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Hada S, Hada M, Yoshida K, Kaneko H, Saita Y, Kubota M, Ishijima M. Conservative Treatment Using Platelet-Rich Plasma for Acute Anterior Cruciate Ligament Injuries in Highly Active Patients: A Retrospective Survey. Cureus 2024; 16:e53102. [PMID: 38414705 PMCID: PMC10898500 DOI: 10.7759/cureus.53102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 02/29/2024] Open
Abstract
Background The recommended treatment for anterior cruciate ligament (ACL) injuries in active, sports-oriented patients is reconstructive surgery in order to regain stability and prevent secondary meniscal injuries. However, ACL reconstruction requires a long recovery period and poses issues such as decreased muscle strength due to tendon harvesting and postoperative osteoarthritis (OA) progression, thereby raising significant expectations for the advancement of conservative treatments. Recent studies have shown that platelet-rich plasma (PRP) therapy, which utilizes the tissue repair-promoting property of platelets, is effective for ACL injuries. Methods We administered PRP therapy within six weeks after ACL injury in patients who expressed the desire for an early return to sports through conservative care. After the treatment, patients wore a simple brace that limited deep flexion but placed no restrictions on weight bearing. Four months was the standard goal established for returning to pre-injury condition, and, depending on the target level, timing, and knee condition, we adjusted the additional PRP treatments and rehabilitation approach, gradually authorizing the patients' return to sport. We assessed the ligament repair status by magnetic resonance imaging (MRI) just before the full return to sports. A retrospective survey was conducted to evaluate the status of ligament repair and the condition of return-to-sport in patients with ACL injuries who underwent conservative treatment using PRP. Results The average patient age was 32.7 years and the average treatment was 2.8 PRP sessions. MRI evaluations confirmed that ligament continuity was regained in all cases. All the patients returned to their pre-injury level (Tegner Activity Scale 7.0) in an average of 139.5 days, but there was one instance of re-rupture following the return to sports. Conclusion All patients with ACL injury who underwent PRP therapy regained ligament continuity and returned to sport successfully with only one case of re-rupture.
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Affiliation(s)
- Shinnosuke Hada
- Department of Orthopaedics, Juntendo University, Tokyo, JPN
- Department of Orthopaedics, Hada Medical Clinic, Tokyo, JPN
| | - Masao Hada
- Department of Internal Medicine, Hada Medical Clinic, Tokyo, JPN
| | | | - Haruka Kaneko
- Department of Orthopaedics, Juntendo University, Tokyo, JPN
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Park J, Soh H, Jo S, Weon S, Lee SH, Park JA, Lee MK, Kim TH, Sung IH, Lee JK. Scaffold-induced compression enhances ligamentization potential of decellularized tendon graft reseeded with ACL-derived cells. iScience 2023; 26:108521. [PMID: 38162024 PMCID: PMC10755058 DOI: 10.1016/j.isci.2023.108521] [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: 06/15/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024] Open
Abstract
Anterior cruciate ligament (ACL) reconstruction is often performed using a tendon graft. However, the predominant synthesis of fibrotic scar tissue (type III collagen) occurs during the healing process of the tendon graft, resulting in a significantly lower mechanical strength than that of normal ACL tissue. In this study, ACL-derived cells were reseeded to the tendon graft, and scaffold-induced compression was applied to test whether the compressive force results in superior cell survival and integration. Given nanofiber polycaprolactone (PCL) scaffold-induced compression, ACL-derived cells reseeded to a tendon graft demonstrated superior cell survival and integration and resulted in higher gene expression levels of type I collagen compared to non-compressed cell-allograft composites in vitro. Translocation of Yes-associated protein (YAP) into the nucleus was correlated with higher expression of type I collagen in the compression group. These data support the hypothesis of a potential role of mechanotransduction in the ligamentization process.
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Affiliation(s)
- Jinsung Park
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Hyunsoo Soh
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, Republic of Korea
| | - Sungsin Jo
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Subin Weon
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Seung Hoon Lee
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Jeong-Ah Park
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
| | - Myung-Kyu Lee
- Department of Research and Development, Korea Public Tissue Bank, Seongnam-si, Gyeonggi-do, Korea
| | - Tae-Hwan Kim
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Disease, Seoul, Republic of Korea
| | - Il-Hoon Sung
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, Republic of Korea
| | - Jin Kyu Lee
- Hanyang University Institute for Rheumatology Research, Seoul, Republic of Korea
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, Republic of Korea
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Burgio V, Casari S, Milizia M, Sanna F, Spezia G, Civera M, Rodriguez Reinoso M, Bertuglia A, Surace C. Mechanical properties of animal ligaments: a review and comparative study for the identification of the most suitable human ligament surrogates. Biomech Model Mechanobiol 2023; 22:1645-1683. [PMID: 37169958 PMCID: PMC10511400 DOI: 10.1007/s10237-023-01718-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/29/2023] [Indexed: 05/13/2023]
Abstract
The interest in the properties of animal soft tissues is often related to the desire to find an animal model to replace human counterparts due to the unsteady availability of human tissues for experimental purposes. Once the most appropriate animal model is identified, it is possible to carry out ex-vivo and in-vivo studies for the repair of ligamentous tissues and performance testing of replacement and support healing devices. This work aims to present a systematic review of the mechanical properties of ligaments reported in the scientific literature by considering different anatomical regions in humans and several animal species. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. Moreover, considering the lack of a standard protocol for preconditioning of tissues, this aspect is also addressed. Ninety-six studies were selected for the systematic review and analysed. The mechanical properties of different animal species are reported and summarised in tables. Only results from studies reporting the strain rate parameter were considered for comparison with human ligaments, as they were deemed more reliable. Elastic modulus, ultimate tensile stress, and ultimate strain properties are graphically reported identifying the range of values for each animal species and to facilitate comparison between values reported in the scientific literature in animal and human ligaments. Useful similarities between the mechanical properties of swine, cow, and rat and human ligaments have been found.
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Affiliation(s)
- V. Burgio
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - S. Casari
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - M. Milizia
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - F. Sanna
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - G. Spezia
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - M. Civera
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - M. Rodriguez Reinoso
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - A. Bertuglia
- Department of Veterinary Science, University of Turin, Largo Paolo Braccini 2-5, 10095 Grugliasco, Italy
| | - C. Surace
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
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Natural, synthetic and commercially-available biopolymers used to regenerate tendons and ligaments. Bioact Mater 2023; 19:179-197. [PMID: 35510172 PMCID: PMC9034322 DOI: 10.1016/j.bioactmat.2022.04.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/15/2022] [Accepted: 04/04/2022] [Indexed: 12/26/2022] Open
Abstract
Tendon and ligament (TL) injuries affect millions of people annually. Biopolymers play a significant role in TL tissue repair, whether the treatment relies on tissue engineering strategies or using artificial tendon grafts. The biopolymer governs the mechanical properties, biocompatibility, degradation, and fabrication method of the TL scaffold. Many natural, synthetic and hybrid biopolymers have been studied in TL regeneration, often combined with therapeutic agents and minerals to engineer novel scaffold systems. However, most of the advanced biopolymers have not advanced to clinical use yet. Here, we aim to review recent biopolymers and discuss their features for TL tissue engineering. After introducing the properties of the native tissue, we discuss different types of natural, synthetic and hybrid biopolymers used in TL tissue engineering. Then, we review biopolymers used in commercial absorbable and non-absorbable TL grafts. Finally, we explain the challenges and future directions for the development of novel biopolymers in TL regenerative treatment. Both natural and synthetic biopolymers are reviewed for regeneration of TL and their interface tissues. Advances on hybrid-composite biopolymers to fabricate TL scaffolds were reviewed. The current biopolymers used in commercial TL grafts are discussed. The challenges and emerging strategies for biopolymer development are presented.
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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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Park J, Jo S, Lee MK, Kim TH, Sung IH, Lee JK. Comparison of ligamentization potential between anterior cruciate ligament-derived cells and adipose-derived mesenchymal stem cells reseeded to acellularized tendon allograft. Bone Joint Res 2022; 11:777-786. [DOI: 10.1302/2046-3758.1111.bjr-2021-0548.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Aims To test the hypothesis that reseeded anterior cruciate ligament (ACL)-derived cells have a better ability to survive and integrate into tendon extracellular matrix (ECM) and accelerate the ligamentization process, compared to adipose-derived mesenchymal stem cells (ADMSCs). Methods Acellularized tibialis allograft tendons were used. Tendons were randomly reseeded with ACL-derived cells or ADMSCs. ACL-derived cells were harvested and isolated from remnants of ruptured ACLs during reconstruction surgery and cultured at passage three. Cell suspensions (200 µl) containing 2 × 106 ACL-derived cells or ADMSCs were prepared for the purpose of reseeding. At days 1, 3, and 7 post-reseeding, graft composites were assessed for repopulation with histological and immunohistochemical analysis. Matrix protein contents and gene expression levels were analyzed. Results In the graft reseeded with ACL-derived cells, a large number of elongated cells that integrated into the matrix were evident at day 3 and day 7. However, in the graft reseeded with ADMSCs, only a small number of elongated cells were found integrated into the matrix. Immunofluorescence for Ki-67 and type I collagen confirmed the pronounced production of type I collagen by Ki-67-positive ACL-derived cells integrated into the ECM. A messenger RNA (mRNA) expression assay demonstrated significantly higher gene expression levels of types I (p = 0.013) and III (p = 0.050) collagen in the composites reseeded with ACL-derived cells than ADMSCs. Conclusion ACL-derived cells, when reseeded to acellularized tendon graft, demonstrated earlier better survival and integration in the tendon ECM and resulted in higher gene expression levels of collagen, which may be essential to the normal ligamentization process compared to ADMSCs. Cite this article: Bone Joint Res 2022;11(11):777–786.
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Affiliation(s)
- Jinsung Park
- Hanyang University Institute for Rheumatology Research (HYIRR), Seoul, South Korea
- Department of Translational Medicine, Graduate School of Biomedical Science and Engineering, Hanyang University, Seoul, South Korea
| | - Sungsin Jo
- Hanyang University Institute for Rheumatology Research (HYIRR), Seoul, South Korea
| | - Myung-Kyu Lee
- Department of Research and Development, Korea Public Tissue Bank, Seongnam-si, South Korea
| | - Tae-Hwan Kim
- Hanyang University Institute for Rheumatology Research (HYIRR), Seoul, South Korea
- Department of Translational Medicine, Graduate School of Biomedical Science and Engineering, Hanyang University, Seoul, South Korea
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Il-Hoon Sung
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea
| | - Jin K. Lee
- Department of Orthopaedic Surgery, Hanyang University Hospital, Seoul, South Korea
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Hada S, Ishijima M, Omiya H, Tomita Y, Hada M. Two cases of contact athletes with anterior cruciate ligament injuries who returned to competition early after conservative treatment with PRP therapy. Int J Surg Case Rep 2022. [PMCID: PMC9168593 DOI: 10.1016/j.ijscr.2022.107268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction Presentation of case Discussion Conclusion Conservative treatment of ACL injuries with platelet-rich plasma Two cases of aggressive conservative treatment of contact athletes with PRP therapy They returned to the same preinjury level as early as 4 and 3.5 months. Their functional score exceeded the median score of ACL reconstructed athletes. The growth factors in PRP may promote graft maturation of ruptured ACL.
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Affiliation(s)
- Shinnosuke Hada
- Dept. of Orthopaedic Surgery, Tokyo Rosai Hospital, Tokyo, Japan
- Dept. of Orthopaedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Hada Medical Clinic, Tokyo, Japan
- Corresponding author at: Department of Orthopaedics, Tokyo Rosai Hospital, 4-13-21, Oomoriminami, Ota-ku, Tokyo 143-0013, Japan.
| | - Muneaki Ishijima
- Dept. of Orthopaedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Hiroyuki Omiya
- Dept. of Rehabilitation, Tokyo Rosai Hospital, Tokyo, Japan
| | - Yoshimasa Tomita
- Dept. of Orthopaedic Surgery, Tokyo Rosai Hospital, Tokyo, Japan
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Calejo I, Reis RL, Domingues RMA, Gomes ME. Texturing Hierarchical Tissues by Gradient Assembling of Microengineered Platelet-Lysates Activated Fibers. Adv Healthc Mater 2022; 11:e2102076. [PMID: 34927396 DOI: 10.1002/adhm.202102076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/14/2021] [Indexed: 11/07/2022]
Abstract
The heterogeneity of hierarchical tissues requires designing multipart engineered constructs as suitable tissue replacements. Herein, the incorporation of platelet lysate (PL) within an electrospun fiber core is proposed aiming for the fabrication of functionally graded 3D scaffolds for heterotypic tissues regeneration, such as tendon-to-bone interfaces. First, anisotropic yarns (A-Yarns) and isotropic threads with nanohydroxyapatite (I-Threads/PL@nHAp) are fabricated to recreate the tendon- and bone-microstructures and both incorporated with PL using emulsion electrospinning for a sustained and local delivery of growth factors, cytokines, and chemokines. Biological performance using human adipose-derived stem cells demonstrates that A-Yarns/PL induce a higher expression of scleraxis, a tenogenic-marker, while in I-Threads/PL@nHAp, higher alkaline phosphatase activity and matrix mineralization suggest an osteogenic commitment without the need for biochemical supplementation compared to controls. As a proof-of-concept, functional 3D gradient scaffolds are fabricated using a weaving technique, resulting in 3D textured hierarchical constructs with gradients in composition and topography. Additionally, the precise delivery of bioactive cues together with in situ biophysical features guide the commitment into a phenotypic gradient exhibiting chondrogenic and osteochondrogenic profiles in the interface of scaffolds. Overall, a promising patch solution for the regeneration of tendon-to-bone tissue interface through the fabrication of PL-functional 3D gradient constructs is demonstrated.
