Combining a novel leucocyte-platelet-concentrated membrane and an injectable collagen scaffold in a single-step AMIC procedure to treat chondral lesions of the knee: a preliminary retrospective study

Pioneering nanomedicine in orthopedic treatment care: a review of current research and practices

A developing use of nanotechnology in medicine involves using nanoparticles to administer drugs, genes, biologicals, or other materials to targeted cell types, such as cancer cells. In healthcare, nanotechnology has brought about revolutionary changes in the treatment of various medical and surgical conditions, including in orthopedic. Its clinical applications in surgery range from developing surgical instruments and suture materials to enhancing imaging techniques, targeted drug delivery, visualization methods, and wound healing procedures. Notably, nanotechnology plays a significant role in preventing, diagnosing, and treating orthopedic disorders, which is crucial for patients' functional rehabilitation. The integration of nanotechnology improves standards of patient care, fuels research endeavors, facilitates clinical trials, and eventually improves the patient's quality of life. Looking ahead, nanotechnology holds promise for achieving sustained success in numerous surgical disciplines, including orthopedic surgery, in the years to come. This review aims to focus on the application of nanotechnology in orthopedic surgery, highlighting the recent development and future perspective to bridge the bridge for clinical translation.

Arthroscopic and open approaches for autologous matrix-induced chondrogenesis repair of the knee have similar results: a meta-analysis

BACKGROUND

Cartilage defects are debilitating injuries that can reduce quality of life in patients. However, the poor regenerative properties of cartilage mean that cartilage repair remains challenging, and many methods have arisen to address that. Autologous matrix-induced chondrogenesis (AMIC®) is a popular technique to manage cartilage defects. Recent advances have allowed AMIC® to be done arthroscopically, instead of a mini-open arthrotomy approach. This systematic review and meta-analysis aims to investigate whether the arthroscopic approach to AMIC® provides better clinical outcomes than does the mini-open approach, in hopes of delineating a gold standard in cartilage repair.

METHODS

With reference to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search of the following databases (PubMed, Embase, Scopus, and Cochrane Library) was performed on 26th October 2022 using a combination of the following search terms: "autologous matrix induced", "chondrogenesis", and "knee". A total of 390 studies were identified, of which, 24 studies were included in our final analysis.

RESULTS

The arthroscopic approach achieves lower Visual Analogue Scale for pain scores. The International Knee documentation Committee) score and Knee Injury and Osteoarthritis Outcome Score were comparable between arthroscopic and open approaches. The open approach achieves a higher Magnetic Resonance Observation of Cartilage Repair Tissue score. Incidence of reported postoperative complications of revision surgery and knee stiffness was higher for the open approach than for the arthroscopic approach, whereas deep vein thrombosis was higher in the arthroscopic approach.

CONCLUSION

The AMIC® repair outcomes indicate that the arthroscopic approach does not hold a distinct advantage over the open approach. The choice of approach should consider surgeon expertise, location of lesion, and patient-specific factors.

LEVEL OF EVIDENCE

Systematic review and meta-analysis; Level III.

Recent developments in nanomaterials for upgrading treatment of orthopedics diseases

