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Durtschi MS, Kim S, Li J, Kim C, Chu C, Cheung E, Safran M, Abrams G, Yang YP. Optimizing Tissue Engineering for Clinical Relevance in Rotator Cuff Repair. TISSUE ENGINEERING. PART B, REVIEWS 2024. [PMID: 38411502 DOI: 10.1089/ten.teb.2023.0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Rotator cuff tear (RCT) is the most common cause of disability in the upper extremity. It results in 4.5 million physician visits in the United States every year and is the most common etiology of shoulder conditions evaluated by orthopedic surgeons. Over 460,000 RCT repair surgeries are performed in the United States annually. Rotator cuff (RC) retear and failure to heal remain significant postoperative complications. Literature suggests that the retear rates can range from 29.5% to as high as 94%. Weakened and irregular enthesis regeneration is a crucial factor in postsurgical failure. Although commercially available RC repair grafts have been introduced to augment RC enthesis repair, they have been associated with mixed clinical outcomes. These grafts lack appropriate biological cues such as stem cells and signaling molecules at the bone-tendon interface. In addition, they do little to prevent fibrovascular scar tissue formation, which causes the RC to be susceptible to retear. Advances in tissue engineering have demonstrated that mesenchymal stem cells (MSCs) and growth factors (GFs) enhance RC enthesis regeneration in animal models. These models show that delivering MSCs and GFs to the site of RCT enhances native enthesis repair and leads to greater mechanical strength. In addition, these models demonstrate that MSCs and GFs may be delivered through a variety of methods including direct injection, saturation of repair materials, and loaded microspheres. Grafts that incorporate MSCs and GFs enhance anti-inflammation, osteogenesis, angiogenesis, and chondrogenesis in the RC repair process. It is crucial that the techniques that have shown success in animal models are incorporated into the clinical setting. A gap currently exists between the promising biological factors that have been investigated in animal models and the RC repair grafts that can be used in the clinical setting. Future RC repair grafts must allow for stable implantation and fixation, be compatible with current arthroscopic techniques, and have the capability to deliver MSCs and/or GFs.
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Affiliation(s)
| | - Sungwoo Kim
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Jiannan Li
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Carolyn Kim
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Constance Chu
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Emilie Cheung
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Marc Safran
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Geoff Abrams
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Yunzhi Peter Yang
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
- Department of Material Science and Engineering, and Stanford University, Stanford, California, USA
- Department of Bioengineering, Stanford University, Stanford, California, USA
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Wang C, Zhang X, Wang DM, Yung PSH, Tuan RS, Ker DFE. Optimized design of an enthesis-mimicking suture anchor-tendon hybrid graft for mechanically robust bone-tendon repair. Acta Biomater 2024; 176:277-292. [PMID: 38244656 DOI: 10.1016/j.actbio.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/22/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Abstract
Repair of functionally graded biological interfaces requires joining dissimilar materials such as hard bone to soft tendon/ligament, with re-injuries/re-tears expected to be minimized by incorporating biomimicking, stress-reducing features within grafts. At bone-tendon interfaces (entheses), stress can be reduced via angled insertion, geometric flaring, mechanical gradation, and interdigitation of tissues. Here, we incorporated enthesis attributes into 3D in silico and physical models of a unique suture anchor-tendon hybrid graft (SATHG) and investigated their effects on stress reduction via finite element analyses (FEA) studies. Over 20 different simulations altering SATHG angulation, flaring, mechanical gradation, and interdigitation identified an optimal design, which included 90° angulation, 25° flaring, and a compliant (ascending then descending) mechanical gradient in SATHG's bone-to-tendon-like transitional region. This design reduced peak stress concentration factor (SCF) by 43.6 % relative to an ascending-only mechanical gradient typically used in hard-to-soft tissue engineering. To verify FEA results, SATHG models were fabricated using a photocrosslinkable bone-tendon-like polyurethane (QHM polymer) for ex vivo tensile assessment. Tensile testing showed that ultimate load (132.9 N), displacement-at-failure (1.78 mm), stiffness (135.4 N/mm), and total work-to-failure (422.1 × 10-3 J) were highest in the optimized design. Furthermore, to assess envisioned usage, SATHG pull-out testing and 6-week in vivo implantation into large, 0.5-cm segmental supraspinatus tendon defects was performed. SATHG pull-out testing showed secure bone attachment while histological assessment such as hematoxylin and eosin (H&E) together with Safranin-O staining showed biocompatibility including enthesis regeneration. This work demonstrates that engineering biomaterials with FEA-optimized, enthesis-like attributes shows potential for enhancing hard-to-soft tissue repair. STATEMENT OF SIGNIFICANCE: Successful repair of hard-to-soft tissue injuries is challenging due to high stress concentrations within bone-tendon/ligament grafts that mechanically compromise repair strength. While stress-reducing gradient biomaterials have been reported, little-to-no attention has focused on other bone-tendon/ligament interface (enthesis) features. To this end, a unique bone-tendon graft (SATHG) was developed by combining two common orthopaedic devices along with biomimetic incorporation of four enthesis-like features to reduce stress and encourage widespread clinician adoption. Notably, utilizing designs based on natural stress dissipation principles such as anchor insertion angle, geometric flaring, and mechanical gradation reduced stress by 43.6 % in silico, which was confirmed ex vivo, while in vivo studies showed SATHG's ability to support native enthesis regeneration. Thus, SATHG shows promise for hard-to-soft tissue repairs.
