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Wang H, Wu J, Yang L, Liu S, Sui X, Guo Q, Chen M. Surgical Therapy and Tissue Engineering for Meniscal Repair. TISSUE ENGINEERING. PART B, REVIEWS 2024. [PMID: 39083434 DOI: 10.1089/ten.teb.2024.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Meniscal damage is one of the prevalent causes of knee pain, swelling, instability, and functional compromise, frequently culminating in osteoarthritis (OA). Timely and appropriate interventions are crucial to relieve symptoms and prevent or delay the onset of OA. Contemporary surgical treatments include total or partial meniscectomy, meniscal repair, allograft meniscal transplantation, and synthetic meniscal implants, but each presents its specific limitations. Recently, regenerative medicine and tissue engineering have emerged as promising fields, offering innovative prospects for meniscal regeneration and repair. This review delineates current surgical methods, elucidating their specific indications, advantages, and disadvantages. Concurrently, it delves into state-of-the-art tissue engineering techniques aimed at the functional regenerative repair of meniscus. Recommendations for future research and clinical practice are also provided.
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Affiliation(s)
- Hao Wang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, China
- Chinese PLA General Hospital, Institute of Orthopedics, The First Medical Center, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Beijing, China
| | - Jie Wu
- Department of Orthopedics, General Hospital of Chinese PLA, Eighth Medical Center, Beijing, China
| | - Liupu Yang
- Chinese PLA General Hospital, Institute of Orthopedics, The First Medical Center, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Beijing, China
| | - Shuyun Liu
- Chinese PLA General Hospital, Institute of Orthopedics, The First Medical Center, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Beijing, China
| | - Xiang Sui
- Chinese PLA General Hospital, Institute of Orthopedics, The First Medical Center, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Beijing, China
| | - Quanyi Guo
- Chinese PLA General Hospital, Institute of Orthopedics, The First Medical Center, Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Beijing, China
| | - Mingxue Chen
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Capital Medical University, Beijing, China
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Bian Y, Cai X, Zhou R, Lv Z, Xu Y, Wang Y, Wang H, Zhu W, Sun H, Zhao X, Feng B, Weng X. Advances in meniscus tissue engineering: Towards bridging the gaps from bench to bedside. Biomaterials 2024; 312:122716. [PMID: 39121731 DOI: 10.1016/j.biomaterials.2024.122716] [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: 03/13/2024] [Revised: 07/12/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024]
Abstract
Meniscus is vital for maintaining the anatomical and functional integrity of knee. Injuries to meniscus, commonly caused by trauma or degenerative processes, can result in knee joint dysfunction and secondary osteoarthritis, while current conservative and surgical interventions for meniscus injuries bear suboptimal outcomes. In the past decade, there has been a significant focus on advancing meniscus tissue engineering, encompassing isolated scaffold strategies, biological augmentation, physical stimulus, and meniscus organoids, to improve the prognosis of meniscus injuries. Despite noteworthy promising preclinical results, translational gaps and inconsistencies in the therapeutic efficiency between preclinical and clinical studies exist. This review comprehensively outlines the developments in meniscus tissue engineering over the past decade (Scheme 1). Reasons for the discordant results between preclinical and clinical trials, as well as potential strategies to expedite the translation of bench-to-bedside approaches are analyzed and discussed.
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Affiliation(s)
- Yixin Bian
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xuejie Cai
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Runze Zhou
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Zehui Lv
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yiming Xu
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yingjie Wang
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Han Wang
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Wei Zhu
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Hanyang Sun
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xiuli Zhao
- Department of Medical Genetics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College, Beijing, 100005, China.