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Affiliation(s)
- Isabel Calejo
- 3B's Research Group i3Bs – Research Institute on Biomaterials, Biodegradables and Biomimetics University of Minho Barco Guimarães 4805‐017 Portugal
| | - Rui L. Reis
- 3B's Research Group i3Bs – Research Institute on Biomaterials, Biodegradables and Biomimetics University of Minho Barco Guimarães 4805‐017 Portugal
| | - Rui M. A. Domingues
- 3B's Research Group i3Bs – Research Institute on Biomaterials, Biodegradables and Biomimetics University of Minho Barco Guimarães 4805‐017 Portugal
| | - Manuela E. Gomes
- 3B's Research Group i3Bs – Research Institute on Biomaterials, Biodegradables and Biomimetics University of Minho Barco Guimarães 4805‐017 Portugal
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Yao S, Yung PSH, Lui PPY. Tackling the Challenges of Graft Healing After Anterior Cruciate Ligament Reconstruction-Thinking From the Endpoint. Front Bioeng Biotechnol 2022; 9:756930. [PMID: 35004636 PMCID: PMC8727521 DOI: 10.3389/fbioe.2021.756930] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/09/2021] [Indexed: 12/30/2022] Open
Abstract
Anterior cruciate ligament (ACL) tear is common in sports and accidents, and accounts for over 50% of all knee injuries. ACL reconstruction (ACLR) is commonly indicated to restore the knee stability, prevent anterior–posterior translation, and reduce the risk of developing post-traumatic osteoarthritis. However, the outcome of biological graft healing is not satisfactory with graft failure after ACLR. Tendon graft-to-bone tunnel healing and graft mid-substance remodeling are two key challenges of biological graft healing after ACLR. Mounting evidence supports excessive inflammation due to ACL injury and ACLR, and tendon graft-to-bone tunnel motion negatively influences these two key processes. To tackle the problem of biological graft healing, we believe that an inductive approach should be adopted, starting from the endpoint that we expected after ACLR, even though the results may not be achievable at present, followed by developing clinically practical strategies to achieve this ultimate goal. We believe that mineralization of tunnel graft and ligamentization of graft mid-substance to restore the ultrastructure and anatomy of the original ACL are the ultimate targets of ACLR. Hence, strategies that are osteoinductive, angiogenic, or anti-inflammatory should drive graft healing toward the targets. This paper reviews pre-clinical and clinical literature supporting this claim and the role of inflammation in negatively influencing graft healing. The practical considerations when developing a biological therapy to promote ACLR for future clinical translation are also discussed.
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Affiliation(s)
- Shiyi Yao
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Patrick Shu Hang Yung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Pauline Po Yee Lui
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
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10
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Yao SY, Cao MD, He X, Fu BSC, Yung PSH. Biological modulations to facilitate graft healing in anterior cruciate ligament reconstruction (ACLR), when and where to apply? A systematic review. J Orthop Translat 2021; 30:51-60. [PMID: 34611514 PMCID: PMC8458724 DOI: 10.1016/j.jot.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background When and where to apply the biological modulations is effective to promote healing in the anterior cruciate ligament (ACL) reconstruction remains unclear. Purpose To perform a systematic review of preclinical animal studies on biological modulation in anterior cruciate ligament reconstruction (ACLR) concerning the time and site of delivery. Study design Systematic review of controlled laboratory studies. Methods PubMed, Ovid, and Scopus were searched until December 2020 using a combination of keywords and their synonym to retrieve all animal studies about biological modulation in ACLR. Studies that assessed mechanical strength after ACLR and compared with negative control were included. The methodological quality of animal studies was evaluated. Results 33 studies were included in this review and the majority reported mechanical strength improvement. 79 % of studies applied the biological modulations intra-operatively with different delivery systems used. For 21 % of post-operative delivery studies, intermittent delivery was tried. 21 of the included studies directly applied the biological modulations in the bone tunnels, 5 studies applied intra-articularly while 7 studies applied both in the bone tunnels and intra-articular part. Biological modulations applied intra-operatively and those applied in both parts showed better mechanical strength increase. A shift of the failure mode of pull-out from the bone tunnel in the early healing phase, to mid-substance rupture in the later phase was observed in most studies. Conclusion The improvement of the mechanical strength depends on how the biological modulations (delivery phase, delivery site, delivery form) are applied. The intra-operative delivery showed an overall higher mechanical strength increase and bone tunnel only delivery or intra-articular and bone tunnel both delivery are preferred than intra-articular only delivery. In addition, intra-articular and bone tunnel both delivery can have better mechanical strength increase for a long follow-up time. Thus, intra-operative application with a carrier to control release rate in both parts should be recommended. Further studies are needed to achieve a better healing outcome and more attention should be given to the intra-articular remodeling of the graft along with the tendon bone healing to increase the final mechanical strength. The Translational potential of this article Here, a systematic review of preclinical evidence of the time, site and the method the biological modulations being applied for ACLR to improve the graft healing would be performed. After reviewing the available studies, a choice of when and where to apply the biological modulations can achieve better mechanical strength after ACLR can be obtained. It provides evidence for both researchers and clinicians to decide when and where to apply the biological modulations can achieve their best effectiveness for ACLR before implementing. Promoting graft healing with targeted time and targeted site may reduce the risk of graft failure, safeguard return to sport.
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Affiliation(s)
- S Y Yao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - M D Cao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - X He
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Bruma S C Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Patrick S H Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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11
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Millan SM, Thorn D, Ford E. A Novel Approach to Augmenting Allograft Hamstring Anterior Cruciate Ligament Reconstructions Utilizing a Resorbable Type I Collagen Matrix with Platelet Rich Plasma. Case Rep Orthop 2021; 2021:5574676. [PMID: 33777468 PMCID: PMC7972856 DOI: 10.1155/2021/5574676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/06/2021] [Accepted: 03/03/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is one of the most common lower extremity orthopedic surgeries performed in the United States. Annually, between 100,000 and 200,000 ACL tears affect 1 in 3,000 people. The selection of autograft versus allograft for ACLR has been widely discussed in terms of risk of graft failure. Allograft reconstructions have been shown to have higher rerupture rates. One factor contributing to this risk is delayed biologic graft incorporation. METHODS A retrospective review was performed examining 14 patients who underwent an augmented quadruple-stranded hamstring allograft ACLR with a type I resorbable collagen matrix impregnated with platelet-rich plasma (PRP). RESULTS Within our clinical practice, the augmentation of quadruple-stranded hamstring allograft ACLR with a type I resorbable matrix impregnated with PRP has yielded good early clinical success at 2-year outcomes (N = 14). Zero ACLR failures have been reported to date in this series. CONCLUSION This case series offers a novel approach for soft tissue allograft ACLR augmented with a type I collagen matrix impregnated with PRP. The authors theorize that this augmentation may improve biologic graft incorporation into the host bone tunnels.
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Affiliation(s)
- Sean Mc Millan
- Department of Orthopedics, Virtua Health System, 2103 Burlington-Mount Holly Rd, Burlington, NJ 08016, USA
| | - Danielle Thorn
- Department of Orthopedics, Virtua Health System, Burlington, NJ, USA
| | - Elizabeth Ford
- Department of Orthopedics, Inspira Health System, Vineland, NJ, USA
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12
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Shiroud Heidari B, Ruan R, De-Juan-Pardo EM, Zheng M, Doyle B. Biofabrication and Signaling Strategies for Tendon/Ligament Interfacial Tissue Engineering. ACS Biomater Sci Eng 2021; 7:383-399. [PMID: 33492125 DOI: 10.1021/acsbiomaterials.0c00731] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tendons and ligaments (TL) have poor healing capability, and for serious injuries like tears or ruptures, surgical intervention employing autografts or allografts is usually required. Current tissue replacements are nonideal and can lead to future problems such as high retear rates, poor tissue integration, or heterotopic ossification. Alternatively, tissue engineering strategies are being pursued using biodegradable scaffolds. As tendons connect muscle and bone and ligaments attach bones, the interface of TL with other tissues represent complex structures, and this intricacy must be considered in tissue engineered approaches. In this paper, we review recent biofabrication and signaling strategies for biodegradable polymeric scaffolds for TL interfacial tissue engineering. First, we discuss biodegradable polymeric scaffolds based on the fabrication techniques as well as the target tissue application. Next, we consider the effect of signaling factors, including cell culture, growth factors, and biophysical stimulation. Then, we discuss human clinical studies on TL tissue healing using commercial synthetic scaffolds that have occurred over the past decade. Finally, we highlight the challenges and future directions for biodegradable scaffolds in the field of TL and interface tissue engineering.
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Affiliation(s)
- Behzad Shiroud Heidari
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, Nedlands, Western Australia 6009, Australia.,School of Engineering, The University of Western Australia, Perth, Western Australia 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia
| | - Rui Ruan
- Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia 6009, Australia
| | - Elena M De-Juan-Pardo
- School of Engineering, The University of Western Australia, Perth, Western Australia 6009, Australia.,T3mPLATE, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, Nedlands, Western Australia 6009, Australia.,Science and Engineering Faculty, Queensland University of Technology, Brisbane, Queensland, 4000, Australia
| | - Minghao Zheng
- Centre for Orthopaedic Research, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia 6009, Australia.,Perron Institute for Neurological and Translational Science, Nedlands, Western Australia 6009, Australia
| | - Barry Doyle
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, Nedlands, Western Australia 6009, Australia.,School of Engineering, The University of Western Australia, Perth, Western Australia 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australia.,BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh EH9 3FD, United Kingdom
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13
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Hexter AT, Sanghani-Kerai A, Heidari N, Kalaskar DM, Boyd A, Pendegrass C, Rodeo SA, Haddad FS, Blunn GW. Mesenchymal stromal cells and platelet-rich plasma promote tendon allograft healing in ovine anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:3678-3688. [PMID: 33331973 PMCID: PMC8514355 DOI: 10.1007/s00167-020-06392-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The effect of bone marrow mesenchymal stromal cells (BMSCs) and platelet-rich plasma (PRP) on tendon allograft maturation in a large animal anterior cruciate ligament (ACL) reconstruction model was reported for the first time. It was hypothesised that compared with non-augmented ACL reconstruction, BMSCs and PRP would enhance graft maturation after 12 weeks and this would be detected using magnetic resonance imaging (MRI). METHODS Fifteen sheep underwent unilateral tendon allograft ACL reconstruction using aperture fixation and were randomised into three groups (n = 5). Group 1 received 10 million allogeneic BMSCs in 2 ml fibrin sealant; Group 2 received 12 ml PRP in a plasma clot injected into the graft and bone tunnels; and Group 3 (control) received no adjunctive treatment. At autopsy at 12 weeks, a graft maturation score was determined by the sum for graft integrity, synovial coverage and vascularisation, graft thickness and apparent tension, and synovial sealing at tunnel apertures. MRI analysis (n = 2 animals per group) of the signal-noise quotient (SNQ) and fibrous interzone (FIZ) was used to evaluate intra-articular graft maturation and tendon-bone healing, respectively. Spearman's rank correlation coefficient (r) of SNQ, autopsy graft maturation score and bone tunnel diameter were analysed. RESULTS The BMSC group (p = 0.01) and PRP group (p = 0.03) had a significantly higher graft maturation score compared with the control group. The BMSC group scored significantly higher for synovial sealing at tunnel apertures (p = 0.03) compared with the control group. The graft maturation score at autopsy significantly correlated with the SNQ (r = - 0.83, p < 0.01). The tunnel diameter of the femoral tunnel at the aperture (r = 0.883, p = 0.03) and mid-portion (r = 0.941, p = 0.02) positively correlated with the SNQ. CONCLUSIONS BMSCs and PRP significantly enhanced graft maturation, which indicates that orthobiologics can accelerate the biologic events in tendon allograft incorporation. Femoral tunnel expansion significantly correlated with inferior maturation of the intra-articular graft. The clinical relevance of this study is that BMSCs and PRP enhance allograft healing in a translational model, and biological modulation of graft healing can be evaluated non-invasively using MRI.
