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McMorrow LA, Czarnecki P, Reid AJ, Tos P. Current perspectives on peripheral nerve repair and management of the nerve gap. J Hand Surg Eur Vol 2024; 49:698-711. [PMID: 38603601 DOI: 10.1177/17531934241242002] [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: 04/13/2024]
Abstract
From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.
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Affiliation(s)
- Liam A McMorrow
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Piotr Czarnecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, Poznań, Poland
| | - Adam J Reid
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Pierluigi Tos
- Azienda Socio Sanitaria Territoriale Gaetano Pini, Milan, Italy
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2
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Monfette V, Choinière W, Godbout-Lavoie C, Pelletier S, Langelier È, Lauzon MA. Thermoelectric Freeze-Casting of Biopolymer Blends: Fabrication and Characterization of Large-Size Scaffolds for Nerve Tissue Engineering Applications. J Funct Biomater 2023; 14:330. [PMID: 37367294 DOI: 10.3390/jfb14060330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/03/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Peripheral nerve injuries (PNIs) are detrimental to the quality of life of affected individuals. Patients are often left with life-long ailments that affect them physically and psychologically. Autologous nerve transplant is still the gold standard treatment for PNIs despite limited donor site and partial recovery of nerve functions. Nerve guidance conduits are used as a nerve graft substitute and are efficient for the repair of small nerve gaps but require further improvement for repairs exceeding 30 mm. Freeze-casting is an interesting fabrication method for the conception of scaffolds meant for nerve tissue engineering since the microstructure obtained comprises highly aligned micro-channels. The present work focuses on the fabrication and characterization of large scaffolds (35 mm length, 5 mm diameter) made of collagen/chitosan blends by freeze-casting via thermoelectric effect instead of traditional freezing solvents. As a freeze-casting microstructure reference, scaffolds made from pure collagen were used for comparison. Scaffolds were covalently crosslinked for better performance under load and laminins were further added to enhance cell interactions. Microstructural features of lamellar pores display an average aspect ratio of 0.67 ± 0.2 for all compositions. Longitudinally aligned micro-channels are reported as well as enhanced mechanical properties in traction under physiological-like conditions (37 °C, pH = 7.4) resulting from crosslinking treatment. Cell viability assays using a rat Schwann cell line derived from sciatic nerve (S16) indicate that scaffold cytocompatibility is similar between scaffolds made from collagen only and scaffolds made from collagen/chitosan blend with high collagen content. These results confirm that freeze-casting via thermoelectric effect is a reliable manufacturing strategy for the fabrication of biopolymer scaffolds for future peripheral nerve repair applications.
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Affiliation(s)
- Vincent Monfette
- Department of Chemical Engineering and Biotechnological of Engineering, Faculty of Engineering, Université de Sherbrooke, Sherbrooke, QC J1K 2R1, Canada
| | - William Choinière
- Department of Chemical Engineering and Biotechnological of Engineering, Faculty of Engineering, Université de Sherbrooke, Sherbrooke, QC J1K 2R1, Canada
| | - Catherine Godbout-Lavoie
- Department of Chemical Engineering and Biotechnological of Engineering, Faculty of Engineering, Université de Sherbrooke, Sherbrooke, QC J1K 2R1, Canada
| | - Samuel Pelletier
- Department of Electrical Engineering and Informatics Engineering, Faculty of Engineering, Université de Sherbrooke, Sherbrooke, QC J1K 2R1, Canada
| | - Ève Langelier
- Department of Mechanical Engineering, Faculty of Engineering, Université de Sherbrooke, Sherbrooke, QC J1K 2R1, Canada
| | - Marc-Antoine Lauzon
- Department of Chemical Engineering and Biotechnological of Engineering, Faculty of Engineering, Université de Sherbrooke, Sherbrooke, QC J1K 2R1, Canada
- Research Center on Aging, CIUSSS de l'ESTRIE-CHUS, Sherbrooke, QC J1H 4C4, Canada
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3
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Frostadottir D, Chemnitz A, Johansson OT LJ, Holst J, Dahlin LB. Evaluation of Processed Nerve Allograft in Peripheral Nerve Surgery: A Systematic Review and Critical Appraisal. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5088. [PMID: 37383478 PMCID: PMC10299771 DOI: 10.1097/gox.0000000000005088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/05/2023] [Indexed: 06/30/2023]
Abstract
Peripheral nerve injuries cause substantial problems when not treated properly. A specific problem is reconstruction of nerve defects, which can be treated in different ways. This study aimed to systematically review whether processed nerve allograft (PNA) is justified in reconstruction of a nerve defect in patients after posttraumatic or iatrogenic peripheral nerve injury and to compare PNA with other established methods. Methods A systematic review with a focused question, PICO (patient, intervention, comparison, outcome) and constraints, was performed. A structured literature search, including several databases, was done to evaluate the existing evidence for outcomes and postoperative complications related to PNA. The certainty of evidence was classified according to Grading of Recommendations, Assessment, Development and Evaluations. Results No conclusions, concerning differences in outcome of nerve reconstruction using PNA compared with the use of nerve autograft or conduits, could be drawn. The level of certainty for all evaluated outcomes was very low (⊕◯◯◯). Most published studies lack a control group to patients treated with PNA; being only descriptive, making it difficult to compare PNA with established methods without substantial risk of bias. For studies including a control group, the scientific evidence was of very low certainty, due to a low number of included patients, and large, undefined loss of patients during follow-up, rendering a high risk of bias. Finally, the authors often had financial disclosures. Conclusion Properly conducted randomized controlled trial studies on the use of PNA in reconstruction of peripheral nerve injuries are needed to establish recommendations in clinical practice.
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Affiliation(s)
- Drifa Frostadottir
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine—Hand Surgery, Lund University, Malmö, Sweden
| | - Anette Chemnitz
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
| | | | - Jan Holst
- Department of Vascular Disease, Skåne University Hospital, Malmö, Sweden
- Department of Research and Education, HTA syd, Skåne University Hospital, Lund, Sweden
| | - Lars B. Dahlin
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine—Hand Surgery, Lund University, Malmö, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Weber MB, Isaacs JE. Digital Nerve Injury: Assessment and Treatment. J Am Acad Orthop Surg 2023; Publish Ahead of Print:00124635-990000000-00703. [PMID: 37205873 DOI: 10.5435/jaaos-d-23-00255] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Undertreated digital nerve injuries may result in sensory deficits and pain. Early recognition and treatment will optimize outcomes, and providers should maintain a high index of suspicion when assessing patients with open wounds. Acute, sharp lacerations may be amenable to direct repair while avulsion injuries or delayed repairs require adequate resection and bridging with nerve autograft, processed nerve allograft, or conduits. Conduits are most appropriate for gaps less than 15 mm, and processed nerve allografts have demonstrated reliable outcomes across longer gaps.
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Affiliation(s)
- Matthew B Weber
- From the Virginia Commonwealth University Medical Center, Richmond, VA
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5
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Choe G, Han UG, Ye S, Kang S, Yoo J, Cho YS, Jung Y. Effect of Electrical Stimulation on Nerve-Guided Facial Nerve Regeneration. ACS Biomater Sci Eng 2023. [PMID: 37126860 DOI: 10.1021/acsbiomaterials.3c00222] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This study aimed to investigate the effect of electrical stimulation on poly(d,l-lactide-co-ε-caprolactone) nerve guidance conduits (NGCs) in promoting the recovery of facial function and nerve regeneration after facial nerve (FN) injury in a rat model. In the experimental group, both the NGC and transcutaneous electrical nerve stimulation (ES) were used simultaneously; in the control group, only NGC was used. ES groups were divided into two groups, and direct current (DC) and charge-balanced pulse stimulation (Pulse) were applied. The ES groups showed significantly improved whisker movement than the NGC-only group. The number of myelinated neurons was higher in ES groups, and the myelin sheath was also thicker and more uniform. In addition, the expression of neurostructural proteins was also higher in ES groups than in the NGC-only group. This study revealed that FN regeneration and functional recovery occurred more efficiently when ES was applied in combination with NGCs.
