Owens BD, et al. J Trauma 2008 Feb; 64(2):295-299.
AFIRM Annual Report 2013

III: Craniofacial Reconstruction

III-2

The primary focus of AFIRM’s Craniofacial 

Reconstruction Program is to help wounded warriors with devastating, disfiguring facial injuries 

return to fully functional lives, which includes their 

reintegration into society through the application 

of regenerative medicine technology. Comprised of 

a multidisciplinary, multi-institutional collaborative research team, the Craniofacial Reconstruction 

Program manages projects ranging from singletissue regeneration to complete face transplants—

from emerging products in the early stages of bench 

research to those entering clinical trials. Drawing 

on the strengths of each team member, an optimal set of complementary technologies have been 

identified to achieve hard and soft tissue regeneration. Ultimately, the Craniofacial Reconstruction 

Program helps to provide wounded warriors with a 

new face to present to the world (Figure III-1).

Unmet Needs 

Craniofacial injuries suffered in combat are highly 

unique and often massive, and most of the current 

treatments in craniomaxillofacial reconstruction 

are too inadequate to treat these deficits resulting from blast injuries. Today, massive bone loss 

to the craniofacial complex incurred in combat is 

reconstructed with nonresorbable synthetic materials, bone implants, or metallic devices, which 

provide limited restoration of anatomical form 

and function. Therefore, readily available or readily generated replacement tissue for craniofacial 

bone, muscle, nerve, and skin are unmet needs 

for craniomaxillofacial reconstruction of severely 

wounded warriors. 

Tissue loss is quite massive in the most severe 

facial injuries, and in such cases, the agreed-upon 

surgical approach for facial replacement is transplantation. However, vascularized composite tissue 

allografts (VCAs) that constitute the face are highly 

antigenic and require aggressive immunosuppression regimens to prevent rejection of the transplanted tissue. The host is placed at substantial risk 

with immunosuppression, both from the toxicity 

of the immunosuppressive agents and from opportunistic infections, and this leads to significantly 

shortened life expectancy for all transplant recipients. In light of this, to provide adequate treatment 

to severe facial injuries, it is necessary to develop a 

technique or therapy that provides modulation of 

the immune response to allografts without indiscriminate immunosuppression. 

Areas of Emphasis 

Rutgers–Cleveland Clinic Consortium (RCCC), 

Wake Forest–Pittsburgh Consortium (WFPC), and 

U.S. Army Institute of Surgical Research (USAISR) 

researchers are pursuing a complementary mix 

of research projects focused on various aspects 

of Craniofacial Reconstruction. As shown in 

Table III-1, projects can be grouped into three clinical challenge topic areas: Bone Regeneration, Soft 

Tissue Regeneration, and Cartilage Regeneration 

(with a focus on the ear). Nontechnical summaries 

of the projects are presented after the summary 

table, and technical progress reports for each project 

can be found in the AFIRM Annual Report 2013 – 

Technical Progress Reports. 

Bone Regeneration 

Studies at WFPC 

In Project 4.1.2, the Mikos/Kasper group

at Rice University and the Wong group

at the University of Texas Health Science 

Center at Houston (UTHSC) are developing porous poly(methyl methacrylate) 

(PMMA)-based space maintainers, with 

and without antibiotics and growth factors, 

that will maintain the proper anatomical relationship of the tissue adjacent to a 

craniofacial defect. The researchers demonstrated in a rabbit jaw defect model that animals receiving porous implants, fabricated 

Regenerating 

Facial Tissues

Restoring Parts/ 

Facial Features

Restoring the 

Whole Face

Figure III-1. Goals and products of the AFIRM Craniofacial 

Reconstruction program.
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Craniofacial Reconstruction III-3

at the site of injury, experienced enhanced soft 

tissue healing and coverage compared to animals 

receiving nonporous implants. During the past year, 

they completed in vitro studies characterizing the 

physicochemical properties of the porous PMMAbased space maintainers. They also incorporated 

microparticles loaded with several common antibiotics into the PMMA-based space maintainers and 

completed comparative in vitro studies with respect 

to morphology, entrapment efficiency, release 

kinetics, and activity against bacteria. Constructs 

demonstrated sustained release up to at least 28 

days with retained antibiotic activity. The researchers also completed an in vivo study evaluating the 

efficacy of colistin-releasing PMMA-based space 

maintainers in mitigating a bacterial infection in a 

rabbit composite tissue defect. They will continue to 

work in partnership with Synthasome, Inc. toward 

the development of the Good Manufacturing 

Practices (GMP)-compliant manufacturing process 

of the porous PMMA-based space maintainer technology. The researchers have received approval for a 

protocol they submitted to the Institutional Review 

Board (IRB) of UTHSC to initiate a randomized, 

Table III-1. Projects funded by RCCC, WFPC, and USAISR per clinical challenge topic area.

Clinical Challenge Consortium/ 

Institution

Project 

No. Project Title

Bone Regeneration

WFPC 4.1.2 Space Maintenance, Wound Optimization, Osseous Regeneration, and 

Reconstruction for Craniomaxillofacial Defects

RCCC

4.5.1a / 

4.5.7

Regeneration of Bone in the Cranio-Mandibulo-Maxillofacial Complex 

Using Allograft Bone/Polymer Composites (4.5.1a) / Expedited 

Commercialization of an Injectable Bone / Allograft Composite for 

Open Fractures (4.5.7)

4.5.1b Regeneration of Bone in the Cranio-Mandibulo-Maxillofacial Complex 

Using Pre-Formed Tyrosine Derived Polycarbonates

4.5.6 Vascular Tissue Engineering

4.5.8 Accelerating the Development of Bone Regeneration Scaffolds Based 

on Tyrosine-Derived Polycarbonate

USAISR 4.5.1c Preclinical Animal Model Development for Bone Regeneration 

Studies

Soft Tissue 

Regeneration

WFPC

4.1.5 Injectable and Implantable Engineered Soft Tissue for Trauma 

Reconstruction

4.1.6 Bioreactors and Biomaterials for Tissue Engineering of Skeletal 

Muscle

RCCC

4.1.2 Develop Innervated, Vascularized Skeletal Muscle

4.3.1c Composite Tissue Allograft Transplantation without Life-Long 

Immunosuppression

4.3.1d Portable Perfusion System to Increase Preservation Time of Isolated 

Limbs for Transplantation

4.3.1e Vascularized Composite Allograft Transplantation with Topical 

Immunosuppression 

4.5.2b Development of Human Lips for Facial Reconstruction

Cartilage 

Regeneration 

(Focus: Ear)

WFPC 4.1.1 Engineered Cartilage Covered Ear Implants for Auricular 

Reconstruction

RCCC 4.5.4 Engineering a Replacement Autologous Outer Ear Using a Collagen / 

Titanium Platform
AFIRM Annual Report 2013

III: Craniofacial Reconstruction

III-4

prospective clinical study of their space maintainer 

technology against clinical standards, evaluating 

safety and efficacy (see Clinical Trials section of this 

chapter for more information).

Studies at RCCC

The Guelcher team (Projects 4.5.1a/4.5.7) at 

Vanderbilt University is developing and evaluating allograft bone/polymer composites for treating 

trauma-related bone defects. The researchers are 

pursuing two related projects in collaboration with 

researchers at the USAISR and Medtronic.

In Project 4.5.1a, they are developing injectable, 

settable LV® bone grafts for the repair of long 

bone defects. In Project 4.5.7, they are developing 

injectable, settable LV bone grafts augmented with 

recombinant human bone morphogenetic protein-2 

(rhBMP-2) for the repair of craniofacial and long 

bone defects. The researchers have demonstrated 

that their LV grafts support bone remodeling and 

healing in a rabbit leg bone defect model. They also 

found that delivery of rhBMP-2 from LV grafts 

enhanced new bone formation in a rat skull defect 

model. During the past year, the researchers determined that LV grafts supported bone remodeling in 

a sheep femoral defect model and passed ISO10993 

biocompatibility tests. They also found that delivery of rhBMP-2 from LV/MasterGraft® (LV-MG) 

formulations enhanced new bone formation in a 

rat critical-size calvarial defect model. During the 

upcoming year, the LV-MG formulation will move 

forward to more extensive testing in larger animal models of craniofacial bone regeneration (e.g., 

preclinical canine and nonhuman primate models 

of alveolar ridge augmentation). Pending 510(k) 

regulatory clearance of the LV bone graft and successful completion of the preclinical studies, preparation for a clinical trial in patients requiring ridge 

augmentation will begin.

In Project 4.5.1b, the Kohn/Ortiz group at Rutgers 

University and the Hollinger group at Carnegie 

Mellon University are developing biodegradable 

scaffolds containing tyrosine-derived polycarbonate 

(TyrPC) enhanced with calcium phosphate (CaP), 

which may provide compelling therapeutic solutions for the regeneration of craniofacial bone. The 

researchers’ imaging and histological data suggested that the synthetic TyrPC+CaP scaffolds were 

biocompatible and osteoconductive (i.e., guides the 

reparative growth of natural bone). They found that 

the addition of a minimal dose of rhBMP-2 to the 

TyrPC+CaP scaffolds led to significantly enhanced 

new bone formation in a rabbit critical-size defect 

(CSD) skull model at 16 weeks, which illustrates 

the effectiveness of adding bioactive factors into 

synthetic scaffolds. They determined that the TyrPC 

scaffolds were gradually resorbed and replaced 

with new bone. During the past year, the researchers optimized the fabrication method for preparing 

scaffolds coated with CaP for the rabbit CSD skull 

and radius models. They completed 60 percent of 

safety and efficacy studies of TyrPC+CaP scaffolds 

in these models. They determined that treatment 

with ethylene oxide is the most suitable sterilization method for TyrPC bone regeneration scaffolds. 

They have obtained Institutional Animal Care 

and Use Committee approval for the evaluation of 

TyrPC-containing bone regeneration scaffolds in 

the goat CSD skull model. In the upcoming year, 

the researchers will evaluate the two best performing TyrPC-based scaffolds in the goat model. The 

surgeries will be conducted at the Allegheny Singer 

Research Institute, and microCT and histology 

RCCC lab technician, Barry Cunningham, prepares 

the Chemspeed SLT100 for the high-speed polymer 

synthesis of polycarbonates at the New Jersey Center 

for Biomaterials.
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Craniofacial Reconstruction III-5

will be used to assess new bone formation 16 weeks 

post-surgery.

Large, biologically compatible scaffolds are needed 

to treat sizable bone defects, and the success of 

long-term engraftment of engineered tissues in 

humans depends on the ability of grafted tissue to 

connect with host blood vessels (i.e., formation of 

an integrated vascular network). In Project 4.5.6, 

the Anderson/Langer team at the Massachusetts 

Institute of Technology is developing a novel biodegradable and bioactive scaffold system that can 

support stem cell growth and produce vascularized bone tissues. The researchers have developed a 

biodegradable scaffold that can dually support the 

growth of endothelial (vessel-producing) and osteoblastic (bone cell-forming) cells. They have demonstrated the ability to graft growth factors onto the 

surface of a poly(ether sulfone) (PES) vascularizing 

membrane. They have also demonstrated in vivo the 

ability to increase blood vessel growth and decrease 

fibrosis by changing the surface geometry of the 

vascularizing membrane. As an alternative to protein and growth factor use, they have incorporated 

new potentially therapeutic surface chemistries onto 

the membranes by grafting additional polymers to 

the PES surface via synthetic organic chemistry. As 

a proof-of-concept, the researchers’ material will be 

used to encapsulate islets to treat a diabetic mouse. 

After demonstrating that transplanted islet cells 

in the PES membranes can replace the function of 

diseased islets in the mouse model of diabetes, the 

researchers will confirm the results in rats and nonhuman primates. Following the success of nonhuman primate trials, clinical trials will be scheduled.

The Iovine/Kohn group (Project 4.5.8) at Rutgers 

University is pursuing a 510(k) submission (used to 

prove the safety and efficacy of a device) with the 

U.S. Food and Drug Administration (FDA) for a 

TyrPC bone fixation pin. The researchers developed 

a robust bone pin fabrication process, involving the 

use of injection molding and the incorporation of 

zinc stearate, a processing aid. During the past year, 

the researchers scaled up the TyrPC polymerization process to the kilogram (kg) scale and initiated 

the production of 3 kg of polymer at a third-party 

manufacturer. They standardized the scaffold characterization techniques and established preliminary 

specifications. They standardized the bone pin 

injection molding process, and had more than 200 

bone pins injection molded by a third-party fabricator. The pins were submitted for evaluation by an 

external venue. Future efforts will be focused on 

completing the process development study for the 

TyrPC bone regeneration scaffold. Specifically, all 

the remaining process steps associated with the CaP 

coating as well as the sterilization and packaging 

of the final product will be investigated. A manufacturing transfer report will be generated, and this 

information will be used to engage third party GMP 

scaffold fabricators in commercial discussions. The 

researchers anticipate that their synthetic, degradable bone fixation pins will have a positive impact 

on warfighters due to the large number of bone 

fractures sustained by military personnel during 

training and combat.

Studies at USAISR

In Project 4.5.1c, the Brown Baer/Hale group at 

USAISR is developing preclinical small and large 

animal models for bone regeneration studies by 

the Guelcher team (Projects 4.5.1a/4.5.7) and 

the Yaszemski team (Project 4.2.1; see Limb and 

Post-doctoral fellow Tricia Van Laar of the USAISR’s 

Dental and Trauma Research Detachment purifies 

bacteria DNA for sequencing analysis.
AFIRM Annual Report 2013

III: Craniofacial Reconstruction

III-6

Digit Repair, Chapter II). 

The researchers determined 

that the notch defect was 

not feasible as a CSD model 

in both the rabbit mandible 

at 12 weeks and in the pig 

mandible at 16 weeks. They 

are now investigating a full 

thickness segmental defect 

of 2 cm in the pig mandible 

to develop a CSD that does 

not heal within 20 weeks and 

can be used to evaluate the 

efficacy of novel biomaterialsbased therapies for bone healing. In addition to creating 

a challenging animal model 

that mimics the battle injuries of our wounded warriors, 

the researchers will continue 

to develop novel ways to 

quantify bone regeneration using clinical computer 

tomography studies in preclinical bone regenerative 

models as a therapy planning tool.

Soft Tissue Regeneration

Studies at WFPC

In Project 4.1.5, the Rubin/Marra group at the 

University of Pittsburgh, the Kaplan group at Tufts 

University, and the Yoo/Lee group at Wake Forest 

University are seeking to develop and deliver a clinically useful, engineered soft tissue replacement that 

can serve as a stand-alone therapy, or be integrated 

with composite tissue regenerative medicine therapy 

of burns, craniofacial injuries, and extremity injuries. The researchers are generating implantable silkbased scaffolds and injectable hydrogels that contain 

autologous (the patient’s own) adipose-derived stem 

cells (ASC), combined with carrier biomaterials, 

to achieve vascularized soft tissues. The researchers completed numerous preclinical studies and 

found that implanted silk scaffolds maintained 

their volumes through an 18-month period in a 

rat model. They observed mature adipose tissue in 

groups pre-seeded with ASC or lipoaspirate (source 

of stem cells, including ASC). Small animal studies are underway in which various formats of silk 

injectables (e.g., hydrogels, sponges, and foams) 

are being tested in physiologically relevant models. 

The researchers have also evaluated the silk biomaterials in a large animal (horse) model, with 

and without autologous lipoaspirate, in terms of 

cellular response, vascularization of the graft, and 

volume retention. Going forward, the researchers 

will develop a composite function tissue through the 

integration of the multiple tissue components. Silk 

scaffolds will follow the pre-Investigational Device 

Exemption (IDE) FDA pathways, and the integrated 

organ printing system will be pursued under present 

FDA regulations for 510(k) device. A clinical trial 

focused on the clinical testing of soft tissue replacement for small defects has begun via the University 

of Pittsburgh (see the Clinical Trials section for 

more information). 

The Christ group (Project 4.1.6) at Wake Forest 

University is developing a technological tool that 

preconditions and accelerates muscle tissue maturation and function. More specifically, the researchers are creating an implantable tissue-engineered 

muscle repair (TEMR) construct capable of restoring clinically relevant force/tension following 

volumetric muscle loss (VML) injury. They have 

completed in vivo pilot studies on the first and 

second generations of controllable silk scaffolds for 

tibialis anterior (TA) VML injury that showed ~47% 

and ~65% functional recovery at 2 months post 

implantation, respectively. The researchers held a 

Jesse Wu, a research laboratory technician at USAISR’s Dental and Trauma 

Research Detachment, analyzes porcine skin graft and scar tissue pathology.
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Craniofacial Reconstruction III-7

pre-Investigational New Drug (IND) conversation 

with the FDA during the past year, which prompted 

the design of a definitive toxicology and proofof-concept study in collaboration with a Contract 

Research Organization. Histological characterization of TEMR scaffolds made using muscle progenitor cells sourced from human skeletal muscle 

biopsies illustrated the formation of multinucleated 

and aligned myotubes after bioreactor preconditioning. A major goal for the future is to conduct the 

aforementioned proof-of-concept study, which will 

consist of five healthy patients with secondary unilateral cleft lip who are willing to participate in the 

use of bioengineered muscle constructs for surgical 

correction of aesthetic and functional deformities 

that have been incompletely corrected by current 

methods. In addition, the researchers will continue 

to develop and optimize a silk-based TEMR scaffold for both rodent TA and lattisimus dorsi VML 

injury models to further expand the potential clinical applications of the TEMR technology. They will 

also strive to achieve FDA guidance and approval 

for a second generation bladder acellular matrixbased TEMR scaffold for the treatment of secondary 

cleft lip.

Studies at RCCC 

More than 10% of blast injury survivors have 

significant eye or eyelid injuries. Damage to the 

orbicularis oculi muscle 

prevents eyelid closure, which 

can result in blindness. The 

replacement of damaged 

orbicularis oculi muscles 

with engineered muscle will 

restore eyelid function, prevent 

blindness, and restore facial 

aesthetics. The Sundback/

Vacanti group (Project 4.1.2)

at Massachusetts General 

Hospital (MGH) is collaborating with researchers 

at Rutgers University and the 

Massachusetts Eye and Ear 

Infirmary to engineer skeletal 

muscle with physiological connections to the host’s neurovascular (nerve and blood vessel) 

network using biodegradable 

polymer scaffolds. The researchers engineered 

three-dimensional (3D) skeletal muscle similar to 

immature skeletal muscle and established protocols 

for the development of functional blood vessels 

and nerves in the tissue. During the past year, the 

researchers (1) demonstrated uniform innervation 

of engineered muscle constructs; (2) determined 

that electrical stimulation with neural-like signals 

increased the engineered muscle’s contractile force; 

(3) found that engineered endothelial networks 

within the muscle constructs rapidly merged with 

the host’s vasculature, and blood perfusion from 

the host supported the implanted construct; and 

(4) developed polymeric sleeves (Rutgers team) 

for scale-up of the muscle constructs. During the 

upcoming year, the researchers will implant muscle 

constructs bundled in sleeves into immunocompromised rodents and innervate the implants with 

a host nerve. The researchers will characterize the 

innervation, vascularization, and muscle function 

of the implants. Future studies will demonstrate the 

use of engineered muscle constructs to replace orbicularis oculi function in immunocompetent rats or 

rabbits. Given the complexity of this product, the 

project team will submit a Request for Designation 

to the FDA Office of Combination Products (OCP)

to determine appropriate regulatory path.

Operating room at the Transplantation Biology Research Center at MGH 

where skin graft surgeries are performed to study the effects of topical 

immunosuppression on the prolongation of graft survival.
AFIRM Annual Report 2013

III: Craniofacial Reconstruction

III-8

VCAs—large segments of complex, vascularized 

tissue—differ in their immunological responses, 

presenting challenges to transplant immunologists. In Project 4.3.1c, the Siemionow group at the 

Cleveland Clinic hopes to transform standards for 

clinical modulation of the immune system, making transplantation of VCAs safer and more widely 

available to victims of disease and traumatic injury. 

The researchers are exploring the use of fused 

donor–recipient “chimeric” cells as potential immunomodulators. They have proven that the fusion 

of cord blood cells from two unrelated donors is 

feasible. During the past year, the researchers studied many properties of the chimeric cells and found 

that: (1) these cells do not secrete inflammatory 

cytokines in vitro; (2) there were few dead cells following cell fusion; and (3) the cells proliferate. The 

research team characterized the cells’ genotype and 

phenotype before and after culturing, and animal 

model testing demonstrated that the cells migrated 

into blood, bone marrow, and lymphoid organs. 

During the upcoming year, the research team plans 

to test the safety of human chimeric cell therapy; 

the phenotypic and genetic stability of human 

chimeric cells; and cryopreservation methods of 

human chimeric cells. Following confirmation of 

safety, stability and cryopreservation of human 

chimeric cells, the research team will apply for IRB 

approval to test the immunomodulatory effects of 

bone marrow-derived human fused chimeric cells 

as a supportive therapy for living kidney and liver 

donor transplantation. Tolera Therapeutics, Inc. 

will support the transition of chimeric cell therapy 

to clinical trials. Overall, the introduction of cellbased therapies to the field of VCA transplantation 

represents a novel, regenerative medicine approach, 

which will minimize or reduce the need for lifelong 

immunosuppression.

In Project 4.3.1d, the Pomahac team at Brigham 

and Women’s Hospital is seeking to attenuate the 

effects of ischemia/reperfusion injury in isolated 

limbs by developing and validating an extracorporeal perfusion device capable of oxygenating, 

sustaining, and preserving amputated limbs. If 

successful, the results of this study would promote 

wider practice of upper limb replantation and 

composite tissue allotransplantation. After successful (delayed) execution of the award in August 2012, 

the Pomahac team actively sought partnerships with 

individuals and groups able to provide programming support for the development of the extracorporeal machine perfusion device. In April 2013, 

after vetting several candidates, the Pomahac team 

paired with Numia Medical (Newport, VT), who 

produced the first working prototype device. Using 

the functional prototype device, the team intends to 

pursue animal studies in a pig model to determine 

the perfusion parameters that must be used to best 

preserve limb tissues, based on observed chemical 

and histological signs of cell injury and death. The 

researchers then intend to use these determinants 

to pursue a series of transplant experiments in pigs, 

analyzing the survival and quality of transplanted 

tissue after reperfusion. After optimization of the 

isolated limb perfusion device has been achieved 

and proof-of-principle has been established in pigs, 

the Pomahac team intends to pursue FDA IDE 

approval for a transition to human studies.

