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Zhang Y, Chen J, Sun Y, Wang M, Liu H, Zhang W. Endogenous Tissue Engineering for Chondral and Osteochondral Regeneration: Strategies and Mechanisms. ACS Biomater Sci Eng 2024; 10:4716-4739. [PMID: 39091217 DOI: 10.1021/acsbiomaterials.4c00603] [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] [Indexed: 08/04/2024]
Abstract
Increasing attention has been paid to the development of effective strategies for articular cartilage (AC) and osteochondral (OC) regeneration due to their limited self-reparative capacities and the shortage of timely and appropriate clinical treatments. Traditional cell-dependent tissue engineering faces various challenges such as restricted cell sources, phenotypic alterations, and immune rejection. In contrast, endogenous tissue engineering represents a promising alternative, leveraging acellular biomaterials to guide endogenous cells to the injury site and stimulate their intrinsic regenerative potential. This review provides a comprehensive overview of recent advancements in endogenous tissue engineering strategies for AC and OC regeneration, with a focus on the tissue engineering triad comprising endogenous stem/progenitor cells (ESPCs), scaffolds, and biomolecules. Multiple types of ESPCs present within the AC and OC microenvironment, including bone marrow-derived mesenchymal stem cells (BMSCs), adipose-derived mesenchymal stem cells (AD-MSCs), synovial membrane-derived mesenchymal stem cells (SM-MSCs), and AC-derived stem/progenitor cells (CSPCs), exhibit the ability to migrate toward injury sites and demonstrate pro-regenerative properties. The fabrication and characteristics of scaffolds in various formats including hydrogels, porous sponges, electrospun fibers, particles, films, multilayer scaffolds, bioceramics, and bioglass, highlighting their suitability for AC and OC repair, are systemically summarized. Furthermore, the review emphasizes the pivotal role of biomolecules in facilitating ESPCs migration, adhesion, chondrogenesis, osteogenesis, as well as regulating inflammation, aging, and hypertrophy-critical processes for endogenous AC and OC regeneration. Insights into the applications of endogenous tissue engineering strategies for in vivo AC and OC regeneration are provided along with a discussion on future perspectives to enhance regenerative outcomes.
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Affiliation(s)
- Yanan Zhang
- School of Medicine, Southeast University, 210009 Nanjing, China
| | - Jialin Chen
- School of Medicine, Southeast University, 210009 Nanjing, China
- Jiangsu Key Laboratory for Biomaterials and Devices, Southeast University, 210096 Nanjing, China
- China Orthopedic Regenerative Medicine Group (CORMed), 310058 Hangzhou, China
| | - Yuzhi Sun
- Department of Orthopaedic Surgery, Institute of Digital Medicine, Nanjing First Hospital, Nanjing Medical University, 210006 Nanjing, China
| | - Mingyue Wang
- School of Medicine, Southeast University, 210009 Nanjing, China
| | - Haoyang Liu
- School of Medicine, Southeast University, 210009 Nanjing, China
| | - Wei Zhang
- School of Medicine, Southeast University, 210009 Nanjing, China
- Jiangsu Key Laboratory for Biomaterials and Devices, Southeast University, 210096 Nanjing, China
- China Orthopedic Regenerative Medicine Group (CORMed), 310058 Hangzhou, China
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Pardiwala DN, Tapasvi S, Chaudhary D, Babhulkar A, Varghese J, Rajan D, Narvekar A, Sancheti P. Outcomes following gel-based autologous chondrocyte implantation for articular cartilage defects of the knee. Knee 2024; 49:70-78. [PMID: 38870617 DOI: 10.1016/j.knee.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/29/2024] [Accepted: 05/20/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Gel-based autologous chondrocyte implantation (GACI) enables a simpler and more effective delivery of chondrocytes with reproducible three-dimensional structural restoration of the articular cartilage surface. There is limited documentation of medium-term outcomes. This study assessed safety and effectiveness of GACI for treatment of cartilage defects of the knee. METHODS This multicentric retrospective study was conducted across eight hospitals in India. Patients who had undergone GACI (CARTIGROW®) between 2008 and 2014 for the treatment of focal articular cartilage defects of the knee (mean defect size 4.5 ± 5.8 cm2) in limbs with normal alignment were analyzed. Primary outcomes were changes in Lysholm Knee Scoring Scale score, and Knee Outcome Sports Activity Scale (SAS). RESULTS A total of 107 patients (110 knee joints) with mean age 31.0 ± 10.5 years were included. The mean follow-up was 9.8 ± 1.5 years (range 7.85-13.43). Majority had osteochondritis dissecans (n = 51; 46.4%). The mean Lysholm Knee Scoring Scale score (81.23 ± 13.21 vs. 51.32 ± 17.89; p < 0.0001) and SAS score (80.93 ± 8.26 vs. 28.11 ± 12.28; p < 0.0001) improved significantly at follow-up as compared to pre-operative. Magnetic Resonance Observation of Cartilage Repair Tissue score in 39 patients at minimum 2 years follow-up was 84.5 ± 4.3. Among 30 patients who were playing sports before treatment, 17 patients (56.7%) could return to the same or higher level of sports post-transplantation. No major intra-operative or post-operative complications were noted. Four patients warranted revision surgery. CONCLUSION GACI is an effective treatment option for large focal articular cartilage defects of the knee with a low complication rate and revision rate and significant improvement in functional scores.
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Affiliation(s)
- Dinshaw N Pardiwala
- Department of Centre for Bone and Joint, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India.
| | - Sachin Tapasvi
- Department of Orthopaedic, The Orthopaedic Specialty Clinic, Pune, India.
| | - Deepak Chaudhary
- Department of Centre for Arthroscopy and Sports Medicine, BLK-Max Super Speciality Hospital, New Delhi, India.
| | - Ashish Babhulkar
- Department of Shoulder and Sports Injuries, Deenanath Mangeshkar Hospital, Pune, India.
| | - Jacob Varghese
- Senior Consultant and HOD, Director of Orthopedics and Department of Joint Replacement & Sports Medicine, VPS Lakeshore Hospital, Kochi, India.
| | - David Rajan
- Department of Orthopaedic, Ortho One Orthopaedic Speciality Centre, Coimbatore, India.
| | - Abhay Narvekar
- Department of Centre for Orthopedic Care, P.D. Hinduja Hospital, Mumbai, India.
| | - Parag Sancheti
- Department of Joint Replacement, Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India.
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Chen X, Wang L, Zhang J, Yan H, Wang S, Xiao J. Controlled Release of Ceria and Ferric Oxide Nanoparticles via Collagen Hydrogel for Enhanced Osteoarthritis Therapy. Adv Healthc Mater 2024:e2401507. [PMID: 39073018 DOI: 10.1002/adhm.202401507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/13/2024] [Indexed: 07/30/2024]
Abstract
Osteoarthritis (OA), characterized by chronic inflammation and cartilage degeneration, significantly affects over 500 million people globally. Nanoparticles have emerged as promising treatments for OA; however, current strategies often employ a single type of nanoparticle targeting specific disease stages, limiting sustained therapeutic efficacy. In this study, a novel collagen hydrogel is introduced, thiol crosslinked collagen-cerium oxide-poly(D,L-lactic-co-glycolic acid) microspheres encapsulating nanoparticles (CSH-CeO2-pFe2O3), designed for the controlled release of cerium oxide (CeO2) and ferric oxide (Fe2O3) nanoparticles for comprehensive OA management. The sulfhydryl cross-linked collagen matrix embeds CeO2 nanoparticles and poly(D,L-lactic-co-glycolic acid) (PLGA) microspheres encapsulating Fe2O3 nanoparticles. The CSH-CeO2-pFe2O3 hydrogel exhibits enhanced mechanical strength and remarkable injectability, along with a significant promotion of cell adhesion, proliferation, and chondrogenic differentiation. Notably, the hydrogel demonstrates intelligent responsiveness to high levels of reactive oxygen species, initiating the rapid release of CeO2 nanoparticles to address the intense inflammatory responses of early-stage OA, followed by the sustained release of Fe2O3 nanoparticles to facilitate cartilage regeneration during the proliferative phase. In a rat model with cartilage defects, the hydrogel significantly alleviates inflammation and enhances cartilage regeneration, holding substantial potential for effectively managing the pathologically complex OA.
