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Chan DD, Guilak F, Sah RL, Calve S. Mechanobiology of Hyaluronan: Connecting Biomechanics and Bioactivity in Musculoskeletal Tissues. Annu Rev Biomed Eng 2024; 26:25-47. [PMID: 38166186 DOI: 10.1146/annurev-bioeng-073123-120541] [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] [Indexed: 01/04/2024]
Abstract
Hyaluronan (HA) plays well-recognized mechanical and biological roles in articular cartilage and synovial fluid, where it contributes to tissue structure and lubrication. An understanding of how HA contributes to the structure of other musculoskeletal tissues, including muscle, bone, tendon, and intervertebral discs, is growing. In addition, the use of HA-based therapies to restore damaged tissue is becoming more prevalent. Nevertheless, the relationship between biomechanical stimuli and HA synthesis, degradation, and signaling in musculoskeletal tissues remains understudied, limiting the utility of HA in regenerative medicine. In this review, we discuss the various roles and significance of endogenous HA in musculoskeletal tissues. We use what is known and unknown to motivate new lines of inquiry into HA biology within musculoskeletal tissues and in the mechanobiology governing HA metabolism by suggesting questions that remain regarding the relationship and interaction between biological and mechanical roles of HA in musculoskeletal health and disease.
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Affiliation(s)
- Deva D Chan
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA;
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Farshid Guilak
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
- Shriners Hospitals for Children-St. Louis, St. Louis, Missouri, USA
| | - Robert L Sah
- Shu Chien-Gene Lay Department of Bioengineering, University of California San Diego, La Jolla, California, USA
| | - Sarah Calve
- Paul M. Rady Department of Mechanical Engineering, University of Colorado Boulder, Boulder, Colorado, USA
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Chen CH, Cheng YH, Chen SH, Chuang ADC, Chen JP. Functional Hyaluronic Acid-Polylactic Acid/Silver Nanoparticles Core-Sheath Nanofiber Membranes for Prevention of Post-Operative Tendon Adhesion. Int J Mol Sci 2021; 22:ijms22168781. [PMID: 34445516 PMCID: PMC8396318 DOI: 10.3390/ijms22168781] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022] Open
Abstract
In this study, we prepared core-sheath nanofiber membranes (CSNFMs) with silver nanoparticles (Ag NPs) embedding in the polylactic acid (PLA) nanofiber sheath and hyaluronic acid (HA) in the nanofiber core. The PLA/Ag NPs sheath provides mechanical support as well as anti-bacterial and anti-inflammatory properties. The controlled release of HA from the core could exert anti-adhesion effects to promote tendon sliding while reducing fibroblast attachment. From the microfibrous structural nature of CSNFMs, they function as barrier membranes to reduce fibroblast penetration without hampering nutrient transports to prevent post-operative peritendinous adhesion. As the anti-adhesion efficacy will depend on release rate of HA from the core as well as Ag NP from the sheath, we fabricated CSNFMs of comparable fiber diameter, but with thick (Tk) or thin (Tn) sheath. Similar CSNFMs with thick (Tk+) and thin (Tn+) sheath but with embedded Ag NPs in the sheath were also prepared. The physico-chemical properties of the barrier membranes were characterized in details, together with their biological response including cell penetration, cell attachment and proliferation, and cytotoxicity. Peritendinous anti-adhesion models in rabbits were used to test the efficacy of CSNFMs as anti-adhesion barriers, from gross observation, histology, and biomechanical tests. Overall, the CSNFM with thin-sheath and Ag NPs (Tn+) shows antibacterial activity with low cytotoxicity, prevents fibroblast penetration, and exerts the highest efficacy in reducing fibroblast attachment in vitro. From in vivo studies, the Tn+ membrane also shows significant improvement in preventing peritendinous adhesions as well as anti-inflammatory efficacy, compared with Tk and Tn CSNFMs and a commercial adhesion barrier film (SurgiWrap®) made from PLA.
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Affiliation(s)
- Chih-Hao Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Keelung 20401, Taiwan; (C.-H.C.); (A.D.-C.C.)
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Collage of Medicine, Chang Gung University, Kwei-San, Taoyuan 33305, Taiwan;
| | - Yuan-Hsun Cheng
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 33302, Taiwan;
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Collage of Medicine, Chang Gung University, Kwei-San, Taoyuan 33305, Taiwan;
| | - Andy Deng-Chi Chuang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Keelung 20401, Taiwan; (C.-H.C.); (A.D.-C.C.)
