Effects of matrix stabilization when using glutaraldehyde on the material properties of porcine meniscus

Meniscal transplantation: state of the art

Meniscal resection is the most common surgical procedure in orthopaedics. When a large meniscal loss becomes clinically relevant, meniscal allograft transplantation (MAT) is a feasible option. However, although this technique has evolved since the ‘80s, there are still several controversial issues related to MAT. Most importantly, its chondroprotective effect is still not completely proven. Its relatively high complication and reoperation rate is another reason for this procedure not yet being universally accepted. Despite its controversial chondroprotective effect, nevertheless, MAT has become a successful treatment for pain localised in a previously meniscectomised knee, in terms of pain relief and knee function. We conducted a careful review of the literature, highlighting the most relevant studies in various aspects of this procedure. Precise indications, how it behaves biomechanically, surgical techniques, return to sport and future perspectives are among the most relevant topics that have been included in this state-of-the-art review.

Meniscal allograft transplantation. Part 1: systematic review of graft biology, graft shrinkage, graft extrusion, graft sizing, and graft fixation

PURPOSE

To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation: graft biology, shrinkage, extrusion, sizing, and fixation.

METHODS

A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies).

RESULTS

Sixty-two studies were finally included: 30 biology, 3 graft shrinkage, 11 graft extrusion, 17 graft size, and 6 graft fixation (some studies were categorized in more than one topic). These studies corresponded to 22 animal studies, 22 in vitro human studies, and 23 in vivo human studies (7 level II, 10 level III, and 6 level IV).

CONCLUSIONS

The principal conclusions were as follows: (a) Donor cells decrease after MAT and grafts are repopulated with host cells form synovium; (b) graft preservation alters collagen network (deep freezing) and causes cell apoptosis with loss of viable cells (cryopreservation); (c) graft shrinkage occurs mainly in lyophilized and gamma-irradiated grafts (less with cryopreservation); (d) graft extrusion is common but has no clinical/functional implications; (e) overall, MRI is not superior to plain radiograph for graft sizing; (f) graft width size matching is more important than length size matching; (g) height appears to be the most important factor influencing meniscal size; (h) bone fixation better restores contact mechanics than suture fixation, but there are no differences for pullout strength or functional results; and (i) suture fixation has more risk of graft extrusion compared to bone fixation.

LEVEL OF EVIDENCE

Systematic review of level II-IV studies, Level IV.

Effect of glutaraldehyde fixation on the frictional response of immature bovine articular cartilage explants

This study examined functional properties and biocompatibility of glutaraldehyde-fixed bovine articular cartilage over several weeks of incubation at body temperature to investigate its potential use as a resurfacing material in joint arthroplasty. In the first experiment, treated cartilage disks were fixed using 0.02, 0.20 and 0.60% glutaraldehyde for 24h then incubated, along with an untreated control group, in saline for up to 28d at 37°C. Both the equilibrium compressive and tensile moduli increased nearly twofold in treated samples compared to day 0 control, and remained at that level from day 1 to 28; the equilibrium friction coefficient against glass rose nearly twofold immediately after fixation (day 1) but returned to control values after day 7. Live explants co-cultured with fixed explants showed no quantitative difference in cell viability over 28d. In general, no significant differences were observed between 0.20 and 0.60% groups, so 0.20% was deemed sufficient for complete fixation. In the second experiment, cartilage-on-cartilage frictional measurements were performed under a migrating contact configuration. In the treated group, one explant was fixed using 0.20% glutaraldehyde while the apposing explant was left untreated; in the control group both explants were left untreated. From day 1 to 28, the treated group exhibited either no significant difference or slightly lower friction coefficient than the untreated group. These results suggest that a properly titrated glutaraldehyde treatment can reproduce the desired functional properties of native articular cartilage and maintain these properties for at least 28d at body temperature.

