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Yu C, Chen R, Chen J, Wang T, Wang Y, Zhang X, Wang Y, Wu T, Yu T. Enhancing tendon-bone integration and healing with advanced multi-layer nanofiber-reinforced 3D scaffolds for acellular tendon complexes. Mater Today Bio 2024; 26:101099. [PMID: 38840797 PMCID: PMC11152696 DOI: 10.1016/j.mtbio.2024.101099] [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: 02/17/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024] Open
Abstract
Advancements in tissue engineering are crucial for successfully healing tendon-bone connections, especially in situations like anterior cruciate ligament (ACL) restoration. This study presents a new and innovative three-dimensional scaffold, reinforced with nanofibers, that is specifically intended for acellular tendon complexes. The scaffold consists of a distinct layered arrangement comprising an acellular tendon core, a middle layer of polyurethane/type I collagen (PU/Col I) yarn, and an outside layer of poly (L-lactic acid)/bioactive glass (PLLA/BG) nanofiber membrane. Every layer is designed to fulfill specific yet harmonious purposes. The acellular tendon core is a solid structural base and a favorable environment for tendon cell functions, resulting in considerable tensile strength. The central PU/Col I yarn layer is vital in promoting the tendinogenic differentiation of stem cells derived from tendons and increasing the expression of critical tendinogenic factors. The external PLLA/BG nanofiber membrane fosters the process of bone marrow mesenchymal stem cells differentiating into bone cells and enhances the expression of markers associated with bone formation. Our scaffold's biocompatibility and multi-functional design were confirmed through extensive in vivo evaluations, such as histological staining and biomechanical analyses. These assessments combined showed notable enhancements in ACL repair and healing. This study emphasizes the promise of multi-layered nanofiber scaffolds in orthopedic tissue engineering and also introduces new possibilities for the creation of improved materials for regenerating the tendon-bone interface.
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Affiliation(s)
- Chenghao Yu
- Department of Orthopedic Surgery, Qingdao Municipal Hospital, University of Health and Rehabilitation Sciences, Qingdao, Shandong, 266071, China
- The Affiliated Hospital of Qingdao University, Qingdao Medical College, Qingdao University, Qingdao, Shandong, 266000, China
- Shandong Key Laboratory of Medical and Health Textile Materials, College of Textile & Clothing, Qingdao University, Qingdao, Shandong, 266071, China
- Institute of Neuroregeneration & Neurorehabilitation, Department of Pathophysiology, School of Basic Medicine, Qingdao University, Qingdao, Shandong, 266071, China
| | - Renjie Chen
- Beijing Jishuitan Hospital National Center for Orthopaedics, Beijing, 102208, China
| | - Jinli Chen
- The Affiliated Hospital of Qingdao University, Qingdao Medical College, Qingdao University, Qingdao, Shandong, 266000, China
| | - Tianrui Wang
- The Affiliated Hospital of Qingdao University, Qingdao Medical College, Qingdao University, Qingdao, Shandong, 266000, China
| | - Yawen Wang
- The Affiliated Hospital of Qingdao University, Qingdao Medical College, Qingdao University, Qingdao, Shandong, 266000, China
- Shandong Key Laboratory of Medical and Health Textile Materials, College of Textile & Clothing, Qingdao University, Qingdao, Shandong, 266071, China
- Institute of Neuroregeneration & Neurorehabilitation, Department of Pathophysiology, School of Basic Medicine, Qingdao University, Qingdao, Shandong, 266071, China
| | - Xiaopei Zhang
- The Affiliated Hospital of Qingdao University, Qingdao Medical College, Qingdao University, Qingdao, Shandong, 266000, China
- Shandong Key Laboratory of Medical and Health Textile Materials, College of Textile & Clothing, Qingdao University, Qingdao, Shandong, 266071, China
- Institute of Neuroregeneration & Neurorehabilitation, Department of Pathophysiology, School of Basic Medicine, Qingdao University, Qingdao, Shandong, 266071, China
| | - Yuanfei Wang
- Qingdao Stomatological Hospital Affiliated to Qingdao University, Qingdao, 266001, China
| | - Tong Wu
- The Affiliated Hospital of Qingdao University, Qingdao Medical College, Qingdao University, Qingdao, Shandong, 266000, China
- Shandong Key Laboratory of Medical and Health Textile Materials, College of Textile & Clothing, Qingdao University, Qingdao, Shandong, 266071, China
- Institute of Neuroregeneration & Neurorehabilitation, Department of Pathophysiology, School of Basic Medicine, Qingdao University, Qingdao, Shandong, 266071, China
| | - Tengbo Yu
- Department of Orthopedic Surgery, Qingdao Municipal Hospital, University of Health and Rehabilitation Sciences, Qingdao, Shandong, 266071, China
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Shi Q, Chen Y, Xu Y, Chen C, Lu H. Engineering a functional ACL reconstruction graft containing a triphasic enthesis-like structure in bone tunnel for the enhancement of graft-to-bone integration. J Orthop Translat 2024; 45:155-167. [PMID: 38559900 PMCID: PMC10979121 DOI: 10.1016/j.jot.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/27/2023] [Accepted: 01/16/2024] [Indexed: 04/04/2024] Open
Abstract
Background Anterior cruciate ligament (ACL) rupture is a common sports injury, which causes knee instability and abnormal joint kinematics. The current ACL graft was single-phasic, and not convenient for the formation of enthesis-like tissue in the bone tunnel, resulting in poor integration of graft-to-bone. Methods A band-shaped acellular tendon (BAT) was prepared as the core component of the ACL reconstruction graft at first, while sleeve-shaped acellular cartilage (SAC) or sleeve-shaped acellular bone (SAB) was fabricated using a vacuum aspiration system (VAS)-based decellularization protocol. The biocompatibility of the three acellular matrixes was evaluated. Furthermore, a collagen-binding peptide (CBP) derived from the A3 domain of von Willebrand factor was respectively fused into the N-terminal of GDF7, TGFβ3, or BMP2 to synthesize three recombinant growth factors capable of binding collagen (named C-GDF7, C-TGFβ3, or C-BMP2), which were respectively tethered to the BAT, SAC or SAB for improving their inducibilities in stem cell differentiation. An in-vitro experiment was performed to evaluate theirs osteogenic, chondrogenic, and tenogenic inducibilities. Then, C-TGFβ3-tethering SAC (C-TGFβ3@SAC) and C-BMP2-tethering SAB (C-BMP2@SAB) were sequentially surrounded at the bone tunnel part of C-GDF7-tethering BAT (C-GDF7@BAT), thus a sleeve-shaped acellular graft with a triphasic enthesis-like structure in bone tunnel part (named tissue-engineered graft, TE graft) was engineered. Lastly, a canine ACL reconstruction model was used to evaluate the in-vivo performance of this TE graft in enhancing graft-to-bone integration. Results The BAT, SAC, and SAB well preserved the structure and components of native tendon, cartilage, and bone, showing good biocompatibility. C-GDF7, C-TGFβ3, or C-BMP2 showed a stronger binding ability to BAT, SAC, and SAB. The C-GDF7@BAT, C-TGFβ3@SAC, or C-BMP2@SAB was a controlled delivery system for the scaffold-specific release of GDF7, TGFβ3, and BMP2, thus showing superior tenogenic, chondrogenic, or osteogenic inducibility, respectively. Using a canine ACL reconstruction model, abundant newly-formed bone and connective collagen fibers could be observed at the integration site between TE graft and bone tunnel at postoperative 16 weeks. Meanwhile, the failure load of the reconstructed ACL by TE graft was significantly higher than that of the autograft. Conclusion The TE graft could be used to reconstruct ruptured ACL and augment graft-to-bone integration, thus demonstrating high potential for clinical translation in ACL reconstruction. Translational potential of this article The findings of the study indicated that the TE graft could be a novel graft for ACL reconstruction with the ability to augment graft-to-bone integration, which may provide a foundation for future clinical application.