| | - Jyh-Ping Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Collage of Medicine, Chang Gung University, Kwei-San, Taoyuan 33305, Taiwan;
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 33302, Taiwan;
- Research Center for Food and Cosmetic Safety, Research Center for Chinese Herbal Medicine, Linkou Campus, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 33305, Taiwan
- Department of Materials Engineering, Ming Chi University of Technology, Tai-Shan, New Taipei City 24301, Taiwan
- Correspondence: ; Tel.: +886-3-2118800
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Coaxial and emulsion electrospinning of extracted hyaluronic acid and keratin based nanofibers for wound healing applications. Eur Polym J 2021. [DOI: 10.1016/j.eurpolymj.2020.110158] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kanchanathepsak T, Pichyangkul P, Suppaphol S, Watcharananan I, Tuntiyatorn P, Tawonsawatruk T. Efficacy Comparison of Hyaluronic Acid and Corticosteroid Injection in Treatment of Trigger Digits: A Randomized Controlled Trial. J Hand Surg Asian Pac Vol 2020; 25:76-81. [PMID: 32000598 DOI: 10.1142/s2424835520500101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Although the current nonsurgical treatment for trigger digits is corticosteroid (CS) injection, it often comes with adverse effects that may cause some limitations. Currently, Hyaluronic acid (HA) has been successfully used in tendinopathy and may be used in stenosing tenosynovitis. The aim of this study is to compare the efficacy of ultrasound-guided injection between the HA and CS in trigger digits treatment. Methods: Double-blind randomized controlled trial was conducted. Fifty patients with 66 trigger digits were randomly assigned into an intervention group (1 ml of low-molecular weight HA) and a control group (1 ml of 10mg/ml triamcinolone acetate). The ultrasound-guided injection and local anesthesia (0.5 ml of 1% lidocaine without adrenaline) were used. The Quinnell grading, Visual Analog Scale (VAS) score of pain, Disabilities of the Arm, Shoulder and Hand (DASH) score and complications were collected at 1-, 3-and 6-month follow-up. Results: The mean age of HA group (33 digits) and CS group (33 digits) were 58.3 years and 54.7 years respectively. Nine patients were loss of follow-up (7 in HA group and 2 in CS group). The Quinnell grades have shown an improvement in both group. The CS group had a significant better improvement at 1-month (p-value < 0.001) and there was no significant difference at 3-and 6-month follow-up between the two groups. The median of VAS and DASH score were significantly improved by time in both groups (p-value < 0.01). The CS group showed a better significant improvement in early period of follow-up (p-value < 0.05). However, there was no significant difference between the two groups in the last follow-up. Conclusions: HA and CS injection has a comparable therapeutic effect in treatment of trigger digits. However, CS injection has higher efficacy of pain and inflammation reduction in the early phase of the disease.
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Affiliation(s)
- Thepparat Kanchanathepsak
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Picharn Pichyangkul
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sorasak Suppaphol
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ittirat Watcharananan
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panithan Tuntiyatorn
- Hand and Microsurgery Unit, Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samutprakan, Thailand
| | - Tulyapruek Tawonsawatruk
- Hand and Microsurgery Unit, Department of Orthopaedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Bazmandeh AZ, Mirzaei E, Fadaie M, Shirian S, Ghasemi Y. Dual spinneret electrospun nanofibrous/gel structure of chitosan-gelatin/chitosan-hyaluronic acid as a wound dressing: In-vitro and in-vivo studies. Int J Biol Macromol 2020; 162:359-373. [PMID: 32574734 DOI: 10.1016/j.ijbiomac.2020.06.181] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/24/2022]
Abstract
Structural and compositional similarity to the natural extracellular matrix (ECM) is a main characteristic of an ideal scaffold for tissue regeneration. In order to resemble the fibrous/gel structure of skin ECM, a multicomponent scaffold was fabricated using biopolymers with structural similarity to ECM and wound healing properties i.e., chitosan (CS), gelatin (Gel) and hyaluronic acid (HA). The CS-Gel and CS-HA nanofibers were simultaneously electrospun on the collector through dual-electrospinning technique. The presence of polymers, possible interactions, and formation of polyelectrolyte complex were proven by attenuated total reflectance Fourier transform infrared (ATR-FTIR) spectroscopy and thermogravimetric analysis (TGA). The noncomplex component of CS-HA fibers formed a gel state when the scaffold was exposed to the aqueous media, while the CS-Gel fibers reserved their fibrous structure, resulting in formation of fibrous/gel structure. The CS-Gel/CS-HA scaffold showed significantly higher cell proliferation (109%) in the first 24 h comparing with CS (90%) and CS-Gel (96%) scaffolds. Additionally, the initial cell adhesion improved by incorporation of HA. The in-vivo wound healing results in rat elucidated more wound healing capability of the CS-Gel/CS-HA scaffold in which new tissue with most similarity to the normal skin was formed.
