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Kawakami J, Hisanaga S, Yoshimoto Y, Mashimo T, Kaneko T, Yoshimura N, Shimada M, Tateyama M, Matsunaga H, Shibata Y, Tanimura S, Takata K, Arima T, Maeda K, Fukuma Y, Uragami M, Ideo K, Sugimoto K, Yonemitsu R, Matsushita K, Yugami M, Uehara Y, Nakamura T, Tokunaga T, Karasugi T, Sueyoshi T, Shukunami C, Okamoto N, Masuda T, Miyamoto T. Remnant tissue enhances early postoperative biomechanical strength and infiltration of Scleraxis-positive cells within the grafted tendon in a rat anterior cruciate ligament reconstruction model. PLoS One 2023; 18:e0293944. [PMID: 37939095 PMCID: PMC10631660 DOI: 10.1371/journal.pone.0293944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023] Open
Abstract
When ruptured, ligaments and tendons have limited self-repair capacity and rarely heal spontaneously. In the knee, the Anterior Cruciate Ligament (ACL) often ruptures during sports activities, causing functional impairment and requiring surgery using tendon grafts. Patients with insufficient time to recover before resuming sports risk re-injury. To develop more effective treatment, it is necessary to define mechanisms underlying ligament repair. For this, animal models can be useful, but mice are too small to create an ACL reconstruction model. Thus, we developed a transgenic rat model using control elements of Scleraxis (Scx), a transcription factor essential for ligament and tendon development, to drive GFP expression in order to localize Scx-expressing cells. As anticipated, Tg rats exhibited Scx-GFP in ACL during developmental but not adult stages. Interestingly, when we transplanted the flexor digitorum longus (FDP) tendon derived from adult Scx-GFP+ rats into WT adults, Scx-GFP was not expressed in transplanted tendons. However, tendons transplanted from adult WT rats into Scx-GFP rats showed upregulated Scx expression in tendon, suggesting that Scx-GFP+ cells are mobilized from tissues outside the tendon. Importantly, at 4 weeks post-surgery, Scx-GFP-expressing cells were more frequent within the grafted tendon when an ACL remnant was preserved (P group) relative to when it was not (R group) (P vs R groups (both n = 5), p<0.05), and by 6 weeks, biomechanical strength of the transplanted tendon was significantly increased if the remnant was preserved (P vsR groups (both n = 14), p<0.05). Scx-GFP+ cells increased in remnant tissue after surgery, suggesting remnant tissue is a source of Scx+ cells in grafted tendons. We conclude that the novel Scx-GFP Tg rat is useful to monitor emergence of Scx-positive cells, which likely contribute to increased graft strength after ACL reconstruction.
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Affiliation(s)
- Junki Kawakami
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Satoshi Hisanaga
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Yuki Yoshimoto
- Department of Molecular Craniofacial Embryology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
- Department of Molecular Biology and Biochemistry, Basic Life Sciences, Graduate School of Biomedical and Health Sciences, Minami-ku, Hiroshima, Japan
| | - Tomoji Mashimo
- Division of Animal Genetics, Laboratory Animal Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Takehito Kaneko
- Graduate School of Science and Engineering, Iwate University, Morioka, Iwate, Japan
| | - Naoto Yoshimura
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Masaki Shimada
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Makoto Tateyama
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Hideto Matsunaga
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Yuto Shibata
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Shuntaro Tanimura
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Kosei Takata
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Takahiro Arima
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Kazuya Maeda
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Yuko Fukuma
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Masaru Uragami
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Katsumasa Ideo
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Kazuki Sugimoto
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Ryuji Yonemitsu
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Kozo Matsushita
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Masaki Yugami
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Yusuke Uehara
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Takayuki Nakamura
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Takuya Tokunaga
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Tatsuki Karasugi
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Takanao Sueyoshi
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Chisa Shukunami
- Department of Molecular Biology and Biochemistry, Basic Life Sciences, Graduate School of Biomedical and Health Sciences, Minami-ku, Hiroshima, Japan
| | - Nobukazu Okamoto
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Tetsuro Masuda
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Takeshi Miyamoto