Nanotechnology has changed science in the last three decades. Recent applications of nanotechnology in the disciplines of medicine and biology have enhanced medical diagnostics, manufacturing, and drug delivery. The latest studies have demonstrated this modern technology's potential for developing novel methods of disease detection and treatment, particularly in orthopedics. According to recent developments in bone tissue engineering, implantable substances, diagnostics and treatment, and surface adhesives, nanomedicine has revolutionized orthopedics. Numerous nanomaterials with distinctive chemical, physical, and biological properties have been engineered to generate innovative medication delivery methods for the local, sustained, and targeted delivery of drugs with enhanced therapeutic efficacy and minimal or no toxicity, indicating a very promising strategy for effectively controlling illnesses. Extensive study has been carried out on the applications of nanotechnology, particularly in orthopedics. Nanotechnology can revolutionize orthopedics cure, diagnosis, and research. Drug delivery precision employing nanotechnology using gold and liposome nanoparticles has shown especially encouraging results. Moreover, the delivery of drugs and biologics for osteosarcoma is actively investigated. Different kind of biosensors and nanoparticles has been used in the diagnosis of bone disorders, for example, renal osteodystrophy, Paget's disease, and osteoporosis. The major hurdles to the commercialization of nanotechnology-based composite are eventually examined, thus helping in eliminating the limits in connection to some pre-existing biomaterials for orthopedics, important variables like implant life, quality, cure cost, and pain and relief from pain. The potential for nanotechnology in orthopedics is tremendous, and most of it looks to remain unexplored, but not without challenges. This review aims to highlight the up tp date developments in nanotechnology for boosting the treatment modalities for orthopedic ailments. Moreover, we also highlighted unmet requirements and present barriers to the practical adoption of biomimetic nanotechnology-based orthopedic treatments.

A mini-review on the emerging role of nanotechnology in revolutionizing orthopedic surgery: challenges and the road ahead

An emerging application of nanotechnology in medicine currently being developed involves employing nanoparticles to deliver drugs, heat, light, or other substances to specific types of cells (such as cancer cells). As most biological molecules exist and function at the nanoscale, engineering and manipulating matter at the molecular level has many advantages in the field of medicine (nanomedicine). Although encouraging, it remains unclear how much of this will ultimately result in improved patient care. In surgical specialties, clinically relevant nanotechnology applications include the creation of surgical instruments, suture materials, imaging, targeted drug therapy, visualization methods, and wound healing techniques. Burn lesion and scar management is an essential nanotechnology application. Prevention, diagnosis, and treatment of numerous orthopedic conditions are crucial technological aspects for patients' functional recovery. Orthopedic surgery is a specialty that deals with the diagnosis and treatment of musculoskeletal disorders. In recent years, the field of orthopedics has been revolutionized by the advent of nanotechnology. Using biomaterials comprised of nanoparticles and structures, it is possible to substantially enhance the efficacy of such interactions through nanoscale material modifications. This serves as the foundation for the majority of orthopedic nanotechnology applications. In orthopedic surgery, nanotechnology has been applied to improve surgical outcomes, enhance bone healing, and reduce complications associated with orthopedic procedures. This mini-review summarizes the present state of nanotechnology in orthopedic surgery, including its applications as well as possible future directions.

Biomolecules-releasing click chemistry-based bioadhesives for repairing acetabular labrum tears

Currently, there are no effective clinical or experimental treatments to fully restore the function of the torn acetabular labrum. To fill the gap, here, we report the finding of progenitor cells in labral tissue, which can be recruited and stimulated to repair torn acetabular labral tissue. This study aimed to develop a biomolecule releasing bioadhesive which can speed up labral tissue healing by eliciting autologous labral progenitor cellular responses. A click chemistry-based bioadhesive, capable of releasing biomolecules, was synthesized to exert ~3× adhesion strength compared with fibrin glue. Via the release of platelet-derived growth factor (PDGF), the adhesive was shown to actively recruit and stimulate the proliferation of labral progenitor cells to the tear sites and within the adhesive. Finally, the ability of this biomolecules-releasing adhesive designed to promote labral tissue regeneration was evaluated using discarded human acetabular labrum tissue compared with surgical suture ex vivo. Histological analysis shows that PDGF-releasing bioadhesive yielded significantly more labrum cell responses and extracellular matrix protein (proteoglycan and collagen) production at the tear tissue site than surgical suture controls. The results confirm that the new PDGF-releasing bioadhesive can activate the responses of autologous labral progenitor cells to significantly improve labral tissue regeneration. Clinical significance: These PDGF-releasing bioadhesives may serve as a new and effective tool for repairing and regenerating acetabular labrum tears.