In Project 4.3.1e, the Sachs/Cetrulo group at 

MGH and the Kohn group at Rutgers University 

are conducting a feasibility study of the topical 

delivery of cyclosporine and tacrolimus to reduce 

the need for the systemic delivery of these powerful 

RCCC researcher Christopher Mallard cleans skin 

grafts prior to delivering topical immunosuppression 

for prolonged graft survival.
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Craniofacial Reconstruction III-9

immunosuppressant medications. The xenogeneic 

skin graft has been selected as the model system 

because the skin of hand and face transplants is 

usually the primary site of immunologic rejection, 

but the wider impact of this work will be the possible reduction of the need for systemic immunosuppression for allogeneic limb and face transplant 

patients as well as for recipients of allogeneic or 

xenogeneic skin grafts. During the past year, the 

research team successfully formulated TyroSphereTM 

dressings that provided sustained release of 

cyclosporine and tacrolimus. These drug-loaded 

TyroSpheresTM were stable over a range of temperatures, penetrated the dermis of cadaveric skin, and 

released the drug over seven days from a gel. In 

addition, the researchers developed a novel clinical 

application of the TyroSpheresTM—direct application to the wound bed prior to graft placement. 

The application of tacrolimus-loaded TyroSphereTM 

dressings both topically to the graft and directly 

to the wound bed significantly reduced inflammation in the skin grafts and wound beds in a baboon 

model. The project team plans to conduct safety and 

efficacy studies in Good Laboratory Practices (GLP) 

guidance, submit an IND, and initiate the design 

of a clinical trial. Future work will focus on the use 

of a different model (a skin flap with an established 

blood supply) and different immunosuppressive 

agents, which have different mechanisms of action 

in vivo and offer promise as topical immunosuppression dressings.

Normal lip structure is required for activities 

such as eating, drinking, talking, and social gestures. Avulsion of the lips is a survivable injury, 

but without functional lip reconstruction, life for 

injured individuals is burdened by drooling, food 

spillage while eating, unintelligible speech, and 

social rejection. Functional reconstruction of the 

lips is so important that when more than 50% of 

the lips are avulsed, face transplantation under 

lifetime immunosuppression becomes an option. In 

Project 4.5.2b, the Feinberg team at the University 

of Michigan is developing a mucocutaneous (M/C) 

junction with mouth and skin cells (oral and epidermal keratinocytes) grown together into 3D patterns 

that can be used in a staged reconstruction of the 

lips. During the past year, the researchers fabricated 

a 3D tissue structure with the key morphological 

features of a lip: epidermal skin, vermillion, and oral 

mucosa. This tissue-engineered mucosa-and-skin 

equivalent was manufactured using human oral and 

skin cells to produce similar anatomic and handling 

properties as native human lips. The researchers 

also developed an animal (rat) model for in vivo 

grafting of the lip construct (made of mucosa and 

skin components) and for testing functional muscle 

performance. In the future, the researchers plan to 

(1) extend these studies to the use of athymic rats 

and use of a cellular M/C construct to fabricate the 

pre-laminated flap; (2) extrapolate these techniques 

to tissue engineering of an anal sphincter; and 

(3) submit an IND to the FDA to perform a human 

clinical trial for lip reconstruction.

Cartilage Regeneration 

(Focus: Ear)

Studies at WFPC

The Yoo group (Project 4.1.1) at Wake Forest 

University is pursuing the development of an 

engineered cartilage-covered ear implant. The 

researchers have fabricated a flexible ear scaffold 

using an integrated organ printing technology that 

was developed in their laboratory. During the past 

year, they optimized their isolation and expansion 

protocols, which yielded an increased production of 

human chondrocytes (cartilage cells). They developed and fabricated a flexible and complex shaped 

ear scaffold using an integrated 3D organ-printing 

system. Their implanted 3D bioprinted ear constructs resulted in the formation of cartilage tissue 

in vivo in animals. They demonstrated the structural and functional integrity of the engineered 

cartilage covered ear implants in vivo. During the 

upcoming year, the researchers will continue to 

optimize the customized ear implants using the 

3D bioprinting system. They plan to contact the 

OCP at the FDA to confirm the classification of 

their 3D bioprinter and, if needed, file a Request for 

Designation (RFD) with OCP in accordance with 21 

CFR Part 3.

Studies at RCCC

The Sundback/Vacanti group (Project 4.5.4) at 

MGH is also developing a permanent, implantable 

external ear. The researchers’ primary approach 

to ear regeneration utilizes a cartilage/titanium 

technology platform. They seed cartilage cells on a 
AFIRM Annual Report 2013

III: Craniofacial Reconstruction

III-10

human ear-shaped collagen scaffold, and an integrated titanium wire support embedded within 

the collagen matrix maintains the dimensions and 

complex central features of the ear. The researchers’ alternative approach to ear regeneration utilizes 

resorbable polymers and stem cells. During the 

past year, they expanded chondrocytes successfully 

and sufficiently without losing the cells’ ability to 

form neocartilage. They engineered high-quality 

stable cartilage in both immunocompromised 

rodents and large immunocompetent animals, and 

made ear-shaped neocartilage from chondrocytes 

in sheep. The ear construct’s size and shape were 

largely maintained after 12 weeks implantation in 

the animal models. The team developed analytical 

non-invasive methods for assessing 3D changes, 

which suggest that the wire framework properties could be improved to eliminate shape changes 

due to wire sliding. Going forward, the long-term 

stability of cartilage engineered from extensively 

expanded chondrocytes and retention of the size 

and shape of ear-shaped scaffolds will be assessed in 

an immunocompetent animal model. The researchers plan to submit an RFD to the FDA to determine 

the regulatory path for the engineered ear. In preparation for clinical trials, they will perform a GLP 

preclinical trial in sheep to demonstrate the safety 

and efficacy of the engineered ear. They will develop 

a protocol for a pilot clinical trial, and submit it to 

the local IRB. 

Clinical Trials

Several AFIRM Craniofacial Reconstruction technologies have advanced to the human clinical trial 

stage. The status of each clinical trial is summarized 

in Table III-2, and additional details on these trials follow the table. Detailed clinical trial progress 

reports, when available, can be found in the AFIRM 

Annual Report 2013 – Technical Progress Reports.

In Project 4.3.1a, the Siemionow group at the 

Cleveland Clinic is performing composite tissue 

allograft face transplantation, which provides a 

single-stage reconstructive procedure for patients 

with severe cranial facial injuries and spares them 

from multiple surgical procedures over many years. 

The researchers performed the first U.S. face transplant prior to the start of AFIRM. Based upon 52 

months of data collected and analyzed from this 

individual to date, face transplantation appears 

to be a safe and effective, single-stage treatment 

procedure for subjects with severe facial deficit and 

deformity. Through objective testing, face transplantation has been shown to provide a return of 

mastication, the ability to speak clearly, smell, smile, 

frown, and kiss. In addition, an improved self-image 

has been shown. Potential serious adverse events, 

such as infection and rejection, which may occur 

with any transplant, have been successfully treated. 

During the past year, the research team completed 

five detailed evaluations on potential face transplant 

subjects enrolled in the study and approved one 

Table III-2. AFIRM-funded Craniofacial Reconstruction projects with pending, active, or closed clinical trials.

Project Title Consortium Project No. Trial Phase Current 

Status

Clinical Trial – Composite Tissue Allograft Transplantation 

(Face) RCCC 4.3.1a Phase I Open

Clinical Trial – Anti-TCR Monoclonal Antibody (TOL-101), for 

Prophylaxis of Acute Organ Rejection in Patients Receiving 

Renal Transplantation

RCCC 4.3.1b Phase I/II

Closed; 

moving into 

Phase III

Clinical Trial – Use of Tissue Engineered Human Oral Mucosa 

for Large Soft-Tissue Intra-Oral Defects RCCC 4.5.2 Phase I/II

Protocol 

approved 

by IRB

Injectable and Implantable Engineered Soft Tissue for Trauma 

Reconstruction WFPC 4.1.5 Phase I Open

Space Maintenance, Wound Optimization, Osseous 

Regeneration, and Reconstruction for Craniomaxillofacial 

Defects

WFPC 4.1.2 Phase I

Protocol 

approved 

by IRB
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Craniofacial Reconstruction III-11

patient for listing for face transplantation. The two 

major goals for the upcoming year are to (1) perform one face transplant and (2) officially list a second patient for face transplantation. Patient safety 

and monitoring regulations will be followed according to IRB and Human Research Protection Office 

(HRPO) regulations. All IRB and HRPO reporting 

and accreditation requirements will be met.

The Siemionow group in Project 4.3.1b is using a 

therapeutic antibody, TOL-101, as a conditioning 

agent prior to transplantation to enhance allograft 

tolerance. The researchers are testing the safety 

and tolerability of TOL-101 in patients who are 

undergoing their first kidney transplantations. To 

date, a total of 36 subjects (nine cohorts) have been 

enrolled in the study, and a total of 60 biopsies 

were sent to the Cleveland Clinic Pathology Core 

for analysis. A Clinical Study Report was prepared 

by Tolera Therapeutics, Inc. and presented to the 

FDA. Drug-related adverse events were limited 

to a transient rash with pruritus (one subject) in 

cohort 9. Twenty-seven (27) serious adverse events 

have been reported, with only one (pneumonia) 

possibly related to the study drug. The data demonstrated that although the total number of patients 

who have received TOL101 to date is relatively small, 

the benign safety profile and easily assessed pharmacodynamic target allows a dosing regimen to be 

selected for Phase III testing from the Part A phase 

of the Phase I/II study.

In Project 4.5.2, the Feinberg team at the 

University of Michigan is using a tissue-engineering/regenerative medicine approach, in conjunction 

with the surgical technique of prelamination, to 

create a prevascularized composite soft tissue flap. 

More specifically, the researchers are using an ex 

vivo-produced oral mucosa equivalent (EVPOME) 

for major areas of intra-oral reconstruction, and 

as a platform technology for the tissue engineering 

of a set of human lips. In the first year of funding, 

they have (1) developed a manufacturing process to 

fabricate large-sized EVPOMEs for a clinical trial, 

(2) successfully fabricated a large EVPOME device 

in a cGMP facility, (3) received FDA approval of an 

amendment to an already existing IND, (4) obtained 

approval from the University of Michigan’s IRB for 

the clinical protocol, and (5) submitted the clinical 

protocol to the HRPO. The technology in development is similar to the development of orphan drugs, 

in that the target market area is very specific: posttraumatic (explosives, burns, gunshot and motor 

vehicle accidents) and post-oncologic surgery.

In Project 4.1.5, the Rubin/Marra group at the 

University of Pittsburgh, the Kaplan group at 

Tufts University, and the Yoo/Lee group at Wake 

Forest University have begun a clinical trial at 

the University of Pittsburgh entitled “Autologous 

Adipose-Derived Stem Cell Therapy for Soft Tissue 

Reconstruction after Facial Trauma.” A progress 

report is not yet available for this clinical trial. 

The Mikos/Kasper and Wong groups (Project 

4.1.2) at Rice University and the UTHSC has 

received approval by the UTHSC IRB for its protocol for a randomized, prospective clinical study of 

the porous PMMA-based space maintainer technology against clinical standards evaluating safety 

and efficacy. The study will commence once HRPO 

approval of the protocol has been issued, which will 

depend upon either FDA clearance of the product 

or approval of an IDE. A progress report is not yet 

available for this clinical trial.
III: Craniofacial Reconstruction

III-12 AFIRM Annual Report 2013
AFIRM OUR SCIENCE FOR THEIR HEALING

Background

The consequences of dysregulated wound repair impact both soldiers 

and civilians, and this can lead to severe functional disability and 

disfigurement. Scar formation following injury is a major biomedical 

burden for the U.S. health care system, and the costs associated with 

treatment of fibrosis—the formation of excess fibrous connective 

tissue in an organ or tissue as a reparative or reactive process—

are estimated to be more than $4 billion per year in the U.S. 

Current treatment regimens for fibrosis, which involve 

surgery, silicone sheeting, anti-inflammatory medications, and laser/radiation, have been disappointing due, in large part, to a lack of understanding 

regarding the fibrotic process. The pathophysiology of scar formation suggests the 

need to regulate numerous aspects of 

the wound environment, including cells and the surrounding 

extracellular matrix, wound 

mechanics, and biochemical signaling.

IV: Scarless 

Wound Healing
AFIRM Annual Report 2013

IV: Scarless Wound Healing

IV-2

The wound healing process occurs through overlapping and well-defined phases of repair, which 

may take months to resolve and often results in 

irreversible scar formation with resultant contractures and disfig-urement. To be truly successful, 

any therapeutic approach must be comprehensive 

and encompass the myriad inputs regulating wound 

healing. Studies of tissue regeneration have implicated the inflammatory environment, matrix components, mechanical context, and cellular players in 

producing a “scarless” wound profile. The AFIRM 

researchers utilize an approach that encompasses a 

broad continuum of technologies aimed at modulating the tissue response to injury. Collectively, the 

AFIRM projects represent a collaborative effort to 

address every aspect and stage of wound repair in a 

single research program—with the overarching aim 

of developing a more effective wound management 

paradigm. 

Unmet Needs 

Given the increasing survival of injured soldiers 

returning from the battlefield, effective strategies 

to promote wound regeneration and prevent scar 

formation are desperately needed. The burden 

of scarring that follows the 230 million surgical 

procedures performed worldwide each year 

is enormous. Although the exact incidence of 

pathologic scarring is unknown, soldiers and 

civilians continue to suffer from functional 

disabilities caused by wound contracture and 

severe disfigurement from hypertrophic scarring. These scars can become so thick that 

they limit the movement of joints and greatly 

restrict a patient’s ability to move about. 

While multiple factors influence wound repair, 

therapeutic modalities aimed at these targets 

(e.g., inflammation and oxygen tension) have 

been largely unsuccessful. Although biomolecules that limit fibrosis have demonstrated 

effectiveness in controlling scarring in vitro, a 

major hurdle for clinical translation has been 

the ability to sustain drug release and bioactivity in a complex wound environment. Also, 

there are insufficient effective animal models 

to study scar formation. Therefore, the development of more appropriate and clinically relevant animal models of hypertrophic scarring 

remains an unmet need. 

Battlefield injury progression and/or impaired healing often occurs secondary to ischemia or repetitive 

ischemia/reperfusion (I/R) injury, which involves 

deficient blood flow to a tissue due to the injury, followed by the return of blood to the damaged area. 

Currently, no therapy exists to mitigate impaired 

wound healing due to ischemia or I/R injury. Hence, 

another unmet need is the limitation of impaired 

healing secondary to ischemia or I/R injury. 

Areas of Emphasis 

Rutgers–Cleveland Clinic Consortium (RCCC), 

Wake Forest–Pittsburgh Consortium (WFPC), and 

U.S. Army Institute of Surgical Research (USAISR) 

researchers are pursuing a complementary mix 

of research projects focused on various aspects of 

scarless wound healing. As shown in Table IV-1, 

projects can be grouped into three clinical challenge topic areas: Control of Wound Environment 

and Mechanics, Therapeutic Delivery to Wounds, 

and Attenuation of Wound Inflammatory Response. 

Nontechnical summaries of the projects are presented after Table IV-1, and full progress reports for 

each project can be found in the AFIRM Annual 

Report 2013 – Technical Progress Reports. 

Two WFPC postdoctoral fellows work on cell culture in a 

hypoxia chamber. 
our science for their healing

Scarless Wound Healing IV-3

Control of Wound Environment 

and Mechanics 

Studies at WFPC 

Using a mouse model of hypertrophic scarring based on increasing the skin stress of healing wounds, the Gurtner team (Project 4.5.1) at 

Stanford University found that the skin’s biomechanical properties correlated with the amount of 

scarring that followed wounding. They have developed a pressure-sensitive, “stress-shielding” device 

that can modify mechanical forces to control scar 

formation in the red Duroc pig model. In an exploration of the molecular mechanisms underlying 

this process, the researchers found that fibroblast 

focal adhesion kinase (FAK) is a key mediator of 

load-induced fibrosis and scar formation. During 

the past year, the researchers evaluated the role 

of keratinocyte-specific FAK on wound healing 

progression and extracellular matrix composition. 

They identified a signaling pathway, mediated by 

FAK activation, leading to increased epidermal 

levels of matrix metalloproteinase 9. They also critically analyzed the role of epidermal FAK in wound 

healing, via a mouse model of keratinocyte FAK 

deletion. They demonstrated that keratinocyte FAK 

influences skin regeneration. Going forward, the 

researchers aim to develop therapeutic approaches 

to specifically target FAK to improve tissue regeneration. They are conducting a Phase III clinical trial 

with significant interim data for their polymeric 

stress-shielding device (see Clinical Trials section, 

Project 4.5.9). Additionally, the group will seek U.S. 

Food and Drug Administration (FDA) approval for 

small molecule FAK inhibition, and will provide an 

appropriate regulatory package to gain allowance 

for the initiation of a Phase I clinical trial.

Therapeutic Delivery to Wounds

A novel approach is needed to alter the trajectory of wound healing in the initial days following 

injury to promote the regeneration of tissue. Such 

an approach could involve the delivery of cells, 

molecules, proteins, compounds, or genes to the 

wound surface.

Studies at RCCC

The Mustoe group (Project 4.6.3) at Northwestern 

University is investigating the wound-healing capability of curcumin, which is a yellow-colored component of the Indian spice turmeric. The researchers 

found that the intravenous delivery of curcumin 

accelerated healing and reduced scarring in a rabbit 

Table IV-1. AFIRM-funded projects per clinical challenge topic area.

Clinical Challenge Consortium/ 

Institution

Project 

No. Project Title

Control of Wound 

Environment and 

Mechanics 

WFPC 4.5.1 Mechanical Manipulation of the Wound Environment

Therapeutic 

Delivery to Wounds

RCCC

4.6.3 Therapy to Limit Injury (TLI) and Promote Non-Scar Healing After 

Burns and Severe Battle Trauma

4.7.1 Adipose-Derived Therapies for Wound Healing, Tissue Repair, and 

Scar Management

WFPC

4.5.2 Regenerative Bandage for Battlefield Wounds

4.5.5 Scarless Wound Healing Through Nanoparticle-Mediated Molecular 

Therapies

4.5.6 Peptide-Mediated Delivery of Therapeutic Compounds into Injured 

Tissues During Secondary Intervention

Attenuation 

of Wound 

Inflammatory 

Response

WFPC

4.5.3 Multi-Functional Bioscaffolds for Promoting Scarless Wound Healing

4.5.4 Regulation of Inflammation, Fibroblast Recruitment, and Activity for 

Regeneration
AFIRM Annual Report 2013

IV: Scarless Wound Healing

IV-4

ear I/R model. They also found that they could 

apply curcumin via tiny nanospheres to the wound 

site in the rabbit I/R model with no apparent toxicity. During the past year, the researchers confirmed 

the effectiveness of curcumin in reducing necrosis 

and supporting the survival of skin flaps in a porcine model. They determined that the most effective time for treatment was at the time of surgery 

with a single 3 μm dose. The effect was confirmed 

7 and 28 days after surgery. The researchers found 

that treatment with curcumin 4 or 24 hours after 

the surgery had no statistically significant effect in 

rescuing injury when compared to vehicle control. 

They expect the transition to Good Manufacturing 

Practices to be straightforward based on discussions 

with manufacturers of curcumin. 

The Katz group (Project 4.7.1) at the University 

of Florida (UF) is developing regenerative therapies using adipose-derived stem cells (ASC). The 

researchers are developing a dermal wound paste 

(DWP) platform for skin repair and replacement 

that involves the combination of ASC (and other 

cells) and a cell-free dermal scaffold. They formulated DWP with cell-stabilizing solutions that 

maintained cell viability and growth over a 2-week 

period in culture. They also determined that cellenhanced DWP reduced wound contraction in a 

mouse wound model more effectively than wound 

paste that does not contain any cells. During the 

past year, the researchers initiated testing and 

characterization of a novel device that can isolate 

stromal vascular fraction cells. They established 

fundamental quality control and potency assays that 

can be used to measure the reproducibility and bioactivity of the wound paste. They compared subtle 

but important variations in the specific formulation 

of the DWP. They also demonstrated that the DWP 

secretes numerous bioactive factors that can impact 

the growth of blood vessels and the movement 

of cells. During the upcoming year, the research 

team will focus efforts on completing pre-clinical 

animal studies that are necessary for supporting 

an Investigational New Drug (IND) application filing, as determined by a previous pre-IND meeting 

with the FDA. Upon completion of the pre-clinical 

studies, the research team will pursue funding for a 

Phase I clinical trial. 

Studies at WFPC 

The Gurtner/Longaker team (Project 4.5.2) at 

Stanford University is capitalizing on the ability 

of wounded fetal tissue to regenerate with minimal scarring by developing a regenerative bandage 

that contains a fetal-like matrix and progenitor 

cells found in wounds. The goal is to maintain an 

acute wound in a pro-regenerative state and prevent the onset of scarring, fibrosis, and infection. 

The researchers have developed a novel, modifiable 

hydrogel scaffold that can deliver matrix components, cells, and/or wound-healing drugs. During 

the past year, they demonstrated the utility 

of mesenchymal stem cell (MSC)-seeded 

bioscaffolds for the accelerated healing 

and appendage formation of humanized 

murine excisional wounds, as compared 

to direct MSC injection and no treatment 

controls. They also evaluated the effect of 

hydrogel seeding on MSC survival within 

humanized excisional wounds and found 

an increase in cell viability and engraftment among hydrogel-seeded cells, compared to direct injection. In addition, they 

determined the beneficial effect of hydrogel 

seeding on MSC secretion of angiogenic 

cytokines in vitro is recapitulated in the in 

vivo wound environment. In the next phase 

of this project, the researchers will utilize 

microfluidic single-cell transcriptional 

analysis to identify the optimal cell source Dr. Ning Yang prepares adipose-derived cells as part of her work 

on an autologous “wound paste” platform.
our science for their healing

Scarless Wound Healing IV-5

for this bandage. Following a refinement period 

over the next few years, the safety and regenerative 

capacity of the hydrogel-based regenerative bandage 

will be tested in a Phase I clinical trial. Phase II–III 

clinical testing will follow. 

The Kathju team (Project 4.5.5) at the University of 

Pittsburgh is using tiny nanoparticles as a nonviral means of delivering molecules into wounds. 

The researchers identified a gene (chaperonincontaining T-complex polypeptide [CCT-eta]) that 

is normally decreased in healing fetal wounds but 

elevated in adult wounds. They developed a nonviral 

nanoparticle-mediated delivery system using small 

interfering RNAs (siRNAs) that can selectively 

decrease the expression of CCT-eta in complex adult 

wounds. They established new protocols that will 

allow them to inhibit CCT-eta more stably and for a 

longer period of time in a healing wound environment. They demonstrated that inhibition of CCTeta can inhibit scar formation in an animal model 

of incisional wound healing, and they identified 

strains of bacteria that may be used as probiotic 

therapy for other pathogens. Finally, they demonstrated that a novel probiotic therapy can rescue 

mice from burn wound-induced sepsis and death, 

and can inhibit burn wound-induced scarring. 