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Affiliation(s)
- Goeun Choe
- Center for Biomaterials, Biomedical Research Institute, Korea Institute of Science and Technology (KIST), Seoul 02792, Korea
| | - Ul Gyu Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Samsung Advanced Institute for Health Sciences & Technology, Department of Health Sciences and Technology, Sungkyunkwan University, Seoul 06351, Korea
| | - Seongryeol Ye
- Center for Biomaterials, Biomedical Research Institute, Korea Institute of Science and Technology (KIST), Seoul 02792, Korea
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, Suwon 08826, Korea
| | - Sujee Kang
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jin Yoo
- Center for Biomaterials, Biomedical Research Institute, Korea Institute of Science and Technology (KIST), Seoul 02792, Korea
| | - Young Sang Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Youngmee Jung
- Center for Biomaterials, Biomedical Research Institute, Korea Institute of Science and Technology (KIST), Seoul 02792, Korea
- School of Electrical and Electronic Engineering, YU-KIST Institute, Yonsei University, Seoul 03722, Korea
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6
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A highly elastic absorbable monofilament suture fabricated from poly(3-hydroxybutyrate-co-4-hydroxybutyrate). Sci Rep 2023; 13:3275. [PMID: 36841914 PMCID: PMC9968320 DOI: 10.1038/s41598-023-30292-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
To address the growing demand for more elastic sutures free from unwanted knot loosening, we fabricated an absorbable monofilament suture from poly(3-hydroxybutyrate-co-4-hydroxybutyrate) and subjected it to physical property characterization and performance evaluation (in vitro and in vivo degradability tests and a porcine abdominal wall suture test). As this flexible, highly stretchable, and difficult-to-untie suture exhibited additional advantages of small knot size and medium to long-term bioabsorbability, it was concluded to be a safe alternative to existing monofilament sutures, with far-reaching potential applications.
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7
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Saeheng C, Fuongfuchat A, Sriyai M, Daranarong D, Namhongsa M, Molloy R, Meepowpan P, Punyodom W. Microstructure, thermal and rheological properties of poly(L‐lactide‐
co
‐
ε
‐caprolactone) tapered block copolymer for potential use in biomedical applications. J Appl Polym Sci 2022. [DOI: 10.1002/app.53091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chutima Saeheng
- Department of Chemistry, Faculty of Science Chiang Mai University Chiang Mai Thailand
| | - Asira Fuongfuchat
- National Metal and Materials Technology Center National Science and Technology Development Agency (NSTDA) Pathum Thani Thailand
| | - Montira Sriyai
- Bioplastic Production Laboratory for Medical Applications, Faculty of Science Chiang Mai University Chiang Mai Thailand
- Center of Excellence in Materials Science and Technology Chiang Mai University Chiang Mai Thailand
| | - Donraporn Daranarong
- Bioplastic Production Laboratory for Medical Applications, Faculty of Science Chiang Mai University Chiang Mai Thailand
- Center of Excellence in Materials Science and Technology Chiang Mai University Chiang Mai Thailand
- Science and Technology Research Institute Chiang Mai University Chiang Mai Thailand
| | - Manasanan Namhongsa
- Department of Chemistry, Faculty of Science Chiang Mai University Chiang Mai Thailand
| | - Robert Molloy
- Center of Excellence in Materials Science and Technology Chiang Mai University Chiang Mai Thailand
| | - Puttinan Meepowpan
- Department of Chemistry, Faculty of Science Chiang Mai University Chiang Mai Thailand
- Bioplastic Production Laboratory for Medical Applications, Faculty of Science Chiang Mai University Chiang Mai Thailand
- Center of Excellence in Materials Science and Technology Chiang Mai University Chiang Mai Thailand
| | - Winita Punyodom
- Department of Chemistry, Faculty of Science Chiang Mai University Chiang Mai Thailand
- Bioplastic Production Laboratory for Medical Applications, Faculty of Science Chiang Mai University Chiang Mai Thailand
- Center of Excellence in Materials Science and Technology Chiang Mai University Chiang Mai Thailand
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8
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Closing the Gap: Bridging Peripheral Sensory Nerve Defects with a Chitosan-Based Conduit a Randomized Prospective Clinical Trial. J Pers Med 2022; 12:jpm12060900. [PMID: 35743685 PMCID: PMC9224872 DOI: 10.3390/jpm12060900] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: If tensionless nerve coaptation is not possible, bridging the resulting peripheral nerve defect with an autologous nerve graft is still the current gold standard. The concept of conduits as an alternative with different materials and architectures, such as autologous vein conduits or bioartificial nerve conduits, could not replace the nerve graft until today. Chitosan, as a relatively new biomaterial, has recently demonstrated exceptional biocompatibility and material stability with neural lineage cells. The purpose of this prospective randomized clinical experiment was to determine the efficacy of chitosan-based nerve conduits in regenerating sensory nerves in the hand. Materials and methods: Forty-seven patients with peripheral nerve defects up to 26 mm distal to the carpal tunnel were randomized to receive either a chitosan conduit or an autologous nerve graft with the latter serving as the control group. Fifteen patients from the conduit group and seven patients from the control group were available for a 12-month follow-up examination. The primary outcome parameter was tactile gnosis measured with two-point discrimination. The secondary outcome parameters were Semmens Weinstein Monofilament Testing, self-assessed pain, and patient satisfaction. Results: Significant improvement (in static two-point discrimination) was observed six months after trauma (10.7 ± 1.2 mm; p < 0.05) for chitosan-based nerve conduits, but no further improvement was observed after 12 months of regeneration (10.9 ± 1.3 mm). After six months and twelve months, the autologous nerve graft demonstrated comparable results to the nerve conduit, with a static two-point discrimination of 11.0 ± 2.0 mm and 7.9 ± 1.1 mm. Semmes Weinstein Filament Testing in the nerve conduit group showed a continuous improvement over the regeneration period by reaching from 3.1 ± 0.3 after three months up to 3.7 ± 0.4 after twelve months. Autologous nerve grafts presented similar results: 3.3 ± 0.4 after three months and 3.7 ± 0.5 after twelve months. Patient satisfaction and self-reported pain levels were similar between the chitosan nerve conduit and nerve graft groups. One patient required revision surgery due to complications associated with the chitosan nerve tube. Conclusion: Chitosan-based nerve conduits are safe and suitable for bridging nerve lesions up to 26 mm in the hand. Tactile gnosis improved significantly during the early regeneration period, and functional outcomes were similar to those obtained with an autologous nerve graft. Thus, chitosan appears to be a sufficient substitute for autologous nerve grafts in the treatment of small nerve defects in the hand.
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9
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Sriyai M, Tasati J, Molloy R, Meepowpan P, Somsunan R, Worajittiphon P, Daranarong D, Meerak J, Punyodom W. Development of an Antimicrobial-Coated Absorbable Monofilament Suture from a Medical-Grade Poly(l-lactide- co-ε-caprolactone) Copolymer. ACS OMEGA 2021; 6:28788-28803. [PMID: 34746572 PMCID: PMC8567407 DOI: 10.1021/acsomega.1c03569] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/07/2021] [Indexed: 06/12/2023]
Abstract
In this study, a medical-grade poly(l-lactide-co-ε-caprolactone) (PLC) copolymer with a monomer ratio of l-lactide (L) to ε-caprolactone (C) of 70:30 mol % for use as an absorbable surgical suture was synthesized via ring-opening polymerization (ROP) using a novel soluble liquid tin(II) n-butoxide (Sn(OnC4H9)2) as an initiator. In fiber fabrication, the process included copolymer melt extrusion with a minimal draw followed by sequential controlled hot-drawing and fixed-annealing steps to obtain oriented semicrystalline fibers with improved mechanical strength. For healing enhancement, the fiber was dip-coated with "levofloxacin" by adding the drug into a solution mixture of acetone, poly(ε-caprolactone) (PCL), and calcium stearate (CaSt) in the ratio of acetone/PCL/CaSt = 100:1% w/v:0.1% w/v. The tensile strength of the coated fiber was found to be increased to ∼400 MPa, which is comparable with that of commercial polydioxanone (PDS II) of a similar size. Finally, the efficiency of the drug-coated fiber regarding its controlled drug release and antimicrobial activity was investigated, and the results showed that the coated fiber was able to release the drug continuously for as long as 30 days. For fiber antimicrobial activity, it was found that a concentration of 1 mg/mL was sufficient to inhibit the growth of Staphylococcus aureus (MRSA), Escherichia coli O157:H7, and Pseudomonas aeruginosa, giving a clear inhibition zone range of 20-24 mm for 90 days. Cytotoxicity testing of the drug-coated fibers showed a %viability of more than 70%, indicating that they were nontoxic.