Microfracture versus Enhanced Microfracture Techniques in Knee Cartilage Restoration: A Systematic Review and Meta-Analysis

This study aimed to compare the efficacy and safety of the microfracture (MFx) and microfracture augmented (MFx + ) techniques for the treatment of cartilage defects of the knee. The PubMed and EMBASE databases were searched from 1 January, 1950 to 1 May, 2019. RevMan5.3 was used to perform statistical analysis. Relative risk was calculated for binary variables, and weighted mean difference and standardized mean difference (SMD) were measured for continuous variables. The 95% confidence interval (CI) of each variable was assessed. Thirteen trials with 635 patients were included. There was a significant difference in the Lysholm's score (SMD = 0.26, 95% CI: 0.01-0.50, p = 0.04) and magnetic resonance observation of cartilage repair tissue score (SMD = 14.01, 95% CI: 8.01-20.02, p < 0.01) between the MFx and MFx+ groups. There was no significant difference in the Western Ontario and McMaster Universities Osteoarthritis Index score (SMD =  - 12.40, 95% CI: -27.50 to 32.71, p = 0.11), International Knee Documentation Committee score (SMD = 8.67, 95% CI: -0.92 to 18.27, p = 0.08), visual analog scale score (SMD =  - 0.20, 95% CI: -2.45 to 0.96, p = 0.57), Tegner's score (SMD = 0.26, 95% CI: -0.67 to 1.18, p = 0.59), modified Cincinnati's score (SMD =  - 4.58, 95% CI: -14.31 to 5.14, p = 0.36) and modified International Cartilage Repair Society pain score (SMD = 0.09, 95% CI: -0.37 to 0.55, p = 0.70) between the groups. Results of the pooled analyses of the MFx+ and MFx groups suggested that the MFx+ technique is slightly superior to the MFx technique for the treatment of articular cartilage defects of the knee. Further research is required and future studies should include assessments of the outcomes at long-term follow-ups. Trial registration number is PROSPERO CRD42019135803.

Recent Advances and Perspective of Nanotechnology-Based Implants for Orthopedic Applications

Bioimplant engineering strives to provide biological replacements for regenerating, retaining, or modifying injured tissues and/or organ function. Modern advanced material technology breakthroughs have aided in diversifying ingredients used in orthopaedic implant applications. As such, nanoparticles may mimic the surface features of real tissues, particularly in terms of wettability, topography, chemistry, and energy. Additionally, the new features of nanoparticles support their usage in enhancing the development of various tissues. The current study establishes the groundwork for nanotechnology-driven biomaterials by elucidating key design issues that affect the success or failure of an orthopaedic implant, its antibacterial/antimicrobial activity, response to cell attachment propagation, and differentiation. The possible use of nanoparticles (in the form of nanosized surface or a usable nanocoating applied to the implant’s surface) can solve a number of problems (i.e., bacterial adhesion and corrosion resilience) associated with conventional metallic or non-metallic implants, particularly when implant techniques are optimised. Orthopaedic biomaterials’ prospects (i.e., pores architectures, 3D implants, and smart biomaterials) are intriguing in achieving desired implant characteristics and structure exhibiting stimuli-responsive attitude. The primary barriers to commercialization of nanotechnology-based composites are ultimately discussed, therefore assisting in overcoming the constraints in relation to certain pre-existing orthopaedic biomaterials, critical factors such as quality, implant life, treatment cost, and pain alleviation.

Does the Choice of Acellular Scaffold and Augmentation With Bone Marrow Aspirate Concentrate Affect Short-term Outcomes in Cartilage Repair? A Systematic Review and Meta-analysis

BACKGROUND

Matrix-induced chondrogenesis (MIC) is a promising treatment option for critical-size cartilage lesions of the knee; however, there exists substantial heterogeneity in the choice of acellular scaffold matrix for MIC cartilage repairs.