Overall, both the researchers’ CCT-eta inhibitor and 

their use of probiotic therapy demonstrate efficacy 

in pre-clinical systems and show great potential to 

achieve clinical translatability.

The Ruoslahti group (Project 4.5.6) at the SanfordBurnham Medical Research Institute has made substantial progress in identifying peptides that home 

to wounds and deliver a therapeutic payload to the 

wounds and other injured tissues. The researchers 

found that treatment of mice with skin wounds with 

the wound-homing CARSKNKDC (CAR) peptide 

promotes wound healing. They generated a smaller 

form of the CAR peptide, tCAR, which they found 

to be biologically more potent than CAR. They 

fused the CAR peptide with the wound-homing 

protein decorin and found that the CAR-decorin 

fusion protein suppressed scar formation in mice 

with skin wounds. They also showed that a woundhoming peptide can deliver co-administered drugs 

not coupled to the peptide to injured tissue. The 

researchers’ technology has been licensed to a biotech company for further pre-clinical studies and 

introduction into the clinic.

Attenuation of Wound 

Inflammatory Response 

Following injury, an intense inflammatory response 

ensues and is necessary for normal wound healing. However, aberrations in this process result in 

chronic wounds and have been strongly implicated 

in fibrotic scar formation. Redirecting this process 

toward a regenerative outcome requires controlling 

the inflammatory response and is the focus of two 

AFIRM projects. 

Studies at WFPC 

The Washburn group (Project 4.5.3) at Carnegie 

Mellon University is developing hyaluronic acid 

(HA) biogels that contain monoclonal antibodies 

or peptides (short versions of proteins) with specific affinities for cytokines and other mediators 

of inflammation to absorb proinflammatory cytokines and decrease inflammation. The researchers 

have identified that a biogel with HA conjugated 

to an antibody against tumor necrosis factor-alpha 

(TNF-α) can effectively inhibit burn progression 

and control inflammation in a rat burn model. They 

developed a new analogue formulation that does 

not require covalent conjugation, which will facilitate clinical translation. During the past year, the 

researchers collaborated with Dr. Robert Christy’s 

A surgical resident and a postdoctoral fellow from 

WFPC perform microsurgery.
IV: Scarless Wound Healing

group at USAISR to test mixtures of anti-TNF-α and 

HA with conjugated (anti-TNF-α)-HA to determine 

whether conjugation was important for activities in 

a burn injury model. Their results confirmed that 

conjugation is necessary for the potent anti-inflammatory effects (e.g., reduction in secondary necrosis) 

observed with these materials. 

The Hebda group (Project 4.5.4) at the University 

of Pittsburgh’s McGowan Institute for Regenerative 

Medicine is working to clarify interactions between 

fibroblasts and inflammatory mediators with the 

goal of developing novel anti-inflammatory therapies to improve the quality of healing. The researchers demonstrated that early, short-term topical 

treatment with the anti-inflammatory agents nimesulide and prostaglandin E2 attenuated the wound 

inflammatory response, which led to the promotion 

of healing. They also showed that early, one-time 

topical treatment with isogenic ASC and fetal skin 

fibroblasts led to reduced scarring and increased 

healing. During the past year, the researchers completed cell therapy studies using regenerative phenotype donor cells. They revised their combination 

drug therapy protocol to use FDA-approved pharmaceutical agents. They found several important 

differences in wound modulation to be shared by 

regenerative fibroblasts, supporting the promise of 

using a patient’s own cells for regenerative (scarless) 

wound therapies. The research team’s goal for the 

next phase of this research project is to design and 

optimize the combination pharmacologic therapy 

that provides a wound environment for rapid, 

regenerative healing with minimal scar formation, 

based on previous and emergent results achieved 

during AFIRM I. 

Clinical Trials

Two AFIRM scarless wound-healing technologies 

have advanced to the human clinical trial stage. 

The status of each clinical trial is summarized in 

Table IV-2, and additional details on these trials follow the table. Detailed clinical trial progress reports, 

when available, can be found in the AFIRM Annual 

Report 2013 – Technical Progress Reports. 

In Project 4.5.9, the Beasley team at Neodyne, in 

collaboration with the Gurtner team at Stanford 

University, is conducting a Phase III clinical trial 

designed to test its third-generation device capable 

of stress-shielding wounds. A Progress Report for 

this project is not available at this time. 

Autologous fat transfer (AFT) is a procedure that 

involves removing adipose tissue from one area of a 

patient’s body and immediately transplanting it to 

a different site in the same person. The Katz group 

(Project 4.7.3) at UF is conducting a Phase I/IIa 

clinical trial designed to test the safety and efficacy 

of using AFT for scar prevention and remodeling. 

Patient enrollment began in July 2010. To date, the 

researchers have enrolled and treated a total of 10 

patients. The key accomplishments for the past year 

were the successful transition of the clinical trial to 

UF, and the finalization of all administrative and 

protocol-related logistics at both UF and USAISR/

Brooke Army Medical Center (BAMC), such that 

the trial is open to enrollment at two new sites. 

The researchers plan to focus future efforts on the 

enrollment of patients at UF and USAISR/BAMC. 

There are multiple companies that currently market 

fat tissue transplantation devices and systems. If the 

evidence from this trial supports the use of AFT for 

scar remodeling, the researchers do not expect commercialization to be a problem.

Table IV-2. AFIRM-funded scarless wound healing projects with active clinical trials.

Project Title Consortium Project No. Trial Phase Current 

Status

Neodyne’s Device to Actively Control the Mechanobiology 

during Wound Healing and Prevent Scar Formation

WFPC/ 

USAISR 4.5.9 III Open

Clinical Trial – Autologous Fat Transfer for Scar Prevention 

and Remodeling (AFT-SPAR)

RCCC/ 

USAISR 4.7.3 I/IIa Open

IV-6 AFIRM Annual Report 2013
AFIRM OUR SCIENCE FOR THEIR HEALING

Background 

Over the past few decades, changes in weaponry have resulted in 

a higher frequency of burn injuries to warfighters, and these often 

occur in combination with other severe injuries. Costly in both 

human and economic terms, these injuries carry risks to survival, 

independence, and function in both the short- and long-term, as the 

wounds mature with scarring and movement-limiting contractures. 

Currently, the standard of care for burn injuries includes early excision of the damaged tissue and autografting (i.e., transplanting 

healthy tissue from one part of the body to another), which 

is a procedure that has not changed fundamentally in 

more than three decades. In light of this, researchers 

have been tasked with discovering new solutions to 

overcome the challenges resulting from burn injuries. Not only will this improve outcomes for 

wounded warfighters suffering from burns, 

but it will also help in the treatment of 

other debilitating and disfiguring 

injuries where wound coverage or 

scarring are problematic. 

V: Burn Repair
AFIRM Annual Report 2013

V: Burn Repair

V-2

The therapies developed by AFIRM researchers are 

expected to benefit both the military and civilian 

populations of the U.S., where more than 1 million burn injury events occur annually, resulting in 

900,000 hospital days, 4,500 deaths, and more than 

$1 billion in treatment costs and lost productivity 

each year.

Unmet Needs 

Respiratory distress remains a critical issue immediately following burn injury; however, skin loss 

becomes the primary problem within the next 24 

hours. This disruption of the skin barrier frequently 

results in fluid and heat loss—often leading to a predisposition to infection. Compounding these problems are progressive inflammation and the extension of burns during the first few days after injury. 

Acutely, deep second-degree burns often extend to 

become full-thickness, third-degree burns, which 

often results in increased tissue loss, longer healing 

times, and excess morbidity and mortality. Over 

the long term, burn progression typically results 

in increased scarring, wound contractures, and 

poor quality of life. Unfortunately, various therapies which utilize non-steroidal anti-inflammatory 

drugs (NSAIDs) and antioxidants have not shown 

substantial benefit in preventing injury extension. 

Therefore, a critical unmet need is prevention of 

burn inflammation and injury progression. 

Within the area of the burn injury, nonviable tissue favors bacteria colonization and infection. This 

complication remains the most common cause of 

morbidity and mortality in patients with extensive 

burns, despite a reduced incidence of invasive infection. Although Sulfamylon®, Silvadene®, and silver 

nitrate are frequently used to prevent burn infections, each has disadvantages or adverse side effects. 

Sulfamylon is bacteriostatic for both gram-positive 

and -negative organisms, and it penetrates burn 

scabs extremely well. However, it is painful when 

applied to partial-thickness burns, and because it 

inhibits an enzyme, it can lead to the accumulation 

of acid in the body fluids if applied over an extensive 

surface. Silvadene does not induce pain or disturb 

acid-base balance, but it does fail to penetrate the 

burn scab well enough to help protect against certain types of bacteria. Furthermore, it can induce 

harmful conditions involving patients’ blood cells. 

Finally, although silver nitrate is active against a 

broad spectrum of bacteria, it cannot penetrate the 

burn scab and is caustic, which results in damage to 

otherwise viable tissue. Clearly, new topical treatments are needed for the prevention of infection in 

burn patients. 

Cutaneous autografts are optimal for closure after 

burn wound excision; however, this treatment 

approach mandates a viable wound bed and available donor sites. As the area in need of grafting 

may outsize available donor sites in patients with 

extensive burns, a skin substitute may be necessary. 

Frozen cutaneous allografts (tissue grafted from one 

individual to a genetically nonidentical member of 

the same species) and porcine cutaneous xenografts 

(tissue grafted from one species to an unlike species) 

are the two most readily available skin substitutes, 

but they are less adherent to the wound bed than 

fresh autografts, less able to control the bacterial 

population of the underlying wound, and usually 

do not become well vascularized (infiltrated with 

blood vessels) from the underlying wound bed. 

Another alternative is cultured autologous keratinocyte sheets; however, this approach is limited by 

a preparation time of 3–4 weeks, sheet fragility, and 

susceptibility to infection. 

Although limited in success, synthetic skin substitutes have also been used to treat burn injury. An 

effective synthetic skin substitute should be compatible with a patient’s own tissue, have no immune 

system-activating effects or toxicity, have water 

vapor permeability similar to that of skin, be impermeable to microorganisms, adhere to the wound, 

be readily vascularized, and have an indefinite shelf 

life. The available skin substitutes must be modified 

to increase their clinical usefulness by enhancing 

both their resistance to infection and their ability 

to accelerate the formation of either neodermis or 

granulation tissue (the fibrous connective tissue that 

replaces a clot in healing wounds).

The various therapies and innovations described in 

this chapter are proposed by AFIRM researchers 

to reduce wound scarring and contractures, while 

also preventing burn injury progression, reducing 

inflammation, and inducing healing following burn 

injury.
our science for their healing

Burn Repair V-3

Areas of Emphasis

Researchers at the Rutgers–Cleveland Clinic 

Consortium (RCCC), Wake Forest–Pittsburgh 

Consortium (WFPC), and U.S. Army Institute of 

Surgical Research (USAISR) are pursuing a complementary mix of research projects focused on various 

aspects of burn repair. As shown in Table V-1, projects can be grouped into four “clinical challenge” 

topic areas: Intravenous Treatment of Burn Injury, 

Topical Treatment of Burn Injury, Wound Healing 

and Scar Prevention, and Skin Products/Substitutes. 

Nontechnical summaries of the projects are presented after the summary table, and full progress 

reports for each project can be found in the AFIRM 

Annual Report 2013 – Technical Progress Reports.

Intravenous Treatment of 

Burn Injury

Studies at RCCC

The Lin/Clark group (Project 4.6.1) at Stony Brook 

University conducted a focused screening investigation for agents that inhibit the progression of 

burn injury. Agents were selected for their reported 

ability to inhibit oxidative stress, cytokine stress, 

or apoptosis. The researchers found that a single 

intravenous infusion of either fibronectin-derived 

P12 or curcumin could significantly inhibit burn 

injury progression in the rat hot comb model. The 

P12 peptide also significantly limited burn injury 

progression in a swine hot comb model. Over the 

Table V-1. AFIRM-funded projects per clinical challenge topic area.

Clinical Challenge Consortium/ 

Institution

Project 

No. Project Title

Intravenous 

Treatment of 

Burn Injury 

RCCC

4.6.1

Therapy to Limit Injury Progression, Attenuate Inflammation, Prevent 

Infection, and Promote Non-Scar Healing After Burns and Battle 

Trauma

4.6.1a Pre-IND Studies for a Novel Cell Survival Peptide that Limits Burn 

Injury Progression

Topical Treatment 

of Burn Injury

WFPC 4.2.3 Novel Keratin Biomaterials That Support the Survival of Damaged 

Cells and Tissues

RCCC

4.6.4 Polymeric, Antimicrobial, Absorbent Wound Dressing Providing 

Sustained Release of Iodine

4.6.5 Topical P12 Therapy to Limit Burn Injury Progression and Improve 

Healing

Wound Healing and 

Scar Prevention WFPC

4.2.2

Delivery of Stem Cells to a Burn Wound via a Clinically Tested Spray 

Device. Exploring Human Skin Progenitor Cells for Regenerative 

Medicine Cell-Based Therapy Using Cell Spray Deposition

4.2.5 In Situ Bioprinting of Skin for Battlefield Burn Injuries

Skin Products/ 

Substitutes

WFPC

4.2.6 Fluid-Derived and Placenta-Derived Stem Cells for Burn

4.2.8 In Vitro Expanded Living Skin for Reparative Procedures

RCCC 4.7.2 Burn Repair with Autologous Engineered Skin Substitutes

USAISR 4.6.8 Autologous Human Debrided Adipose-Derived Stem Cells for Wound 

Repair in Traumatic Burn Injuries
AFIRM Annual Report 2013

V: Burn Repair

V-4

past year, the researchers 

strove to further determine 

the safety and efficacy of P12, 

and establish systemic dosing details and treatment 

validation to prevent burn 

injury progression, reduce 

inflammation, induce healing and inhibit scarring. They 

determined that intravenous 

delivery of P12 in concert with 

growth factors sustains tissue 

cell survival. They also demonstrated that P12 is a cryptic 

peptide that is exposed by the 

interaction of fibroblasts with 

fibronectin when cells are 

seeded. During the upcoming year, the researchers will 

continue to investigate the 

mechanism of P12 bioactivity 

at the molecular level in both endothelial cells and 

fibroblasts (supported by a National Institutes of 

Health R21 grant). 

The Clark group (Project 4.6.1a) at NeoMatrix 

Formulations, Inc., are extending the research 

completed by the Lin/Clark group at Stony Brook 

University to develop the P12 peptide as a first-inclass therapeutic for burn injury progression. The 

researchers have obtained orphan drug designation 

for P12, thus creating access to potential funding 

through the U.S. Food and Drug Administration 

(FDA) as well as non-government sources to support clinical trials and commercialization. During 

the past year, they demonstrated that an infusion of 

P12 limits burn injury progression and speeds reepithelialization of burn injury in the swine vertical 

burn injury model. During the upcoming year, the 

researchers will continue to execute pre-Investigational New Drug (IND) studies of P12 treatment to 

prevent burn injury progression. The group intends 

to file an IND based on the activities supported by 

this award by the end of 2015.

Topical Treatment of Burn Injury 

Studies at WFPC 

Keratins are tough, fibrous structural proteins 

found in structures that grow from the skin (e.g., 

hair and nails). The Van Dyke group (Project 

4.2.3) at Wake Forest University School of Medicine 

is exploiting the thermoprotective properties of 

keratins to ameliorate the progression of injury 

immediately following a burn. The researchers 

have completed a mechanistic study and a pivotal 

preclinical study in swine. The swine study showed 

promising results for faster wound closure and no 

scarring. However, more testing of the tissue salvage 

capabilities of keratin biomaterials is required in a 

critical-size swine burn model (i.e., one that does 

not spontaneously heal and would require grafting 

to completely close). The researchers have completed pre-Investigational Device Exemption (IDE) 

activities with the FDA. The FDA has responded 

favorably, and the team is currently preparing a 

formal IDE application and finalizing manufacturing operations under Quality System Regulation 21

Code of Federal Regulations (CFR) 820. The commercial product being developed from this research, 

KeraStatTM Burn, is being considered for clinical trial 

evaluation under an IDE currently in preparation 

by KeraNetics.

Studies at RCCC 

In Project 4.6.4, the Iovine group at Rutgers 

University initially identified a polymer system that 

releases molecular iodine from a wound dressing 

to potentially prevent infection. However, various 

RCCC researcher, Ganesh Subramanian, prepares for a release study using 

Starch-Iodine polymers for potential use in patients to control wound infection.
our science for their healing

Burn Repair V-5

technical- and toxicity-related issues limited the 

usefulness and applicability of this system. The 

research team abandoned research efforts on the 

initial polymer system and instead created a tunable iodine delivery system in an absorbent wound 

dressing that releases iodine on demand and does 

not require frequent dressing changes, resulting in 

better patient comfort. During the past year, the 

researchers coupled the pre-polymer process with a 

mold/cure/cut fabrication sequence that produces a 

uniform, well-defined product on a very consistent 

basis. This process has been scaled up in the laboratory, and the researchers have shown that it is reproducible and controllable at this laboratory scale. 

They completed studies demonstrating the broad 

anti-bacterial and anti-fungal properties and sustainable slow release benefits of the starch polymer 

approach. Their room temperature stability studies 

on the packaged device indicate no change in product functionality over a 6-month period. During 

the upcoming year, the researchers will complete a 

12-month shelf life study. They also plan to evaluate 

the efficacy of the iodine-releasing wound dressing 

in an infected animal model, and pursue discussions with potential commercialization partners.

The Macri/Clark group (Project 4.6.5) at Stony 

Brook University is engineering a drug delivery 

scaffold for the topical therapy of large, acute burn 

injuries that cannot be closed. The researchers are 

exploring the effects of sustained release of the 

fibronectin-derived peptide 

P12 in this scaffold model. 

They developed tyrosinederived polycarbonate 

(TyrPC) terpolymers as fiberbased drug delivery matrices 

for releasing P12 at ultrafast 

(<24 hours) and fast (4 days) 

rates. During the past year, 

the researchers demonstrated 

the linear release of cyclized 

peptide (cP12) from both 

ultrafast- and fast-eroding 

cP12-loaded electrospun fiber 

mats. They determined that 

electron-beam irradiation 

with 25 kGy serves as a suitable sterilization method for 

cP12-loaded fiber mats. They 

demonstrated the in vivo safety of the cP12-loaded 

fiber mats. They also developed a porcine partialthickness burn model suitable for evaluating topical 

therapies. During the upcoming year, the researchers will focus on the delivery of cP12 from gel 

matrix technologies, rather than from TyrPC, with 

hopes to eliminate the potential for polymer degradation product interference with cP12 bioavailability and bioactivity. They also plan to conduct safety 

and efficacy studies (TRL 5) in Good Laboratory 

Practices guidance, submit an IND application, and 

initiate the design of a clinical trial.

Wound Healing and Scar 

Prevention

Studies at WFPC

The Gerlach group (Project 4.2.2) at the University 

of Pittsburgh is finding that skin progenitor cells 

derived from human fetal skin tissue may provide 

an interesting new cell source for regenerative cellbased therapy for acute and chronic skin disease 

and burn patient treatment. The researchers are 

expanding on successful work, conducted previously in Germany, in which fetal skin cells are 

sprayed onto excised burn wounds with a precision 

device, known as a “Skin Gun.” They have established methods for isolating, growing, and freezing 

fetal skin cells. They established an antibody marker 

panel for characterizing stem cell markers in fetal 

WFPC researcher preparing a bioreactor.
AFIRM Annual Report 2013

V: Burn Repair

V-6

as well as adult epidermal and 

dermal cells. Freshly isolated adult 

epidermal and dermal progenitor cells can now be provided for 

full-thickness burn wound healing. 

Fetal dermal derived fibroblasts 

exhibited higher wound healing 

activity than bone-marrow mesenchymal stromal cells. Overall, in 

vitro cultured fetal dermal derived 

stem cells show a high potential 

for full thickness and larger burn 

wound healing as an anticipated 

off-the-shelf product. Additionally, 

adult dermal progenitor cells will 

enhance autologous on-site cell 

grafting and should lead to clinical 

studies on advancing adult autologous skin cell grafting into the area 

of third-degree burn therapy.

The Yoo group (Project 4.2.5) at Wake Forest 

University is using inkjet technology to achieve the 

“printing” of skin onto an excised burn wound. 

Since bioprinting has been used successfully to 

fabricate other tissues, skin should be similarly 

amenable to this approach, especially given its 

minimally three-dimensional, linear spatial orientation. The researchers developed a portable skin 

printing device to deploy skin cells to a wound in 

a spatial-specific manner. This process involved 

design, construction, laser scanner integration, software development, and validation. The researchers 

also developed isolation and expansion techniques 

for skin keratinocytes and dermal fibroblasts. They 

first achieved direct delivery of skin cells onto skin 

defects in a mouse model. They also developed a 

porcine full-thickness burn wound model. They 

found that bioprinting of autologous skin cells 

enhanced the healing time of full thickness excisional wounds as well as third degree burn wounds 

in the porcine model. By 2 weeks post-bioprinting, 

the autologous cells formed an epithelial layer 

that covered up to 90% of the wound. This work 

will continue under other funding sources. The 

researchers will contact the Office of Combination 

Products at the FDA to confirm the classification of the bioprinter and, if needed, file a Request 

for Designation with the Office of Combination 

Products in accordance with 21 CFR Part 3. 

Skin Products/Substitutes 

Studies at WFPC 

The need for a skin replacement that is instantly 

available and alleviates the need to take a split- or 

full-thickness skin graft has long been sought. 

The Jackson/Furth group (Project 4.2.6) at Wake 

Forest University is developing an improved off-theshelf bioengineered skin product that uses amniotic 

fluid-derived stem (AFS) cells for the treatment of 

extensive burns. The researchers are capitalizing on 

the capability of AFS cells to differentiate into skin 

progenitor (stem) cells without forming tumors to 

facilitate healing of a burn wound following the 

introduction of cells. They established a nude mouse 

full-thickness wound model and bioprinted AFS 

cells into the wound. They demonstrated enhanced 

wound healing as well as increased neovascularization using AFS cells. They also combined AFC cells 

with mature keratinocytes, which led to enhanced 

wound healing. These results suggest that AFS cells 

bioprinted as a cell therapy may be a potentially 

powerful tool for burn and wound healing treatments. This work will continue under other funding 

sources.

The Lee/Yoo/Holmes group (Project 4.2.8)

at Wake Forest University has developed an in 

vitro tissue expander system that permits a rapid 

increase in surface dimensions of donor skin 

WFPC researcher Brian Phelps designing new parts for a bioreactor.
our science for their healing

Burn Repair V-7

while maintaining tissue viability for subsequent 

skin transplantation. This system allows for an 

approximately 40 cm2

 split-thickness piece of skin 

to be harvested at the initial operation from a burn 

patient who is anticipated to require multiple graft 

operations. The harvested skin is then expanded 

in the bioreactor to approximately 100 cm2 over 

2 weeks and subsequently “grafted” back onto the 

patient in the standard manner, with or without 

meshing, at the next operation. The researchers 

are defining parameters that maximize the surface 

dimensions of skin for treating battlefield burns. 