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Affiliation(s)
- Montira Sriyai
- Bioplastics
Production Laboratory for Medical Applications, Faculty of Science, Chiang Mai University, Chiang Mai 50200, Thailand
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
| | - Jagkrit Tasati
- Department
of Chemistry, Faculty of Science, Chiang
Mai University, Chiang Mai 50200, Thailand
| | - Robert Molloy
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
| | - Puttinan Meepowpan
- Department
of Chemistry, Faculty of Science, Chiang
Mai University, Chiang Mai 50200, Thailand
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
| | - Runglawan Somsunan
- Department
of Chemistry, Faculty of Science, Chiang
Mai University, Chiang Mai 50200, Thailand
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
| | - Patnarin Worajittiphon
- Department
of Chemistry, Faculty of Science, Chiang
Mai University, Chiang Mai 50200, Thailand
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
| | - Donraporn Daranarong
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
- Science
and Technology Research Institute, Chiang
Mai University, Chiang Mai 50200, Thailand
| | - Jomkwan Meerak
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
- Department
of Biology, Faculty of Science, Chiang Mai
University, Chiang Mai 50200, Thailand
| | - Winita Punyodom
- Department
of Chemistry, Faculty of Science, Chiang
Mai University, Chiang Mai 50200, Thailand
- Center
of Excellence in Materials Science and Technology, Chiang Mai University, Chiang
Mai 50200, Thailand
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10
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Bachtiar EO, Ritter VC, Gall K. Structure-property relationships in 3D-printed poly(l-lactide-co-ε-caprolactone) degradable polymer. J Mech Behav Biomed Mater 2021; 121:104650. [PMID: 34166872 DOI: 10.1016/j.jmbbm.2021.104650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/09/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
The recent growth of polymer 3D-printing has brought innovation to the medical implant field. Implants with complex porous structures can be fabricated by printing to tune mechanical behavior and enable diffusion, consequently improving integration with tissues in the human body. Poly(L-lactide-co-ε-caprolactone) (PLCL) is a 3D-printable polymer that possess a wide range of possible mechanical properties depending on its monomer composition. It is often used in biomedical applications requiring degradability. In this study, we explore 1) the effect of annealing 3D-printed PLCL and 2) the degradation profile of both annealed and unannealed 3D-printed PLCL scaffolds. The degraded samples were characterized for its molecular weight, mass loss, microstructure, and mechanical properties. By annealing the 3D-printed PLCL, we reveal the structure-property relationship of PLCL. Crystallization was found to be a crucial factor in the resulting mechanical properties, increasing stiffness significantly. The subsequent degradation study revealed that there was no significant difference brought about by pre-annealing the scaffolds. The scaffolds were found to maintain their mechanical properties until up to 8 weeks, at which point the scaffolds reached a critical molecular weight and lost their mechanical integrity.
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Affiliation(s)
- Emilio Omar Bachtiar
- Department of Mechanical Engineering and Materials Science, Duke University, USA.
| | | | - Ken Gall
- Department of Mechanical Engineering and Materials Science, Duke University, USA
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11
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Selim OA, Lakhani S, Midha S, Mosahebi A, Kalaskar DM. Three-Dimensional Engineered Peripheral Nerve: Toward a New Era of Patient-Specific Nerve Repair Solutions. TISSUE ENGINEERING PART B-REVIEWS 2021; 28:295-335. [PMID: 33593147 DOI: 10.1089/ten.teb.2020.0355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Reconstruction of peripheral nerve injuries (PNIs) with substance loss remains challenging because of limited treatment solutions and unsatisfactory patient outcomes. Currently, nerve autografting is the first-line management choice for bridging critical-sized nerve defects. The procedure, however, is often complicated by donor site morbidity and paucity of nerve tissue, raising a quest for better alternatives. The application of other treatment surrogates, such as nerve guides, remains questionable, and it is inefficient in irreducible nerve gaps. More importantly, these strategies lack customization for personalized patient therapy, which is a significant drawback of these nerve repair options. This negatively impacts the fascicle-to-fascicle regeneration process, critical to restoring the physiological axonal pathway of the disrupted nerve. Recently, the use of additive manufacturing (AM) technologies has offered major advancements to the bioengineering solutions for PNI therapy. These techniques aim at reinstating the native nerve fascicle pathway using biomimetic approaches, thereby augmenting end-organ innervation. AM-based approaches, such as three-dimensional (3D) bioprinting, are capable of biofabricating 3D-engineered nerve graft scaffolds in a patient-specific manner with high precision. Moreover, realistic in vitro models of peripheral nerve tissues that represent the physiologically and functionally relevant environment of human organs could also be developed. However, the technology is still nascent and faces major translational hurdles. In this review, we spotlighted the clinical burden of PNIs and most up-to-date treatment to address nerve gaps. Next, a summarized illustration of the nerve ultrastructure that guides research solutions is discussed. This is followed by a contrast of the existing bioengineering strategies used to repair peripheral nerve discontinuities. In addition, we elaborated on the most recent advances in 3D printing and biofabrication applications in peripheral nerve modeling and engineering. Finally, the major challenges that limit the evolution of the field along with their possible solutions are also critically analyzed.
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Affiliation(s)
- Omar A Selim
- Department of Surgical Biotechnology, Division of Surgery and Interventional Sciences, Royal Free Hospital, University College London (UCL), London, United Kingdom
| | - Saad Lakhani
- Department of Surgical Biotechnology, Division of Surgery and Interventional Sciences, Royal Free Hospital, University College London (UCL), London, United Kingdom
| | - Swati Midha
- Department of Surgical Biotechnology, Division of Surgery and Interventional Sciences, Royal Free Hospital, University College London (UCL), London, United Kingdom.,Department of Surgical Biotechnology, Special Centre for Nanoscience, Jawaharlal Nehru University, New Delhi, India
| | - Afshin Mosahebi
- Department of Plastic Surgery, Royal Free Hospital, University College London (UCL), London, United Kingdom
| | - Deepak M Kalaskar
- Department of Surgical Biotechnology, Division of Surgery and Interventional Sciences, Royal Free Hospital, University College London (UCL), London, United Kingdom.,Department of Surgical Biotechnology, Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital, University College London (UCL), Stanmore, United Kingdom
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12
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Leversedge FJ, Zoldos J, Nydick J, Kao DS, Thayer W, MacKay B, McKee D, Hoyen H, Safa B, Buncke GM. A Multicenter Matched Cohort Study of Processed Nerve Allograft and Conduit in Digital Nerve Reconstruction. J Hand Surg Am 2020; 45:1148-1156. [PMID: 33010972 DOI: 10.1016/j.jhsa.2020.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/26/2020] [Accepted: 07/27/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Biomaterials used to restore digital nerve continuity after injury associated with a defect may influence ultimate outcomes. An evaluation of matched cohorts undergoing digital nerve gap reconstruction was conducted to compare processed nerve allograft (PNA) and conduits. Based on scientific evidence and historical controls, we hypothesized that outcomes of PNA would be better than for conduit reconstruction. METHODS We identified matched cohorts based on patient characteristics, medical history, mechanism of injury, and time to repair for digital nerve injuries with gaps up to 25 mm. Data were stratified into 2 gap length groups: short gaps of 14 mm or less and long gaps of 15 to 25 mm. Meaningful sensory recovery was defined as a Medical Research Council scale of S3 or greater. Comparisons of meaningful recovery were made by repair method between and across the gap length groups. RESULTS Eight institutions contributed matched data sets for 110 subjects with 162 injuries. Outcomes data were available in 113 PNA and 49 conduit repairs. Meaningful recovery was reported in 61% of the conduit group, compared with 88% in the PNA group. In the group with a 14-mm or less gap, conduit and PNA outcomes were 67% and 92% meaningful recovery, respectively. In the 15- to 25-mm gap length group, conduit and PNA outcomes were 45% and 85% meaningful recovery, respectively. There were no reported adverse events in either treatment group. CONCLUSIONS Outcomes of digital nerve reconstruction in this study using PNA were consistent and significantly better than those of conduits across all groups. As gap lengths increased, the proportion of patients in the conduit group with meaningful recovery decreased. This study supports the use of PNA for nerve gap reconstruction in digital nerve reconstructions up to 25 mm. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Fraser J Leversedge
- Department of Orthopedic Surgery, University of Colorado, Aurora, CO; Department of Orthopaedic Surgery, Duke University, Durham, NC.