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Affiliation(s)
- Adam T Hexter
- Division of Surgery and Interventional Science, University College London (UCL), London, UK.
- Institute of Orthopaedics and Musculoskeletal Sciences, Division of Surgery and Interventional Science, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, HA7 4LP, UK.
| | - Anita Sanghani-Kerai
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Nima Heidari
- Royal London Hospital and Orthopaedic Specialists (OS), London, UK
| | - Deepak M Kalaskar
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Ashleigh Boyd
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Catherine Pendegrass
- Division of Surgery and Interventional Science, University College London (UCL), London, UK
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14
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He X, Li Y, Guo J, Xu J, Zu H, Huang L, Tim-Yun Ong M, Shu-Hang Yung P, Qin L. Biomaterials developed for facilitating healing outcome after anterior cruciate ligament reconstruction: Efficacy, surgical protocols, and assessments using preclinical animal models. Biomaterials 2020; 269:120625. [PMID: 33395579 DOI: 10.1016/j.biomaterials.2020.120625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 12/17/2022]
Abstract
Anterior cruciate ligament (ACL) reconstruction is the recommended treatment for ACL tear in the American Academy of Orthopaedic Surgeons (AAOS) guideline. However, not a small number of cases failed because of the tunnel bone resorption, unsatisfactory bone-tendon integration, and graft degeneration. The biomaterials developed and designed for improving ACL reconstruction have been investigated for decades. According to the Food and Drug Administration (FDA) and the International Organization for Standardization (ISO) regulations, animal studies should be performed to prove the safety and bioeffect of materials before clinical trials. In this review, we first evaluated available biomaterials that can enhance the healing outcome after ACL reconstruction in animals and then discussed the animal models and assessments for testing applied materials. Furthermore, we identified the relevance and knowledge gaps between animal experimental studies and clinical expectations. Critical analyses and suggestions for future research were also provided to design the animal study connecting basic research and requirements for future clinical translation.
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Affiliation(s)
- Xuan He
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Ye Li
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Jiaxin Guo
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Jiankun Xu
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Haiyue Zu
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Le Huang
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Michael Tim-Yun Ong
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Patrick Shu-Hang Yung
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region
| | - Ling Qin
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region.
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15
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Wang J, Xu J, Wang X, Sheng L, Zheng L, Song B, Wu G, Zhang R, Yao H, Zheng N, Yun Ong MT, Yung PSH, Qin L. Magnesium-pretreated periosteum for promoting bone-tendon healing after anterior cruciate ligament reconstruction. Biomaterials 2020; 268:120576. [PMID: 33271449 DOI: 10.1016/j.biomaterials.2020.120576] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 09/01/2020] [Accepted: 11/21/2020] [Indexed: 12/21/2022]
Abstract
Periosteum can improve tendon-bone healing when applied to wrap the tendon graft in both animal studies and clinical trials. As magnesium (Mg) ions can significantly elevate the levels of relevant cytokines involving in the osteogenic differentiation of periosteum-derived stem cells, the Mg-pretreated periosteum may be an innovative approach for enveloping the tendon graft. To test this hypothesis, we compared the effects of Mg-pretreated periosteum (M - P) and the stainless steel (SS)-pretreated periosteum (SS-P) in ACL reconstruction. We firstly found that the released Mg ions from the Mg implants were partially accumulated in periosteum, resulting in higher Mg/Ca ratio in the M - P compared to the SS-P. Additionally, the M - P showed significantly higher expression levels of calcitonin gene-related peptide (CGRP) and periostin than the SS-P due to the decrease in Cathepsin K (CTSK). Elevation of CGRP and periostin was beneficial for the osteogenic differentiation of periosteum-derived stem cells. More importantly, we demonstrated that the M - P remarkably increased the formation of fibrocartilage at the interface between the periosteum and tendon. Collectively, M - P group demonstrated significantly prevented peri-tunnel bone loss, more osseous ingrowth into the tendon graft and higher maximum load to failure as compared to the SS-P group. In summary, our study warrants further investigations for translating the current proof-of-concept findings to optimize the delivery of CGRP, periostin, and cells as novel practical therapeutic strategy for enhancing tendon-bone interface healing in patients undergoing ACL reconstruction.
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Affiliation(s)
- Jiali Wang
- Biomedical Engineering School, Sun Yat-sen University, Guangzhou, 510006, PR China; Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China.
| | - Jiankun Xu
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Xinluan Wang
- Translational Medicine R&D Center, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, PR China
| | - Liyuan Sheng
- Shenzhen Institute, Peking University, Shenzhen, Guangdong province, 518057, PR China
| | - Lizhen Zheng
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Bin Song
- Department of Sports Medicine, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510006, PR China
| | - Ge Wu
- Department of Mechanical and Biomedical Engineering, City University of Hong Kong, Kowloon, Hong Kong, PR China
| | - Ri Zhang
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Hao Yao
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Nianye Zheng
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Michael Tim Yun Ong
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Patrick Shu-Hang Yung
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China
| | - Ling Qin
- Musculoskeletal Research Laboratory of Department of Orthopaedics & Traumatology and Drug Translational Research Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, PR China.
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16
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Wei B, Wang C, Yan C, Tang B, Yu X, Zhang H, Tang L, Wang Q. Osteoprotegerin/bone morphogenetic protein 2 combining with collagen sponges on tendon-bone healing in rabbits. J Bone Miner Metab 2020; 38:432-441. [PMID: 31980897 DOI: 10.1007/s00774-019-01078-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 12/17/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim was to investigate the effect of collagen sponges (CS) as a delivery device for osteoprotegerin (OPG)/bone morphogenetic protein 2 (BMP-2) and support matrix on the tendon-bone healing after anterior crusicate ligament (ACL) reconstruction in modeled rabbits. MATERIALS AND METHODS Sixty New Zealand white rabbits were randomly divided into four groups based on treatments they received at the tendon-bone interface after left knee ACL reconstruction: the control group, OPG/BMP-2, CS, and OPG/BMP-2/CS combination. At 4, 8 and 12 weeks post-surgery, five rabbits from each group were euthanized to examine the tendon-bone healing. Levels of OPG and BMP-2 in synovial fluid, the bone tunnel enlargement value, the histomorphological typing of tendon-bone interface, and the bone tunnel area of the tendon-bone interface were compared among different treatments. RESULTS The OPG/BMP-2/CS combination treatment group had the highest levels of OPG and BMP-2 in synovial fluid (both P < 0.05), the greatest number of Sharpey-like collagen fibers at all test points (P < 0.05), the most fibrocartilage enthesis on week 12, the greatest bone tunnel area (P < 0.05), and the greatest decrease in bone tunnel enlargement on week 12 (P < 0.05). Histomorphological typing of tendon-bone interface of all groups showed changes varying from tendon-bone separation to firm healing, and the change was most significant in the OPG/BMP-2/CS combination treatment group. CONCLUSION CS treatment alone serves as a fixing support, and CS combining with growth factors OPG/BMP-2 ensures slow and stable release of OPG/BMP-2, significantly improves the tendon-bone healing in the rabbit ACL model.
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Affiliation(s)
- Bing Wei
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Chao Wang
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Cheng Yan
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Bushun Tang
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Xiaofei Yu
- Department of Pathology, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Hui Zhang
- Department of General Diseases, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China
| | - Lixia Tang
- Department of General Diseases, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China.
| | - Qing Wang
- Department of Orthopedics, The First People's Hospital of Yongkang, Jinhua, 321300, People's Republic of China.
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17
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Kruppa P, Flies A, Wulsten D, Collette R, Duda GN, Schaser KD, Becker R, Kopf S. Significant Loss of ACL Graft Force With Tibial-Sided Soft Tissue Interference Screw Fixation Over 24 Hours: A Biomechanical Study. Orthop J Sports Med 2020; 8:2325967120916437. [PMID: 32440520 PMCID: PMC7225828 DOI: 10.1177/2325967120916437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Tibial-sided graft fixation is thought to be critical for the success of anterior cruciate ligament (ACL) reconstruction. Nevertheless, little is known about the graft force after fixation during the first 24 hours after surgery or the influence of screw diameter and length during this time. Purpose To investigate the force, over the course of 24 hours, in soft tissue grafts secured with a tibial interference screw and to evaluate the effect of different screw diameters (7, 8, and 9 mm) and lengths (25 and 30 mm) on the force in these grafts. Study Design Controlled laboratory study. Methods Quadruple-strand flexor tendon grafts were fixed with bioabsorbable interference screws in 60 porcine tibiae. Grafts were pretensioned at 80 N over 10 minutes, and screws were inserted outside-in while a preload force of 80 N was applied. Different screw lengths (25 and 30 mm) and diameters (7, 8, and 9 mm), resulting in 6 groups with 10 specimens each, were tested. After release of the preload, graft force was recorded over 24 hours. Results A significant decrease in graft force progressed in all groups over the 24-hour period. In total, a median loss of 75 N (IQR, 68-79 N) compared with the initial loading force was observed. Compared with the loading force of 80 N, this corresponded to a median loss of 91%. No significant differences in the remaining graft force could be found among the 6 different screw length and diameter groups after 10 minutes, 100 minutes, or 24 hours. Conclusion Graft force in soft tissue grafts secured with a tibial interference screw decreased substantially over the first 24 hours after fixation. Neither the screw diameter nor the screw length affected the decrease in graft force. This raises substantial questions regarding the remaining fixation strength in vivo. Clinical Relevance It should not be expected that ACL reconstruction can mechanically restabilize an injured knee as would an intact ACL. Reconstructed knees should be protected from mechanical overload in the early postoperative period.
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Affiliation(s)
- Philipp Kruppa
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany.,Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Anne Flies
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Dag Wulsten
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Robert Collette
- Department of Anesthesiology and Intensive Care, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Georg N Duda
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany
| | - Klaus-Dieter Schaser
- Department of Orthopedic and Trauma Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Roland Becker
- Center of Orthopaedics and Traumatology, Brandenburg Medical School Theodor Fontane, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany
| | - Sebastian Kopf
- Julius-Wolff-Institute, Charité-University Medicine Berlin, Berlin, Germany.,Center of Orthopaedics and Traumatology, Brandenburg Medical School Theodor Fontane, University Hospital Brandenburg an der Havel, Brandenburg an der Havel, Germany
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18
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Beyzadeoglu T, Pehlivanoglu T, Yildirim K, Buldu H, Tandogan R, Tuzun U. Does the Application of Platelet-Rich Fibrin in Anterior Cruciate Ligament Reconstruction Enhance Graft Healing and Maturation? A Comparative MRI Study of 44 Cases. Orthop J Sports Med 2020; 8:2325967120902013. [PMID: 32128315 PMCID: PMC7036517 DOI: 10.1177/2325967120902013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 01/03/2023] Open
Abstract
Background: Anterior cruciate ligament (ACL) reconstruction performed with growth factors
and activated platelets has been suggested to accelerate tendon
ligamentization, leading to earlier return to daily activities and
sports. Hypotheses: Platelet-rich fibrin (PRF) will result in improved graft maturation and
healing as evaluated by magnetic resonance imaging (MRI) in patients
undergoing hamstring ACL reconstruction. Hemostatic and analgesic properties
of PRF will lead to less postoperative blood loss and pain. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 44 patients with isolated ACL injuries who underwent arthroscopic
all-inside anatomic single-bundle ACL reconstruction with semitendinosus
tendon graft were enrolled. Group 1 included 23 patients who had PRF sprayed
to the surface of the graft; group 2 included 21 patients for whom no PRF
was used. Patients were discharged after 24 hours and examined for
hemarthrosis that needed to be aspirated. MRI was performed at the fifth
postoperative month. A blinded radiologist evaluated graft maturation
according to its signal intensity and the presence of synovial fluid at the
tunnel-graft interface. Results: PRF-treated grafts demonstrated lower MRI signal intensity and less fluid in
the graft-tunnel interface as compared with controls for the entire length
of the graft. The mean full-length MRI signal intensities were 9.19 versus
16.59 (P = .047) for groups 1 and 2, respectively. Subgroup
analysis of the semitendinosus grafts demonstrated a signal intensity of
11.57 versus 23.98 (P = .044) for the proximal third, 9.53
versus 13.83 (P = .237) for the midbody, and 6.48 versus
11.98 (P = .087) for the distal third. Synovial fluid at
the graft-tunnel interface was detected in 1 patient in group 1 (4.3%) and 3
patients in group 2 (14.3%; P < .001). Patients in group
1 had significantly less hemarthrosis that needed to be aspirated
(P = .003), while postoperative analgesia requirements
were similar in both groups (P = .08). No clinical benefit
of PRF could be demonstrated in clinical outcomes. Conclusion: Application of PRF led to superior graft integration and maturation in the
proximal third of the ACL graft. There was no significant difference in MRI
signal intensity in the midbody or distal tibial graft. Application of PRF
also resulted in significantly lower rates of postoperative hemarthrosis
that needed to be aspirated.