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Affiliation(s)
- Qiang Shi
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Yang Chen
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Yan Xu
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Can Chen
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Hongbin Lu
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China
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Xie X, Cai J, Li D, Chen Y, Wang C, Hou G, Steinberg T, Rolauffs B, EL-Newehy M, EL-Hamshary H, Jiang J, Mo X, Zhao J, Wu J. Multiphasic bone-ligament-bone integrated scaffold enhances ligamentization and graft-bone integration after anterior cruciate ligament reconstruction. Bioact Mater 2024; 31:178-191. [PMID: 37637081 PMCID: PMC10448241 DOI: 10.1016/j.bioactmat.2023.08.004] [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: 04/22/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 08/29/2023] Open
Abstract
The escalating prevalence of anterior cruciate ligament (ACL) injuries in sports necessitates innovative strategies for ACL reconstruction. In this study, we propose a multiphasic bone-ligament-bone (BLB) integrated scaffold as a potential solution. The BLB scaffold comprised two polylactic acid (PLA)/deferoxamine (DFO)@mesoporous hydroxyapatite (MHA) thermally induced phase separation (TIPS) scaffolds bridged by silk fibroin (SF)/connective tissue growth factor (CTGF)@Poly(l-lactide-co-ε-caprolactone) (PLCL) nanofiber yarn braided scaffold. This combination mimics the native architecture of the ACL tissue. The mechanical properties of the BLB scaffolds were determined to be compatible with the human ACL. In vitro experiments demonstrated that CTGF induced the expression of ligament-related genes, while TIPS scaffolds loaded with MHA and DFO enhanced the osteogenic-related gene expression of bone marrow stem cells (BMSCs) and promoted the migration and tubular formation of human umbilical vein endothelial cells (HUVECs). In rabbit models, the BLB scaffold efficiently facilitated ligamentization and graft-bone integration processes by providing bioactive substances. The double delivery of DFO and calcium ions by the BLB scaffold synergistically promoted bone regeneration, while CTGF improved collagen formation and ligament healing. Collectively, the findings indicate that the BLB scaffold exhibits substantial promise for ACL reconstruction. Additional investigation and advancement of this scaffold may yield enhanced results in the management of ACL injuries.
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Affiliation(s)
- Xianrui Xie
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, PR China
- School of Pharmacy, Key Laboratory of Prescription Effect and Clinical Evaluation of State Administration of Traditional Chinese Medicine of China, Binzhou Medical University, Yantai, 264003, China
| | - Jiangyu Cai
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
- National Engineering Laboratory for Modern Silk, Soochow University, Suzhou, 215123, China
| | - Dan Li
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, PR China
| | - Yujie Chen
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, PR China
| | - Chunhua Wang
- School of Pharmacy, Key Laboratory of Prescription Effect and Clinical Evaluation of State Administration of Traditional Chinese Medicine of China, Binzhou Medical University, Yantai, 264003, China
| | - Guige Hou
- School of Pharmacy, Key Laboratory of Prescription Effect and Clinical Evaluation of State Administration of Traditional Chinese Medicine of China, Binzhou Medical University, Yantai, 264003, China
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Bernd Rolauffs
- G.E.R.N. Research Center for Tissue Replacement, Regeneration & Neogenesis, Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center—Albert-Ludwigs-University of Freiburg, 79085, Freiburg im Breisgau, Germany
| | - Mohamed EL-Newehy
- Department of Chemistry, College of Science, King Saud University, P.O. Box 2455, Riyadh, 11451, Saudi Arabia
| | - Hany EL-Hamshary
- Department of Chemistry, College of Science, King Saud University, P.O. Box 2455, Riyadh, 11451, Saudi Arabia
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Xiumei Mo
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, PR China
- School of Pharmacy, Key Laboratory of Prescription Effect and Clinical Evaluation of State Administration of Traditional Chinese Medicine of China, Binzhou Medical University, Yantai, 264003, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Jinglei Wu
- State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, Shanghai Engineering Research Center of Nano-Biomaterials and Regenerative Medicine, College of Biological Science and Medical Engineering, Donghua University, Shanghai, 201620, PR China
- School of Pharmacy, Key Laboratory of Prescription Effect and Clinical Evaluation of State Administration of Traditional Chinese Medicine of China, Binzhou Medical University, Yantai, 264003, China
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Chen Y, Zhang Y, Chen X, Huang J, Zhou B, Zhang T, Yin W, Fang C, Yin Z, Pan H, Li X, Shen W, Chen X. Biomimetic Intrafibrillar Mineralization of Native Tendon for Soft-Hard Interface Integration by Infiltration of Amorphous Calcium Phosphate Precursors. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2304216. [PMID: 37870172 DOI: 10.1002/advs.202304216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/21/2023] [Indexed: 10/24/2023]
Abstract
Soft and hard tissues possess distinct biological properties. Integrating the soft-hard interface is difficult due to the inherent non-osteogenesis of soft tissue, especially of anterior cruciate ligament and rotator cuff reconstruction. This property makes it difficult for tendons to be mineralized and integrated with bone in vivo. To overcome this challenge, a biomimetic mineralization strategy is employed to engineer mineralized tendons. The strategy involved infiltrating amorphous calcium phosphate precursors into collagen fibrils, resulting in hydroxyapatite deposition along the c-axis. The mineralized tendon presented characteristics similar to bone tissue and induced osteogenic differentiation of mesenchymal stem cells. Additionally, the interface between the newly formed bone and tendon is serrated, suggesting a superb integration between the two tissues. This strategy allows for biomineralization of tendon collagen and replicating the hallmarks of the bone matrix and extracellular niche, including nanostructure and inherent osteoinductive properties, ultimately facilitating the integration of soft and hard tissues.