HYPOTHESIS

The choice of acellular matrix will not affect patient outcomes after MIC cartilage repair procedures, and the addition of concentrated bone marrow aspirate (cBMA) will improve short-term patient outcomes regardless of matrix choice.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

Studies were stratified by matrix type: multilayered, single layered, and gel based. Continuous outcomes were analyzed with pairwise meta-analysis using the inverse variance model with random effects applied. Binary outcomes were analyzed as pooled proportions in a single-arm fashion; after which, reconstruction of relative risks (RRs) with confidence intervals was performed using the Katz logarithmic method.

RESULTS

A total of 876 patients were included: 469 received multilayered bioscaffolds; 238, gel-based scaffolds; and 169, single-layered scaffolds. The mean age of patients was 36.2 years (95% CI, 33.9 to 38.4), while the mean lesion size was 3.91 cm² (95% CI, 3.40 to 4.42). The weighted mean follow-up was 23.8 months (95% CI, 20.1 to 27.6). Multilayered bioscaffolds were most effective at improving visual analog scale scores (P = .03; weighted mean difference [WMD], -4.44 [95% CI, -4.83 to -4.06]; P < .001). There were significantly lower risks of incomplete defect filling for gel-based scaffolds when compared with multilayered scaffolds (RR, 0.78 [95% CI, 0.69 to 0.88]; P < .001) and single-layered scaffolds (RR, 0.58 [95% CI, 0.41 to 0.81]; P = .001). Augmentation with cBMA further improved clinical scores across all scaffolds, with significant improvements in Tegner score (P = .02), while decreasing incomplete defect filling rates as well. There was significantly greater improvement in visual analog scale scores (P = .01) for single-layered scaffolds with cBMA augmentation (WMD, -4.88 [95% CI, -5.38 to -4.37]; P < .001) as compared with single-layered scaffolds without cBMA augmentation (WMD, -4.08 [95% CI, -4.46 to -3.71]; P < .001). All significant improvements were below their respective minimum clinically important differences.

CONCLUSION

While cartilage repair with acellular scaffolds provides significant improvements in pain and function for patients, there is insufficient clinical evidence to suggest which scaffold material is the most superior in influencing such improvements. The enhancement of cartilage repair procedures with cBMA may provide further functional improvements and improve defect filling; however, more long-term evidence is required to evaluate the effects.

Intra-articular Injection of Type I Atelocollagen to Alleviate Knee Pain: A Double-Blind, Randomized Controlled Trial

OBJECTIVE

Collagen disruption is one of the underlying causes of knee pain in patients with osteoarthritis and/or diverse cartilage defects. Atelocollagen is a type of collagen that lacks telopeptides and thus has reduced antigenicity. The intra-articular injection of type I atelocollagen supplements collagen levels in the disrupted articular cartilage. This randomized controlled trial evaluated the effects of the intra-articular injection of atelocollagen for the management of knee pain.

DESIGN

Two hundred patients with osteoarthritis, chondromalacia, or other cartilage defects were randomly assigned to receive a 3-mL intra-articular injection of atelocollagen (BioCollagen group) or saline (Placebo group). Clinical improvement was evaluated over a 24-week period using the 100-mm visual analogue scale (VAS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the 36-item Short-Form Health Survey (SF-36).

RESULTS

VAS scores were significantly better in the BioCollagen group as compared with the Placebo group at 24 weeks. More patients in the BioCollagen group reported exceeding 20% and 40% VAS improvements. The WOMAC and SF-36 scores were also significantly improved from baseline after the intra-articular injection of atelocollagen; although, the differences between the BioCollagen and Placebo groups were not significant. There were no unexpected or severe adverse events reported for either group.

CONCLUSIONS

The results show that an intra-articular injection of atelocollagen effectively alleviates knee pain, as intended. Therefore, the intra-articular injection of atelocollagen can be considered an alternative solution to controlling knee pain due to osteoarthritis and diverse cartilage defects.

Enhanced microfracture using acellular scaffolds improves results after treatment of symptomatic focal grade III/IV knee cartilage lesions but current clinical evidence does not allow unequivocal recommendation

PURPOSE

To systematically analyse post-operative outcomes following enhanced microfracture procedures in focal cartilage injuries of the knee.