They have built a new generation uniaxial bioreactor 

system. They also have devised a strategy to perform a clinical trial. During the upcoming year, the 

researchers will develop working parameters for the 

skin bioreactor expander system that will maximize 

skin expansion while maintaining tissue viability. 

They are working towards obtaining an IDE by the 

FDA for approval of a prospective, multicenter, nonrandomized, uncontrolled pilot study (Feasibility/

Phase I), and are currently seeking IRB approval. 

Based on conversations with an FDA consultant, the 

researchers will perform a preclinical large animal 

study, which is essential for FDA approval for the 

clinical trial.

Studies at RCCC

Engineered skin substitutes (ESSs) have been 

developed and tested clinically as an adjunctive 

treatment for burn repair. Although ESSs reduce the 

requirements for harvesting skin autografts, these 

have two major deficiencies: (1) incomplete pigmentation, which does not resolve with time, and (2) the 

absence of a network of blood vessels, which limits 

the thickness and rate of engraftment of ESSs. The 

Boyce/Clark group (Project 4.7.2) at the University 

of Cincinnati and Stony Brook University is designing and testing new prototypes of ESSs that restore 

skin color and develop vascular networks, thereby 

resulting in improved outcomes in recovery from 

life-threatening burns. They have restored skin color 

in an animal model using ESSs, and have developed 

protocols to translate research procedures into a 

testable therapy. During the past year, the research 

group demonstrated complete restoration of skin 

color in autologous ESS with pigment (ESS-P). Their 

preliminary data showed that melanin expression 

can be downregulated to promote cryopreservation 

of human melanocytes to allow multiple applications of ESS-P. Going forward, the researchers plan 

to develop a set of standard operating procedures 

to determine any variability in uniformity of pigment distribution among 

ESS-P containing human 

melanocytes from different 

skin donors or body sites. 

As a first step in the process 

toward a clinical trial, the 

researchers will prepare a 

Request for Designation with 

advice from the translational 

research office at WFIRM. 

Determination by the FDA 

of the regulatory identity of 

ESS-P as a device, biologic, 

drug or combination product 

will facilitate development 

of the technical, clinical and 

regulatory protocols needed 

to prepare for and perform 

clinical trials directed toward 

delivery of an advanced 

therapy to reduce morbidity 

and mortality for our nation’s 

wounded warriors.

At the University of Cincinnati, project staff member Rachel Zimmerman 

prepares selective cultures of human epidermal melanocytes for 

transplantation to full-thickness skin wounds. Melanocytes are combined with 

epidermal keratinocytes and dermal fibroblasts on collagen-based scaffolds to 

restore normal skin color to wounds treated with the engineered skin grafts.
AFIRM Annual Report 2013

V: Burn Repair

V-8

Studies at USAISR

Adipose-derived stem cells (ASC) have the potential to grow into cells found in human skin. The 

Christy group (Project 4.6.8) at USAISR hypothesized that a person’s own ASC could be used to 

produce a clinically relevant tissue-engineered skin 

equivalent. The researchers isolated human ASC 

using a point-of-care device. They developed the 

technology to differentiate ASC into epithelial cells 

for use on patients so severely burned that they do 

not have an autologous source of epithelial cells. 

The team also demonstrated that stem cells can be 

isolated in adequate quantities from the adipose 

layer of discarded burn skin. During the past year, 

the researchers developed the technology to remove 

the cells from the amniotic membrane for epithelial 

wound covering and epithelial differentiated ASC 

sheets. They developed PEGylated plasma-based 

biomaterial products to be used for wound healing and the development of skin equivalents. They 

also developed platelet-free plasma to use instead of 

purified fibrin for vascularized biomaterial matrix. 

Finally, they developed a porcine model to determine the validity of skin constructs in deep partial 

thickness burns. The researchers plan to continue to 

use and optimize the InGeneron, Inc. point-of-care 

device for the isolation of ASCs. This will be used 

for the isolation of cells from debrided burn patient 

tissue, as well as from surgically isolated adipose 

tissue obtained from abdominoplasty. The researchers will continue to develop a more clinically 

relevant porcine burn model, and they will use this 

model for the development of a large (up to 20%) 

total body surface area burn, which will provide a 

stringent test for their and other AFIRM-related 

skin equivalent products. Finally, they are continuing to address and use FDA-approved products that 

are commercially available. 

Clinical Trials 

Several AFIRM burn repair technologies have 

advanced to the human clinical trial stage. The status of each clinical trial is summarized in Table V-2,

and additional details are presented in the following 

paragraphs. Detailed clinical trial progress reports 

can be found in the AFIRM Annual Report 2013 – 

Technical Progress Reports. 

The Holmes group (Project 4.2.7) at Wake Forest 

University is collaborating with researchers at 

USAISR and Avita Medical, among other institutions, to conduct a multicenter clinical trial for the 

ReCell® Device. The device is designed to provide 

a simple, safe technique for the harvesting of skin 

cells for enhancement of epidermal repair. The 

first step involves harvesting a thin, split-thickness 

skin sample, followed by harvesting the cells of the 

epidermis, dermis and epidermal-dermal junction. 

The separated cells and associated signaling factors 

are combined into a suspension containing a mixed 

population of live keratinocytes, melanocytes and 

papillary fibroblasts. The suspension is then sprayed 

onto the prepared wound bed. The cells migrate 

over the surface providing epidermal reconstruction with site-matched characteristics of color and 

texture. The applied cells are incorporated into the 

developing epidermis. The speed of re-epithelialization is very important as the “sealing” of the 

skin surface limits the inflammation that has been 

Table V-2. AFIRM-funded burn repair projects with pending or active clinical trials.

Project Title Consortium Project No. Trial 

Phase Current Status

A Multicenter Comparative Study of the ReCell® Device 

and Autologous Split-thickness Meshed Skin Graft in the 

Treatment of Acute Burn Injuries

WFPC / 

USAISR 4.2.7 Phase III Open

Stratatech Technology for Burns WFPC / 

USAISR 4.2.9 Phase Ib Open

Enhanced Detection of Pathogens in Burn Wounds Using 

a Novel Multi-primer PCR/Mass Spectrometric Assay WFPC 4.5.5a Phase I Awaiting HRPO approval

Expedited Availability of Autologous Engineered Human 

Skin for Treatment of Burned Soldiers

RCCC / 

USAISR 4.7.4 Phase I Awaiting IND 

approval
our science for their healing

Burn Repair V-9

implicated as the pivotal factor in hypertrophic 

scar formation. Patient enrollment for this clinical 

trial began in May 2010. The researchers enrolled 

and treated a total of 21 subjects during the past 

year, bringing total enrollment to date to 85 (of 106) 

subjects. Thirty-six (36) subjects have been followed through 52 weeks. Eight (8) sites are actively 

enrolling subjects. Enrollment has been discontinued at sites with limited performance in terms of 

enrollment in order to focus the use of resources. 

Permission from the FDA and ethics approval has 

been secured for the addition of the Sunnybrook 

Health Sciences Centre to the study. Avita Medical 

is engaged in dialog with the FDA regarding potential changes toward expediting completion of the 

study and product approval. Additional sites are 

being considered for participation in the study to 

increase the rate of enrollment. 

In Project 4.2.9, the Holmes group at Wake Forest 

University is collaborating with researchers at 

USAISR and Stratatech Corporation, among other 

institutions, to conduct a multicenter, Phase Ib 

clinical trial to assess the safety, tolerability, and 

efficacy of prolonged exposure to increasing 

amounts of a single application of StrataGraft® skin 

tissue compared to autograft in the deep partial 

thickness component of complex skin defects. 

StrataGraft tissue is a living, meshable, suturable, 

human skin substitute developed by Stratatech 

Corporation that reproduces many of the structural 

and biological properties of normal human skin. 

The research team has obtained all necessary regulatory approvals for the dose-escalation clinical trial 

and has performed site initiation visits at each of the 

six clinical sites. The researchers have maintained a 

continuous production stream of StrataGraft skin 

tissue for the clinical trial at a cGMP-compliant 

biomanufacturing facility. Two (2) cohorts of 10 

subjects each have been fully enrolled. The second 

patient cohort was treated with a larger area of 

StrataGraft tissue than the first cohort. None of the 

sites in either cohort required autografting of any 

percentage of the StrataGraft treated site by Day 28. 

The researchers found no evidence of safety concerns or immunological responses to the StrataGraft 

tissue. The researchers’ data suggest that StrataGraft 

provides immediate wound closure and is replaced 

as the patient’s own cells heal the wound. Research 

plans for the upcoming year include completion of 

follow-up assessments of safety and efficacy outcomes, and preparation of a study report. Results 

of this study will inform the design of a Phase III 

registration study in patients with complex skin 

defects.

The diagnosis of an actual burn wound infection remains largely a clinical one, depending on 

such signs as surrounding cellulitis, drainage of 

pus, and skin graft failure, and aided by cultural 

microbiology obtained from swabs, biopsies, or 

operative specimens. However, it has recently been 

recognized that numerous bacteria (and fungi) 

exist within burn wounds in the form of biofilms 

(organized communities of microorganisms encased 

in a matrix of extracellular polymeric substance). 

The recent advent of a novel coupled polymerase 

chain reaction-mass spectrometric technology, the 

Ibis PLEX-IDTM, offers multiple potential advantages for the molecular detection of biofilm-based 

and other infections compared to all previous 

molecular assays. The semi-quantitative Ibis assay 

simultaneously tests for more than 3,000 species, including virtually all known pathogens, in 

a multiplex fashion, eliminating the need for an a 

priori choice as to the likely infecting organism. The 

Researchers at Lonza Walkersville, Inc. perform cell 

therapy manufacturing in one of several clean room 

suites.
V: Burn Repair

V-10 AFIRM Annual Report 2013

Kathju group (Project 4.5.5a) at the University of 

Pittsburgh is preparing to conduct a clinical trial 

designed to evaluate the utility of the Ibis PLEX-ID 

system in the diagnosis of burn wound infection. 

The researchers have begun the process of patient 

accrual for the clinical trial and currently have up 

to 52 discrete patients enrolled. They are optimizing 

the sample extraction and preparation techniques 

and have demonstrated that sample extraction and 

analysis are proceeding within acceptable technical 

parameters. Notably, the Ibis PLEX-ID technology 

is already under commercial development by Abbott 

Laboratories.

In Project 4.7.4, the Smith/Nigida/D’Souza group

at Lonza Walkersville, Inc. (LWI) has developed 

autologous ESSs to promptly and effectively close 

extensive, deep burns. LWI has licensed the technology and completed the technology transfer and 

product development. The researchers received an 

Orphan Drug Product Designation for the ESSs on 

June 1, 2012. They submitted an IND application to 

the FDA on July 26, 2012, and received a “Clinical 

Hold Letter” for the ESSs on September 21, 2012. 

They have completed all but one item in the Clinical 

Hold Letter and are providing all completed actions 

to the FDA for additional review. The researchers anticipate that upon receiving FDA approval 

to proceed with this IND-based study, they will 

enroll 14 subjects (4 for a “priming phase” and 10 

for the clinical trial) at the USAISR and Harborview 

Medical Center in Seattle, Washington. In the 

upcoming year, the research team plans to develop 

rapid release assays and potency assays, evaluate the matrix by assessing its physical attributes, 

prepare for large-scale matrix manufacturing, and 

determine commercial packaging. In addition, 

the researchers are looking to increase their ESS 

manufacturing capability should there be a national 

emergency with multiple casualties or a national 

emergency that might include multiple treatment sites. Expansion is being explored through 

two paths, one being increased output per lot and 

the other by establishing additional manufacturing sites. Besides the aforementioned clinical trial, 

the researchers anticipate conducting (at a future 

date) a larger, Phase II trial that will include up to 

40 subjects
AFIRM OUR SCIENCE FOR THEIR HEALING

Background

While many consider battlefield trauma to be the visible types of 

injuries caused by blasts and projectiles, often the Warfighter experiences hidden complications that are a result of these injuries. 

Compartment Syndrome (CS) is a potentially serious medical 

condition in which increased pressure or swelling within 

a “compartment” compromises the blood supply to that 

area. Simply put, compartments are confined spaces 

throughout the human body that contain muscles, 

nerves, and blood vessels. While CS can result 

from fractures, blunt and penetrating trauma, 

blast trauma, injury to blood vessels, and 

the return of blood flow to a muscle after 

surgical intervention, it can also result 

from the use of a combat tourniquet in the field. Regardless of 

the cause, the diagnosis of CS 

is considered a medical 

emergency. 

VI: Compartment 

Syndrome
AFIRM Annual Report 2013

VI: Compartment Syndrome

VI-2

In the arms and legs, thick layers of connective 

tissue called fascia surround the groups of muscles 

within these compartments, holding them in place 

and protecting them. If CS is identified, release of 

the fascia (known as a fasciotomy) must be performed within 6 hours of diagnosis to reduce the 

likelihood of limb amputation and death. 

As no effective treatments are available currently to 

overcome the complications caused by CS, military 

surgeons are seeking safe and effective therapies to 

replace and regenerate damaged cells and tissues. 

Service members who develop CS have prolonged 

recovery times and rarely regain complete muscle 

function, and typically they do not return to active 

duty at the same level of performance. Notably, 

most unrecognized CS injuries of the extremities 

result in permanent disability. 

The AFIRM Compartment Syndrome Program is 

focused on helping to reduce the impact of CS on 

wounded warriors and to improve their functional 

recovery through the application of regenerative 

medicine. These projects seek to increase the salvage 

of injured limbs affected by CS utilizing an interdisciplinary approach based on a combination of stem 

cells and inductive biodegradable scaffolds for the 

reconstruction of functional compartment tissues. 

Unmet Needs 

Unfortunately, little improvement has been realized 

in the treatment of CS since the introduction of surgical fasciotomy more than a century ago. Lack of 

progress in this area is due partially to 

the fact that, despite decades of research 

attempts, no satisfactory surrogate 

animal models have been established to 

study new prospective treatments. The 

AFIRM is supporting the successful 

creation of platform animal models of 

small and large wounds complicated by 

CS. Additionally, instrumentation has 

been developed within the program to 

quantitatively assess muscle and nerve 

regeneration in a precise, reproducible 

manner in these models. 

Complications of untreated CS include 

Volkmann’s contracture, which is a 

permanent shortening of musculature 

of the hand at the wrist that results 

in a claw-like deformity of the hand and fingers. 

Advanced CS can lead to permanent paralysis due 

to the failure of muscles and nerves in an affected 

compartment to recover. At that advanced stage, 

amputation of the affected limb may be the patient’s 

only remaining treatment option, and in light of 

this, partial replacement of the dysfunctional tissue 

by living engineered muscle tissue is an attractive 

concept. Therefore, this continues to be an unmet 

need. Researchers at the AFIRM are generating 

technologies that will provide improved functional 

recovery for injured soldiers through the regeneration of muscle, nerve, and blood vessels lost to CS 

and other battlefield wounds. 

Areas of Emphasis 

AFIRM researchers are pursuing a complementary 

mix of research projects focused on various aspects 

of treatment of CS. Projects can be grouped into two 

“clinical challenge” topic areas: Cellular Therapy 

of CS and Biological Scaffold-Based Treatment of 

CS. Nontechnical summaries of the projects are 

presented after Table VI-1, and technical progress 

reports for each project can be found in the AFIRM 

Annual Report 2013 – Technical Progress Reports. 

Cellular Therapy of CS 

Studies at Wake Forest–Pittsburgh 

Consortium 

Wake Forest–Pittsburgh Consortium (WFPC) 

researchers are using human muscle-derived and 

WFPC researcher Zhan Wang preparing samples for analysis with 

Dr. Shay Soker.
our science for their healing

Compartment Syndrome VI-3

bone marrow-derived stem and progenitor cells to 

reconstruct functional compartment tissues following the development of CS. In Project 4.3.1, 

the Huard group at the McGowan Institute for 

Regenerative Medicine (MIRM) and the Soker 

group at the Wake Forest Institute for Regenerative 

Medicine have developed a rat model of CS using 

neonatal blood pressure cuffs to apply external 

compression on the hindlimb. The researchers 

characterized anatomic and functional changes 

in the muscular, vascular and neural components 

of the hind limb muscles following compressioninduced damage in their rat model, which mimics 

CS observed in clinical patients. They found that 

muscle precursor cell (MPC)-injected muscles 

exhibited significant functional improvement 14 

days after injury, and this effect was observed for 

both adult and young animals. The research team 

also demonstrated that co-seeding of endothelial 

cells with MPCs led to enhanced vascularization, 

innervation and skeletal muscle tissue formation in 

vivo. They developed cell culture expansion protocols that maintained the muscle tissue-forming 

capability of MPCs for at least 25 cell passages. 

They also obtained and characterized biopsies from 

CS patients, and found variability among patients. 

The researchers used the U.S. Food and Drug 

Administration (FDA)-approved drug Losartan and 

found it to be effective in reducing the amount of 

fibrosis in injured skeletal muscle. Based on these 

findings, a two-person case study conducted at the 

University of Pittsburgh Medical Center showed 

that Losartan is an effective treatment for grade II 

hamstring injuries. During the upcoming year, the 

researchers will conduct combinatorial therapeutic 

strategies in the CS animal model including delivering MPCs with and without angiogenic factors, 

Losartan, and Platelet Rich Plasma fractions. They 

will also continue using Losartan to reduce fibrosis 

and optimize the ideal dose and time after injury 

to begin Losartan treatment. They are planning a 

larger, double-blinded, multi-center, clinical study.

The Gregory group (Project 4.3.2) at the Oregon 

Medical Laser Center is evaluating the effectiveness of autologous bone marrow mononuclear cell 

(BM-MNC) treatments in CS injuries. The researchers have developed an in vivo cell-tracking technique that allows them to demonstrate extremely 

robust cell engraftment up to 3 months post treatment. They completed a pivotal proof-of-concept 

preclinical study in Sinclair mini-swine to evaluate 

the use of BM-MNCs to treat extremity injuries 

complicated by CS. They observed significantly 

improved muscle and nerve function in animals 

treated with BM-MNCs compared to control animals. While control animals stopped improving 

clinically 6 weeks after injury, BM-MNC treated 

animals continued to improve clinically through the 

12-week study endpoint. Significant gait improvement was observed at 3 months in the cell-treated 

animals compared to control animals. No adverse 

events or complications were associated with any 

cell treatments. This research demonstrates the 

potential of a safe, new treatment for severe extremity injury that offers injured troops an improved 

* Wake Forest–Pittsburgh Consortium

**U.S. Army Institute of Surgical Research

Table VI-1. Projects Funded by WFPC* and USAISR** per Clinical Challenge Topic Area 

Clinical Challenge Consortium/ 

Institution

Project 

No. Project Title

Cellular Therapy 

of CS WFPC

4.3.1 Cellular Therapy for Treatment and Consequences of Compartment 

Syndrome

4.3.2 Use of Bone Marrow-Derived Cells for Treatment of Compartment 

Syndrome

Biological ScaffoldBased Treatment 

of CS

WFPC

4.3.3 Biodegradable Elastomeric Scaffolds Microintegrated with MuscleDerived Stem Cells for Fascial Reconstruction Following Fasciotomy

4.3.4 Use of Autologous Inductive Biologic Scaffold Materials for Treatment 

of Compartment Syndrome

4.3.5 Material-Induced Host Cell Recruitment for Muscle Regeneration
AFIRM Annual Report 2013

VI: Compartment Syndrome

VI-4

functional recovery. During the upcoming year, the 

researchers will finish their randomized 6-month 

study comparing BM-MNC treatments (10 animals) 

to sham controls (10 animals) for validating safety 

and efficacy as a prelude to clinical trials. They will 

also perform a rodent study to evaluate the toxicology, biodistribution, tumorigenicity, and microbiological effects of the treatment protocol. In addition, 

they aim to begin a multicenter Phase I human 

clinical trial. 

Biological Scaffold-Based 

Treatment of CS 

Studies at WFPC 

WFPC researchers are developing animal models 

of CS and implantable scaffolds that can be used 

to treat this potentially devastating condition. 

The Wagner group (Project 4.3.3) at the MIRM 

is focused on developing biodegradable scaffolds 

with elastic properties that can be integrated with 

autologous muscle-derived stem cells (MDSCs) to 

reconstruct fascia (thick, fibrous tissue that encloses 

and protects the organs) after abdominal CS injury. 

The researchers created three scaffold designs that 

incorporate skin extracellular matrix (ECM) and 

an elastic polymer. ECM provides structural and 

functional support to cells. The researchers assessed 

the bioactivity and mechanical properties of these 

scaffolds in a full-thickness abdominal wall reconstruction rat model. The scaffold that performed the 

best consisted of outer layers of elastic polymer surrounding an inner hybrid skin ECM-polymer layer. 

During the past year, the researchers developed new 

material processing techniques to produce mechanically robust biocompatible and bioactive scaffolds. 

They investigated concurrent electrospinning of 

degradable poly(ester urethane)urea fibers with electrospraying of a saline solution to integrate MDSCs 

into the scaffolds. Evaluation in a rat abdominal 

wall defect demonstrated that such constructs were 

capable of producing pronounced cellularity and 

de novo formation of ECM. The researchers added 

reinforcing surface layers to this material to improve 

mechanical integrity. Constructs developed in this 

manner were found to be superior to currently 

clinically available materials in terms of cellularity, 

ECM content, and tensile mechanical properties. 

In Year 5, the researchers will evaluate their biohybrid scaffolds in a more clinically relevant porcine 

model. The developed materials will also be considered for other applications, including skin, craniofacial, and soft tissue reconstruction. 

The Badylak group (Project 4.3.4) at the University 

of Pittsburgh is investigating a method for using 

the inductive properties of ECM as a scaffold for 

the recruitment of one’s own stem cells and the 

attachment, proliferation, and spatial organization 

of these cells into functional tissue. The researchers 

are also developing methods of decellularization 

(removing the cells) from necrotic (dead) tissue 

while retaining native ECM. Notably, the decellularization of cellular material produces ECM that can 

be used to promote the regeneration of tissue in an 

animal model. During the past year, the researchers completed an evaluation of decellularization as 

a treatment of peripheral CS (PCS) in rabbits. They 

also developed a mouse model of volumetric muscle 

loss (VML) to investigate the mechanisms of ECM 

remodeling associated with massive skeletal muscle 

injury. Using this model, they found that resident 

perivascular stem cells participate in remodeling 

and may promote increased myogenesis (muscle formation) and reduced scarring compared to a fasciotomy and debridement (removal of dead, damaged, 

WFPC researcher adding cells to a tissue scaffold.
our science for their healing

Compartment Syndrome VI-5

or infected tissue) PCS treatment alone. Finally, the 

researchers began applying their optimized decellularization method to a porcine model of PCS. 

