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Zhao X, Wu G, Zhang J, Yu Z, Wang J. Activation of CGRP receptor-mediated signaling promotes tendon-bone healing. SCIENCE ADVANCES 2024; 10:eadg7380. [PMID: 38457499 PMCID: PMC10923525 DOI: 10.1126/sciadv.adg7380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/05/2024] [Indexed: 03/10/2024]
Abstract
Calcitonin gene-related peptide (CGRP), an osteopromotive neurotransmitter with a short half-life, shows increase while calcitonin receptor-like (CALCRL) level is decreased at the early stage in bone fractures. Therefore, the activation of CALCRL-mediated signaling may be more critical to promote the tendon-bone healing. We found CGRP enhanced osteogenic differentiation of BMSCs through PKA/CREB/JUNB pathway, contributing to improved sonic hedgehog (SHH) expression, which was verified at the tendon-bone interface (TBI) in the mice with Calcrl overexpression. The osteoblast-derived SHH and slit guidance ligand 3 were reported to favor nerve regeneration and type H (CD31hiEMCNhi) vessel formation, respectively. Encouragingly, the activation or inactivation of CALCRL-mediated signaling significantly increased or decreased intensity of type H vessel and nerve fiber at the TBI, respectively. Simultaneously, improved gait characteristics and biomechanical performance were observed in the Calcrl overexpression group. Together, the gene therapy targeting CGRP receptor may be a therapeutic strategy in sports medicine.
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Affiliation(s)
- Xibang Zhao
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, Guangdong, P. R. China
| | - Guanfu Wu
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Chemical Engineering, Nanjing Tech University, Nanjing, 211816, P. R. China
| | - Jing Zhang
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Chemical Engineering, Nanjing Tech University, Nanjing, 211816, P. R. China
| | - Ziyi Yu
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Chemical Engineering, Nanjing Tech University, Nanjing, 211816, P. R. China
| | - Jiali Wang
- School of Biomedical Engineering, Shenzhen Campus of Sun Yat-Sen University, Shenzhen 518107, Guangdong, P. R. China
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Hedvičáková V, Žižková R, Buzgo M, Vištejnová L, Klein P, Hovořáková M, Bartoš M, Steklíková K, Luňáčková J, Šebová E, Paurová I, Rysová M, Filová E, Rampichová M. The Gradual Release of Alendronate for the Treatment of Critical Bone Defects in Osteoporotic and Control Rats. Int J Nanomedicine 2023; 18:541-560. [PMID: 36756052 PMCID: PMC9901358 DOI: 10.2147/ijn.s386784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023] Open
Abstract
Purpose Osteoporosis is a severe health problem with social and economic impacts on society. The standard treatment consists of the systemic administration of drugs such as bisphosphonates, with alendronate (ALN) being one of the most common. Nevertheless, complications of systemic administration occur with this drug. Therefore, it is necessary to develop new strategies, such as local administration. Methods In this study, emulsion/dispersion scaffolds based on W/O emulsion of PCL and PF68 with ALN, containing hydroxyapatite (HA) nanoparticles as the dispersion phase were prepared using electrospinning. Scaffolds with different release kinetics were tested in vitro on the co-cultures of osteoblasts and osteoclast-like cells, isolated from adult osteoporotic and control rats. Cell viability, proliferation, ALP, TRAP and CA II activity were examined. A scaffold with a gradual release of ALN was tested in vivo in the bone defects of osteoporotic and control rats. Results The release kinetics were dependent on the scaffold composition and the used system of the poloxamers. The ALN was released from the scaffolds for more than 22 days. The behavior of cells cultured in vitro on scaffolds with different release kinetics was comparable. The difference was evident between cell co-cultures isolated from osteoporotic and control animals. The PCL/HA scaffold show slow degradation in vivo and residual scaffold limited new bone formation inside the defects. Nevertheless, the released ALN supported bone formation in the areas surrounding the residual scaffold. Interestingly, a positive effect of systemic administration of ALN was not proved. Conclusion The prepared scaffolds enabled tunable control release of ALN. The effect of ALN was proved in vitro and in in vivo study supported peri-implant bone formation.