- Faculty of Life Sciences, Department of Orthopaedic Surgery, Kumamoto University, Chuo-ku, Kumamoto, Japan
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Kubo T, Takahashi T, Kimura M, Takeshita K. Biomechanical Comparisons of Anterior Cruciate Ligament Avulsion Fracture Fixation Using High-Strength Suture and Ultra-High Molecular Weight Polyethylene Suture Tape in a Porcine Model. J Knee Surg 2022; 35:1199-1203. [PMID: 33482672 DOI: 10.1055/s-0040-1722347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A wide variety of fixation methods have been reported to fix anterior cruciate ligament (ACL) tibial avulsion fractures, but there have been no studies into the fixation of these fractures with ultra-high molecular weight polyethylene (UHMWPE) suture tape as an alternative to conventional thread. Type III ACL tibial avulsion fractures were created in 20 skeletally immature porcine knees. All specimens were randomized into two treatment groups: (1) pullout repair using no. 2 suture fixation and (2) pullout repair using UHMWPE suture tape fixation. The specimens were tested cyclically (20 cycles, 0-40 N, 100 mm/min) in the direction of the native ACL and loaded to failure (100 mm/min) on a tensile tester. Statistically significant differences between the structural properties (displacement, upper yield load, maximum load, linear stiffness, and elongation at failure) under cyclic loading and single-cycle loading were analyzed. Displacement during cyclic testing was 1.56 ± 1.03 mm in the UltraBraid group and 0.99 ± 0.48 mm in the SUTURETAPE group, with no significant differences found between the groups (p = 0.13). There were no significant differences in upper yield load (161.9 ± 68.9 N in the UltraBraid group, 210.4 ± 60.1 N in the SUTURETAPE group, p = 0.11), linear stiffness (14.7 ± 4.7N/mm in the UltraBraid group, 18.1 ± 7.9 N/mm in the SUTURETAPE group, p = 0.27), or elongation at failure (20.1 ± 8.0 mm in the UltraBraid group, 21.5 ± 7.2 mm in the SUTURETAPE group, p = 0.69). On the other hand, significant differences were observed in maximum load in the SUTURETAPE group (219.7 ± 89.2 N in the UltraBraid group, 319.3 ± 92.6 N in the SUTURETAPE group, p = 0.025).
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Affiliation(s)
- Tatsuya Kubo
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Tsuneari Takahashi
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Masashi Kimura
- Gunma Sports Medicine Research Center, Zenshukai Hospital, Maebashi, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Japan
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Implantation of autogenous meniscal fragments wrapped with a fascia sheath induces fibrocartilage regeneration in a large meniscal defect in sheep: A histological and biomechanical study. Orthop Traumatol Surg Res 2022; 108:103225. [PMID: 35104627 DOI: 10.1016/j.otsr.2022.103225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Currently, various studies have been reported to regenerate the meniscus tissue in a large defect after partial meniscectomy using biological or synthetic scaffolds with or without fibrochondrocytes. However, the clinical utility of those treatments has not been established as of yet. HYPOTHESIS Purposes of this study were to develop a sheep model to evaluate feasibility of this new surgical strategy to treat the irreparable meniscus injury, and to test the hypothesis that implantation of autogenous meniscal fragments wrapped with a fascia sheath may significantly induce fibrocartilage regeneration in a large meniscal defect in the sheep model. METHODS AND METHODS Twenty Suffolk sheep were used. In each animal, an anterior 10-mm width of the right medial meniscus was resected. Then, the animals were divided into the following 2 groups. In Group I, the defect was enveloped with a fascia from the left thigh. In Group II, the resected meniscus fragmented into small pieces was grafted into the defect. Then the defect was enveloped with a fascia. In each group, 5 of 10 sheep were used for histological and biomechanical evaluations, respectively, at 12 weeks after surgery. RESULTS In Group I, the defect was incompletely filled with thin fibrous tissues, while fibrocartilage tissues rarely regenerated in the tissue. In Group II, all defects were completely filled with thick fibrocartilage tissues, which were richly stained with the safranin O staining. Both the gross and histological observation score of Group II was significantly (p=0.0005, p=0.0005) greater than that of Group I. Concerning the cross-sectional area of the regenerated tissue, Group II was significantly (p=0.0002) greater than Group I. In the biomechanical evaluation, the maximal load and the linear stiffness of the meniscus-tibia complex were significantly (p=0.0015, p=0.0283) greater in Group II than in Group I. DISCUSSION Implantation of autogenous meniscal fragments wrapped with a fascia sheath significantly induces fibrocartilage regeneration into a large meniscal defect in the sheep model. LEVEL OF EVIDENCE Not applicable; Controlled Laboratory Study, Experimental in vivo study.
