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Weng PW, Chen CH, Lin YC, Chen KH, Yeh YY, Lai JM, Chiang CJ, Wong CC. Platelet-Rich Fibrin-Augmented Gap-Bridging Strategy in Rabbit Anterior Cruciate Ligament Repair. Am J Sports Med 2023; 51:642-655. [PMID: 36752674 DOI: 10.1177/03635465221149993] [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] [Indexed: 02/09/2023]
Abstract
BACKGROUND We assessed the efficacy of a novel platelet-rich fibrin (PRF)-augmented repair strategy for promoting biological healing of an anterior cruciate ligament (ACL) midsubstance tear in a rabbit model. The biological gap-bridging effect of a PRF scaffold alone or in combination with rabbit ligamentocytes on primary ACL healing was evaluated both in vitro and in vivo. HYPOTHESIS A PRF matrix can be implanted as a provisional fibrin-platelet bridging scaffold at an ACL defect to facilitate functional healing. STUDY DESIGN Controlled laboratory study. METHODS The biological effects of PRF on primary rabbit ligamentocyte proliferation, tenogenic differentiation, migration, and tendon-specific matrix production were investigated for treatment of cells with PRF-conditioned medium (PRFM). Three-dimensional (3D) lyophilized PRF (LPRF)-cell composite was fabricated by culturing ligamentocytes on an LPRF patch for 14 days. Cell-scaffold interactions were investigated under a scanning electron microscope and through histological analysis. An ACL midsubstance tear model was established in 3 rabbit groups: a ruptured ACL was treated with isolated suture repair in group A, whereas the primary repair was augmented with LPRF and LPRF-cell composite to bridge the gap between ruptured ends of ligaments in groups B and C, respectively. Outcomes-gross appearance, magnetic resonance imaging, and histological analysis-were evaluated in postoperative weeks 8 and 12. RESULTS PRFM promoted cultured ligamentocyte proliferation, migration, and expression of tenogenic genes (type I and III collagen and tenascin). PRF was noted to upregulate cell tenogenic differentiation in terms of matrix production. In the 3D culture, viable cells formed layers at high density on the LPRF scaffold surface, with notable cell ingrowth and abundant collagenous matrix depositions. Moreover, ACL repair tissue and less articular cartilage damage were observed in knee joints in groups B and C, implying the existence of a chondroprotective phenomenon associated with PRF-augmented treatment. CONCLUSION Our PRF-augmented strategy can facilitate the formation of stable repair tissue and thus provide gap-bridging in ACL repair. CLINICAL RELEVANCE From the translational viewpoint, effective primary repair of the ACL may enable considerable advancement in therapeutic strategy for ACL injuries, particularly allowing for proprioception retention and thus improved physiological joint kinematics.
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Affiliation(s)
- Pei-Wei Weng
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hwa Chen
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Cheng Lin
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuan-Hao Chen
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Biomedical Materials and Engineering, Taipei Medical University, Taipei, Taiwan
| | - Yi-Yen Yeh
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jen-Ming Lai
- Department of Orthopaedic Surgery, Woodlands Health, Singapore
| | - Chang-Jung Chiang
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chin-Chean Wong
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Amini M, Venkatesan JK, Liu W, Leroux A, Nguyen TN, Madry H, Migonney V, Cucchiarini M. Advanced Gene Therapy Strategies for the Repair of ACL Injuries. Int J Mol Sci 2022; 23:ijms232214467. [PMID: 36430947 PMCID: PMC9695211 DOI: 10.3390/ijms232214467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/07/2022] [Accepted: 11/19/2022] [Indexed: 11/23/2022] Open
Abstract
The anterior cruciate ligament (ACL), the principal ligament for stabilization of the knee, is highly predisposed to injury in the human population. As a result of its poor intrinsic healing capacities, surgical intervention is generally necessary to repair ACL lesions, yet the outcomes are never fully satisfactory in terms of long-lasting, complete, and safe repair. Gene therapy, based on the transfer of therapeutic genetic sequences via a gene vector, is a potent tool to durably and adeptly enhance the processes of ACL repair and has been reported for its workability in various experimental models relevant to ACL injuries in vitro, in situ, and in vivo. As critical hurdles to the effective and safe translation of gene therapy for clinical applications still remain, including physiological barriers and host immune responses, biomaterial-guided gene therapy inspired by drug delivery systems has been further developed to protect and improve the classical procedures of gene transfer in the future treatment of ACL injuries in patients, as critically presented here.
