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Yao SY, Cao MD, He X, Fu BSC, Yung PSH. Biological modulations to facilitate graft healing in anterior cruciate ligament reconstruction (ACLR), when and where to apply? A systematic review. J Orthop Translat 2021; 30:51-60. [PMID: 34611514 PMCID: PMC8458724 DOI: 10.1016/j.jot.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background When and where to apply the biological modulations is effective to promote healing in the anterior cruciate ligament (ACL) reconstruction remains unclear. Purpose To perform a systematic review of preclinical animal studies on biological modulation in anterior cruciate ligament reconstruction (ACLR) concerning the time and site of delivery. Study design Systematic review of controlled laboratory studies. Methods PubMed, Ovid, and Scopus were searched until December 2020 using a combination of keywords and their synonym to retrieve all animal studies about biological modulation in ACLR. Studies that assessed mechanical strength after ACLR and compared with negative control were included. The methodological quality of animal studies was evaluated. Results 33 studies were included in this review and the majority reported mechanical strength improvement. 79 % of studies applied the biological modulations intra-operatively with different delivery systems used. For 21 % of post-operative delivery studies, intermittent delivery was tried. 21 of the included studies directly applied the biological modulations in the bone tunnels, 5 studies applied intra-articularly while 7 studies applied both in the bone tunnels and intra-articular part. Biological modulations applied intra-operatively and those applied in both parts showed better mechanical strength increase. A shift of the failure mode of pull-out from the bone tunnel in the early healing phase, to mid-substance rupture in the later phase was observed in most studies. Conclusion The improvement of the mechanical strength depends on how the biological modulations (delivery phase, delivery site, delivery form) are applied. The intra-operative delivery showed an overall higher mechanical strength increase and bone tunnel only delivery or intra-articular and bone tunnel both delivery are preferred than intra-articular only delivery. In addition, intra-articular and bone tunnel both delivery can have better mechanical strength increase for a long follow-up time. Thus, intra-operative application with a carrier to control release rate in both parts should be recommended. Further studies are needed to achieve a better healing outcome and more attention should be given to the intra-articular remodeling of the graft along with the tendon bone healing to increase the final mechanical strength. The Translational potential of this article Here, a systematic review of preclinical evidence of the time, site and the method the biological modulations being applied for ACLR to improve the graft healing would be performed. After reviewing the available studies, a choice of when and where to apply the biological modulations can achieve better mechanical strength after ACLR can be obtained. It provides evidence for both researchers and clinicians to decide when and where to apply the biological modulations can achieve their best effectiveness for ACLR before implementing. Promoting graft healing with targeted time and targeted site may reduce the risk of graft failure, safeguard return to sport.
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Affiliation(s)
- S Y Yao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - M D Cao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - X He
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Bruma S C Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Patrick S H Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Wei B, Wang C, Yan C, Tang B, Yu X, Zhang H, Tang L, Wang Q. Osteoprotegerin/bone morphogenetic protein 2 combining with collagen sponges on tendon-bone healing in rabbits. J Bone Miner Metab 2020; 38:432-441. [PMID: 31980897 DOI: 10.1007/s00774-019-01078-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim was to investigate the effect of collagen sponges (CS) as a delivery device for osteoprotegerin (OPG)/bone morphogenetic protein 2 (BMP-2) and support matrix on the tendon-bone healing after anterior crusicate ligament (ACL) reconstruction in modeled rabbits. MATERIALS AND METHODS Sixty New Zealand white rabbits were randomly divided into four groups based on treatments they received at the tendon-bone interface after left knee ACL reconstruction: the control group, OPG/BMP-2, CS, and OPG/BMP-2/CS combination. At 4, 8 and 12 weeks post-surgery, five rabbits from each group were euthanized to examine the tendon-bone healing. Levels of OPG and BMP-2 in synovial fluid, the bone tunnel enlargement value, the histomorphological typing of tendon-bone interface, and the bone tunnel area of the tendon-bone interface were compared among different treatments. RESULTS The OPG/BMP-2/CS combination treatment group had the highest levels of OPG and BMP-2 in synovial fluid (both P < 0.05), the greatest number of Sharpey-like collagen fibers at all test points (P < 0.05), the most fibrocartilage enthesis on week 12, the greatest bone tunnel area (P < 0.05), and the greatest decrease in bone tunnel enlargement on week 12 (P < 0.05). Histomorphological typing of tendon-bone interface of all groups showed changes varying from tendon-bone separation to firm healing, and the change was most significant in the OPG/BMP-2/CS combination treatment group. CONCLUSION CS treatment alone serves as a fixing support, and CS combining with growth factors OPG/BMP-2 ensures slow and stable release of OPG/BMP-2, significantly improves the tendon-bone healing in the rabbit ACL model.
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Affiliation(s)
- Bing Wei
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Chao Wang
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Cheng Yan
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Bushun Tang
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Xiaofei Yu
- Department of Pathology, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Hui Zhang
- Department of General Diseases, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Lixia Tang
- Department of General Diseases, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China.
| | - Qing Wang
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China.