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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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Medial Meniscal Ramp Lesion Repair Concomitant With Anterior Cruciate Ligament Reconstruction Did Not Contribute to Better Anterior Knee Stability and Structural Properties After Cyclic Loading: A Porcine Model. Arthrosc Sports Med Rehabil 2021; 3:e1967-e1973. [PMID: 34977655 PMCID: PMC8689255 DOI: 10.1016/j.asmr.2021.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
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Takahashi T, Takeshita K. In Vivo biomechanical evaluations of suture anchors for repairing grade 3 superficial medial collateral ligament injury in a porcine model. J Orthop Surg (Hong Kong) 2021; 29:23094990211021536. [PMID: 34121508 DOI: 10.1177/23094990211021536] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To clarify the biomechanical and radiological outcomes of superficial medial collateral ligament (sMCL) repair using suture anchors in a large animal model. METHODS The right sMCLs of nine male castrated pigs was completely detached at the femoral attachment. sMCL repair surgery was performed using two suture anchors. The same skin incision, sMCL exposure, and immediate wound closure were made at the left knee as a sham surgery. Magnetic resonance imaging was performed preoperatively and 4 weeks after surgery. The structural properties (upper yield load, maximum load, linear stiffness, and elongation at failure) of the femur-sMCL-tibia complex were determined. RESULTS During tensile testing, all the repaired sMCLs avulsed from the femoral attachment. There were no significant differences in the upper yield load, maximum load, linear stiffness, or elongation at failure between the groups 4 weeks after surgery or in the MRI-derived signal-to-noise quotients (SNQs) at the mid and tibial sMCL. The SNQs differed significantly at the femoral (2.7 ± 1.2 vs 0.3 ± 0.7; P = 0.00064) portions between groups. CONCLUSION The injured sMCLs biomechanically recovered after surgery using suture anchors even though the SNQs were higher than those with native contralateral sMCLs. For clinical relevance, sMCL repair of grade 3 sMCL injuries using suture anchors was both safe and successful with less tissue dissection.
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Affiliation(s)
- Tsuneari Takahashi
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
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Hexter AT, Karali A, Kao A, Tozzi G, Heidari N, Petrie A, Boyd A, Kalaskar DM, Pendegrass C, Rodeo S, Haddad F, Blunn G. Effect of Demineralized Bone Matrix, Bone Marrow Mesenchymal Stromal Cells, and Platelet-Rich Plasma on Bone Tunnel Healing After Anterior Cruciate Ligament Reconstruction: A Comparative Micro-Computed Tomography Study in a Tendon Allograft Sheep Model. Orthop J Sports Med 2021; 9:23259671211034166. [PMID: 34568508 PMCID: PMC8461134 DOI: 10.1177/23259671211034166] [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: 03/12/2021] [Accepted: 04/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background: The effect of demineralized bone matrix (DBM), bone marrow–derived mesenchymal stromal cells (BMSCs), and platelet-rich plasma (PRP) on bone tunnel healing in anterior cruciate ligament reconstruction (ACLR) has not been comparatively assessed. Hypothesis: These orthobiologics would reduce tunnel widening, and the effects on tunnel diameter would be correlated with tunnel wall sclerosis. Study Design: Controlled laboratory study. Methods: A total of 20 sheep underwent unilateral ACLR using tendon allograft and outside-in interference screw fixation. The animals were randomized into 4 groups (n = 5 per group): Group 1 received 4mL of DBM paste, group 2 received 10 million BMSCs in fibrin sealant, group 3 received 12 mL of activated leukocyte-poor platelet-rich plasma, and group 4 (control) received no treatment. The sheep were euthanized after 12 weeks, and micro-computed tomography scans were performed. The femoral and tibial tunnels were divided into thirds (aperture, midportion, and exit), and the trabecular bone structure, bone mineral density (BMD), and tunnel diameter were measured. Tunnel sclerosis was defined by a higher bone volume in a 250-µm volume of interest compared with a 4-mm volume of interest surrounding the tunnel. Results: Compared with the controls, the DBM group had a significantly higher bone volume fraction (bone volume/total volume [BV/TV]) (52.7% vs 31.8%; P = .020) and BMD (0.55 vs 0.47 g/cm3; P = .008) at the femoral aperture and significantly higher BV/TV at femoral midportion (44.2% vs 32.9%; P = .038). There were no significant differences between the PRP and BMSC groups versus controls in terms of trabecular bone analysis or BMD. In the controls, widening at the femoral tunnel aperture was significantly greater than at the midportion (46.7 vs 41.7 mm2; P = .034). Sclerosis of the tunnel was common and most often seen at the femoral aperture. In the midportion of the femoral tunnel, BV/TV (r = 0.52; P = .019) and trabecular number (rS = 0.50; P = .024) were positively correlated with tunnel widening. Conclusion: Only DBM led to a significant increase in bone volume, which was seen in the femoral tunnel aperture and midportion. No treatment significantly reduced bone tunnel widening. Tunnel sclerosis in the femoral tunnel midportion was correlated significantly with tunnel widening. Clinical Relevance: DBM might have potential clinical use to enhance healing in the femoral tunnel after ACLR.