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Affiliation(s)
- Mahnaz Amini
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Jagadeesh K. Venkatesan
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Wei Liu
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Amélie Leroux
- Laboratoire CSPBAT UMR CNRS 7244, Université Sorbonne Paris Nord, Avenue JB Clément, 93430 Villetaneuse, France
| | - Tuan Ngoc Nguyen
- Laboratoire CSPBAT UMR CNRS 7244, Université Sorbonne Paris Nord, Avenue JB Clément, 93430 Villetaneuse, France
| | - Henning Madry
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
| | - Véronique Migonney
- Laboratoire CSPBAT UMR CNRS 7244, Université Sorbonne Paris Nord, Avenue JB Clément, 93430 Villetaneuse, France
| | - Magali Cucchiarini
- Center of Experimental Orthopaedics, Saarland University Medical Center, Kirrbergerstr. Bldg 37, D-66421 Homburg, Germany
- Correspondence: or
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Second Generation of Tissue-Engineered Ligament Substitutes for Torn ACL Replacement: Adaptations for Clinical Applications. Bioengineering (Basel) 2021; 8:bioengineering8120206. [PMID: 34940359 PMCID: PMC8698634 DOI: 10.3390/bioengineering8120206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
The anterior cruciate ligament (ACL) of the knee joint is one of the strongest ligaments of the body and is often the target of traumatic injuries. Unfortunately, its healing potential is limited, and the surgical options for its replacement are frequently associated with clinical issues. A bioengineered ACL (bACL) was developed using a collagen matrix, seeded with autologous cells and successfully grafted and integrated into goat knee joints. We hypothesize that, in order to reduce the cost and simplify the model, an acellular bACL can be used as a substitute for a torn ACL, and bone plugs can be replaced by endobuttons to fix the bACL in situ. First, acellular bACLs were successfully grafted in the goat model with 18% recovery of ultimate tensile strength 6 months after implantation (94 N/mm2 vs. 520). Second, a bACL with endobuttons was produced and tested in an exvivo bovine knee model. The natural collagen scaffold of the bACL contributes to supporting host cell migration, growth and differentiation in situ post-implantation. Bone plugs were replaced by endobuttons to design a second generation of bACLs that offer more versatility as biocompatible grafts for torn ACL replacement in humans. A robust collagen bACL will allow solving therapeutic issues currently encountered by orthopedic surgeons such as donor-site morbidity, graft failure and post-traumatic osteoarthritis.
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Savić L, Augustyniak EM, Kastensson A, Snelling S, Abhari RE, Baldwin M, Price A, Jackson W, Carr A, Mouthuy PA. Early development of a polycaprolactone electrospun augment for anterior cruciate ligament reconstruction. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 129:112414. [PMID: 34579923 DOI: 10.1016/j.msec.2021.112414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
Despite the clinical success of Anterior Cruciate Ligament reconstruction (ACLR) in some patients, unsatisfactory clinical outcomes secondary to graft failure are seen, indicating the need to develop new regeneration strategies. The use of degradable and bioactive textiles has the potential to improve the biological repair of soft tissue. Electrospun (ES) filaments are particularly promising as they have the ability to mimic the structure of natural tissues and influence endogenous cell behaviour. In this study, we produced continuous polycaprolactone (PCL) ES filaments using a previously described electrospinning collection method. These filaments were stretched, twisted, and assembled into woven structures. The morphological, tensile, and biological properties of the woven fabric were then assessed. Scanning electron microscopy (SEM) images highlighted the aligned and ACL-like microfibre structure found in the stretched filaments. The tensile properties indicated that the ES fabric reached suitable strengths for a use as an ACLR augmentation device. Human ACL-derived cell cultured on the fabric showed approximately a 3-fold increase in cell number over 2 weeks and this was equivalent to a collagen coated synthetic suture commonly used in ACLR. Cells generally adopted a more elongated cell morphology on the ES fabric compared to the control suture, aligning themselves in the direction of the microfibres. A NRU assay confirmed that the ES fabric was non-cytotoxic according to regulatory standards. Overall, this study supports the development of ES textiles as augmentation devices for ACLR.