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Affiliation(s)
- Chenyang Wang
- Institute for Tissue Engineering and Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; School of Biomedical Sciences, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR
| | - Xu Zhang
- Institute for Tissue Engineering and Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; School of Biomedical Sciences, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; Center for Neuromusculoskeletal Restorative Medicine, InnoHK, Hong Kong Science Park, Hong Kong SAR
| | - Dan Michelle Wang
- Institute for Tissue Engineering and Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; School of Biomedical Sciences, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; Ministry of Education Key Laboratory for Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; Center for Neuromusculoskeletal Restorative Medicine, InnoHK, Hong Kong Science Park, Hong Kong SAR; Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Lui Che Woo Clinical Science Building, Prince of Wales Hospital, Hong Kong SAR
| | - Patrick S H Yung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Lui Che Woo Clinical Science Building, Prince of Wales Hospital, Hong Kong SAR; Center for Neuromusculoskeletal Restorative Medicine, InnoHK, Hong Kong Science Park, Hong Kong SAR; Institute for Tissue Engineering and Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR
| | - Rocky S Tuan
- Institute for Tissue Engineering and Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; School of Biomedical Sciences, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; Center for Neuromusculoskeletal Restorative Medicine, InnoHK, Hong Kong Science Park, Hong Kong SAR; Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Lui Che Woo Clinical Science Building, Prince of Wales Hospital, Hong Kong SAR
| | - Dai Fei Elmer Ker
- Institute for Tissue Engineering and Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; School of Biomedical Sciences, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; Ministry of Education Key Laboratory for Regenerative Medicine, Lo Kwee-Seong Biomedical Sciences Building, Area 39, The Chinese University of Hong Kong, Hong Kong SAR; Center for Neuromusculoskeletal Restorative Medicine, InnoHK, Hong Kong Science Park, Hong Kong SAR; Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Lui Che Woo Clinical Science Building, Prince of Wales Hospital, Hong Kong SAR.
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Yanke A, Dandu N, Credille K, Damodar D, Wang Z, Cole BJ. Indications and Technique: Rotator Cuff Repair Augmentation. J Am Acad Orthop Surg 2023; 31:1205-1210. [PMID: 37816190 DOI: 10.5435/jaaos-d-23-00101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/20/2023] [Indexed: 10/12/2023] Open
Abstract
Rotator cuff repair (RCR) augmentation is often considered for patients with large-to-massive rotator cuff tears or chronic tears with poor tissue quality. Augmentation can provide mechanical stability and improved biology to improve the likelihood of a successful repair. This article discusses the indications, diagnosis, surgical techniques, and outcomes for RCR augmentation using an acellular dermal allograft, partially demineralized cancellous allograft, dermal xenograft, bone marrow aspirate concentrate, and platelet-rich plasma.
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Affiliation(s)
- Adam Yanke
- From the Midwest Orthopedics at Rush, Chicago, IL (Yanke, Damodar, Wang, and Cole), the Department of Orthopedics, University of Illinois Chicago, Chicago, IL (Dandu), and the Department of Orthopedics, Houston Methodist Hospital, Houston, TX (Credille)
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