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Affiliation(s)
- Xian Chen
- State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou, 730000, P. R. China
- Gansu Engineering Research Center of Medical Collagen, Lanzhou, 730000, P. R. China
| | - Lili Wang
- State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou, 730000, P. R. China
- Gansu Engineering Research Center of Medical Collagen, Lanzhou, 730000, P. R. China
| | - Jingting Zhang
- State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou, 730000, P. R. China
- Gansu Engineering Research Center of Medical Collagen, Lanzhou, 730000, P. R. China
| | - Huiyu Yan
- State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou, 730000, P. R. China
- Gansu Engineering Research Center of Medical Collagen, Lanzhou, 730000, P. R. China
| | - Shenghong Wang
- Department of Orthopaedics, Lanzhou University Second Hospital, Lanzhou, 730030, P. R. China
| | - Jianxi Xiao
- State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou, 730000, P. R. China
- Gansu Engineering Research Center of Medical Collagen, Lanzhou, 730000, P. R. China
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Volz M, Schaumburger J, Gellißen J, Grifka J, Anders S. A randomized controlled trial demonstrating sustained benefit of autologous matrix-induced chondrogenesis (AMIC ®) over microfracture: 10-year follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2429-2437. [PMID: 38630297 PMCID: PMC11291581 DOI: 10.1007/s00590-024-03948-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/02/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Autologous matrix-induced chondrogenesis (AMIC®) and microfracture are established treatments for focal chondral defects in the knee, but there are little clinical data concerning these procedures over the long term. This study evaluates the outcomes of AMIC® compared to microfracture over 10-year follow-up. METHODS Forty-seven patients were randomized and treated either with MFx (n = 13), sutured AMIC® (n = 17) or glued AMIC® (n = 17) in a prospective, randomized, controlled multicentre trial. The Modified Cincinnati Knee Score, a visual analogue scale for pain and MOCART score were used to assess outcomes over 10 years post-operatively. RESULTS All treatment arms improved in the first 2 years, but a progressive and significant deterioration in scores was observed in the MFx group, while both AMIC® groups remained stable. MOCART scores were comparable between groups. CONCLUSION The AMIC® procedure results in improved patient outcomes in comparison with microfracture up to 10 years following surgery for the repair of focal chondral defects in the knee. CLINICALTRIALS gov Identifier: NCT02993510.
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Affiliation(s)
| | - Jens Schaumburger
- Department of Orthopedic Surgery, Asklepios Clinical Center Bad Abbach, University of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | | | - Joachim Grifka
- Department of Orthopedic Surgery, Asklepios Clinical Center Bad Abbach, University of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Sven Anders
- Department of Orthopedic Surgery, Asklepios Clinical Center Bad Abbach, University of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany.
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Muthu S, Viswanathan VK, Chellamuthu G, Thabrez M. Clinical effectiveness of various treatments for cartilage defects compared with microfracture: a network meta-analysis of randomized controlled trials. JOURNAL OF CARTILAGE & JOINT PRESERVATION 2024; 4:100163. [DOI: 10.1016/j.jcjp.2023.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
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Taghizadeh S, Tayebi L, Akbarzadeh M, Lohrasbi P, Savardashtaki A. Magnetic hydrogel applications in articular cartilage tissue engineering. J Biomed Mater Res A 2024; 112:260-275. [PMID: 37750666 DOI: 10.1002/jbm.a.37620] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023]
Abstract
Articular cartilage defects afflict millions of individuals worldwide, presenting a significant challenge due to the tissue's limited self-repair capability and anisotropic nature. Hydrogel-based biomaterials have emerged as promising candidates for scaffold production in artificial cartilage construction, owing to their water-rich composition, biocompatibility, and tunable properties. Nevertheless, conventional hydrogels typically lack the anisotropic structure inherent to natural cartilage, impeding their clinical and preclinical applications. Recent advancements in tissue engineering (TE) have introduced magnetically responsive hydrogels, a type of intelligent hydrogel that can be remotely controlled using an external magnetic field. These innovative materials offer a means to create the desired anisotropic architecture required for successful cartilage TE. In this review, we first explore conventional techniques employed for cartilage repair and subsequently delve into recent breakthroughs in the application and utilization of magnetic hydrogels across various aspects of articular cartilage TE.
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Affiliation(s)
- Saeed Taghizadeh
- Department of Medical Biotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Science Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Lobat Tayebi
- Marquette University School of Dentistry, Milwaukee, Wisconsin, USA
| | - Majid Akbarzadeh
- Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parvin Lohrasbi
- Department of Reproductive Biology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Savardashtaki
- Department of Medical Biotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Grzelak A, Hnydka A, Higuchi J, Michalak A, Tarczynska M, Gaweda K, Klimek K. Recent Achievements in the Development of Biomaterials Improved with Platelet Concentrates for Soft and Hard Tissue Engineering Applications. Int J Mol Sci 2024; 25:1525. [PMID: 38338805 PMCID: PMC10855389 DOI: 10.3390/ijms25031525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Platelet concentrates such as platelet-rich plasma, platelet-rich fibrin or concentrated growth factors are cost-effective autologous preparations containing various growth factors, including platelet-derived growth factor, transforming growth factor β, insulin-like growth factor 1 and vascular endothelial growth factor. For this reason, they are often used in regenerative medicine to treat wounds, nerve damage as well as cartilage and bone defects. Unfortunately, after administration, these preparations release growth factors very quickly, which lose their activity rapidly. As a consequence, this results in the need to repeat the therapy, which is associated with additional pain and discomfort for the patient. Recent research shows that combining platelet concentrates with biomaterials overcomes this problem because growth factors are released in a more sustainable manner. Moreover, this concept fits into the latest trends in tissue engineering, which include biomaterials, bioactive factors and cells. Therefore, this review presents the latest literature reports on the properties of biomaterials enriched with platelet concentrates for applications in skin, nerve, cartilage and bone tissue engineering.
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Affiliation(s)
- Agnieszka Grzelak
- Chair and Department of Biochemistry and Biotechnology, Medical University of Lublin, Chodzki Street 1, 20-093 Lublin, Poland; (A.G.); (A.H.)
| | - Aleksandra Hnydka
- Chair and Department of Biochemistry and Biotechnology, Medical University of Lublin, Chodzki Street 1, 20-093 Lublin, Poland; (A.G.); (A.H.)
| | - Julia Higuchi
- Laboratory of Nanostructures, Institute of High Pressure Physics, Polish Academy of Sciences, Prymasa Tysiaclecia Avenue 98, 01-142 Warsaw, Poland;
| | - Agnieszka Michalak
- Independent Laboratory of Behavioral Studies, Medical University of Lublin, Chodzki 4 a Street, 20-093 Lublin, Poland;
| | - Marta Tarczynska
- Department and Clinic of Orthopaedics and Traumatology, Medical University of Lublin, Jaczewskiego 8 Street, 20-090 Lublin, Poland; (M.T.); (K.G.)
- Arthros Medical Centre, Chodzki 31 Street, 20-093 Lublin, Poland
| | - Krzysztof Gaweda
- Department and Clinic of Orthopaedics and Traumatology, Medical University of Lublin, Jaczewskiego 8 Street, 20-090 Lublin, Poland; (M.T.); (K.G.)
- Arthros Medical Centre, Chodzki 31 Street, 20-093 Lublin, Poland
| | - Katarzyna Klimek
- Chair and Department of Biochemistry and Biotechnology, Medical University of Lublin, Chodzki Street 1, 20-093 Lublin, Poland; (A.G.); (A.H.)
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Makarczyk MJ. Cell Therapy Approaches for Articular Cartilage Regeneration. Organogenesis 2023; 19:2278235. [PMID: 37963189 PMCID: PMC10898818 DOI: 10.1080/15476278.2023.2278235] [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: 07/10/2023] [Accepted: 10/27/2023] [Indexed: 11/16/2023] Open
Abstract
Articular cartilage is a common cartilage type found in a multitude of joints throughout the human body. However, cartilage is limited in its regenerative capacity. A range of methods have been employed to aid adults under the age of 45 with cartilage defects, but other cartilage pathologies such as osteoarthritis are limited to non-steroidal anti-inflammatory drugs and total joint arthroplasty. Cell therapies and synthetic biology can be utilized to assist not only cartilage defects but have the potential as a therapeutic approach for osteoarthritis as well. In this review, we will cover current cell therapy approaches for cartilage defect regeneration with a focus on autologous chondrocyte implantation and matrix autologous chondrocyte implantation. We will then discuss the potential of stem cells for cartilage repair in osteoarthritis and the use of synthetic biology to genetically engineer cells to promote cartilage regeneration and potentially reverse osteoarthritis.
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Affiliation(s)
- Meagan J Makarczyk
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Shankar AN, Jeyaraman M, Jayakumar T, Jeyaraman N, Nallakumarasamy A, Pranav NG. Gel-Based Autologous Chondrocyte Implantation (GACI) in the Chondral Defects of the Knee: An Observational Study. Indian J Orthop 2023; 57:1809-1818. [PMID: 37881295 PMCID: PMC10593730 DOI: 10.1007/s43465-023-00989-1] [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] [Received: 06/13/2023] [Accepted: 08/27/2023] [Indexed: 10/27/2023]
Abstract
Introduction Gel-based autologous chondrocyte implantation (GACI) is known to have superior results when compared to conventional autologous chondrocyte implantation (ACI) in terms of delivery of chondrocytes to the articular cartilage surface with reproducible three-dimensional structural restoration. This study aims to evaluate the short-term outcomes of gel-based autologous chondrocyte implantation (GACI) for the treatment of large focal articular cartilage defects of the knee. Methods This was a prospective observational study among 25 patients who underwent GACI. Primary outcome measures included Lysholm Knee Scoring Scale and IKDC score and secondary outcome measures included MRI assessment of cartilage repair using MOCART. Results Mean age of the population was 39.8 ± 7.5 years. The study found a highly significant improvement in both Lysholm knee score (pre-op: 45.1 to post-op: 72.4) and IKDC score (pre-op: 36.7 to post-op: 78.5) (p < 0.001) at the final follow-up of 24 months, even with the mean defect size being 4.5 ± 5.8 cm2. Postoperative MRI showed a mean MOCART score improvement from 39.4 to 67.4 at the final follow-up. No major complications were observed. Conclusion GACI is an effective and safe treatment option for large focal articular cartilage defects around the knee, with significant improvement in functional scores and low revision rates at medium-term follow-up.