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Affiliation(s)
- Věra Hedvičáková
- Department of Tissue Engineering, Institute of Experimental Medicine, the Czech Academy of Sciences, Prague, Czech Republic
| | - Radmila Žižková
- Department of Tissue Engineering, Institute of Experimental Medicine, the Czech Academy of Sciences, Prague, Czech Republic,Department of Chemistry, Faculty of Science, Humanities and Education, Technical University of Liberec, Liberec, Czech Republic
| | - Matěj Buzgo
- Department of Tissue Engineering, Institute of Experimental Medicine, the Czech Academy of Sciences, Prague, Czech Republic,BIOFABICS Lda, Porto, Portugal
| | - Lucie Vištejnová
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Pavel Klein
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic,Department of Pathological Physiology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Maria Hovořáková
- Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Bartoš
- Institute of Dental Medicine, First Faculty of Medicine and General University Hospital, Prague, Czech Republic,Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Klára Steklíková
- Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jitka Luňáčková
- Institute of Dental Medicine, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Eva Šebová
- Department of Tissue Engineering, Institute of Experimental Medicine, the Czech Academy of Sciences, Prague, Czech Republic
| | - Iveta Paurová
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Miroslava Rysová
- Department of Applied Biology, Institute for Nanomaterials, Advanced Technologies and Innovation, Technical University of Liberec, Liberec, Czech Republic
| | - Eva Filová
- Department of Tissue Engineering, Institute of Experimental Medicine, the Czech Academy of Sciences, Prague, Czech Republic
| | - Michala Rampichová
- Department of Tissue Engineering, Institute of Experimental Medicine, the Czech Academy of Sciences, Prague, Czech Republic,Correspondence: Michala Rampichová, Department of Tissue engineering, Institute of Experimental Medicine, the Czech Academy of Sciences, Videnska 1083, Prague, 14220, Czech Republic, Tel +420 241 062 692, Email
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Yao S, Yung PSH, Lui PPY. Tackling the Challenges of Graft Healing After Anterior Cruciate Ligament Reconstruction-Thinking From the Endpoint. Front Bioeng Biotechnol 2022; 9:756930. [PMID: 35004636 PMCID: PMC8727521 DOI: 10.3389/fbioe.2021.756930] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/09/2021] [Indexed: 12/30/2022] Open
Abstract
Anterior cruciate ligament (ACL) tear is common in sports and accidents, and accounts for over 50% of all knee injuries. ACL reconstruction (ACLR) is commonly indicated to restore the knee stability, prevent anterior–posterior translation, and reduce the risk of developing post-traumatic osteoarthritis. However, the outcome of biological graft healing is not satisfactory with graft failure after ACLR. Tendon graft-to-bone tunnel healing and graft mid-substance remodeling are two key challenges of biological graft healing after ACLR. Mounting evidence supports excessive inflammation due to ACL injury and ACLR, and tendon graft-to-bone tunnel motion negatively influences these two key processes. To tackle the problem of biological graft healing, we believe that an inductive approach should be adopted, starting from the endpoint that we expected after ACLR, even though the results may not be achievable at present, followed by developing clinically practical strategies to achieve this ultimate goal. We believe that mineralization of tunnel graft and ligamentization of graft mid-substance to restore the ultrastructure and anatomy of the original ACL are the ultimate targets of ACLR. Hence, strategies that are osteoinductive, angiogenic, or anti-inflammatory should drive graft healing toward the targets. This paper reviews pre-clinical and clinical literature supporting this claim and the role of inflammation in negatively influencing graft healing. The practical considerations when developing a biological therapy to promote ACLR for future clinical translation are also discussed.
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Affiliation(s)
- Shiyi Yao
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Patrick Shu Hang Yung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Pauline Po Yee Lui
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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Rodríguez-Merchán EC. Anterior Cruciate Ligament Reconstruction: Is Biological Augmentation Beneficial? Int J Mol Sci 2021; 22:ijms222212566. [PMID: 34830448 PMCID: PMC8625610 DOI: 10.3390/ijms222212566] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 12/28/2022] Open
Abstract
Surgical reconstruction in anterior cruciate ligament (ACL) ruptures has proven to be a highly effective technique that usually provides satisfactory results. However, despite the majority of patients recovering their function after this procedure, ACL reconstruction (ACLR) is still imperfect. To improve these results, various biological augmentation (BA) techniques have been employed mostly in animal models. They include: (1) growth factors (bone morphogenetic protein, epidermal growth factor, granulocyte colony-stimulating factor, basic fibroblast growth factor, transforming growth factor-β, hepatocyte growth factor, vascular endothelial growth factor, and platelet concentrates such as platelet-rich plasma, fibrin clot, and autologous conditioned serum), (2) mesenchymal stem cells, (3) autologous tissue, (4) various pharmaceuticals (matrix metalloproteinase-inhibitor alpha-2-macroglobulin bisphosphonates), (5) biophysical/environmental methods (hyperbaric oxygen, low-intensity pulsed ultrasound, extracorporeal shockwave therapy), (6) biomaterials (fixation methods, biological coatings, biosynthetic bone substitutes, osteoconductive materials), and (7) gene therapy. All of them have shown good results in experimental studies; however, the clinical studies on BA published so far are highly heterogeneous and have a low degree of evidence. The most widely used technique to date is platelet-rich plasma. My position is that orthopedic surgeons must be very cautious when considering using PRP or other BA methods in ACLR.