During the upcoming year, the research team will 

complete the porcine model studies, which they 

anticipate will provide the foundation for a Phase I 

clinical trial. They will continue to use the mouse 

model of VML to elucidate the mechanisms of ECM 

remodeling following skeletal muscle injury.

The Lee group (Project 4.3.5) at Wake Forest 

University is focused on developing an approach to 

enhance the recruitment of endogenous stem and 

progenitor cells to the site of CS injury to increase 

the regenerative response. The researchers are using 

biomaterials containing myogenic (muscle cell)-

inducing factors that can be implanted within the 

injured muscle compartment. They have demonstrated that host muscle stem cells can be recruited 

into implanted biomaterials in situ, and that these 

cells can be transformed into muscle cells using 

myogenic-inducing factors. They have developed 

novel injectable and implantable scaffolding systems 

using heparin-conjugated gelatin microparticles and 

heparin-conjugated cell-free muscle matrix, respectively. The researchers demonstrated the mobilization of host stem and progenitor cells, as well as 

new muscle tissue regeneration in vivo in rats, using 

these scaffolding systems. During the upcoming 

year, the Lee group plans to continue to optimize 

and validate the injectable/implantable systems 

that can deploy multiple bioactive molecules in a 

controlled manner. To evaluate the clinical feasibility of the delivery of multiple bioactive molecules 

from the systems in vivo, they will use two rabbit 

muscle injury models, including models of muscle 

atrophy and VML.

WFPC researcher Manasi Vadhavkar preparing 

samples for histological analysis of muscle tissue.

AFIRM OUR SCIENCE FOR THEIR HEALING

Introduction

The AFIRM is a large, multifaceted complex biomedical research and 

development consortium of collaborating scientists, engineers, and 

medical product development experts. Across the AFIRM consortia, 

hundreds of basic and clinical researchers apply their expertise in 

regenerative medicine research and development to find medical solutions to treat our Service members with severe combat 

wounds. AFIRM investigators and product developers represent nearly 60 research universities and hospitals, and 

26 commercial partners at the core institutions and 

collaborating organizations.

VII: AFIRM 

Statistics
AFIRM Annual Report 2013

VII: AFIRM Statistics

VII-2

While the previous chapters of this report demonstrate the depth of the AFIRM’s individual 

research projects, this chapter displays the research 

consortium as a whole to provide an overarching 

perspective of the program’s breadth. This chapter 

demonstrates the extent and quality of scientific and 

technical expertise being applied to the problems 

of regenerative medicine by displaying aggregated 

program data. This chapter also demonstrates 

tangible, scientific outcomes attributable to AFIRMsupported research: inventions disclosed, patent 

applications filed, research or review articles published, conference and meeting presentations and 

posters presented, and the advancement of products 

through research and development stages. The 

AFIRM data shown in this chapter cover the 5 years 

of the program with particular emphasis placed on 

the AFIRM in Program Year 5 (PY5). 

Personnel

A substantial workforce has contributed to AFIRMfunded studies to conduct research on regenerative biology and medicine. From faculty members 

to undergraduate students, nearly 500 researchers contributed to the AFIRM research activities 

in PY5.1 The distribution of these scientists and 

students is illustrated in Figure VII-1. For example, 

85 faculty members from the Rutgers–Cleveland 

Clinic Consortium (RCCC) and 90 faculty members from the Wake Forest–Pittsburgh Consortium 

(WFPC) contributed to the AFIRM in PY5. In 

addition, more than 100 postdoctoral associates and 

fellows and more than 120 scientific and technical staff contributed to the AFIRM studies in PY5.2

Figure VII-1 also depicts the 9 research investigators and technical staff at the U.S. Army Institute 

of Surgical Research (USAISR) who contributed to 

the AFIRM through the support of the Clinical and 

Rehabilitative Medicine Research Program in PY5.

1 For the purpose of this annual report, PY5 is defined as the period from June 1, 2012 to May 31, 2013. PY4 spans from June 1, 2011 to 

May 31, 2012; PY3 spans June 1, 2010 to May 31, 2011; PY2 spans June 1, 2009 to May 31, 2010; and PY1 spans the period from the 

initiation of research projects in May 2008 through the end of May 2009.

2 The numbers may be slightly overestimated due to some individuals working on multiple projects. To minimize duplicate counts of 

the same individuals, the names of scientists and students provided by project investigators were cross-referenced. Anyone who 

contributed to more than one project was counted only once. However, not all individuals who worked on the AFIRM were named; thus, 

it is possible that some individuals working on two or more projects could have been included in the count for each separate project.

3 This chart displays the number of unique individuals, both funded and unfunded by the AFIRM, who contributed to the AFIRM program 

during any part of PY5.

Figure VII-1. Numbers of scientists and students contributing to the AFIRM program during PY5.3

0 50 100 150 200 

Faculty 

Post-Doctorates 

Graduate Students 

Undergraduate Students 

S&T Sta 

Number of Scientists 

RCCC 

WFPC 

USAISR
our science for their healing

AFIRM Statistics VII-3

Another highlight of the AFIRM is the substantial 

recruitment and training of the next generation of 

scientists to advance regenerative medicine research 

and development into the future. More than 100 

students (57 graduate students and 44 undergraduate students) received valuable scientific training 

through AFIRM-sponsored research projects in PY5 

(Figure VII-1). 

The numbers of AFIRM-supported graduate 

students who completed their degree requirements each year of the program are shown in 

Figure VII-2. During the first PY, three graduate degree recipients were supported through the 

AFIRM. In each of the following 4 years, between 

12 and 24 graduate degree recipients had received 

training support through the AFIRM. For the 

5-year span of the program, a total of 70 graduate 

students supported through the AFIRM completed 

their degree requirements (54 received a PhD and 16 

received a master’s degree).

The AFIRM program was originally organized into 

five research focus areas: Limb and Digit Salvage, 

Craniofacial Reconstruction, Burn Repair, Scarless 

Wound Healing, and Compartment Syndrome.4

Figure VII-3 depicts the proportion of all core 

personnel, funded and unfunded, who worked on 

the different program areas in PY5.5

 Two of these 

research focus areas account for more than half 

the personnel: Limb and Digit Salvage (32%) and 

Craniofacial Reconstruction (25%).

Honors and Achievements

The AFIRM program’s faculty members are highly 

accomplished in their respective scientific fields. 

From June 2012 through May 2013, 43 honors and 

awards were conferred upon the AFIRM faculty. 

These honors include selection to membership 

or leadership positions in professional societies, 

invited presentations and lectureships, receiving 

honorary degrees, awards from private foundations, 

Figure VII-2. Number of graduate degrees awarded to students who received training through AFIRM projects.

30

25

20

15

10

5

Number of AFIRM Students 

Receiving Advanced Degrees

0

PY1

Program Year

PY2 PY3 PY4 PY5

WFPC

RCCC

4 As the AFIRM program has matured, the overarching research focus areas have been redefined by the consortia to more accurately 

describe their research focus. To compare the consortia across different years, Figure VII-3 displays the percentage of personnel 

conducting research according to the original research focus areas.

5 Figure VII-3 counts each person once. The few researchers who worked on projects in two or more research focus areas are only 

represented once in the chart according to their principal research area.
AFIRM Annual Report 2013

VII: AFIRM Statistics

VII-4

recognition of excellence at conferences, and faculty 

teaching awards. The distribution of the honors 

received is displayed according to the type of conferring organization in Figure VII-4.

6

 The complete 

lists of honors and awards received by the AFIRM 

faculty during PY5 are shown in Appendix A.

In addition to awards and honors received by 

AFIRM researchers, many AFIRM investigators 

have successfully competed for new research funds. 

AFIRM investigators reported the submission of 45 

proposals in PY5 that were under review. AFIRM 

investigators also reported the initiation of 52 newly 

awarded grants, contracts, or subcontracts in PY5.7

Figure VII-3. Percentage of personnel conducting research in the 

AFIRM program across the five research focus areas in PY5.

Limb and Digit Salvage 

Craniofacial Reconstruction 

Burn Repair 

Scarless Wound Healing 

Compartment Syndrome

32% 

22% 

16% 

5% 

25% 

Figure VII-4. Distribution of honors and awards to the AFIRM faculty 

by type of conferring organization in PY5.

Professional Societies 

Research/Academic Institutions 

Private Foundations 

Government Agencies 

18 

10

4

11

6 Awards to faculty are reported by the researchers. Data exclude awards to postdoctoral fellows and students, and also exclude the 

awarding of competed grants and contracts.

7 The number of proposals submitted includes those with self-reported submission dates falling within PY5 as well as proposals that 

were reported without submission dates. The number of new grants or contracts includes those reported with funding start dates 

within PY5 and those that did not report funding dates.
our science for their healing

AFIRM Statistics VII-5

Publications and Presentations

The presentation and publication of research findings are the most immediate gauges of the accomplishments of AFIRM-supported researchers.

For the purposes of this report, the following definitions have been applied for consistency:

Non-Peer-Reviewed Publications and 

Presentations

Meeting symposia, invited talks, oral presentations, 

and posters delivered or accepted are included in 

the PY numbers regardless of the review process for 

accepting a presentation or the eventual publication 

of an abstract in a scientific journal. Additionally, 

editorial comments, letters, non-peer-reviewed book 

chapters, and other types of non-peer-reviewed 

published works are included.

Peer-Reviewed Publications 

Research or review articles accepted to, in press, 

or published in peer-reviewed journals or peerreviewed edited books are included for each PY. 

Research or review manuscripts in preparation or 

submitted to a journal but not yet accepted are not 

included in this annual report.

The number of non-peer-reviewed publications and 

presentations resulting from AFIRM-sponsored 

research by WFPC and RCCC investigators in PY5 

was 70, and the number has ranged from 125 in 

PY1 to 188 in PY3 (Figure VII-5).8

 In addition, 86 

peer-reviewed manuscripts were published in PY5 

by the WFPC and RCCC investigators, and the 

number has ranged from 62 in PY1 to 104 in PY3. 

The complete lists of AFIRM researchers’ publication and presentation citations from PY5 are shown 

in Appendix B.

Figure VII-5. Dissemination of AFIRM-sponsored research findings 

to the scientific community through presentations and publications.

300

250

200

150

100

50

0

PY1 PY2 PY3 PY4 PY1 PY2 PY3 PY4

Non-Peer-Reviewed 

Publications and Presentations

Peer-Reviewed 

Publications

Number of Publications and 

Presentations

PY5 PY5

RCCC 

WFPC 

USAISR

8 Articles published or accepted, and presentations and posters delivered or accepted during the PYs were included in the count for 

only one PY even if the acceptance and publication dates spanned two PYs.
AFIRM Annual Report 2013

VII: AFIRM Statistics

VII-6

Inventions, Patent Applications, 

and Patents

The successful development of tangible products 

or inventions can be tracked across three milestone phases: (1) an invention disclosure is filed by 

a researcher with his/her institutional technology 

licensing office, (2) a patent application is submitted to the government patent office (e.g., U.S. Patent 

and Trademark Office [USPTO]), and (3) a patent is 

awarded by the USPTO or another government patent office for the intellectual property. 

Many of the AFIRM program’s principal investigators were already developing regenerative 

medicine-related research products at the time the 

program was initiated. Products developed before 

the AFIRM program existed are not recognized 

as AFIRM program outcome accomplishments.9

However, products initially developed prior to 

AFIRM support but refined during the AFIRM 

program period are considered AFIRM program 

outcome accomplishments as are all newly disclosed 

intellectual property.

Through the first 4 years of the program, a combined 75 invention disclosures and/or patent applications were made,10 of which more than 60 patent 

applications were filed with government patent 

offices. The distributions of invention disclosures 

and patent applications are shown in Figure VII-6. 

In PY5, 8 patent applications were filed, which are 

also indicated in Figure VII-6 as invention disclosures. The complete lists of patent applications filed 

and inventions disclosed in PY5 that are attributable to AFIRM-sponsored research are shown in 

Appendix C.

Developmental 

Accomplishments and 

Milestones

Technology Readiness Levels (TRLs) 

of Products

Research progress can be measured in terms of the 

transition of products through research and development stages.11 Biomedical research and development activities funded through the U.S. Army 

Figure VII-6. AFIRM-attributable invention disclosures and government patent applications filed.

0 

5 

10 

15 

20 

25 

30 

PY1 PY2 PY3 PY4 PY5 PY1 PY2 PY3 PY4 PY5 

Number of Intellectual 

Property Submissions

Invention Disclosures Patent Applications

RCCC 

WFPC 

USAISR

9 Definitions of AFIRM-attributable inventions, patent applications, and patents were developed to standardize the self-reported 

intellectual property and are described in Appendix C.

10 The number of invention disclosures includes self-reports of invention disclosures to institutional technology offices and selfreported patent applications filed that were not previously reported as “invention disclosures.”

11 A given research project can develop one or more products. Each developed product is separately assigned a TRL; therefore, a 

given project may have one or more products, each of which would be designated a separate TRL. For the TRL analysis, the term 

“product” can describe either the project (if no specific product has resulted from basic research) or product (if a specific product is 

being further developed).
our science for their healing

AFIRM Statistics VII-7

Medical Research and Materiel Command are categorized by TRLs.12 TRLs identify a given product’s 

research and development stage along a 9-point 

scale, which for therapeutic products extends from 

basic research at TRLs 1 and 2 to proof-of-concept 

studies (TRLs 3–4), preclinical (TRL 5) and clinical (TRLs 6–8) technology development stages, and 

post-marketing surveillance (TRL 9).13

Figure VII-7 shows the AFIRM’s overall research 

and development progression from predominantly 

basic research to proof-of-concept and technology 

development stages.14 At the start of the AFIRM 

program, 58 of 63 research and development products (92%) were distributed across TRLs 1, 2, and 3; 

the other 5 products were initially at TRLs 4 and 5.15

By the end of PY2, most of the products (56 of 78) 

were at TRL 2 or 3, and 19 of the other 22 products 

were distributed at TRLs 4 and above. By the end of 

PY5, approximately one-third of the products were 

at TRLs 2 and 3, one-third at TRL 4, and one-third 

above TRL 4. The 15 products at TRL 5 and the 

8 products at TRLs 6 and above demonstrate the 

increasing translation of products into preclinical 

studies and human clinical studies, respectively. 

While Figure VII-7 displays the status of all products’ TRL stages at annual intervals, it does not 

track the transition of products over time. Most 

products in the AFIRM portfolio at the end of PY5 

have been part of the portfolio since the program 

began, while other projects have been added 

to the AFIRM’s portfolio in subsequent years. 

Figure VII-8 summarizes the transition of the 74 

products being developed by AFIRM investigators 

at the end of PY5 that have been part of the AFIRM 

portfolio for 2 or more years. AFIRM investigators 

report that 34 products (48%) advanced one TRL 

Figure VII-7. AFIRM research products’ progression through research and development stages.

12 For simplicity, the term TRL is used in this report to generically refer to both TRL and knowledge product readiness level (KRL). 

The KRL is intended for tracking the development of practical medical and health performance knowledge (e.g., clinical practice 

guideline) and is analogous to the TRL, which is used to track the development of pharmaceuticals, biologics, devices, or other 

materiel medical and health products.

13 See Appendix D for more detailed descriptions of biomedical TRLs.

14 As the program progressed, AFIRM investigators better understood TRL definitions, and some previously self-reported TRL values 

have been revised. The TRL values in Figure VII-7 reflect the most recent assessment of past and present TRL values and may not 

be consistent with previously reported TRL values.

15 The AFIRM is a dynamic program, and investigators make programmatic decisions about the continuation or termination of projects 

or the initiation of new projects. As such, the portfolio of AFIRM research and development products will change from year to year.

0 

5 

10 

15 

20 

25 

30 

35 

40 

Start of PY1 End of PY1 End of PY2 

TRL 1 

TRL 2 

TRL 3 

TRL 4 

TRL 5 

TRL 6 

TRL 7 

TRL 8 

TRL 9 

Number of Products 

End of PY3 End of PY4 End of PY5 
AFIRM Annual Report 2013

VII: AFIRM Statistics

VII-8

and another 31 products (42%) advanced two or 

more TRLs.

Preclinical Models and Clinical Studies

Products at TRL 4 or 5 are being tested in in vivo 

animal models, some of which had to be newly 

developed or validated for the purpose of testing 

the products in an appropriate injury model. In 

PY5, AFIRM researchers completed the development and/or validation of 9 experimental models 

for studying injury mechanisms, developing therapeutic approaches, and conducting the necessary 

preclinical studies to demonstrate the safety and 

efficacy potential of therapeutic products to enable 

regulatory submissions. 

Products at TRLs 6 and above are being evaluated in 

human clinical studies that require federal regulatory approval and approval through local institutional review boards (IRBs). Medical devices and 

therapeutics require federal regulatory approval by 

the appropriate U.S. Food and Drug Administration 

(FDA) center prior to conducting studies with 

human subjects and again prior to marketing the 

device or therapeutic. For medical devices, the 

FDA’s Center for Diagnostics and Radiological 

Health (CDRH) reviews Investigational Device 

Exemption (IDE) applications prior to product 

testing in human subjects, and the CDRH evaluates 

the Premarket Approval application for approval 

to market the device or the 510(k) application 

for clearing a device as “ 510(k) exempt” prior to 

commercial marketing of the device. For clinical 

therapeutics, the FDA’s Center for Drug Evaluation 

and Research (CDER) and Center for Biologics 

Evaluation and Research (CBER) are responsible 

for reviewing the Investigational New Drug (IND) 

application for sponsors seeking to test the drug or 

biologic in humans. After clinical testing is completed, sponsors submit a New Drug Application or 

Biologics License Application, respectively, to CDER 

or CBER for the approval to market the drug or 

biologic. 

Over the 5 years of the AFIRM, sponsors have 

introduced medical devices and therapeutics across 

a wide range of developmental stages, including 

conducting investigations with products that had 

previously been approved by the FDA. In PY5, sponsors affiliated with the RCCC submitted one IDE 

application, one 510(k) exemption application, and 

two IND applications.16 Other sponsors have initiated pre-IND and pre-IDE meetings with the FDA 

and have begun to prepare IND or IDE applications.

Figure VII-8. Advancement of AFIRM products through TRL stages.

30 

35 

0 

5 

10 

15 

20 

25 

Number of R&D Products 

No TRL

Change 

Advanced 1 

TRL

Advanced 2 

TRLs

Advanced 3 

TRLs

Advanced 4 

TRLs

16 Prior to PY5, IND and IDE applications submitted to the FDA for medical devices and therapeutics under investigation by the AFIRM 

were not reported.
our science for their healing

AFIRM Statistics VII-9

Through PY5, AFIRM investigators advanced 

numerous products through clinical study planning, 

approval, and execution stages. Nine clinical trials 

were open to patient enrollment in PY5, including 

three Phase III, three Phase I/II, and three Phase I 

protocols.17 An additional two clinical protocols for 

Phase I studies and one clinical protocol for a Phase 

I/II study had been submitted to IRBs or human 

research protection offices. One diagnostic study 

was also open to enrollment in PY5. Figure VII-9

shows the number of unique products undergoing 

clinical evaluations by the most advanced stage of 

development. 

Commercialization Plans

Commercial partnerships are important and necessary to complete the final development and fielding 

of medical materiel products. The collaboration 

of AFIRM investigators with commercial partners will enable clinical trials to be conducted as 

commercial and venture capital is leveraged with 

government funds. Furthermore, commercial partners can provide expertise and facilities for Good 

Manufacturing Practices-compliant product manufacturing, product testing and validation, clinical 

study design and execution, and filing regulatory 

submissions for approval to market the products. 

The formal agreement between an investigator and 

an industry partner is also a surrogate measure of 

the potential utility of the product being developed. 

In PY5, 35 commercial organizations were involved 

in the AFIRM program in a variety of capacities. 

Of these, 26 are AFIRM members or collaborators with the AFIRM, while the other 9 partners 

provided materials or services under contracts or 

agreements.18 

Figure VII-9. A snapshot of the clinical protocol stages of AFIRM products at the end of PY5.

17 See Appendix D for descriptions of clinical study phases. 18 Some of the commercial partnerships preceded the start of the program, including some investigations of off-the-shelf products or 

products licensed by the partnering company.

4

3

2

1

0

Phase I 

Protocol 

Submitted

to IRB

Diagnostic 

Study Open 

to 

Enrollment

Phase I

Trial

Open to 

Enrollment

Phase I

Trial 

Completed

Phase I/II 

Protocol 

Submitted 

to IRB

Phase I/II

Trial

Completed

Phase I/II 

Trial

Open to 

Enrollment

Phase III

Protocol 

Submitted 

to IRB

Phase III

Trial

Open to 

Enrollment

Number of Projects

Status of Clinical Studies at End of PY5

AFIRM OUR SCIENCE FOR THEIR HEALING

Appendices

our science for their healing

Appendix A A-1

Appendix A: 

Honors and Awards to AFIRM Faculty

During the reporting period from June 2012 through May 2013, 43 honors or awards were received by AFIRMsupported faculty, as reported by the investigators. The honors and awards are listed below by the recipient 

faculty member. Awards to postdoctorate fellows, students, and staff are not presented. Honors and awards 

reported in previous years are not repeated.

Rutgers–Cleveland Clinic 

Consortium

Anderson, D (Massachusetts Institute of 

Technology): Goldblith Career Development 

Professorship, MIT.

Cwykiel, J (Cleveland Clinic Foundation): 

Postgraduate Poster Award, Case Western Reserve 

University’s National Center for Regenerative 

Medicine 4th Annual Retreat.

Langer, R (Massachusetts Institute of Technology): 

Wilhelm Exner Medal (Austria), Oesterreichischer 

Gewerbeverein.

Langer, R (Massachusetts Institute of Technology): 

Fellow, American Institute of Chemical Engineers.

Langer, R (Massachusetts Institute of Technology): 

National Academy of Inventors (Charter Fellow), 

National Academy of Inventors.

Langer, R (Massachusetts Institute of Technology): 

Feodor Lynen Award, Nature Biotechnology.

Langer, R (Massachusetts Institute of Technology): 

Scientist of the Year, R&D Magazine.

Langer, R (Massachusetts Institute of Technology): 

Perkin Medal, Society of Chemical Industry, 

America International Group.

Langer, R (Massachusetts Institute of Technology): 

United States National Medal of Technology and 

Innovation, U.S. Patent and Trademark Office at the 

Department of Commerce.

Langer, R (Massachusetts Institute of Technology): 

Distinguished Investigator Award, American 

College of Clinical Pharmacology.

Langer, R (Massachusetts Institute of Technology): 

Chemical Pioneer Award, American Institute of 

Chemists.