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Affiliation(s)
- A. Navaladi Shankar
- Department of Orthopaedics, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu India
| | - Madhan Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu India
| | - Tarun Jayakumar
- Department of Orthopaedics, KIMS-Sunshine Hospital, Hyderabad, Telangana India
| | - Naveen Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu India
| | - Arulkumar Nallakumarasamy
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu India
| | - N. Giri Pranav
- Department of Orthopaedics, Apollo Hospitals, Greams Road, Chennai, Tamil Nadu India
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Zhang Z, Mu Y, Zhou H, Yao H, Wang DA. Cartilage Tissue Engineering in Practice: Preclinical Trials, Clinical Applications, and Prospects. TISSUE ENGINEERING. PART B, REVIEWS 2023; 29:473-490. [PMID: 36964757 DOI: 10.1089/ten.teb.2022.0190] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
Articular cartilage defects significantly compromise the quality of life in the global population. Although many strategies are needed to repair articular cartilage, including microfracture, autologous osteochondral transplantation, and osteochondral allograft, the therapeutic effects remain suboptimal. In recent years, with the development of cartilage tissue engineering, scientists have continuously improved the formulations of therapeutic cells, biomaterial-based scaffolds, and biological factors, which have opened new avenues for better therapeutics of cartilage lesions. This review focuses on advances in cartilage tissue engineering, particularly in preclinical trials and clinical applications, prospects, and challenges.
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Affiliation(s)
- Zhen Zhang
- Department of Biomedical Engineering, City University of Hong Kong, Kowloon, Hong Kong SAR
| | - Yulei Mu
- Department of Biomedical Engineering, City University of Hong Kong, Kowloon, Hong Kong SAR
| | - Huiqun Zhou
- Department of Biomedical Engineering, City University of Hong Kong, Kowloon, Hong Kong SAR
| | - Hang Yao
- School of Chemistry and Chemical Engineering, Yangzhou University, Yangzhou, P.R. China
| | - Dong-An Wang
- Department of Biomedical Engineering, City University of Hong Kong, Kowloon, Hong Kong SAR
- Karolinska Institutet Ming Wai Lau Centre for Reparative Medicine, HKSTP, Sha Tin, Hong Kong SAR
- Shenzhen Research Institute, City University of Hong Kong, Shenzhen, P.R. China
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Park S, Na JY, Gwon Y, Kim W, Kang JY, Seon JK, Kim J. Transplantable stem cell nanobridge scaffolds for accelerating articular cartilage regeneration. Biomaterials 2023; 301:122287. [PMID: 37639976 DOI: 10.1016/j.biomaterials.2023.122287] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/04/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023]
Abstract
Microfracture technique for treating articular cartilage defects usually has poor clinical outcomes due to critical heterogeneity and extremely limited in quality. To improve the effects of current surgical technique (i.e., microfracture technique), we propose the transplantable stem cell nanobridge scaffold, acting as a protective bridge between host tissue and defected cartilage as well as microfracture-derived cells. Nanobridge scaffolds have a sophisticated nanoaligned structure with freestanding and flexible shapes for imposing direct structural guidance to cells including transplanted stem cells and host cells, and it can induce not only chondrocyte migration but also stem cell differentiation, maturation, and growth factor secretion. The transplantable stem cell nanobridge scaffold is capable of reconstructing the defected cartilage with homogeneous architecture and highly enhanced adhesive stress similar with native cartilage tissue by the synergistic effects of stem cells-based chondro-induction and nanotopography-based chondro-conduction. Our findings demonstrate a significant advancement in the traditional treatment technique by using a nanoengineered tool for achieving successful cartilage regeneration.
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Affiliation(s)
- Sunho Park
- Department of Convergence Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Department of Rural and Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Interdisciplinary Program in IT-Bio Convergence System, Chonnam National University, Gwangju 61186, Republic of Korea
| | - Ju Yong Na
- Department of Orthopedics, Chonnam National University Medical School & Hospital, Hwasun 58128, Republic of Korea
| | - Yonghyun Gwon
- Department of Convergence Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Department of Rural and Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Interdisciplinary Program in IT-Bio Convergence System, Chonnam National University, Gwangju 61186, Republic of Korea
| | - Woochan Kim
- Department of Convergence Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Department of Rural and Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Interdisciplinary Program in IT-Bio Convergence System, Chonnam National University, Gwangju 61186, Republic of Korea
| | - Ju Yeon Kang
- Department of Orthopedics, Chonnam National University Medical School & Hospital, Hwasun 58128, Republic of Korea
| | - Jong Keun Seon
- Department of Orthopedics, Chonnam National University Medical School & Hospital, Hwasun 58128, Republic of Korea.
| | - Jangho Kim
- Department of Convergence Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Department of Rural and Biosystems Engineering, Chonnam National University, Gwangju, 61186, Republic of Korea; Interdisciplinary Program in IT-Bio Convergence System, Chonnam National University, Gwangju 61186, Republic of Korea; Institute of Nano-Stem Cells Therapeutics, NANOBIOSYSTEM Co., Ltd, Gwangju, Republic of Korea.
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Seewoonarain S, Ganesh D, Perera E, Popat R, Jones J, Sugand K, Gupte C. Scaffold-associated procedures are superior to microfracture in managing focal cartilage defects in the knee: A systematic review & meta-analysis. Knee 2023; 42:320-338. [PMID: 37148615 DOI: 10.1016/j.knee.2023.04.001] [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] [Received: 07/23/2022] [Revised: 01/10/2023] [Accepted: 04/02/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Debate continues as to whether surgical treatment with chondral-regeneration devices is superior to microfracture for focal articular cartilage defects in the knee. PURPOSE To evaluate the superiority of scaffold-associated chondral-regeneration procedures over microfracture by assessing: (1) Patient-reported outcomes; (2) Intervention failure; (3) Histological quality of cartilage repair. STUDY DESIGN A three-concept keyword search strategy was designed, in accordance with PRISMA guidelines: (i) knee (ii) microfracture (iii) scaffold. Four databases (Ovid Medline, Embase, CINAHL and Scopus) were searched for comparative clinical trials (Level I-III evidence). Critical appraisal used two Cochrane tools: the Risk of Bias tool (RoB2) for randomized control trials and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I). Study heterogeneity permitted qualitative analysis with the exception of three patient-reported scores, for which a meta-analysis was performed. RESULTS Twenty-one studies were identified (1699 patients, age range 18-66 years): ten randomized control trials and eleven non-randomized study interventions. Meta-analyses of the International Knee Documentation Committee (IKDC), Knee Injury And Osteoarthritis Outcome Score (KOOS) for pain and activities of daily living, and Lysholm score demonstrated statistically significant improvement in outcomes for scaffold procedures compared to microfracture at two years. No statistical difference was seen at five years. CONCLUSION Despite the limitations of study heterogeneity, scaffold-associated procedures appear to be superior to MF in terms of patient-reported outcomes at two years though similar at five years. Future evaluation would benefit from studies using validated clinical scoring systems, reporting failure, adverse events and long-term clinical follow up to determine technique safety and superiority.
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Affiliation(s)
- Sheena Seewoonarain
- MsK Lab, Dept of Medicine and Surgery, Sir Michael Uren Hub, Imperial College, London W12 0BZ, United Kingdom
| | - Divolka Ganesh
- MsK Lab, Dept of Medicine and Surgery, Sir Michael Uren Hub, Imperial College, London W12 0BZ, United Kingdom.
| | - Edward Perera
- MsK Lab, Dept of Medicine and Surgery, Sir Michael Uren Hub, Imperial College, London W12 0BZ, United Kingdom.
| | - Ravi Popat
- MsK Lab, Dept of Medicine and Surgery, Sir Michael Uren Hub, Imperial College, London W12 0BZ, United Kingdom.
| | - Julian Jones
- MsK Lab, Dept of Medicine and Surgery, Sir Michael Uren Hub, Imperial College, London W12 0BZ, United Kingdom.
| | - Kapil Sugand
- MsK Lab, Dept of Medicine and Surgery, Sir Michael Uren Hub, Imperial College, London W12 0BZ, United Kingdom.
| | - Chinmay Gupte
- MsK Lab, Dept of Medicine and Surgery, Sir Michael Uren Hub, Imperial College, London W12 0BZ, United Kingdom.