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Affiliation(s)
- Yangwu Chen
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
- China Orthopedic Regenerative Medicine Group (CORMed), Hangzhou, 310000, P. R. China
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
| | - Yuxiang Zhang
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Department of Plastic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, P. R. China
- China Orthopedic Regenerative Medicine Group (CORMed), Hangzhou, 310000, P. R. China
| | - Xiaoyi Chen
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
| | - Jiayun Huang
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
- China Orthopedic Regenerative Medicine Group (CORMed), Hangzhou, 310000, P. R. China
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
| | - Bo Zhou
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
| | - Tao Zhang
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
- China Orthopedic Regenerative Medicine Group (CORMed), Hangzhou, 310000, P. R. China
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
| | - Wei Yin
- Core Facilities, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
| | - Cailian Fang
- Rehabilitation Department, Lishui People's Hospital, Lishui, 323000, P. R. China
| | - Zi Yin
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
- China Orthopedic Regenerative Medicine Group (CORMed), Hangzhou, 310000, P. R. China
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine, and Department of Orthopedic Surgery of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
| | - Haihua Pan
- Qiushi Academy for Advanced Studies, Zhejiang University, Hangzhou, 310058, P. R. China
| | - Xiongfeng Li
- Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, 313000, P. R. China
| | - Weiliang Shen
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
- China Orthopedic Regenerative Medicine Group (CORMed), Hangzhou, 310000, P. R. China
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
| | - Xiao Chen
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cells and Regenerative Medicine and Department of Orthopedic Surgery of The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310058, P. R. China
- Key Laboratory of Tissue Engineering and Regenerative Medicine of Zhejiang Province, Zhejiang University, Hangzhou, 310058, P. R. China
- China Orthopedic Regenerative Medicine Group (CORMed), Hangzhou, 310000, P. R. China
- Department of Sports Medicine, Zhejiang University School of Medicine, Hangzhou, 310000, P. R. China
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Legnani C, Ventura A. Synthetic grafts for anterior cruciate ligament reconstructive surgery. Med Eng Phys 2023; 117:103992. [PMID: 37331747 DOI: 10.1016/j.medengphy.2023.103992] [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: 05/17/2022] [Revised: 05/06/2023] [Accepted: 05/11/2023] [Indexed: 06/20/2023]
Abstract
The quest for a good and durable substitute to anterior cruciate ligament (ACL) is driving scientists to explore new promising areas of research. Autologous and allogenic ligament reconstruction bring satisfactory results in managing ACL surgery although their use is associated with significant drawbacks. To overcome the limitations of biologic grafts, many artificial devices have been developed and implanted as a substitute to the native ACL over the past decades. Although many synthetic grafts used in the past have been withdrawn from the market due to early mechanical failures ultimately leading to synovitis and osteoarthritis, there is recently a resurgence of interest in the use of synthetic ligaments for ACL reconstruction. However, this new generation of artificial ligaments, despite promising initial results, have shown to produce serious side effects such as high rupture rates, insufficient tendon-bone healing and loosening. For these reasons, recent advancements in biomedical engineering are focusing on improving technical features of artificial ligaments combining mechanical properties to biocompatibility. Bioactive coatings and surface modification methods have been proposed to enhance synthetic ligament biocompatibility and promote osseointegration. The path to the development of a safe and effective artificial ligament is still full of challenges, however recent advancements are leading the way towards a tissue-engineered substitute to the native ACL.
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Affiliation(s)
- Claudio Legnani
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy.
| | - Alberto Ventura
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy
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Li W, Xu F, Dai F, Deng T, Ai Y, Xu Z, He C, Ai F, Song L. Hydrophilic surface-modified 3D printed flexible scaffolds with high ceramic particle concentrations for immunopolarization-regulation and bone regeneration. Biomater Sci 2023; 11:3976-3997. [PMID: 37115001 DOI: 10.1039/d3bm00362k] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Bioceramic scaffolds used in bone tissue engineering suffer from a low concentration of ceramic particles (<50 wt%), because the high concentration of ceramic particles increases the brittleness of the composite. 3D printed flexible PCL/HA scaffolds with high ceramic particle concentrations (84 wt%) were successfully fabricated in this study. However, the hydrophobicity of PCL weakens the composite scaffold hydrophilicity, which may limit the osteogenic ability to some extent. Thus, as a less time-consuming, less labour intensive, and more cost-effective treatment method, alkali treatment (AT) was employed to modify the surface hydrophilicity of the PCL/HA scaffold, and its regulation of immune responses and bone regeneration were investigated in vivo and in vitro. Initially, several concentrations of NaOH (0.5, 1, 1.5, 2, 2.5, and 5 mol L-1) were employed in tests to determine the appropriate concentration for AT. Based on the comprehensive consideration of the results of mechanical experiments and hydrophilicity, 2 mol L-1 and 2.5 mol L-1 of NaOH were selected for further investigation in this study. The PCL/HA-AT-2 scaffold dramatically reduced foreign body reactions as compared to the PCL/HA and PCL/HA-AT-2.5 scaffolds, promoted macrophage polarization towards the M2 phenotype and enhanced new bone formation. The Wnt/β-catenin pathway might participate in the signal transduction underlying hydrophilic surface-modified 3D printed scaffold-regulated osteogenesis, according to the results of immunohistochemical staining. In conclusion, hydrophilic surface-modified 3D printed flexible scaffolds with high ceramic particle concentrations can regulate the immune reactions and macrophage polarization to promote bone regeneration, and the PCL/HA-AT-2 scaffold is a potential candidate for bone tissue repair.
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Affiliation(s)
- Wenfeng Li
- The Center of Stomatology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Institute of Periodontal Disease, Nanchang University, Nanchang, China.
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
| | - Fancheng Xu
- The Center of Stomatology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Institute of Periodontal Disease, Nanchang University, Nanchang, China.
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
| | - Fang Dai
- The Center of Stomatology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Institute of Periodontal Disease, Nanchang University, Nanchang, China.
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
| | - Tian Deng
- The Center of Stomatology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Institute of Periodontal Disease, Nanchang University, Nanchang, China.
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
| | - Yufeng Ai
- The Center of Stomatology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Institute of Periodontal Disease, Nanchang University, Nanchang, China.
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
| | - Zhiyong Xu
- School of Pharmacy, Nanchang University, Nanchang, China
| | - Chenjiang He
- The Center of Stomatology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Institute of Periodontal Disease, Nanchang University, Nanchang, China.
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
| | - Fanrong Ai
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
- School of Advanced Manufacturing, Nanchang University, Nanchang, China.
| | - Li Song
- The Center of Stomatology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Institute of Periodontal Disease, Nanchang University, Nanchang, China.