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Hexter AT, Thangarajah T, Blunn G, Haddad FS. Biological augmentation of graft healing in anterior cruciate ligament reconstruction: a systematic review. Bone Joint J 2018; 100-B:271-284. [PMID: 29589505 DOI: 10.1302/0301-620x.100b3.bjj-2017-0733.r2] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aims The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR. Materials and Methods In all, 1879 studies were identified across three databases. Following assessment against strict criteria, 112 studies were included (20 clinical studies; 92 animal studies). Results Seven categories of biological interventions were identified: growth factors, biomaterials, stem cells, gene therapy, autologous tissue, biophysical/environmental, and pharmaceuticals. The methodological quality of animal studies was moderate in 97%, but only 10% used clinically relevant outcome measures. The most interventions in clinical trials target the graft-tunnel interface and are applied intraoperatively. Platelet-rich plasma is the most studied intervention, but the clinical outcomes are mixed, and the methodological quality of studies was suboptimal. Other biological therapies investigated in clinical trials include: remnant-augmented ACLR; bone substitutes; calcium phosphate-hybridized grafts; extracorporeal shockwave therapy; and adult autologus non-cultivated stem cells. Conclusion There is extensive preclinical research supporting the use of biological therapies to augment ACLR. Further clinical studies that meet the minimum standards of reporting are required to determine whether emerging biological strategies will provide tangible benefits in patients undergoing ACLR. Cite this article: Bone Joint J 2018;100-B:271-84.
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Affiliation(s)
- A T Hexter
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - T Thangarajah
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - G Blunn
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
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Zou G, Song E, Wei B. Effects of tendon-bone healing of anterior cruciate ligament reconstruction by osteoprotegerin combined with deproteinized bovine bone. Muscles Ligaments Tendons J 2017; 7:256-262. [PMID: 29264336 DOI: 10.11138/mltj/2017.7.2.256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The healing of a tendon graft in a bone tunnel depends on bone ingrowth into the interface between tendon and bone, or that can enhance tendon-bone healing, which is important to reduce the failure rate after ACL reconstruction. Methods Sixty skeletally mature, New Zealand white rabbits underwent left ACL reconstruction. OPG/DBB compound (concentration ratio of 30%, 60%, 100%) was delivered to the tendon-bone interface with use of a DBB carrier, and nothing as control group. Twenty animals were killed at 4, 8 and 12 weeks after surgery. I-IV levels of semi-quantitative and Sharpey fibers at the healing tendon-bone interface were evaluated, and the biomechanical properties were tested. Results A significantly greater amount of Sharpey fibers at the healing tendon-bone interface in the concentration ratio of 100% OPG/DBB-treated group was found compared with the others at all time-points (P<0.05), and it is the same to the Grade Scores at 12 weeks (P<0.05). The femur-ACL-tibia complex of the concentration ratio of 100% OPG/DBB-treated group has significantly increased stiffness compared with the others at 12 weeks (P<0.05). Conclusion The concentration ratio of 100% OPG/DBB compound significantly improve bone formation around the grafted tendon and improve the stiffness at the healing tendon-bone junction in a rabbit model.
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Affiliation(s)
- Guoyao Zou
- Department of Spinal and Joint Surgery, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Enhong Song
- Department of Spinal and Joint Surgery, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Bing Wei
- Department of Spinal and Joint Surgery, Affiliated Hospital of Guilin Medical University, Guilin, China
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Weimin P, Zheng C, Shuaijun J, Dan L, Jianchang Y, Yue H. Synergistic enhancement of bone regeneration by LMP-1 and HIF-1α delivered by adipose derived stem cells. Biotechnol Lett 2015; 38:377-84. [PMID: 26564407 DOI: 10.1007/s10529-015-1988-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/28/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To investigate the effect of the combination of LMP-1 and HIF-1α delivered by adipose-derived stem cells (ADSCs) on osteogenesis in vitro and in vivo. RESULTS Cells expressing both LMP-1 and HIF-1α genes had elevated mRNA expression of BMP-2, RunX2, alkaline phosphatase, osteocalcin, collagen I and alkaline phosphatase activity compared to cells from other groups. Furthermore, mineralization at day 14 in the cells expressing both LMP-1 and HIF-1α was significantly higher than in all the other groups. In vivo, H&E staining and immunohistochemical analysis of the cell-scaffolds also showed more ectopic bone formation at 4 weeks compared to other groups. More new vessel formation was apparent in the pLVX-rHIF-1α and pLVX-rLMP-1-rHIF-1α groups. CONCLUSION LMP-1 and HIF-1α gene delivery synergistically enhanced the osteo-differentiation of ADSCs in vitro and promoted osteogenesis in vivo compared with LMP-1 alone or HIF-1α alone.