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13
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Snow M, Middleton L, Mehta S, Roberts A, Gray R, Richardson J, Kuiper JH, Smith A, White S, Roberts S, Griffiths D, Mohammed A, Moholkar K, Ashraf T, Green M, Hutchinson J, Bhullar T, Chitnis S, Shaw A, van Niekerk L, Hui A, Drogset JO, Knutsen G, McNicholas M, Bowditch M, Johnson D, Turner P, Chugh S, Hunt N, Ali S, Palmer S, Perry A, Davidson A, Hill P, Deo S, Satish V, Radford M, Langstaff R, Houlihan-Burne D, Spicer D, Phaltankar P, Hegab A, Marsh D, Cannon S, Briggs T, Pollock R, Carrington R, Skinner J, Bentley G, Price A, Schranz P, Mandalia V, O'Brien S. A Randomized Trial of Autologous Chondrocyte Implantation Versus Alternative Forms of Surgical Cartilage Management in Patients With a Failed Primary Treatment for Chondral or Osteochondral Defects in the Knee. Am J Sports Med 2023; 51:367-378. [PMID: 36661257 DOI: 10.1177/03635465221141907] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. PURPOSE To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. RESULTS Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, -1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation (P = .03; 6.4 points in favor of ACI; 95% CI, -0.4 to 13.1). More participants experienced a serious adverse event with ACI (P = .02). CONCLUSION Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. REGISTRATION International Standard Randomised Controlled Trial Number: 48911177.
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Affiliation(s)
- Martyn Snow
- Orthopaedics Department, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK; School of Pharmacy and Bioengineering, Keele University, Staffordshire, UK
| | - Lee Middleton
- Birmingham Clinical Trials Unit, Birmingham University, Midlands, UK
| | - Samir Mehta
- Birmingham Clinical Trials Unit, Birmingham University, Midlands, UK
| | - Andrew Roberts
- Orthopaedics Department, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK
| | - Richard Gray
- Nuffield Department of Population Health, Oxford University, Oxfordshire, UK
| | - James Richardson
- Orthopaedics Department, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK; School of Pharmacy and Bioengineering, Keele University, Staffordshire, UK
| | - Jan Herman Kuiper
- School of Pharmacy and Bioengineering, Keele University, Staffordshire, UK
| | | | - Anthony Smith
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry
| | - Steve White
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry
| | - Simon Roberts
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry
| | - David Griffiths
- County Hospital, Stafford, University Hospitals of North Midlands NHS Trust, Stoke
| | - Aslam Mohammed
- Wrightington Wigan and Leigh teaching hospitals NHSFT, Wigan
| | | | | | - Marcus Green
- Royal Orthopaedic Hospital Birmingham, Birmingham
| | - James Hutchinson
- Edith Cavell Hospital Peterborough [now Peterborough City Hospital], NW Anglia NHSFT, Peterborough
| | - Tony Bhullar
- Edith Cavell Hospital Peterborough [now Peterborough City Hospital], NW Anglia NHSFT, Peterborough
| | | | - Andrew Shaw
- Royal Alexandra Hospital, Paisley; NHS Greater Glasgow and Clyde, Paisley
| | - Louw van Niekerk
- Friarage Hospital, South Tees; South Tees Hospitals NHSFT, Northallerton
| | - Anthony Hui
- The James Cook University Hospital, Middlesborough; South Tees Hospitals NHSFT, Middlesborough
| | | | | | | | - Mark Bowditch
- Ipswich Hospital, East Suffolk and North Essex NHSFT, Ipswich
| | | | | | - Sanjiv Chugh
- New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton
| | - Neil Hunt
- York Hospital, York and Scarborough Teaching Hospitals NHSFT, York
| | - Salman Ali
- Russels Hall Hospital, The Dudley Group NHSFT, Dudley
| | - Simon Palmer
- Worthing Hospital, University Hospitals Sussex NHSFT, Worthing
| | - Andrew Perry
- Frimley Park Hospital, Frimley Health NHSFT, Frimley Park
| | | | - Peter Hill
- Frimley Park Hospital, Frimley Health NHSFT, Frimley Park
| | - Sunny Deo
- The Great Western Hospitals NHSFT, Swindon
| | | | - Michael Radford
- Weston General Hospital, Weston Area Health NHS Trust, Weston-Super-Mare
| | - Ron Langstaff
- Hillingdon Hospital, The Hillingdon Hospitals NHSFT, Hillingdon
| | | | - Dominic Spicer
- St Mary's Hospital, Imperial College Healthcare NHS Trust, Paddington
| | - Padman Phaltankar
- North Manchester General Hospital, Manchester University NHSFT, Manchester
| | - Ahmed Hegab
- Fairfield General Hospital, Northern Care Alliance NHSFT, Bury
| | - David Marsh
- The Royal National Orthopaedic Hospital Stanmore, Stanmore
| | - Steve Cannon
- The Royal National Orthopaedic Hospital Stanmore, Stanmore
| | - Tim Briggs
- The Royal National Orthopaedic Hospital Stanmore, Stanmore
| | - Rob Pollock
- The Royal National Orthopaedic Hospital Stanmore, Stanmore
| | | | - John Skinner
- The Royal National Orthopaedic Hospital Stanmore, Stanmore
| | - George Bentley
- The Royal National Orthopaedic Hospital Stanmore, Stanmore
| | - Andrew Price
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHSFT, Oxford
| | | | | | - Shaun O'Brien
- Sunderland Royal Hospital, South Tyneside and Sunderland NHSFT, Sunderland.,Investigation performed at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK
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14
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Zhou Z, Zheng J, Meng X, Wang F. Effects of Electrical Stimulation on Articular Cartilage Regeneration with a Focus on Piezoelectric Biomaterials for Articular Cartilage Tissue Repair and Engineering. Int J Mol Sci 2023; 24:ijms24031836. [PMID: 36768157 PMCID: PMC9915254 DOI: 10.3390/ijms24031836] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
There is increasing evidence that chondrocytes within articular cartilage are affected by endogenous force-related electrical potentials. Furthermore, electrical stimulation (ES) promotes the proliferation of chondrocytes and the synthesis of extracellular matrix (ECM) molecules, which accelerate the healing of cartilage defects. These findings suggest the potential application of ES in cartilage repair. In this review, we summarize the pathogenesis of articular cartilage injuries and the current clinical strategies for the treatment of articular cartilage injuries. We then focus on the application of ES in the repair of articular cartilage in vivo. The ES-induced chondrogenic differentiation of mesenchymal stem cells (MSCs) and its potential regulatory mechanism are discussed in detail. In addition, we discuss the potential of applying piezoelectric materials in the process of constructing engineering articular cartilage, highlighting the important advances in the unique field of tissue engineering.
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Affiliation(s)
- Zhengjie Zhou
- The Key Laboratory of Pathobiology Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
| | - Jingtong Zheng
- The Key Laboratory of Pathobiology Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
| | - Xiaoting Meng
- Department of Histology & Embryology, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
- Correspondence: (X.M.); (F.W.); Tel.: +86-0431-8561-9486 (X.M. & F.W.)
| | - Fang Wang
- The Key Laboratory of Pathobiology Ministry of Education, College of Basic Medical Sciences, Jilin University, Changchun 130021, China
- Correspondence: (X.M.); (F.W.); Tel.: +86-0431-8561-9486 (X.M. & F.W.)
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15
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Browe DC, Burdis R, Díaz-Payno PJ, Freeman FE, Nulty JM, Buckley CT, Brama PA, Kelly DJ. Promoting endogenous articular cartilage regeneration using extracellular matrix scaffolds. Mater Today Bio 2022; 16:100343. [PMID: 35865410 PMCID: PMC9294195 DOI: 10.1016/j.mtbio.2022.100343] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 12/13/2022] Open
Abstract
Articular cartilage defects fail to heal spontaneously, typically progressing to osteoarthritis. Bone marrow stimulation techniques such as microfracture (MFX) are the current surgical standard of care; however MFX typically produces an inferior fibro-cartilaginous tissue which provides only temporary symptomatic relief. Here we implanted solubilised articular cartilage extracellular matrix (ECM) derived scaffolds into critically sized chondral defects in goats, securely anchoring these implants to the joint surface using a 3D-printed fixation device that overcame the need for sutures or glues. In vitro these ECM scaffolds were found to be inherently chondro-inductive, while in vivo they promoted superior articular cartilage regeneration compared to microfracture. In an attempt to further improve the quality of repair, we loaded these scaffolds with a known chemotactic factor, transforming growth factor (TGF)-β3. In vivo such TGF-β3 loaded scaffolds promoted superior articular cartilage regeneration. This study demonstrates that ECM derived biomaterials, either alone and particularly when combined with exogenous growth factors, can successfully treat articular cartilage defects in a clinically relevant large animal model.