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Affiliation(s)
- Tahsin Beyzadeoglu
- Beyzadeoglu Clinic, Department of Orthopaedics and Traumatology, Istanbul, Turkey.,Department of Sports Medicine, Faculty of Health Sciences, Halic University, Istanbul, Turkey
| | - Tuna Pehlivanoglu
- Department of Orthopaedic Surgery and Traumatology, Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Kerem Yildirim
- Beyzadeoglu Clinic, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Halil Buldu
- Beyzadeoglu Clinic, Department of Orthopaedics and Traumatology, Istanbul, Turkey.,Department of Sports Medicine, Faculty of Health Sciences, Halic University, Istanbul, Turkey
| | - Reha Tandogan
- Cankaya Ortopedi, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Umit Tuzun
- Department of Radiology, Sonomed Imaging Center, Istanbul, Turkey
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19
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Berdis AS, Veale K, Fleissner PR. Outcomes of Anterior Cruciate Ligament Reconstruction Using Biologic Augmentation in Patients 21 Years of Age and Younger. Arthroscopy 2019; 35:3107-3113. [PMID: 31439458 DOI: 10.1016/j.arthro.2019.05.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To report on the outcomes of a subset of patients ≤21 years of age after anterior cruciate ligament (ACL) reconstruction coupled with biologic augmentation using platelet-rich plasma (PRP) and a porous collagen carrier. METHODS A cohort of patients was retrospectively reviewed after ACL reconstruction with hamstring autograft tendon. All reconstructive surgeries combined biologic augmentation in which the ACL graft was coupled with PRP contained within porous collagen membrane. Patients were included if they maintained a minimum follow-up period of 24 months. Outcomes were assessed through patient-reported questionnaires and physical examination in the clinical setting. Patient-reported outcomes including International Knee Documentation Committee (IKDC), Lysholm, Tegner, and Single Assessment Numeric Evaluation (SANE) scores were collected. ACL stability was evaluated using Lachman and KT-1000 testing. Patients were also evaluated for return to play at the same level of competition, family history of ACL injury, and time to complete rehabilitation. RESULTS A total of 194 patients were initially eligible; 143 (74%) patients with 151 knees were ultimately evaluated. The average patient age was 16 years; 79 patients were female and 64 were male. Follow-up duration averaged 52 months. IKDC and Lysholm scores averaged 91 and 91; the average SANE score was 94. The KT-1000 side-to-side difference averaged 1.2 mm. The average time to complete physical therapy was 22 weeks, and 132 patients (92%) returned to their preinjury level of competition. There were 23 cases of contralateral ACL injury (15%) and 7 cases of ACL reinjury necessitating revision surgery (5%). CONCLUSIONS Biologic augmentation with hamstring autograft in ACL reconstruction shows a decreased rate of second ACL injury, specifically with regard to ACL revision surgery. The patients in this study also show higher return to preinjury level of competition at a faster rate than other studies have shown. LEVEL OF EVIDENCE Level IV, Therapeutic Case Series.
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Affiliation(s)
- Anthony S Berdis
- Department of Graduate Medical Education, Aultman Hospital, Canton, Ohio, U.S.A..
| | - Kodi Veale
- Crystal Clinic Orthopaedic Center, Bell Chapter of the Hawkins Foundation, Akron, Ohio, U.S.A
| | - Paul R Fleissner
- Crystal Clinic Orthopaedic Center, Bell Chapter of the Hawkins Foundation, Akron, Ohio, U.S.A
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20
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Efird WM, Fletcher AG, Draeger RW, Spang JT, Dahners LE, Weinhold PS. Deferoxamine-Soaked Suture Improves Angiogenesis and Repair Potential After Acute Injury of the Chicken Achilles Tendon. Orthop J Sports Med 2018; 6:2325967118802792. [PMID: 30370309 PMCID: PMC6201186 DOI: 10.1177/2325967118802792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: A major obstacle to the treatment of soft tissue injuries is the hypovascular
nature of the tissues. Deferoxamine (DFO) has been shown to stimulate
angiogenesis by limiting the degradation of intracellular hypoxia-inducible
factor 1–alpha. Hypothesis: DFO-saturated suture would induce angiogenesis and improve the markers of
early healing in an Achilles tendon repair model. Study Design: Controlled laboratory study. Methods: Broiler hens were randomly assigned to the control (CTL) group or DFO group
(n = 9 per group). The right Achilles tendon was partially transected at its
middle third. The defect was surgically repaired using 3-0 Vicryl suture
soaked in either sterile water (CTL group) or 324 mM DFO solution (DFO
group). All animals were euthanized 2 weeks after the injury, and the tendon
was harvested. Half of the tendon was used to evaluate angiogenesis via
hemoglobin content and tissue repair via DNA content and proteoglycan (PG)
content. The other half of the tendon was sectioned and stained with
hematoxylin and eosin, safranin O, and lectin to evaluate vessel
density. Results: Hemoglobin content (percentage of wet tissue weight) was significantly
increased in the DFO group compared with the CTL group (0.081 ± 0.012 vs
0.063 ± 0.016, respectively; P = .046). DNA content
(percentage of wet tissue weight) was also significantly increased in the
DFO group compared with the CTL group (0.31 ± 0.05 vs 0.23 ± 0.03,
respectively; P = .024). PG content (percentage of wet
tissue weight) was significantly decreased in the DFO group compared with
the CTL group (0.26 ± 0.02 vs 0.33 ± 0.08, respectively; P
= .035). Total chondroid area (number of vessels per mm2 of
tissue area evaluated) was significantly decreased in the DFO group compared
with the CTL group (17.2 ± 6.6 vs 24.6 ± 5.1, respectively;
P = .038). Articular zone vessel density
(vessels/mm2) was significantly increased in the DFO group
compared with the CTL group (7.1 ± 2.5 vs 2.1 ± 0.9, respectively;
P = .026). Conclusion: The significant increase in hemoglobin content as well as articular zone
vessel density in the DFO group compared with the CTL group is evidence of
increased angiogenesis in the fibrocartilaginous region of the tendon
exposed to DFO. The DFO group also displayed a significantly greater level
of DNA and significantly lower level of PG, suggesting enhanced early
healing by fibrous tissue formation. Clinical Relevance: Stimulating angiogenesis by DFO-saturated suture may be clinically useful to
improve healing of poorly vascularized tissues.
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Affiliation(s)
- William M Efird
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alex G Fletcher
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Reid W Draeger
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeffrey T Spang
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laurence E Dahners
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Paul S Weinhold
- Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina and North Carolina State University, Raleigh, North Carolina, USA
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21
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Von Hippel-Lindau (VHL) protein antagonist, VH298, promotes functional activities of tendon-derived stem cells and accelerates healing of entheses in rats by inhibiting ubiquitination of hydroxy-HIF-1α. Biochem Biophys Res Commun 2018; 505:1063-1069. [PMID: 30314704 DOI: 10.1016/j.bbrc.2018.09.172] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/27/2018] [Indexed: 12/30/2022]
Abstract
Enthesis is the region where a tendon attaches to a bone. It is a relatively vulnerable position, and in most cases surgical treatment is required upon rupture. The reconstructed enthesis is usually weaker compared to the original, and is prone to rupture again. Hypoxia-inducible factor-1 α (HIF-1α) is known to be involved in extensive activities in cells. It is inhibited under normoxic conditions, and undergoes two essential processes, hydroxylation and ubiquitination, the latter of which has been largely unexplored. Herein, we measured the levels of HIF-1α and hydroxy-HIF-1α in VH298-treated rat tendon-derived stem cells (TDSCs) by immunoblotting. We also detected the proliferation of TDSCs using CCK-8 assay and the mRNA levels of related genes by quantitative RT-PCR. The TDSCs were observed to be induced and the chondrogenic differentiation related genes were found to be enhanced. We also simulated in-vitro wounding in a scratch test and reconstructed the enthesis in a rat model of Achilles tendon by classical surgery followed by administration of phosphate buffer saline (PBS) injection or VH298 injection. We observed that HIF-1α and hydroxy-HIF-1α levels were increased in VH298-treated TDSCs in a dose- and time-dependent manner. Thirty micromolar VH298 could significantly increase cell proliferation, migration, and expression of collagen-1α, collagen-3α, decorin, tenomodulin, tenascin C genes, and chondrogenic differentiation-related genes, collagen-2α, SRY-box9, aggrecan. VH298-treated enthesis could tolerate more load-to-failure, had a better healing pattern, and activation of HIF signaling pathway. VH298 can thus enhance the functional activities of TDSCs, enhance their chondrogenic differentiation potential, and accelerate enthesis healing by inhibiting the ubiquitination of hydroxy-HIF-1α.
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22
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Hexter AT, Thangarajah T, Blunn G, Haddad FS. Biological augmentation of graft healing in anterior cruciate ligament reconstruction: a systematic review. Bone Joint J 2018; 100-B:271-284. [PMID: 29589505 DOI: 10.1302/0301-620x.100b3.bjj-2017-0733.r2] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aims The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR. Materials and Methods In all, 1879 studies were identified across three databases. Following assessment against strict criteria, 112 studies were included (20 clinical studies; 92 animal studies). Results Seven categories of biological interventions were identified: growth factors, biomaterials, stem cells, gene therapy, autologous tissue, biophysical/environmental, and pharmaceuticals. The methodological quality of animal studies was moderate in 97%, but only 10% used clinically relevant outcome measures. The most interventions in clinical trials target the graft-tunnel interface and are applied intraoperatively. Platelet-rich plasma is the most studied intervention, but the clinical outcomes are mixed, and the methodological quality of studies was suboptimal. Other biological therapies investigated in clinical trials include: remnant-augmented ACLR; bone substitutes; calcium phosphate-hybridized grafts; extracorporeal shockwave therapy; and adult autologus non-cultivated stem cells. Conclusion There is extensive preclinical research supporting the use of biological therapies to augment ACLR. Further clinical studies that meet the minimum standards of reporting are required to determine whether emerging biological strategies will provide tangible benefits in patients undergoing ACLR. Cite this article: Bone Joint J 2018;100-B:271-84.
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Affiliation(s)
- A T Hexter
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - T Thangarajah
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - G Blunn
- Institute of Orthopaedics and Musculoskeletal Science, Division of Surgery and Interventional Science, University College London, and Royal National Orthopaedic Hospital Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
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23
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Mallett KF, Arruda EM. Digital image correlation-aided mechanical characterization of the anteromedial and posterolateral bundles of the anterior cruciate ligament. Acta Biomater 2017; 56:44-57. [PMID: 28366841 DOI: 10.1016/j.actbio.2017.03.045] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 03/10/2017] [Accepted: 03/27/2017] [Indexed: 01/12/2023]
Abstract
The anterior cruciate ligament (ACL) is one of the most commonly injured soft tissue structures in the articular knee joint, often requiring invasive surgery for patients to restore pre-injury knee kinematics. There is a pressing need to understand the role of the ACL in knee function, in order to select proper replacements. Digital image correlation (DIC), a non-contact full field displacement measurement technique, is an established tool for evaluating non-biological materials. The application of DIC to soft tissues has been in the nascent stages, largely due to patterning challenges of such materials. The ACL is notoriously difficult to mechanically characterize, due to the complex geometry of its two bundles and their insertions. This paper examines the use of DIC to determine the tensile mechanical properties of the AM and PL bundles of ovine ACLs in a well-known loading state. Homogenous loading in the mid-substance of the bundles provides for accurate development of stress/strain curves using DIC. Animal to animal variability is reduced, and the bundles are stiffer than previously thought when tissue-level strains are accurately measured. STATEMENT OF SIGNIFICANCE The anterior cruciate ligament (ACL), a major stabilizing ligament of the articular knee joint, is one of the most commonly injured soft tissue structures in the knee. Often, invasive surgery is required to restore pre-injury knee kinematics, and there are several long-term consequences of ACL reconstructions, including early-onset osteoarthritis. The role of the ACL in knee stability and motion has received much attention in the biomechanics community. This paper examines the use of a non-contact full-field displacement measurement technique, digital image correlation, to determine the tensile mechanical properties of the ACL. The focus of this work is to investigate the intrinsic mechanical properties of the ACL, as new knowledge in these areas will aid clinicians in selecting ACL replacements.
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Affiliation(s)
- Kaitlyn F Mallett
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, United States.
| | - Ellen M Arruda
- Department of Mechanical Engineering, Department of Biomedical Engineering, Program in Macromolecular Science and Engineering, University of Michigan, Ann Arbor, MI 48109, United States.
