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Moffat KL., Wang INE, Rodeo SA, Lu HH. Orthopedic interface tissue engineering for the biological fixation of soft tissue grafts. Clin Sports Med 2009; 28:157-76. [PMID: 19064172 PMCID: PMC3260008 DOI: 10.1016/j.csm.2008.08.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Interface tissue engineering is a promising new strategy aimed at the regeneration of tissue interfaces and ultimately enabling the biological fixation of soft tissue grafts used in orthopedic repair and sports medicine. Many ligaments and tendons with direct insertions into subchondral bone exhibit a complex enthesis consisting of several distinct yet continuous regions of soft tissue, noncalcified fibrocartilage, calcified fibrocartilage, and bone. Regeneration of this multi-tissue interface will be critical for functional graft integration and improving long-term clinical outcome. This review highlights current knowledge of the structure-function relationship at the interface, the mechanism of interface regeneration, and the strategic biomimicry implemented in stratified scaffold design for interface tissue engineering and multi-tissue regeneration. Potential challenges and future directions in this emerging field are also discussed. It is anticipated that interface tissue engineering will lead to the design of a new generation of integrative fixation devices for soft tissue repair, and it will be instrumental for the development of integrated musculoskeletal tissue systems with biomimetic complexity and functionality.
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Affiliation(s)
- Kristen L . Moffat
- Biomaterials and Interface Tissue Engineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, NY 10027
| | - I-Ning Elaine Wang
- Biomaterials and Interface Tissue Engineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, NY 10027
| | - Scott A. Rodeo
- Soft Tissue Research Laboratory, Hospital for Special Surgery, New York, NY 10021
| | - Helen H. Lu
- Biomaterials and Interface Tissue Engineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, NY 10027
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Spalazzi JP, Vyner MC, Jacobs MT, Moffat KL, Lu HH. Mechanoactive scaffold induces tendon remodeling and expression of fibrocartilage markers. Clin Orthop Relat Res 2008; 466:1938-48. [PMID: 18512112 PMCID: PMC2584247 DOI: 10.1007/s11999-008-0310-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 05/05/2008] [Indexed: 01/31/2023]
Abstract
Biological fixation of soft tissue-based grafts for anterior cruciate ligament (ACL) reconstruction poses a major clinical challenge. The ACL integrates with subchondral bone through a fibrocartilage enthesis, which serves to minimize stress concentrations and enables load transfer between two distinct tissue types. Functional integration thus requires the reestablishment of this fibrocartilage interface on reconstructed ACL grafts. We designed and characterized a novel mechanoactive scaffold based on a composite of poly-alpha-hydroxyester nanofibers and sintered microspheres; we then used the scaffold to test the hypothesis that scaffold-induced compression of tendon grafts would result in matrix remodeling and the expression of fibrocartilage interface-related markers. Histology coupled with confocal microscopy and biochemical assays were used to evaluate the effects of scaffold-induced compression on tendon matrix collagen distribution, cellularity, proteoglycan content, and gene expression over a 2-week period. Scaffold contraction resulted in over 15% compression of the patellar tendon graft and upregulated the expression of fibrocartilage-related markers such as Type II collagen, aggrecan, and transforming growth factor-beta3 (TGF-beta3). Additionally, proteoglycan content was higher in the compressed tendon group after 1 day. The data suggest the potential of a mechanoactive scaffold to promote the formation of an anatomic fibrocartilage enthesis on tendon-based ACL reconstruction grafts.