Three-dimensional in vitro effects of compression and time in culture on aggregate modulus and on gene expression and protein content of collagen type II in murine chondrocytes

The objectives of this study were to determine how culture time and dynamic compression, applied to murine chondrocyte-agarose constructs, influence construct stiffness, expression of col2 and type II collagen. Chondrocytes were harvested from the ribs of six newborn double transgenic mice carrying transgenes that use enhanced cyan fluorescent protein (ECFP) and green fluorescent protein (GFP-T) as reporters for expression from the col2a1 and col1a1 promoters, respectively. Sixty-three constructs (8 mm diameter x 3 mm thick) per animal were created by seeding chondrocytes (10 x 10(6) per mL) in agarose gel (2% w/v). Twenty-eight constructs from each animal were stimulated for 7, 14, 21, or 28 days in a custom bioreactor housed in an electromagnetic system. Twenty-eight constructs exposed to identical culture conditions but without mechanical stimulation served as nonstimulated controls for 7, 14, 21, and 28 days. The remaining seven constructs served as day 0 controls. Fluorescing cells with rounded morphology were present in all constructs at all five time points. Seven, 14, 21, and 28 days of stimulation significantly increased col2 expression according to ECFP fluorescence and messenger RNA expression according to quantitative reverse transcriptase polymerase chain reaction. Col2 gene expression in stimulated and nonstimulated constructs showed initial increases up to day 14 and then showed decreases by day 28. Stimulation significantly increased type II collagen content at 21 and 28 days and aggregate modulus only at 28 days. There was a significant increase in aggregate modulus in stimulated constructs between day 0 and 7 and between day 21 and day 28. This study reveals that compressive mechanical stimulation is a potent stimulator of col2 gene expression that leads to measurable but delayed increases in protein (type II collagen) and then biomechanical stiffness. Future studies will examine the effects of components of the mechanical signal in culture and address the question of whether such in vitro improvements in tissue-engineered constructs enhance repair outcomes after surgery.

Biomechanical and biologic effects of meniscus stabilization using triglycidyl amine

The susceptibility of meniscus allografts to enzymatic degradation may be reduced through tissue stabilization. We have previously reported on an epoxide-based crosslinker, triglycidyl amine (TGA), which can be used alone or with a bisphosphonate (MABP) to stabilize heterograft heart valves and reduce their pathologic calcification. Our objective was to evaluate the effects of TGA and TGA-MABP pretreatment on an orthopedic allograft involving meniscus crosslinking, degradation, calcification, and compressive properties. Ovine menisci treated with TGA or TGA-MABP for up to seven days and glutaraldehyde crosslinked controls were examined in vitro for degree of crosslinking, resistance to degradation by collagenase, and material property changes. Likewise treated menisci were implanted in rats for eight weeks and examined for calcium content and biomechanical changes. TGA treatment for three days significantly reduced collagen loss by 88% and increased thermal denaturation temperatures (Ts) above 80 degrees C versus Ts of 70 degrees C or less for non-crosslinked meniscus. In vitro, TGA and TGA-MABP significantly increased aggregate modulus by 19% and 32% compared to native controls, respectively. TGA decreased permeability by 53% while TGA-MABP increased it by 303%. In vivo, TGA significantly reduced explant calcification by 42% compared to glutaraldehyde, and including MABP reduced it by 90%. Analyses revealed that TGA and TGA-MABP stabilized menisci had significantly lower modulus and permeability values than glutaraldehyde controls by at least 28% and 86%, respectively. It is concluded that TGA crosslinking of meniscus increases resistance to both collagenase degradation and pathologic calcification, while demonstrating comparable or improved biomechanical properties versus glutaraldehyde controls.

Finite Element Analysis of Meniscal Anatomical 3D Scaffolds: Implications for Tissue Engineering

Solid Free-Form Fabrication (SFF) technologies allow the fabrication of anatomical 3D scaffolds from computer tomography (CT) or magnetic resonance imaging (MRI) patients’ dataset. These structures can be designed and fabricated with a variable, interconnected and accessible porous network, resulting in modulable mechanical properties, permeability, and architecture that can be tailored to mimic a specific tissue to replace or regenerate. In this study, we evaluated whether anatomical meniscal 3D scaffolds with matching mechanical properties and architecture are beneficial for meniscus replacement as compared to meniscectomy. After acquiring CT and MRI of porcine menisci, 3D fiber-deposited (3DF) scaffolds were fabricated with different architectures by varying the deposition pattern of the fibers comprising the final structure. The mechanical behaviour of 3DF scaffolds with different architectures and of porcine menisci was measured by static and dynamic mechanical analysis and the effect of these tissue engineering templates on articular cartilage was assessed by finite element analysis (FEA) and compared to healthy conditions or to meniscectomy. Results show that 3DF anatomical menisci scaffolds can be fabricated with pore different architectures and with mechanical properties matching those of natural menisci. FEA predicted a beneficial effect of meniscus replacement with 3D scaffolds in different mechanical loading conditions as compared to meniscectomy. No influence of the internal scaffold architecture was found on articular cartilage damage. Although FEA predictions should be further confirmed by in vitro and in vivo experiments, this study highlights meniscus replacement by SFF anatomical scaffolds as a potential alternative to meniscectomy.