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Affiliation(s)
- Luka Savić
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Edyta M Augustyniak
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Adele Kastensson
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Snelling
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Roxanna E Abhari
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andrew Price
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - William Jackson
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andrew Carr
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Pierre-Alexis Mouthuy
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
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Looney AM, Leider JD, Horn AR, Bodendorfer BM. Bioaugmentation in the surgical treatment of anterior cruciate ligament injuries: A review of current concepts and emerging techniques. SAGE Open Med 2020; 8:2050312120921057. [PMID: 32435488 PMCID: PMC7222656 DOI: 10.1177/2050312120921057] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/22/2020] [Indexed: 12/27/2022] Open
Abstract
Injuries involving the anterior cruciate ligament are among the most common athletic injuries, and are the most common involving the knee. The anterior cruciate ligament is a key translational and rotational stabilizer of the knee joint during pivoting and cutting activities. Traditionally, surgical intervention in the form of anterior cruciate ligament reconstruction has been recommended for those who sustain an anterior cruciate ligament rupture and wish to remain active and return to sport. The intra-articular environment of the anterior cruciate ligament makes achieving successful healing following repair challenging. Historically, results following repair were poor, and anterior cruciate ligament reconstruction emerged as the gold-standard for treatment. While earlier literature reported high rates of return to play, the results of more recent studies with longer follow-up have suggested that anterior cruciate ligament reconstruction may not be as successful as once thought: fewer athletes are able to return to sport at their preinjury level, and many still go on to develop osteoarthritis of the knee at a relatively younger age. The four principles of tissue engineering (cells, growth factors, scaffolds, and mechanical stimuli) combined in various methods of bioaugmentation have been increasingly explored in an effort to improve outcomes following surgical treatment of anterior cruciate ligament injuries. Newer technologies have also led to the re-emergence of anterior cruciate ligament repair as an option for select patients. The different biological challenges associated with anterior cruciate ligament repair and reconstruction each present unique opportunities for targeted bioaugmentation strategies that may eventually lead to better outcomes with better return-to-play rates and fewer revisions.
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Affiliation(s)
| | - Joseph Daniel Leider
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, USA
| | - Andrew Ryan Horn
- Department of Orthopaedic Surgery, Georgetown University Medical Center, Washington, DC, USA
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Mahapatra P, Horriat S, Anand BS. Anterior cruciate ligament repair - past, present and future. J Exp Orthop 2018; 5:20. [PMID: 29904897 PMCID: PMC6002325 DOI: 10.1186/s40634-018-0136-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/31/2018] [Indexed: 12/14/2022] Open
Abstract
Background This article provides a detailed narrative review on the history and current concepts surrounding ligamentous repair techniques in athletic patients. In particular, we will focus on the anterior cruciate ligament (ACL) as a case study in ligament injury and ligamentous repair techniques. PubMed (MEDLINE), EMBASE and Cochrane Library databases for papers relating to primary anterior cruciate ligament reconstruction were searched by all participating authors. All relevant historical papers were included for analysis. Additional searches of the same databases were made for papers relating to biological enhancement of ligament healing. Current standard The poor capacity of the ACL to heal is one of the main reasons why the current gold standard surgical treatment for an ACL injury in an athletic patient is ACL reconstruction with autograft from either the hamstrings or patella tendon. It is hypothesised that by preserving and repairing native tissues and negating the need for autograft that primary ACL repair may represent a key step change in the treatment of ACL injuries. History of primary ACL repair The history of primary ACL repair will be discussed and the circumstances that led to the near-abandonment of primary ACL repair techniques will be reviewed. New primary repair techniques There has been a recent resurgence in interest with regards to primary ACL repair. Improvements in imaging now allow for identification of tear location, with femoral-sided injuries, being more suitable for repair. We will discuss in details strategies for improving the mechanical and biological environment in order to allow primary healing to occur. In particular, we will explain mechanical supplementation such as Internal Brace Ligament Augmentation and Dynamic Intraligamentary Stabilisation techniques. These are novel techniques that aim to protect the primary repair by providing a stabilising construct that connects the femur and the tibia, thus bridging the repair. Bio enhanced repair In addition, biological supplementation is being investigated as an adjunct and we will review the current literature with regards to bio-enhancement in the form platelet rich plasma, bio-scaffolds and stem cells. On the basis of current evidence, there appears to be a role for bio-enhancement, however, this is not yet translated into clinical practice. Conclusions Several promising avenues of further research now exist in the form of mechanical and biological augmentation techniques. Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair.
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Affiliation(s)
- Piyush Mahapatra
- Trauma and Orthopaedic Department, Croydon University Hospital, 530 London Road, London, CR7 7YE, UK.
| | - Saman Horriat
- Trauma and Orthopaedic Department, Croydon University Hospital, 530 London Road, London, CR7 7YE, UK
| | - Bobby S Anand
- Trauma and Orthopaedic Department, Croydon University Hospital, 530 London Road, London, CR7 7YE, UK
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Prządka P, Kiełbowicz Z, Osiński B, Dzimira S, Madej JA, Nowacki W, Kubiak K, Reichert P, Cegielski M. Reconstruction of cranial cruciate ligament in rabbits using polyester implants saturated with PRP, antlerogenic stem cells MIC-1 and their homogenate. Connect Tissue Res 2017; 58:464-478. [PMID: 27791406 DOI: 10.1080/03008207.2016.1251911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM OF THE STUDY The attempt to limit the negative effects of polyester implants on the articular cavity by using preparations containing growth factors. MATERIALS AND METHODS Polyester implants used for the reconstruction of a rabbit's cranial cruciate ligament (CCL) were saturated with autogenic platelet-rich plasma (PRP), antlerogenic stem cells MIC-1 and their homogenate prior to the surgery. Six months after CCL reconstruction, morphological, and biochemical blood tests were carried out, including proteinogram and acute phase proteins. The knee joints were also examined macro- and microscopically. RESULTS The results, compared to the control group, showed a favorable effect of the PRP and homogenate of antlerogenic cells on limiting the inflammation caused by the presence of polyester implant in the knee joint. The addition of growth factors caused covering the implant faster with the recipient's connective tissue, thus contributing to reducing the inflammatory reaction of the articular capsule to the presence of polyester. At the same time, no enhanced local or general reaction of the rabbit organism was observed to the presence of xenogenic antlerogenic stem cells MIC-1 homogenate which, like the PRP, may provide an easily available source of growth factors, increasingly often used in regenerative medicine. CONCLUSIONS Applying antlerogenic stem cells, their homogenate or PRP increases the volume of connective tissue that surrounds and intertwines polyester CCL implant, separating it from synovial cavity environment.