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Affiliation(s)
- Emerito Carlos Rodríguez-Merchán
- Department of Orthopedic Surgery, La Paz University Hospital—IdiPaz, 28046 Madrid, Spain;
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research—IdiPAZ (La Paz University Hospital—Autonomous University of Madrid), 28046 Madrid, Spain
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5
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Yao SY, Cao MD, He X, Fu BSC, Yung PSH. Biological modulations to facilitate graft healing in anterior cruciate ligament reconstruction (ACLR), when and where to apply? A systematic review. J Orthop Translat 2021; 30:51-60. [PMID: 34611514 PMCID: PMC8458724 DOI: 10.1016/j.jot.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background When and where to apply the biological modulations is effective to promote healing in the anterior cruciate ligament (ACL) reconstruction remains unclear. Purpose To perform a systematic review of preclinical animal studies on biological modulation in anterior cruciate ligament reconstruction (ACLR) concerning the time and site of delivery. Study design Systematic review of controlled laboratory studies. Methods PubMed, Ovid, and Scopus were searched until December 2020 using a combination of keywords and their synonym to retrieve all animal studies about biological modulation in ACLR. Studies that assessed mechanical strength after ACLR and compared with negative control were included. The methodological quality of animal studies was evaluated. Results 33 studies were included in this review and the majority reported mechanical strength improvement. 79 % of studies applied the biological modulations intra-operatively with different delivery systems used. For 21 % of post-operative delivery studies, intermittent delivery was tried. 21 of the included studies directly applied the biological modulations in the bone tunnels, 5 studies applied intra-articularly while 7 studies applied both in the bone tunnels and intra-articular part. Biological modulations applied intra-operatively and those applied in both parts showed better mechanical strength increase. A shift of the failure mode of pull-out from the bone tunnel in the early healing phase, to mid-substance rupture in the later phase was observed in most studies. Conclusion The improvement of the mechanical strength depends on how the biological modulations (delivery phase, delivery site, delivery form) are applied. The intra-operative delivery showed an overall higher mechanical strength increase and bone tunnel only delivery or intra-articular and bone tunnel both delivery are preferred than intra-articular only delivery. In addition, intra-articular and bone tunnel both delivery can have better mechanical strength increase for a long follow-up time. Thus, intra-operative application with a carrier to control release rate in both parts should be recommended. Further studies are needed to achieve a better healing outcome and more attention should be given to the intra-articular remodeling of the graft along with the tendon bone healing to increase the final mechanical strength. The Translational potential of this article Here, a systematic review of preclinical evidence of the time, site and the method the biological modulations being applied for ACLR to improve the graft healing would be performed. After reviewing the available studies, a choice of when and where to apply the biological modulations can achieve better mechanical strength after ACLR can be obtained. It provides evidence for both researchers and clinicians to decide when and where to apply the biological modulations can achieve their best effectiveness for ACLR before implementing. Promoting graft healing with targeted time and targeted site may reduce the risk of graft failure, safeguard return to sport.
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Affiliation(s)
- S Y Yao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - M D Cao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - X He
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Bruma S C Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Patrick S H Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Histopathological Examination of the Effects of Local and Systemic Bisphosphonate Usage in Bone Graft Applications on Bone Healing. J Maxillofac Oral Surg 2020; 20:144-148. [PMID: 33584056 DOI: 10.1007/s12663-020-01335-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022] Open
Abstract
Background The effect of bisphosphonates on the resorption process of normal bone tissue has been clearly mentioned in the literature, while their effect on the grafting material is a new research area. Limited former study is not sufficient to determine the strength, reliability and dosage of bisphosphonates. In this study, our aim is to examine the effects of local and systemic use of bisphosphonates in bone graft applications on bone healing, histopathologically. Methods Therefore, 32 Sprague-Dawley rats are separated into four groups. In the first group, only an empty bone defect is made on tibia and the tissue is sutured primarily without any other application. In the second group, bone defect is filled with allograft material and closed without any other application. In the third group (LA), alendronate solution is locally added to the graft material before its application to the site of bone defect. In the fourth group, alendronate is applied systemically after the site of bone defect is grafted and primarily closed. After 6 weeks, all rats are killed and the obtained samples are examined histopathologically. Results Local and systemic application of alendronate increases new bone formation in a statistically significant degree. In LA group, newly formed bone was observed more mature and well developed. Alendronate application does not cause an increase in inflammation, fibrosis and necrosis. There is no increased necrosis with alendronate application. Conclusion Local and systemic application of alendronate in bone grafting increases bone formation without any other complication. But we believe that further research should be made on dosage, usage and possible side effects.