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Affiliation(s)
- David C. Browe
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Department of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, Ireland
| | - Ross Burdis
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Department of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, Ireland
| | - Pedro J. Díaz-Payno
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Department of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, Ireland
| | - Fiona E. Freeman
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Department of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, Ireland
- Institute for Medical Engineering and Science Massachusetts Institute of Technology Cambridge, MA, 02142, USA
- Department of Medicine Division of Engineering in Medicine Brigham and Women’s Hospital Harvard Medical School Boston, MA, 02115, USA
| | - Jessica M. Nulty
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Department of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, Ireland
| | - Conor T. Buckley
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Department of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, Ireland
- Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pieter A.J. Brama
- Section of Veterinary Clinical Sciences, School of Veterinary Medicine, University College Dublin, Ireland
| | - Daniel J. Kelly
- Trinity Centre for Biomedical Engineering, Trinity Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Department of Mechanical, Manufacturing and Biomedical Engineering, School of Engineering, Trinity College Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, Ireland
- Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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16
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Angele P, Zellner J, Schröter S, Flechtenmacher J, Fritz J, Niemeyer P. Biological Reconstruction of Localized Full-Thickness Cartilage Defects of the Knee: A Systematic Review of Level 1 Studies with a Minimum Follow-Up of 5 Years. Cartilage 2022; 13:5-18. [PMID: 36250517 PMCID: PMC9924981 DOI: 10.1177/19476035221129571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the best available mid- to long-term evidence of surgical procedures for the treatment of localized full-thickness cartilage defects of the knee. DESIGN Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of Level 1 randomized clinical trials (RCTs), meta-analyses of RCTs and systematic reviews with a minimum follow-up of 5 years. Data extracted included patient demographics, defect characteristics, clinical and radiological outcomes, as well as treatment failures. RESULTS Six RCTs and 3 Level 1 systematic reviews were included. Two RCTs compared microfracture (MFx) to periosteum-covered autologous chondrocyte implantation (ACI-P), 1 to matrix-associated ACI (M-ACI) and 2 to osteochondral autograft transplantation (OAT). One study compared OAT to collagen membrane covered ACI (ACI-C). The 3 Level 1 systematic reviews/meta-analyses assessed the outcome of MFx, OAT, and various ACI methods in RCTs. OAT showed significantly better outcomes compared with MFx. In the 2 RCTs comparing ACI-P and MFx, no significant differences in clinical outcomes were seen, whereas significantly better outcomes were reported for M-ACI versus MFx in 1 study including patients with larger defects (5 cm2), and for ACI-C versus OAT in terms of Cincinnati Score. Higher failure rates were reported for MFx compared with OAT and for OAT compared with ACI-C, while no significant differences in failure rates were observed for ACI-P compared to MFx. CONCLUSION Restorative cartilage procedures (ACI-C or M-ACI and OAT) are associated with better long-term clinical outcomes including lower complication and failure rates when compared with reparative techniques (MFx). Among the restorative procedures, OAT seems to be inferior to ACI especially in larger defects after longer follow-up periods. LEVEL OF EVIDENCE Level I: Systematic review of Level I studies.
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Affiliation(s)
- Peter Angele
- Sporthopaedicum Regensburg, Regensburg,
Germany,Klinik für Unfall- und
Wiederherstellungschirurgie, Universitätsklinikum Regensburg, Regensburg,
Germany,Peter Angele, Sporthopaedicum Regensburg,
Hildegard-von-Bingen-Strasse 1, 93053 Regensburg, Germany.
| | | | - Steffen Schröter
- Abteilung für Unfall- und
Wiederherstellungschirurgie, Jung-Stilling Krankenhaus, Diakonie Klinikum GmbH,
Siegen, Germany
| | | | - Jürgen Fritz
- Orthopädisch Chirurgisches Centrum,
Tübingen, Germany
| | - Philipp Niemeyer
- OCM—Orthopädische Chirurgie München,
München, Germany,Klinik für Orthopädie und
Traumatologie, Universitätsklinikum Freiburg, Freiburg, Germany
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17
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Faber S, Niemeyer P, Fickert S. Knorpelersatzverfahren und Regeneration am Knie- und
Hüftgelenk. PHYSIKALISCHE MEDIZIN, REHABILITATIONSMEDIZIN, KURORTMEDIZIN 2022. [DOI: 10.1055/a-1821-7068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Die operative Therapie von Knorpelschäden am Kniegelenk hat sich in den
letzten Jahren von vorsichtigen Anfängen mit innovativen
Therapieansätzen zu einem festen und etablierten Baustein der
gelenkerhaltenden Therapie entwickelt. Hingegen hat sich am Hüftgelenk
erst in den letzten 10 Jahren, basierend auf einem erweiterten
Verständnis grundlegender mechanischer Pathomechanismen, die
gelenkerhaltende Hüftchirurgie und insbesondere die Knorpeltherapie
etabliert. Der Beitrag stellt die zur Verfügung stehenden Techniken
vor.
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18
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Neunaber C, Dalinghaus C, Bundkirchen K, Toumpaniari S, Gladitz LM, Joda A, Morticelli L, Krettek C, Korossis S. Towards the development of osteochondral allografts with reduced immunogenicity. J Mech Behav Biomed Mater 2022; 133:105359. [PMID: 35841749 DOI: 10.1016/j.jmbbm.2022.105359] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 06/30/2022] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
Nowadays, repair and replacement of hyaline articular cartilage still challenges orthopedic surgery. Using a graft of decellularized articular cartilage as a structural scaffold is considered as a promising therapy. So far, successful cell removal has only been possible for small samples with destruction of the macrostructure or loss of biomechanics. Our aim was to develop a mild, enzyme-free chemical decellularization procedure while preserving the biomechanical properties of cartilage. Porcine osteochondral cylinders (diameter: 12 mm; height: 10 mm) were divided into four groups: Native plugs (NA), decellularized plugs treated with PBS, Triton-X-100 and SDS (DC), and plugs additionally treated with freeze-thaw-cycles of -20 °C, -80 °C or shock freezing in nitrogen (N2) before decellularization. In a non-decalcified HE stain the decellularization efficiency (cell removal, cell size, depth of decellularization) was calculated. For biomechanics the elastic and compression modulus, transition and failure strain as well as transition and failure stress were evaluated. The -20 °C, -80 °C, and N2 groups showed a complete decellularization of the superficial and middle zone. In the deep zone cells could not be removed in any experimental group. The biomechanical analysis showed only a reduced elastic modulus in all decellularized samples. No significant differences were found for the other biomechanical parameters.
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Affiliation(s)
- Claudia Neunaber
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Catharina Dalinghaus
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Katrin Bundkirchen
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Sotiria Toumpaniari
- Cardiopulmonary Regenerative Engineering (CARE) Group, Centre for Biological Engineering, Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Holywell Park, Loughborough University, LE11 3TU, Loughborough, UK.
| | - Luisa Marilena Gladitz
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Akram Joda
- Cardiopulmonary Regenerative Engineering (CARE) Group, Centre for Biological Engineering, Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Holywell Park, Loughborough University, LE11 3TU, Loughborough, UK; Higher Colleges of Technology, Faculty of Engineering Technology and Science, Dubai, United Arab Emirates.
| | - Lucrezia Morticelli
- Lower Saxony Centre for Biomedical Engineering Implant Research & Development, Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany.
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Sotirios Korossis
- Cardiopulmonary Regenerative Engineering (CARE) Group, Centre for Biological Engineering, Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Holywell Park, Loughborough University, LE11 3TU, Loughborough, UK; Lower Saxony Centre for Biomedical Engineering Implant Research & Development, Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany; Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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19
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Klimek K, Benko A, Vandrovcova M, Travnickova M, Douglas TEL, Tarczynska M, Broz A, Gaweda K, Ginalska G, Bacakova L. Biomimetic biphasic curdlan-based scaffold for osteochondral tissue engineering applications - Characterization and preliminary evaluation of mesenchymal stem cell response in vitro. BIOMATERIALS ADVANCES 2022; 135:212724. [PMID: 35929204 DOI: 10.1016/j.bioadv.2022.212724] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 06/15/2023]
Abstract
Osteochondral defects remain a huge problem in medicine today. Biomimetic bi- or multi-phasic scaffolds constitute a very promising alternative to osteochondral autografts and allografts. In this study, a new curdlan-based scaffold was designed for osteochondral tissue engineering applications. To achieve biomimetic properties, it was enriched with a protein component - whey protein isolate as well as a ceramic ingredient - hydroxyapatite granules. The scaffold was fabricated via a simple and cost-efficient method, which represents a significant advantage. Importantly, this technique allowed generation of a scaffold with two distinct, but integrated phases. Scanning electron microcopy and optical profilometry observations demonstrated that phases of biomaterial possessed different structural properties. The top layer of the biomaterial (mimicking the cartilage) was smoother than the bottom one (mimicking the subchondral bone), which is beneficial from a biological point of view because unlike bone, cartilage is a smooth tissue. Moreover, mechanical testing showed that the top layer of the biomaterial had mechanical properties close to those of natural cartilage. Although the mechanical properties of the bottom layer of scaffold were lower than those of the subchondral bone, it was still higher than in many analogous systems. Most importantly, cell culture experiments indicated that the biomaterial possessed high cytocompatibility towards adipose tissue-derived mesenchymal stem cells and bone marrow-derived mesenchymal stem cells in vitro. Both phases of the scaffold enhanced cell adhesion, proliferation, and chondrogenic differentiation of stem cells (revealing its chondroinductive properties in vitro) as well as osteogenic differentiation of these cells (revealing its osteoinductive properties in vitro). Given all features of the novel curdlan-based scaffold, it is worth noting that it may be considered as promising candidate for osteochondral tissue engineering applications.