- JXHC Key Laboratory of Periodontology (The Second Affiliated Hospital of Nanchang University), Nanchang, China
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7
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Karahaliloglu Z, Ercan B, Hazer B. Impregnation of polyethylene terephthalate (PET) grafts with BMP-2 loaded functional nanoparticles for reconstruction of anterior cruciate ligament. J Microencapsul 2023; 40:197-215. [PMID: 36881484 DOI: 10.1080/02652048.2023.2188940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Current artificial ligaments based on polyethylene terephthalate (PET) are associated with some disadvantages due to their hydrophobicity and low biocompatibility. In this study, we aimed to modify the surface of PET using polyethylene glycol (PEG)-terminated polystyrene (PS)-linoleic nanoparticles (PLinaS-g-PEG-NPs). We accomplished that BMP-2 in two different concentrations encapsulated in nanoparticles with an efficiency of 99.71 ± 1.5 and 99.95 ± 2.8%. While the dynamic contact angle of plain PET surface reduced from 116° to 115° after a measurement periods of 10 s, that of PLinaS-g-PEG-NPs modified PET from 80° to 17.5° within 0.35 s. According to in vitro BMP2 release study, BMP-2 was released 13.12 ± 1.76% and 45.47 ± 1.78% from 0.05 and 0.1BMP2-PLinaS-g-PEG-NPs modified PET at the end of 20 days, respectively. Findings from this study revealed that BMP2-PLinaS-g-PEG-NPs has a great potential to improve the artificial PET ligaments, and could be effectively applied for ACL reconstruction.
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Affiliation(s)
| | - Batur Ercan
- Department of Metallurgical and Materials Engineering, Middle East Technical University, Çankaya, Ankara, Turkey
- Biomedical Engineering Program, Middle East Technical University, Çankaya, Ankara, Turkey
- BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering, Middle East Technical University, Çankaya, Ankara, Turkey
| | - Baki Hazer
- Department of Aircraft Airframe Engine Maintenance, Kapadokya University, Ürgüp, Nevsehir, Turkey
- Department of Chemistry, Bulent Ecevit University, Zonguldak, Turkey
- Department of Nanotechnology Engineering, Bulent Ecevit University, Zonguldak, Turkey
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8
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Gomez-Cerezo MN, Perevoshchikova N, Ruan R, Moerman KM, Bindra R, Lloyd DG, Zheng MH, Saxby DJ, Vaquette C. Additively manufactured polyethylene terephthalate scaffolds for scapholunate interosseous ligament reconstruction. BIOMATERIALS ADVANCES 2023; 149:213397. [PMID: 37023566 DOI: 10.1016/j.bioadv.2023.213397] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023]
Abstract
The regeneration of the ruptured scapholunate interosseous ligament (SLIL) represents a clinical challenge. Here, we propose the use of a Bone-Ligament-Bone (BLB) 3D-printed polyethylene terephthalate (PET) scaffold for achieving mechanical stabilisation of the scaphoid and lunate following SLIL rupture. The BLB scaffold featured two bone compartments bridged by aligned fibres (ligament compartment) mimicking the architecture of the native tissue. The scaffold presented tensile stiffness in the range of 260 ± 38 N/mm and ultimate load of 113 ± 13 N, which would support physiological loading. A finite element analysis (FEA), using inverse finite element analysis (iFEA) for material property identification, showed an adequate fit between simulation and experimental data. The scaffold was then biofunctionalized using two different methods: injected with a Gelatin Methacryloyl solution containing human mesenchymal stem cell spheroids (hMSC) or seeded with tendon-derived stem cells (TDSC) and placed in a bioreactor to undergo cyclic deformation. The first approach demonstrated high cell viability, as cells migrated out of the spheroid and colonised the interstitial space of the scaffold. These cells adopted an elongated morphology suggesting the internal architecture of the scaffold exerted topographical guidance. The second method demonstrated the high resilience of the scaffold to cyclic deformation and the secretion of a fibroblastic related protein was enhanced by the mechanical stimulation. This process promoted the expression of relevant proteins, such as Tenomodulin (TNMD), indicating mechanical stimulation may enhance cell differentiation and be useful prior to surgical implantation. In conclusion, the PET scaffold presented several promising characteristics for the immediate mechanical stabilisation of disassociated scaphoid and lunate and, in the longer-term, the regeneration of the ruptured SLIL.
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9
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Xue Y, Zhang L, Liu F, Dai F, Kong L, Ma D, Han Y. Alkaline "Nanoswords" Coordinate Ferroptosis-like Bacterial Death for Antibiosis and Osseointegration. ACS NANO 2023; 17:2711-2724. [PMID: 36662033 DOI: 10.1021/acsnano.2c10960] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Ferroptosis is an iron-dependent cell death and is associated with cancer therapy. Can it play a role in resistance of postoperative infection of implants, especially with an extracellular supplement of Fe ions in a non-cytotoxic dose? To answer this, "nanoswords" of Fe-doped titanite are fabricated on a Ti implant surface to resist bacterial invasion by a synergistic action of ferroptosis-like bacteria killing, proton disturbance, and physical puncture. The related antibiosis mechanism is explored by atomic force microscopy and genome sequencing. The nanoswords induce an increased local pH value, which not only weakens the proton motive force, reducing adenosine triphosphate synthesis of Staphylococcus aureus, but also decreases the membrane modulus, making the nanoswords distort and even puncture a bacterial membrane easily. Simultaneously, more Fe ions are taken by bacteria due to increased bacterial membrane permeability, resulting in ferroptosis-like death of bacteria, and this is demonstrated by intracellular iron enrichment, lipid peroxidation, and glutathione depletion. Interestingly, a microenvironment constructed by these nanoswords improves osteoblast behavior in vitro and bone regeneration in vivo. Overall, the nanoswords can induce ferroptosis-like bacterial death without cytotoxicity and have great promise in applications with clinical implants for outstanding antibiosis and biointegration performance.