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7
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Leite CBG, Demange MK. BIOLOGICAL ENHANCEMENTS FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. ACTA ORTOPEDICA BRASILEIRA 2019; 27:325-330. [PMID: 31798325 PMCID: PMC6870547 DOI: 10.1590/1413-785220192706226481] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/01/2019] [Indexed: 02/06/2023]
Abstract
The anterior cruciate ligament (ACL) is mostly responsible for providing knee stability. ACL injury has a marked effect on daily activities, causing pain, dysfunction, and elevated healthcare costs. ACL reconstruction (ACLR) is the standard treatment for this injury. However, despite good results, ACLR is associated with a significant rate of failure. In this context, the mechanical and biological causes must be considered. From a biological perspective, the ACLR depends on the osseointegration of the graft in the adjacent bone and the process of intra-articular ligamentization for good results. Here, we discuss the mechanisms underlying the normal graft healing process after ACLR and its biological modulation, thus, presenting novel strategies for biological enhancements of the ACL graft. Level of evidence III, Systematic review of level III studies.
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Affiliation(s)
- Chilan Bou Ghosson Leite
- Universidade de São Paulo, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Marco Kawamura Demange
- Universidade de São Paulo, Hospital das Clínicas, HCFMUSP, Faculdade de Medicina, Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
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Crispim JF, Fu SC, Lee YW, Fernandes HAM, Jonkheijm P, Yung PSH, Saris DBF. Bioactive Tape With BMP-2 Binding Peptides Captures Endogenous Growth Factors and Accelerates Healing After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2018; 46:2905-2914. [PMID: 30074814 DOI: 10.1177/0363546518787507] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The anterior cruciate ligament (ACL) has poor regenerative capacity, and an injury leads to loss of function, limiting quality of life and increasing the incidence of osteoarthritis. Surgical interventions can stabilize the joint and improve functional recovery. The delivery of growth factors (GFs) enhances the healing process; however, this is complex in its regulation, is high in costs, has side effects, and can only be accomplished with supraphysiological concentrations and thus is currently not clinically feasible. However, the immobilization of a patient's endogenous GFs in biomaterials can overcome these problems. PURPOSE To develop a method to capture endogenous bone morphogenetic protein-2 (BMP-2) and ultimately show enhanced ACL healing in vivo using this novel methodology. STUDY DESIGN Controlled laboratory study. METHODS BMP-2 binding peptides were synthetized, purified, and immobilized on polycaprolactone (PCL) films. The affinity between the peptide and human BMP-2 (hBMP-2) was confirmed with immunofluorescence and enzyme-linked immunosorbent assay. The C2C12 Luc reporter cell line was used to confirm the bioactivity of immobilized BMP-2. For in vivo experiments, the same functionalization technology was applied to the commercially available Polytape, and the functionalized tape was sutured together with the graft used for ACL reconstruction in rats. Each animal underwent reconstruction with either native Polytape (n = 3) or Polytape with BMP-2 binding peptides (n = 3). At 2 and 6 weeks after surgery, the graft was assessed by histology and micro-computed tomography. RESULTS The covalent immobilization of the peptide in PCL was successful, allowing the peptide to capture hBMP-2, which remained bioactive and led to the osteogenic differentiation of C2C12. In vivo experiments confirmed the potential of the Polytape functionalized with the BMP-2 binding peptide to capture endogenous BMP-2, leading to enhanced bone formation inside the femoral and tibial tunnels and ultimately improving the graft's quality. CONCLUSION The incorporation of BMP-2 binding peptides into materials used for ACL reconstruction can capture endogenous hBMP-2, which enhances the healing process inside the bone tunnels. CLINICAL RELEVANCE These results demonstrate the potential of using synthetic peptides to endow biomaterials with novel biological functions, namely to capture and immobilize endogenous GFs.