| | | | - Jason Nydick
- Florida Orthopaedic Institute, Temple Terrace, FL
| | - Dennis S Kao
- Division of Plastic Surgery, University of Washington, Seattle, WA
| | - Wesley Thayer
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Brendan MacKay
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Desirae McKee
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Harry Hoyen
- Department of Orthopedic Surgery, MetroHealth System, Cleveland, OH
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13
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Yurie H, Ikeguchi R, Aoyama T, Ito A, Tanaka M, Noguchi T, Oda H, Takeuchi H, Mitsuzawa S, Ando M, Yoshimoto K, Akieda S, Nakayama K, Matsuda S. Mechanism of Peripheral Nerve Regeneration Using a Bio 3D Conduit Derived from Normal Human Dermal Fibroblasts. J Reconstr Microsurg 2020; 37:357-364. [PMID: 32957155 DOI: 10.1055/s-0040-1716855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND We previously reported the development of a scaffold-free Bio three-dimensional (3D) nerve conduit from normal human dermal fibroblasts (NHDFs). The aim of this study was to investigate the regenerative mechanism of peripheral nerve cells using a Bio 3D conduit in a rat sciatic nerve defect model. METHODS Bio 3D conduits composed of NHDFs were developed, and cell viability was evaluated using a LIVE/DEAD cell viability assay immediately before transplantation and 1-week post-surgery. Tracking analysis using PKH26-labeled NHDFs was performed to assess the distribution of NHDFs within the regenerated nerve and the differentiation of NHDFs into functional Schwann cells (SCs). RESULTS The assessment of the viability of cells within the Bio 3D conduit showed high cell viability both immediately before transplantation and 1-week post-surgery (88.56 ± 1.70 and 87.58 ± 9.11, respectively). A modified Masson's trichrome staining of the Bio 3D conduit revealed the formation of a prominent extracellular matrix (ECM) in between the cells. We observed, via tracking analysis, that the tube-like distribution of the NHDFs remained stable, the majority of the regenerated axons had penetrated this structure and PKH26-labeled cells were also positive for S-100. CONCLUSION Abundant ECM formation resulted in a stable tube-like structure of the Bio 3D conduit with high cell viability. NHDFs in the Bio 3D conduit have the potential to differentiate into SCs-like cells.
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Affiliation(s)
- Hirofumi Yurie
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoki Aoyama
- Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akira Ito
- Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mai Tanaka
- Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Noguchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Oda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hisataka Takeuchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Sadaki Mitsuzawa
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Maki Ando
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichi Yoshimoto
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Koichi Nakayama
- Department of Regenerative Medicine and Biomedical Engineering Faculty of Medicine, Saga University, Saga, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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14
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Isaacs J, Mallu S, Patel G, Kite A, Shah S, Graham GP. Implantation of Acellular Nerve Allograft Using Nerve Connectors. Hand (N Y) 2020; 15:625-630. [PMID: 30782010 PMCID: PMC7543223 DOI: 10.1177/1558944719828009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Nerve connectors are short nerve conduits used to approximate nerve ends. Acellular nerve allografts are viable alternatives when direct repair is not possible but do not produce exudate essential for fibrin clot formation. We hypothesize that acellular nerve allograft implanted using nerve connectors must have end-to-end contact with the in situ nerve stumps to support nerve regeneration. Methods: Sixty Sprague Dawley rats underwent a 14-mm unilateral tibial nerve injury and subsequent repair using various combinations of acellular nerve grafts and nerve connectors. Proximal repairs for all groups utilized direct contact with the nerve stump within connector. Variations in distal repair methods (allograft length, nerve gap, and connector length) defined our 4 groups-group A: 14 mm allograft, no distal gap, and distal connector; group B: 11.5 mm allograft, 2.5 mm distal gap, and distal connector; group C: 9 mm allograft, 5 mm distal gap, and distal connector; group D: 14 mm allograft, no distal gap, and no distal connector. At 3 months post-repair, function and histomorphology were assessed. Results: Developed muscle force was significantly lower in group C (0.073 ± 0.077 N) compared with the other 3 groups (group A = 0.529 ± 0.312 N, group B = 0.461 ± 0.462 N, and group D = 0.409 ± 0.327 N). Axon counts were significantly lower in group C (2121 ± 389) compared with group A (6401 ± 855), group B (4710 ± 755), and group D (4450 ± 126). There was no statistically significant difference in G-ratios (myelination) between groups (P > .05). Conclusion: Nerve regeneration was significantly impaired as the gap distance between the distal end of the allograft and the distal nerve stump increased to 5 mm.
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Affiliation(s)
- Jonathan Isaacs
- Virginia Commonwealth University Health System, Richmond, USA,Jonathan Isaacs, Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, P.O. Box 980153, Richmond, VA 23298, USA.
| | - Satya Mallu
- Virginia Commonwealth University Health System, Richmond, USA
| | | | - Amy Kite
- Virginia Commonwealth University Health System, Richmond, USA
| | - Sagar Shah
- Virginia Commonwealth University Health System, Richmond, USA
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15
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Li X, Yang W, Xie H, Wang J, Zhang L, Wang Z, Wang L. CNT/Sericin Conductive Nerve Guidance Conduit Promotes Functional Recovery of Transected Peripheral Nerve Injury in a Rat Model. ACS APPLIED MATERIALS & INTERFACES 2020; 12:36860-36872. [PMID: 32649170 DOI: 10.1021/acsami.0c08457] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Peripheral nerve injury usually leads to poor outcomes such as painful neuropathies and disabilities. Autogenous nerve grafting is the current gold standard; however, the limited source of a donor nerve remains a problem. Numerous tissue engineering nerve guidance conduits have been developed as substitutes for autografts. However, a few conduits can achieve the reparative effect equivalent to autografts. Here, we report for the development and application of a carbon nanotube (CNT)/sericin nerve conduit with electrical conductivity and suitable mechanical properties for nerve repair. This CNT/sericin conduit possesses favorable properties including biocompatibility, biodegradability, porous microarchitecture, and suitable swelling property. We thus applied this conduit for bridging a 10 mm gap defect of a transected sciatic nerve combined with electrical stimulation (ES) in a rat injury model. By the end of 12 weeks, we observed that the CNT/sericin conduit combined with electrical stimulation could effectively promote both structural repair and functional recovery comparable to those of the autografts, evidenced by the morphological and histological analyses, electrophysiological responses, functional studies, and target muscle reinnervation evaluations. These findings suggest that this electric conductive CNT/sericin conduit combined with electrical stimulation may have the potential to serve as a new alternative for the repair of transected peripheral nerves.