| | - Bin Feng
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Xisheng Weng
- Department of Orthopedic Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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Otsuki S, Sezaki S, Okamoto Y, Ishitani T, Wakama H, Neo M. Safety and Efficacy of a Novel Polyglycolic Acid Meniscal Scaffold for Irreparable Meniscal Tear. Cartilage 2024; 15:110-119. [PMID: 37632127 DOI: 10.1177/19476035231193087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE Meniscal tears treated with a partial meniscectomy could induce knee osteoarthritis, thereby altering or damaging knee kinetics and biomechanics. We have developed a meniscal scaffold made of polyglycolic acid (PGA) coated with polylactic acid/caprolactone (PGA scaffold), which could induce new tissue growth of meniscus-like tissue. This study aimed to evaluate the safety and efficacy of a novel meniscal scaffold for the treatment of irreparable meniscal injuries. DESIGN This study describes the findings of a cyclic torque test and first clinical trial of a PGA scaffold for inducing meniscus-like tissue in humans. As the first step, biomechanical testing of the PGA scaffold was performed using a cyclic torque test. Six patients underwent arthroscopic implantation of the PGA scaffold. Furthermore, the patients underwent preoperative clinical, serological, radiographic, and magnetic resonance imaging examinations at 3, 6, and 12 months postoperatively. The patients also underwent a second-look arthroscopy 12 months after implantation. RESULTS Torque increased with increasing cyclic loading. However, no structural damage to the sample was noted after 70,000 loading cycles. All patients showed improvement in pain, Lysholm scores, Tegner activity scores, International Knee Documentation Committee, and knee injury and osteoarthritis outcome. The second-look arthroscopy revealed that meniscal tissue had regenerated in 5 patients (83%). Radiography and magnetic resonance imaging confirmed no progression of degenerative joint disease. CONCLUSIONS The PGA scaffold could tolerate shear forces, did not produce safety concerns, and may have therapeutic potentials for irreparable meniscal tears in humans.
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Affiliation(s)
- Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Shunsuke Sezaki
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
- QOL Research Division, GUNZE MEDICAL Limited, Kyoto, Japan
| | - Yoshinori Okamoto
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Takashi Ishitani
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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Bandyopadhyay A, Ghibhela B, Mandal BB. Current advances in engineering meniscal tissues: insights into 3D printing, injectable hydrogels and physical stimulation based strategies. Biofabrication 2024; 16:022006. [PMID: 38277686 DOI: 10.1088/1758-5090/ad22f0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/26/2024] [Indexed: 01/28/2024]
Abstract
The knee meniscus is the cushioning fibro-cartilage tissue present in between the femoral condyles and tibial plateau of the knee joint. It is largely avascular in nature and suffers from a wide range of tears and injuries caused by accidents, trauma, active lifestyle of the populace and old age of individuals. Healing of the meniscus is especially difficult due to its avascularity and hence requires invasive arthroscopic approaches such as surgical resection, suturing or implantation. Though various tissue engineering approaches are proposed for the treatment of meniscus tears, three-dimensional (3D) printing/bioprinting, injectable hydrogels and physical stimulation involving modalities are gaining forefront in the past decade. A plethora of new printing approaches such as direct light photopolymerization and volumetric printing, injectable biomaterials loaded with growth factors and physical stimulation such as low-intensity ultrasound approaches are being added to the treatment portfolio along with the contemporary tear mitigation measures. This review discusses on the necessary design considerations, approaches for 3D modeling and design practices for meniscal tear treatments within the scope of tissue engineering and regeneration. Also, the suitable materials, cell sources, growth factors, fixation and lubrication strategies, mechanical stimulation approaches, 3D printing strategies and injectable hydrogels for meniscal tear management have been elaborated. We have also summarized potential technologies and the potential framework that could be the herald of the future of meniscus tissue engineering and repair approaches.
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Affiliation(s)
- Ashutosh Bandyopadhyay
- Biomaterials and Tissue Engineering Laboratory, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, 781039, India
| | - Baishali Ghibhela
- Biomaterials and Tissue Engineering Laboratory, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, 781039, India
| | - Biman B Mandal
- Biomaterials and Tissue Engineering Laboratory, Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, 781039, India
- Centre for Nanotechnology, Indian Institute of Technology Guwahati, Guwahati, Assam 781039, India
- Jyoti and Bhupat Mehta School of Health Sciences and Technology, Indian Institute of Technology Guwahati, Guwahati, Assam 781039, India