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Affiliation(s)
- Katarzyna Klimek
- Medical University of Lublin, Chair and Department of Biochemistry and Biotechnology, Chodzki 1 Street, 20-093 Lublin, Poland.
| | - Aleksandra Benko
- AGH University of Science and Technology, Faculty of Materials Science and Ceramics, 30 A. Mickiewicza Av., 30-059 Krakow, Poland
| | - Marta Vandrovcova
- Institute of Physiology of the Czech Academy of Sciences, Laboratory of Biomaterials and Tissue Engineering, Videnska 1083 Street, 14220 Prague, Czech Republic
| | - Martina Travnickova
- Institute of Physiology of the Czech Academy of Sciences, Laboratory of Biomaterials and Tissue Engineering, Videnska 1083 Street, 14220 Prague, Czech Republic
| | - Timothy E L Douglas
- Engineering Department, Lancaster University, Gillow Avenue, LA1 4YW Lancaster, United Kingdom; Materials Science Institute (MSI), Lancaster University, Lancaster, United Kingdom
| | - Marta Tarczynska
- Medical University of Lublin, Department and Clinic of Orthopaedics and Traumatology, Jaczewskiego 8 Street, 20-090 Lublin, Poland
| | - Antonin Broz
- Institute of Physiology of the Czech Academy of Sciences, Laboratory of Biomaterials and Tissue Engineering, Videnska 1083 Street, 14220 Prague, Czech Republic
| | - Krzysztof Gaweda
- Medical University of Lublin, Department and Clinic of Orthopaedics and Traumatology, Jaczewskiego 8 Street, 20-090 Lublin, Poland
| | - Grazyna Ginalska
- Medical University of Lublin, Chair and Department of Biochemistry and Biotechnology, Chodzki 1 Street, 20-093 Lublin, Poland
| | - Lucie Bacakova
- Institute of Physiology of the Czech Academy of Sciences, Laboratory of Biomaterials and Tissue Engineering, Videnska 1083 Street, 14220 Prague, Czech Republic
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20
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Anders S, Grifka J. [Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]. DER ORTHOPADE 2022; 51:151-164. [PMID: 35076725 DOI: 10.1007/s00132-022-04220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.
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Affiliation(s)
- S Anders
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - J Grifka
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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21
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Anders S, Grifka J. [Surgical treatment of focal cartilage defects in the knee : Indications, techniques, modifications and results]. Z Rheumatol 2021; 80:855-867. [PMID: 34581873 DOI: 10.1007/s00393-021-01084-2] [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] [Accepted: 08/19/2021] [Indexed: 11/27/2022]
Abstract
The treatment strategies for focal cartilage damage in the knee are multifarious. For established procedures, such as microfracturing (MFX), autologous matrix-induced chondrogenesis (AMIC), osteochondral transplantation (OCT) and autologous chondrocyte transplantation (ACT), well-founded, partly comparative long-term studies and overlapping size-dependent differential indications are available. Innovative cell sources, the utilization of biological scaffolds as well as biologic agents and various combinations, have recently become the focus of scientific attention; however, high regulatory demands are restricting their use in Germany. The success of every procedure is dependent on the appropriate indications, the treatment of comorbidities, such as axis deviations or ligamentous instability, the surgeon's experience and an adequate follow-up treatment.
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Affiliation(s)
- S Anders
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - J Grifka
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
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22
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Aoqierbatu, Luo A, Shi Y, Na Y, Tuo Y. Microarray analysis of hub genes and pathways in damaged cartilage tissues of knee. Medicine (Baltimore) 2021; 100:e27183. [PMID: 34664844 PMCID: PMC8448002 DOI: 10.1097/md.0000000000027183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 08/21/2021] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to identify genes and functional pathways associated with damaged cartilage tissues of knee using microarray analysis.The gene expression profile GSE129147 including including 10 knee cartilage tissues from damaged side and 10 knee nonweight-bearing healthy cartilage was downloaded and bioinformatics analysis was made.A total of 182 differentially-expressed genes including 123 up-regulated and 59 down-regulated genes were identified from the GSE129147 dataset. Gene ontology and pathway enrichment analysis confirmed that extracellular matrix organization, collagen catabolic process, antigen processing and presentation of peptide or polysaccharide antigen, and endocytic vesicle membrane were strongly associated with cartilage injury. Furthermore, 10 hub differentially-expressed genes with a higher connectivity degree in protein-protein interactions network were found such as POSTN, FBN1, LOX, insulin-like growth factor binding proteins3, C3AR1, MMP2, ITGAM, CDKN2A, COL1A1, COL5A1.These hub genes and pathways provide a new perspective for revealing the potential pathological mechanisms and therapy strategy of cartilage injury.
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Affiliation(s)
- Aoqierbatu
- Department of Mongolian Osteopath, International Hospital of Mongolian Medicine, Saihan District, Hohhot, Inner Mongolia Autonomous Region, China
| | - Aqilatu Luo
- Department of Mongolian Osteopath, International Hospital of Mongolian Medicine, Saihan District, Hohhot, Inner Mongolia Autonomous Region, China
| | - Yuting Shi
- Cardiac Function Department, Cadre Health Care Center, Inner Mongolia Autonomous Region People's Hospital, Saihan District, Hohhot, Inner Mongolia Autonomous Region, China
| | - Yuyan Na
- Department of Arthroscopy and Sports Medicine, the Second Affiliated Hospital of Inner Mongolia Medical University, Huimin District, Hohhot, Inner Mongolia Autonomous Region, China
| | - Ya Tuo
- Department of Anesthesia, the Second Affiliated Hospital of Inner Mongolia Medical University, Huimin District, Hohhot, Inner Mongolia Autonomous Region, China
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23
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Ajeeb B, Acar H, Detamore MS. Chondroinductive Peptides for Cartilage Regeneration. TISSUE ENGINEERING PART B-REVIEWS 2021; 28:745-765. [PMID: 34375146 DOI: 10.1089/ten.teb.2021.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Inducing and maintaining a hyaline cartilage phenotype is the greatest challenge for cartilage regeneration. Synthetic chondroinductive biomaterials might be the answer to the unmet clinical need for a safe, stable, and cost-effective material capable of inducing true hyaline cartilage formation. The past decade witnessed an emergence of peptides to achieve chondrogenesis, as peptides have the advantages of versatility, high target specificity, minimized toxicity and immunogenicity, and ease of synthesis. Here, we review peptides as the basis for creating promising synthetic chondroinductive biomaterials for in situ scaffold-based cartilage regeneration. We provide a thorough review of peptides evaluated for cartilage regeneration while distinguishing between peptides reported to induce chondrogenesis independently, and peptides reported to act in synergy with other growth factors to induce cartilage regeneration. Additionally, we highlight that most peptide studies have been in vitro, and appropriate controls are not always present. A few rigorously-performed in vitro studies have proceeded to in vivo studies, but the peptides in those in vivo studies were mainly introduced via systemic, subcutaneous, or intraarticular injections, with a paucity of studies employing in situ defects with appropriate controls. Clinical translation of peptides will require the evaluation of these peptides in well-controlled in vivo cartilage defect studies. In the decade ahead, we may be poised to leverage peptides to design devices that are safe, reproducible, cost-efficient, and scalable biomaterials, which are themselves chondroinductive to achieve true hyaline cartilage regeneration without the need for growth factors and other small molecules.
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Affiliation(s)
- Boushra Ajeeb
- University of Oklahoma, 6187, Biomedical Engineering, Norman, Oklahoma, United States;
| | - Handan Acar
- University of Oklahoma, 6187, Biomedical Engineering, Norman, Oklahoma, United States;
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24
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Schreiner AJ, Stannard JP, Stoker AM, Bozynski CC, Kuroki K, Cook CR, Cook JL. Unicompartmental bipolar osteochondral and meniscal allograft transplantation is effective for treatment of medial compartment gonarthrosis in a canine model. J Orthop Res 2021; 39:1093-1102. [PMID: 32672863 DOI: 10.1002/jor.24801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/29/2020] [Accepted: 07/13/2020] [Indexed: 02/04/2023]
Abstract
Osteochondral allograft (OCA) transplantation can restore large articular defects in the knee. Bipolar OCA transplantations for partial and whole joint resurfacing often have less favorable results than single-surface transplants. This study was designed to use a large animal model to test the hypothesis that unicompartmental bipolar osteochondral and meniscal allograft transplantation (BioJoint) would be as or more effective for treatment of medial compartment osteoarthritis (OA) compared to standard-of-care nonoperative treatment. OA was induced in one knee of each research hound (n = 8) using a meniscal release model and pretreatment assessments were performed. After 3 months, dogs were randomly assigned to either the control group (n = 4, no surgical intervention, daily nonsteroidal antiinflammatory drugs [NSAIDs]) or the BioJoint group (n = 4). Clinical, radiographic, and arthroscopic assessments were performed longitudinally and histopathology was evaluated at the 6-month endpoint. At study endpoint, functional, pain, and total pressure index measures, as well as radiographic and arthroscopic grading of graft appearance and joint health, demonstrated superior outcomes for BioJoints compared to NSAID controls. Furthermore, histologic assessments showed that osteochondral and meniscal transplants maintain integrity and integrated into host tissues. Clinical significance: The results support the safety and efficacy of unicompartmental bipolar osteochondral and meniscal allograft transplantation in a preclinical model with highly functional outcomes without early OA progression.