METHODS

Database searches were conducted in PubMed, EMBASE and Cochrane Library databases up to 30 November 2018, for clinical studies in humans that assessed surgical outcomes of enhanced microfracture procedures in focal cartilage injuries of the knee. The clinical, functional and imaging outcomes were assessed and summarized. The MINORS scale was used to assess the methodological quality of the studies included.

RESULTS

Ten studies were included comprising a total of 331 patients (mean age of 37.0 ± 5.5 years, body mass 25.2 ± 1.7 kg m², 56% male and 42% left knee), 278 femoral condyle chondral defects (147 medial, 35 lateral and 78 undefined) and 43 chondral defects distributed by the tibial plateau, patella and femoral trochlea. The chondral defects were mostly Outerbridge grade III or IV and the mean defect size was 3.2 ± 0.6 cm². Studies consistently demonstrated significant improvement in the patient-reported outcome measures from baseline to final follow-up. Overall, imaging outcomes showed inconsistent results. Treatment-related adverse events were poorly reported.

CONCLUSION

Enhanced microfracture techniques significantly result in improved patient-reported outcome measures over the MCID, but provide inconsistent imaging results. Current clinical evidence does not allow for unequivocal recommendation of enhanced microfracture to treat symptomatic focal grade III/IV knee cartilage lesions.

LEVEL OF EVIDENCE

IV.

Cartilage Regeneration with Cell-free Type 1 Collagen Matrix - Past, Present and Future (Part 1 - Clinical Aspects)

Cartilage regeneration with cell-free matrices has developed from matrix-associated autologous cartilage cell transplantation (MACT) over ten years ago. Adjustments to the legal framework and higher hurdles for cell therapy have led to the procedures being established as an independent alternative to MACT. These procedures, which can be classified as matrix-induced autologous cartilage regeneration (MACR), all rely on the chemotactic stimulus of a cross-linked matrix, which mostly consists of collagens. Given the example of a commercially available type I collagen hydrogel, the state of clinical experience with MACR shall be summarized and an outlook on the development of the method shall be provided. It has been demonstrated in the clinical case series summarized here over the past few years that the use of the matrix is not only safe but also yields good clinical-functional and MR-tomographic results for both small (~ 10 mm) and large (> 10 mm) focal cartilage lesions. Depending on the size of the defect, MACR with a collagen type I matrix plays an important role as an alternative treatment method, in direct competition with both: microfracture and MACT.

Functional Biomolecule Delivery Systems and Bioengineering in Cartilage Regeneration

Osteoarthritis (OA) is a common degenerative disease which involves articular cartilage, and leads to total joint disability in the advanced stages. Due to its avascular and aneural nature, damaged cartilage cannot regenerate itself. Stem cell therapy and tissue engineering represent a promising route in OA therapy, in which cooperation of mesenchymal stem cells (MSCs) and three-dimensional (3D) scaffolds contribute to cartilage regeneration. However, this approach still presents some limits such as poor mechanical properties of the engineered cartilage. The natural dynamic environment of the tissue repair process involves a collaboration of several signals expressed in the biological system in response to injury. For this reason, tissue engineering involving exogenous "influencers" such as mechanostimulation and functional biomolecule delivery systems (BDS), represent a promising innovative approach to improve the regeneration process. BDS provide a controlled release of biomolecules able to interact between them and with the injured tissue. Nano-dimensional BDS is the future hope for the design of personalized scaffolds, able to overcome the delivery problems. MSC-derived extracellular vesicles (EVs) represent an attractive alternative to BDS, due to their innate targeting abilities, immunomodulatory potential and biocompatibility. Future advances in cartilage regeneration should focus on multidisciplinary strategies such as modular assembly strategies, EVs, nanotechnology, 3D biomaterials, BDS, mechanobiology aimed at constructing the functional scaffolds for actively targeted biomolecule delivery. The aim of this review is to run through the different approaches adopted for cartilage regeneration, with a special focus on biomaterials, BDS and EVs explored in terms of their delivery potential, healing capabilities and mechanical features.