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Affiliation(s)
- Xiaolin Li
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Wen Yang
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Hongjian Xie
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jian Wang
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lei Zhang
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zheng Wang
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lin Wang
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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16
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Kasper M, Deister C, Beck F, Schmidt CE. Bench-to-Bedside Lessons Learned: Commercialization of an Acellular Nerve Graft. Adv Healthc Mater 2020; 9:e2000174. [PMID: 32583574 DOI: 10.1002/adhm.202000174] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/11/2020] [Indexed: 12/19/2022]
Abstract
Peripheral nerve injury can result in debilitating outcomes including loss of function and neuropathic pain. Although nerve repair research and therapeutic development are widely studied, translation of these ideas into clinical interventions has not occurred at the same rate. At the turn of this century, approaches to peripheral nerve repair have included microsurgical techniques, hollow conduits, and autologous nerve grafts. These methods provide satisfactory results; however, they possess numerous limitations that can prevent effective surgical treatment. Commercialization of Avance, a processed nerve allograft, sought to address limitations of earlier approaches by providing an off-the-shelf alternative to hollow conduits while maintaining many proregenerative properties of autologous grafts. Since its launch in 2007, Avance has changed the landscape of the nerve repair market and is used to treat tens of thousands of patients. Although Avance has become an important addition to surgeon and patient clinical options, the product's journey from bench to bedside took over 20 years with many research and commercialization challenges. This article reviews the events that have brought a processed nerve allograft from the laboratory bench to the patient bedside. Additionally, this review provides a perspective on lessons and considerations that can assist in translation of future medical products.
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Affiliation(s)
- Mary Kasper
- J. Crayton Pruitt Family Department of Biomedical EngineeringUniversity of Florida Gainesville FL 32611 USA
| | | | | | - Christine E. Schmidt
- J. Crayton Pruitt Family Department of Biomedical EngineeringUniversity of Florida Gainesville FL 32611 USA
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17
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Safa B, Jain S, Desai MJ, Greenberg JA, Niacaris TR, Nydick JA, Leversedge FJ, Megee DM, Zoldos J, Rinker BD, McKee DM, MacKay BJ, Ingari JV, Nesti LJ, Cho M, Valerio IL, Kao DS, El-Sheikh Y, Weber RV, Shores JT, Styron JF, Thayer WP, Przylecki WH, Hoyen HA, Buncke GM. Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study. Microsurgery 2020; 40:527-537. [PMID: 32101338 PMCID: PMC7496926 DOI: 10.1002/micr.30574] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 01/23/2020] [Accepted: 02/12/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.
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Affiliation(s)
- Bauback Safa
- Department of Plastic and Reconstructive Surgery, The Buncke Clinic, San Francisco, California
| | - Sonu Jain
- Plastics and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mihir J Desai
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Timothy R Niacaris
- Department of Orthopedic Surgery, John Peter Smith Hospital, Fort Worth, Texas
| | - Jason A Nydick
- Orthopaedic Surgery, Florida Orthopaedic Institute, Temple Terrace, Florida
| | - Fraser J Leversedge
- Divisions of Orthopaedic Surgery and Plastic Surgery, Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - David M Megee
- Plastic, Reconstructive & Hand Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jozef Zoldos
- Orthopaedic Surgery, Arizona Center for Hand Surgery, Phoenix, Arizona
| | - Brian D Rinker
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida.,Reconstructive Plastic Surgery, University of Kentucky Healthcare, Lexington, Kentucky
| | - Desirae M McKee
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Brendan J MacKay
- Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - John V Ingari
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Leon J Nesti
- Clinical and Experimental Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Mickey Cho
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Houston, Texas
| | - Ian Lee Valerio
- Department of Plastic Surgery, University of Washington, Seattle, Washington
| | - Dennis S Kao
- Plastics and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yasser El-Sheikh
- Department of Surgery, Division of Plastic Reconstructive Surgery, North York General Hospital, Toronto, Ontario, Canada
| | - Renata V Weber
- Department of Plastic and Reconstructive Surgery, Multidisciplinary Specialists, Rutherford, New Jersey
| | - Jaimie T Shores
- Plastic and Reconstructive Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Joseph F Styron
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Wesley P Thayer
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wojciech H Przylecki
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Harry A Hoyen
- Department of Orthopedic Surgery, MetroHealth System, Cleveland, Ohio
| | - Gregory M Buncke
- Department of Plastic and Reconstructive Surgery, The Buncke Clinic, San Francisco, California
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18
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Raza C, Riaz HA, Anjum R, Shakeel NUA. Repair strategies for injured peripheral nerve: Review. Life Sci 2020; 243:117308. [PMID: 31954163 DOI: 10.1016/j.lfs.2020.117308] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 12/27/2022]
Abstract
Compromised functional regains in about half of the patients following surgical nerve repair pose a serious socioeconomic burden to the society. Although surgical strategies such as end-to-end neurorrhaphy, nerve grafting and nerve transfer are widely applied in distal injuries leading to optimal recovery; however in proximal nerve defects functional outcomes remain unsatisfactory. Biomedical engineering approaches unite the efforts of the surgeons, engineers and biologists to develop regeneration facilitating structures such as extracellular matrix based supportive polymers and tubular nerve guidance channels. Such polymeric structures provide neurotrophic support from injured nerve stumps, retard the fibrous tissue infiltration and guide regenerating axons to appropriate targets. The development and application of nerve guidance conduits (NGCs) to treat nerve gap injuries offer clinically relevant and feasible solutions. Enhanced understanding of the nerve regeneration processes and advances in NGCs design, polymers and fabrication strategies have led to developing modern NGCs with superior regeneration-conducive capacities. Current review focuses on the advances in surgical and engineering approaches to treat peripheral nerve injuries. We suggest the incorporation of endothelial cell growth promoting cues and factors into the NGC interior for its possible enhancement effects on the axonal regeneration process that may result in substantial functional outcomes.
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Affiliation(s)
- Chand Raza
- Department of Zoology, Government College University, Lahore 54000, Pakistan.
| | - Hasib Aamir Riaz
- Department of Molecular Biology, Cell Biology and Biochemistry, Brown University, Providence, RI 02912, USA
| | - Rabia Anjum
- Department of Zoology, Government College University, Lahore 54000, Pakistan
| | - Noor Ul Ain Shakeel
- Department of Zoology, Government College University, Lahore 54000, Pakistan
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19
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Pan D, Mackinnon SE, Wood MD. Advances in the repair of segmental nerve injuries and trends in reconstruction. Muscle Nerve 2020; 61:726-739. [PMID: 31883129 DOI: 10.1002/mus.26797] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022]
Abstract
Despite advances in surgery, the reconstruction of segmental nerve injuries continues to pose challenges. In this review, current neurobiology regarding regeneration across a nerve defect is discussed in detail. Recent findings include the complex roles of nonneuronal cells in nerve defect regeneration, such as the role of the innate immune system in angiogenesis and how Schwann cells migrate within the defect. Clinically, the repair of nerve defects is still best served by using nerve autografts with the exception of small, noncritical sensory nerve defects, which can be repaired using autograft alternatives, such as processed or acellular nerve allografts. Given current clinical limits for when alternatives can be used, advanced solutions to repair nerve defects demonstrated in animals are highlighted. These highlights include alternatives designed with novel topology and materials, delivery of drugs specifically known to accelerate axon growth, and greater attention to the role of the immune system.