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Affiliation(s)
- Yang Xue
- State-key Laboratory for Mechanical Behavior of Materials, Xi'an Jiaotong University, Xi'an 710049, China
| | - Lan Zhang
- State-key Laboratory for Mechanical Behavior of Materials, Xi'an Jiaotong University, Xi'an 710049, China
| | - Fuwei Liu
- Fourth Military Medical University, Xi'an 710038, China
| | - Fang Dai
- State-key Laboratory for Mechanical Behavior of Materials, Xi'an Jiaotong University, Xi'an 710049, China
| | - Liang Kong
- Fourth Military Medical University, Xi'an 710038, China
| | - Dayan Ma
- State-key Laboratory for Mechanical Behavior of Materials, Xi'an Jiaotong University, Xi'an 710049, China
| | - Yong Han
- State-key Laboratory for Mechanical Behavior of Materials, Xi'an Jiaotong University, Xi'an 710049, China
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10
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Advanced Graft Development Approaches for ACL Reconstruction or Regeneration. Biomedicines 2023; 11:biomedicines11020507. [PMID: 36831043 PMCID: PMC9953332 DOI: 10.3390/biomedicines11020507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/28/2023] [Accepted: 01/30/2023] [Indexed: 02/12/2023] Open
Abstract
The Anterior Cruciate Ligament (ACL) is one of the major knee ligaments, one which is greatly exposed to injuries. According to the British National Health Society, ACL tears represent around 40% of all knee injuries. The number of ACL injuries has increased rapidly over the past ten years, especially in people from 26-30 years of age. We present a brief background in currently used ACL treatment strategies with a description of surgical reconstruction techniques. According to the well-established method, the PubMed database was then analyzed to scaffold preparation methods and materials. The number of publications and clinical trials over the last almost 30 years were analyzed to determine trends in ACL graft development. Finally, we described selected ACL scaffold development publications of engineering, medical, and business interest. The systematic PubMed database analysis indicated a high interest in collagen for the purpose of ACL graft development, an increased interest in hybrid grafts, a numerical balance in the development of biodegradable and nonbiodegradable grafts, and a low number of clinical trials. The investigation of selected publications indicated that only a few suggest a real possibility of creating healthy tissue. At the same time, many of them focus on specific details and fundamental science. Grafts exhibit a wide range of mechanical properties, mostly because of polymer types and graft morphology. Moreover, most of the research ends at the in vitro stage, using non-certificated polymers, thus requiring a long time before the medical device can be placed on the market. In addition to scientific concerns, official regulations limit the immediate introduction of artificial grafts onto the market.
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11
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Cai J, Liu J, Xu J, Li Y, Zheng T, Zhang T, Han K, Chen S, Jiang J, Wu S, Zhao J. Constructing high-strength nano-micro fibrous woven scaffolds with native-like anisotropic structure and immunoregulatory function for tendon repair and regeneration. Biofabrication 2023; 15:025002. [PMID: 36608336 DOI: 10.1088/1758-5090/acb106] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/06/2023] [Indexed: 01/07/2023]
Abstract
Tendon injuries are common debilitating musculoskeletal diseases with high treatment expenditure in sports medicine. The development of tendon-biomimetic scaffolds may be promising for improving the unsatisfactory clinical outcomes of traditional therapies. In this study, we combined an advanced electrospun nanofiber yarn-generating technique with a traditional textile manufacturing strategy to fabricate innovative nano-micro fibrous woven scaffolds with tendon-like anisotropic structure and high-strength mechanical properties for the treatment of large-size tendon injury. Electrospun nanofiber yarns made from pure poly L-lactic acid (PLLA) or silk fibroin (SF)/PLLA blend were fabricated, and their mechanical properties matched and even exceeded those of commercial PLLA microfiber yarns. The PLLA or SF/PLLA nanofiber yarns were then employed as weft yarns interlaced with commercial PLLA microfiber yarns as warp yarns to generate two new types of nanofibrous scaffolds (nmPLLA and nmSF/PLLA) with a plain-weaving structure. Woven scaffolds made from pure PLLA microfiber yarns (both weft and warp directions) (mmPLLA) were used as controls.In vitroexperiments showed that the nmSF/PLLA woven scaffold with aligned fibrous topography significantly promoted cell adhesion, elongation, proliferation, and phenotypic maintenance of tenocytes compared with mmPLLA and nmPLLA woven scaffolds. Moreover, the nmSF/PLLA woven scaffold exhibited the strongest immunoregulatory functions and effectively modulated macrophages towards the M2 phenotype.In vivoexperiments revealed that the nmSF/PLLA woven scaffold notably facilitated Achilles tendon regeneration with improved structure by macroscopic, histological, and ultrastructural observations six months after surgery, compared with the other two groups. More importantly, the regenerated tissue in the nmSF/PLLA group had excellent biomechanical properties comparable to those of the native tendon. Overall, our study provides an innovative biological-free strategy with ready-to-use features, which presents great potential for clinical translation for damaged tendon repair.
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Affiliation(s)
- Jiangyu Cai
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
- National Engineering Laboratory for Modern Silk, Soochow University, Suzhou 215123, People's Republic of China
| | - Jiao Liu
- College of Textiles and Clothing, Qingdao University, Qingdao 266071, People's Republic of China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
| | - Yufeng Li
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
| | - Ting Zheng
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
| | - Tianlun Zhang
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
| | - Kang Han
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
| | - Shaojuan Chen
- College of Textiles and Clothing, Qingdao University, Qingdao 266071, People's Republic of China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
| | - Shaohua Wu
- College of Textiles and Clothing, Qingdao University, Qingdao 266071, People's Republic of China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200233, People's Republic of China
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12
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Cho E, Qiao Y, Chen C, Xu J, Cai J, Li Y, Zhao J. Injectable FHE+BP composites hydrogel with enhanced regenerative capacity of tendon-bone interface for anterior cruciate ligament reconstruction. Front Bioeng Biotechnol 2023; 11:1117090. [PMID: 36911205 PMCID: PMC9996450 DOI: 10.3389/fbioe.2023.1117090] [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: 12/06/2022] [Accepted: 02/14/2023] [Indexed: 02/25/2023] Open
Abstract
Features of black phosphorous (BP) nano sheets such as enhancing mineralization and reducing cytotoxicity in bone regeneration field have been reported. Thermo-responsive FHE hydrogel (mainly composed of oxidized hyaluronic acid (OHA), poly-ε-L-lysine (ε-EPL) and F127) also showed a desired outcome in skin regeneration due to its stability and antibacterial benefits. This study investigated the application of BP-FHE hydrogel in anterior cruciate ligament reconstruction (ACLR) both in in vitro and in vivo, and addressed its effects on tendon and bone healing. This BP-FHE hydrogel is expected to bring the benefits of both components (thermo-sensitivity, induced osteogenesis and easy delivery) to optimize the clinical application of ACLR and enhance the recovery. Our in vitro results confirmed the potential role of BP-FHE via significantly increased rBMSC attachment, proliferation and osteogenic differentiation with ARS and PCR analysis. Moreover, In vivo results indicated that BP-FHE hydrogels can successfully optimize the recovery of ACLR through enhancing osteogenesis and improving the integration of tendon and bone interface. Further results of Biomechanical testing and Micro-CT analysis [bone tunnel area (mm2) and bone volume/total volume (%)] demonstrated that BP can indeed accelerate bone ingrowth. Additionally, histological staining (H&E, Masson and Safranin O/fast green) and immunohistochemical analysis (COL I, COL III and BMP-2) strongly supported the ability of BP to promote tendon-bone healing after ACLR in murine animal models.