Langer, R (Massachusetts Institute of Technology): 

Honorary Degree, Ben Gurion University.

Langer, R (Massachusetts Institute of Technology): 

Honorary Degree, Boston University.

Langer, R (Massachusetts Institute of Technology): 

Medal for Innovations in Healthcare Technology, 

IEEE.

Langer, R (Massachusetts Institute of Technology): 

Medal, Industrial Research Institute.

Langer, R (Massachusetts Institute of Technology): 

Founders Award, Society of Biomaterials.

Langer, R (Massachusetts Institute of Technology): 

Honorary Degree, Tel Aviv University.

Langer, R (Massachusetts Institute of Technology): 

Wolf Prize in Chemistry, Wolf Foundation.

Pomahac, B (Brigham and Women’s Hospital): 

Transplant Foundation Award, Czech Transplant 

Foundation.

Pomahac, B (Brigham and Women’s Hospital): 

Award for “Excellence in Design” Education 

Exhibit, Radiological Society of North America.

Sarac, T (Cleveland Clinic Foundation): Cleveland 

Clinic Innovator Award, Cleveland Clinic.

Siemionow, M (Cleveland Clinic Foundation): 

Honorary Guest, 75th Annual Pulaski Day Parade 

Banquet, New York City, 75th Annual Pulaski Day.

Siemionow, M (Cleveland Clinic Foundation): 

SAPIENTI SAT Medal, Ministry of Education of 

Poland.

Siemionow, M (Cleveland Clinic Foundation): 

President, American Society for Reconstructive 

Transplantation.

Siemionow, M (Cleveland Clinic Foundation): Best 

Paper Award, Clinical Category, American Society 

of Maxillofacial Surgeons.
AFIRM Annual Report 2013

Appendix A

A-2

Siemionow, M (Cleveland Clinic Foundation): 

Nomination Award, Honorary Citizen of 

Krotoszyna, Mayor of Krotoszyna.

Siemionow, M (Cleveland Clinic Foundation): 

International Member of the Polish Academy of 

Arts and Science, President of the Republic of 

Poland.

Windebank, A (Mayo Clinic): Educator of the 

Year Award, Mayo Clinic Center for Translational 

Science Activities.

Yaszemski, M (Mayo Clinic): William W. 

Tipton, Jr., MD, Leadership Award, American 

Academy of Orthopedic Surgeons Annual Meeting.

Wake Forest–Pittsburgh 

Consortium

Atala, A (Wake Forest School of Medicine): The 

Research Excellence Award, Wake Forest School of 

Medicine.

Christ, G (Wake Forest School of Medicine): 

Innovation Award, Wake Forest Innovations.

Guldberg, R (Georgia Institute of Technology): 

Host of the TERMIS-AM 2013 meeting, Tissue 

Engineering and Regenerative Medicine 

International Society – Americas Chapter 

(TERMIS-AM).

Hebda, P (University of Pittsburgh): Medical 

Student Research Mentoring Merit Award, 

University of Pittsburgh.

Ibrahim, Z (Johns Hopkins University School of 

Medicine): JK Hardesty Award, Plastic Surgery 

Research Council.

Kasper, FK (Rice University): Young Alumnus 

Award, The Alumni Association of Case Western 

Reserve University.

Kasper, FK (Rice University): Young Investigator 

Award, Society for Biomaterials.

Marra, K (University of Pittsburgh): TERMIS 

Educational Award, TERMIS.

Mikos, AG (Rice University): Founding Fellow, 

TERMIS.

Mikos, AG (Rice University): Member, Institute of 

Medicine of the National Academies.

Ruoslahti, E (UC Santa Barbara): Citation Laureate, 

Thomson Reuters.

Tirrell, M (University of Chicago): Polymer Physics 

Prize, American Physical Society.

Wagner, WR (McGowan Institute): Chairman, 2013 

Annual Meeting, Biomedical Engineering Society.

WFIRM (Wake Forest School of Medicine): Game 

Changer, Science/Medical Section, Edison Awards.
our science for their healing

Appendix B B-1

Appendix B: 

Publications and Presentations

Peer-reviewed journal articles are defined as research articles and review articles accepted to, “in press,” or 

published in scientific and technical journals from June 2012 through May 2013. Additionally, book chapters 

are included as peer-reviewed publications when indicated by investigators. Peer-reviewed publications recognized in previous AFIRM Annual Reports are not repeated here. The publications shown in Tables B-1a, B-1b, 

and B-1c were self-reported by the AFIRM investigators.

Table B-1a. Peer-Reviewed Publications: Rutgers–Cleveland Clinic Consortium

Alghoul M, Mendiola A, Seth R, Rubin B, Zins J, Calabro A, Siemionow M, Kusuma S. The Effect of Hyaluronan on Fat Graft 

Survival, Aesthetic Surgery Journal, 32(5):622-633. 2012 Jul 1.

Angius D, Wang H, Spinner RJ, Gutierrez-Cotto Y, Yaszemski MJ, Windebank AJ. A systematic review of animal models used to 

study nerve regeneration in tissue-engineered scaffolds. Biomaterials 33(32):8034-8039, 2012. 

Baldini EH, Lapidus MR, Wang Q, Manola J, Orgill DP, Pomahac B, Marcus KJ, Bertagnolli MM, Devlin PM, George S, Abraham J, 

Ferrone ML, Ready JE, Raut CP. Predictors for Major Wound Complications Following Preoperative Radiotherapy and Surgery for 

Soft-Tissue Sarcoma of the Extremities and Trunk: Importance of Tumor Proximity to Skin Surface. Ann Surg Oncol. 2012 Dec 15. 

[Epub ahead of print]

Bassiri Gharb B, Rampazzo A, Altuntas SH, Madajka M, Cwykiel J, Stratton J, Siemionow M. Effectiveness of Topical 

Immunosuppressants in Prevention and Treatment of Rejection in Face Allotransplantation. Transplantation. 2013 Mar 25. [Epub 

ahead of print]

Bourin P, Bunnell BA, Casteilla L, Dominici M, Katz AJ, March KL, Redl H, Rubin JP, Yoshimura K, Gimble JM. Stromal cells 

from the adipose tissue-derived stromal vascular fraction and culture expanded adipose tissue-derived stromal/stem cells: a joint 

statement of IFATS and ISCT. 2013 Jun;15(6):641-8. DOI: 10.1016/j.jcyt.2013.02.006. [Epub 2013 Apr 6]

Boyce ST, RK Rice, KC Lynch, AP Supp, VB Swope, RJ Kagan, and DM Supp. Assessment of replication rates of human 

keratinocytes in engineered skin substitutes grafted to athymic mice. Wound Repair Regen 20(4):544-51. 2012. PMID:22672265. 

Bozkurt M, Klimczak A, Nasir S, Zor F, Krokowicz L, Siemionow M. Composite Osseomusculocutaneous Sternum, Ribs, Thymus, 

Pectoralis Muscles, and Skin Allotransplantation Model of Bone Marrow Transplantation. Microsurgery, 33(1):43-50, Jan 2013. 

[Epub 23 Jul 2012]

Bueno EM, Diaz-Siso JR, Sisk GC, Chandawarkar A, Kiwanuka H, Lamparello B, Caterson EJ, Pomahac B. Vascularized 

composite allotransplantation and tissue engineering. J Craniofac Surg. 2013 Jan;24(1):256-63.

Caralla T, Joshi P, Fluery S, Luangphakdy V, Shinohara K, Pan H, Boehm C, Bryan JA, Vasanji A, Hefferan TE, Walker EA, 

Yaszemski M, Hascall V, Zborowski M, Muschler G. In vivo transplantation of autogenous marrow-derived cells following rapid 

intraoperative magnetic separation based on hyaluronan to augment bone regeneration. Tissue Eng Part A. 2013 Jan;19(1-2):125-34.

Carty MJ, Hivelin M, Dumontier C, Talbot SG, Benjoar MD, Pribaz JJ, Lantieri L, Pomahac B. Lessons Learned from Simultaneous 

Face and Bilateral Hand Allotransplantation. Plast Reconstr Surg. 2013 Apr 11. [Epub ahead of print]

Carty MJ, Zuker R, Cavadas P, Pribaz JJ, Talbot SG, Pomahac B. The Case for Lower Extremity Allotransplantation: Lower 

Extremity Transplantation. Plast Reconstr Surg. 2013 Feb 14. [Epub ahead of print]

Caterson EJ, Diaz-Siso JR, Bueno EM, Shetye P, Soga S, Rybicki FJ, Pomahac B. Craniofacial Principles in Face Transplantation. 

J Craniofac Surg. 2012 Sep;23(5):1234-8. 

Caterson EJ, Lopez J, Medina M, Pomahac B, Tullius SG. Ischemia-Reperfusion Injury in Vascularized Composite 

Allotransplantation. J Craniofac Surg. 2013 Jan 13. [Epub ahead of print]

Chang G and Pomahac B. Psychosocial Changes Six Months after Face Transplantation. Psychosomatics. 2012 Nov 27.
AFIRM Annual Report 2013

Appendix B

B-2

Cloud BA, Ball BG, Chen BK, Knight AM, Hakim JS, Ortiz AM, Windebank AJ. Hemisection spinal cord injury in rat: The value of 

intraoperative somatosensory evoked potential monitoring. J Neurosci Methods. 2012;211:179-84.

Coffman KL, Siemionow MZ. Face Transplantation: Psychological Outcomes at Three-Year Follow-Up. Psychosomatics. 2013 Jan 

22. DOI:pii: S0033-3182(12)00195-8. 10.1016/j.psym.2012.10.009 [Epub ahead of print]

Cwykiel J, Klimczak A, Krokowicz L, Siemionow M. Pre- and Postischemic Pulsed Acoustic Cellular Expression Conditioning 

Modulates Expression of Inflammation Factors in Cremaster Ischemia/Reperfusion Injury Model. Microsurgery. 33(2):134-40, Feb. 

2013. [Epub 14 Nov 2012]

Dadsetan M, Taylor KE, Yong C, Bajzer Z, Lu L, Yaszemski MJ. Controlled release of doxorubicin from pH-responsive microgels. 

Acta Biomater. 2013 Mar;9(3):5438-46.

Diaz-Siso JR, Bueno EM, Sisk GC, Marty FM, Pomahac B, Tullius SG. Vascularized composite tissue allotransplantation – state of 

the art. Clin Transplant. 2013 Apr 14. [Epub ahead of print]

Donnelly EM, Madigan NN, Rooney GE, Knight A, Chen B, Ball B, Kinnavane L, Garcia Y, Dockery P, Fraher J, Strappe PM, 

Windebank AJ, O'Brien T, McMahon SS. Lentiviral vector delivery of short hairpin RNA to NG2 and neurotrophin-3 promotes 

locomotor recovery in injured rat spinal cord. Cytotherapy. 2012; 14(10):1235-44.

Edrich T, Cywinski JB, Colomina MJ, López IJ, Xiong L, Sedaghati A, Pomahac B, Gilton A. Perioperative management of face 

transplantation: a survey. Anesth Analg. 2012 Sep;115(3):668-70. DOI: 10.1213/ANE.0b013e3182554493. [Epub 2012 Apr 20] 

Gastman B, Djohan R, Siemionow M. Extending the Cordeiro Maxillofacial Defect Classification System for Use in the Era of 

Vascularized Composite Transplantation. Plast Reconstr Surg. 130(2): 419-422, Aug 2012.

Grisold W, Cavaletti G, Windebank AJ. Peripheral neuropathies from chemotherapeutics and targeted agents: diagnosis, treatment, 

and prevention. Neuro Oncol. 2012 Suppl 4:iv45-54. DOI: 10.1093/neuonc/nos203. 

Hahn JM, Glaser K, McFarland KL, Aronow B, Boyce ST, and Supp DM. Keloid-derived keratinocytes exhibit an abnormal gene 

expression profile consistent with a distinct causal role in keloid pathology. Wound Repair Regen. 2013 Jul-Aug;21(4):530-44. DOI: 

10.1111/wrr.12060.

Harsono K, Finelt N, Castano EB, Tonnesen MG, Clark RAF. Curcumin myths or wonders? – a systematic analysis of in vitro 

studies. Wound Repair Regen 21:335-336, 2013.

Hirth DA, McClain SA, Singer AJ, Clark RAF. Endothelial necrosis at 1h post-burn predicts progression of tissue injury. Wound 

Repair Regen. 2013 Jul-Aug;21(4):563-70. DOI: 10.1111/wrr.12053. [Epub 2013 Apr 29]

Hirth DA, Singer AJ, Clark RAF, McClain SA. Histopathogic staining of low temperature cutaneous burns: comparing biomarkers of 

epithelial and vascular injury. Wound Repair Regen 20:918-927, 2012.

Knoll BM, Hammond SP, Koo S, Issa NC, Tullius SG, Baden LR, Pomahac B, Marty FM. Infections Following Facial Composite 

Tissue Allotransplantation-Single Center Experience and Review of the Literature. Am J Transplant. 2012 Dec 27. DOI: 10.1111/

ajt.12013. [Epub ahead of print]

Lehman RA Jr, Huddleston P, Yaszemski M. Axial spine injuries in the current conflicts in Iraq and Afghanistan. J Am Acad Orthop 

Surg. 2012;20 Suppl 1:S13-7.

Luangphakdy V, Walker E, Shinohara K, Pan H, Hefferan T, Bauer TW, Stockdale L, Saini S, Dadsetan M, Runge MB, Vasanji A, 

Griffith L, Yaszemski M, Muschler GF. Evaluation of osteoconductive scaffolds in the canine femoral multi-defect model. Tissue Eng

Part A. 2013 Mar;19(5-6):634-48.

Ma M, Guo L, Anderson DG, Langer RS. Bio-inspired Polymer Composite Actuator and Generator Driven by Water Gradients. 

Science. 339(6116); 186–189, Jan, 2013.

McGee-Lawrence ME, Bradley EW, Dudakovic A, Carlson SW, Ryan ZC, Kumar R, Dadsetan M, Yaszemski MJ, Chen Q, An KN, 

Westendorf JJ. Histone deacetylase 3 is required for maintenance of bone mass during aging. Bone. 2013 Jan;52(1):296-307.

McIlhenny SE, Zhang P, Tulenko T, Comeau J, Fernandez S, Policha A, Ferroni M, Faul E, Bagameri G, Shapiro I, Dimuzio P. 

eNOS transfection of adipose-derived stem cells yields bioactive nitric oxide production and improved results in vascular tissue 

engineering. J Tissue Eng Regen Med. 2013 Jan 14. DOI: 10.1002/term.1645. PMID:23319464. [Epub ahead of print]

Nijhuis TH, Bodar CW, van Neck JW, Walbeehm ET, Siemionow M, Madajka M, Cwykiel J, Blok JH, Hovius SE. Natural conduits 

for bridging a 15-mm nerve defect: Comparison of the vein supported by muscle and bone marrow stromal cells with a nerve 

autograft. J Plast Reconstr Aesthet Surg. 66(2):251-9, Feb 2013. [Epub 10 Oct 2012]

Table B-1a. Peer-Reviewed Publications: Rutgers–Cleveland Clinic Consortium (cont.)
our science for their healing

Appendix B B-3

Pan Z, Ghosh K, Hung V, Macri L, Einhorn J, Bhatnagar D, Simon M, Clark RA, Rafailovich MH. Deformation gradients imprint the 

direction and speed of en masse fibroblast migration for fast healing. J Invest Dermatol. 2013 Oct;133(10):2471-9. DOI: 10.1038/

jid.2013.184. [Epub 2013 Apr 17]

Peramo A, Marcelo CL, Feinberg SE. Tissue Engineering of Lips and Muco-Cutaneous Junctions: In Vitro Development of Tissue 

Engineered Constructs of Oral Mucosa and Skin for Lip Reconstruction. Tissue Engineering. 18:273-282 (2012) PMID: 22067042. 

Pomahac B, Bueno EM, Sisk GC, Pribaz JJ. Current Principles of Facial Allotransplantation: The Brigham and Women’s Hospital 

Experience. Plast Reconstr Surg. 2013 May;131(5):1069-76.

Pomahac B, Pribaz JJ, Bueno EM, Sisk GC, Diaz-Siso JR, Chandawarkar A, Westvik TS, Malin EW, Eriksson E. Novel Surgical 

Technique for full face transplantation. Plast Reconstr Surg. 2012 Sep;130(3):549-55. 

Shen FH, Werner BC, Liang H, Shang H, Yang N, Li X, Shimer AL, Balian G, Katz AJ. Implications of adipose-derived stromal cells 

in a 3D culture system for osteogenic differentiation: an in vitro and in vivo investigation. The Spine Journal. 2013, Jan;13(1):32-43.

Siemionow M, Klimczak A. Chimerism-Based Experimental Models for Tolerance Induction in Vascularized Composite Allografts: 

Cleveland Clinic Research Experience. Clinical and Developmental Immunology. 2013; 2013.831410. DOI: 10.1155/2013/831410. 

Review [Epub 2013 Mar 14]

Siemionow M, Madajka M, Cwykiel J. Application of Cell Based Therapies in Facial Transplantation. Ann Plast Surg. 69(5):575-9, 

Nov 2012.

Siemionow M, Uygur S, Ozturk C, Siemionow K. Techniques and Materials for Enhancement of Peripheral Nerve Regeneration: A 

Literature Review. Microsurgery. 2013 Apr 9. DOI: 10.1002/micr.22104. [Epub ahead of print]

Singer, AG, DH Ahrenholz, P Chang, RAF Clark, R Fey, P Fidler, W Garner, N Gibran, D Greenhalgh, S Honari, L Jones, R Kagan, 

J Kirby, J Leggett, N Meyer, C Reigart, K Richey, L Rosenberg, J Weber, B Wiggins, and ST Boyce. 2013. Consensus metrics for 

healing of burn wounds. J Burn Care and Res, In Press. 

Sisk GC, Kumamaru KK, Schultz K, Bueno EM, Diaz-Siso JR, George E, Redjaee MM, Mitsouras D, Steigner ML, Pomahac B, 

Rybicki FJ. Cine computed tomography angiography evaluation of blood flow for full face transplant surgical planning. Eplasty. 

2012;12:e57. [Epub 2012 Dec 18]

Soga S, Pomahac B, Kumamaru K, Wake N, Schultz K, Powers SL, Prior RF, Steigner ML, Mitsouras D, Bueno EM, Rybicki FJ. 

CT Angiography for Surgical Planning in Face Transplantation Candidates. AJNR Am J Neuroradiol. 2012 Aug 9. PubMed PMID: 

22878008. [Epub ahead of print]

Sriwiriyanont P, Lynch KA, McFarland KL, Supp DM, Boyce ST. Characterization of hair follicle development in engineered skin 

substitutes. PLoS One. 2013 Jun 17;8(6):e65664. DOI: 10.1371/journal.pone.0065664.

Sriwiriyanont P, Maier EA, Lynch KA, Supp DM, and Boyce ST. Dermal papilla cells stimulate trichogenesis in engineered skin 

substitutes. Exp Dermatol. 21(10):783-785; 2012. PMID:23078401. 

Ta LE, Schmelzer JD, Bieber AJ, Loprinzi CL, Sieck GC, Brederson JD, Low PA, Windebank AJ. A novel and selective poly (adpribose) polymerase inhibitor ameliorates chemotherapy-induced painful neuropathy. PLoS One. 2013; 8(1):e54161. [Epub 2013 Jan 

10]

Wu P, Spinner RJ, Gu Y, Yaszemski MJ, Windebank AJ, Wang H. Delayed repair of the peripheral nerve: A novel model in the rat 

sciatic nerve. J Neurosci Methods. 2013 Mar 30;214(1):37-44. DOI: 10.1016/j.jneumeth.2013.01.003. [Epub 2013 Jan 11]

Yang SY, O’Cearbhaill ED, Sisk GC, Park KM, Cho WK, Villiger M, Bouma BE, Pomahac B, Karp JM. Nat Commun. 2013 Apr 

16;4:1702.

Yoshii T, Hafeman AE, Esparza JM, Okawa A, Gutierrez G, Guelcher SA. Local injection of lovastatin in biodegradable 

polyurethane scaffolds enhances bone regeneration in a critical-sized segmental defect in rat femora. J Tissue Eng Regen Med. 

2012 Jun 20. DOI: 10.1002/term.1547. [Epub ahead of print]

Table B-1a. Peer-Reviewed Publications: Rutgers–Cleveland Clinic Consortium (cont.)
AFIRM Annual Report 2013

Appendix B

B-4

Table B-1b. Peer-Reviewed Publications: Wake Forest–Pittsburgh Consortium

Atala A, Kasper FK and Mikos AG. Engineering Complex Tissues. Science Translational Medicine, 4(160):160rv12, 2012.

Bellas E, Panilaitis B, Glettig DL, Kirker-Head CA, Yoo JJ, Marra KG, Rubin JP, Kaplan DL. Sustained volume retention in vivo with 

adipocyte and lipoaspirate seeded silk scaffolds. Biomaterials 2013 Apr; 34(12):2960-8.

Boerckel JD, Kolambkar YM, Stevens HY, Dupont KM, Guldberg RE. Mechanical Loading Enhances Segmental Bone Defect 

Repair by Altering Bone Formation and Distribution. Journal of Orthopaedic Research. 30(7):1067-75, 2012.

Brandacher G, Lee WPA, Schneeberger S. Minimizing Immunosuppression in Hand Transplantation. Expert Rev Clin Immunol. 

2012 Sep;8(7):673-84.

Brandacher G. Composite Tissue Transplantation. In Andrea A. Zachary and Mary S. Leffell (eds.), Transplantation Immunology: 

Methods and Protocols, Second Edition, Methods in Molecular Biology, vol. 1034, pp. 103-115. DOI 10.1007/978-1-62703-493-7_5, 

© Springer Science+Business Media, LLC 2013.

Criswell TL, Corona BT, Wang Z, Zhou Y, Niu G, Xu Y, Christ GJ, Soker S. The role of endothelial cells in myofiber differentiation 

and the vascularization and innervation of bioengineered muscle tissue in vivo. Biomaterials. 2013 Jan;34(1):140-9. DOI: 10.1016/j.

biomaterials.2012.09.045. [Epub 2012 Oct 8]

Ekenseair AK, Kasper FK and Mikos AG. Perspectives on the Interface of Drug Delivery and Tissue Engineering, Advanced Drug 

Delivery Reviews, 65(1):89-92, 2013.

Fong ELS, Watson BM, Kasper FK and Mikos AG. Building Bridges: Leveraging Interdisciplinary Collaborations in the Development 

of Biomaterials to Meet Clinical Needs. Advanced Materials, 24(36):4995-5013, 2012.

Friedrich EE, Sun LT, Natesan S, Zamora DO, Christy RJ, Washburn NR. Effects of hyaluronic acid conjugation on anti-TNF-α 

inhibition of inflammation in burns. J Biomed Mater Res A. 2013 Jun 13. DOI: 10.1002/jbm.a.34829. PMID:23765644. [Epub ahead of 

print], In press.