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Affiliation(s)
- Anna J Schreiner
- Thompson Laboratory for Regenerative Orthopaedics, Orthopaedic Research Division, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Trauma and Reconstructive Surgery, BG Center for Trauma and Reconstructive Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - James P Stannard
- Thompson Laboratory for Regenerative Orthopaedics, Orthopaedic Research Division, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Aaron M Stoker
- Thompson Laboratory for Regenerative Orthopaedics, Orthopaedic Research Division, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Chantelle C Bozynski
- Thompson Laboratory for Regenerative Orthopaedics, Orthopaedic Research Division, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Keiichi Kuroki
- Thompson Laboratory for Regenerative Orthopaedics, Orthopaedic Research Division, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - Cristi R Cook
- Thompson Laboratory for Regenerative Orthopaedics, Orthopaedic Research Division, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, Orthopaedic Research Division, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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25
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Zhu J, Fu Q, Shao J, Jinhui Peng, Qian Q, Zhou Y, Yi Chen. Regulating effect of Circ_ATRNL1 on the promotion of SOX9 expression to promote chondrogenic differentiation of hAMSCs mediated by MiR-145-5p. J Tissue Eng Regen Med 2021; 15:487-502. [PMID: 33734580 DOI: 10.1002/term.3189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 03/01/2021] [Indexed: 01/08/2023]
Abstract
Circ_ATRNL1 is significantly highly expressed in cartilage tissues of patients with osteoarthritis. This study explored the role and mechanism of circ_ATRNL1 in cartilage differentiation of human adipose-derived mesenchymal stem cells (hAMSCs). hAMSCs were isolated and identified by flow cytometry. The degree of chondrocyte and adipogenic differentiation was assessed using Alcian blue staining and Oil Red O staining, respectively. The expressions of cartilage- and adipogenic-related genes, circ_ATRNL1, and SOX9 were detected by reverse transcription quantitative polymerase chain reaction. The correlation between SOX9 and circ_ATRNL1 was analyzed using Pearson test. Bioinformatics and luciferase analysis were used to detect the overlapped target miRNAs of circ_ATRNL1 and SOX9. The role of circ_ATRNL1/miRNA/SOX9 was examined using functional rescue assays. hAMSCs were identified as CD90-, CD105-, and CD44-positive. The degree of cartilage differentiation of hAMSCs was significantly enhanced after 2 weeks. Cartilage-related genes, circ_ATRNL1 and SOX9, were significantly upregulated, and positively correlated with each other. Circ_ATRNL1 overexpression enhanced hAMSC proliferation and differentiation into chondrogenesis, and promoted the expressions of COL2, Aggrecan, and SOX9. Overexpression of circ_ATRNL1 inhibited the adipogenic differentiation of hAMSCs and the expressions of adipogenic-related genes. miR-145-5p was a target miRNA for circ_ATRNL1 and SOX9. miR-145-5p mimic inhibited hAMSC differentiation toward cartilage, and inhibited the expression of cartilage-related factors. miR-145-5p mimic effectively reversed the regulating effect of circ_ATRNL1 on hAMSCs. Circ_ATRNL1 regulates the promotion of SOX9 expression to promote chondrogenic differentiation of hAMSCs mediated by miR-145-5p.
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Affiliation(s)
- Jun Zhu
- Department of Joint Surgery and Orthopedic Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Qiwei Fu
- Department of Joint Surgery and Orthopedic Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Jiahua Shao
- Department of Joint Surgery and Orthopedic Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Jinhui Peng
- Department of Joint Surgery and Orthopedic Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Qirong Qian
- Department of Joint Surgery and Orthopedic Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Yiqin Zhou
- Department of Joint Surgery and Orthopedic Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Yi Chen
- Department of Joint Surgery and Orthopedic Medicine, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
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26
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Kon E, Di Matteo B, Verdonk P, Drobnic M, Dulic O, Gavrilovic G, Patrascu JM, Zaslav K, Kwiatkowski G, Altschuler N, Robinson D. Aragonite-Based Scaffold for the Treatment of Joint Surface Lesions in Mild to Moderate Osteoarthritic Knees: Results of a 2-Year Multicenter Prospective Study. Am J Sports Med 2021; 49:588-598. [PMID: 33481631 DOI: 10.1177/0363546520981750] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Osteoarthritis (OA) is considered a contraindication to most cartilage repair techniques. Several regenerative approaches have been attempted with the aim of delaying or preventing joint replacement, with controversial results. Currently, there is a paucity of data on the use of single-step techniques, such as cell-free biomimetic scaffolds, for the treatment of joint surface lesions (JSLs) in OA knees. PURPOSE To present the 2-year follow-up clinical and radiological outcomes after implantation of a novel, cell-free aragonite-based scaffold for the treatment of JSLs in patients with mild to moderate knee OA in a multicenter prospective study. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 86 patients, 60 male and 26 female, with a mean age of 37.4 ± 10.0 years, mild to moderate knee OA, and a mean defect size of 3.0 ± 1.7 cm2, were recruited at 8 medical centers according to the following criteria: radiographic mild to moderate knee OA (Kellgren-Lawrence grade 2 or 3); up to 3 treatable chondral/osteochondral defects (International Cartilage Repair Society grades 3 and 4) on the femoral condyles or trochlea; a total defect size ≤7 cm2; and no concurrent knee instability, severe axial malalignment, or systemic arthropathy. All patients were evaluated at baseline and at 6, 12, 18, and 24 months after implantation using the Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective score. Additionally, magnetic resonance imaging (MRI) was performed to assess the amount of cartilage defect filling at the repaired site. RESULTS Significant improvement on all KOOS subscales was recorded from baseline (Pain: 49.6 ± 13.1; Activities of Daily Living [ADL]: 56.1 ± 18.4; Sport: 22.8 ± 18.8; Quality of Life [QoL]: 23.5 ± 16.5; Symptoms: 55.4 ± 19.9) to the 24 months' follow-up (Pain: 79.5 ± 21.1 [P < .001]; ADL: 84.1 ± 21.4 [P < .001]; Sport: 60.8 ± 31.9 [P < .001]; QoL: 54.9 ± 30.4 [P < .001]; Symptoms: 77.7 ± 21.2 [P < .001]). The IKDC subjective score showed a similar trend and improved from 37.8 ± 14.7 at baseline to 65.8 ± 23.5 at 24 months (P < .001). MRI showed a significant increase in defect filling over time: up to 78.7% ± 25.3% of surface coverage after 24 months. Treatment failure requiring revision surgery occurred in 8 patients (9.3%). CONCLUSION The use of an aragonite-based osteochondral scaffold in patients with JSLs and mild to moderate knee OA provided significant clinical improvement at the 24-month follow-up, as reported by the patients. These findings were associated with good cartilage defect filling, as observed on MRI.
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Affiliation(s)
- Elizaveta Kon
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center, IRCCS, Milan, Italy.,First Moscow State Medical University, Sechenov University, Moscow, Russia
| | - Peter Verdonk
- ORTHOCA, AZ Monica, Antwerp, Belgium.,Department of Orthopaedic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Matej Drobnic
- Department of Orthopedic Surgery, Ljubljana University Medical Centre, Ljubljana, Slovenia
| | - Oliver Dulic
- Department of Orthopedic Surgery and Traumatology, Clinical Center of Vojvodina, Novi Sad, Serbia
| | | | - Jenel M Patrascu
- Spitalul Clinic Judeţean de Urgenţa±"Pius Brînzeu" Timişoara, Timişoara, Romania
| | - Ken Zaslav
- OrthoVirginia, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Grzegorz Kwiatkowski
- Department of Knee Surgery, Arthroscopy and Sports Trauma, District Hospital of Orthopedics and Trauma Surgery, Piekary Slaskie, Poland
| | | | - Dror Robinson
- Orthopedic Research Unit and Foot and Ankle Service, Hasharon Hospital, Rabin Medical Center, Petah Tikva, Israel
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27
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Yoshimatsu M, Ohnishi H, Zhao C, Hayashi Y, Kuwata F, Kaba S, Okuyama H, Kawai Y, Hiwatashi N, Kishimoto Y, Sakamoto T, Ikeya M, Omori K. In vivo regeneration of rat laryngeal cartilage with mesenchymal stem cells derived from human induced pluripotent stem cells via neural crest cells. Stem Cell Res 2021; 52:102233. [PMID: 33607469 DOI: 10.1016/j.scr.2021.102233] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/21/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022] Open
Abstract
The laryngotracheal cartilage is a cardinal framework for the maintenance of the airway for breathing, which occasionally requires reconstruction. Because hyaline cartilage has a poor intrinsic regenerative ability, various regenerative approaches have been attempted to regenerate laryngotracheal cartilage. The use of autologous mesenchymal stem cells (MSCs) for cartilage regeneration has been widely investigated. However, long-term culture may limit proliferative capacity. Human-induced pluripotent stem cell-derived MSCs (iMSCs) can circumvent this problem due to their unlimited proliferative capacity. This study aimed to investigate the efficacy of iMSCs in the regeneration of thyroid cartilage in immunodeficient rats. Herein, we induced iMSCs through neural crest cell intermediates. For the relevance to prospective future clinical application, induction was conducted under xeno-free/serum-free conditions. Then, clumps fabricated from an iMSC/extracellular matrix complex (C-iMSC) were transplanted into thyroid cartilage defects in immunodeficient rats. Histological examinations revealed cartilage-like regenerated tissue and human nuclear antigen (HNA)-positive surviving transplanted cells in the regenerated lesion. HNA-positive cells co-expressed SOX9, and type II collagen was identified around HNA-positive cells. These results indicated that the transplanted C-iMSCs promoted thyroid cartilage regeneration and some of the iMSCs differentiated into chondrogenic lineage cells. Induced MSCs may be a promising candidate cell therapy for human laryngotracheal reconstruction.