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Affiliation(s)
- Przemysław Prządka
- a Department of Surgery, Faculty of Veterinary Medicine , Wroclaw University of Environmental and Life Sciences , Wroclaw , Poland
| | - Zdzisław Kiełbowicz
- a Department of Surgery, Faculty of Veterinary Medicine , Wroclaw University of Environmental and Life Sciences , Wroclaw , Poland
| | - Bogdan Osiński
- a Department of Surgery, Faculty of Veterinary Medicine , Wroclaw University of Environmental and Life Sciences , Wroclaw , Poland
| | - Stanisław Dzimira
- b Department of Pathology , Wroclaw University of Environmental and Life Sciences , Wroclaw , Poland
| | - Janusz A Madej
- b Department of Pathology , Wroclaw University of Environmental and Life Sciences , Wroclaw , Poland
| | - Wojciech Nowacki
- c Department of Immunology, Pathophysiology and Preventive Medicine , Wroclaw University of Environmental and Life Sciences , Wroclaw , Poland
| | - Krzysztof Kubiak
- d Department of Internal Medicine and Clinic of Disease of Horses, Dogs and Cats , Wroclaw University of Environmental and Life Sciences , Wroclaw , Poland
| | - Paweł Reichert
- e Department and Clinic of Traumatology and Hand Surgery , Medical University of Wroclaw , Wroclaw , Poland
| | - Marek Cegielski
- f Department of Histology and Embryology , Medical University of Wroclaw , Wroclaw , Poland.,g Stem Cells Spin , Wroclaw , Poland
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Negahi Shirazi A, Chrzanowski W, Khademhosseini A, Dehghani F. Anterior Cruciate Ligament: Structure, Injuries and Regenerative Treatments. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 881:161-86. [PMID: 26545750 DOI: 10.1007/978-3-319-22345-2_10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Anterior cruciate ligament (ACL) is one of the most vulnerable ligaments of the knee. ACL impairment results in episodic instability, chondral and meniscal injury and early osteoarthritis. The poor self-healing capacity of ACL makes surgical treatment inevitable. Current ACL reconstructions include a substitution of torn ACL via biological grafts such as autograft, allograft. This review provides an insight of ACL structure, orientation and properties followed by comparing the performance of various constructs that have been used for ACL replacement. New approaches, undertaken to induce ACL regeneration and fabricate biomimetic scaffolds, are also discussed.
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Affiliation(s)
- Ali Negahi Shirazi
- School of Chemical and Biomolecular Engineering, University of Sydney, Sydney, NSW, 2006, Australia
| | | | - Ali Khademhosseini
- Center for Biomedical Engineering, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, MA, USA.,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Fariba Dehghani
- School of Chemical and Biomolecular Engineering, University of Sydney, Sydney, NSW, 2006, Australia. .,Department of Bioengineering, University of Sydney, Sydney, NSW, Australia.
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Hao ZC, Wang SZ, Zhang XJ, Lu J. Stem cell therapy: a promising biological strategy for tendon-bone healing after anterior cruciate ligament reconstruction. Cell Prolif 2016; 49:154-62. [PMID: 26929145 DOI: 10.1111/cpr.12242] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022] Open
Abstract
Tendon-bone healing after anterior cruciate ligament (ACL) reconstruction is a complex process, impacting significantly on patients' prognosis. Natural tendon-bone healing usually results in fibrous scar tissue, which is of inferior quality compared to native attachment. In addition, the early formed fibrous attachment after surgery is often not reliable to support functional rehabilitation, which may lead to graft failure or unsatisfied function of the knee joint. Thus, strategies to promote tendon-bone healing are crucial for prompt and satisfactory functional recovery. Recently, a variety of biological approaches, including active substances, gene transfer, tissue engineering and stem cells, have been proposed and applied to enhance tendon-bone healing. Among these, stem cell therapy has been shown to have promising prospects and draws increasing attention. From commonly investigated bone marrow-derived mesenchymal stem cells (bMSCs) to emerging ACL-derived CD34+ stem cells, multiple stem cell types have been proven to be effective in accelerating tendon-bone healing. This review describes the current understanding of tendon-bone healing and summarizes the current status of related stem cell therapy. Future limitations and perspectives are also discussed.