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Affiliation(s)
- Abbas Zakeri Bazmandeh
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Esmaeil Mirzaei
- Department of Medical Nanotechnology, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Milad Fadaie
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sadegh Shirian
- Department of Pathology, School of Veterinary Medicine, Shahrekord University, Shahrekord, Iran; Shiraz Molecular Pathology Research Center, Dr Daneshbod Path Lab, Shiraz, Iran; Shefa Neuroscience Research Center, Tehran, Iran
| | - Younes Ghasemi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Liu C, Tian S, Bai J, Yu K, Liu L, Liu G, Dong R, Tian D. Regulation of ERK1/2 and SMAD2/3 Pathways by Using Multi-Layered Electrospun PCL-Amnion Nanofibrous Membranes for the Prevention of Post-Surgical Tendon Adhesion. Int J Nanomedicine 2020; 15:927-942. [PMID: 32103947 PMCID: PMC7023877 DOI: 10.2147/ijn.s231538] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background Adhesion after tendon injury is a common complication in clinical practice. The lack of effective prevention mechanisms seriously affects the functional rehabilitation of patients. This research aimed to optimise the amniotic membrane and explain the mechanism of tendon–amniotic membrane by imitating the tendon sheath to construct a multilayer electrospun polycaprolactone (PCL) nanofibre membrane. Materials and Methods Fresh amnions were subjected to freezing and vacuum drying. The two surfaces of freeze-dried amnions were coated with PCL nanofibres by electrospinning, thereby forming a multilayer composite membrane and constructing a growth factor-sustained release system conforming to the tendon-healing cycle. The new materials were characterised, and the biological effects on tenocytes and fibroblasts were evaluated. The tendon injury model of New Zealand rabbits was constructed to observe the effects on tendon adhesion and healing. Results After freezing and vacuum drying, fresh amnions were found to effectively remove most of the cell components but retained the active components TGF-β1, bFGF, VEGF, and PDGF, as well as the fibrous reticular structure of the basement membrane. After coating with PCL nanofibres, a composite membrane mimicking the structure of the tendon sheath was constructed, thereby strengthening the tensile strength of the amnion. By up-regulating the phosphorylation of ERK1/2 and SMAD2/3, the adhesion and proliferation of tenocytes and fibroblasts were promoted, and collagen synthesis was enhanced. In the rabbit tendon repair model, the composite membrane effectively isolated the exogenous adhesion tissue and promoted endogenous tendon healing. Conclusion The composite membrane mimicking the structure of tendon sheath effectively isolated the exogenous adhesion tissue and achieved good tendon slip. By slowly releasing the growth factors TGF-β1, bFGF, VEGF and PDGF, the ERK1/2 and SMAD2/3 pathways were regulated. Consequently, endogenous tendon healing was promoted. This strategy can alternatively address the clinical problem of tendon adhesion.
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Affiliation(s)
- Chunjie Liu
- Department of Orthopedics, Tangshan Workers Hospital, Tangshan, Hebei 063000, People's Republic of China
| | - Siyu Tian
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Jiangbo Bai
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Kunlun Yu
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Lei Liu
- Department of Orthopedics, Changping District Hospital, Beijing 102200, People's Republic of China
| | - Guoli Liu
- Department of Orthopedics, The Second Hospital of Tangshan, Tangshan, Hebei 063000,People's Republic of China
| | - Ruiyi Dong
- Department of Orthopedics, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, Hebei 061001, People's Republic of China
| | - Dehu Tian
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, People's Republic of China
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Chen CT, Chen CH, Sheu C, Chen JP. Ibuprofen-Loaded Hyaluronic Acid Nanofibrous Membranes for Prevention of Postoperative Tendon Adhesion through Reduction of Inflammation. Int J Mol Sci 2019; 20:E5038. [PMID: 31614502 PMCID: PMC6834315 DOI: 10.3390/ijms20205038] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/01/2019] [Accepted: 10/08/2019] [Indexed: 02/07/2023] Open
Abstract
A desirable multi-functional nanofibrous membrane (NFM) for prevention of postoperative tendon adhesion should be endowed with abilities to prevent fibroblast attachment and penetration and exert anti-inflammation effects. To meet this need, hyaluronic acid (HA)/ibuprofen (IBU) (HAI) NFMs were prepared by electrospinning, followed by dual ionic crosslinking with FeCl3 (HAIF NFMs) and covalent crosslinking with 1,4-butanediol diglycidyl ether (BDDE) to produce HAIFB NFMs. It is expected that the multi-functional NFMs will act as a physical barrier to prevent fibroblast penetration, HA will reduce fibroblast attachment and impart a lubrication effect for tendon gliding, while IBU will function as an anti-inflammation drug. For this purpose, we successfully fabricated HAIFB NFMs containing 20% (HAI20FB), 30% (HAI30FB), and 40% (HAI40FB) IBU and characterized their physico-chemical properties by scanning electron microscopy, Fourier transformed infrared spectroscopy, thermal gravimetric analysis, and mechanical testing. In vitro cell culture studies revealed that all NFMs except HAI40FB possessed excellent effects in preventing fibroblast attachment and penetration while preserving high biocompatibility without influencing cell proliferation. Although showing significant improvement in mechanical properties over other NFMs, the HAI40FB NFM exhibited cytotoxicity towards fibroblasts due to the higher percentage and concentration of IBU released form the membrane. In vivo studies in a rabbit flexor tendon rupture model demonstrated the efficacy of IBU-loaded NFMs (HAI30FB) over Seprafilm® and NFMs without IBU (HAFB) in reducing local inflammation and preventing tendon adhesion based on gross observation, histological analyses, and biomechanical functional assays. We concluded that an HAI30FB NFM will act as a multi-functional barrier membrane to prevent peritendinous adhesion after tendon surgery.
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Affiliation(s)
- Chien-Tzung Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Collage of Medicine, Kwei-San, Taoyuan 33305, Taiwan.