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Li X, Li D, Li J, Wang G, Yan L, Liu H, Jiu J, Li JJ, Wang B. Preclinical Studies and Clinical Trials on Cell-Based Treatments for Meniscus Regeneration. TISSUE ENGINEERING. PART B, REVIEWS 2023; 29:634-670. [PMID: 37212339 DOI: 10.1089/ten.teb.2023.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This study aims at performing a thorough review of cell-based treatment strategies for meniscus regeneration in preclinical and clinical studies. The PubMed, Embase, and Web of Science databases were searched for relevant studies (both preclinical and clinical) published from the time of database construction to December 2022. Data related to cell-based therapies for in situ regeneration of the meniscus were extracted independently by two researchers. Assessment of risk of bias was performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Statistical analyses based on the classification of different treatment strategies were performed. A total of 5730 articles were retrieved, of which 72 preclinical studies and 6 clinical studies were included in this review. Mesenchymal stem cells (MSCs), especially bone marrow MSCs (BMSCs), were the most commonly used cell type. Among preclinical studies, rabbit was the most commonly used animal species, partial meniscectomy was the most commonly adopted injury pattern, and 12 weeks was the most frequently chosen final time point for assessing repair outcomes. A range of natural and synthetic materials were used to aid cell delivery as scaffolds, hydrogels, or other morphologies. In clinical trials, there was large variation in the dose of cells, ranging from 16 × 106 to 150 × 106 cells with an average of 41.52 × 106 cells. The selection of treatment strategy for meniscus repair should be based on the nature of the injury. Cell-based therapies incorporating various "combination" strategies such as co-culture, composite materials, and extra stimulation may offer greater promise than single strategies for effective meniscal tissue regeneration, restoring natural meniscal anisotropy, and eventually achieving clinical translation. Impact Statement This review provides an up-to-date and comprehensive overview of preclinical and clinical studies that tested cell-based treatments for meniscus regeneration. It presents novel perspectives on studies published in the past 30 years, giving consideration to the cell sources and dose selection, delivery methods, extra stimulation, animal models and injury patterns, timing of outcome assessment, and histological and biomechanical outcomes, as well as a summary of findings for individual studies. These unique insights will help to shape future research on the repair of meniscus lesions and inform the clinical translation of new cell-based tissue engineering strategies.
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Affiliation(s)
- Xiaoke Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Orthopaedic Surgery, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Dijun Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Orthopaedic Surgery, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Jiarong Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, Australia
| | - Guishan Wang
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, China
| | - Lei Yan
- Department of Orthopaedic Surgery, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Haifeng Liu
- Department of Orthopaedic Surgery, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Jingwei Jiu
- Department of Orthopaedic Surgery, Shanxi Medical University Second Affiliated Hospital, Taiyuan, China
| | - Jiao Jiao Li
- School of Biomedical Engineering, Faculty of Engineering and IT, University of Technology Sydney, Ultimo, Australia
| | - Bin Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Dabaghi M, Eras V, Kaltenhaeuser D, Ahmed N, Wildemann B. Allografts for partial meniscus repair: an in vitro and ex vivo meniscus culture study. Front Bioeng Biotechnol 2023; 11:1268176. [PMID: 37901839 PMCID: PMC10603185 DOI: 10.3389/fbioe.2023.1268176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/11/2023] [Indexed: 10/31/2023] Open
Abstract
The purpose of this study was to evaluate the treatment potential of a human-derived demineralized scaffold, Spongioflex® (SPX), in partial meniscal lesions by employing in vitro models. In the first step, the differentiation potential of human meniscal cells (MCs) was investigated. In the next step, the ability of SPX to accommodate and support the adherence and/or growth of MCs while maintaining their fibroblastic/chondrocytic properties was studied. Control scaffolds, including bovine collagen meniscus implant (CMI) and human meniscus allograft (M-Allo), were used for comparison purposes. In addition, the migration tendency of MCs from fresh donor meniscal tissue into SPX was investigated in an ex vivo model. The results showed that MCs cultured in osteogenic medium did not differentiate into osteogenic cells or form significant calcium phosphate deposits, although AP activity was relatively increased in these cells. Culturing cells on the scaffolds revealed increased viability on SPX compared to the other scaffold materials. Collagen I synthesis, assessed by ELISA, was similar in cells cultured in 2D and on SPX. MCs on micro-porous SPX (weight >0.5 g/cm3) exhibited increased osteogenic differentiation indicated by upregulated expression of ALP and RUNX2, while also showing upregulated expression of the chondrogen-specific SOX9 and ACAN genes. Ingrowth of cells on SPX was observed after 28 days of cultivation. Overall, the results suggest that SPX could be a promising biocompatible scaffold for meniscal regeneration.