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Affiliation(s)
- Zi-Chen Hao
- Department of Orthopaedics, Zhongda Hospital, Medical School of Southeast University, Nanjing, 210009, China
| | - Shan-Zheng Wang
- Department of Orthopaedics, Zhongda Hospital, Medical School of Southeast University, Nanjing, 210009, China
| | - Xue-Jun Zhang
- Department of Orthopaedics, Zhongda Hospital, Medical School of Southeast University, Nanjing, 210009, China
| | - Jun Lu
- Department of Orthopaedics, Zhongda Hospital, Medical School of Southeast University, Nanjing, 210009, China.,Surgical Research Center, Medical School of Southeast University, Nanjing, 210009, China
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Chabaud S, Rousseau A, Marcoux TL, Bolduc S. Inexpensive production of near-native engineered stromas. J Tissue Eng Regen Med 2015; 11:1377-1389. [PMID: 26010652 DOI: 10.1002/term.2036] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 02/23/2015] [Accepted: 04/22/2015] [Indexed: 01/10/2023]
Abstract
Although the self-assembly approach is an efficient method for the production of engineered physiological and pathological tissues, avoiding the use of exogenous materials, it nevertheless remains expensive and requires dexterity, which are features incompatible with large-scale production. We propose a modification to this technique to make easier the production of mesenchymal compartment, to reduce the cost and to improve the histological quality of the self-assembled tissues. The stroma produced by this novel approach allowed epithelial cell differentiation, resulting in a pseudostratified epithelium that shared several features with native tissues. The incorporation of endothelial cells in the reconstructed mesenchyme formed a three-dimensional capillary-like network, positive for CD31 and von Willebrand factor and surrounded by NG2 positive cells. It could limit self-contraction of the resulting tissue by recruiting α-Smooth Muscle Actin positive cells. With this new technique, which is relatively inexpensive and easy to use in a research laboratory set-up, near-native stromas can now be produced with minimal handling time. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
| | | | | | - Stéphane Bolduc
- LOEX/CMDGT, Université Laval, Quebec, Canada
- Department of Surgery, Université Laval, Quebec, Canada
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Petrigliano FA, Arom GA, Nazemi AN, Yeranosian MG, Wu BM, McAllister DR. In vivo evaluation of electrospun polycaprolactone graft for anterior cruciate ligament engineering. Tissue Eng Part A 2015; 21:1228-36. [PMID: 25412879 DOI: 10.1089/ten.tea.2013.0482] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The anterior cruciate ligament (ACL) is critical for the structural stability of the knee and its injury often requires surgical intervention. Because current reconstruction methods using autograft or allograft tissue suffer from donor-site morbidity and limited supply, there has been emerging interest in the use of bioengineered materials as a platform for ligament reconstruction. Here, we report the use of electrospun polycaprolactone (PCL) scaffolds as a candidate platform for ACL reconstruction in an in vivo rodent model. Electrospun PCL was fabricated and laser cut to facilitate induction of cells and collagen deposition and used to reconstruct the rat ACL. Histological analysis at 2, 6, and 12 weeks postimplantation revealed biological integration, minimal immune response, and the gradual infiltration of collagen in both the bone tunnel and intra-articular regions of the scaffold. Biomechanical testing demonstrated that the PCL graft failure load and stiffness at 12 weeks postimplantation (13.27±4.20N, 15.98±5.03 N/mm) increased compared to time zero testing (3.95±0.33N, 1.95±0.35 N/mm). Taken together, these results suggest that electrospun PCL serves as a biocompatible graft for ACL reconstruction with the capacity to facilitate collagen deposition.