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Affiliation(s)
- Jeffrey P. Spalazzi
- Department of Biomedical Engineering, Biomaterials and Interface Tissue Engineering Laboratory, Columbia University, 351 Engineering Terrace Building, MC 8904, 1210 Amsterdam Avenue, New York, NY 10027 USA
| | - Moira C. Vyner
- Department of Biomedical Engineering, Biomaterials and Interface Tissue Engineering Laboratory, Columbia University, 351 Engineering Terrace Building, MC 8904, 1210 Amsterdam Avenue, New York, NY 10027 USA
| | - Matthew T. Jacobs
- Department of Biomedical Engineering, Biomaterials and Interface Tissue Engineering Laboratory, Columbia University, 351 Engineering Terrace Building, MC 8904, 1210 Amsterdam Avenue, New York, NY 10027 USA
| | - Kristen L. Moffat
- Department of Biomedical Engineering, Biomaterials and Interface Tissue Engineering Laboratory, Columbia University, 351 Engineering Terrace Building, MC 8904, 1210 Amsterdam Avenue, New York, NY 10027 USA
| | - Helen H. Lu
- Department of Biomedical Engineering, Biomaterials and Interface Tissue Engineering Laboratory, Columbia University, 351 Engineering Terrace Building, MC 8904, 1210 Amsterdam Avenue, New York, NY 10027 USA
- College of Dental Medicine, Columbia University, New York, NY USA
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Lopez MJ, Spencer N, Casey JP, Monroe WT. Biomechanical characteristics of an implant used to secure semitendinosus-gracilis tendon grafts in a canine model of extra-articular anterior cruciate ligament reconstruction. Vet Surg 2007; 36:599-604. [PMID: 17686135 PMCID: PMC2168393 DOI: 10.1111/j.1532-950x.2007.00310.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare initial femoral fixation properties of a new implant, Graftgrab (GG), with 2 established methods of extra-articular femoral graft fixation, spiked washers (SW) and bone staples (ST). STUDY DESIGN Experimental in vitro cohort study. METHODS Canine semitendinosus-gracilis tendon grafts were passed through bone tunnels and fixed to the lateral surface of femoral condyles with spiked washers, bone staples, or new implant prototypes. The fixations were tested to failure with a single-cycle load at a rate of 50 mm/min. Failure and yield strength, stiffness, energy, and elongation were determined from load-displacement curves and failure modes were recorded. RESULTS The graft failed midsubstance in 4 SW, 4 ST, and 1 GG fixations. In 3 SW, 3 ST, and 1 GG specimens, the graft slipped from the fixation. The graft ruptured at the clip (3) and the intra-articular (2) surface of the bone tunnel in the remaining GG specimens. There were no significant differences between fixation groups in femoral tunnel length, femoral width, or the mechanical properties evaluated. CONCLUSIONS The initial in vitro mechanical properties of the new fixation implant are comparable with those of spiked washers and bone staples. CLINICAL RELEVANCE The initial mechanical performance of the new implant tested in this study was similar to those of comparable, established implants. The new implant is novel and may be useful for human anterior and veterinary cranial cruciate ligament graft reconstruction fixation.
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Affiliation(s)
- Mandi J Lopez
- Laboratory for Equine and Comparative Orthopedic Research, School of Veterinary Medicine, and the Department of Biological and Agricultural Engineering, Louisiana State University and AgCenter, Baton Rouge, LA 70803-8410, USA.
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Harvey A, Thomas NP, Amis AA. Fixation of the graft in reconstruction of the anterior cruciate ligament. ACTA ACUST UNITED AC 2005; 87:593-603. [PMID: 15855357 DOI: 10.1302/0301-620x.87b5.15803] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- A Harvey
- Royal Bournemouth Hospital, Castle Lane, Bournemouth BH7 7DW, UK.
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Robbe R, Paletta GA. Soft-tissue graft fixation in anterior cruciate ligament reconstruction. OPER TECHN SPORT MED 2004. [DOI: 10.1053/j.otsm.2004.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Janssen RPA, Scheltinga MRM, Sala HAGM. Pseudoaneurysm of the popliteal artery after anterior cruciate ligament reconstruction with bicortical tibial screw fixation. Arthroscopy 2004; 20:E4-6. [PMID: 14716289 DOI: 10.1016/j.arthro.2003.11.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We present a case report of a pseudoaneurysm of the popliteal artery after anterior cruciate ligament reconstruction using a bicortical tibial screw fixation 12 days after surgery. Surgical exploration and repair of an intimal lesion of the popliteal artery was performed. At 4-months' follow-up, there was still sensory loss in areas of the saphenous, medial plantar, calcaneal, and superficial peroneal nerves.
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Affiliation(s)
- Rob P A Janssen
- Department of Orthopaedic Surgery and Traumatology, Máxima Medical Center, Veldhoven, The Netherlands.
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Kousa P, Järvinen TLN, Vihavainen M, Kannus P, Järvinen M. The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part II: tibial site. Am J Sports Med 2003; 31:182-8. [PMID: 12642250 DOI: 10.1177/03635465030310020501] [Citation(s) in RCA: 184] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial fixation is more problematic than femoral fixation in anterior cruciate ligament reconstruction. HYPOTHESIS There is no difference in initial fixation strength among hamstring tendon graft tibial fixation devices. STUDY DESIGN Randomized experimental study. METHODS Each of six devices used to fix 120 quadrupled human semitendinosus-gracilis tendon grafts into porcine tibiae was tested 10 times with a single-cycle load-to-failure test and 10 times with a 1500-cycle loading test. Specimens surviving cyclic loading were subjected to a single-cycle load-to-failure test. RESULTS Intrafix (1332 N) was the strongest in the single-cycle load-to-failure test, followed by WasherLoc (975 N), tandem spiked washer (769 N), SmartScrew ACL (665 N), BioScrew (612 N), and SoftSilk (471 N). After cyclic-loading tests, Intrafix showed the lowest residual displacement (1.5 mm) and was also strongest (1309 N) in the single-cycle load-to-failure test after the cyclic-loading test, followed by WasherLoc (3.2 mm; 917 N). CONCLUSION The Intrafix provided clearly superior strength in the fixation of hamstring tendon grafts to the tibial drill hole. CLINICAL RELEVANCE Some caution may be warranted when using the implants that showed increased residual displacement, especially if aggressive rehabilitation is to be used. Preconditioning of the hamstring tendon graft-implant complex before tibial fixation is needed.