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Affiliation(s)
- Mohammad Dabaghi
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Volker Eras
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), Berlin, Germany
| | - Daniel Kaltenhaeuser
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), Berlin, Germany
| | - Norus Ahmed
- German Institute for Cell and Tissue Replacement (DIZG, gemeinnützige GmbH), Berlin, Germany
| | - Britt Wildemann
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
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Sezaki S, Otsuki S, Ikeda K, Ishitani T, Okamoto Y, Wakama H, Matsuyama J, Nakamura K, Neo M. Biomechanical assessment of a novel meniscal scaffold compared to partial meniscectomy: A study on porcine meniscal injury. J Biomed Mater Res B Appl Biomater 2023; 111:895-902. [PMID: 36374005 DOI: 10.1002/jbm.b.35199] [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: 04/12/2022] [Revised: 09/26/2022] [Accepted: 11/06/2022] [Indexed: 11/16/2022]
Abstract
This study aimed to investigate the appropriate size of scaffold implantation on stress distribution and evaluate its mechanical and biomechanical properties considering hydrolysis. The meniscus acts as a load distribution in the knee, and its biomechanical properties are essential for the development of the PGA scaffold. We established a novel meniscal scaffold, which consists of polyglycolic acid (PGA) covered with L-lactide-ε-caprolactone copolymer (P[LA/CL]). After 4 weeks of hydrolysis, the scaffold had a 7% volume reduction compared to the initial volume. In biomechanical tests, the implantation of scaffolds 20% larger than the circumferential and vertical defect size results in greater contact stress than the intact meniscus. In the mechanical evaluation associated with the decomposition behavior, the strength decreased after 4 weeks of hydrolysis. Meanwhile, in the biomechanical test considering hydrolysis, contact stress and area equivalent to intact were obtained after 4 weeks of hydrolysis. In conclusion, the implantation of the PGA scaffold might be a useful alternative to partial meniscectomy in terms of mechanical properties, and the PGA scaffold should be implanted up to 20% of the defect size.
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Affiliation(s)
- Shunsuke Sezaki
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan.,QOL Research Laboratory, Gunze Limited, Kyoto, Japan
| | - Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kuniaki Ikeda
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Takashi Ishitani
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Yoshinori Okamoto
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Junya Matsuyama
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kaito Nakamura
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
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Shen S, Ye M, Wu M, Zhou W, Xu S. MRI and DC/TMD Methods Analyze the Diagnostic Accuracy of the Change in Articular Disc of Temporomandibular Joint. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1770810. [PMID: 35211184 PMCID: PMC8863444 DOI: 10.1155/2022/1770810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/27/2021] [Accepted: 01/05/2022] [Indexed: 01/10/2023]
Abstract
METHODS DC/TMD clinical questionnaire diagnosis was conducted for 30 patients with temporomandibular disorder (TMD) and 11 asymptomatic volunteers who were admitted to the Department of Oral Medicine of the First Hospital affiliated with Jinan University from June 2020 to June 2021. At the same time, MRI scanned the opening and closed positions to obtain the image information of the articular disc and compared the diagnostic difference between MRI and DC/TMD to the position of the articular disc through statistical analysis. RESULTS The probability of DC/TMD's diagnosis of reusable/nonreusable anterior disc displacement (ADD) was 80.1% and 62.7%, respectively. CONCLUSION DC/TMD's diagnosis of abnormal articular disc position is less accurate than MRI testing. Therefore, the diagnosis of these two diseases for DC/TMD examination is of little significance, and MRI examination is required at the same time. It can improve diagnosis specificity and sensitivity, reduce missed diagnosis and misdiagnosis rates to ensure that true positive patients can be detected in time, and establish a basis for clinical diagnosis and treatment.
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Affiliation(s)
- Shan Shen
- Stomatology, The First Affiliated Hospital of Jinan University, Guangzhou 510632, China
- Stomatology, Jinan University Daliang Hospital, Foshan 528300, China
| | - Mingjun Ye
- School of Stomatology, Jinan University, Guangzhou 510632, China
| | - Mingle Wu
- Stomatology, Jinan University Daliang Hospital, Foshan 528300, China
| | - Wencheng Zhou
- School of Stomatology, Jinan University, Guangzhou 510632, China
| | - Sanghui Xu
- School of Stomatology, Jinan University, Guangzhou 510632, China
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Zhou YF, Zhang D, Yan WT, Lian K, Zhang ZZ. Meniscus Regeneration With Multipotent Stromal Cell Therapies. Front Bioeng Biotechnol 2022; 10:796408. [PMID: 35237572 PMCID: PMC8883323 DOI: 10.3389/fbioe.2022.796408] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/11/2022] [Indexed: 12/20/2022] Open
Abstract
Meniscus is a semilunar wedge-shaped structure with fibrocartilaginous tissue, which plays an essential role in preventing the deterioration and degeneration of articular cartilage. Lesions or degenerations of it can lead to the change of biomechanical properties in the joints, which ultimately accelerate the degeneration of articular cartilage. Even with the manual intervention, lesions in the avascular region are difficult to be healed. Recent development in regenerative medicine of multipotent stromal cells (MSCs) has been investigated for the significant therapeutic potential in the repair of meniscal injuries. In this review, we provide a summary of the sources of MSCs involved in repairing and regenerative techniques, as well as the discussion of the avenues to utilizing these cells in MSC therapies. Finally, current progress on biomaterial implants was reviewed.