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Affiliation(s)
- Adam T Hexter
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Aikaterina Karali
- Zeiss Global Centre, School of Mechanical and Design Engineering, University of Portsmouth, Portsmouth, UK
| | - Alex Kao
- Zeiss Global Centre, School of Mechanical and Design Engineering, University of Portsmouth, Portsmouth, UK
| | - Gianluca Tozzi
- Zeiss Global Centre, School of Mechanical and Design Engineering, University of Portsmouth, Portsmouth, UK
| | - Nima Heidari
- Royal London Hospital and Orthopaedic Specialists (OS), London, UK
| | - Aviva Petrie
- Eastman Dental Institute, University College London, London, UK
| | - Ashleigh Boyd
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Deepak M Kalaskar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Catherine Pendegrass
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Scott Rodeo
- Hospital of Special Surgery, New York, New York, USA
| | | | - Gordon Blunn
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
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Bouguennec N, Robinson J, Douiri A, Graveleau N, Colombet PD. Two-year postoperative MRI appearances of anterior cruciate ligament hamstrings autografts are not correlated with functional outcomes, anterior laxity, or patient age. Bone Jt Open 2021; 2:569-575. [PMID: 34325524 PMCID: PMC8384440 DOI: 10.1302/2633-1462.28.bjo-2021-0104.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Aims MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. Methods A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity differential laxity testing. Results Two-year postoperative mean outcome scores were: Tegner 6.5 (2 to 10); Lysholm 89.8 (SD 10.4; 52 to 100); and IKDC subjective 86.8 (SD 11.8; 51 to 100). The objective IKDC score was 86% A (128 patients), 13% B (19 patients), and 1% C (two patients). Mean side-to-side anterior laxity difference (134 N force) was 0.6 mm (SD 1.8; -4.1 to 5.6). Mean graft SNQ was 2.0 (SD 3.5; -14 to 17). Graft Howell scores were I (61%, 91 patients), II (25%, 37 patients), III (13%, 19 patients), and IV (1%, two patients). There was no correlation between either Howell score or SNQ with instrumented anterior or Lysholm, Tegner, and IKDC scores, nor was any correlation found between patient age and ACL graft SNQ or Howell score. Conclusion The two-year postoperative MRI appearances of four-strand, semitendinosus ACL autografts (as measured by SNQ and Howell score) do not appear to have a relationship with postoperative functional scores, instrumented anterior laxity, or patient age at surgery. Other tools for analysis of graft maturity should be developed. Cite this article: Bone Jt Open 2021;2(8):569–575.
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Affiliation(s)
| | - James Robinson
- Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
| | - Adil Douiri
- Clinique du Sport de Bordeaux-Mérignac, Bordeaux, France
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Yao S, Fu BSC, Yung PSH. Graft healing after anterior cruciate ligament reconstruction (ACLR). ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 25:8-15. [PMID: 34094881 PMCID: PMC8134949 DOI: 10.1016/j.asmart.2021.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/05/2021] [Accepted: 03/21/2021] [Indexed: 01/11/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) is a commonly performed procedure in Orthopaedic sports medicine. With advances in surgical techniques providing better positioning and fixation of the graft, subsequent graft failure to certain extent should be accounted by poor graft healing. Although different biological modulations for enhancement of graft healing have been tried in different clinical and animal studies, complete graft incorporation into bone tunnels and the “ligamentization” of the intra-articular part have not been fully achieved yet. Based on the understanding of graft healing process and its failure mechanism, the purpose of this review is to combine both the known basic science & clinical evidence, to provide a much clearer picture of the obstacle encountered in graft healing, so as to facilitate researchers on subsequent work on the enhancement of ACL graft healing.
