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Kang Y, Wang L, Zhang S, Liu B, Gao H, Jin H, Xiao L, Zhang G, Li Y, Jiang J, Zhao J. Bioactive Patch for Rotator Cuff Repairing via Enhancing Tendon-to-Bone Healing: A Large Animal Study and Short-Term Outcome of a Clinical Trial. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024:e2308443. [PMID: 38922803 DOI: 10.1002/advs.202308443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/26/2024] [Indexed: 06/28/2024]
Abstract
Tissue engineering has demonstrated its efficacy in promoting tissue regeneration, and extensive research has explored its application in rotator cuff (RC) tears. However, there remains a paucity of research translating from bench to clinic. A key challenge in RC repair is the healing of tendon-bone interface (TBI), for which bioactive materials suitable for interface repair are still lacking. The umbilical cord (UC), which serves as a vital repository of bioactive components in nature, is emerging as an important source of tissue engineering materials. A minimally manipulated approach is used to fabricate UC scaffolds that retain a wealth of bioactive components and cytokines. The scaffold demonstrates the ability to modulate the TBI healing microenvironment by facilitating cell proliferation, migration, suppressing inflammation, and inducing chondrogenic differentiation. This foundation sets the stage for in vivo validation and clinical translation. Following implantation of UC scaffolds in the canine model, comprehensive assessments, including MRI and histological analysis confirm their efficacy in inducing TBI reconstruction. Encouraging short-term clinical results further suggest the ability of UC scaffolds to effectively enhance RC repair. This investigation explores the mechanisms underlying the promotion of TBI repair by UC scaffolds, providing key insights for clinical application and translational research.
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Affiliation(s)
- Yuhao Kang
- Department of Sports Medicine, Department of Orthopedics, Shanghai Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Liren Wang
- Department of Sports Medicine, Department of Orthopedics, Shanghai Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Shihao Zhang
- Key Laboratory for Ultrafine Materials of Ministry of Education, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Engineering Research Center for Biomedical Materials of Ministry of Education, School of Materials Science and Engineering, East China University of Science and Technology, Shanghai, 200237, China
| | - Bowen Liu
- Bioarticure Medical Technology (Shanghai) Co., Ltd, No.81-82, Zuchongzhi Road, Pudong, Shanghai, 200120, China
| | - Haihan Gao
- Department of Sports Medicine, Department of Orthopedics, Shanghai Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Haocheng Jin
- Department of Sports Medicine, Department of Orthopedics, Shanghai Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Lan Xiao
- School of Mechanical, Medical and Process Engineering, Center of Biomedical Technology, Queensland University of Technology, Brisbane, 4059, Australia
| | - Guoyang Zhang
- Department of Sports Medicine, Department of Orthopedics, Shanghai Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Yulin Li
- Key Laboratory for Ultrafine Materials of Ministry of Education, Frontiers Science Center for Materiobiology and Dynamic Chemistry, Engineering Research Center for Biomedical Materials of Ministry of Education, School of Materials Science and Engineering, East China University of Science and Technology, Shanghai, 200237, China
| | - Jia Jiang
- Department of Sports Medicine, Department of Orthopedics, Shanghai Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Department of Orthopedics, Shanghai Institute of Microsurgery on Extremities, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
- Regenerative Sports Medicine and Translational Youth Science and Technology Innovation Workroom, Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, 200233, China
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Lai A, Tamea C, Shou J, Okafor A, Sparks J, Dodd R, Woods C, Lambert N, Schulte O, Barrett T. Safety and Efficacy of Wharton's Jelly Connective Tissue Allograft for Rotator Cuff Tears: Findings from a Retrospective Observational Study. Biomedicines 2024; 12:710. [PMID: 38672066 PMCID: PMC11048385 DOI: 10.3390/biomedicines12040710] [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: 01/24/2024] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/28/2024] Open
Abstract
With the increasing occurrence of rotator cuff injuries every year, there is a great need for a reliable treatment option. Wharton's Jelly contains several components that can positively impact the replacement and repair of musculoskeletal defects. The overall objective of this study is to evaluate the improvement of patient-reported pain scales after applying Wharton's Jelly (WJ) in rotator cuff defects. Eighty-seven patients with rotator cuff defects who failed at least eight weeks of conservative treatment were selected from the retrospective repository. A total of 2 cc of WJ flowable allograft was applied to the specific affected anatomy, the most common being supraspinatus tendon, biceps tendon insertion, labral tear, and subscapularis tear. No adverse reactions were reported. Statistically significant improvements were found from the initial to Day 90 in all scales. Patient satisfaction was calculated using minimal clinically important differences. No statistically significant differences were found in mean changes between gender, BMI, and age. Scanning electron microscopy images reveal the similarities between the collagen matrix in WJ and the rotator cuff. The significant improvement in patient outcomes coincides with the current literature analyzing WJ applications with other structural defects around the body. WJ is a promising alternative for musculoskeletal defects when the standard of care fails.