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Affiliation(s)
- Frank A Petrigliano
- 1 Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California at Los Angeles , Los Angeles, California
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Full SM, Delman C, Gluck JM, Abdmaulen R, Shemin RJ, Heydarkhan-Hagvall S. Effect of fiber orientation of collagen-based electrospun meshes on human fibroblasts for ligament tissue engineering applications. J Biomed Mater Res B Appl Biomater 2015; 103:39-46. [PMID: 24757041 PMCID: PMC7678503 DOI: 10.1002/jbm.b.33153] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 02/26/2014] [Accepted: 03/13/2014] [Indexed: 11/08/2022]
Abstract
Within the past two decades polylactic-co-glycolic acid (PLGA) has gained considerable attention as a biocompatible and biodegradable polymer that is suitable for tissue engineering and regenerative medicine. In this present study, we have investigated the potential of PLGA, collagen I (ColI), and polyurethane (PU) scaffolds for ligament tissue regeneration. Two different ratios of PLGA (50:50 and 85:15) were used to determine the effects on mechanical tensile properties and cell adhesion. The Young's modulus, tensile stress at yield, and ultimate tensile strain of PLGA(50:50)-ColI-PU scaffolds demonstrated similar tensile properties to that of ligaments found in the knee. Whereas, scaffolds composed of PLGA(85:15)-ColI-PU had lower tensile properties than that of ligaments. Furthermore, we investigated the effect of fiber orientation on mechanical properties and our results indicate that aligned fiber scaffolds demonstrate higher tensile properties than scaffolds with random fiber orientation. Also, human fibroblasts attached and proliferated with no need for additional surface modifications to the presented electrospun scaffolds in both categories. Collectively, our investigation demonstrates the effectiveness of electrospun PLGA scaffolds as a suitable candidate for regenerative medicine, capable of being manipulated and combined with other polymers to create three-dimensional microenvironments with adjustable tensile properties to mimic native tissues.
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Affiliation(s)
- Sean Michael Full
- Department of Surgery, Division Cardiothoracic Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
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Hammer N, Huster D, Fritsch S, Hädrich C, Koch H, Schmidt P, Sichting F, Wagner MFX, Boldt A. Do cells contribute to tendon and ligament biomechanics? PLoS One 2014; 9:e105037. [PMID: 25126746 PMCID: PMC4134275 DOI: 10.1371/journal.pone.0105037] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 07/18/2014] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Acellular scaffolds are increasingly used for the surgical repair of tendon injury and ligament tears. Despite this increased use, very little data exist directly comparing acellular scaffolds and their native counterparts. Such a comparison would help establish the effectiveness of the acellularization procedure of human tissues. Furthermore, such a comparison would help estimate the influence of cells in ligament and tendon stability and give insight into the effects of acellularization on collagen. MATERIAL AND METHODS Eighteen human iliotibial tract samples were obtained from nine body donors. Nine samples were acellularized with sodium dodecyl sulphate (SDS), while nine counterparts from the same donors remained in the native condition. The ends of all samples were plastinated to minimize material slippage. Their water content was adjusted to 69%, using the osmotic stress technique to exclude water content-related alterations of the mechanical properties. Uniaxial tensile testing was performed to obtain the elastic modulus, ultimate stress and maximum strain. The effectiveness of the acellularization procedure was histologically verified by means of a DNA assay. RESULTS The histology samples showed a complete removal of the cells, an extensive, yet incomplete removal of the DNA content and alterations to the extracellular collagen. Tensile properties of the tract samples such as elastic modulus and ultimate stress were unaffected by acellularization with the exception of maximum strain. DISCUSSION The data indicate that cells influence the mechanical properties of ligaments and tendons in vitro to a negligible extent. Moreover, acellularization with SDS alters material properties to a minor extent, indicating that this method provides a biomechanical match in ligament and tendon reconstruction. However, the given protocol insufficiently removes DNA. This may increase the potential for transplant rejection when acellular tract scaffolds are used in soft tissue repair. Further research will help optimize the SDS-protocol for clinical application.
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Affiliation(s)
- Niels Hammer
- Institute of Anatomy, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Daniel Huster
- Institute of Medical Physics and Biophysics, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Sebastian Fritsch
- Institute of Materials Science and Engineering, Chemnitz University of Technology, Chemnitz, Germany
| | - Carsten Hädrich
- Institute of Forensic Medicine, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Holger Koch
- Translational Centre for Regenerative Medicine, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Peter Schmidt
- Institute of Medical Physics and Biophysics, University of Leipzig, Faculty of Medicine, Leipzig, Germany
| | - Freddy Sichting
- Institute of Sport Science, Department Human Locomotion, Chemnitz University of Technology, Chemnitz, Germany
| | - Martin Franz-Xaver Wagner
- Institute of Materials Science and Engineering, Chemnitz University of Technology, Chemnitz, Germany
| | - Andreas Boldt
- Translational Centre for Regenerative Medicine, University of Leipzig, Faculty of Medicine, Leipzig, Germany
- Institute of Clinical Immunology, University of Leipzig, Faculty of Medicine, Leipzig, Germany
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da Silveira Franciozi CE, Ingham SJM, Gracitelli GC, Luzo MVM, Fu FH, Abdalla RJ. Updates in biological therapies for knee injuries: anterior cruciate ligament. Curr Rev Musculoskelet Med 2014; 7:228-38. [PMID: 25070265 DOI: 10.1007/s12178-014-9228-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
There have been many advances in anterior cruciate ligament reconstruction (ACLR) techniques incorporating biological treatment. The aim of this review is to discuss the recent contributions that may enlighten our understanding of biological therapies for anterior cruciate ligament (ACL) injuries and improve management decisions involving these enhancement options. Three main biological procedures will be analyzed: bio-enhanced ACL repair, bio-enhanced ACLR scrutinized under the four basic principles of tissue engineering (scaffolds, cell sources, growth factors/cytokines including platelet-rich plasma, and mechanical stimuli), and remnant-preserving ACLR. There is controversial information regarding remnant-preserving ACLR, since different procedures are grouped under the same designation. A new definition for remnant-preserving ACLR surgery is proposed, dividing it into its three major procedures (selective bundle augmentation, augmentation, and nonfunctional remnant preservation); also, an ACL lesion pattern classification and a treatment algorithm, which will hopefully standardize these terms and procedures for future studies, are presented.