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Affiliation(s)
- Petteri Kousa
- Department of Surgery, University of Tampere and Tampere University Hospital, Tampere, Finland
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Kousa P, Järvinen TLN, Vihavainen M, Kannus P, Järvinen M. The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part I: femoral site. Am J Sports Med 2003; 31:174-81. [PMID: 12642249 DOI: 10.1177/03635465030310020401] [Citation(s) in RCA: 224] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Strength of graft fixation is the weakest link in anterior cruciate ligament reconstruction. HYPOTHESIS There is no difference in initial fixation strength between different hamstring tendon graft femoral fixation devices. STUDY DESIGN Randomized experimental study. METHODS Each of six devices was used in the fixation of 10 quadrupled human semitendinosus-gracilis tendon grafts in tunnels drilled in porcine femora and tested 10 times with a single-cycle load-to-failure test at a rate of 50 mm/min and 10 times with a 1500-cycle loading test between 50 and 200 N at one cycle every 2 seconds. The specimens that survived the cyclic loading were subjected to a single-cycle load-to-failure test. RESULTS The Bone Mulch Screw (1112 N) was strongest in the single-cycle load-to-failure test, followed by EndoButton CL (1086 N), RigidFix (868 N), SmartScrew ACL (794 N), BioScrew (589 N), and RCI screw (546 N). It also showed the lowest residual displacement (2.2 mm) and was strongest in the single-cycle load-to-failure test after cyclic loading. CONCLUSIONS The Bone Mulch Screw was superior to all other devices. CLINICAL RELEVANCE Caution may be warranted in employing aggressive rehabilitation after reconstruction with these devices. Preconditioning of the graft-implant complex before fixation is important.
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Affiliation(s)
- Petteri Kousa
- Department of Surgery, University of Tampere and Tampere University Hospital, Tampere, Finland
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Trumble DR, Melvin DB, Magovern JA. Method for anchoring biomechanical implants to muscle tendon and chest wall. ASAIO J 2002; 48:62-70. [PMID: 11814099 DOI: 10.1097/00002480-200201000-00013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Reliable tissue fixation is of fundamental importance to the successful development of muscle powered motor prostheses. This report describes a series of canine implant trials used to develop stable tissue-device interface mechanisms. Muscle pumps were fitted with prototype tendon and chest wall anchoring schemes and secured to the ribs and humeral insertion of latissimus dorsi (LD) muscles. LD stimulation was initiated 1 week postimplantation and continued throughout the implant period to stress these fixation sites. Design modification and implant testing were continued until both muscle and chest wall attachment points were found to be stable. Chest wall fixation was best achieved using perforated metallic plates wired to the ribs, as opposed to bone screws or wire mesh, which were subject to degradation. Direct attachment of the native tendon by means of spiked clamping plates proved ineffective. Stable muscle attachment was ultimately achieved by replacing the humeral tendon with an artificial substitute formed from fine polyester fibers gathered into 6-8 bundles and sewn into the LD insertion. Braided into a single cord, these fibers were fixed to the device by means of spiked clamping plates. Based on these findings, we conclude that perforated anchor plates and multifibrous artificial tendons can function as effective tissue-device interface mechanisms.