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Affiliation(s)
- Albert Lai
- Desert Physical Medicine and Pain Management, Indio, CA 92201, USA; (A.L.); (R.D.)
| | - Conrad Tamea
- Orthopedic Associates of Tampa Bay, Tampa, FL 33603, USA;
| | - John Shou
- Pharmacology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Anthony Okafor
- Mathematics & Statistics, University of West Florida, Pensacola, FL 32514, USA; (A.O.); (J.S.)
| | - Jay Sparks
- Mathematics & Statistics, University of West Florida, Pensacola, FL 32514, USA; (A.O.); (J.S.)
| | - Renee Dodd
- Desert Physical Medicine and Pain Management, Indio, CA 92201, USA; (A.L.); (R.D.)
| | - Crislyn Woods
- Regenative Labs, Pensacola, FL 32501, USA; (C.W.); (O.S.); (T.B.)
| | - Naomi Lambert
- Regenative Labs, Pensacola, FL 32501, USA; (C.W.); (O.S.); (T.B.)
| | - Orion Schulte
- Regenative Labs, Pensacola, FL 32501, USA; (C.W.); (O.S.); (T.B.)
| | - Tyler Barrett
- Regenative Labs, Pensacola, FL 32501, USA; (C.W.); (O.S.); (T.B.)
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Codispoti G, Carniato M, Brogini S, Romanelli A, Martini L, Giavaresi G, Tschon M. Decellularized biological matrices for the repair of rotator cuff lesions: a systematic review of preclinical in vivo studies. Front Bioeng Biotechnol 2024; 12:1345343. [PMID: 38361793 PMCID: PMC10867272 DOI: 10.3389/fbioe.2024.1345343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/11/2024] [Indexed: 02/17/2024] Open
Abstract
Background: Rotator cuff tears (RCTs), resulting from degeneration or trauma of the shoulder tendons, are one of the main causes of shoulder pain. In particular, massive RCTs represent 40% of all injuries, require surgical treatment, and are characterized by poor clinical outcomes and a high rate of failure. In recent years, the use of biological decellularized patches for augmentation procedures has received great interest owing to their excellent self-integration properties, improving healing and, thus, presenting an innovative therapeutic option. However, the findings from clinical studies have emerged with conflicting viewpoints regarding the benefits of this procedure, as an excessive tension load might compromise the integrity of the tendon-to-bone connection when the patch exhibits low elasticity or insufficient strength. This could prevent the healing process, leading to unpredictable results in clinical practice. Methods: This systematic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines across three databases (PubMed, Scopus, and Web of Knowledge) to underline the results obtained in preclinical studies involving animal models of RCT surgeries that utilized the biological decellularized matrix augmentation technique in the last 5 years. Results: Thirteen articles were included after the screening, and the SYRCLE tools were applied to assess the risk of bias in in vivo studies. Open-surgery techniques were conducted to create tendon defects or detachment in different animal models: rat (31%), rabbit (46%), dog (15%), and sheep (8%). Patches decellularized with non-standardized protocols were used in 77% of studies, while commercially available matrices were used in 15%. Of the studies, 31% used allogenic patches, 61% used xenogenic patches, and 8% utilized both xenogenic and autologous patches. Conclusion: Overall, this review provides a comprehensive overview of the use of acellular patches and their effective therapeutic potential in rotator cuff (RC) repair at the preclinical level with the aim of expanding the strategies and matrices available for surgeons. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023468716.