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24
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Acceleration of tendon-bone healing of anterior cruciate ligament graft using intermittent negative pressure in rabbits. J Orthop Surg Res 2017; 12:60. [PMID: 28420425 PMCID: PMC5395760 DOI: 10.1186/s13018-017-0561-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 04/03/2017] [Indexed: 12/14/2022] Open
Abstract
Background The purpose of this study was to test effects of negative pressure on tendon–bone healing after reconstruction of anterior cruciate ligament (ACL) in rabbits. Methods Hind legs of 24 New Zealand White rabbits were randomly selected as negative pressure group and the contralateral hind legs as control. Reconstruction of the ACL was done. Joints of the negative pressure side were placed with drainage tubes connecting the micro-negative pressure aspirator. Control side was placed with ordinary drainage tubes. Drainage tubes on both sides were removed at the same time 5 days after operation. After 6 weeks, joint fluid was drawn to detect the expression levels of interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α); at the same time, femur–ligament–tibia complex was obtained to determine tendon graft tension and to observe the histomorphology, blood vessels of the tendon–bone interface, and expression of vascular endothelial growth factor (VEGF). Results The maximum load breakage of tendon graft was significantly greater in the negative pressure group than in the control group (P < 0.05). Histological studies of the tendon–bone interface found that there was more new bone formation containing chondroid cells and aligned connective tissue in the negative pressure group than in the control group. Expression of VEGF was higher in the negative pressure group than in the control group (P < 0.01). Content of IL-1β and TNF-α in synovial fluid is lower in the negative pressure group than in the control group (P < 0.01). Conclusions Intermittent negative pressure plays an active role in tendon–bone healing and creeping substitution of ACL reconstruction in the rabbits.
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25
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Cross-sectional area of hamstring tendon autograft after anatomic triple-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:1219-1226. [PMID: 26585909 DOI: 10.1007/s00167-015-3880-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/11/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose was to evaluate the cross-sectional area changes in hamstring tendon autografts up to 5 years after the anatomic triple-bundle anterior cruciate ligament (ACL) reconstruction. METHODS A total of 178 MRI scans from 139 patients (35 males, 104 females, mean age 30.4 years) with the anatomic triple-bundle ACL reconstructions were obtained to evaluate the cross-sectional area of the ACL grafts. They were classified into seven groups according to the period from reconstruction to MRI evaluation: Group -2 months (m.), Group 3-6 m., Group 7-12 m, Group 1-2 years (y.), Group 2-3 y., Group 3-4 y., and Group 4 y.-. Intra-operatively, the cross-sectional area of the graft was measured directly using a custom-made area micrometre. Post-operatively, the cross-sectional area of the grafts' mid-substance was measured with oblique axial MRI slices perpendicular to the long axis of the grafts using a digital radiology viewing program. The percent increase in the cross-sectional area was calculated by dividing the post-operative cross-sectional area by the intra-operative cross-sectional area. RESULTS The mean percent increase in the cross-sectional area in Groups -2 m., 3-6 m., 7-12 m., 1-2 y., 2-3 y., 3-4 y., and 4 y.- was 105.7 ± 14.0, 134.9 ± 20.0, 137.3 ± 27.8, 129.4 ± 22.2, 124.1 ± 20.4, 117.8 ± 16.9, and 117.1 ± 17.2 %, respectively. The percent increase in Groups 3-6 m., 7-12 m., and 1-2 y. was significantly greater than in Group -2 m., while that in Group 4 y.- was significantly less than in Group 7-12 m. CONCLUSIONS The cross-sectional area of the hamstring tendon autografts after the anatomic triple-bundle ACL reconstruction increases over time up to 1 year post-operatively, decreases gradually thereafter, and reaches plateau at around 3 years. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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26
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Ćuti T, Antunović M, Marijanović I, Ivković A, Vukasović A, Matić I, Pećina M, Hudetz D. Capacity of muscle derived stem cells and pericytes to promote tendon graft integration and ligamentization following anterior cruciate ligament reconstruction. INTERNATIONAL ORTHOPAEDICS 2017; 41:1189-1198. [PMID: 28299448 DOI: 10.1007/s00264-017-3437-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 03/01/2017] [Indexed: 01/08/2023]
Abstract
PURPOSE The aim of this study is to examine the capacity of muscle tissue preserved on hamstring tendons forming candy-stripe grafts in order to improve tendon to bone ingrowth and ligamentization. We hypothesized that muscle tissue does possess a stem cell population that could enhance the healing process of the ACL graft when preserved on the tendons. METHODS Human samples from gracilis and semitendinosus muscles were collected during ACL surgery from ten patients and from these tissue samples human muscle-derived stem cells and tendon-derived stem cells were isolated and propagated. Both stem cell populations were in-vitro differentiated into osteogenic lineage. Alkaline phosphatase activity was determined at days zero and 14 of the osteogenic induction and von Kossa staining to assess mineralization of the cultures. Total RNA was collected from osteoblast cultures and real time quantitative PCR was performed. Western-blot for osteocalcin and collagen type I followed protein isolation. Immunofluorescence double labeling of pericytes in muscle and tendon tissue was performed. RESULTS Mesenchymal stem cells from muscle and tendon tissue were isolated and expanded in cell culture. More time was needed to grow the tendon derived culture compared to muscle derived culture. Muscle derived stem cells exhibited more alkaline phosphatase actvity compared to tendon derived stem cells, whereas tendon derived stem cells formed more mineralized nodules after 14 days of osteoinduction. Muscle derived stem cells exhibited higher expression levels of bone sialoprotein, and tendon derived stem cells showed higher expression of dental-matrix-protein 1 and osteocalcin. Immunofluorescent staining against pericytes indicated that they are more abundant in muscle tissue. CONCLUSIONS These results indicate that muscle tissue is a better source of stem cells than tendon tissue. Achievement of this study is proof that there is vast innate capacity of muscle tissue for enhancement of bone-tendon integration and ligamentization of ACL hamstring grafts and consequently muscle tissue should not be treated as waste after harvesting.
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Affiliation(s)
- Tomislav Ćuti
- Clinic for Trauma Surgery, University Hospital Center "Sestre Milosrdnice", Vinogradska cesta 29, Zagreb, Croatia
| | - Maja Antunović
- Department of Molecular Biology, Faculty of Science, University of Zagreb, Horvatovac 102a, Zagreb, Croatia
| | - Inga Marijanović
- Department of Molecular Biology, Faculty of Science, University of Zagreb, Horvatovac 102a, Zagreb, Croatia
| | - Alan Ivković
- Department for Orthopaedic Surgery, University Hospital "Sveti Duh", Sveti Duh 64, Zagreb, Croatia.,Department of Biotechnology, University of Rijeka, Radmile Matejčić 2, Rijeka, Croatia.,Department of Histology and Embriology, School of Medicine, University of Zagreb, Šalata 3, Zagreb, Croatia
| | - Andreja Vukasović
- Department of Histology and Embriology, School of Medicine, University of Zagreb, Šalata 3, Zagreb, Croatia
| | - Igor Matić
- Department of Molecular Biology, Faculty of Science, University of Zagreb, Horvatovac 102a, Zagreb, Croatia
| | - Marko Pećina
- Department of Orthopaedic Surgery, School of Medicine University of Zagreb, Šalata 7, Zagreb, Croatia
| | - Damir Hudetz
- Department for Orthopaedic Surgery, University Hospital "Sveti Duh", Sveti Duh 64, Zagreb, Croatia. .,St.Catherine Specialty Hospital, Bračak 8, Zabok, Croatia. .,University of Osijek, Medical School, Osijek, Croatia.
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27
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Zhou Y, Zhang J, Yang J, Narava M, Zhao G, Yuan T, Wu H, Zheng N, Hogan MV, Wang JHC. Kartogenin with PRP promotes the formation of fibrocartilage zone in the tendon-bone interface. J Tissue Eng Regen Med 2017; 11:3445-3456. [DOI: 10.1002/term.2258] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/11/2016] [Accepted: 07/03/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Yiqin Zhou
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
- Joint Surgery and Sports Medicine Department; Shanghai Changzheng Hospital, Second Military Medical University; 415 Fengyang Road, Huangpu Shanghai 200003 China
| | - Jianying Zhang
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Jinsong Yang
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Manoj Narava
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Guangyi Zhao
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Ting Yuan
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Haishan Wu
- Joint Surgery and Sports Medicine Department; Shanghai Changzheng Hospital, Second Military Medical University; 415 Fengyang Road, Huangpu Shanghai 200003 China
| | - Nigel Zheng
- Department of Mechanical Engineering and Engineering Science, Center for Biomedical Engineering and Science; University of North Carolina at Charlotte; Charlotte NC USA
| | - MaCalus V. Hogan
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - James H.-C. Wang
- MechanoBiology Laboratory, Department of Orthopaedic Surgery; University of Pittsburgh School of Medicine; Pittsburgh PA USA
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28
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Takeuchi H, Niki Y, Matsunari H, Umeyama K, Nagashima H, Enomoto H, Toyama Y, Matsumoto M, Nakamura M. Temporal Changes in Cellular Repopulation and Collagen Fibril Remodeling and Regeneration After Allograft Anterior Cruciate Ligament Reconstruction: An Experimental Study Using Kusabira-Orange Transgenic Pigs. Am J Sports Med 2016; 44:2375-83. [PMID: 27329998 DOI: 10.1177/0363546516650881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Distinguishing recipient cells from donor ligament cells is difficult in the early graft-healing phase after anterior cruciate ligament (ACL) reconstruction. The ability to track the distribution and differentiation of recipient cells using genetically engineered transgenic (Tg) animals would have significant clinical and research effects on graft healing after ACL reconstruction. HYPOTHESIS Kusabira-Orange Tg pigs may allow the tracking of recipient cells infiltrating the graft after ACL reconstruction. The repopulation of recipient cells within the graft would be apparent even in the early graft-healing phase when necrotic donor cells are still present. STUDY DESIGN Descriptive laboratory study. METHODS In 17 genetically engineered Tg pigs, which carried the red fluorescent protein Kusabira-Orange, ACL reconstruction was performed on the right knee using a digital flexor tendon harvested from wild-type pigs. Tissue samples harvested at different time points were subjected to histological, immunohistochemical, and electron microscopic analyses. RESULTS At 3 weeks postoperatively, recipient cells expressing red fluorescence embraced the graft and were infiltrating the central part of the graft. These cells with oval nuclei gradually infiltrated the gap of collagen fibers, losing their regular orientation. At 6 weeks, cellularity within the graft had doubled to match that of the native ACL, while acellular necrotic regions still existed centrally. Ubiquitous cellular distributions resembling the native ACL were observed at 24 weeks. Electron microscopic analysis showed that the mean collagen fibril diameter and density gradually decreased over 24 weeks. CONCLUSION Genetically engineered pigs carrying the Kusabira-Orange gene were useful animal models for analyzing intrinsic and extrinsic cellular dynamics during the course of graft healing after ACL reconstruction. Cellular repopulation by recipient cells occurred in the very early stage, and the cellular distribution within the graft resembled that in the native ACL by 24 weeks, but the reconstructed graft had not restored the ultrastructure of the native ACL by that stage. CLINICAL RELEVANCE In allograft ACL reconstruction in a pig model, cellular repopulation was completed by 24 weeks after surgery, but the collagen matrix had not resumed the ultrastructure of the native ACL. Surgeons should be aware that risks may remain with returning to sports activities at 24 weeks after surgery.
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Affiliation(s)
- Hiroki Takeuchi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasuo Niki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hitomi Matsunari
- International Institute for Bio-Resource Research, Meiji University, Kawasaki, Japan
| | - Kazuhiro Umeyama
- International Institute for Bio-Resource Research, Meiji University, Kawasaki, Japan
| | - Hiroshi Nagashima
- International Institute for Bio-Resource Research, Meiji University, Kawasaki, Japan
| | - Hiroyuki Enomoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiaki Toyama
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
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29
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Moewis P, Duda GN, Jung T, Heller MO, Boeth H, Kaptein B, Taylor WR. The Restoration of Passive Rotational Tibio-Femoral Laxity after Anterior Cruciate Ligament Reconstruction. PLoS One 2016; 11:e0159600. [PMID: 27467744 PMCID: PMC4965218 DOI: 10.1371/journal.pone.0159600] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/01/2016] [Indexed: 01/15/2023] Open
Abstract
While the anterior cruciate ligament (ACL) is considered one of the most important ligaments for providing knee joint stability, its influence on rotational laxity is not fully understood and its role in resisting rotation at different flexion angles in vivo remains unknown. In this prospective study, we investigated the relationship between in vivo passive axial rotational laxity and knee flexion angle, as well as how they were altered with ACL injury and reconstruction. A rotometer device was developed to assess knee joint rotational laxity under controlled passive testing. An axial torque of ±2.5Nm was applied to the knee while synchronised fluoroscopic images of the tibia and femur allowed axial rotation of the bones to be accurately determined. Passive rotational laxity tests were completed in 9 patients with an untreated ACL injury and compared to measurements at 3 and 12 months after anatomical single bundle ACL reconstruction, as well as to the contralateral controls. Significant differences in rotational laxity were found between the injured and the healthy contralateral knees with internal rotation values of 8.7°±4.0° and 3.7°±1.4° (p = 0.003) at 30° of flexion and 9.3°±2.6° and 4.0°±2.0° (p = 0.001) at 90° respectively. After 3 months, the rotational laxity remained similar to the injured condition, and significantly different to the healthy knees. However, after 12 months, a considerable reduction of rotational laxity was observed towards the levels of the contralateral controls. The significantly greater laxity observed at both knee flexion angles after 3 months (but not at 12 months), suggests an initial lack of post-operative rotational stability, possibly due to reduced mechanical properties or fixation stability of the graft tissue. After 12 months, reduced levels of rotational laxity compared with the injured and 3 month conditions, both internally and externally, suggests progressive rotational stability of the reconstruction with time.