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, College of Medicine, Keelung 20401, Taiwan.
| | - Chih-Hao Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Collage of Medicine, Kwei-San, Taoyuan 33305, Taiwan.
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 33302, Taiwan.
| | - Chialin Sheu
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 33302, Taiwan.
| | - Jyh-Ping Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Collage of Medicine, Kwei-San, Taoyuan 33305, Taiwan.
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 33302, Taiwan.
- Research Center for Food and Cosmetic Safety, Research Center for Chinese Herbal Medicine, College of Human Ecology, Chang Gung University of Science and Technology, Taoyuan 33302, Taiwan.
- Department of Materials Engineering, Ming Chi University of Technology, Tai-Shan, New Taipei City 24301, Taiwan.
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Experimental study of tendon sheath repair via decellularized amnion to prevent tendon adhesion. PLoS One 2018; 13:e0205811. [PMID: 30325952 PMCID: PMC6191119 DOI: 10.1371/journal.pone.0205811] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 10/02/2018] [Indexed: 12/27/2022] Open
Abstract
The adhesion of tendon and surrounding tissue is the most common complication after repairing an injured tendon. The injured flexor tendons in zone II are frequently accompanied by tendon sheath defects, which lead to poor recovery. A variety of biological and non-biological materials have been recently used for repair or as substitute for tendon sheaths to prevent tendon adhesion. However, non-biological materials, such as polyethylene films, have been used to prevent tendon adhesions by mechanical isolation. The possibility of tendon necrosis and permanent foreign body remains due to the lack of permeability and the obstruction of nutrient infiltration. The natural macromolecule amniotic membrane derived from organisms is a semi-permeable membrane with the following characteristics: smooth; without vascular, nerve, and lymphatic; and rich in matrix, cytokines, enzymes, and other active ingredients. The unique structure of this membrane makes it an ideal biomaterial. In the experiment in Henry chicken, the model of tendon sheath defect and the flexor digitorum tendon in zone II was established and randomly divided into control group, medical membrane group, and decellularized amniotic membrane group. Samples were obtained at the 2nd, 4th, 8th, and 12th week after operation. General, histological, and biomechanical tests were performed to investigate the preventive effect of repaired tendon sheath by decallularized amniotic membrane. Experimental results showed the following: the amniotic membrane group and the medical membrane group had mild inflammatory reaction and tissue edema, and nearly no adhesion was observed in the surrounding tissue; the fibroblast-like cells were distributed in layers under the light microscope; the amniotic membrane group was denser than the medical membrane group cells, and numerous fibroblasts were disorganized in the control group. Biomechanical measurements showed that the sliding distance of tendon, the total flexion angle of the toes, and the tendon maximum tensile breaking strength at the early postoperative were significantly better than in the control group. Through this experiment, the amniotic membrane, as a natural biological substitute material in the construction of tendon sheath, can effectively inhibit exogenous healing and promote endogenous healing to prevent tendon adhesion.
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Monnier A, Al Tawil E, Nguyen QT, Valleton JM, Fatyeyeva K, Deschrevel B. Functionalization of poly(lactic acid) scaffold surface by aminolysis and hyaluronan immobilization: How it affects mesenchymal stem cell proliferation. Eur Polym J 2018. [DOI: 10.1016/j.eurpolymj.2018.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shalumon K, Sheu C, Chen CH, Chen SH, Jose G, Kuo CY, Chen JP. Multi-functional electrospun antibacterial core-shell nanofibrous membranes for prolonged prevention of post-surgical tendon adhesion and inflammation. Acta Biomater 2018; 72:121-136. [PMID: 29626695 DOI: 10.1016/j.actbio.2018.03.044] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/10/2018] [Accepted: 03/28/2018] [Indexed: 11/24/2022]
Abstract
The possibility of endowing an electrospun anti-adhesive barrier membrane with multi-functionality, such as lubrication, prevention of fibroblast attachment and anti-infection and anti-inflammation properties, is highly desirable for the management of post-surgical tendon adhesion. To this end, we fabricated core-shell nanofibrous membranes (CSNMs) with embedded silver nanoparticles (Ag NPs) in the poly(ethylene glycol) (PEG)/poly(caprolactone) (PCL) shell and hyaluronic acid (HA)/ibuprofen in the core. HA imparted a lubrication effect for smooth tendon gliding and reduced fibroblast attachment, while Ag NPs and ibuprofen functioned as anti-infection and anti-inflammation agents, respectively. CSNMs with a PEG/PCL/Ag shell (PPA) and HA core containing 0% (H/PPA), 10% (HI10/PPA), 30% (HI30/PPA) and 50% (HI50/PPA) ibuprofen were fabricated through co-axial electrospinning and assessed through microscopic, spectroscopic, thermal, mechanical and drug release analyses. Considering nutrient passage through the barrier, the microporous CSNMs exerted the same barrier effect but drastically increased the mass transfer coefficients of bovine serum albumin compared with the commercial anti-adhesive membrane SurgiWrap®. Cell attachment/focal adhesion formation of fibroblasts revealed effective reduction of initial cell attachment on the CSNM surface with minimum cytotoxicity (except HI50/PPA). The anti-bacterial effect against both Gram-negative and Gram-positive bacteria was verified to be due to the Ag NPs in the membranes. In vivo studies using H/PPA and HI30/PPA CSNMs and SurgiWrap® in a rabbit flexor tendon rupture model demonstrated the improved efficacy of HI30/PPA CSNMs in reducing inflammation and tendon adhesion formation based on gross observation, histological analysis and functional assays. We conclude that HI30/PPA CSNMs can act as a multifunctional barrier membrane to prevent peritendinous adhesion after tendon surgery. STATEMENT OF SIGNIFICANCE A multi-functional anti-adhesion barrier membrane that could reduce fibroblasts attachment and penetration while simultaneously prevent post-surgical infection and inflammation is urgently needed. To this end, we prepared electrospun core-shell hyaluronic acid + ibuprofen/polyethylene glycol + polycaprolactone + Ag nanoparticles nanofibrous membranes by co-axial electrospinning as an ideal anti-adhesive membrane. The core-shell structure could meet the need of a desirable anti-adhesion barrier through release of ibuprofen and Ag nanoparticles to reduce infection and inflammation while hyaluronic acid can reduce fibroblasts adhesion. The superior performance of this multi-functional core-shell nanofibrous membrane in preventing peritendinous adhesion and post-surgical inflammation was demonstrated in a rabbit flexor tendon rupture model.