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Affiliation(s)
| | | | - Silvia Brogini
- Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Zhong S, Lan Y, Liu J, Seng Tam M, Hou Z, Zheng Q, Fu S, Bao D. Advances focusing on the application of decellularization methods in tendon-bone healing. J Adv Res 2024:S2090-1232(24)00033-X. [PMID: 38237768 DOI: 10.1016/j.jare.2024.01.020] [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: 09/18/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The tendon or ligament is attached to the bone by a triphasic but continuous area of heterogeneous tissue called the tendon-bone interface (TBI). The rapid and functional regeneration of TBI is challenging owing to its complex composition and difficulty in self-healing. The development of new technologies, such as decellularization, has shown promise in the regeneration of TBI. Several ex vivo and in vivo studies have shown that decellularized grafts and decellularized biomaterial scaffolds achieved better efficacy in enhancing TBI healing. However further information on the type of review that is available is needed. AIM OF THE REVIEW In this review, we discuss the current application of decellularization biomaterials in promoting TBI healing and the possible mechanisms involved. With this work, we would like to reveal how tissues or biomaterials that have been decellularized can improve tendon-bone healing and to provide a theoretical basis for future related studies. KEY SCIENTIFIC CONCEPTS OF THE REVIEW Decellularization is an emerging technology that utilizes various chemical, enzymatic and/or physical strategies to remove cellular components from tissues while retaining the structure and composition of the extracellular matrix (ECM). After decellularization, the cellular components of the tissue that cause an immune response are removed, while various biologically active biofactors are retained. This review further explores how tissues or biomaterials that have been decellularized improve TBI healing.
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Affiliation(s)
- Sheng Zhong
- Department of Orthopaedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan 646000, China; School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Yujian Lan
- Department of Orthopaedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan 646000, China; School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Jinyu Liu
- Department of Orthopaedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan 646000, China; School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | | | - Zhipeng Hou
- Department of Orthopaedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan 646000, China; School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Qianghua Zheng
- Department of Orthopaedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan 646000, China; School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Shijie Fu
- Department of Orthopaedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan 646000, China; School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China.
| | - Dingsu Bao
- Department of Orthopaedics, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan 646000, China; School of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou, Sichuan 646000, China; Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 610075, China.
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Mandalia K, Mousad A, Welborn B, Bono O, Le Breton S, MacAskill M, Forlizzi J, Ives K, Ross G, Shah S. Scaffold- and graft-based biological augmentation of rotator cuff repair: an updated systematic review and meta-analysis of preclinical and clinical studies for 2010-2022. J Shoulder Elbow Surg 2023; 32:1784-1800. [PMID: 37178960 DOI: 10.1016/j.jse.2023.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/05/2023] [Accepted: 03/22/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Despite advancements in the surgical techniques of rotator cuff repair (RCR), there remains a high retear rate. Biological augmentation of repairs with overlaying grafts and scaffolds may enhance healing and strengthen the repair construct. This study aimed to investigate the efficacy and safety of scaffold-based (nonstructural) and overlay graft-based (structural) biological augmentation in RCR (excluding superior capsule reconstruction and bridging techniques) in both preclinical and clinical studies. METHODS This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, as well as guidelines outlined by The Cochrane Collaboration. A search of the PubMed, Embase, and Cochrane Library databases from 2010 until 2022 was conducted to identify studies reporting the clinical, functional, and/or patient-reported outcomes of ≥1 biological augmentation method in either animal models or humans. The methodologic quality of included primary studies was appraised using the Checklist to Evaluate a Report of a Non-pharmacological Trial (CLEAR-NPT) for randomized controlled trials and using the Methodological Index for Non-randomized Studies (MINORS) for nonrandomized studies. RESULTS A total of 62 studies (Level I-IV evidence) were included, comprising 47 studies reporting outcomes in animal models and 15 clinical studies. Of the 47 animal-model studies, 41 (87.2%) demonstrated biomechanical and histologic enhancement with improved RCR load to failure, stiffness, and strength. Of the 15 clinical studies, 10 (66.7%) illustrated improvement in postoperative clinical, functional, and patient-reported outcomes (eg, retear rate, radiographic thickness and footprint, and patient functional scores). No study reported a significant detriment to repair with augmentation, and all studies endorsed low complication rates. A meta-analysis of pooled retear rates demonstrated significantly lower odds of retear after treatment with biological augmentation of RCR compared with treatment with non-augmented RCR (odds ratio, 0.28; P < .00001), with low heterogeneity (I2 = 0.11). CONCLUSIONS Graft and scaffold augmentations have shown favorable results in both preclinical and clinical studies. Of the investigated clinical grafts and scaffolds, acellular human dermal allograft and bovine collagen demonstrate the most promising preliminary evidence in the graft and scaffold categories, respectively. With a low risk of bias, meta-analysis revealed that biological augmentation significantly lowered the odds of retear. Although further investigation is warranted, these findings suggest graft and scaffold biological augmentation of RCR to be safe.