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Affiliation(s)
- Deng Pan
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Wood
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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20
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Lauder A, Leversedge FJ. Long Segment, Mixed Sensorimotor Nerve Reconstruction with Allograft: A Case Report of High Radial Nerve Injury. JBJS Case Connect 2020; 10:e0207. [PMID: 31899719 DOI: 10.2106/jbjs.cc.19.00207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 35-year-old man sustained a Grade I open right mid-diaphyseal humerus fracture and high radial nerve transection from a motor vehicle accident. Acute humeral plate osteosynthesis and radial nerve reconstruction using an intercalary 4-cm processed nerve allograft (PNA) was performed. Five years postoperatively, elbow extension, forearm supination, and wrist extension were 5/5 strength and independent digital extension was 5-/5. Radial nerve sensation recovered to 90% of the uninjured side. CONCLUSIONS Use of PNA resulted in outcomes comparable with or superior to autograft reconstruction or secondary tendon transfers and is a reasonable reconstructive option for similar acute, mixed sensorimotor nerve injuries.
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Affiliation(s)
- Alexander Lauder
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Fraser J Leversedge
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina.,Department of Surgery-Plastic Surgery, Duke University, Durham, North Carolina
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21
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Wang Y, Zhang Y, Li X, Zhang Q. The progress of biomaterials in peripheral nerve repair and regeneration. JOURNAL OF NEURORESTORATOLOGY 2020. [DOI: 10.26599/jnr.2020.9040022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Repair and regeneration of the injured peripheral nerve (PN) is a challenging issue in clinics. Although the regeneration outcome of large PN defects is currently unsatisfactory, recently, the study of PN repair has considerably progressed. In particular, biomaterials for repairing PNs, such as nerve guidance conduits and nerve repair membranes, have been well developed. Herein, we summarize the anatomy of the PN, the pathophysiological features of the nerve injury, and the repair process post injury. Then, we highlight the progress in the development of natural and synthetic biomaterials and summarize the applications, advantages, and disadvantages of these materials. These materials can be used as nerve repair membranes and nerve conduits in the field of PN repair. Finally, we discuss the challenges encountered and development strategies for PN repair in the future.
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22
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Houshyar S, Bhattacharyya A, Shanks R. Peripheral Nerve Conduit: Materials and Structures. ACS Chem Neurosci 2019; 10:3349-3365. [PMID: 31273975 DOI: 10.1021/acschemneuro.9b00203] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Peripheral nerve injuries (PNIs) are the most common injury types to affect the nervous system. Restoration of nerve function after PNI is a challenging medical issue. Extended gaps in transected peripheral nerves are only repaired using autologous nerve grafting. This technique, however, in which nerve tissue is harvested from a donor site and grafted onto a recipient site in the same body, has many limitations and disadvantages. Recent studies have revealed artificial nerve conduits as a promising alternative technique to substitute autologous nerves. This Review summarizes different types of artificial nerve grafts used to repair peripheral nerve injuries. These include synthetic and natural polymers with biological factors. Then, desirable properties of nerve guides are discussed based on their functionality and effectiveness. In the final part of this Review, fabrication methods and commercially available nerve guides are described.
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Affiliation(s)
- Shadi Houshyar
- School of Engineering, RMIT University, Melbourne, Victoria 3000, Australia
| | - Amitava Bhattacharyya
- Nanoscience and Technology, Department of Electronics and Communication, PSG College of Technology, Coimbatore − 641004, India
| | - Robert Shanks
- School of Science, RMIT University, Melbourne, Victoria 3000, Australia
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23
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Bassilios Habre S, Bond G, Jing XL, Kostopoulos E, Wallace RD, Konofaos P. The Surgical Management of Nerve Gaps: Present and Future. Ann Plast Surg 2019; 80:252-261. [PMID: 29166306 DOI: 10.1097/sap.0000000000001252] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peripheral nerve injuries can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Nowadays, the gold standard for the treatment of nerve section is end-to-end neurorrhaphy. Unfortunately, in some cases, there is segmental loss of the nerve trunk. Nerve mobilization allows primary repair of the sectioned nerve by end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. To overcome the limited availability and the donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers, and end-to-side neurorrhaphy. The purpose of this review is to present an overview of the literature on the applications of these techniques in peripheral nerve repair. Furthermore, preoperative evaluation, timing of repair, and future perspectives are also discussed.
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24
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Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2163. [PMID: 31044125 PMCID: PMC6467606 DOI: 10.1097/gox.0000000000002163] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 01/04/2019] [Indexed: 01/02/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Severe trauma often results in the transection of major peripheral nerves. The RANGER Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (PNAs; Avance Nerve Graft, AxoGen, Inc., Alachua, Fla.). Here, we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature. Methods: The RANGER database was queried for mixed and motor nerve injuries in the upper extremities, head, and neck area having completed greater than 1 year of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the Medical Research Council scale. Demographics, outcomes, and covariate analysis were performed to further characterize this subgroup. Results: The subgroup included 20 subjects with 22 nerve repairs. The mean ± SD (minimum–maximum) age was 38 ± 19 (16–77) years. The median repair time was 9 (0–133) days. The mean graft length was 33 ± 17 (10–70) mm with a mean follow-up of 779 ± 480 (371–2,423) days. Meaningful motor recovery was observed in 73%. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events. Conclusions: PNAs were safe and provided functional motor recovery in mixed and motor nerve repairs. Outcomes compare favorably to historical controls for nerve autograft and exceed those for hollow tube conduit. PNA may be considered as an option when reconstructing major peripheral nerve injuries.
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25
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Weller WJ. Emerging Technologies in Upper Extremity Surgery: Polyvinyl Alcohol Hydrogel Implant for Thumb Carpometacarpal Arthroplasty and Processed Nerve Allograft and Nerve Conduit for Digital Nerve Repairs. Orthop Clin North Am 2019; 50:87-93. [PMID: 30477709 DOI: 10.1016/j.ocl.2018.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the field of upper extremity surgery there are myriad new and developing technologies. The purpose of this article is to highlight a few of the most compelling new technologies and review their background, indications for use, and most recently reported outcomes in clinical practice.
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Affiliation(s)
- William J Weller
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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26
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Duffy P, McMahon S, Wang X, Keaveney S, O'Cearbhaill ED, Quintana I, Rodríguez FJ, Wang W. Synthetic bioresorbable poly-α-hydroxyesters as peripheral nerve guidance conduits; a review of material properties, design strategies and their efficacy to date. Biomater Sci 2019; 7:4912-4943. [DOI: 10.1039/c9bm00246d] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Implantable tubular devices known as nerve guidance conduits (NGCs) have drawn considerable interest as an alternative to autografting in the repair of peripheral nerve injuries.
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Affiliation(s)
- Patrick Duffy
- The Charles Institute of Dermatology
- School of Medicine
- University College Dublin
- Dublin
- Ireland
| | - Seán McMahon
- Ashland Specialties Ireland Ltd
- Synergy Centre
- Dublin
- Ireland
| | - Xi Wang
- The Charles Institute of Dermatology
- School of Medicine
- University College Dublin
- Dublin
- Ireland
| | - Shane Keaveney
- School of Mechanical & Materials Engineering
- UCD Centre for Biomedical Engineering
- UCD Conway Institute of Biomolecular and Biomedical Research
- University College Dublin
- Dublin
| | - Eoin D. O'Cearbhaill
- School of Mechanical & Materials Engineering
- UCD Centre for Biomedical Engineering
- UCD Conway Institute of Biomolecular and Biomedical Research
- University College Dublin
- Dublin
| | - Iban Quintana
- IK4-Tekniker
- Surface Engineering and Materials Science Unit
- Eibar
- Spain
| | | | - Wenxin Wang
- The Charles Institute of Dermatology
- School of Medicine
- University College Dublin
- Dublin
- Ireland
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27
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Magaz A, Faroni A, Gough JE, Reid AJ, Li X, Blaker JJ. Bioactive Silk-Based Nerve Guidance Conduits for Augmenting Peripheral Nerve Repair. Adv Healthc Mater 2018; 7:e1800308. [PMID: 30260575 DOI: 10.1002/adhm.201800308] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/22/2018] [Indexed: 02/03/2023]
Abstract
Repair of peripheral nerve injuries depends upon complex biology stemming from the manifold and challenging injury-healing processes of the peripheral nervous system. While surgical treatment options are available, they tend to be characterized by poor clinical outcomes for the injured patients. This is particularly apparent in the clinical management of a nerve gap whereby nerve autograft remains the best clinical option despite numerous limitations; in addition, effective repair becomes progressively more difficult with larger gaps. Nerve conduit strategies based on tissue engineering approaches and the use of silk as scaffolding material have attracted much attention in recent years to overcome these limitations and meet the clinical demand of large gap nerve repair. This review examines the scientific advances made with silk-based conduits for peripheral nerve repair. The focus is on enhancing bioactivity of the conduits in terms of physical guidance cues, inner wall and lumen modification, and imbuing novel conductive functionalities.