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Affiliation(s)
- Philippe Moewis
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Georg N. Duda
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Jung
- Knee Surgery and Sports Traumatology, Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus O. Heller
- Bioengineering Research Group, University of Southhampton, Southhampton, United Kingdom
| | - Heide Boeth
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Bart Kaptein
- Department of Orthopaedic Surgery, Biomechanics and Imaging Group, Leiden University Medical Center, Leiden, Netherlands
| | - William R. Taylor
- Department of Health Sciences and Technology, Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
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30
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Takahashi T, Kondo E, Yasuda K, Miyatake S, Kawaguchi Y, Onodera J, Kitamura N. Effects of Remnant Tissue Preservation on the Tendon Graft in Anterior Cruciate Ligament Reconstruction: A Biomechanical and Histological Study. Am J Sports Med 2016; 44:1708-16. [PMID: 27159314 DOI: 10.1177/0363546516643809] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is controversy regarding the efficacy of remnant tissue preservation on graft healing in anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS The preserved remnant tissue will (1) adhere to the graft surface and undergo a remodeling process, (2) accelerate graft revascularization, (3) increase the number of graft mechanoreceptors by 4 weeks, and (4) improve anteroposterior knee laxity and structural properties of the graft by 12 weeks. STUDY DESIGN Controlled laboratory study. METHODS Forty-two sheep were randomly divided into 2 groups of 21 animals. In group I, the ACL was completely removed. In group II, the ACL was transected at the midsubstance but not debrided. ACL reconstruction was performed using a semitendinosus tendon autograft in both groups. Histological changes of the grafted tendon and the remnant tissue were evaluated at 4 and 12 weeks after surgery. Biomechanically, anterior translation and knee joint stiffness under an anterior drawer force and the structural properties of the femur-graft-tibia complex were evaluated. RESULTS The preserved remnant tissue was histologically distinct from the graft at 4 weeks, while the tissue partially adhered to the graft surface at 12 weeks. The ACL remnant tissue significantly accelerated revascularization in the grafted tendon at 4 weeks and significantly increased the number of mechanoreceptors at 4 and 12 weeks. In addition, remnant preservation significantly improved anterior translation (9.3 ± 2.1 mm and 5.4 ± 1.7 mm at 60° of knee flexion in groups I and II, respectively) and knee joint stiffness at 12 weeks. However, there were no significant differences in the structural properties between the 2 groups at 4 and 12 weeks after surgery. CONCLUSION Preservation of the ACL remnant tissue in ACL reconstruction enhanced cell proliferation, revascularization, and regeneration of proprioceptive organs in the reconstructed ACL and reduced anterior translation. However, remnant preservation did not improve the structural properties of the graft. CLINICAL RELEVANCE These results imply that preservation of the ACL remnant tissue may improve graft healing after ACL reconstruction.
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Affiliation(s)
- Tsuneari Takahashi
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Eiji Kondo
- Department of Advanced Therapeutic Research for Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazunori Yasuda
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Shin Miyatake
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yasuyuki Kawaguchi
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Jun Onodera
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Nobuto Kitamura
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Younger A, Wing K, Penner M, Cresswell M. A study to evaluate the safety of platelet-derived growth factor for treatment of osteochondral defects of the talus. Knee Surg Sports Traumatol Arthrosc 2016; 24:1250-8. [PMID: 25796584 PMCID: PMC4823349 DOI: 10.1007/s00167-015-3549-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 02/24/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE An arthroscopic procedure for the treatment of osteochondral defects using platelet-derived growth factor (PDGF) carried out in a matrix of tricalcium phosphate was developed. This prospective, case-series-based study was designed to evaluate the safety and clinical utility of this procedure. METHODS Patients with an isolated osteochondral defect larger than 5 mm long, 3 mm wide, and 5 mm deep and smaller than 30 mm long, 25 mm wide, or 20 mm deep were considered for enrolment. Only patients with chronic lesions were enroled. Arthroscopic debridement was followed by the placement of recombinant human PDGF in a matrix of tricalcium phosphate. The Ankle Osteoarthritis Scale (AOS), visual analogue scale (VAS) for pain, and SF-36 questionnaires were administered at 0, 2, 6, 12, and 24 weeks. Magnetic resonance imaging (MRI) and computed tomography (CT) scans were taken before and after surgery. RESULTS Five patients were ultimately enroled in this proof-of-concept trial. All outcome measures demonstrated marked improvement from baseline to final follow-up: The mean weight bearing VAS pain score improved by 49%, and the mean AOS functional score improved by 28%. Bone healing was seen on CT, and reduction in oedema signal was seen on MRI. CONCLUSION This new procedure may offer a promising alternative for the treatment of osteochondral defects. Further high-quality studies are needed to confirm these results and to analyse the long-term effects of the procedure. The clinical relevance of this study is that the procedure may provide a less invasive option with improved bone healing compared to standard techniques . LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Alastair Younger
- Department of Orthopedics, University of British Columbia, 560 – 1144 Burrard Street, Vancouver, BC V6Z 2A5 Canada
| | - Kevin Wing
- Department of Orthopaedics, University of British Columbia, 1000 – 1200 Burrard Street, Vancouver, BC V6Z 2C7 Canada
| | - Murray Penner
- Department of Orthopaedics, University of British Columbia, 1000 – 1200 Burrard Street, Vancouver, BC V6Z 2C7 Canada
| | - Mark Cresswell
- Department of Radiology, University of British Columbia, St. Paul’s Hospital - 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
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Song Y, Yu C, Wang C, Ma X, Xu K, Zhong JL, Lv Y, Sung KP, Yang L. Mechano growth factor-C24E, a potential promoting biochemical factor for ligament tissue engineering. Biochem Eng J 2016. [DOI: 10.1016/j.bej.2015.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Font Tellado S, Balmayor ER, Van Griensven M. Strategies to engineer tendon/ligament-to-bone interface: Biomaterials, cells and growth factors. Adv Drug Deliv Rev 2015; 94:126-40. [PMID: 25777059 DOI: 10.1016/j.addr.2015.03.004] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 02/27/2015] [Accepted: 03/07/2015] [Indexed: 02/06/2023]
Abstract
Integration between tendon/ligament and bone occurs through a specialized tissue interface called enthesis. The complex and heterogeneous structure of the enthesis is essential to ensure smooth mechanical stress transfer between bone and soft tissues. Following injury, the interface is not regenerated, resulting in high rupture recurrence rates. Tissue engineering is a promising strategy for the regeneration of a functional enthesis. However, the complex structural and cellular composition of the native interface makes enthesis tissue engineering particularly challenging. Thus, it is likely that a combination of biomaterials and cells stimulated with appropriate biochemical and mechanical cues will be needed. The objective of this review is to describe the current state-of-the-art, challenges and future directions in the field of enthesis tissue engineering focusing on four key parameters: (1) scaffold and biomaterials, (2) cells, (3) growth factors and (4) mechanical stimuli.
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Affiliation(s)
- Sonia Font Tellado
- Department of Experimental Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675 Munich, Germany.
| | - Elizabeth R Balmayor
- Department of Experimental Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675 Munich, Germany
| | - Martijn Van Griensven
- Department of Experimental Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Strasse 22, 81675 Munich, Germany
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Laver L, Carmont MR, McConkey MO, Palmanovich E, Yaacobi E, Mann G, Nyska M, Kots E, Mei-Dan O. Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial. Knee Surg Sports Traumatol Arthrosc 2015; 23:3383-92. [PMID: 24938396 DOI: 10.1007/s00167-014-3119-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 06/03/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied. METHODS Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6 weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome. RESULTS All patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion-external rotation, and larger neutral tibia-fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0) days for the PRP and control groups, respectively (p = 0.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5 %) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5 %). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction. CONCLUSIONS Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Lior Laver
- Department of Orthopaedic Surgery, Sports Medicine Unit, "Meir" Medical Center, The Sackler School of Medicine (Tel-Aviv University), Kfar-Saba, Israel. .,Division of Sports Medicine, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.
| | - Michael R Carmont
- Department of Trauma and Orthopaedic Surgery, Princess Royal Hospital, Telford, Shropshire, UK
| | - Mark O McConkey
- Pacific Orthopaedics and Sports Medicine, North Vancouver, BC, Canada
| | - Ezequiel Palmanovich
- Department of Orthopaedic Surgery, Sports Medicine Unit, "Meir" Medical Center, The Sackler School of Medicine (Tel-Aviv University), Kfar-Saba, Israel
| | - Eyal Yaacobi
- Department of Orthopaedic Surgery, Sports Medicine Unit, "Meir" Medical Center, The Sackler School of Medicine (Tel-Aviv University), Kfar-Saba, Israel
| | - Gideon Mann
- Department of Orthopaedic Surgery, Sports Medicine Unit, "Meir" Medical Center, The Sackler School of Medicine (Tel-Aviv University), Kfar-Saba, Israel.,Ribstein Center for Sport Medicine Sciences and Research, Wingate Institute, Netanya, Israel
| | - Meir Nyska
- Department of Orthopaedic Surgery, Sports Medicine Unit, "Meir" Medical Center, The Sackler School of Medicine (Tel-Aviv University), Kfar-Saba, Israel
| | - Eugene Kots
- Department of Radiology, Sports Medicine Unit, "Meir" Medical Center, Kfar-Saba, Israel
| | - Omer Mei-Dan
- Department of Sports Medicine, University of Colorado Hospitals, Boulder, CO, USA
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Dong S, Xie G, Zhang Y, Shen P, Huangfu X, Zhao J. Ligamentization of Autogenous Hamstring Grafts After Anterior Cruciate Ligament Reconstruction: Midterm Versus Long-term Results. Am J Sports Med 2015; 43:1908-17. [PMID: 26033971 DOI: 10.1177/0363546515584039] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In previous studies, unimodal, small-diameter collagen fibrils have been commonly observed as the final collagen ultrastructure of the implanted grafts used in anterior cruciate ligament (ACL) reconstruction. However, the native ACL and hamstring tendon show bimodal collagen fibril distribution, consisting of both large- and small-diameter collagen fibrils. HYPOTHESIS Bimodal collagen fibril distribution of the graft is a common phenomenon after ACL reconstruction with hamstring tendon grafts and is time dependent. STUDY DESIGN Controlled laboratory study. METHODS A total of 52 patients who underwent double-bundle ACL reconstruction using autogenous hamstring tendons and who also underwent second-look arthroscopic surgery were enrolled. The patients were divided into 2 groups according to the time interval between the 2 operations: the midterm group (27 patients), with a 13- to 30-month time interval between operations, and the long-term group (25 patients) with a 31- to 62-month interval. During the second-look arthroscopic procedures, ACL graft biopsies were performed. Normal ACL tissues were harvested from 9 patients who underwent total knee replacement, and biopsy specimens of the to-be-grafted semitendinosus tendon tissues were also harvested from another 9 patients who underwent ACL reconstruction with hamstring tendons, which were designated as normal controls. Graft vascularity, cellularity, metaplasia, cellular metabolism, and collagen fibril distribution were analyzed. RESULTS Large-diameter (>100 nm) collagen fibrils were detected in 81.5% of the specimens in the midterm group and in 68.0% of the specimens in the long-term group. A typical bimodal distribution mode was observed in 62.6% of the specimens in the midterm group and in 52.0% of the specimens in the long-term group. There was no significant difference between groups with respect to the presence of large-diameter collagen fibrils, bimodal distribution, graft vascularity, cellularity, metaplasia, or cellular metabolic status. CONCLUSION Graft ultrastructural maturation, characterized by large-diameter collagen fibrils and a bimodal collagen fibril distribution, is a common phenomenon and is not time dependent in the midterm to long term. CLINICAL RELEVANCE After hamstring tendon ACL reconstruction, the implanted grafts can transform into ACL-like tissue with a similar ultrastructure and metabolism, implying their usefulness as grafts.