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Affiliation(s)
- João F Crispim
- Department of Developmental Bioengineering, TechMed Centre, University of Twente, Enschede, the Netherlands.,Bioinspired Molecular Engineering Laboratory, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Sai C Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Yuk W Lee
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | | | - Pascal Jonkheijm
- Bioinspired Molecular Engineering Laboratory, TechMed Centre, University of Twente, Enschede, the Netherlands.,Molecular Nanofabrication Group, MESA+ Institute for Nanotechnology, University of Twente, Enschede, the Netherlands
| | - Patrick S H Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.,Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Daniël B F Saris
- Department of Developmental Bioengineering, TechMed Centre, University of Twente, Enschede, the Netherlands.,Department of Orthopaedics, University Medical Center Utrecht, Utrecht, the Netherlands
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Hexter AT, Thangarajah T, Blunn G, Haddad FS. Biological augmentation of graft healing in anterior cruciate ligament reconstruction: a systematic review. Bone Joint J 2018; 100-B:271-284. [PMID: 29589505 DOI: 10.1302/0301-620x.100b3.bjj-2017-0733.r2] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aims The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR. Materials and Methods In all, 1879 studies were identified across three databases. Following assessment against strict criteria, 112 studies were included (20 clinical studies; 92 animal studies). Results Seven categories of biological interventions were identified: growth factors, biomaterials, stem cells, gene therapy, autologous tissue, biophysical/environmental, and pharmaceuticals. The methodological quality of animal studies was moderate in 97%, but only 10% used clinically relevant outcome measures. The most interventions in clinical trials target the graft-tunnel interface and are applied intraoperatively. Platelet-rich plasma is the most studied intervention, but the clinical outcomes are mixed, and the methodological quality of studies was suboptimal. Other biological therapies investigated in clinical trials include: remnant-augmented ACLR; bone substitutes; calcium phosphate-hybridized grafts; extracorporeal shockwave therapy; and adult autologus non-cultivated stem cells. Conclusion There is extensive preclinical research supporting the use of biological therapies to augment ACLR. Further clinical studies that meet the minimum standards of reporting are required to determine whether emerging biological strategies will provide tangible benefits in patients undergoing ACLR. Cite this article: Bone Joint J 2018;100-B:271-84.
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Affiliation(s)
- A T Hexter
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - T Thangarajah
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - G Blunn
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
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10
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Wang J, Wu Y, Li H, Liu Y, Bai X, Chau W, Zheng Y, Qin L. Magnesium alloy based interference screw developed for ACL reconstruction attenuates peri-tunnel bone loss in rabbits. Biomaterials 2018; 157:86-97. [DOI: 10.1016/j.biomaterials.2017.12.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 12/05/2017] [Accepted: 12/10/2017] [Indexed: 01/03/2023]
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11
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Stolarz M, Ficek K, Binkowski M, Wróbel Z. Bone tunnel enlargement following hamstring anterior cruciate ligament reconstruction: a comprehensive review. PHYSICIAN SPORTSMED 2017; 45:31-40. [PMID: 27788037 DOI: 10.1080/00913847.2017.1253429] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nowadays, bone tunnel enlargement (BTE) after anterior cruciate ligament reconstruction is a well-known phenomenon. It has been identified, investigated and described by many authors during the last thirty years. Nevertheless, the etiology of bone tunnel enlargement still remains unclear. It is known that the causes are multifactorial and may include the surgical technique, the method of fixation, materials used, type of graft as well as biological factors. Due to the recent popularization of the use of hamstring grafts in anterior cruciate ligament reconstruction, the bone tunnel enlargement phenomenon is becoming increasingly common. In this review article, the authors focus on compiling current knowledge about the etiology, diagnosis, and the possibility of reducing the occurrence of this phenomenon by using the latest methods of supporting reconstruction surgery.
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Affiliation(s)
- Mateusz Stolarz
- a X-ray Microtomography Lab, Department of Computer Biomedical Systems , Institute of Computer Science, University of Silesia , Sosnowiec , Poland.,b Department of Orthopedics and Traumatology , City Hospital in Zabrze , Zabrze , Poland.,c Galen-Orthopaedics , Bieruń , Poland
| | - Krzysztof Ficek
- c Galen-Orthopaedics , Bieruń , Poland.,d Department of Physiotherapy Basics , Academy of Physical Education in Katowice , Katowice , Poland
| | - Marcin Binkowski
- a X-ray Microtomography Lab, Department of Computer Biomedical Systems , Institute of Computer Science, University of Silesia , Sosnowiec , Poland
| | - Zygmunt Wróbel
- a X-ray Microtomography Lab, Department of Computer Biomedical Systems , Institute of Computer Science, University of Silesia , Sosnowiec , Poland
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12
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Saccomanno MF, Capasso L, Fresta L, Milano G. Biological enhancement of graft-tunnel healing in anterior cruciate ligament reconstruction. JOINTS 2016; 4:174-182. [PMID: 27900311 DOI: 10.11138/jts/2016.4.3.174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The sites where graft healing occurs within the bone tunnel and where the intra-articular ligamentization process takes place are the two most important sites of biological incorporation after anterior cruciate ligament (ACL) reconstruction, since they help to determine the mechanical behavior of the femur-ACL graft-tibia complex. Graft-tunnel healing is a complex process influenced by several factors, such as type of graft, preservation of remnants, bone quality, tunnel length and placement, fixation techniques and mechanical stress. In recent years, numerous experimental and clinical studies have been carried out to evaluate potential strategies designed to enhance and optimize the biological environment of the graft-tunnel interface. Modulation of inflammation, tissue engineering and gene transfer techniques have been applied in order to obtain a direct-type fibrocartilaginous insertion of the ACL graft, similar to that of native ligament, and to accelerate the healing process of tendon grafts within the bone tunnel. Although animal studies have given encouraging results, clinical studies are lacking and their results do not really support the use of the various strategies in clinical practice. Further investigations are therefore needed to optimize delivery techniques, therapeutic concentrations, maintenance of therapeutic effects over time, and to reduce the risk of undesirable effects in clinical practice.