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Affiliation(s)
- Shiyi Yao
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Bruma Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
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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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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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Nishio Y, Kondo E, Onodera J, Onodera T, Yagi T, Iwasaki N, Yasuda K. Double-Bundle Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Hybrid Grafts in Patients Over 40 Years of Age: Comparisons Between Different Age Groups. Orthop J Sports Med 2018; 6:2325967118773685. [PMID: 29854859 PMCID: PMC5971394 DOI: 10.1177/2325967118773685] [Citation(s) in RCA: 6] [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] [Indexed: 01/10/2023] Open
Abstract
Background: Several recent studies have reported that favorable clinical results and a
high level of patient satisfaction can generally be obtained with no
increased risk of complications after single-bundle anterior cruciate
ligament (ACL) reconstruction performed in patients >40 years of age.
However, no studies have yet clarified the age-based differences in clinical
outcomes after double-bundle reconstruction. Purpose: To compare clinical outcomes after double-bundle ACL reconstruction using
hamstring tendon hybrid grafts between patients in 2 different age groups:
≥40 years and <40 years. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was conducted using 96 patients (48 men, 48 women ;
mean age, 37 years) who underwent unilateral ACL reconstruction between 2008
and 2011. These patients were divided into 2 groups: group M included
patients ≥40 years of age (n = 40 patients), and group Y included patients
<40 years of age (n = 56 patients). All patients underwent the same
anatomic double-bundle ACL reconstruction procedure. Clinical outcomes were
evaluated at 2 years after surgery. Tunnel enlargement was also evaluated by
computed digital radiography at 1 week and 2 years after surgery. Results: Mean postoperative side-to-side differences in anterior laxity were 0.5 ± 1.9
mm and 1.2 ± 1.5 mm in groups M and Y, respectively; there was a significant
difference between the 2 groups (P = .039). There were no
significant differences between the groups in Lysholm knee scores,
International Knee Documentation Committee (IKDC) scores, or peak muscle
torque of the hamstring. On the other hand, peak muscle torque of the
quadriceps was significantly lower in group M (81%) than in group Y (89%)
(P = .025). With respect to femoral tunnel enlargement,
the posterolateral tunnel in group M was significantly larger than that in
group Y on anteroposterior and lateral radiographs (P =
.015 and P = .002, respectively). Conclusion: Equivalent clinical outcomes were seen between the 2 age groups after
double-bundle ACL reconstruction. Postoperative anterior laxity was
significantly less in older patients than in younger patients, however,
older patients had significantly less quadriceps muscle strength than
younger patients. Surgeons should be aware of residual muscle weakness and
tunnel enlargement when performing double-bundle ACL reconstruction in older
patients.
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Affiliation(s)
- Yusuke Nishio
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Eiji Kondo
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Jun Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tomonori Yagi
- Department of Orthopaedic Surgery, Yagi Orthopaedic Hospital, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazunori Yasuda
- Sports Medicine and Arthroscopy Center, Yagi Orthopaedic Hospital, Sapporo, Japan
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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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Teuschl A, Heimel P, Nürnberger S, van Griensven M, Redl H, Nau T. A Novel Silk Fiber-Based Scaffold for Regeneration of the Anterior Cruciate Ligament: Histological Results From a Study in Sheep. Am J Sports Med 2016; 44:1547-57. [PMID: 26957219 DOI: 10.1177/0363546516631954] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Because of ongoing problems with anterior cruciate ligament (ACL) reconstruction, new approaches in the treatment of ACL injuries, particularly strategies based on tissue engineering, have gained increasing research interest. To allow for ACL regeneration, a structured scaffold that provides a mechanical basis, has cells from different sources, and comprises mechanical as well as biological factors is needed. Biological materials, biodegradable polymers, and composite materials are being used and tested as scaffolds. The optimal scaffold for ACL regeneration should be biocompatible and