Role of cell location and morphology in the mechanical environment around meniscal cells

Fibrochondrocytes within meniscal tissue have been shown to alter their biochemical activity in response to changes in their mechanical environment. Meniscal tissue is known to contain both spherical (chondrocytic-like) and elliptical (fibroblastic-like) cells. We hypothesize that a cell's mechanical environment is governed by local material properties of the tissue around the cell, the cell morphology and the cell's position within the tissue. A two-dimensional, non-linear, fiber (collagen) reinforced, multi-scale, finite element model was utilized to quantify changes in the stress, strain, fluid velocity and fluid flow induced shear stress (FFISS) within and around fibrochondrocytes. Cells differing in morphology and size were modeled at different locations within an explant 6mm in diameter and 5mm thick, under 5% unconfined compression. Cellular stresses were an order of magnitude less than surrounding extracellular matrix stresses but cellular strains were higher. Cell size affected both the stress and strain levels within the cell, with smaller cells being exposed to smaller principal stresses and strains than larger cells of the same shape. The pericellular matrix of an elliptical cell was less effective at shielding the cell from large principal strains and stresses. FFISS were largest around small circular cells ( approximately 0.13Pa), and were dramatically affected by the position of the cell relative to the axis of the explant, with cells closer to the periphery experiencing greater FFISS than cells near the central axis of the explant. These results will allow biosynthetic activity of fibrochondrocytes to be correlated with position and morphology in the future.

Constitutive Modeling of Cartilaginous Tissues: A Review

An important and longstanding field of research in orthopedic biomechanics is the elucidation and mathematical modeling of the mechanical response of cartilaginous tissues. Traditional approaches have treated such tissues as continua and have described their mechanical response in terms of macroscopic models borrowed from solid mechanics. The most important of such models are the biphasic and single-phase viscoelastic models, and the many variations thereof. These models have reached a high level of maturity and have been successful in describing a wide range of phenomena. An alternative approach that has received considerable recent interest, both in orthopedic biomechanics and in other fields, is the description of mechanical response based on consideration of a tissue's structure—so-called microstructural modeling. Examples of microstructurally based approaches include fibril-reinforced biphasic models and homogenization approaches. A review of both macroscopic and microstructural constitutive models is given in the present work.

Meniscal material properties are minimally affected by matrix stabilization using glutaraldehyde and glycation with ribose

Knee meniscus replacement holds promise, but current allografts are susceptible to biodegradation. Matrix stabilization with glutaraldehyde, a crosslinking agent used clinically to fabricate cardiovascular bioprostheses, or with glycation, a process of crosslinking collagen with sugars such as ribose, is a potential means of rendering tissue resistant to such degradation. However, stabilization should not significantly alter meniscal material properties, which could disturb normal function in the knee. Our objective was to evaluate the effects of glutaraldehyde- and glycation-induced matrix stabilization on the material properties of porcine meniscus. Normal untreated meniscus specimens were tested in confined compression at one of three applied stresses (0.069, 0.208, 0.347 MPa), subjected to either a glutaraldehyde or glycation stabilization treatment, and then re-tested to measure changes in tissue aggregate modulus, permeability, and compressive strain at equilibrium. Changes in these properties significantly increased with glutaraldehyde concentration and exposure time to ribose. One glutaraldehyde and three glycation treatments did not alter aggregate modulus or compressive strain at equilibrium compared to controls (p > 0.10). However, all treatments increased permeability by at least 108% compared to controls (p < 0.001). This study reveals a dose-dependent relationship between meniscal material properties and certain stabilization conditions and identifies treatments that minimally affect these properties. Further research is necessary to determine whether these treatments prevent enzymatic degradation before and after surgical implantation in the knee.