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Affiliation(s)
- Maristella F Saccomanno
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Rome, Italy
| | - Luigi Capasso
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Rome, Italy
| | - Luca Fresta
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Rome, Italy
| | - Giuseppe Milano
- Department of Orthopaedics, Catholic University, "A. Gemelli" University Hospital, Rome, Italy
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Giorgio N, Moretti L, Pignataro P, Carrozzo M, Vicenti G, Moretti B. Correlation between fixation systems elasticity and bone tunnel widening after ACL reconstruction. Muscles Ligaments Tendons J 2016; 6:467-472. [PMID: 28217568 DOI: 10.11138/mltj/2016.6.4.467] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Femoral and tibial tunnel widening (TW) after ACL reconstruction is a phenomenon increasing talk in the literature. It is underlying biological and mechanical causes. OBJECTIVE The aim of this study was to evaluate the relationship between bone tunnel enlargement and two different ACL fixation systems. PATIENTS AND METHODS 40 patient underwent ACL reconstruction with hamstring; randomly divided into group A with 20 patients treated with stiff systems (femoral Rigidfix and tibial interference screw), and into group B, with 20 patients treated with morel elastic system (femoral and tibial Tight-rope). Evaluated postoperatively with knee MRI at 40 days, 3 months, 6 months to measure bone tunnel diameters widening. RESULTS At 40 days tunnel widening between two groups shows no statistically difference. At 3 months postoperatively, femoral bone tunnel widening amounted on average to 1.84 mm in middle of tunnel and 1 mm at the mouth in joint in group A, and respectively 3.2 mm and 2.5 mm in group B (p<0.05). Tibial tunnel widening was 1.24 mm at the mouth in joint and 1.3 mm in middle in group A and respectively 2.26 mm and 2.43 mm in group B (p<0.05). At 6 months femoral tunnel widening amounted on average to 2.45 mm in middle and 1.35 mm at the mouth in joint in group A and respectively 3.5 mm and 2.7 mm in group B (p<0.01). Tibial tunnel widening amounted on average to 1.27 at mouth in joint and 1 mm in middle of tunnel in group A and respectively 2.6 mm and 2.3 mm in group B (p<0.01). CONCLUSIONS This study results suggest elastic fixation system increases bone tunnel enlargement after ACL reconstruction with hamstring without correlation with worse clinical performance. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Nicola Giorgio
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Lorenzo Moretti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Paolo Pignataro
- UO University Diagnostic Radiology, Azienda Ospedaliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Massimiliano Carrozzo
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Giovanni Vicenti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Biagio Moretti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
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Ayranci F, Gungormus M, Omezli MM, Gundogdu B. The Effect of Alendronate on Various Graft Materials Used in Maxillary Sinus Augmentation: A Rabbit Study. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e33569. [PMID: 26756022 PMCID: PMC4706848 DOI: 10.5812/ircmj.33569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 10/21/2015] [Accepted: 11/11/2015] [Indexed: 11/16/2022]
Abstract
Background: Increasing sinus pneumatization and the accompanying alveolar bone resorption complicate dental implant placement. This problem can be overcome today by raising the maxillary sinus floor with graft materials. Bisphosphonates are commonly used to accelerate the recovery of the graft materials and to prevent resorption. Objectives: The purpose of this study is to investigate whether systemic administration of a bisphosphonate (alendronate) would improve new bone formation and reduce fibrous tissue formation over a 6-week follow-up in rabbits treated with two different grafting materials for maxillary sinus floor augmentation. Materials and Methods: This experimental animal study was conducted at the Experimental Medical Application and Research Center at Erzurum/ Turkey. Twelve New Zealand rabbits, each weighing between 2.7 and 3.3 kg, were used. Twenty-four maxillary sinus floor elevation operations were performed, two on each animal (n = 24). Each elevation was repaired with either deproteinized