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Affiliation(s)
- Yun-Feng Zhou
- Department of Orthopedics, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Di Zhang
- Department of Obstetrics-Gynecology, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Wan-Ting Yan
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- School of Medicine, Sun Yat-sen University, Shenzhen, China
| | - Kai Lian
- Department of Orthopedics, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
- *Correspondence: Zheng-Zheng Zhang, ; Kai Lian,
| | - Zheng-Zheng Zhang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Zheng-Zheng Zhang, ; Kai Lian,
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10
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Nakagawa K, Otsuki S, Murakami T, Okamoto Y, Okuno N, Wakama H, Sezaki S, Ikeda K, Okayoshi T, Neo M. Histological Analysis of the Wrapping Treatment for Meniscal Horizontal Tears in Rabbits. Cartilage 2021; 13:1551S-1561S. [PMID: 31466462 PMCID: PMC8804842 DOI: 10.1177/1947603519870838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To investigate meniscal regeneration and prevent cartilage degeneration using wrapping treatment for meniscal horizontal tears that have been difficult to repair in rabbits. DESIGN Thirty knees from 15 Japanese white rabbits were divided into the horizontal (horizontal tears) or wrapping (horizontal tears with wrapping treatment) groups. Horizontal tears were created and wrapped with a sheet scaffold containing polyglycolic acid, polylactic acid, and polycaprolactone. The meniscus was stained with Safranin-O/Fast Green and evaluated with modified Pauli scores at 8, 12, and 16 weeks after implantation (n = 5). Cell morphology was determined with hematoxylin and eosin staining. Mature collagen was confirmed with Picrosirius Red staining. Furthermore, immunohistochemical analysis of inducible nitric oxide synthase (iNOS) for inflammation, Ki-67 for proliferation, and type II collagen for regeneration was performed. Medial femoral cartilage was stained with Safranin-O/Fast Green and evaluated with the Osteoarthritis Research Society International score at 8 and 16 weeks. RESULTS The wrapping group had significantly better regeneration than the horizontal group, especially at 16 weeks (P < 0.05). Wrapping treatment induced fibrochondrocyte-like cells at 16 weeks. After wrapping treatment, iNOS was overexpressed at 8 weeks, Ki-67 at 8 and 12 weeks, and type II collagen at 16 weeks. Cartilage degeneration in the wrapping group did not progress significantly compared with that in the horizontal group at 16 weeks (P < 0.05). CONCLUSIONS Wrapping treatment for meniscal horizontal tears induced meniscal regeneration as the sheet scaffold might induce intrinsic and extrinsic repair. Regaining the meniscal function by the wrapping treatment prevented cartilage degeneration.
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Affiliation(s)
- Kosuke Nakagawa
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
| | - Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan,Shuhei Otsuki, Department of Orthopedic
Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki-city, Osaka
569-8686, Japan.