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Affiliation(s)
- Eunshinae Cho
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Yi Qiao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Changan Chen
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Jiangyu Cai
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Yamin Li
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School Of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School Of Medicine, Shanghai, China
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13
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Wang F, Sun P, Xie E, Ji Y, Niu Y, Li F, Wei J. Phytic acid/magnesium ion complex coating on PEEK fiber woven fabric as an artificial ligament with anti-fibrogenesis and osteogenesis for ligament-bone healing. BIOMATERIALS ADVANCES 2022; 140:213079. [PMID: 35985068 DOI: 10.1016/j.bioadv.2022.213079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/09/2022] [Accepted: 08/08/2022] [Indexed: 06/15/2023]
Abstract
Development of an artificial ligament possessing osteogenic activity to enhance ligament-bone healing for reconstruction of anterior cruciate ligament (ACL) is a great challenge. Herein, polyetheretherketone fibers (PKF) were coated with phytic acid (PA)/magnesium (Mg) ions complex (PKPM), which were woven into fabrics as an artificial ligament. The results demonstrated that PKPM with PA/Mg complex coating exhibited optimized surface properties with improved hydrophilicity and surface energy, and slow release of Mg ions. PKPM significantly enhanced responses of rat bone marrow stem cells in vitro. Moreover, PKPM remarkably promoted M2 macrophage polarization that upregulated production of anti-inflammatory cytokine while inhibited M1 macrophage polarization that downregulated production of pro-inflammatory cytokine in vitro. Further, PKPM inhibited fibrous encapsulation by preventing M1 macrophage polarization while promoted osteogenesis for ligament-bone healing by triggering M2 macrophage polarization in vivo. The results suggested that the downregulation of M1 macrophage polarization for inhibiting fibrogenesis and upregulation of M2 macrophage polarization for improving osteogenesis of PKPM were attributed to synergistic effects of PA and sustained release of Mg ions. In summary, PKPM with PA/Mg complex coating upregulated pro-osteogenic macrophage polarization that supplied a profitable anti-inflammatory environments for osteogenesis and ligament-bone healing, thereby possessing tremendous potential for reconstruction of ACL.
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Affiliation(s)
- Fan Wang
- Shanghai Key Laboratory of Advanced Polymeric Materials, Key Laboratory for Ultrafine Materials of Ministry of Education, School of Material Science and Engineering, East China University of Science and Technology, Shanghai 200237, China
| | - Ping Sun
- Department of Orthopaedics, Shanghai Eighth People's Hospital, Shanghai 200235, China
| | - En Xie
- Shanghai Key Laboratory of Advanced Polymeric Materials, Key Laboratory for Ultrafine Materials of Ministry of Education, School of Material Science and Engineering, East China University of Science and Technology, Shanghai 200237, China
| | - Yinjun Ji
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yunfei Niu
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, Shanghai 200433, China.
| | - Fengqian Li
- Department of Orthopaedics, Shanghai Eighth People's Hospital, Shanghai 200235, China.
| | - Jie Wei
- Shanghai Key Laboratory of Advanced Polymeric Materials, Key Laboratory for Ultrafine Materials of Ministry of Education, School of Material Science and Engineering, East China University of Science and Technology, Shanghai 200237, China.
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14
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A regeneration process-matching scaffold with appropriate dynamic mechanical properties and spatial adaptability for ligament reconstruction. Bioact Mater 2022; 13:82-95. [PMID: 35224293 PMCID: PMC8844703 DOI: 10.1016/j.bioactmat.2021.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022] Open
Abstract
Ligament regeneration is a complicated process that requires dynamic mechanical properties and allowable space to regulate collagen remodeling. Poor strength and limited space of currently available grafts hinder tissue regeneration, yielding a disappointing success rate in ligament reconstruction. Matching the scaffold retreat rate with the mechanical and spatial properties of the regeneration process remains challenging. Herein, a scaffold matching the regeneration process was designed via regulating the trajectories of fibers with different degradation rates to provide dynamic mechanical properties and spatial adaptability for collagen infiltration. This core-shell structured scaffold exhibited biomimetic fiber orientation, having tri-phasic mechanical behavior and excellent strength. Besides, by the sequential material degradation, the available space of the scaffold increased from day 6 and remained stable on day 24, consistent with the proliferation and deposition phase of the native ligament regeneration process. Furthermore, mature collagen infiltration and increased bone integration in vivo confirmed the promotion of tissue regeneration by the adaptive space, maintaining an excellent failure load of 67.65% of the native ligament at 16 weeks. This study proved the synergistic effects of dynamic strength and adaptive space. The scaffold matching the regeneration process is expected to open new approaches in ligament reconstruction. Regeneration process-matching scaffold was made via regulating fiber trajectory. The scaffold showed tri-phasic mechanical behavior and fatigue properties. Matching repair process with dynamic mechanical property and spatial adaptability. A feasible substitute for the T/L reconstruction by spatial adaptability.
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15
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Meng F, Yin Z, Ren X, Geng Z, Su J. Construction of Local Drug Delivery System on Titanium-Based Implants to Improve Osseointegration. Pharmaceutics 2022; 14:pharmaceutics14051069. [PMID: 35631656 PMCID: PMC9146791 DOI: 10.3390/pharmaceutics14051069] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/01/2022] [Accepted: 05/13/2022] [Indexed: 02/04/2023] Open
Abstract
Titanium and its alloys are the most widely applied orthopedic and dental implant materials due to their high biocompatibility, superior corrosion resistance, and outstanding mechanical properties. However, the lack of superior osseointegration remains the main obstacle to successful implantation. Previous traditional surface modification methods of titanium-based implants cannot fully meet the clinical needs of osseointegration. The construction of local drug delivery systems (e.g., antimicrobial drug delivery systems, anti-bone resorption drug delivery systems, etc.) on titanium-based implants has been proved to be an effective strategy to improve osseointegration. Meanwhile, these drug delivery systems can also be combined with traditional surface modification methods, such as anodic oxidation, acid etching, surface coating technology, etc., to achieve desirable and enhanced osseointegration. In this paper, we review the research progress of different local drug delivery systems using titanium-based implants and provide a theoretical basis for further research on drug delivery systems to promote bone–implant integration in the future.
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Affiliation(s)
- Fanying Meng
- Institute of Translational Medicine, Shanghai University, Shanghai 200444, China;
- School of Medicine, Shanghai University, Shanghai 200444, China
- School of Life Sciences, Shanghai University, Shanghai 200444, China
| | - Zhifeng Yin
- Department of Orthopedics, Shanghai Zhongye Hospital, Shanghai 200941, China;
| | - Xiaoxiang Ren
- Institute of Translational Medicine, Shanghai University, Shanghai 200444, China;
- Correspondence: (X.R.); (Z.G.); (J.S.)
| | - Zhen Geng
- Institute of Translational Medicine, Shanghai University, Shanghai 200444, China;
- Correspondence: (X.R.); (Z.G.); (J.S.)
| | - Jiacan Su
- Institute of Translational Medicine, Shanghai University, Shanghai 200444, China;
- Correspondence: (X.R.); (Z.G.); (J.S.)