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Affiliation(s)
- Krishna Mandalia
- Tufts University School of Medicine, Boston, MA, USA; New England Shoulder and Elbow Center, Boston, MA, USA.
| | - Albert Mousad
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | | | | | | | | | - Glen Ross
- New England Baptist Hospital, Boston, MA, USA
| | - Sarav Shah
- New England Baptist Hospital, Boston, MA, USA
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Aratikatla A, Sidhu J, Maffulli N, Gupta M, Potty AG, Gupta A. Allogenic Umbilical Cord Tissue for Rotator Cuff Injuries. Sports Med Arthrosc Rev 2023; 31:73-79. [PMID: 37976128 DOI: 10.1097/jsa.0000000000000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Highly prone to injury, the rotator cuff greatly contributes to the stability and mobility of the shoulder. Clinicians prioritize conservative treatment, resorting to surgery only when necessary, although they are hindered by inherent limitations. Biological therapies, including perinatal tissue, such as umbilical cord (UC) tissue, hold promise for treating rotator cuff injuries (RCIs) in the field of regenerative medicine. This article qualitatively presents the in vitro, preclinical, clinical, and ongoing scientific literature exploring the application of UC tissue and associated mesenchymal stem cells in the context of RCIs. Employing the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines, a systematic review was conducted. These studies have presented substantial evidence indicating that UC tissue and UC-derived mesenchymal stem cells are safe and potentially efficacious for managing RCIs, though more adequately powered randomized controlled trials are warranted to further establish efficacy and justify clinical use.
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Affiliation(s)
| | - Justin Sidhu
- The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano, Italy
- San Giovanni di Dio e Ruggi D'Aragona Hospital "Clinica Ortopaedica" Department, Hospital of Salerno, Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK
- School of Pharmacy and Bioengineering, Keele University School of Medicine, UK
| | - Manu Gupta
- Polar Aesthetics Dental and Cosmetic Centre
| | - Anish G Potty
- South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX
| | - Ashim Gupta
- Regenerative Orthopaedics, Noida, UP, India
- South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX
- Future Biologics
- BioIntegrate, Lawrenceville, GA
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Viganò M, Ragni E, Marmotti A, de Girolamo L. The effects of orthobiologics in the treatment of tendon pathologies: a systematic review of preclinical evidence. J Exp Orthop 2022; 9:31. [PMID: 35394237 PMCID: PMC8994001 DOI: 10.1186/s40634-022-00468-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/24/2022] [Indexed: 02/06/2023] Open
Abstract
Purpose The aim of this systematic review is to explore the current available knowledge about tendon disorders and orthobiologics derived by preclinical experiments to evaluate their role and efficacy in the different stages and conditions related to the tendon healing processes. Methods The systematic review was performed according to the PRISMA guidelines. Different electronic databases (MEDLINE, Web of Science, EMBASE) were searched for studies investigating orthobiologics (PRP and cell-based products from adipose tissue or bone marrow) in animal models or veterinary clinical trials for tendon pathologies (complete/partial tendon ruptures, rotator cuff tears, tendinopathy, enthesis-related injuries). Data regarding the specific product used, the treatment site/pathology, the host and the model were collected. The results were classified into the following categories: histological, biomechanical, molecular and imaging. Results A large pool of preclinical studies on tendon disorders have been found on platelet-rich plasma (PRP), while data about stromal vascular fraction (SVF) and bone marrow concentrate (BMAC) are still limited and frequently focused on expanded cells, rather than orthobiologics prepared at the point of care. The effect of PRP is related to an acceleration of the healing process, without improvements in the final structure and properties of repaired tendon. Cell-based products have been reported to produce more durable results, but the level of evidence is currently insufficient to draw clear indications. Conclusions The preclinical results about orthobiologics applications to tendon pathologies would support the rationale of their clinical use and encourage the performance of clinical trials aimed to confirm these data in human subjects. Supplementary Information The online version contains supplementary material available at 10.1186/s40634-022-00468-w.
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Affiliation(s)
- Marco Viganò
- Orthopaedics biotechnology Lab, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Enrico Ragni
- Orthopaedics biotechnology Lab, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy.
| | - Antonio Marmotti
- San Luigi Gonzaga Hospital, Orthopedics and Traumatology Department, University of Turin - Medical School, Turin, Italy
| | - Laura de Girolamo
- Orthopaedics biotechnology Lab, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
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