Guldberg RE, Awad HA, Vunjak-Novakovic G, Donahue H, Das A. Principles of Engineering Tissue Regeneration, IBMS Bonekey, 

In Press.

Hronik-Tupaj M, Raja WK, Tang-Schomer M, Omenetto FG, Kaplan DL. Neural Responses to Electrical Stimulation on Patterned 

Silk Films. J Biomed Mater Res A. 2013 Sep;101(9):2559-72. DOI: 10.1002/jbm.a.34565. [Epub 2013 Feb 11]

Hutmacher DW, Woodruff MA, Shakesheff K, Guldberg RE. Direct Fabrication as a Patient-Targeted Therapeutic in a Clinical 

Environment. Methods Mol Biol. 868:327-40, 2012.

Hwang CM, Ay B, Kaplan DL, Rubin JP, Marra KG, Atala A, Yoo JJ, and Lee SJ. Assessments of injectable alginate particleembedded fibrin hydrogels for soft tissue reconstruction. Biomed. Mat. 2013;8(1): 014105.

Ibrahim Z, Cooney DS, Schneeberger S, Shores JT, Bonawitz S, Sacks JM, Lee WPA, Brandacher G. A modified hetrotopic swine 

hind limb transplant model for translational Vascularized Composite Allotransplantation (VCA) research. JOVE 2013, In Press.

Järvinen TAH, Ruoslahti E. Targeted antiscarring therapy for tissue injuries. Adv Wound Care, 2(2):50-54, Mar, 2013. DOI:10.1089/

wound.2011.0299.

Järvinen TAH. Design of Target-Seeking Antifibrotic Compounds. Meth Enzymol 509: 243-261, 2012.

Johnen C, Chinnici C, Triolo F, Plettig J, Bräutigam K, Amico G, Young M, Over P, Esteban-Vives R, Schmelzer E, Conaldi PG, 

Turner M, Thompson R, Zeilinger K, Rubin P, Vizzini G, Gridelli B, Gerlach JC. Phenotypical characterization of 6-21-week 

gestational age human dermis and epidermal cell isolation methods for in vitro studies on epidermal progenitors. Burns. 2013 

Mar;39(2):300-10. DOI: 10.1016/j.burns.2012.05.025. [Epub 2012 Jun 30]

Kathju S, Gallo PH, Satish L. Scarless integumentary wound healing in the mammalian fetus: molecular basis and therapeutic 

implications. Birth Defects Res C Embryo Today. 2012 Sep;96(3):223-36.

Kinard LA, Chu C, Tabata Y, Kasper FK and Mikos AG. Bone Morphogenetic Protein-2 Release from Composite Hydrogels of 

Oligo(poly(ethylene glycol) fumarate) and Gelatin. Pharmaceutical Research, DOI:10.1007/s11095-013-1077-5, In Press.

Lang RS, Gorantla VS, Esper S, Montoya M, Losee JE, Hilmi IA, Sakai T, Lee WPA, Raval JS, Kiss JE, Shores JT, Brandacher 

G, Planinsic RM. Anesthetic Management in Upper Extremity Transplantation: The Pittsburgh Experience. Anesth Analg. 2012 

Sep;115(3):678-88. DOI: 10.1213/ANE.0b013e31825da401. [Epub 2012 Jun 28]

Lin Y-C, Oh SJ, Marra KG. Synergistic Lithium Chloride and Glial Cell Line-Derived Neurotrophic Factor Delivery for Peripheral 

Nerve Repair in a Rodent Sciatic Nerve Injury Model. Plastic and Reconstructive Surgery, 2013, In Press.
our science for their healing

Appendix B B-5

Nozaki M, Ota S, Terada S, Li Y, Uehara K, Gharaibeh B, Fu FH, and Huard J. Timing of the administration of Suramin treatment 

after muscle injury. Muscle and Nerve. Muscle Nerve. 2012 Jul;46(1):70-9. DOI: 10.1002/mus.23280. [Epub 2012 May 29]

Pace LA, Plate JF, Smith TL, Van Dyke M. The Effect of Human Hair Keratin Hydrogel on Early Cellular Response to Sciatic Nerve 

Injury in a Rat Model. Biomaterials. 2013, In Press.

Rutten MJ, Janes MA, Chang IR, Gregory CR, Gregory KW. Development of a functional Schwann cell phenotype from 

autologous porcine bone marrow mononuclear cells for nerve repair. Stem Cells Int. 2012;2012:738484. DOI: 10.1155/2012/738484. 

[Epub 2012 Jun 24]

Satish L, O'Gorman DB, Johnson S, Raykha C, Gan BS, Wang JH, Kathju S. Increased CCT-eta expression is a marker of latent 

and active disease and a modulator of fibroblast contractility in Dupuytren's contracture. Cell Stress Chaperones. 2013 Jan 6. [Epub 

ahead of print]

Schneeberger S, Gorantla VS, Brandacher G, Zeevi A, Demetris AJ, Lunz JG, Metes DM, Donnenberg AD, Shores JT, Dimartini 

AF, Kiss JE, Imbriglia JE, Azari K, Goitz RJ, Manders EK, Nguyen VT, Cooney DS, Wachtman GS, Keith JD, Fletcher DR, Macedo 

C, Planinsic R, Losee JE, Shapiro R, Starzl TE, Lee WP. Upper-Extremity Transplantation Using a Cell-Based Protocol to Minimize 

Immunosuppression. Ann Surg. 2013; 257(2): 345-51.

Sicari BM, Agrawal V, Sui BF, Medberry CJ, Dearth CL, Turner NJ, Badylak SF. A murine model of volumetric muscle loss and a 

regenerative medicine approach for tissue replacement. Tissue Engineering, Part A. Oct;18 (19-20):1941-8, 2012.

Skardal A, Mack D, Kapetanovic E, Atala A, Jackson JD, Yoo J, Soker S. Bioprinted aminiotic fluid-derived stem cells accelerate 

healing of large skin wounds. Stem Cells Transl Med. 2012 Nov; 1(11):792-802.

Stoppato M, Stevens HY, Carletti E, Migliaresi C, Motta A, Guldberg RE. The Effects of Silk Fibroin Fiber Incorporation on 

Mechanical Properties, Endothelial Cell Colonization, and Vascularization of PDLLA Scaffolds. Biomaterials, In Press.

Uhrig BA, Boerckel JD, Willett NJ, Huebsch N, Guldberg RE. Recovery from hind limb ischemia enhances rhBMP-2-mediated 

segmental bone defect repair in a rat composite injury model. Bone, In Press.

Uhrig BA, Clements IP, Boerckel JD, Huebsch N, Bellamkonda RV, Guldberg RE. Characterization of a Composite Injury Model of 

Severe Lower Limb Bone and Nerve Trauma. J Tissue Eng Regen Med. 2012 Jun 11. DOI: 10.1002/term.1537. PMID:22689452. 

[Epub ahead of print]

Wang L, Yoon DM, Spicer PP, Henslee AM, Scott DW, Wong ME, Kasper FK and Mikos AG. Characterization of Porous 

Polymethylmethacrylate Space Maintainers for Craniofacial Reconstruction. J Biomed Mater Res B Appl Biomater. 2013 

Jul;101(5):813-25. DOI: 10.1002/jbm.b.32885. [Epub 2013 Jan 29]

Willett NJ, Li MA, Uhrig BA, Boerckel JD, Huebsch N, Lundgren TL, Warren GL, Guldberg RE. Attenuated rhBMP-2 Mediated Bone 

Regeneration in a Rat Model of Composite Bone and Muscle Injury. Tissue Engineering Part C. 19(4):316-25, 2013.

Xu T, Binder KW, Albanna MZ, et al. Hybrid printing of mechanically and biologically improved constructs for cartilage tissue 

engineering applications. Biofabrication. 2013;5(1):015001.

Xu T, Zhao W, Zhu J-M, Albanna MZ, Yoo JJ, Atala A. Complex heterogeneous tissue constructs containing multiple cell types 

prepared by inkjet printing technology. Biomaterials. 2013;34(1):130-139.

Table B-1c. Peer-Reviewed Publications: USAISR

Rathbone CR, Guda T, Singleton B, Oh S, Appleford MR, Ong JL, Wenke JC. Effect of cell-seeded hydroxyapatite scaffolds on 

rabbit radius bone regeneration. J Biomed Mater Res A. 2013 Jun 15. DOI: 10.1002/jbm.a.34834. [Epub ahead of print]

Wu X, Corona BT, Chen X, Walters TJ. A standardized rat model of volumetric muscle loss injury for the development of tissue 

engineering therapies. Biores Open Access. 2012 Dec;1(6):280-90. DOI: 10.1089/biores.2012.0271.

Wu X, Walters T, Rathbone CR. Skeletal Muscle Satellite Cell Activation Following Cutaneous Burn in Rats. Burns. 2013 

Jun;39(4):736-44. DOI: 10.1016/j.burns.2012.10.016. [Epub 2012 Nov 10]

Table B-1b. Peer-Reviewed Publications: Wake Forest–Pittsburgh Consortium (cont.)
AFIRM Annual Report 2013

Appendix B

B-6

Tables B-2a and B-2b list non-peer-reviewed publications and all presentations self-reported by AFIRM 

investigators. The non-peer-reviewed publications are defined as editorials, letters, or opinion writings that 

have been accepted to, “in press,” or published in scientific and technical journals from June 2012 through 

May 2013. Books and book chapters are included here as indicated by the authors. Presentations include all 

invited talks, symposia, oral presentations, and posters presented at scientific research conferences and meetings regardless of the peer review process. All such presentations made and all presentations accepted from 

June 2012 through May 2013 are included. Presentations not specifically labeled as accepted in the researchers’ progress reports were not assumed to be accepted and were not included in the following tables. Nonpeer-reviewed publications and presentation citations recognized in previous AFIRM Annual Reports are not 

repeated for this year.

Table B-2a. Presentations and Non-Peer-Reviewed Publications: Rutgers–Cleveland Clinic Consortium

Cervantes T, Bassett E, Tseng A, Kimura A, Roscioli N, Gupta R, Randolph MA, Vacanti JP, Pomerantseva I, Sundback CA. 

3D Imaging Analysis and Rapid Prototyping of Composite Scaffolds for Tissue Engineered Ear Reconstruction. MGH Scientific 

Advisory Committee Scientific Poster Session. March 20–21, 2013.

Cervantes T, Bassett E, Tseng A, Kimura A, Roscioli N, Gupta R, Randolph MA, Vacanti JP, Pomerantseva I, Sundback CA. 

Design and Analysis of Flexible Composite Scaffolds for Engineered Ear. 2013 Annual Meeting Society of Biomaterials. Boston, 

MA, April 11–12, 2013.

Cervantes T, Bassett E, Tseng A, Kimura A, Roscioli N, Vacanti JP, Pomerantseva I, Sundback CA. Rapid Prototyping of Flexible 

Structures for Tissue Engineered Ear Reconstruction. 2013 Design of Medical Devices Conference. Minneapolis, MN, April 8–11, 

2013.

Chawla AS, Spinner RJ, Yaszemski MJ, Windebank AJ, Wang H. Non-invasive isometric muscle force measurement of plantar 

flexion in the rat sciatic nerve injury model. Annual Meeting of the American Society for Peripheral Nerve, Naples, FL, January 

11–13, 2013.

Clark RAF. Bioactives and biomechanics provide key signals for dermal healing.

Cullen DK, Kameswaran N, Struzyna LA, Morand JP, Wolf JA, Ledebur H, Smith DH. Tissue Engineered Grafts with Stretch-Grown 

Axons Accelerate Peripheral Nerve Regeneration. Annual Hilton Head Workshop, Regenerative Medicine: Technologies Enabling 

Novel Therapies, Hilton Head Island, SC, March 2013.

Cwkiel J, Askar M, Siemionow M. Phenotype Characterization of Human Di-Chimeric Cells for Tolerance Inducing Protocols 

in Transplantation. Preliminary Study (poster presentation), 24th International Congress of The Transplantation Society, Berlin, 

Germany, July 16, 2012.

Cwykiel J, Askar M, Siemionow M. Characterization of Human Di-Chimeric Cells for Tolerance Inducing Protocols in 

Transplantation: A Preliminary Study (oral presentation), Session: Experimental and Research, 17th World Congress of the Int’l. 

Confederation for Plastic, Reconstructive, & Aesthetic Surgery, Santiago, Chile, February 27, 2013.

Cwykiel J, Askar M, Siemionow M. Human Di-Chimeric Cells – A New Approach for Tolerance Inducing Protocols in 

Transplantation: A Preliminary Study (oral presentation), Session: Basic Science and CTA papers, American Society for 

Reconstructive Microsurgery Annual Meeting, Naples, FL, January 14, 2013.

Cwykiel J, Askar M, Siemionow M. Human Di-Chimeric Cells – a New Approach for Tolerance Inducing Protocols in 

Transplantation: A Preliminary Study (poster presentation), American Society for Blood and Bone Marrow Transplantation/Center 

for International Blood and Marrow Transplant Research, BMT Tandem Meetings, Salt Lake City, UT, February 13, 2013.

Cwykiel J, Askar M, Siemionow M. Human Di-Chimeric Cells: A New Approach for Tolerance Inducing Protocols in Transplantation 

(poster presentation), 4th Annual National Center for Regenerative Medicine Scientific Retreat, Case Western Reserve University, 

Cleveland, OH, November 12, 2012.

Cwykiel J, Askar M, Siemionow M. New Tolerance Inducing Cellular Therapy of Human Di-Chimeric Cells for Vascularized 

Composite Allotransplantation: A Preliminary Study (oral presentation), 3rd Biennial Meeting of the American Society for 

Reconstructive Transplantation, Chicago, IL, November 17, 2012.

Daly B, Yao L, Abu-Rub M, Zeugolis D, Windebank A, Pandit A. Intraluminal contact mediated guidance signals decrease axonal 

mismatch of distal nerve targets during repair of peripheral nerves. Program No. 234.07/B48. 2012 Neuroscience Meeting Planner. 

New Orleans: Society for Neuroscience, 2012.
our science for their healing

Appendix B B-7

Feinberg S, et al. Regenerating Human Oral Mucosa. AAAS Annual Meeting, Boston, MA, February 15, 2013.

Grahn P, Hakim J, Ball B, Knight AM, Chen BK, Schmeichel A, Windebank AJ. 3-dimensional, temporal resolution of cell entry 

into schwann cell-loaded oligo-polyethylene glycol fumarate (OPF) scaffolds in rat spinal cord. Program No. 556.06/Q8. 2012 

Neuroscience Meeting Planner. New Orleans: Society for Neuroscience, 2012.

Guo L, Ma M, Hendy G, Hill PS, Farokhzad O, Anderson DG, and Langer RS. An organic stretchable microelectrode array. The 

40th Neural Interfaces Conference, Salt Lake City, Utah, June 18–20, 2012.

Jia S, Xie P, Vracar-Grabar M, Singer A, Clark RAF, and Mustoe TA. Systemically administered curcumin can significantly decrease 

the necrosis and scab formation of skin flaps in a swine model. Presented at: Wound Healing Society Meeting, Denver, CO, 2013. 

Johnson C, Podratz J, Knight AM, Windebank AJ. Neuron-specific gsts1 and sod1/2 genes but not PARP1 affect the climbing 

and survival phenotype in Cisplatin-induced neurotoxicity in Drosophila melanogaster. Program No. 66.11/T8. 2012 Neuroscience 

Meeting Planner. New Orleans: Society for Neuroscience, 2012.

Light D, Kundu N, Djohan R, Gastman B, Siemionow M. Total Abdominal Wall Composite Tissue Allotransplantation: An 

Anatomical Study and Classification System (Poster). The Plastic Surgery Research Council 57th Annual Meeting Abstract 

Supplement, Plast Reconstr Surg., 1S(130): #14P, pg 90, July 2012 Supplement.

Macri L, Sheihet L, Singer AJ, Kohn J, Clark RAF. Fast and slow bioerodible electrospun fiber mats for topical delivery.

Madajka M, Mendiola A, Siemionow M. Epineural Sheath Conduit: A New Technique for Peripheral Nerve Restoration. The 

Plastic Surgery Research Council 57th Annual Meeting Abstract Supplement, Plast Reconstr Surg., 1S(130): #55, pg 45, July 2012 

Supplement.

Merriam AR, Patel JM, Dunn MG, Gatt CJ. A Novel Fiber-Reinforced Scaffold for Reconstruction of the Meniscus. Oral 

presentation at: Orthopaedic Research Society, San Antonio, TX, 2013. 

Mwizerwa O, Cervantes T, Kulig K, Widrick J, Pomerantseva I, Neville C, Sundback C. Engineered skeletal muscle for 

craniomaxillofacial reconstruction, MGH Scientific Advisory Committee Scientific Poster Session. March 20–21 2013.

Ortiz O, LeGeros RZ, Kohn J. Performance of polymer + OCP composite scaffolds in the CSD rabbit calvaria model. Society for 

Biomaterials Conference, Boston, MA, 2013.

Pluhar G, Nicholson A, Muschler G, Luangphakdy V, Bechtold J, Boehm C, Carlson C, Pan H, Shinohara K, Wenke J. Development 

of a Caprine Chronic Tibial Defect Model. Poster presented at: ORS 2013 Annual Meeting in San Antonio, Texas, January 26–29.

Podratz J, Boykoff N, Windebank A. Erythropoietin and NGF synergistically protect against cisplatin-induced neurotoxicity by 

regulation of Akt. Program No. 66.18/T15. 2012 Neuroscience Meeting Planner. New Orleans: Society for Neuroscience, 2012.

Prasad, A. Fibronectin-peptide derivatized biomimetic surfaces for optimal adult human dermal fibroblast function in vitro.

Review of The Biology Of Stem Cells And Tissue Regeneration in Symposium: Current Update on Stem Cells and Tissue 

Regeneration. AAOMS 94th Annual Meeting, Scientific Sessions and Exhibition, San Diego, CA, September 14, 2012.

Rui J, Spinner RJ, Yaszemski MJ, Windebank AJ, Wang H. Outcomes evaluation modalities: the pursuit to identify a “toolbox” in 

conducting peripheral nerve research. Annual Meeting of the American Society for Peripheral Nerve, Naples, FL, January 11–13, 

2013.

Siemionow M, Zor F. Chapter 16: Face Transplantation in Rats. In: Chen H and Qian S (eds.), Experimental Organ Transplantation, 

Nova Science Publishers, Inc., In press.

Siemionow M, Zor F. Chapter 18: Craniomaxillofacial Allotransplantation: From a Basic Science Perspective, In: Zins J. (editor) 

Handbook of Craniofacial Surgery, World Scientific Publishing Co., Inc., 2013.

Siemionow M. Chapter 8: Impact of Reconstructive Transplantation on the Future of Plastic and Reconstructive Surgery, In: Dobke 

M. (guest editor) Clinics in Plastic Surgery: Surgical Advances in Plastic Surgery, 39(4):425-434, Elsevier, Oct 2012.

Staff NP, Podratz JL, Grassner L, Lange M, Paz J, Knight AM, Loprinzi CL, Trushina E, Windebank AJ. Bortezomib Alters 

Microtubule Localization and Mitochondrial Dynamics in Rat Dorsal Root Ganglion Neurons. #M1461. 2012 Annual Meeting of the 

American Neurological Association, Boston, MA, October 7–9, 2012.

Staff NP, Weis D, Padley D, Butler G, Sorenson E, Gastineau D, Dietz A, Windebank A. Intrathecal Delivery of Autologous 

Mesenchymal Stem Cells for Amyotrophic Lateral Sclerosis. World Stem Cell Summit 2012. West Palm Beach, FL, December 3–5, 

2012.

Table B-2a. Presentations and Non-Peer-Reviewed Publications: Rutgers–Cleveland Clinic Consortium (cont.)
AFIRM Annual Report 2013

Appendix B

B-8

Sundback CA and Vacanti JP. Tissue Engineering in Facial Plastic Surgery book chapter accepted for publication in Facial Surgery: 

Plastic and Reconstructive. Eds. Mack Cheney and Tessa Hadlock.

Sundback CA. Engineered facial skeletal muscle. (Oral presentation) Healthcare and Biotechnology in the 21st Century, Dartmouth 

University, Hanover, NH, April 11, 2013. 

The Role of Tissue Engineering/Regenerative Medicine in Soft Tissue Reconstruction in the Craniomaxillofacial Region. 3rd Pan 

African Meeting, Cape Town, South Africa, October 13, 2012.

Vacanti NM, Cheng H, Hill PS, Guerreiro JD, Dang TT, Ma M, Watson S, Hwang NS, Langer R, Anderson DG. Localized delivery 

of dexamethasone from electrospun fibers reduces the foreign body response. Biomacromolecules. 2012 Oct 8;13(10):3031-8. DOI: 

10.1021/bm300520u. [Epub 2012 Sep 11]

Wang H. Translational Peripheral Nerve Regeneration Research: What Tools Do We Have? Hotchkiss Brain Institute Seminar, 

University of Calgary, Canada, June 22, 2012.

Windebank AJ, Milaster C, Boesche J, Giorno N, Hainy M, Nowakowski S, Krug R, Podratz J. An automated climbing apparatus to 

measure chemotherapy-induced neurotoxicity in Drosophila melanogaster. Program No. 659.10/Q6. 2012 Neuroscience Meeting 

Planner. New Orleans: Society for Neuroscience, 2012.

Zhao X, Bichara D, Tseng A, Pomerantseva I, Bassett E, Vacanti JP, Sundback CA, Randolph MA, Yaremchuk M. Advances in the 

Development of Engineered Ear in Ovine Model. NESPS 29th Annual Meeting. September 27–29, 2012. Boston, MA.

Zor F, Karagoz H, Erdemir A, Karslioglu Y, Agikel CH, Kapas R, Guzey S, Gurel M, Siemionow M. Reflectance Confocal 

Microscopy May Reduce the Need for Skin Biopsy in Composite Tissue Allotransplantation (oral presentation), American Society 

for Reconstructive Microsurgery Annual Meeting, Naples, FL, January 14, 2013.

Table B-2b. Presentations and Non-Peer-Reviewed Publications: Wake Forest–Pittsburgh Consortium

Albanna M, Murphy S, Zhao W, El-Amin I, Tan J, Dice D, Kang HW, Jackson J, Yoo J, Atala A. In situ bioprinting of skin for 

reconstruction. Southeastern Section of the American Urological Association, Williamsburg, VA, 14–17 March, 2013.

Albanna MZ, Murphy S, Zhao W, El-Amin IB, Tan J, Dice DD, Kang HW, Jackson JD, Yoo JJ, Atala A. Bioprinting of Skin Cells for 

Skin Reconstruction of Burn Wounds. Regenerative Medicine Foundation 2012 Conference, Charlotte, NC, 18–19 Oct, 2012.