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Affiliation(s)
- Masayoshi Yoshimatsu
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Hiroe Ohnishi
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Chengzhu Zhao
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Yasuyuki Hayashi
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fumihiko Kuwata
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Kaba
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okuyama
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshitaka Kawai
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nao Hiwatashi
- Department of Otolaryngology, Kyoto-Katsura Hospital, Kyoto, Japan
| | - Yo Kishimoto
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Tatsunori Sakamoto
- Department of Otorhinolaryngology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Makoto Ikeya
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Koichi Omori
- Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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28
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Lavender C, Fravel W, Patel T, Adil S, Blickenstaff B. Nanoscopic Single-Incision Autograft Cartilage Transfer (ACT). Arthrosc Tech 2021; 10:e545-e549. [PMID: 33680790 PMCID: PMC7917345 DOI: 10.1016/j.eats.2020.10.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/20/2020] [Indexed: 02/03/2023] Open
Abstract
Osteochondral defects in the young active patient remain a difficult issue to treat. Autograft cartilage implantation is a procedure that was originally devised as a difficult 2-stage process, with disadvantages including donor-site morbidity and the need for multiple procedures. Recently, a technique for a single stage autograft cartilage transfer, also known as AutoCart using the GraftNet device for autograft harvest and BioCartilage in addition to bone marrow concentrate to aid in graft incorporation and healing, has been described. In this article, we discuss a modification of this autograft cartilage transfer procedure using a minimally invasive single incision for lesion preparation, microfracture, graft harvest, and graft delivery using visualization from the NanoScope.
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Affiliation(s)
- Chad Lavender
- Address correspondence to Chad Lavender, M.D., 300 Corporate Center Dr., Scott Depot, WV 25560.
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29
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Banerjee S, Sahanand KS. Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines. Indian J Orthop 2021; 55:252-262. [PMID: 33927804 PMCID: PMC8046678 DOI: 10.1007/s43465-021-00355-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Articular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly. STUDY DESIGN AND METHODS A clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed. RESULTS Systematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm2 respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm2, newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation. CONCLUSIONS Most treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.
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Affiliation(s)
- Sumit Banerjee
- Department of Orthopedics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342001 India
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30
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Kassarjian A, Rubin DA. Postoperative Knee and Shoulder. IDKD SPRINGER SERIES 2021. [DOI: 10.1007/978-3-030-71281-5_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractArthroscopic surgery in the knee most commonly addresses ligament, meniscal, or articular cartilage abnormalities. Similarly, arthroscopic surgery of the shoulder most commonly addresses tendon and labral abnormalities. The expected postoperative MRI findings depend on both the procedure performed and the time since surgery. Identifying complications and failed procedures relies on both clinical and imaging evaluations.
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31
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Schreiner AJ, Stoker AM, Bozynski CC, Kuroki K, Stannard JP, Cook JL. Clinical Application of the Basic Science of Articular Cartilage Pathology and Treatment. J Knee Surg 2020; 33:1056-1068. [PMID: 32583400 DOI: 10.1055/s-0040-1712944] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The joint is an organ with each tissue playing critical roles in health and disease. Intact articular cartilage is an exquisite tissue that withstands incredible biologic and biomechanical demands in allowing movement and function, which is why hyaline cartilage must be maintained within a very narrow range of biochemical composition and morphologic architecture to meet demands while maintaining health and integrity. Unfortunately, insult, injury, and/or aging can initiate a cascade of events that result in erosion, degradation, and loss of articular cartilage such that joint pain and dysfunction ensue. Importantly, articular cartilage pathology affects the health of the entire joint and therefore should not be considered or addressed in isolation. Treating articular cartilage lesions is challenging because left alone, the tissue is incapable of regeneration or highly functional and durable repair. Nonoperative treatments can alleviate symptoms associated with cartilage pathology but are not curative or lasting. Current surgical treatments range from stimulation of intrinsic repair to whole-surface and whole-joint restoration. Unfortunately, there is a relative paucity of prospective, randomized controlled, or well-designed cohort-based clinical trials with respect to cartilage repair and restoration surgeries, such that there is a gap in knowledge that must be addressed to determine optimal treatment strategies for this ubiquitous problem in orthopedic health care. This review article discusses the basic science rationale and principles that influence pathology, symptoms, treatment algorithms, and outcomes associated with articular cartilage defects in the knee.
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Affiliation(s)
- Anna J Schreiner
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,BG Center for Trauma and Reconstructive Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Aaron M Stoker
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Chantelle C Bozynski
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Keiichi Kuroki
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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32
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Desai S, Jayasuriya CT. Implementation of Endogenous and Exogenous Mesenchymal Progenitor Cells for Skeletal Tissue Regeneration and Repair. Bioengineering (Basel) 2020; 7:E86. [PMID: 32759659 PMCID: PMC7552784 DOI: 10.3390/bioengineering7030086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/25/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
Harnessing adult mesenchymal stem/progenitor cells to stimulate skeletal tissue repair is a strategy that is being actively investigated. While scientists continue to develop creative and thoughtful ways to utilize these cells for tissue repair, the vast majority of these methodologies can ultimately be categorized into two main approaches: (1) Facilitating the recruitment of endogenous host cells to the injury site; and (2) physically administering into the injury site cells themselves, exogenously, either by autologous or allogeneic implantation. The aim of this paper is to comprehensively review recent key literature on the use of these two approaches in stimulating healing and repair of different skeletal tissues. As expected, each of the two strategies have their own advantages and limitations (which we describe), especially when considering the diverse microenvironments of different skeletal tissues like bone, tendon/ligament, and cartilage/fibrocartilage. This paper also discusses stem/progenitor cells commonly used for repairing different skeletal tissues, and it lists ongoing clinical trials that have risen from the implementation of these cells and strategies. Lastly, we discuss our own thoughts on where the field is headed in the near future.
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Affiliation(s)
| | - Chathuraka T. Jayasuriya
- Department of Orthopaedics, Warren Alpert Medical School of Brown University and the Rhode Island Hospital, Providence, RI 02903, USA;
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Stannard JP, Cook JL. Prospective Assessment of Outcomes After Primary Unipolar, Multisurface, and Bipolar Osteochondral Allograft Transplantations in the Knee: A Comparison of 2 Preservation Methods. Am J Sports Med 2020; 48:1356-1364. [PMID: 32134685 DOI: 10.1177/0363546520907101] [Citation(s) in RCA: 44] [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 Articular cartilage lesions in the knee remain a challenging clinical problem. HYPOTHESIS A novel graft preservation method combined with surgical technique and patient management improvements would lead to consistently successful outcomes after osteochondral allograft (OCA) transplantation. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS With institutional review board approval and informed consent, patients were prospectively enrolled into a registry to follow outcomes after OCA transplantation. Patients were included when ≥1-year follow-up data were available, including complications and reoperations, patient-reported outcome measures (PROMs), compliance with rehabilitation, revisions, and failures. RESULTS For patients meeting inclusion criteria (N = 194), mean ± SD age was 37.9 ± 12.2 years and mean BMI was 28.9 ± 5; 38% received unipolar transplants (44% multisurface) and 62% received bipolar transplants. OCAs were preserved by standard tissue bank methods (standard preservation [SP]; 29%) or the novel method (Missouri Osteochondral Preservation System [MOPS]; 71%). Initial success rates were 79% for all cases combined, 60% for SP, and 84% for MOPS. MOPS cases were significantly (P = .028) more likely to be associated with successful outcomes when compared with SP cases. PROMs improved significantly (P < .05) for all cohorts through 3 to 4 years of follow-up. Revisions were performed in 19 cases (10%). MOPS grafts were associated with a significantly (P = .0014) lower revision rate (5%) than SP grafts (21%). Failures occurred in 26 patients (13%), with all undergoing total knee arthroplasty. Bipolar cases were significantly (P = .008) more likely to be associated with failure. MOPS grafts were associated with a significantly (P = .048) lower failure rate (11%) than were SP grafts (19%). Noncompliance with the prescribed rehabilitation protocol was significantly (P = .00008) more likely to be associated with failure. CONCLUSION Prospective data for 194 cases revealed that OCA transplantation for unipolar, multisurface, and bipolar cartilage restoration can be associated with consistently successful outcomes. The 5% revision rate, 11% failure rate, 82%-94% survival probability estimates, and continually improving PROMs through postoperative 3 to 4 years underscore major advances in outcomes as compared with previous reports. These encouraging results were realized with the use of a novel graft preservation method; autogenous bone marrow concentrate pretreatment of donor bone; advancements in graft cutting, implantation, and stabilization techniques; and procedure-specific rehabilitation protocols.
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Affiliation(s)
- James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, USA
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Decellularized tissue engineered hyaline cartilage graft for articular cartilage repair. Biomaterials 2020; 235:119821. [DOI: 10.1016/j.biomaterials.2020.119821] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/03/2020] [Accepted: 01/23/2020] [Indexed: 01/17/2023]
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