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Sheu C, Shalumon KT, Chen CH, Kuo CY, Fong YT, Chen JP. Dual crosslinked hyaluronic acid nanofibrous membranes for prolonged prevention of post-surgical peritoneal adhesion. J Mater Chem B 2016; 4:6680-6693. [DOI: 10.1039/c6tb01376g] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A HA NFM crosslinked with FeCl3and BDDE shows prolonged degradation to prevent peritoneal adhesion.
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Affiliation(s)
- Chialin Sheu
- Department of Chemical and Materials Engineering
- Chang Gung University
- Taoyuan 33302
- Republic of China
| | - K. T. Shalumon
- Department of Chemical and Materials Engineering
- Chang Gung University
- Taoyuan 33302
- Republic of China
| | - Chih-Hao Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
- Chang Gung Memorial Hospital
- Taoyuan 33305
- Republic of China
| | - Chang-Yi Kuo
- Department of Chemical and Materials Engineering
- Chang Gung University
- Taoyuan 33302
- Republic of China
| | - Yi Teng Fong
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
- Chang Gung Memorial Hospital
- Taoyuan 33305
- Republic of China
| | - Jyh-Ping Chen
- Department of Chemical and Materials Engineering
- Chang Gung University
- Taoyuan 33302
- Republic of China
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center
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Chen CH, Chen SH, Shalumon KT, Chen JP. Dual functional core-sheath electrospun hyaluronic acid/polycaprolactone nanofibrous membranes embedded with silver nanoparticles for prevention of peritendinous adhesion. Acta Biomater 2015; 26:225-35. [PMID: 26234491 DOI: 10.1016/j.actbio.2015.07.041] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 01/18/2023]
Abstract
Peritendinous adhesions, one of the common complications after tendon injury and subsequent surgery, could be minimized by directly placing a physical barrier between the injured site and the surrounding tissue. We used silver (Ag) nanoparticles embedded in electrospun hyaluronic acid (HA)/polycaprolactone (PCL) nanofibrous membranes (NFMs) (HA/PCL+Ag NFMs) to prevent peritendinous adhesions and bacterial infection after tendon surgery. HA was used for effective lubrication, and Ag provided antibacterial activity. A dual functional anti-adhesion barrier with core-sheath nanofibrous architecture was made from an HA core solution and a photo-reduced silver nitrate/PCL sheath solution. Polycaprolactone NFMs (PCL NFMs), hyaluronic acid/polycaprolactone core-sheath NFMs (HA/PCL NFMs) and HA/PCL+Ag NFMs with comparable fiber diameters and pore sizes were prepared and analyzed. The microporous structure of NFMs is expected to effectively block the penetration of adhesion-forming fibroblasts during tendon healing. The release of Ag from HA/PCL+Ag NFMs plateaued after 4 days, which confirmed the short-term anti-bacterial effect, and this result was verified with agar diffusion tests. In contrast, the release of HA was extended up to 21 days to simulate the lubrication effect offered by HA in the synovial fluid of the tendon sheath. In vitro cell culture experiments revealed that HA/PCL+Ag NFMs exhibited the highest inhibition of fibroblast attachment and proliferation without significant cytotoxicity due to the synergistic effect of Ag and HA. In vivo studies with a rabbit flexor tendon model further confirmed the efficacy of HA/PCL+Ag NFMs in reducing peritendinous adhesion as determined by gross observation, histology, joint range-of-motion, tendon gliding and biomechanical tests.