Albanna MZ, Murphy S, Zhao W, El-Amin IB, Tan J, Dice DD, Kang HW, Jackson JD, Yoo JJ, Atala A. In Situ Bioprinting of Skin for 

Reconstruction. American College of Surgeons Annual Clinical Congress. Chicago, IL, 30 Sept–4 Oct, 2012.

Albanna MZ, Murphy S, Zhao W, El-Amin IB, Tan J, Holmes JH, Jackson JD, Atala A, Yoo JJ. Bioprinting of Skin Cells for skin 

Reconstruction of Burn Wounds. NC TERMS Annual Meeting, North Raleigh, NC, 2012.

Albanna MZ, Murphy S, Zhao W, El-Amin IB, Tan J, Jackson JD, Atala A, Yoo JJ. In situ bioprinting of autologous skin cells 

accelerates skin regeneration. J Tissue Eng Regen Med 2012; 6 (Suppl. 1): 94.

Brandacher G, Ibrahim Z, Brat G, Wu L, Buretta K, Christensen J, Yuan N, Mao Q, Tzeng Y, Grahammer J, Wimmers E, Wachtman 

G, Gorantla V, Schneeberger S, Cooney D, Shores J, Sacks JM, Lee WPA. Co-stimulatory Blockade and Donor Bone Marrow Cell 

Infusion for Immunomodulation and Tolerance Induction in Vascularized Composite Allografts – A Large Animal Translational Trial. 

Transplantation. The XXIV International Congress of The Transplantation Society. Berlin, Germany, July 2012.

Christ GJ, Andersson KE, Eds. Regenerative Pharmacology. (ISBN 9780521899499), Cambridge University Press, May 2013.

Evers LH, Liu W, Simons D, Sorkin M, Longaker MT, Gurtner GC. A promising concept of organ tissue engineering using 

autologous decellularized microcirculatory beds as vascularized bioscaffolds. Plastic Surgery Research Council Meeting, Santa 

Monica, CA, April 2013.

Guldberg RE. Hold Your Forces: The Role of Biomechanics in Tissue Engineering/Regenerative Medicine. NAVRMA View, 

November 2012.

Hwang CM, Atala A, Yoo JJ, Jackson J, Lee SJ. A porous injectable hydrogel system for soft tissue regeneration. 3rd TERMIS 

World Congress 2012 “Tissue Engineering and Regenerative Medicine.” Hofburg Congress Centre, Vienna, Austria, September 

5–8, 2012.

Table B-2a. Presentations and Non-Peer-Reviewed Publications: Rutgers–Cleveland Clinic Consortium (cont.)
our science for their healing

Appendix B B-9

Hwang CM, Kaplan DL, Rubin P, Marra KG, Atala A, Yoo JJ, Lee SJ. Injectable Alginate Particle-embedded Fibrin Hydrogels for 

Soft Tissue Reconstruction. Military Health System Research Symposium 2012. Harbor Beach Marriott, Ft Lauderdale, FL, August 

13–16, 2012.

Ibrahim Z, Brat G, Wu L, Furtmueller G, Grahammer J, Buretta KJ, Christensen J, Yuan N, Wimmers E, Wachtman G, Cooney DS, 

Schneeberger S, Shores JT, Bonawitz S, Sacks M, Lee WPA, Brandacher G. Combined Co-stimulatory Blockade and Donor Bone 

Marrow Cells for Tolerance Induction in a Fully MHC-Mismatched Swine Hind Limb Transplantation Model. American Society for 

Reconstructive Transplantation 3rd Biennial Meeting. Chicago, IL, November 2012.

Ibrahim Z, Christensen J, Cooney DS, Sacks JM, Lee WP, Polydefkis M, Hauer P, Alrakan M, Furtmuller G, Sarhane K, Brandacher 

G. Cutaneous collateral axonal sprouting re-innervates the skin component and restores sensation of denervated swine 

osteomyocutaneous alloflaps. Plastic and reconstructive surgery 131 (5S), 2013. Presented at Plastic Surgery Research Council, 

Santa Monica, CA, May 2013.

Ibrahim Z, Leto Barone AA, Wu L, Christensen J, Furtmueller G, Sarhane KA, Santiago G, Alrakan M, Wimmers E, Wachtman G, 

Schneeberger S, Cooney DS, Shores JT, Bonawitz S, Sacks M, Lee WPA, Brandacher G. Combined Co-stimulatory Blockade and 

Donor Bone Marrow Cells induce robust immune tolerance in a Fully MHC-Mismatched Swine Hind Limb Transplantation Model. 

92nd Annual Meeting of American Association of Plastic Surgeons (AAPS). New Orleans, LA, 19–22 April 2013.

Ibrahim Z, Wachtman G, Wimmers E, Brat G, Grahammer J, Buretta K, Christensen J, Yuan N, Furtmuller G, Gorantla VS, 

Schneeberger S, Shores JT, Cooney D, Sacks JM, Lee WPA, Brandacher G. Co-Stimulatory Blockade and Donor Bone Marrow 

Cell Infusion for Targeted Immunomodulation in a Complete MHC-Mismatched Swine Hind Limb Transplant Model - A Large Animal 

Translational Study. Northeastern Society of Plastic Surgeons Annual meeting. Boston, MA, September 2012.

Ibrahim Z, Wu L, Furtmueller G, Sarhane K, Christensen J, Grahammer J, Santiago G, Wimmers E, Wachtman G, Gorantla VS, 

Schneeberger S, Cooney D, Shores JT, Bonawitz S, Sacks M, Lee WPA, Brandacher G. Combined Co-stimulatory Blockade and 

Donor Bone Marrow Cells for Tolerance Induction in a Fully MHC-Mismatched Swine Hind Limb Transplantation Model. European 

Society for Organ Transplantation/American Society of Transplantation Joint Meeting. Nice, France, October 2012.

Kang HW, Kengla C, Lee SJ, Atala A, Yoo JJ. Development and validation of an integrated organ printing system. 3rd TERMIS 

World Congress 2012 “Tissue Engineering and Regenerative Medicine.” Hofburg Congress Centre, Vienna, Austria, September 

5–8, 2012.

Kang H-W, Kengla C, Yoo JJ, Lee SJ, and Atala A. Chapter 9: 3-D organ printing for tissue engineering applications. In Rapid 

Prototyping of Biomaterials: Principles and Applications, Edited by Narayan R, Woodhead Publishing Limited, Cambridge, UK, In 

Press.

Prim P, Moore R, Jackson S, Cohen P, Wysk R, Lee Y-S, Kim J, Kang H-W, Jackson JD, Lee SJ, Yoo JJ, Atala A. Transforming 

regenerative medicine procedures into manufacturing processes. 2013 The Industrial and Systems Engineering Research 

Conference (ISERC). San Juan, Puerto Rico, May 18–22, 2013.

Purser M, Shirwaiker R, Green D, Wysk R, Lee SJ, Jackson JD, Yoo JJ, Atala A. Application of Manufacturing Process Engineering 

Approach to Regenerative Medicine – A Cartilage Tissue Production Case-study. 2013 ISERC Annual Conference & Expo. San 

Juan, Puerto Rico, May 18–22, 2013.

Purser MF, Wysk RA, Shirwaiker RA, Harrysson O, Cohen PH, Jackson JD, Lee SJ, Atala A, Chapter 3, Regenerative Medicine 

Manufacturing—A systems engineering perspective, In New Directions in Informatics, Optimization, Logistics, and Production, 

Edited by Smith JC, INFORMS TutORials in Operations Research, Vol. 9. INFORMS, Hanover, MD, pp50-58 (ISBN 978-0-

9843378-3-5), 2012.

Shah SR, Tatara AM, D’Souza RN, Mikos AG and Kasper FK. Old and New: Evolving Strategies for Preventing Biofilm on 

Implantable Materials. Materials Today. 2013;16:177-182.

Skardal A, Mack D, Kapetanovic E, Markert C, Atala A, Jackson J, Yoo J, Soker S. Bioprinted amniotic fluid-derived stem cells 

accelerate wound healing in skin. J Tissue Eng Regen Med 2012; 6 (Suppl. 1): 376.

Takanari K, Hong Yi, Amoroso NJ, Hashizume R, Burhan G, Nonaka K, Kamei Y, Huard J, Wagner WR. Abdominal wall muscle 

repair with mechanically analogous elastic polymer scaffolds laden with skeletal muscle-derived stem cells. Plastic Surgery 

Research Council, 2013.

Table B-2b. Presentations and Non-Peer-Reviewed Publications: Wake Forest–Pittsburgh Consortium (cont.)
AFIRM Annual Report 2013

Appendix B

B-10

Trachtenberg JE, Kasper FK and Mikos AG. Chapter 22: Polymer Scaffold Fabrication. Principles of Tissue Engineering, Fourth 

Edition. Lanza R, Langer R, Vacanti JP, Eds., Elsevier, DOI:10.1016/B978-0-12-398358-9.00022-7, In Press.

Wolf M, Dearth C, Daly K, Johnson S, Badylak SF. Autologous Inductive Biologic Scaffold Materials and Bone Marrow Derived 

Mononuclear Cells for Treatment of Compartment Syndrome. WFPC AFIRM Enabling Technologies Workshop for Young Minds. 

(Abstract and oral presentation) Pittsburgh, PA, February 4–5, 2013.

Wolf M, Kelly J, Hirsh D, Daly K, Reing J, Johnson S, Badylak SF. Cardiac and Skeletal Muscle Extracellular Matrix Scaffolds for 

Muscle Tissue Engineering. McGowan Institute for Regenerative Medicine Annual Retreat. (Abstract and poster presentation) 

Nemacolin, PA, 2013.

Yang T, Cetin-Ferra S, Tano Z, Barsic M, Dohar JE, Hebda PA. Differential inflammatory signaling and synthesis of collagen 

and fibronectin by adipose stem cells and fibroblasts of different phenotypes relevant to outcome of cell-based wound therapies. 

(selected for oral presentation) 58th Annual Meeting of the Plastic Surgery Research Council, Santa Monica, CA, May 2–4, 2013.

Table B-2b. Presentations and Non-Peer-Reviewed Publications: Wake Forest–Pittsburgh Consortium (cont.)
our science for their healing

Appendix C C-1

Appendix C: Patent Applications and 

Invention Disclosures

The attribution of inventions and patent applications to specific research support is subject to 

varying interpretations in the absence of a standard 

definition. Optimally, only those patents and patent 

applications displaying the AFIRM contract number 

in the Government Interest field in the U.S. Patent 

and Trademark Office (USPTO) patent application 

record should be included as directly attributable to 

the AFIRM program; however, this strict definition 

would exclude provisional patent applications left 

undisclosed to the public and recently filed applications not yet included in government databases. 

Rather than applying the more rigid validation 

approach outlined above, the following definitions 

were applied to self-reported intellectual property 

milestones:

- A self-reported invention disclosure filed with 

the inventor’s institutional technology licensing 

office during a given program year is attributed 

to the AFIRM program in that program year.

- A self-reported patent application filed with a 

government patent office during a program year 

period is attributed to the AFIRM program that 

program year (e.g., June 2012 – May 2013 for 

PY5).

- A self-reported patent award is attributed to the 

AFIRM program when the patent application 

was filed after September 2008. 

All self-reported patent application numbers 

and inventors (i.e., principal investigators) were 

queried against the World Intellectual Property 

Organization (WIPO) patent application database (http://www.wipo.int/pctdb/en/), the USPTO 

AppFT patent application database (http://patft.

uspto.gov/), and/or Google Patent Search (http://

www.google.com/patents). The database queries 

were used to (1) identify patent applications filed for 

self-reported inventions and (2) identify and validate filing dates for patent applications.

Patent Applications: 

AFIRM researchers self-reported 8 governmentfiled patent applications that included a filing date 

or year; a patent priority number, serial number, 

or other patent application number; and/or were 

identified on the USPTO or WIPO databases. The 

reported patent applications were either new applications or continuing applications to earlier filed 

patent applications. 

Rutgers–Cleveland Clinic Consortium

A Bio-inspired Polymer Composite Actuator Driven 

by Water Gradient and Methods of Making the 

Same (Priority Number 61/721639). Anderson D, 

Guo L, and Langer R (Massachusetts Institute of 

Technology).

Reinforced Tissue Graft. (20130053961 A1). Filed 

on October 30, 2012. Derwin K, Ianotti JP, Sahoo S 

(Cleveland Clinic Foundation).

Reinforced Tissue Graft. (20130116799 A1). Filed on 

December 27, 2012. Derwin K, Ianotti JP, Sahoo S 

(Cleveland Clinic Foundation).

Synthetic Polyurethane Composite (20130236513 

A1). Filed on April 10, 2013. Guelcher SA, Dumas 

J, Prieto EM, Kalpakci K, Talley A, Harmata A, 

Zienkiewicz K (Vanderbilt University).

Polyurethane Composite for Wound Healing and 

Methods Thereof (20130295081 A1). Filed on April 

16, 2013. Guelcher SA, Hafeman A, Davidson J, 

Nanney LM, Adolph E (Vanderbilt University).

A Method of Making Tissue Engineered Blood 

Vessels, Articles, and Methods of Use Thereof (PCT/

US2013/041535). Filed on May 17, 2013. Tulenko T, 

Disanto M (The Cooper Health System).
AFIRM Annual Report 2013

Appendix C

C-2

Wake Forest–Pittsburgh Consortium

Implantable Medical Devices Having Double 

Walled Microspheres (US20130190687 A1). Filed 

on July 9, 2012. Marra KG, Kokai LE (University of 

Pittsburgh).

Injectable Silk Fibroin Foams and Use Thereof 

(PCT/US2012/064471). Filed on November 9, 2012. 

Leisk GG, Lo T J-C, Li L, Bellas E, Kaplan DL (Tufts 

University).

Invention Disclosures: 

Invention disclosures are not publicly reposed in 

standard databases; therefore, the AFIRM consortium reports are the only information source 

for inventions disclosed. From June 2012 through 

May 2013, the self-reported disclosure of inventions 

corresponded to the self-reported filing of patent 

applications; therefore, no invention disclosures are 

specifically cited for PY5.
our science for their healing

Appendix D D-1

Appendix D: Descriptions of Technology 

Readiness Levels and Clinical Study Phases

Technology Readiness Levels 

(TRLs) – Biomedical

TRL 1 – Maintain scientific technical watch.

TRL 2 – Research ideas and protocols are developed.

TRL 3 – Hypothesis testing and initial proof of concept is demonstrated in a limited number of in vitro 

and in vivo models.

TRL 4 – Proof of concept and safety of candidate 

product (e.g., drug formulation, biologic or vaccine 

construct, or device or system) is demonstrated in a 

defined laboratory or animal model.

TRL 5 – Pre-clinical studies, including GLP animal 

safety and toxicity, sufficient to support IND application. For devices, medical device review of IDE 

results is sufficient to begin investigation.

TRL 6 – Phase I clinical trial support proceeding to 

Phase II clinical trials. IND application submitted 

to and reviewed by FDA. For devices, Class 3 device 

safety demonstrated. 510(k) data demonstrates substantial equivalency to predicate device.

TRL 7 – Phase II clinical trial is completed, and 

Phase III clinical trial plan is approved by FDA. For 

devices, final product design is validated and final 

prototypes are produced and tested.

TRL 8 – Phase III clinical trial is completed, and 

FDA approves NDA or BLA. For devices, FDA 

approves the premarket approval for medical device 

or applicable 510(k) for devices.

TRL 9 – Post marketing studies and surveillance.

Biomedical TRL descriptions provide a systematic 

way for the science and technology community to 

assess and communicate the level of maturity of 

a particular technology or combination of technologies. The TRL descriptions above summarize 

the pharmaceutical product and medical device 

TRL descriptions accessible on the U.S. Army 

Medical Research and Materiel Command’s Army 

Technology Objectives website (https://mrmc.

amedd.army.mil/index.cfm?pageid=researcher_

resources.ppae.atostat). 

Clinical Study Phases

Phase 0: Exploratory study involving very limited 

human exposure to the drug, with no therapeutic or 

diagnostic goals (e.g., screening studies, microdose 

studies). 

Phase I: Studies that are usually conducted with 

healthy volunteers and that emphasize safety. The 

goal is to find out what the drug’s most frequent and 

serious adverse events are and, often, how the drug 

is metabolized and excreted. 

Phase II: Studies that gather preliminary data on 

effectiveness (whether the drug works in people who 

have a certain disease or condition). For example, 

participants receiving the drug may be compared 

with similar participants receiving a different 

treatment, usually an inactive substance (called a 

placebo) or a different drug. Safety continues to 

be evaluated, and short-term adverse events are 

studied. 

Phase III: Studies that gather more information 

about safety and effectiveness by studying different 

populations and different dosages, and by using the 

drug in combination with other drugs. 

Phase IV: Studies occurring after FDA has approved 

a drug for marketing. These including postmarket requirement and commitment studies that 

are required of or agreed to by the sponsor. These 

studies gather additional information about a drug’s 

safety, efficacy, or optimal use.

The description of clinical study phases is attributed to ClinicalTrials.gov, a website maintained by 

the National Library of Medicine at the National 

Institutes of Health. More information on clinical studies can be found at the link http://www.

clinicaltrials.gov/ct2/about-studies/learn. Clinical 

study phases are the FDA categories for describing the clinical trial of a drug based on the study’s 

characteristics, such as the objective and number of 

participants (http://www.fda.gov/drugs/resourcesforyou/consumers/ucm143534.htm).

our science for their healing

Appendix E E-1

Appendix E: Acronyms

3D........................................................three-dimensional

AFIRM.......................................Armed Forces Institute of 

Regenerative Medicine

AFS .......................................amniotic fluid-derived stem

AFT-SPAR.....................................Autologous fat transfer 

for scar prevention and remodeling

ASC...........................................adipose-derived stem cell

BAMC..................................Brooke Army Medical Center

BIODOME...............................Biomechanical Interface for 

Optimized Delivery of MEMS 

Orchestrated Mammalian Epimorphosis

BMA...............................................bone marrow aspirate

BM-MNC.........................bone marrow mononuclear cell

BMP.................................... bone morphogenetic protein

BMP-2..............................bone morphogenetic protein-2

BMSC.....................................bone marrow stromal cells

BOD .................................................... Board of Directors

CaP .................................................... calcium phosphate

CAR.................................................peptide CARSKNKDC

CBER.........Center for Biologics Evaluation and Research

cBMA..................................................concentrated BMA

CCTD ................................... chronic caprine tibial defect

CCT-eta....chaperonin containing T-complex polypeptide

CDER ...............Center for Drug Evaluation and Research

CDRH........... Center for Devices and Radiological Health

CFR......................................Code of Federal Regulations

cGMP.................. current Good Manufacturing Practices

cm....................................................................centimeter

CRMRP.....................................Clinical and Rehabilitative 

Medicine Research Program

CS.............................................Compartment Syndrome

CSD..................................................... critical-size defect

CTP-O.........................connective tissue progenitor cells

DNA ...............................................deoxyribonucleic acid

DoD..............................................Department of Defense 

DS....................................................... density separation

DWP ................................................ dermal wound paste

ECM ...................................................extracellular matrix

EMB .................................explantable microvascular bed

eNOS.............................endothelial nitric-oxide synthase 

ESS.......................................Engineered skin substitutes

ESS-P .................................................. ESS with pigment

EtO.............................................................ethylene oxide

EVPOME .........ex vivo-produced oral mucosa equivalent

FAK ................................................ focal adhesion kinase

FDA...........................U.S. Food and Drug Administration 

GLP........................................Good Laboratory Practices

GMP.................................Good Manufacturing Practices 

HA............................................................ hyaluronic acid

HRPO........................ Human Research Protection Office

I/R.................................................. ischemia/reperfusion 

IDE...............................Investigational Device Exemption

IND........................................... Investigational New Drug

IPT ............................................. Integrated Project Team

IRB......................................... Institutional Review Board

ISO...........International Organization for Standardization

kg....................................................................... kilogram

LWI .............................................Lonza Walkersville, Inc.

M ...........................................................................million

M/C.........................................................mucocutaneous

MCC.............................................multipotent cell cluster

MDSC .......................................muscle-derived stem cell

MG.............................................................. MasterGraft®

MGH..............................Massachusetts General Hospital

MHC............................ major histocompatibility complex 

MIRM.......McGowan Institute for Regenerative Medicine

MPC...............................................muscle precursor cell

MSC............................................mesenchymal stem cell

MSD......................................... molecular surface design

NGT.................................................. nerve guidance tube

NHP ................................................... nonhuman primate

NIH.......................................National Institutes of Health
AFIRM Annual Report 2013

Appendix E

E-2

NSAID................... non-steroidal anti-inflammatory drug

OCP................................Office of Combination Products

ONR .......................................... Office of Naval Research

OSMEA ...........organic, stretchable microelectrode array

PCLF ......................................polycaprolactone fumarate

PCS...........................peripheral compartment syndrome

PES....................................................poly(ether sulfone)

PMMA.................................... poly(methyl methacrylate)

PMO......................................Project Management Office

POG ....................................particulate oxygen generator

PPF ..........................................poly(propylene fumarate)

PY...............................................................Program Year

RCCC ....................Rutgers–Cleveland Clinic Consortium

RFD............................................Request for Designation

rhBMP-2 ...................................recombinant human bone 

morphogenetic protein-2

RNA ....................................................... Ribonucleic acid

siRNA........................... small interfering ribonucleic acid

SR....................................................... selective retention

TA .............................................................tibialis anterior

TEBV...............................tissue-engineered blood vessel

TEMR............................ tissue-engineered muscle repair

TENG................................. tissue-engineered nerve graft

TNF-α................................tumor necrosis factor-alpha

TRL......................................... technology readiness level

TyrPC..............................tyrosine-derived polycarbonate

UF .................................................... University of Florida

USAISR............U.S. Army Institute of Surgical Research

USAMRMC.................... U.S. Army Medical Research and 

Materiel Command

UTHSC................................................ University of Texas 

Health Science Center at Houston

USPTO........................ U.S. Patent and Trademark Office

VA ........................... U.S. Department of Veterans Affairs

VCA...................vascularized composite tissue allografts

VML .............................................volumetric muscle loss

WFPC.....................Wake Forest–Pittsburgh Consortium

WRNMMC........................................Walter Reed National 

Military Medical Center

μM ........................................................................ micron

Text

stars

wreath

Proud Sponsors of the AFIRM

The Armed Forces Institute of Regenerative Medicine establishes national collaborative 

teams that include leading scientists in the field of regenerative medicine. 

For more information about the AFIRM, please contact:

Ms. Kristy S. Pottol

Program Director

Armed Forces Institute of Regenerative Medicine 

Project Management Office 

Kristy.s.pottol.civ@mail.mil