| | - Tomohiko Murakami
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
| | - Yoshinori Okamoto
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
| | - Nobuhiro Okuno
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
| | - Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
| | - Shunsuke Sezaki
- Department of QOL Research Center
Laboratory, Gunze Limited, Osaka, Japan
| | - Kuniaki Ikeda
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
| | - Tomohiro Okayoshi
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka
Medical College, Takatsuki, Osaka, Japan
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Biomaterials and Meniscal Lesions: Current Concepts and Future Perspective. Pharmaceutics 2021; 13:pharmaceutics13111886. [PMID: 34834301 PMCID: PMC8617690 DOI: 10.3390/pharmaceutics13111886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 11/16/2022] Open
Abstract
Menisci are crucial structures for knee homeostasis. After a meniscal lesion, the golden rule, now, is to save as much meniscus as possible; only the meniscus tissue that is identified as unrepairable should be excised, and meniscal sutures find more and more indications. Several different methods have been proposed to improve meniscal healing. They include very basic techniques, such as needling, abrasion, trephination and gluing, or more complex methods, such as synovial flaps, meniscal wrapping or the application of fibrin clots. Basic research of meniscal substitutes has also become very active in the last decades. The aim of this literature review is to analyze possible therapeutic and surgical options that go beyond traditional meniscal surgery: from scaffolds, which are made of different kind of polymers, such as natural, synthetic or hydrogel components, to new technologies, such as 3-D printing construct or hybrid biomaterials made of scaffolds and specific cells. These recent advances show that there is great interest in the development of new materials for meniscal reconstruction and that, with the development of new biomaterials, there will be the possibility of better management of meniscal injuries
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Bansal S, Floyd ER, Kowalski MA, Aikman E, Elrod P, Burkey K, Chahla J, LaPrade RF, Maher SA, Robinson JL, Patel JM. Meniscal repair: The current state and recent advances in augmentation. J Orthop Res 2021; 39:1368-1382. [PMID: 33751642 PMCID: PMC8249336 DOI: 10.1002/jor.25021] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/04/2021] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
Meniscal injuries represent one of the most common orthopedic injuries. The most frequent treatment is partial resection of the meniscus, or meniscectomy, which can affect joint mechanics and health. For this reason, the field has shifted gradually towards suture repair, with the intent of preservation of the tissue. "Save the Meniscus" is now a prolific theme in the field; however, meniscal repair can be challenging and ineffective in many scenarios. The objectives of this review are to present the current state of surgical management of meniscal injuries and to explore current approaches being developed to enhance meniscal repair. Through a systematic literature review, we identified meniscal tear classifications and prevalence, approaches being used to improve meniscal repair, and biological- and material-based systems being developed to promote meniscal healing. We found that biologic augmentation typically aims to improve cellular incorporation to the wound site, vascularization in the inner zones, matrix deposition, and inflammatory relief. Furthermore, materials can be used, both with and without contained biologics, to further support matrix deposition and tear integration, and novel tissue adhesives may provide the mechanical integrity that the meniscus requires. Altogether, evaluation of these approaches in relevant in vitro and in vivo models provides new insights into the mechanisms needed to salvage meniscal tissue, and along with regulatory considerations, may justify translation to the clinic. With the need to restore long-term function to injured menisci, biologists, engineers, and clinicians are developing novel approaches to enhance the future of robust and consistent meniscal reparative techniques.
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Affiliation(s)
- Sonia Bansal
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | - Kyley Burkey
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | | | | | | | - Jay M. Patel
- Emory University, Atlanta, Georgia, USA
- Atlanta VA Medical Center, Decatur, Georgia, USA
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Ikeda K, Otsuki S, Okuno N, Sezaki S, Nakagawa K, Miyamoto Y, Okamoto Y, Wakama H, Okayoshi T, Neo M. Development of a novel meniscal sheet scaffold and its effectiveness for meniscal regeneration in a rabbit defect model. J Biomater Appl 2021; 36:517-527. [PMID: 33691527 DOI: 10.1177/08853282211000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study evaluated the biomechanical strength of a novel two-layer meniscal sheet scaffold (MSS) consisting of polyglycolic acid and poly-Llactic acid/caprolactone and investigated meniscal healing using wrapping treatment for meniscal defect model in a rabbit. The ultimate failure load of the MSS was determined using a tensile testing machine, in vitro. A 2-mm cylindrical defects were created at the medial meniscus of rabbit knees (n = 40). Each knee was assigned to one of two groups. The defect group was not treated and the MSS group underwent wrapping treatment with MSS. Menisci were harvested at 2, 4, 8, and 12 weeks post-implantation. The regenerated meniscus and defect size were evaluated using macrophotographs. Ishida scores for regenerated tissue were determined using Safranin-O/Fast Green staining. Immunohistochemical analysis of Ki-67 for cell proliferation, anti-type I and II collagen antibodies for structure of the regenerated tissue was elucidated. Medial femoral cartilage was stained with Safranin-O/Fast Green and evaluated with Osteoarthritis Research Society International (OARSI) scores. The strength of MSS was maintained over 90% from initial time point to 4 weeks after hydrolysis and over 60% of the strength remained at 8 weeks. The surface area of the meniscus was larger and the defect size smaller in the MSS group than in the defect group at 8 and 12 weeks. Ishida scores revealed that the MSS group improved significantly compared to that of the defect group at all postsurgery time points evaluated. Ki-67 positive cell ratio was significantly higher in the MSS group. OARSI score of the defect group was significantly higher and the defect group showed progressive degeneration in the articular cartilage from 8 to 12 weeks. Overall, wrapping meniscus defects with MSS was useful for accelerating meniscal healing from an early stage and beneficial for tissue regeneration and promoting extracellular matrix maturation.