bovine bone (xenograft) or autogenous bone graft obtained from the iliac crest. Both groups were divided into 2 subgroups: saline-treated and alendronate-treated. All groups underwent the same surgical procedures and evaluation, and were sacrificed at the 6th postoperative week. Sinuses augmented with deproteinized bovine bone (xenograft) and autogenous bone graft were examined histopathologically and histomorphometrically. Results: At 6 weeks, the bone area was significantly larger in the Xenograft-Alendronate group (33.0% ± 5.0%) than in the Xenograft-Saline group (20.8% ± 4.9%) and the bone area was significantly larger in the Autogenous-Alendronate group (43.3% ± 3.8%) than in the Autogenous-Saline group (37.5% ± 6.6%) (P = 0.001). The histomorphometric and histopathological results consistently showed that alendronate stimulated bone formation and reduced fibrous tissue formation in maxillary sinus augmentation grafts, especially in the deproteinized bovine bone group (xenograft). Conclusions: Alendronate may be considered a therapeutic option for improving the bone formation process and reducing resorption in different bone grafting procedures. Further detailed studies should focus on dosage and time-dependent effects of alendronate on bone remodeling.
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Affiliation(s)
- Ferhat Ayranci
- Department of Oral Maxillofacial Surgery, Faculty of Dentistry, Ordu University, Ordu, Turkey
- Corresponding Author: Ferhat Ayranci, Department of Oral Maxillofacial Surgery, Faculty of Dentistry, Ordu University, 52200, Ordu, Turkey. Tel: +90-4522125005, Fax: +90-4522121289, E-mail:
| | - Metin Gungormus
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey
| | - Mehmet Melih Omezli
- Department of Oral Maxillofacial Surgery, Faculty of Dentistry, Ordu University, Ordu, Turkey
| | - Betul Gundogdu
- Department of Pathology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
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Rodeo SA, Sugiguchi F, Fortier LA, Cunningham ME, Maher S. What's new in orthopaedic research. J Bone Joint Surg Am 2014; 96:2015-9. [PMID: 25471917 DOI: 10.2106/jbjs.n.01001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Scott A Rodeo
- The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | - Fumitaka Sugiguchi
- The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | - Lisa A Fortier
- Cornell University of Veterinary Medicine, 930 Campus Road, Room C3-181, Ithaca, NY 14853-6401
| | | | - Suzanne Maher
- The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
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Fu SC, Cheuk YC, Yung SH, Rolf CG, Chan KM. Systematic Review of Biological Modulation of Healing in Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2014; 2:2325967114526687. [PMID: 26535311 PMCID: PMC4555564 DOI: 10.1177/2325967114526687] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Whether biological modulation is effective to promote healing in anterior cruciate ligament (ACL) reconstruction remains unclear. Purpose: To perform a systematic review of both clinical and experimental evidence of preclinical animal studies on biological modulation to promote healing in ACL reconstruction. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic search was performed using the PubMed, Ovid, and Scopus search engines. Inclusion criteria were clinical and animal studies involving subjects with ACL injury with the use of biological modulation to promote healing outcomes. Methodological quality of clinical studies was evaluated using the Critical Appraisal Skill Programme (CASP) appraisal tool, and animal studies were evaluated by a scoring system based on a published checklist of good animal studies. Results: Ten clinical studies and 50 animal studies were included. Twenty-five included studies were regarded as good quality, with a methodological score ≥5. These studies suggested that transforming growth factor–beta (TGF-β), mesenchymal stem cells, osteogenic factors, and modalities that reduce local inflammation may be beneficial to promote graft healing in ACL reconstruction. Conclusion: This systematic review suggests that biological modulation is able to promote healing on top of surgical treatment for ACL injuries. This treatment strategy chiefly works through promotion of healing at the tunnel-graft interface, but the integrity of the intra-articular midsubstance of the graft would be another target for biological modulation.