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Affiliation(s)
- Shikui Dong
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yang Zhang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Peng Shen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoqiao Huangfu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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PRP Augmentation for ACL Reconstruction. BIOMED RESEARCH INTERNATIONAL 2015; 2015:371746. [PMID: 26064903 PMCID: PMC4430629 DOI: 10.1155/2015/371746] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 08/15/2014] [Indexed: 12/19/2022]
Abstract
Current research is investigating new methods to enhance tissue healing to speed up recovery time and decrease the risk of failure in Anterior Cruciate Ligament (ACL) reconstructive surgery. Biological augmentation is one of the most exploited strategies, in particular the application of Platelet Rich Plasma (PRP). Aim of the present paper is to systematically review all the preclinical and clinical papers dealing with the application of PRP as a biological enhancer during ACL reconstructive surgery. Thirty-two studies were included in the present review. The analysis of the preclinical evidence revealed that PRP was able to improve the healing potential of the tendinous graft both in terms of histological and biomechanical performance. Looking at the available clinical evidence, results were not univocal. PRP administration proved to be a safe procedure and there were some evidences that it could favor the donor site healing in case of ACL reconstruction with patellar tendon graft and positively contribute to graft maturation over time, whereas the majority of the papers did not show beneficial effects in terms of bony tunnels/graft area integration. Furthermore, PRP augmentation did not provide superior functional results at short term evaluation.
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Kovacevic D, Gulotta LV, Ying L, Ehteshami JR, Deng XH, Rodeo SA. rhPDGF-BB promotes early healing in a rat rotator cuff repair model. Clin Orthop Relat Res 2015; 473:1644-54. [PMID: 25349036 PMCID: PMC4385379 DOI: 10.1007/s11999-014-4020-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tendon-bone healing after rotator cuff repair occurs by fibrovascular scar tissue formation, which is weaker than a normal tendon-bone insertion site. Growth factors play a role in tissue formation and have the potential to augment soft tissue healing in the perioperative period. QUESTIONS/PURPOSES Our study aim was to determine if rhPDGF-BB delivery on a collagen scaffold can improve tendon-to-bone healing after supraspinatus tendon repair compared with no growth factor in rats as measured by (1) gross observations; (2) histologic analysis; and (3) biomechanical testing. METHODS Ninety-five male Sprague-Dawley rats underwent acute repair of the supraspinatus tendon. Rats were randomized into one of five groups: control (ie, repair only), scaffold only, and three different platelet-derived growth factor (PDGF) doses on the collagen scaffold. Animals were euthanized 5 days after surgery to assess cellular proliferation and angiogenesis. The remaining animals were analyzed at 4 weeks to assess repair site integrity by gross visualization, fibrocartilage formation with safranin-O staining, and collagen fiber organization with picrosirius red staining, and to determine the biomechanical properties (ie, load-to-failure testing) of the supraspinatus tendon-bone construct. RESULTS The repaired supraspinatus tendon was in continuity with the bone in all animals. At 5 days, rhPDGF-BB delivery on a scaffold demonstrated a dose-dependent response in cellular proliferation and angiogenesis compared with the control and scaffold groups. At 28 days, with the numbers available, rhPDGF-BB had no effect on increasing fibrocartilage formation or improving collagen fiber maturity at the tendon-bone insertion site compared with controls. The control group had higher tensile loads to failure and stiffness (35.5 ± 8.8 N and 20.3 ± 4.5 N/mm) than all the groups receiving the scaffold, including the PDGF groups (scaffold: 27 ± 6.4 N, p = 0.021 and 13 ± 5.7 N/mm, p = 0.01; 30 µg/mL PDGF: 26.5 ± 7.5 N, p = 0.014 and 13.3 ± 3.2 N/mm, p = 0.01; 100 µg/mL PDGF: 25.7 ± 6.1 N, p = 0.005 and 11.6 ± 3.3 N/mm, p = 0.01; 300 µg/mL PDGF: 27 ± 6.9 N, p = 0.014 and 12.7 ± 4.1 N/mm, p = 0.01). CONCLUSIONS rhPDGF-BB delivery on a collagen scaffold enhanced cellular proliferation and angiogenesis during the early phase of healing, but this did not result in either a more structurally organized or stronger attachment site at later stages of healing. The collagen scaffold had a detrimental effect on healing strength at 28 days, and its relatively larger size compared with the rat tendon may have caused mechanical impingement and extrinsic compression of the healing tendon. Future studies should be performed in larger animal models where healing occurs more slowly. CLINICAL RELEVANCE Augmenting the healing environment to improve the structural integrity and to reduce the retear rate after rotator cuff repair may be realized with continued understanding and optimization of growth factor delivery systems.
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Affiliation(s)
- David Kovacevic
- Tissue Engineering, Regeneration, and Repair Program, Hospital for Special Surgery, New York, NY USA
| | - Lawrence V. Gulotta
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 525 East 71st Street, New York, NY 10021 USA
| | - Liang Ying
- Tissue Engineering, Regeneration, and Repair Program, Hospital for Special Surgery, New York, NY USA
| | - John R. Ehteshami
- Tissue Engineering, Regeneration, and Repair Program, Hospital for Special Surgery, New York, NY USA
| | - Xiang-Hua Deng
- Tissue Engineering, Regeneration, and Repair Program, Hospital for Special Surgery, New York, NY USA
| | - Scott A. Rodeo
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 525 East 71st Street, New York, NY 10021 USA
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Tingstad EM, Bratt SN, Hildenbrand KJ, O'Malley BA, Mitchell ER, Gaddis CE, Jacobson CA. Platelet-rich plasma does not decrease blood loss in total knee arthroplasty. Orthopedics 2015; 38:e434-6. [PMID: 25970373 DOI: 10.3928/01477447-20150504-63] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/13/2014] [Indexed: 02/03/2023]
Abstract
This study was designed to assess the use of platelet-rich plasma (PRP) during primary total knee arthroplasty (TKA). The authors hypothesized that this would result in less blood loss and greater hemoglobin and hematocrit levels at discharge and would potentially decrease the length of hospital stay. Leukocyte rich PRP was used during the procedure and at wound closure. Two surgeons performed all procedures in a similar fashion. Two different TKA implants were used. Each surgeon used the same implant throughout the study. A limited medial parapatellar approach was used and drains were used at closure. No tranexamic acid preparations were used. Continuous passive motion machines were used in all patients during their hospital stay. A total of 102 consecutive TKAs were performed. The study group (n=46) consecutively received the PRP injections during the TKA, whereas the control group (n=47) did not. Hemoglobin and hematocrit levels were obtained pre- and postoperatively. Estimated blood loss was recorded during surgery, and the auto-collection reinfusion drain system output was measured. The length of hospital stay was collected and recorded. The study showed that hemoglobin and hematocrit levels were not different when comparing study and control groups. Age and sex differences were insignificant. Finally, no statistical difference was seen for the estimated blood loss and hospital stay between the 2 groups. Platelet-rich plasma use during TKA does not decrease hospital stay or reduce estimated blood loss in the perioperative period.
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Fleming BC, Proffen BL, Vavken P, Shalvoy MR, Machan JT, Murray MM. Increased platelet concentration does not improve functional graft healing in bio-enhanced ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:1161-70. [PMID: 24633008 PMCID: PMC4167989 DOI: 10.1007/s00167-014-2932-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 03/04/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE The use of an extracellular matrix scaffold (ECM) combined with platelets to enhance healing of an anterior cruciate ligament (ACL) graft ("bio-enhanced ACL reconstruction") has shown promise in animal models. However, the effects of platelet concentration on graft healing remain unknown. The objectives of this study were to determine whether increasing the platelet concentration in the ECM scaffold would (1) improve the graft biomechanical properties and (2) decrease cartilage damage after surgery. METHODS Fifty-five adolescent minipigs were randomized to five treatment groups: untreated ACL transection (n = 10), conventional ACL reconstruction (n = 15) and bio-enhanced ACL reconstruction using 1× (n = 10), 3× (n = 10) or 5× (n = 10) platelet-rich plasma. The graft biomechanical properties, anteroposterior (AP) knee laxity, graft histology and macroscopic cartilage integrity were measured at 15 weeks. RESULTS The mean linear stiffness of the bio-enhanced ACL reconstruction procedure using the 1× preparation was significantly greater than traditional reconstruction, while the 3× and 5× preparations were not. The failure loads of all the ACL-reconstructed groups were equivalent but significantly greater than untreated ACL transection. There were no significant differences in the Ligament Maturity Index or AP laxity between reconstructed knees. Macroscopic cartilage damage was relatively minor, though significantly less when the ECM-platelet composite was used. CONCLUSIONS Only the 1× platelet concentration improved healing over traditional ACL reconstruction. Increasing the platelet concentration from 1× to 5× in the ECM scaffold did not further improve the graft mechanical properties. The use of an ECM-platelet composite decreased the amount of cartilage damage seen after ACL surgery.
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Affiliation(s)
- Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI, USA,
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40
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Does fibrin clot really enhance graft healing after double-bundle ACL reconstruction in a caprine model? Knee Surg Sports Traumatol Arthrosc 2015; 23:669-79. [PMID: 25326761 DOI: 10.1007/s00167-014-3380-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 10/07/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE Graft healing following anterior cruciate ligament (ACL) reconstruction is a complex process characterized by phases of healing that lead to ACL remodelling. Our hypothesis is that fibrin clot addition to ACL reconstruction will result in advanced graft remodelling and healing when compared to a control group at 12 weeks as observed by histology, immunohistochemistry and magnetic resonance imaging (MRI). METHODS Eleven Spanish Boar goats underwent double-bundle ACL reconstruction: 8 were analysed and 3 were excluded. Group 1 was treated with DB ACL reconstruction utilizing autologous fibrin clots (n = 4), and group 2 was treated with standard DB ACL-R (n = 4). Histological and radiographic analysis was performed at 12 weeks. Each animal underwent 3-T MRI immediately after euthanization for evaluation of graft signal intensity utilizing the signal noise quotient (SNQ). Specimens were then sectioned and stored for standard histological and immunohistochemistry testing. RESULTS The mean ligament tissue maturity index score was significantly higher for group 1 (15 ± 2.3) compared with group 2 (7.7 ± 5.2) (p < 0.05). The mean vascularity (cell/mm(2)) for group 1 was 7.1 ± 1.3 and 9.3 ± 3.1 for group 2 (n.s.). The mean collagen type 1 (% 50× field) for group 1 was 35.8 ± 22.1 and 19.9 ± 20.5 for group 2 (n.s.). The mean SNQ for the AM bundle was 1.1 ± 0.7 for group 1 and 3.1 ± 1.8 for group 2 (n.s.). The mean SNQ for the total PL bundle was significantly lower for group 1 (1.1 ± 0.7) compared with group 2 (3.7 ± 1.3) (p < 0.05). There was a significant correlation between the vascularity and the ligament tissue maturity index score as well as between collagen type 1 and SNQ, both AM and PL bundles (p < 0.05). CONCLUSION The use of fibrin clot in ACL reconstruction in a caprine model demonstrated improved healing with respect to histological analysis of the intra-articular ACL reconstruction segment and decreased signal intensity on MRI. It may lead to improved graft healing and maturation. By accelerating the intra-articular healing and ligamentization, the outcome of patients after ACL-R can be improved with faster return to sports and daily activity.
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Abstract
Tendon–bone junctions (TBJs) are frequently injured, especially in athletic settings. Healing of TBJ injuries is slow and is often repaired with scar tissue formation that compromises normal function. This study explored the feasibility of using kartogenin (KGN), a biocompound, to enhance the healing of injured TBJs. We first determined the effects of KGN on the proliferation and chondrogenic differentiation of rabbit bone marrow stromal cells (BMSCs) and patellar tendon stem/progenitor cells (PTSCs) in vitro. KGN enhanced cell proliferation in both cell types in a concentration-dependent manner and induced chondrogenic differentiation of stem cells, as demonstrated by high expression levels of chondrogenic markers aggrecan, collagen II and Sox-9. Besides, KGN induced the formation of cartilage-like tissues in cell cultures, as observed through the staining of abundant proteoglycans, collagen II and osteocalcin. When injected into intact rat patellar tendons in vivo, KGN induced cartilage-like tissue formation in the injected area. Similarly, when KGN was injected into experimentally injured rat Achilles TBJs, wound healing in the TBJs was enhanced, as evidenced by the formation of extensive cartilage-like tissues. These results suggest that KGN may be used as an effective cell-free clinical therapy to enhance the healing of injured TBJs.