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Affiliation(s)
- Kuniaki Ikeda
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Nobuhiro Okuno
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | | | - Kosuke Nakagawa
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Yuki Miyamoto
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Yoshinori Okamoto
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Tomohiro Okayoshi
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
| | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan
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Feng Z, Fan Y, Guo J, Fu W. [Research progress of scaffold materials for tissue engineered meniscus]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1019-1028. [PMID: 31407563 PMCID: PMC8337896 DOI: 10.7507/1002-1892.201810046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 06/26/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To summarize and analyze the research progress of scaffold materials used in tissue engineered meniscus. METHODS The classification and bionics design of scaffold materials were summarized by consulting domestic and foreign literature related to the research of tissue engineered meniscus in recent years. RESULTS Tissue engineered meniscus scaffolds can be roughly classified into synthetic polymers, hydrogels, extracellular matrix components, and tissue derived materials. These different materials have different characteristics, so the use of a single material has its unique disadvantages, and the use of a variety of materials composite scaffolds can learn from each other, which is a hot research area at present. In addition to material selection, material processing methods are also the focus of research. At the same time, according to the morphological structure and mechanical characteristics of the meniscus, the bionic design of tissue engineered meniscus scaffolds has great potential. CONCLUSION At present, there are many kinds of scaffold materials for tissue engineered meniscus. However, there is no material that can completely simulate the natural meniscus, and further research of scaffold materials is still needed.
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Affiliation(s)
- Ziyan Feng
- West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yifei Fan
- West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Jiusi Guo
- West China School of Stomatology, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Weili Fu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041,
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Otsuki S, Nakagawa K, Murakami T, Sezaki S, Sato H, Suzuki M, Okuno N, Wakama H, Kaihatsu K, Neo M. Evaluation of Meniscal Regeneration in a Mini Pig Model Treated With a Novel Polyglycolic Acid Meniscal Scaffold. Am J Sports Med 2019; 47:1804-1815. [PMID: 31172797 DOI: 10.1177/0363546519850578] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Meniscal injury is a severe impediment to movement and results in accelerated deterioration of the knee joint. PURPOSE To evaluate the effect of a novel meniscal scaffold prepared from polyglycolic acid coated with polylactic acid/caprolactone on the treatment of meniscal injury in a mini pig model. STUDY DESIGN Controlled laboratory study. METHODS The model was established with a 10-mm resection at the anterior medial meniscus on both knee joints. A scaffold was implanted in the right knee joint. The meniscal scaffold was inserted and sutured next to the native meniscus. The histological analysis was performed to determine meniscal regeneration with safranin O staining, cell proliferation with PCNA, inflammation with TNF, and collagen structure and production with picrosirius red and immunofluorescence. Cartilage degeneration was evaluated with Safranin O. Meniscal regeneration and joint fluid were evaluated with magnetic resonance imaging. RESULTS Although compressive stress and elastic modulus were significantly lower in the scaffold than in the native porcine menisci, ultimate tensile stress was similar. Implanted scaffolds were covered with tissue beginning at 4 weeks, with increased migration of proliferating cells to the implant area at 4 and 8 weeks. Scaffolds were absorbed with freshly produced collagen at 24 weeks. Cartilage degeneration was significantly lower in the meniscus-implanted group than in the meniscectomy group. Magnetic resonance imaging results did not show severe accumulation of joint fluids, suggesting negligible inflammation. Density of the implanted menisci was comparable with that of the native menisci. CONCLUSION Meniscal scaffold prepared from polyglycolic acid has therapeutic potential for meniscal regeneration. CLINICAL RELEVANCE This meniscal scaffold can improve biological knee reconstruction and prevent the increase of total knee arthroplasty.