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16
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Wang L, Jiang J, Lin H, Zhu T, Cai J, Su W, Chen J, Xu J, Li Y, Wang J, Zhang K, Zhao J. Advances in Regenerative Sports Medicine Research. Front Bioeng Biotechnol 2022; 10:908751. [PMID: 35646865 PMCID: PMC9136559 DOI: 10.3389/fbioe.2022.908751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/21/2022] [Indexed: 01/08/2023] Open
Abstract
Regenerative sports medicine aims to address sports and aging-related conditions in the locomotor system using techniques that induce tissue regeneration. It also involves the treatment of meniscus and ligament injuries in the knee, Achilles’ tendon ruptures, rotator cuff tears, and cartilage and bone defects in various joints, as well as the regeneration of tendon–bone and cartilage–bone interfaces. There has been considerable progress in this field in recent years, resulting in promising steps toward the development of improved treatments as well as the identification of conundrums that require further targeted research. In this review the regeneration techniques currently considered optimal for each area of regenerative sports medicine have been reviewed and the time required for feasible clinical translation has been assessed. This review also provides insights into the direction of future efforts to minimize the gap between basic research and clinical applications.
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Affiliation(s)
- Liren Wang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Regenerative Sports Medicine Lab of the Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People’ Hospital, Shanghai, China
| | - Hai Lin
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, China
| | - Tonghe Zhu
- School of Chemistry and Chemical Engineering, Shanghai Engineering Research Center of Pharmaceutical Intelligent Equipment, Shanghai Frontiers Science Research Center for Druggability of Cardiovascular Non-Coding RNA, Institute for Frontier Medical Technology, Shanghai University of Engineering Science, Shanghai, China
| | - Jiangyu Cai
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yamin Li
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jing Wang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Kai Zhang
- National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, China
- *Correspondence: Kai Zhang, ; Jinzhong Zhao,
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Regenerative Sports Medicine Lab of the Institute of Microsurgery on Extremities, Shanghai Jiao Tong University Affiliated Sixth People’ Hospital, Shanghai, China
- *Correspondence: Kai Zhang, ; Jinzhong Zhao,
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17
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Materials Properties and Application Strategy for Ligament Tissue Engineering. J Med Biol Eng 2022. [DOI: 10.1007/s40846-022-00706-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Modular Bioreactor Design for Directed Tendon/Ligament Tissue Engineering. Bioengineering (Basel) 2022; 9:bioengineering9030127. [PMID: 35324816 PMCID: PMC8945228 DOI: 10.3390/bioengineering9030127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Functional tissue-engineered tendons and ligaments remain to be prepared in a reproducible and scalable manner. This study evaluates an acellular 3D extracellular matrix (ECM) scaffold for tendon/ligament tissue engineering and their ability to support strain-induced gene regulation associated with the tenogenesis of cultured mesenchymal stromal cells. Preliminary data demonstrate unique gene regulation patterns compared to other scaffold forms, in particular in Wnt signaling. However, the need for a robust bioreactor system that minimizes process variation was also evident. A design control process was used to design and verify the functionality of a novel bioreactor. The system accommodates 3D scaffolds with clinically-relevant sizes, is capable of long-term culture with customizable mechanical strain regimens, incorporates in-line load measurement for continuous monitoring and feedback control, and allows a variety of scaffold configurations through a unique modular grip system. All critical functional specifications were met, including verification of physiological strain levels from 1–10%, frequency levels from 0.2–0.5 Hz, and accurate load measurement up to 50 N, which can be expanded on the basis of load cell capability. The design process serves as a model for establishing statistical functionality and reliability of investigative systems. This work sets the stage for detailed analyses of ECM scaffolds to identify critical differentiation signaling responses and essential matrix composition and cell–matrix interactions.
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19
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Liu X, Sun K, Xu P, Yu Z, Lei Z, Zhou H, Li J, Li X, Zhu Z, Wang H, Chen C, Bai X. Effect of Low-Intensity Pulsed Ultrasound on the Graft-Bone Healing of Artificial Ligaments: An In Vitro and In Vivo Study. Am J Sports Med 2022; 50:801-813. [PMID: 35289229 DOI: 10.1177/03635465211063158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND As many researchers have focused on promoting the graft-bone healing of artificial ligaments, even with numerous chemical coatings, identifying a biosafe, effective, and immediately usable method is still important clinically. PURPOSE (1) To determine whether a low-intensity pulsed ultrasound system (LIPUS) promotes in vitro cell viability and osteogenic differentiation and (2) to assess the applicability and effectiveness of LIPUS in promoting the graft-bone healing of artificial ligaments in vivo. STUDY DESIGN Controlled laboratory study. METHODS Polyethylene terephthalate (PET) sheets and grafts were randomly assigned to control and LIPUS groups. MC3T3-E1 preosteoblasts were cultured on PET sheets. Cell viability and morphology were evaluated using a live/dead viability assay and scanning electron microscopy. Alkaline phosphatase activity, calcium nodule formation, and Western blot were evaluated for osteogenic differentiation. For in vivo experiments, the effect of LIPUS was evaluated via an extra-articular graft-bone healing model in 48 rabbits: the osteointegration and new bone formation were tested by micro-computed tomography and histological staining, and the graft-bone bonding was tested by biomechanical testing. RESULTS Cell viability was significantly higher in the LIPUS group as compared with control (living and dead compared between control and LIPUS groups, P = .0489 vs P = .0489). Better adherence of cells and greater development of extracellular matrix were observed in the LIPUS group. Furthermore, LIPUS promoted alkaline phosphatase activity, calcium nodule formation, and the protein expression of collagen 1 (P = .0002) and osteocalcin (P = .0006) in vitro. Micro-computed tomography revealed higher surrounding bone mass at 4 weeks and newly formed bone mass at 8 weeks in the LIPUS group (P = .0014 and P = .0018). Histological analysis showed a narrower interface and direct graft-bone contact in the LIPUS group; the surrounding bone area at 4 weeks and the mass of newly formed bone at 4 and 8 weeks in the LIPUS group were also significantly higher as compared with control (surrounding bone, P < .0001; newly formed bone, P = .0016 at 4 weeks and P = .005 at 8 weeks). The ultimate failure load in the LIPUS group was significantly higher than in the control group (P < .0001 at 4 weeks; P = .0008 at 8 weeks). CONCLUSION LIPUS promoted the viability and osteogenic differentiation of MC3T3-E1 preosteoblasts in vitro and enhanced the graft-bone healing of PET artificial ligament in vivo. CLINICAL RELEVANCE LIPUS is an effective physical stimulation to enhance graft-bone healing after artificial ligament implantation.