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Affiliation(s)
- Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yau-Chuk Cheuk
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Christer Gustav Rolf
- Department of Orthopaedic Surgery, Huddinge University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Kai-Ming Chan
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Lui PPY, Wong OT, Lee YW. Application of tendon-derived stem cell sheet for the promotion of graft healing in anterior cruciate ligament reconstruction. Am J Sports Med 2014; 42:681-9. [PMID: 24451112 DOI: 10.1177/0363546513517539] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Both osteointegration and remodeling of graft midsubstance (collectively called graft healing) are slow processes after anterior cruciate ligament (ACL) reconstruction. Tendon-derived stem cells (TDSCs) form a cell sheet after treatment with connective tissue growth factor (CTGF) and ascorbic acid, which exhibits higher tenogenic and maintains high chondro-osteogenic gene expression of TDSCs. No external scaffold is required for cell delivery. HYPOTHESIS Wrapping the TDSC sheet around the ACL graft would promote early graft healing in a rat model. STUDY DESIGN Controlled laboratory study. METHODS Green fluorescent protein (GFP) rat TDSCs were treated with connective tissue growth factor and ascorbic acid to promote cell sheet formation. Rats undergoing unilateral ACL reconstruction were divided into a control group and a TDSC group. The tendon graft was wrapped with the GFP-TDSC sheet before graft insertion in the TDSC group. At weeks 2, 6, and 12 after reconstruction, the samples were harvested for computed tomography imaging and histologic or biomechanical testing. The fate of the transplanted cell sheet was examined by immunohistochemical staining of GFP. RESULTS There were significantly higher tunnel bone mineral density (BMD) (42.3% increase, P = .047) and bone volume/total volume (BV/TV) (625% increase, P = .009) at the metaphyseal region of the tibial tunnel at week 2 and at the femoral tunnel at week 6 (BMD: 30.8% increase, P = .014; BV/TV: 100% increase, P = .014) in the TDSC group compared with the control group. Only the TDSC group showed a time-dependent increase in tunnel BMD (overall P = .038) and BV/TV (overall P = .015) at the epiphyseal region of the tibial tunnel. Semiquantitative image analysis showed better graft osteointegration and higher intra-articular graft integrity with lower cellularity and vascularity, better cell alignment, and higher collagen birefringence in the TDSC group. The ultimate load at week 2 (52.5% increase, P = .027) and stiffness at week 6 (62% increase, P = .008) were significantly higher in the TDSC group. Cells positive for GFP were observed in all samples in the TDSC group at week 2 but became reduced with time after reconstruction. CONCLUSION The TDSC sheet improved early graft healing after ACL reconstruction in the rat model. CLINICAL RELEVANCE The TDSC sheet could potentially be used for the promotion of graft healing in ACL reconstruction.
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Affiliation(s)
- Pauline Po Yee Lui
- Pauline Po Yee Lui, Headquarters, Hospital Authority, 9/F, Rumsey Street Multi-Storey Carpark Building, 2 Rumsey Street, Sheung Wan, Hong Kong SAR, China.
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Lo KWH, Jiang T, Gagnon KA, Nelson C, Laurencin CT. Small-molecule based musculoskeletal regenerative engineering. Trends Biotechnol 2014; 32:74-81. [PMID: 24405851 DOI: 10.1016/j.tibtech.2013.12.002] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 12/09/2013] [Accepted: 12/10/2013] [Indexed: 01/13/2023]
Abstract
Clinicians and scientists working in the field of regenerative engineering are actively investigating a wide range of methods to promote musculoskeletal tissue regeneration. Small-molecule-mediated tissue regeneration is emerging as a promising strategy for regenerating various musculoskeletal tissues and a large number of small-molecule compounds have been recently discovered as potential bioactive molecules for musculoskeletal tissue repair and regeneration. In this review, we summarize the recent literature encompassing the past 4 years in the area of small bioactive molecules for promoting repair and regeneration of various musculoskeletal tissues including bone, muscle, cartilage, tendon, and nerve.
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Affiliation(s)
- Kevin W-H Lo
- Institute for Regenerative Engineering, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; The Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; Department of Medicine, Division of Endocrinology, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; Department of Biomedical Engineering, University of Connecticut, School of Engineering, Storrs, CT 06268, USA.
| | - Tao Jiang
- Institute for Regenerative Engineering, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; The Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; Department of Medicine, Division of Endocrinology, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA
| | - Keith A Gagnon
- Institute for Regenerative Engineering, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA
| | - Clarke Nelson
- Institute for Regenerative Engineering, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; The Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA
| | - Cato T Laurencin
- Institute for Regenerative Engineering, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; The Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; Department of Biomedical Engineering, University of Connecticut, School of Engineering, Storrs, CT 06268, USA; Department of Orthopaedic Surgery, University of Connecticut Health Center, School of Medicine, Farmington, CT 06030, USA; Department of Chemical, Materials and Biomolecular Engineering, University of Connecticut, School of Engineering, Storrs, CT 06268, USA.
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