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Chen CH, Lee CH. Biological fixation in anterior cruciate ligament surgery. Asia Pac J Sports Med Arthrosc Rehabil Technol 2014. [DOI: 10.1016/j.asmart.2014.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Fu SC, Cheuk YC, Yung SH, Rolf CG, Chan KM. Systematic Review of Biological Modulation of Healing in Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2014; 2:2325967114526687. [PMID: 26535311 PMCID: PMC4555564 DOI: 10.1177/2325967114526687] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Whether biological modulation is effective to promote healing in anterior cruciate ligament (ACL) reconstruction remains unclear. Purpose: To perform a systematic review of both clinical and experimental evidence of preclinical animal studies on biological modulation to promote healing in ACL reconstruction. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic search was performed using the PubMed, Ovid, and Scopus search engines. Inclusion criteria were clinical and animal studies involving subjects with ACL injury with the use of biological modulation to promote healing outcomes. Methodological quality of clinical studies was evaluated using the Critical Appraisal Skill Programme (CASP) appraisal tool, and animal studies were evaluated by a scoring system based on a published checklist of good animal studies. Results: Ten clinical studies and 50 animal studies were included. Twenty-five included studies were regarded as good quality, with a methodological score ≥5. These studies suggested that transforming growth factor–beta (TGF-β), mesenchymal stem cells, osteogenic factors, and modalities that reduce local inflammation may be beneficial to promote graft healing in ACL reconstruction. Conclusion: This systematic review suggests that biological modulation is able to promote healing on top of surgical treatment for ACL injuries. This treatment strategy chiefly works through promotion of healing at the tunnel-graft interface, but the integrity of the intra-articular midsubstance of the graft would be another target for biological modulation.
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Affiliation(s)
- Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yau-Chuk Cheuk
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Christer Gustav Rolf
- Department of Orthopaedic Surgery, Huddinge University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Kai-Ming Chan
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. ; Lui Che Woo Institute of Innovative Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Intra-articular remodelling of hamstring tendon grafts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:2102-8. [PMID: 23982759 PMCID: PMC4142140 DOI: 10.1007/s00167-013-2634-5] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 08/18/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE A summary is provided on the existing knowledge about the specific healing phases of the intra-articular hamstring tendon graft used for ACL reconstruction. Differences between human and animal in vivo studies are explained, and implications for the postoperative time period are laid out. METHODS A systematic review of the existing literature was performed on the topic of tendon remodelling of hamstring grafts in ACL reconstruction using Medline database. Publications between 1982 and 2012 were included. Special focus was directed on in vivo human and animal studies analysing intra-articular free tendon graft remodelling. RESULTS Animal and human in vitro and vivo researches have demonstrated three characteristic stages of graft healing after ACL reconstruction: an early graft healing phase with central graft necrosis and hypocellularity and no detectable revascularization of the graft tissue, followed by a phase of proliferation, the time of most intensive remodelling and revascularization and finally, a ligamentization phase with characteristic restructuring of the graft towards the properties of the intact ACL. However, a full restoration of either the biological or biomechanical properties of the intact ACL is not achieved. CONCLUSION Significant knowledge on human cruciate ligament remodelling has been added in the understanding of the processes during the course of graft healing. Most importantly, the remodelling process in humans is prolonged compared to animal studies. While today´s rehabilitation protocols are often extrapolated from findings of animal in vivo healing studies, current findings of human in vivo healing studies might require new post-operative regimens following hamstring ACL reconstruction.
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Sun L, Wu B, Tian M, Liu B, Luo Y. Comparison of graft healing in anterior cruciate ligament reconstruction with and without a preserved remnant in rabbits. Knee 2013; 20:537-44. [PMID: 24119389 DOI: 10.1016/j.knee.2013.09.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 07/25/2013] [Accepted: 09/11/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND The remnant of the native anterior cruciate ligament (ACL) might contribute to the biological integration of the graft in ACL reconstruction. The aim of this study was to explore whether the preserved remnant enhanced graft healing in ACL reconstruction. METHODS Forty New Zealand rabbits underwent bilateral anterior cruciate ligament reconstructions. One knee was treated with a 2-mm remnant preserved on the tibial side (remnant-preservation, RP group) while the contralateral knee underwent a complete removal of the remnants by cauterization (remnant-resection, RR group) in each animal. Gross observations combined with microangiography, histological evaluation, and uniaxial load testing were performed after 4, 8, and 12weeks. RESULTS The vascular density on the graft surface was statistically higher in the RP group as compared to that of the RR group at 4 (P=0.002) and 8weeks (P=0.020). Additionally, the accelerated intra-articular and intra-tunnel graft integration were histologically observed in the RP group. Histological scores in the RP group were statistically higher than the RR group at 4weeks (P=0.028 for the intra-articular healing and P=0.046 for the intra-tunnel healing) and 8weeks (P=0.031 for the intra-articular healing and P=0.014 for the intra-tunnel healing). The ultimate failure load (P=0.017), yield load (P=0.025), and stiffness (P=0.004) were statistically higher in the RP group as compared to those of the RR group, with corresponding significant differences in the failure mode (P=0.020) between the two groups at 8weeks. CONCLUSIONS The preserved remnant enhanced ACL graft healing with improved biomechanical properties in the rabbit model. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Lei Sun
- Orthopaedic Center of PLA, The 88th Hospital of PLA, Tai'an City, Shandong Province, China.
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MRI evaluation of tibial tunnel wall cortical bone formation after platelet-rich plasma applied during anterior cruciate ligament reconstruction. Radiol Oncol 2013; 47:119-24. [PMID: 23801907 PMCID: PMC3691087 DOI: 10.2478/raon-2013-0009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 09/06/2012] [Indexed: 02/07/2023] Open
Abstract
Background After anterior cruciate ligament (ACL) reconstruction, formation of cortical sclerotic bone encircling the femoral and tibial tunnel is a part of intratunnel graft healing. During the physiological cascades of soft tissue healing and bone growth, cellular and hormonal factors play an important role. The purpose of this study was to non-invasively but quantitatively assess the effect of intraoperatively applied platelet-rich plasma (PRP) on the formation of cortical bone encircling the tibial tunnel. Patients and methods In fifty patients, standard arthroscopic ACL reconstructions were performed. The PRP group (n = 25) received a local application of PRP while the control group (n = 25) did not receive PRP. The proximal tibial tunnel was examined by MRI in the paraxial plane where the portion of the tibial tunnel wall circumference consisting of sclerotic cortical bone was assessed with testing occurring at one, two and a half and six months after surgery. Results At one month after surgery, differences between the groups in the amount of cortical sclerotic bone encircling the tunnel were not significant (p = 0.928). At two and a half months, the sclerotic portion of the tunnel wall in the PRP group (36.2%) was significantly larger than in the control (22.5%) group (p = 0.004). At six months, the portion of sclerotic bone in the PRP group (67.1%) was also significantly larger than in the control (53.5%) group (p = 0.003). Conclusions Enhanced cortical bone formation encircling the tibial tunnel at 2.5 and 6 months after ACL graft reconstruction results from locally applied platelet-rich plasma.
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Oka S, Matsumoto T, Kubo S, Matsushita T, Sasaki H, Nishizawa Y, Matsuzaki T, Saito T, Nishida K, Tabata Y, Kurosaka M, Kuroda R. Local Administration of Low-Dose Simvastatin-Conjugated Gelatin Hydrogel for Tendon–Bone Healing in Anterior Cruciate Ligament Reconstruction. Tissue Eng Part A 2013. [DOI: 10.1089/ten.tea.2012.0325] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shinya Oka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Matsumoto
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Seiji Kubo
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takehiko Matsushita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Sasaki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichiro Nishizawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tokio Matsuzaki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Saito
- Department of Biomaterials, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
| | - Kotaro Nishida
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasuhiko Tabata
- Department of Biomaterials, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
| | - Masahiro Kurosaka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Seijas R, Ares O, Catala J, Alvarez-Diaz P, Cusco X, Cugat R. Magnetic resonance imaging evaluation of patellar tendon graft remodelling after anterior cruciate ligament reconstruction with or without platelet-rich plasma. J Orthop Surg (Hong Kong) 2013; 21:10-4. [PMID: 23629979 DOI: 10.1177/230949901302100105] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To evaluate the stages of patellar tendon graft remodelling using magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) reconstruction with or without platelet-rich plasma (PRP) injection. METHODS 98 patients aged 18 to 65 years with complete rupture of the ACL were randomised to undergo reconstruction with the autologous patellar tendon grafts with or without PRP injection. For the PRP group, 8 ml of PRP was obtained in the surgery room and was percutaneously injected into the suprapatellar joint after portal suture. MRI was obtained at months 4, 6, and 12. Remodelling stages of the grafts were classified as hypointense, mildly hyperintense, moderately hyperintense, severely hyperintense, and diffusely hyperintense by a radiologist blinded to treatment allocation. RESULTS More patients in the PRP group than controls attained higher stages of remodelling at month 4 (p=0.003), month 6 (p=0.0001), and month 12 (p=0.354). CONCLUSION PRP enabled faster remodelling of patellar tendon grafts.
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Affiliation(s)
- Roberto Seijas
- Instituto de Ortopedia y Traumatologia, Fundacion García Cugat Hospital Quiron Barcelona, Spain.
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Vadalà A, Iorio R, De Carli A, Ferretti M, Paravani D, Caperna L, Iorio C, Gatti A, Ferretti A. Platelet-rich plasma: does it help reduce tunnel widening after ACL reconstruction? Knee Surg Sports Traumatol Arthrosc 2013; 21:824-9. [PMID: 22488012 DOI: 10.1007/s00167-012-1980-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 03/16/2012] [Indexed: 12/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the efficacy of platelet-rich plasma (PRP) in reducing femoral and tibial tunnel enlargement in patients operated on for anterior cruciate ligament reconstruction with hamstrings. METHODS Forty male patients, in which both femoral and tibial 9-mm tunnels were performed because of the graft size, were enrolled in this prospective study. They were randomly assigned to group A (20 patients, PRP group) and group B (20 patients, control group). All patients were followed up at a median of 14.7 months (range 10-16 months), with a physical examination, the Tegner, Lysholm and objective IKDC scoring scales, and with the KT-1000 arthrometer. Moreover, they underwent a CT evaluation in order to assess the amount of tunnel enlargement. RESULTS Femoral tunnel diameter increased from 9.0 ± 0.1 mm to 9.8 ± 0.3 mm in group A (p = 0.032) and from 9.0 ± 0.1 mm to 9.4 ± 0.5 mm in group B (p = 0.043). Tibial tunnel diameter increased from 9.0 ± 0.2 mm to 10.9 ± 0.2 mm in group A (p = 0.029) and from 9.1 ± 0.1 mm to 10.1 ± 0.4 mm in group B (p = 0.028). Physical examination as well as the evaluation scales used showed no differences between the two groups. CONCLUSIONS The use of PRP does not seem to be effective in preventing tunnel enlargement.
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Affiliation(s)
- Antonio Vadalà
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, S. Andrea Hospital, University of Rome La Sapienza, Via Grottarossa, 1035, Rome, Italy.
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Mifune Y, Ota S, Takayama K, Hoshino Y, Matsumoto T, Kuroda R, Kurosaka M, Fu FH, Huard J. Therapeutic advantage in selective ligament augmentation for partial tears of the anterior cruciate ligament: results in an animal model. Am J Sports Med 2013; 41:365-73. [PMID: 23299851 DOI: 10.1177/0363546512471614] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND As a result of recent studies describing the double-bundle anterior cruciate ligament (ACL), selected ACL augmentation procedures, either anteromedial (AM) or posterolateral (PL), have been introduced as the treatment of choice for partial ACL ruptures. The preserved mechanoreceptor and vascularity of the remnant ACL are considered to provide additional biological benefits. Although enhanced knee joint proprioception in ACL augmented patients has been previously reported, there is no study assessing biological healing advantages of the graft after the ACL augmentation procedure. HYPOTHESIS Selected ACL augmentation for partial tears can accelerate the healing process of the grafted tendon, which promotes better biomechanical recovery of the tendon, compared with conventional ACL reconstruction of complete tears. STUDY DESIGN Controlled laboratory study. METHODS Two rat models were established in this study: an ACL augmentation partial tear model and conventional ACL reconstruction for a complete tear. Biological assessments of cellularity and angiogenesis were measured by hematoxylin and eosin staining and immunostaining, respectively. Additionally, rat-specific type III collagen and α-smooth muscle actin were evaluated by immunohistochemical staining to analyze the healing process, whereas anti-rat neurofilament antigen was assessed to examine proprioceptive recovery. Biological assessments of the augmented and reconstructed grafts were conducted postoperatively at week 2, whereas biomechanical testing was performed postoperatively at week 8. RESULTS An increase in cellularity and angiogenesis was observed in the augmented grafts compared with the conventionally reconstructed grafts. Also, increased amounts of rat-specific type III collagen, α-smooth muscle actin, and anti-rat neurofilament antigen were expressed in the augmented grafts. Biomechanical testing showed that failure to load was significantly higher in the augmentation group compared with the conventional reconstruction group (augmentation, 15.9 ± 1.0; reconstruction, 7.0 ± 1.3; P < .01). CLINICAL RELEVANCE Selected ACL augmentation could be a good choice for the repair of partial ACL injury by preserving the uninjured portion of the ACL, which in turn could maintain the anatomic position of the ligament and its biomechanical function.
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Affiliation(s)
- Yutaka Mifune
- Stem Cell Research Center, Department of Orthopaedic Surgery, University of Pittsburgh, School of Medicine, 450 Technology Drive, 2 Bridgeside Point, Suite 206, Pittsburgh, PA 15219, USA
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