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Affiliation(s)
- Carlos Eduardo da Silveira Franciozi
- Department of Orthopaedic Surgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Borges Lagoa, 783-5°Andar, Vila Clementino, 04038-032, São Paulo, SP, Brazil,
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15
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Abstract
Injury to the anterior cruciate ligament (ACL) is one of the most devastating and frequent injuries of the knee. Surgical reconstruction is the current standard of care for treatment of ACL injuries in active patients. The widespread adoption of ACL reconstruction over primary repair was based on early perception of the limited healing capacity of the ACL. Although the majority of ACL reconstruction surgeries successfully restore gross joint stability, post-traumatic osteoarthritis is commonplace following these injuries, even with ACL reconstruction. The development of new techniques to limit the long-term clinical sequelae associated with ACL reconstruction has been the main focus of research over the past decades. The improved knowledge of healing, along with recent advances in tissue engineering and regenerative medicine, has resulted in the discovery of novel biologically augmented ACL-repair techniques that have satisfactory outcomes in preclinical studies. This instructional review provides a summary of the latest advances made in ACL repair. Cite this article: Bone Joint Res 2014;3:20-31.
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Affiliation(s)
- A M Kiapour
- Boston Children's Hospital, Harvard MedicalSchool, Sports Medicine Research Laboratory, Departmentof Orthopaedic Surgery, 300 Longwood Avenue, Boston, Massachusetts 02115, USA
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16
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Leong NL, Petrigliano FA, McAllister DR. Current tissue engineering strategies in anterior cruciate ligament reconstruction. J Biomed Mater Res A 2013; 102:1614-24. [DOI: 10.1002/jbm.a.34820] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/21/2013] [Accepted: 05/22/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Natalie L. Leong
- Department of Orthopaedic Surgery; David Geffen School of Medicine at UCLA; Los Angeles California
| | - Frank A. Petrigliano
- Department of Orthopaedic Surgery; David Geffen School of Medicine at UCLA; Los Angeles California
| | - David R. McAllister
- Department of Orthopaedic Surgery; David Geffen School of Medicine at UCLA; Los Angeles California
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Cai C, Chen C, Chen G, Wang F, Guo L, Yin L, Feng D, Yang L. Type I collagen and polyvinyl alcohol blend fiber scaffold for anterior cruciate ligament reconstruction. Biomed Mater 2013; 8:035001. [PMID: 23531980 DOI: 10.1088/1748-6041/8/3/035001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The aim of this study was to perform an evaluation of a braided fiber scaffold for anterior cruciate ligament (ACL) reconstruction. The scaffold was composed of 50% type I collagen (Col-I) and 50% polyvinyl alcohol (PVA). First, the biocompatibility and in vitro weight loss of the scaffold were tested. Then, the scaffolds were used to reconstruct the ACL in China Bama mimi pigs. At 24 weeks post-operation, the mechanical properties and histology of the regenerated ACL were analyzed. The maximum load and tensile strength were 472.43± 15.2 N and 29.71± 0.96 MPa, respectively; both were ~75% of those of native ACL and ~90% of those of fiber scaffold. This indicated that the scaffold maintained a large portion of native ACL's mechanical properties, and tissue formation on the scaffold compensated most of the tensile strength loss caused by scaffold degradation. Histology and immunohistology analysis showed the morphology and major extracellular matrix components of the regenerated ligament resembled the native ACL. Thus, the Col-I/PVA blend fiber ACL scaffold showed good potential for clinical applications.