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Affiliation(s)
- Adrián Magaz
- Bio‐Active Materials GroupSchool of MaterialsMSS TowerThe University of Manchester Manchester M13 9PL UK
- Institute of Materials Research and Engineering (IMRE)Agency for Science Technology and Research (A*STAR) 2 Fusionopolis, Way, Innovis #08‐03 Singapore 138634 Singapore
| | - Alessandro Faroni
- Blond McIndoe LaboratoriesDivision of Cell Matrix Biology and Regenerative MedicineSchool of Biological SciencesFaculty of Biology, Medicine and HealthThe University of ManchesterManchester Academic Health Science Centre Manchester M13 9PL UK
| | - Julie E. Gough
- School of MaterialsThe University of Manchester Manchester M13 9PL UK
| | - Adam J. Reid
- Blond McIndoe LaboratoriesDivision of Cell Matrix Biology and Regenerative MedicineSchool of Biological SciencesFaculty of Biology, Medicine and HealthThe University of ManchesterManchester Academic Health Science Centre Manchester M13 9PL UK
- Department of Plastic Surgery and BurnsWythenshawe HospitalManchester University NHS Foundation TrustManchester Academic Health Science Centre Manchester M23 9LT UK
| | - Xu Li
- Institute of Materials Research and Engineering (IMRE)Agency for Science Technology and Research (A*STAR) 2 Fusionopolis, Way, Innovis #08‐03 Singapore 138634 Singapore
| | - Jonny J. Blaker
- Bio‐Active Materials GroupSchool of MaterialsMSS TowerThe University of Manchester Manchester M13 9PL UK
- School of MaterialsThe University of Manchester Manchester M13 9PL UK
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28
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Frost HK, Andersson T, Johansson S, Englund-Johansson U, Ekström P, Dahlin LB, Johansson F. Electrospun nerve guide conduits have the potential to bridge peripheral nerve injuries in vivo. Sci Rep 2018; 8:16716. [PMID: 30425260 PMCID: PMC6233209 DOI: 10.1038/s41598-018-34699-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/22/2018] [Indexed: 01/22/2023] Open
Abstract
Electrospinning can be used to mimic the architecture of an acellular nerve graft, combining microfibers for guidance, and pores for cellular infiltration. We made electrospun nerve guides, from polycaprolactone (PCL) or poly-L-lactic acid (PLLA), with aligned fibers along the insides of the channels and random fibers around them. We bridged a 10 mm rat sciatic nerve defect with the guides, and, in selected groups, added a cell transplant derived from autologous stromal vascular fraction (SVF). For control, we compared to hollow silicone tubes; or autologous nerve grafts. PCL nerve guides had a high degree of autotomy (8/43 rats), a negative indicator with respect to future usefulness, while PLLA supported axonal regeneration, but did not outperform autologous nerve grafts. Transplanted cells survived in the PLLA nerve guides, but axonal regeneration was not enhanced as compared to nerve guides alone. The inflammatory response was partially enhanced by the transplanted cells in PLLA nerve grafts; Schwann cells were poorly distributed compared to nerve guide without cells. Tailor-made electrospun nerve guides support axonal regeneration in vivo, and can act as vehicles for co-transplanted cells. Our results motivate further studies exploring novel nerve guides and the effect of stromal cell-derived factors on nerve generation.
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Affiliation(s)
- Hanna K Frost
- Department of Translational Medicine - Hand Surgery, Lund University, SE-205 02, Malmö, Sweden.
- Department of Hand Surgery, Skåne University Hospital, SE-205 02, Malmö, Sweden.
| | - Tomas Andersson
- Department of Biology, Lund University, SE-223 62, Lund, Sweden
| | | | - U Englund-Johansson
- Department of Clinical Sciences in Lund - Ophtalmology, Lund University, SE-211 84, Lund, Sweden
| | - Per Ekström
- Department of Clinical Sciences in Lund - Ophtalmology, Lund University, SE-211 84, Lund, Sweden
| | - Lars B Dahlin
- Department of Translational Medicine - Hand Surgery, Lund University, SE-205 02, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, SE-205 02, Malmö, Sweden
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29
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Tang P, Schimoler PJ, Kim H, Gillman BM, Kharlamov A, Miller MC. The optimal number and location of sutures in conduit-assisted primary digital nerve repair. J Hand Surg Eur Vol 2018; 43:621-625. [PMID: 29562807 DOI: 10.1177/1753193418764290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We evaluated the strength of conduit-assisted primary digital nerve repairs, with varying suture location and number, in 56 digital nerves from cadavers. Maximum load to failure was tested for the following seven repairs, designated by the number of epineurial sutures followed by the number of sutures at each end of the conduit: 4 (epineurial sutures)/0 (sutures at each end of conduit), 4/4, 4/2, 2/2, 0/4, 0/2, 0/1. The 4/4 repair (3.0 N) was significantly stronger than 4/0 (1.5 N), 2/2 (1.6 N), 0/4 (2.0 N), 0/2 (1.4 N) and 0/1 (1.1 N). Considering all repair types, there was a significant correlation between suture number and failure load, with the strongest repair having a total of 12 sutures, which is impractical. Reasonable repair options, which have two sutures at each end of the conduit and either two or no epineurial sutures, are as strong as a four-suture epineurial repair but have less sutures at the coaptation site.
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Affiliation(s)
- Peter Tang
- 1 Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Patrick J Schimoler
- 1 Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA.,4 Mechanical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hongkyun Kim
- 1 Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA.,2 Orthopaedic Surgery, Hallym University, Seoul, Korea
| | - Brad M Gillman
- 1 Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA.,3 Orthopaedic Surgery, University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA
| | | | - Mark Carl Miller
- 1 Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA.,4 Mechanical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
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30
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Du J, Chen H, Qing L, Yang X, Jia X. Biomimetic neural scaffolds: a crucial step towards optimal peripheral nerve regeneration. Biomater Sci 2018; 6:1299-1311. [PMID: 29725688 PMCID: PMC5978680 DOI: 10.1039/c8bm00260f] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Peripheral nerve injury is a common disease that affects more than 20 million people in the United States alone and remains a major burden to society. The current gold standard treatment for critical-sized nerve defects is autologous nerve graft transplantation; however, this method is limited in many ways and does not always lead to satisfactory outcomes. The limitations of autografts have prompted investigations into artificial neural scaffolds as replacements, and some neural scaffold devices have progressed to widespread clinical use; scaffold technology overall has yet to be shown to be consistently on a par with or superior to autografts. Recent advances in biomimetic scaffold technologies have opened up many new and exciting opportunities, and novel improvements in material, fabrication technique, scaffold architecture, and lumen surface modifications that better reflect biological anatomy and physiology have independently been shown to benefit overall nerve regeneration. Furthermore, biomimetic features of neural scaffolds have also been shown to work synergistically with other nerve regeneration therapy strategies such as growth factor supplementation, stem cell transplantation, and cell surface glycoengineering. This review summarizes the current state of neural scaffolds, highlights major advances in biomimetic technologies, and discusses future opportunities in the field of peripheral nerve regeneration.