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Affiliation(s)
- Chih-Hao Chen
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 333, Taiwan, ROC; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Kwei-San, Taoyuan 333, Taiwan, ROC
| | - Shih-Hsien Chen
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 333, Taiwan, ROC
| | - K T Shalumon
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 333, Taiwan, ROC
| | - Jyh-Ping Chen
- Department of Chemical and Materials Engineering, Chang Gung University, Kwei-San, Taoyuan 333, Taiwan, ROC.
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13
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Nakamura H, Gotoh M, Kanazawa T, Ohta K, Nakamura K, Honda H, Ohzono H, Shimokobe H, Mitsui Y, Shirachi I, Okawa T, Higuchi F, Shirahama M, Shiba N, Matsueda S. Effects of corticosteroids and hyaluronic acid on torn rotator cuff tendons in vitro and in rats. J Orthop Res 2015; 33:1523-30. [PMID: 26174562 DOI: 10.1002/jor.22921] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 04/07/2015] [Indexed: 02/04/2023]
Abstract
Corticosteroids (CS) or hyaluronic acid (HA) is used in subacromial injection for the conservative treatment of rotator cuff tears (RCT); this study addresses the question of how CS and HA affect the tendon tissue and fibroblasts in vitro and in rats. Cell proliferation assays were performed in human tendon fibroblasts from RCT. Rats underwent surgery to create RCT, and the surgical sites were injected with CS or HA. The rotator cuff tendons were subjected to biomechanical testing, microscopic and immunohistochemical analysis of proliferating cell nuclear antigen (PCNA), and ultrastructural analysis. Cell proliferation was significantly decreased with CS in vitro (p < 0.05). Maximal load of CS-treated tendons was significantly decreased compared with that of HA-treated tendons (p < 0.05), as well as PCNA(+) cells at 2 weeks (p < 0.05). Ultrastructural observations of the CS-treated rats detected apoptosis of tendon fibroblasts 24 h after surgery. Histological and biomechanical data 4 weeks after surgery were not significant among the three groups. Unlike HA, CS caused cell death, and inhibition of the proliferation of tendon fibroblasts, leading to a delay of tendon healing involved and a subsequent decrease of biomechanical strength at the surgical site.
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Affiliation(s)
- Hidehiro Nakamura
- Department of Orthopedic Surgery, Kurume University Medical Center, Fukuoka, Japan
| | - Masafumi Gotoh
- Department of Orthopedic Surgery, Kurume University, Fukuoka, Japan
| | - Tomonoshin Kanazawa
- Division of Microscopic and Developmental Anatomy, Department of Anatomy, Kurume University school of Medicine, Fukuoka, Japan
| | - Keisuke Ohta
- Division of Microscopic and Developmental Anatomy, Department of Anatomy, Kurume University school of Medicine, Fukuoka, Japan
| | - Keiichirou Nakamura
- Division of Microscopic and Developmental Anatomy, Department of Anatomy, Kurume University school of Medicine, Fukuoka, Japan
| | - Hirokazu Honda
- Department of Orthopedic Surgery, Kurume University Medical Center, Fukuoka, Japan
| | - Hiroki Ohzono
- Department of Orthopedic Surgery, Kurume University Medical Center, Fukuoka, Japan
| | - Hisao Shimokobe
- Department of Orthopedic Surgery, Kurume University Medical Center, Fukuoka, Japan
| | - Yasuhiro Mitsui
- Department of Orthopedic Surgery, Kurume University, Fukuoka, Japan
| | - Isao Shirachi
- Department of Orthopedic Surgery, Kurume University, Fukuoka, Japan
| | - Takahiro Okawa
- Department of Orthopedic Surgery, Kurume University, Fukuoka, Japan
| | - Fujio Higuchi
- Department of Orthopedic Surgery, Kurume University, Fukuoka, Japan
| | - Masahiro Shirahama
- Department of Orthopedic Surgery, Kurume University Medical Center, Fukuoka, Japan
| | - Naoto Shiba
- Department of Orthopedic Surgery, Kurume University Medical Center, Fukuoka, Japan
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14
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Leigh DR, Kim MS, Kovacevic D, Baker AR, Tan CD, Calabro A, Derwin KA. Human fascia lata ECM scaffold augmented with immobilized hyaluronan: inflammatory response and remodeling in the canine body wall and shoulder implantation sites. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2014; 26:1-15. [PMID: 25400204 DOI: 10.1080/09205063.2014.975394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We postulate that immobilization of tyramine-substituted hyaluronan (THA) into an extracellular matrix (ECM) scaffold may be a strategy to promote an anti-inflammatory response to the ECM. Further, we posit that the implantation site could influence the inflammatory response and remodeling of an ECM scaffold. Eight beagles underwent implantation of fascia ECM grafts, treated with either immobilized low molecular weight (57 kDa) THA or water only, in both the shoulder injury and body wall sites. Dogs were euthanized at 12 weeks and fascia grafts harvested en bloc for histology. Grafts implanted at the body wall had significantly higher inflammatory cell infiltrate and vascularity, and significantly lower retardance (collagen density), than grafts at the shoulder, suggestive of a more intense, persistent, and perhaps degradative inflammatory and remodeling response at the body wall than shoulder injury site in the canine model. However, the presence of immobilized low MW THA had no effect on the inflammation response or remodeling of fascia ECM compared to water-treated controls. Importantly, these results suggest that the inflammatory response and remodeling of biomaterial implants depends on the location of implantation and therefore our animal models need to be carefully chosen. Further, the potential anti-inflammatory advantages of hyaluronan (HA) in wound healing do not appear to be realized when presenting it to the host as non-degradable hydrogel even if its capacity for binding HA binding protein is maintained. Further study treating ECM with uncross-linked (free) HA or immobilized low MW THA as a means to deliver free HA or other biomolecules to a surgical repair site is warranted.