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Affiliation(s)
- Changbin Cai
- Center for Joint Surgery, Southwest Hospital, the Third Military Medical University, Chongqing 400038, People's Republic of China
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Chabaud S, Marcoux TL, Deschênes-Rompré MP, Rousseau A, Morissette A, Bouhout S, Bernard G, Bolduc S. Lysophosphatidic acid enhances collagen deposition and matrix thickening in engineered tissue. J Tissue Eng Regen Med 2013; 9:E65-75. [DOI: 10.1002/term.1711] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 10/28/2012] [Accepted: 12/20/2012] [Indexed: 12/29/2022]
Affiliation(s)
- Stéphane Chabaud
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
| | - Thomas-Louis Marcoux
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
| | - Marie-Pier Deschênes-Rompré
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
| | - Alexandre Rousseau
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
| | - Amélie Morissette
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
| | - Sara Bouhout
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
| | - Geneviève Bernard
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
| | - Stéphane Bolduc
- Centre LOEX de l'Université Laval, Génie tissulaire et régénération: LOEX du Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Département de Chirurgie, Faculté de Médecine; Université Laval; Québec QC Canada
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Yoshida R, Vavken P, Murray MM. Decellularization of bovine anterior cruciate ligament tissues minimizes immunogenic reactions to alpha-gal epitopes by human peripheral blood mononuclear cells. Knee 2012; 19:672-5. [PMID: 21925883 PMCID: PMC3243811 DOI: 10.1016/j.knee.2011.08.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 07/25/2011] [Accepted: 08/09/2011] [Indexed: 02/02/2023]
Abstract
Rupture of ACL is a common injury. While the current surgical treatments are effective, many patients still suffer from precocious osteoarthritis, and there is an increasing interest in bioengineering approaches to improve ACL repair. Bovine collagen is a material currently in use for tissue engineering of ligaments. The alpha-gal epitopes found on bovine cells are a source of immunogenic stimulus for human cells. In this study, we wished to determine if those epitopes could be removed sufficiently to mitigate an immunogenic response using either a decellularization protocol or decellularization followed by alpha-galactosidase treatment. Bovine ACLs were treated with Triton-X, sodium deoxycholate, ribonuclease, and deoxyribonuclease to remove cells. A subset of the decellularized tissues was further treated with alpha-galactosidase. Human peripheral blood mononuclear cells (PBMCs) were exposed to untreated, decellularized, and alpha-galactosidase-treated tissues, and PBMC migration and IL-6 release were measured. PBMCs were significantly more attracted to untreated ACL compared to decellularized or alpha-galactosidase-treated tissue, but no difference was seen between the two treatment groups. PBMCs also released significantly more IL-6 when exposed to untreated tissue compared to decellularized ACL or alpha-galactosidase-treated ACL, but no difference was seen between the two treatment groups. Immunohistochemistry using anti-alpha-gal antibody detected the epitopes throughout the untreated ACL, but similar areas of reaction were not seen on decellularized or alpha-galactosidase-treated ACL. These results suggest that our decellularization protocol minimizes the immunogenic reactions of human PBMCs to bovine ACL tissue. Therefore, decellularized bovine ACL tissue may be a safe, effective biomaterial for ACL injury treatments.
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Affiliation(s)
- Ryu Yoshida
- Department of Orthopaedic Surgery, Children's Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Enders 270.4, Boston, MA 02115, USA
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Ulery BD, Nair LS, Laurencin CT. Biomedical Applications of Biodegradable Polymers. JOURNAL OF POLYMER SCIENCE. PART B, POLYMER PHYSICS 2011; 49:832-864. [PMID: 21769165 PMCID: PMC3136871 DOI: 10.1002/polb.22259] [Citation(s) in RCA: 1179] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Utilization of polymers as biomaterials has greatly impacted the advancement of modern medicine. Specifically, polymeric biomaterials that are biodegradable provide the significant advantage of being able to be broken down and removed after they have served their function. Applications are wide ranging with degradable polymers being used clinically as surgical sutures and implants. In order to fit functional demand, materials with desired physical, chemical, biological, biomechanical and degradation properties must be selected. Fortunately, a wide range of natural and synthetic degradable polymers has been investigated for biomedical applications with novel materials constantly being developed to meet new challenges. This review summarizes the most recent advances in the field over the past 4 years, specifically highlighting new and interesting discoveries in tissue engineering and drug delivery applications.
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Affiliation(s)
- Bret D. Ulery
- Department of Orthopaedic Surgery, New England Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut 06030
- Institute of Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut 06030
| | - Lakshmi S. Nair
- Department of Orthopaedic Surgery, New England Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut 06030
- Institute of Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut 06030
- Department of Chemical, Materials & Biomolecular Engineering, University of Connecticut, Storrs, Connecticut 06268
| | - Cato T. Laurencin
- Department of Orthopaedic Surgery, New England Musculoskeletal Institute, University of Connecticut Health Center, Farmington, Connecticut 06030
- Institute of Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut 06030
- Department of Chemical, Materials & Biomolecular Engineering, University of Connecticut, Storrs, Connecticut 06268
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