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Affiliation(s)
- Pan Weimin
- Department of Human Movement Studies, Xi'an Physical Education University, Xi'an City, Shaanxi Province, 710068, People's Republic of China.
| | - Cao Zheng
- Departments of Orthopaedics, The First Affiliated Hospital of China People's Liberation Army General Hospital, Beijing, 100037, People's Republic of China.
| | - Jia Shuaijun
- Department of Orthopaedics, Hospital of Armed Police Force of Shaanxi, Xi'an City, Shaanxi Province, 710054, People's Republic of China.
| | - Li Dan
- Institute of Orthopaedics and Traumatology, Xijing Hospital, The Fourth Military Medical University, Xi'an City, Shaanxi Province, 710032, People's Republic of China.
| | - Yang Jianchang
- Department of Human Movement Studies, Xi'an Physical Education University, Xi'an City, Shaanxi Province, 710068, People's Republic of China.
| | - Huang Yue
- Department of Human Movement Studies, Xi'an Physical Education University, Xi'an City, Shaanxi Province, 710068, People's Republic of China.
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Moreau D, Villain A, Ku DN, Corté L. Poly(vinyl alcohol) hydrogel coatings with tunable surface exposure of hydroxyapatite. BIOMATTER 2015; 4:e28764. [PMID: 25482413 PMCID: PMC4122568 DOI: 10.4161/biom.28764] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Insufficient bone anchoring is a major limitation of artificial substitutes for connective osteoarticular tissues. The use of coatings containing osseoconductive ceramic particles is one of the actively explored strategies to improve osseointegration and strengthen the bone-implant interface for general tissue engineering. Our hypothesis is that hydroxyapatite (HA) particles can be coated robustly on specific assemblies of PVA hydrogel fibers for the potential anchoring of ligament replacements. A simple dip-coating method is described to produce composite coatings made of microscopic hydroxyapatite (HA) particles dispersed in a poly(vinyl alcohol) (PVA) matrix. The materials are compatible with the requirements for implant Good Manufacturing Practices. They are applied to coat bundles of PVA hydrogel fibers used for the development of ligament implants. By means of optical and electronic microscopy, we show that the coating thickness and surface state can be adjusted by varying the composition of the dipping solution. Quantitative analysis based on backscattered electron microscopy show that the exposure of HA at the coating surface can be tuned from 0 to over 55% by decreasing the weight ratio of PVA over HA from 0.4 to 0.1. Abrasion experiments simulating bone-implant contact illustrate how the coating cohesion and wear resistance increase by increasing the content of PVA relative to HA. Using pullout experiments, we find that these coatings adhere well to the fiber bundles and detach by propagation of a crack inside the coating. These results provide a guide to select coated implants for anchoring artificial ligaments.
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Affiliation(s)
- David Moreau
- a Centre des Matériaux; UMR 7633 Mines-ParisTech; Evry, France
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Santos SG, Lamghari M, Almeida CR, Oliveira MI, Neves N, Ribeiro AC, Barbosa JN, Barros R, Maciel J, Martins MCL, Gonçalves RM, Barbosa MA. Adsorbed fibrinogen leads to improved bone regeneration and correlates with differences in the systemic immune response. Acta Biomater 2013; 9:7209-17. [PMID: 23571000 DOI: 10.1016/j.actbio.2013.04.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 03/21/2013] [Accepted: 04/02/2013] [Indexed: 12/25/2022]
Abstract
Designing new biomaterials that can modulate the inflammatory response instead of attempting just to reduce it constitutes a paradigm change in regenerative medicine. This work aimed to investigate the capacity of an immunomodulatory biomaterial to enhance bone regeneration. For that purpose we incorporated a molecule with well-established pro-inflammatory and pro-healing roles, fibrinogen, in chitosan scaffolds. Two different incorporation strategies were tested, leading to concentrations of 0.54±0.10mg fibrinogen g(-1) scaffold immediately upon adsorption (Fg-Sol), and 0.34±0.04mg fibrinogen g(-1) scaffold after washing (Fg-Ads). These materials were implanted in a critical size bone defect in rats. At two months post-implantation the extent of bone regeneration was examined by histology and the systemic immune response triggered was evaluated by determining the percentages of myeloid cells, T and B lymphocytes in the draining lymph nodes. The results obtained indicate that the fibrinogen incorporation strategy conditioned the osteogenic capacity of biomaterials. Fg-Ads scaffolds led to more bone formation, and the presence of Fg stimulated angiogenesis. Furthermore, animals implanted with Fg-Ads scaffolds showed significant increases in the percentages of B lymphocytes and myeloid cells in the draining lymph nodes, while levels of T lymphocytes were not significantly different. Finally, a significant increase in TGF-β1 was detected in the plasma of animals implanted with Fg-Ads. Taken together the results presented suggest a potential correlation between the elicited immune response and biomaterial osteogenic performance.
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Affiliation(s)
- S G Santos
- Instituto de Engenharia Biomédica, Universidade do Porto, Rua do Campo Alegre 823, 4150-180 Porto, Portugal.
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