Platelet-Rich Fibrin Scaffolds for Cartilage and Tendon Regenerative Medicine: From Bench to Bedside

Nowadays, research in Tissue Engineering and Regenerative Medicine is focusing on the identification of instructive scaffolds to address the requirements of both clinicians and patients to achieve prompt and adequate healing in case of injury. Among biomaterials, hemocomponents, and in particular Platelet-rich Fibrin matrices, have aroused widespread interest, acting as delivery platforms for growth factors, cytokines and immune/stem-like cells for immunomodulation; their autologous origin and ready availability are also noteworthy aspects, as safety- and cost-related factors and practical aspects make it possible to shorten surgical interventions. In fact, several authors have focused on the use of Platelet-rich Fibrin in cartilage and tendon tissue engineering, reporting an increasing number of in vitro, pre-clinical and clinical studies. This narrative review attempts to compare the relevant advances in the field, with particular reference being made to the regenerative role of platelet-derived growth factors, as well as the main pre-clinical and clinical research on Platelet-rich Fibrin in chondrogenesis and tenogenesis, thereby providing a basis for critical revision of the topic.

Biofabrication of a novel leukocyte-fibrin-platelet membrane as a cells and growth factors delivery platform for tissue engineering applications

Autologous platelet-rich hemocomponents have emerged as potential biologic tools for regenerative purpose, but their therapeutic efficacy still remains controversial. This work represents the characterization study of an innovative autologous leukocyte-fibrin-platelet membrane (LFPm), which we prepared according to a novel protocol involving multiple cycles of apheresis. The high content in fibrinogen gave to our hemocomponent the appearance of a manipulable and suturable membrane with high elasticity and deformation capacity. Moreover, being highly enriched with platelets, leukocytes, and monocytes/macrophages, the LFPm sustained the local release of bioactive molecules (platelet derived growth factor, vascular endothelial growth factor, interleukin-10, and tumour necrosis factor alpha). In parallel, the evaluation of stemness potential highlighted also that the LFPm contained cells expressing pluripotency and multipotency markers both at the messenger ribonucleic acid (NANOG, SOX2, THY1, NT5E, and ENG) and surface-protein level (CD44^high /CD73⁺ /CD34⁺ /CD117⁺ /CD31⁺ ). Finally, biodegradation analysis interestingly showed a good stability of the membrane for at least 3 weeks in vitro and 1 week in vivo. In both cases, biodegradation was associated with progressive exposure of fibrin scaffold, loss/migration of cellular elements, and release of growth factors. Overall, collected evidence could shed some light on the regenerative effect that LFPms may exert after the autologous implant on a defect site.

Nanotechnology: the scope and potential applications in orthopedic surgery

Nanotechnology involves manipulation of matter measuring 1-100 nm in at least one of its dimensions at the molecular level. Engineering and manipulation of matter at the molecular level has several advantages in the field of medicine (nanomedicine) since most of the biological molecules exist and function at a nanoscale. Though promising, questions still remain on how much of this will ultimately translate into achieving better patient care. Concerns of cost-effectiveness and nanotechnology safety still remain unclear. Orthopedics is an attractive area for the application of nanotechnology since the bone, and its constituents such as hydroxyapatite, Haversian systems, and the collagen fibrils are nanocompounds. The major orthopedic applications of nanotechnology involve around (i) effective drug delivery systems for antibiotics and chemotherapeutic agents, (ii) surface preparation of implants and prosthesis to improve osteointegration and reduce biofilm formation, (iii) controlled drug eluting systems to combat implant-related infections, (iv) tissue engineering for scaffolds preparation to deal with bone and cartilage defects, and (v) diagnostic applications in the field of oncology and musculoskeletal infections.