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Affiliation(s)
- Diane R Leigh
- a Department of Biomedical Engineering and the Orthopaedic Research Center , Cleveland Clinic , Cleveland , OH , USA
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15
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Chen SH, Chen CH, Shalumon KT, Chen JP. Preparation and characterization of antiadhesion barrier film from hyaluronic acid-grafted electrospun poly(caprolactone) nanofibrous membranes for prevention of flexor tendon postoperative peritendinous adhesion. Int J Nanomedicine 2014; 9:4079-92. [PMID: 25187711 PMCID: PMC4149458 DOI: 10.2147/ijn.s67931] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peritendinous adhesion is one of the common complications encountered after tendon injury and subsequent surgery, and it can be minimized by introducing a physical barrier between the injured site and the surrounding tissue. An electrospun hyaluronic acid-grafted poly(caprolactone) (PCL-g-HA) nanofibrous membrane (NFM) is proposed as an alternative to current antiadhesion barrier films. HA is covalently grafted to surface-aminolyzed PCL nanofibers, using carbodiimide as the coupling agent. Pristine PCL and PCL-g-HA NFMs were characterized by scanning electron microscopy, thermogravimetric analysis, X-ray photoelectron spectroscopy, Fourier-transform infrared spectroscopy, and mechanical testing. In vitro cell culture with fibroblasts showed that PCL-g-HA NFMs reduced cellular adhesion on the membrane surface while maintaining cell proliferation. Animal experiments using a rabbit flexor digitorum profundus tendon model confirmed the efficacy of PCL-g-HA in reducing peritendinous adhesion, based on gross observation, histology, joint flexion-angle measurements, gliding tests, and biomechanical evaluation.
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Affiliation(s)
- Shih-Hsien Chen
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China
| | - Chih-Hao Chen
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China ; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China
| | - K T Shalumon
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China
| | - Jyh-Ping Chen
- Department of Chemical and Materials Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taiwan, Republic of China ; Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Taoyuan, Taiwan, Republic of China
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16
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Uchihashi K, Tsuruta T, Mine H, Aoki S, Nishijima-Matsunobu A, Yamamoto M, Kuraoka A, Toda S. Histopathology of tenosynovium in trigger fingers. Pathol Int 2014; 64:276-82. [DOI: 10.1111/pin.12168] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 04/14/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Kazuyoshi Uchihashi
- Department of Pathology and Microbiology; Faculty of Medicine, Saga University; Saga Japan
| | | | | | - Shigehisa Aoki
- Department of Pathology and Microbiology; Faculty of Medicine, Saga University; Saga Japan
| | | | - Mihoko Yamamoto
- Department of Pathology and Microbiology; Faculty of Medicine, Saga University; Saga Japan
| | - Akio Kuraoka
- Department of Anatomy and Physiology; Faculty of Medicine, Saga University; Saga Japan
| | - Shuji Toda
- Department of Pathology and Microbiology; Faculty of Medicine, Saga University; Saga Japan
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17
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Jonsson EL, Nylander K, Hallén L, Laurell G. Effect of radiotherapy on expression of hyaluronan and EGFR and presence of mast cells in squamous cell carcinoma of the head and neck. Oncol Lett 2012. [PMID: 23205115 DOI: 10.3892/ol.2012.907] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Head and neck squamous cell carcinoma is a common form of cancer, and despite improvements in treatment during the last decades, survival rates have not significantly increased. There is therefore a need to better understand how these tumours and the adjacent tissues react to radiotherapy, the most common type of treatment for this group of tumours. In order to improve this understanding, the expression of hyaluronan (HA) and epidermal growth factor receptor (EGFR) and the presence of mast cells were mapped before and after radiotherapy using immunohistochemistry. The results showed HA and EGFR to have similar expression patterns in tumour tissue and histologically normal squamous epithelium prior to radiotherapy. Following radiotherapy, EGFR increased in histologically normal epithelium. An increased number of mast cells were also observed as a result of radiotherapy. No expression of EGFR was observed in the connective tissue either prior to or following radiotherapy.