biodegradable to allow tissue ingrowth but also needs to have the right mechanical properties to provide immediate mechanical stability. HYPOTHESES The study hypotheses were that (1) a novel degradable silk fiber-based scaffold with mechanical properties similar to the native ACL will be able to initiate ligament regeneration after ACL resection and reconstruction under in vivo conditions and (2) additional cell seeding of the scaffold with autologous stromal vascular fraction-containing adipose-derived stem cells will increase regenerative activity. STUDY DESIGN Controlled laboratory study. METHODS A total of 33 mountain sheep underwent ACL resection and randomization to 2 experimental groups: (1) ACL reconstruction with a scaffold alone and (2) ACL reconstruction with a cell-seeded scaffold. Histological evaluation of the intra-articular portion of the reconstructed/regenerated ligament was performed after 6 and 12 months. RESULTS After 6 months, connective tissue surrounded the silk scaffold with ingrowth in some areas. The cell-seeded scaffolds had a significant lower silk content compared with the unseeded scaffolds and demonstrated a higher content of newly formed tissue. After 12 months, the density of the silk fibers decreased significantly, and the ingrowth of newly formed tissue increased in both groups. No differences between the 2 groups regarding silk fiber degradation and regenerated tissue were detected at 12 months. CONCLUSION The novel silk fiber-based scaffold was able to stimulate ACL regeneration under in vivo conditions. Additional cell seeding led to increased tissue regeneration and decreased silk fiber content at 6 months, whereas these differences were not present at 12 months. CLINICAL RELEVANCE ACL regeneration using a silk fiber-based scaffold with and without additional cell seeding may provide a new treatment option after joint injuries.
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Affiliation(s)
- Andreas Teuschl
- Department of Biochemical Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Patrick Heimel
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria Karl Donath Laboratory for Hard Tissue and Biomaterial Research, Medical University of Vienna, Vienna, Austria
| | - Silvia Nürnberger
- Austrian Cluster for Tissue Regeneration, Vienna, Austria Department of Traumatology, Medical University of Vienna, Vienna, Austria
| | - Martijn van Griensven
- Department of Experimental Trauma Surgery, Technical University of Munich, Munich, Germany
| | - Heinz Redl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Thomas Nau
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria Austrian Cluster for Tissue Regeneration, Vienna, Austria
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15
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Murrell WD, Anz AW, Badsha H, Bennett WF, Boykin RE, Caplan AI. Regenerative treatments to enhance orthopedic surgical outcome. PM R 2016; 7:S41-S52. [PMID: 25864660 DOI: 10.1016/j.pmrj.2015.01.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 01/09/2015] [Accepted: 01/14/2015] [Indexed: 12/20/2022]
Abstract
In orthopedic surgery there has been a never-ending quest to improve surgical outcome and the patient's experience. Progression has been marked by the refinement of surgical techniques and instruments and later by enhanced diagnostic imaging capability, specifically magnetic resonance. Over time implant optimization was achieved, along with the development of innovative minimally invasive arthroscopic technical skills to leverage new versions of classic procedures and implants to improve short-term patient morbidity and initial, mid-term, and long-term patient outcomes. The use of regenerative and/or biological adjuncts to aid the healing process has followed in the drive for continual improvement, and major breakthroughs in basic science have significantly unraveled the mechanisms of key healing and regenerative pathways. A wide spectrum of primary and complementary regenerative treatments is becoming increasingly available, including blood-derived preparations, growth factors, bone marrow preparations, and stem cells. This is a new era in the application of biologically active material, and it is transforming clinical practice by providing effective supportive treatments either at the time of the index procedure or during the postoperative period. Regenerative treatments are currently in active use to enhance many areas of orthopedic surgery in an attempt to improve success and outcome. In this review we provide a comprehensive overview of the peer-reviewed evidence-based literature, highlighting the clinical outcomes in humans both with preclinical data and human clinical trials involving regenerative preparations within the areas of rotator cuff, meniscus, ligament, and articular cartilage surgical repair.