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Affiliation(s)
- Shuhei Otsuki
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
| | - Kosuke Nakagawa
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
| | - Tomohiko Murakami
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
| | | | - Hideki Sato
- Gunze Limited, QOL Research Laboratory, Kyoto, Japan
| | | | - Nobuhiro Okuno
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
| | - Hitoshi Wakama
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
| | | | - Masashi Neo
- Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan
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Murakami T, Otsuki S, Okamoto Y, Nakagawa K, Wakama H, Okuno N, Neo M. Hyaluronic acid promotes proliferation and migration of human meniscus cells via a CD44-dependent mechanism. Connect Tissue Res 2019; 60:117-127. [PMID: 29658360 DOI: 10.1080/03008207.2018.1465053] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Treatment of meniscal injury is important for osteoarthritis (OA) prevention. Meniscus cells are divided between inner and outer cells, which have different characteristics and vascularity. We evaluated the effects of hyaluronic acid (HA) on the proliferation and migration of human inner and outer meniscus cells, and investigated the underlying healing mechanisms. MATERIALS AND METHODS Lateral menisci from 18 patients who underwent total knee arthroplasty were used. Meniscus cells were harvested from the outer and inner menisci and evaluated using migration and proliferation assays after treatment with HA or chondroitin sulfate (CS). The effects of HA on prostaglandin E2 (PGE2)-induced apoptosis and gene expression were evaluated. RESULTS Cell migration and proliferation were increased by HA in a concentration-dependent manner, in both inner and outer meniscus cells. PGE2-induced apoptosis and caspase-3/7 activity were suppressed by HA in both inner and outer meniscus cells, and these effects were blocked by an anti-CD44 antibody. COL2A1 and ACAN mRNA levels were upregulated following HA treatment of inner meniscus cells. MMP13 mRNA was downregulated following CS stimulation of both inner and outer meniscus cells. These results suggest that CS treatment suppresses the inflammatory reaction rather than providing meniscal restoration. The phosphatidylinositol 3-kinase (PI3K) and mitogen-activated protein kinase (MAPK) pathways were activated by HA in both types of meniscus cells; these effects were blocked by treatment with an anti-CD44 antibody. CONCLUSIONS HA promoted human meniscus regeneration by inhibiting apoptosis, promoting cell migration, and accelerating cell proliferation, potentially through the PI3K/MAPK pathway via the CD44 receptor.
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Affiliation(s)
| | - Shuhei Otsuki
- a Orthopedic Surgery , Osaka Medical College , Osaka , Japan
| | | | - Kosuke Nakagawa
- a Orthopedic Surgery , Osaka Medical College , Osaka , Japan
| | - Hitoshi Wakama
- a Orthopedic Surgery , Osaka Medical College , Osaka , Japan
| | - Nobuhiro Okuno
- a Orthopedic Surgery , Osaka Medical College , Osaka , Japan
| | - Masashi Neo
- a Orthopedic Surgery , Osaka Medical College , Osaka , Japan
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Kean CO, Brown RJ, Chapman J. The role of biomaterials in the treatment of meniscal tears. PeerJ 2017; 5:e4076. [PMID: 29158995 PMCID: PMC5695244 DOI: 10.7717/peerj.4076] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/31/2017] [Indexed: 12/15/2022] Open
Abstract
Extensive investigations over the recent decades have established the anatomical, biomechanical and functional importance of the meniscus in the knee joint. As a functioning part of the joint, it serves to prevent the deterioration of articular cartilage and subsequent osteoarthritis. To this end, meniscus repair and regeneration is of particular interest from the biomaterial, bioengineering and orthopaedic research community. Even though meniscal research is previously of a considerable volume, the research community with evolving material science, biology and medical advances are all pushing toward emerging novel solutions and approaches to the successful treatment of meniscal difficulties. This review presents a tactical evaluation of the latest biomaterials, experiments to simulate meniscal tears and the state-of-the-art materials and strategies currently used to treat tears.
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Affiliation(s)
- Crystal O. Kean
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | | | - James Chapman
- School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
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Abstract
Meniscal resection is the most common surgical procedure in orthopaedics. When a large meniscal loss becomes clinically relevant, meniscal allograft transplantation (MAT) is a feasible option. However, although this technique has evolved since the ‘80s, there are still several controversial issues related to MAT. Most importantly, its chondroprotective effect is still not completely proven. Its relatively high complication and reoperation rate is another reason for this procedure not yet being universally accepted. Despite its controversial chondroprotective effect, nevertheless, MAT has become a successful treatment for pain localised in a previously meniscectomised knee, in terms of pain relief and knee function. We conducted a careful review of the literature, highlighting the most relevant studies in various aspects of this procedure. Precise indications, how it behaves biomechanically, surgical techniques, return to sport and future perspectives are among the most relevant topics that have been included in this state-of-the-art review.
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