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18
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Anitua E, Sanchez M, De la Fuente M, Zalduendo MM, Orive G. Plasma rich in growth factors (PRGF-Endoret) stimulates tendon and synovial fibroblasts migration and improves the biological properties of hyaluronic acid. Knee Surg Sports Traumatol Arthrosc 2012; 20:1657-65. [PMID: 21987365 DOI: 10.1007/s00167-011-1697-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 09/27/2011] [Indexed: 10/16/2022]
Abstract
PURPOSE Cell migration plays an essential role in development, wound healing, and tissue regeneration. Plasma rich in growth factors (PRGF-Endoret) technology offers a potential source of growth factors involved in tissue regeneration. Here, we evaluate the potential of PRGF-Endoret over tendon cells and synovial fibroblasts migration and study whether the combination of this autologous technology with hyaluronic acid (HA) improves the effect and potential of the biomaterials over the motility of both types of fibroblasts. METHODS Migration of primary tendon cells and synovial fibroblasts after culturing with either PRGF or PPGF (plasma poor in growth factors) at different doses was evaluated. Furthermore, the migratory capacity induced by the combination of PPGF and PRGF with HA was tested. RESULTS PPGF stimulated migration of both types of cells but this effect was significantly higher when PRGF was used. Tendon cells showed an increase of 212% in migratory ability when HA was combined with PPGF and of 335% in the case of HA + PRGF treatment compared with HA alone. CONCLUSIONS PRGF-Endoret stimulates migration of tendon cells and synovial fibroblasts and improves the biological properties of HA.
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Affiliation(s)
- E Anitua
- Private Practice in Implantology and Oral Rehabilitation in Vitoria, Vitoria, Spain.
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19
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Yagi M, Mitsui Y, Gotoh M, Sato N, Yoshida K, Nagata K. ROLE OF THE HYALURONAN-PRODUCING TENOSYNOVIUM IN PREVENTING ADHESION FORMATION DURING HEALING OF FLEXOR TENDON INJURIES. ACTA ACUST UNITED AC 2012; 17:13-7. [DOI: 10.1142/s0218810412500025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 07/20/2011] [Indexed: 11/18/2022]
Abstract
Flexor tendons of white Leghorn chickens (n = 25) were used for this study. One chicken was used as a normal control (no surgery), and the remaining 24 were used for experiments. After partial tendon-severing in both legs of 24 chickens, the right and the left leg were treated differently, thereby creating two groups: Group I, in which the tenosynovium was preserved, and Group II, in which the tenosynovium was removed. Hematoxylin-eosin staining was performed to observe adhesions; immunohistochemical analysis was used to localize HA. HA production was noted in granulation tissue invading between the tendon stumps in both groups; however, HA expression in the tenosynovium was observed only in Group I where adhesion formation was minimal. The HA-producing tenosynovium plays a crucial role in preventing adhesion formation in this model of flexor tendon injuries.
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Affiliation(s)
- Masaharu Yagi
- Department of Orthopaedic Surgery, Kurume University, Fukuoka 830-0011, Japan
| | - Yasuhiro Mitsui
- Department of Orthopaedic Surgery, Kurume University Medical Center, Fukuoka 839-0863, Japan
| | - Masafumi Gotoh
- Department of Orthopaedic Surgery, Kurume University Medical Center, Fukuoka 839-0863, Japan
| | - Naoto Sato
- Department of Orthopaedic Surgery, Kurume University, Fukuoka 830-0011, Japan
| | - Kenji Yoshida
- Department of Orthopaedic Surgery, Kurume University, Fukuoka 830-0011, Japan
| | - Kensei Nagata
- Department of Orthopaedic Surgery, Kurume University, Fukuoka 830-0011, Japan
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20
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Chin L, Calabro A, Rodriguez ER, Tan CD, Walker E, Derwin KA. Characterization of and host response to tyramine substituted-hyaluronan enriched fascia extracellular matrix. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2011; 22:1465-1477. [PMID: 21553156 PMCID: PMC3245546 DOI: 10.1007/s10856-011-4325-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 04/18/2011] [Indexed: 05/30/2023]
Abstract
Naturally-occurring biomaterial scaffolds derived from extracellular matrix (ECM) have been previously investigated for soft tissue repair. We propose to enrich fascia ECM with high molecular weight tyramine substituted-hyaluronan (TS-HA) to modulate inflammation associated with implantation and enhance fibroblast infiltration. As critical determinants of constructive remodeling, the host inflammatory response and macrophage polarization to TS-HA enriched fascia were characterized in a rat abdominal wall model. TS-HA treated fascia with cross-linking had a similar lymphocyte (P = 0.11) and plasma cell (P = 0.13) densities, greater macrophage (P = 0.001) and giant cell (P < 0.0001) densities, and a lower density of fibroblast-like cells (P < 0.0001) than water treated controls. Treated fascia, with or without cross-linking, exhibited a predominantly M2 pro-remodeling macrophage profile similar to water controls (P = 0.82), which is suggestive of constructive tissue remodeling. Our findings demonstrated that HA augmentation can alter the host response to an ECM, but the appropriate concentration and molecular weight needed to minimize chronic inflammation within the scaffold remains to be determined.
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Affiliation(s)
- LiKang Chin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, ND20, Cleveland, OH 44195, USA. Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Anthony Calabro
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, ND20, Cleveland, OH 44195, USA
| | - E. Rene Rodriguez
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Carmela D. Tan
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Esteban Walker
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Kathleen A. Derwin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, ND20, Cleveland, OH 44195, USA
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