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Affiliation(s)
- Xingwang Liu
- The Sports Medicine Department of Huashan Hospital, Fudan University, Shanghai, China
| | - Kai Sun
- Department of Orthopedics, the General Hospital of Fushun Mining Bureau of Liaoning Province, Fushun, China
| | - Pengzhi Xu
- Department of Orthopedics, the People's Hospital of China Medical University, Shenyang, China
| | - Zhongshen Yu
- Department of Orthopedics, the People's Hospital of China Medical University, Shenyang, China
| | - Zeming Lei
- The Hand Surgery 5 Ward of Central Hospital, Shenyang Medical College, Shenyang, China
| | - Huihui Zhou
- Department of Orthopedics, the General Hospital of Benxi Iron and Steel Industry Group of Liaoning Health Industry Group, Benxi, China
| | - Jutao Li
- Department of Thyroid and Breast Surgery, Dalian Municipal Central Hospital Affiliated to Dalian Medical University, Dalian, China
| | - Xi Li
- Department of Orthopedics, the People's Hospital of China Medical University, Shenyang, China
| | - Zhiyong Zhu
- Department of Orthopedics, the People's Hospital of China Medical University, Shenyang, China
| | - Huisheng Wang
- Department of Orthopedics, the People's Hospital of China Medical University, Shenyang, China
| | - Chen Chen
- Department of Arthroscopic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xizhuang Bai
- Department of Orthopedics, the People's Hospital of China Medical University, Shenyang, China
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20
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Xu J, Ye Z, Han K, Zheng T, Zhang T, Dong S, Jiang J, Yan X, Cai J, Zhao J. Infrapatellar Fat Pad Mesenchymal Stromal Cell-Derived Exosomes Accelerate Tendon-Bone Healing and Intra-articular Graft Remodeling After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2022; 50:662-673. [PMID: 35224997 DOI: 10.1177/03635465211072227] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Exosomes derived from mesenchymal stromal cells (MSCs) reportedly enhance the healing process. However, no studies have investigated the effect of exosomes from infrapatellar fat pad (IPFP) MSCs on tendon-bone healing and intra-articular graft remodeling after anterior cruciate ligament reconstruction (ACLR). PURPOSE To evaluate the in vivo effect of exosomes from IPFP MSCs on tendon-bone healing and intra-articular graft remodeling in a rat model of ACLR. STUDY DESIGN Controlled laboratory study. METHODS A total of 90 skeletally mature male Sprague Dawley rats underwent unilateral ACLR using an autograft. All rats were randomly divided into 3 groups: sham injection (SI) group (n = 30), control injection (CI) group (n = 30), and IPFP MSC-derived exosome injection (IMEI) group (n = 30). At 2, 4, and 8 weeks postoperatively, tendon-bone healing and intra-articular graft remodeling were evaluated via biomechanical testing, micro-computed tomography, and histological analysis; macrophage polarization was evaluated using immunohistochemical staining. RESULTS Biomechanical testing demonstrated a significantly higher failure load and stiffness in the IMEI group than in the SI and CI groups at 4 and 8 weeks postoperatively. Moreover, a thinner graft-to-bone healing interface with more fibrocartilage was observed in the IMEI group at both time points. Micro-computed tomography revealed greater new bone ingrowth in the IMEI group than in the other groups, as demonstrated by smaller mean bone tunnel areas and a larger bone volume/total volume ratio. Additionally, more cellular infiltration was observed in the intra-articular graft in the IMEI group than in the other groups at 4 weeks, followed by more regularly organized fibers with mature collagen at 8 weeks. Notably, similar trends of macrophage polarization were found at both the graft-to-bone interface and the intra-articular graft in the IMEI group, with significantly fewer proinflammatory M1 macrophages and larger numbers of reparative M2 macrophages than in the SI and CI groups. CONCLUSION IPFP MSC-derived exosomes accelerated tendon-bone healing and intra-articular graft remodeling after ACLR, which may have resulted from the immunomodulation of macrophage polarization. CLINICAL RELEVANCE The IPFP can be easily harvested by most orthopaedic surgeons. Exosomes from IPFP MSCs, constituting a newly emerging cell-free approach, may represent a treatment option for improving tendon-bone healing and intra-articular graft remodeling after ACLR.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zipeng Ye
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ting Zheng
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tianlun Zhang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoyu Yan
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiangyu Cai
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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21
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Cai J, Xu J, Kang Y, Li Y, Wang L, Yan X, Jiang J, Zhao J. Acceleration of ligamentization and osseointegration processes after anterior cruciate ligament reconstruction with autologous tissue-engineered polyethylene terephthalate graft. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:770. [PMID: 34268383 PMCID: PMC8246152 DOI: 10.21037/atm-20-8048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/05/2021] [Indexed: 12/18/2022]
Abstract
Background Despite the advantages of excellent mechanical properties for rapid return to sports and early rehabilitation after anterior cruciate ligament (ACL) reconstruction with polyethylene terephthalate (PET) artificial ligament, the graft failure rate during long-term follow-up is relatively high due to poor graft-host incorporation. The purpose of the present study was to investigate the effect of autologous tissue-engineered PET (ATE-PET) grafts on osseointegration and ligamentization after ACL reconstruction. Methods Forty-eight New Zealand white rabbits were randomly divided into PET group (n=24) and ATE-PET group (n=24). In the ATE-PET group, the rabbits initially underwent subcutaneous implantation of the PET ligament. Two weeks later, unilateral ipsilateral ACL reconstruction was performed using an ATE-PET graft. In the PET group, the rabbits underwent ACL reconstruction using PET grafts as controls. Macroscopic observation, micro-computed tomography, histological and immunofluorescent staining, and biomechanical tests were conducted to evaluate the effects at 4 and 12 weeks postoperatively. Results The ATE-PET graft was highly pre-vascularized with myofibroblast aggregation after two weeks of subcutaneous implantation. With regard to the intraosseous part of the graft, the ATE-PET group had significantly higher bone mineral density and bone volume/total volume ratio at 12 weeks. Histologically, the width of the interface between the graft and bone was smaller. Regarding the intra-articular part, thicker tissue coverage with a glossy appearance was observed in the ATE-PET group at 12 weeks on macroscopic observation. Histological staining also showed more collagen fibers grew in the grafts with fewer inflammatory reactions of the ATE-PET group at both 4 and 12 weeks. Immunofluorescently, both α-SMA-positive vessels and α-SMA-positive myofibroblasts were found to be significantly greater around the graft in the ATE-PET group at 4 weeks and markedly declined at 12 weeks. Moreover, the ATE-PET group presented significantly greater failure load and stiffness than the PET group at 12 weeks (53.7±5.4 vs. 42.5±4.5 N, P<0.01; 12.9±3.0 vs. 9.8±1.3 N/mm, P=0.04). Conclusions The ATE-PET artificial ligament with pre-vascularization and myofibroblast aggregation could effectively accelerate intra-articular graft ligamentization and intraosseous graft osseointegration, thus enhancing the biomechanical properties after ACL reconstruction in a rabbit model.
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Affiliation(s)
- Jiangyu Cai
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.,State Key Laboratory of Molecular Engineering of Polymers, Fudan University, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuhao Kang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yufeng Li
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Liren Wang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoyu Yan
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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