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Affiliation(s)
- Dennis R Trumble
- Cardiac Surgery Research, Allegheny-Singer Research Institute, and Department of Surgery, Allegheny General Hospital, West Penn Allegheny Health System, Pittsburgh 15212-4772, USA
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Post WR, King SS. Neurovascular risk of bicortical tibial drilling for screw and spiked washer fixation of soft-tissue anterior cruciate ligament graft. Arthroscopy 2001; 17:244-247. [PMID: 11239343 DOI: 10.1053/jars.2001.21539] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE: As the use of soft-tissue anterior cruciate ligament (ACL) grafts, including hamstring grafts, has become more prominent and the benefits of aggressive rehabilitation have become clear, maximizing fixation with screw and spiked washers is important. Bicortical fixation may be superior. We were concerned about potential neurovascular risks and designed this study to define the posterior neurovasculature structures at risk when drilling for bicortical tibial screw fixation during ACL reconstruction. Type of Study: Consecutive sample. METHODS: We placed the tibial tunnel arthroscopically in 10 cadaveric knees using a standard tibial drill guide. Accurate tibial tunnel position was documented in each knee by lateral radiograph. A 4.5-mm bicortical drill hole was placed perpendicular to the tibial surface 1 cm distal to the tibial tunnel. The distances from the posterior tibial drill exit point to nearby neurovascular structures were measured with a caliper. RESULTS: The closest structure to the exit point was the bifurcation of the popliteal artery/vein (11.4 +/- 0.6 mm; range, 8.4 to 14.0 mm). The next closest was the anterior tibial vein (11.7 +/- 1.6 mm; range, 3.5 to 22.8 mm). The closest any individual hole came to a neurovascular structure was 3.5 mm from the anterior tibial vein. CONCLUSIONS: Bicortical drilling for fixation of soft tissue grafts appears reasonably safe. The structures at greatest risk for injury are the bifurcation of the popliteal artery/vein and the anterior tibial vein.
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Affiliation(s)
- William R. Post
- Department of Orthopedics, West Virginia University, Morgantown (W.R.P.); and Marshall University School of Medicine, Huntington, West Virginia (S.S.K.), U.S.A
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Höher J, Scheffler SU, Withrow JD, Livesay GA, Debski RE, Fu FH, Woo SL. Mechanical behavior of two hamstring graft constructs for reconstruction of the anterior cruciate ligament. J Orthop Res 2000; 18:456-61. [PMID: 10937634 DOI: 10.1002/jor.1100180319] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We compared the mechanical behavior of two common hamstring graft constructs that are frequently used for reconstruction of the anterior cruciate ligament-Graft A: quadrupled semitendinosus tendon fixed with titanium button/polyester tape and suture/screw post, and Graft B: a double semitendinosus and double gracilis tendon fixed with a cross pin and two screws over washers. The experimental protocol used to evaluate each graft construct included stress relaxation (with and without preconditioning), cyclic loading, and a tensile load-to-failure test. The amount of stress relaxation without preconditioning was 60.6% for Graft A and 53.8% for Graft B. With preconditioning, it significantly decreased (p < 0.05) to 48.7 and 42.3%, respectively. Elongation of the graft construct in response to 100 cycles of loading (20-150 N) was 1.8 and 0.6% of the original length for Grafts A and B, respectively. However, after a series of five cyclic loading tests, the residual permanent elongation for each construct was 3.8 +/- 1.2 and 0.3 +/- 0.2 mm, a significant difference (p < 0.05) between the two graft constructs. Further analysis found more than 90% of the permanent elongation in the proximal and distal regions of Graft A, which consisted of polyester tape tied to a titanium button (proximal) and sutures tied around a screw post (distal). The tensile load-to-failure tests also revealed significant differences (p < 0.05) between the two graft constructs. Linear stiffness was 32 +/- 1 and 119 +/- 19 Nmm and ultimate load was 415 +/- 36 and 658 +/- 128 N for Grafts A and B, respectively. For Graft A, the polyester tape consistently failed; for Graft B, slippage or tearing from the washers was the mode of failure. We conclude that a quadruple-hamstring graft fixed over a cross pin proximally and with metal washers distally (Graft B) has less permanent elongation in response to cyclic loading and has structural properties superior to those of a graft construct that includes suture and tape material (Graft A). The large permanent elongation following repetitive loading of a graft construct with tape and suture material during the early postoperative period is of concern.
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Affiliation(s)
- J Höher
- Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pennsylvania 15213, USA
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Janis L, Massa E. Spiked metallic washer and screw for reattachment of the Achilles tendon after repair of a distal rupture. J Foot Ankle Surg 2000; 39:49-53. [PMID: 10658951 DOI: 10.1016/s1067-2516(00)80064-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The authors review Achilles tendon ruptures and treatment options for the acute and chronic rupture. A case is described involving reattachment of a chronic distal Achilles tendon rupture repair with a spiked metal washer and fully threaded cannulated cancellous screw. Spiked metal washers and their effects on soft-tissue pullout strength, and possible complications are discussed. In review of the literature, the authors have not found this type of fixation used to anchor the Achilles tendon, and feel it may be a viable option when faced with distal Achilles reattachment for the acute and chronic rupture.
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Affiliation(s)
- L Janis
- Grant Medical Center, Columbus, OH 43228, USA
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