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Affiliation(s)
- William D Murrell
- Dr Humeira Badsha Medical Center, Dubai, United Arab Emirates 391203; and Fort Belvoir Community Hospital, Department of Orthopaedics, Podiatry, Physical Therapy, and Rehabilitation, Ft. Belvoir, VVA 22060
| | - Adam W Anz
- Andrews Reseach & Education Institute, Gulf Breeze, FL
| | - Humeira Badsha
- Dr Humeira Badsha Medical Center, Dubai, United Arab Emirates 391203
| | | | | | - Arnold I Caplan
- Department of Biology, Skeletal Research Center, Case Western Reserve University, Cleveland, OH
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16
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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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"Ligamentization" in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future. Arthroscopy 2013; 29:1712-21. [PMID: 23859954 DOI: 10.1016/j.arthro.2013.05.009] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 04/26/2013] [Accepted: 05/06/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The aims of this study were to provide a systematic review of the literature on "ligamentization" in hamstring tendon (HT) grafts after anterior cruciate ligament (ACL) reconstruction and analyze the postoperative remodeling process in human patients and animal models. METHODS We performed a search in the Medline, PubMed, Embase and The Cochrane Library databases, followed by a manual search of reference lists to identify relevant articles. Only studies that investigated the ligamentization of hamstring grafts by histologic examination and comprehensively reported on the remodeling process were deemed eligible for review. RESULTS A total of 4 studies were determined appropriate for systematic review: 2 of the included studies investigated human ACL grafts and 2 were performed in animal models. The studies included the examination of 79 human hamstring graft biopsy specimens and grafts of 27 skeletally mature sheep. To verify the remodeling process, authors reported on various aspects of cellularity, vascularity, and collagen organization. None of the included studies reached a level of evidence higher than 3. CONCLUSIONS A postoperative ligamentization process can be found in HT grafts after ACL reconstruction and shows a typical progression through 3 distinguishable remodeling phases in humans and in animal models, whereas the progression and intensity of remodeling is distinctly increased in animals. CLINICAL RELEVANCE Because postoperative remodeling influences biomechanical properties of hamstring grafts, a better understanding of this process and its timing could lead to substantial improvements in postoperative care strategies and indirectly to the optimization of surgical techniques.
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18
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Kondo E, Yasuda K, Katsura T, Hayashi R, Kotani Y, Tohyama H. Biomechanical and histological evaluations of the doubled semitendinosus tendon autograft after anterior cruciate ligament reconstruction in sheep. Am J Sports Med 2012; 40:315-24. [PMID: 22088579 DOI: 10.1177/0363546511426417] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A sheep or goat anterior cruciate ligament (ACL) reconstruction model with the semitendinosus tendon autograft has not as of yet been established. HYPOTHESIS The semitendinosus tendon graft may be necrotized after ACL reconstruction until 12 weeks. Structural properties of the femur-graft-tibia complex may not be restored to the normal ACL level even at 12 months after surgery. STUDY DESIGN Controlled laboratory study. METHODS Thirty-eight mature sheep were used. In each animal, the right knee underwent ACL reconstruction using the semitendinosus tendon autograft. Two of them were not tested because of pneumonia. Twenty of 36 sheep were used for biomechanical evaluations. Five randomly selected animals were sacrificed at 0, 12, 24, or 52 weeks after surgery. In each animal, both the knees were harvested, and the left knee was used to obtain the control data. The remaining 16 sheep were used for histological evaluation. Two or 3 randomly selected animals were sacrificed at 0, 2, 6, 12, 24, or 52 weeks after surgery. RESULTS The tendon graft was predominantly acellular at 2 weeks. Although cell infiltration increased at 6 weeks, the core portion remained necrotic even at 12 weeks. At 24 and 52 weeks, the necrotic lesion disappeared in the core portion. In each period, the anteroposterior translation of the reconstructed knee remained significantly greater than that of the control (P < .0001). At 52 weeks, the maximum load of the femur-graft-tibia complex was significantly lower than that of the femur-ACL-tibia complex (P < .0001), although there was no significant difference in the cell density, the tissue dimensions, the stiffness, and the elongation at failure between the 2 complexes. CONCLUSION The sheep ACL reconstruction model showed predominant intrinsic fibroblast necrosis in the tendon autograft until 12 weeks. Although the structural properties of the femur-graft-tibia complex gradually improved, they were not completely restored to the femur-ACL-tibia complex level even at 52 weeks. CLINICAL RELEVANCE Remodeling of the semitendinosus tendon autograft after ACL reconstruction is not different from that of the bone-tendon-bone graft. This study has suggested that vigorous activity should not be permitted for patients in the early periods after ACL reconstruction using semitendinosus tendon autografts, which are necrotized and weakened after surgery.
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Affiliation(s)
- Eiji Kondo
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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