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Affiliation(s)
- Jian Du
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA. ; Tel: +1 410-706-5025
| | - Huanwen Chen
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA. ; Tel: +1 410-706-5025
| | - Liming Qing
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA. ; Tel: +1 410-706-5025
| | - Xiuli Yang
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA. ; Tel: +1 410-706-5025
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA. ; Tel: +1 410-706-5025
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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31
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Huang J, Patel N, Lyon K. An update–tissue engineered nerve grafts for the repair of peripheral nerve injuries. Neural Regen Res 2018. [DOI: 10.4103/1673-5374.232458
expr 973353844 + 912195704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
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Patel NP, Lyon KA, Huang JH. An update-tissue engineered nerve grafts for the repair of peripheral nerve injuries. Neural Regen Res 2018; 13:764-774. [PMID: 29862995 PMCID: PMC5998615 DOI: 10.4103/1673-5374.232458] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Peripheral nerve injuries (PNI) are caused by a range of etiologies and result in a broad spectrum of disability. While nerve autografts are the current gold standard for the reconstruction of extensive nerve damage, the limited supply of autologous nerve and complications associated with harvesting nerve from a second surgical site has driven groups from multiple disciplines, including biomedical engineering, neurosurgery, plastic surgery, and orthopedic surgery, to develop a suitable or superior alternative to autografting. Over the last couple of decades, various types of scaffolds, such as acellular nerve grafts (ANGs), nerve guidance conduits, and non-nervous tissues, have been filled with Schwann cells, stem cells, and/or neurotrophic factors to develop tissue engineered nerve grafts (TENGs). Although these have shown promising effects on peripheral nerve regeneration in experimental models, the autograft has remained the gold standard for large nerve gaps. This review provides a discussion of recent advances in the development of TENGs and their efficacy in experimental models. Specifically, TENGs have been enhanced via incorporation of genetically engineered cells, methods to improve stem cell survival and differentiation, optimized delivery of neurotrophic factors via drug delivery systems (DDS), co-administration of platelet-rich plasma (PRP), and pretreatment with chondroitinase ABC (Ch-ABC). Other notable advancements include conduits that have been bioengineered to mimic native nerve structure via cell-derived extracellular matrix (ECM) deposition, and the development of transplantable living nervous tissue constructs from rat and human dorsal root ganglia (DRG) neurons. Grafts composed of non-nervous tissues, such as vein, artery, and muscle, will be briefly discussed.
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Affiliation(s)
| | - Kristopher A Lyon
- Texas A&M College of Medicine; Department of Neurosurgery, Baylor Scott & White Healthcare, Temple, TX, USA
| | - Jason H Huang
- Texas A&M College of Medicine; Department of Neurosurgery, Baylor Scott & White Healthcare, Temple, TX, USA
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33
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Malikmammadov E, Tanir TE, Kiziltay A, Hasirci V, Hasirci N. PCL and PCL-based materials in biomedical applications. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2017; 29:863-893. [PMID: 29053081 DOI: 10.1080/09205063.2017.1394711] [Citation(s) in RCA: 376] [Impact Index Per Article: 53.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Biodegradable polymers have met with an increasing demand in medical usage over the last decades. One of such polymers is poly(ε-caprolactone) (PCL), which is a polyester that has been widely used in tissue engineering field for its availability, relatively inexpensive price and suitability for modification. Its chemical and biological properties, physicochemical state, degradability and mechanical strength can be adjusted, and therefore, it can be used under harsh mechanical, physical and chemical conditions without significant loss of its properties. Degradation time of PCL is quite long, thus it is used mainly in the replacement of hard tissues in the body where healing also takes an extended period of time. It is also used at load-bearing tissues of the body by enhancing its stiffness. However, due to its tailorability, use of PCL is not restricted to one type of tissue and it can be extended to engineering of soft tissues by decreasing its molecular weight and degradation time. This review outlines the basic properties of PCL, its composites, blends and copolymers. We report on various techniques for the production of different forms, and provide examples of medical applications such as tissue engineering and drug delivery systems covering the studies performed in the last decades.
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Affiliation(s)
- Elbay Malikmammadov
- a BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering , Middle East Technical University , Ankara , Turkey.,b Graduate Department of Micro and Nanotechnology, Graduate School of Natural and Applied Sciences , Middle East Technical University , Ankara , Turkey
| | - Tugba Endogan Tanir
- a BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering , Middle East Technical University , Ankara , Turkey.,c Central Laboratory , Middle East Technical University , Ankara , Turkey
| | - Aysel Kiziltay
- a BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering , Middle East Technical University , Ankara , Turkey.,c Central Laboratory , Middle East Technical University , Ankara , Turkey
| | - Vasif Hasirci
- a BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering , Middle East Technical University , Ankara , Turkey.,b Graduate Department of Micro and Nanotechnology, Graduate School of Natural and Applied Sciences , Middle East Technical University , Ankara , Turkey.,d Department of Biological Sciences , Middle East Technical University , Ankara , Turkey
| | - Nesrin Hasirci
- a BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering , Middle East Technical University , Ankara , Turkey.,b Graduate Department of Micro and Nanotechnology, Graduate School of Natural and Applied Sciences , Middle East Technical University , Ankara , Turkey.,e Department of Chemistry , Middle East Technical University , Ankara , Turkey
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34
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Huber JL, Maier C, Mainka T, Mannil L, Vollert J, Homann HH. Recovery of mechanical detection thresholds after direct digital nerve repair versus conduit implantation. J Hand Surg Eur Vol 2017; 42:720-730. [PMID: 28395576 DOI: 10.1177/1753193417699777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED The purpose of this study was to assess sensory and functional nerve recovery after digital nerve injury in patients with an end-to-end suture (S) or with implantation of a collagen conduit (C) to bridge a nerve gap. Fifteen S and 11 C with a follow-up of 6-36 months and 28 healthy control participants were enrolled. Methods of assessments were quantitative sensory testing, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), range of motion and the painDetect questionnaire. After both procedures, sensory profiles showed largely recovered function of C and Aδ fibres but severe loss of Aβ-fibre function leading to increased mechanical detection thresholds. There was only minimal allodynia. Severe pain was absent. Patients with conduits reported more functional impairment, especially in work performance, which correlated with the assessed loss of Aß-fibre function. LEVEL OF EVIDENCE III.
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Affiliation(s)
- J L Huber
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - C Maier
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - T Mainka
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany.,3 Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L Mannil
- 2 Department of Plastic Surgery and Hand Surgery, Burn Center, BG Trauma Center Duisburg, Duisburg, Germany.,4 Division of Plastic and Hand Surgery, University Hospital Zurich, Switzerland
| | - J Vollert
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - H-H Homann
- 2 Department of Plastic Surgery and Hand Surgery, Burn Center, BG Trauma Center Duisburg, Duisburg, Germany
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35
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Rbia N, Shin AY. The Role of Nerve Graft Substitutes in Motor and Mixed Motor/Sensory Peripheral Nerve Injuries. J Hand Surg Am 2017; 42:367-377. [PMID: 28473159 DOI: 10.1016/j.jhsa.2017.02.017] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 02/22/2017] [Indexed: 02/02/2023]
Abstract
Alternatives to nerve autograft have been invented and approved for clinical use. The reported outcomes of these alternatives in mixed motor nerve repair in humans are scarce and marked by wide variabilities. The purpose of our Current Concepts review is to provide an evidence-based overview of the effectiveness of nerve conduits and allografts in motor and mixed sensory/motor nerve reconstruction. Nerve graft substitutes have good outcomes in mixed/motor nerves in gaps less than 6 mm and internal diameters between 3 and 7 mm. There is insufficient evidence for their use in larger-gap and -diameter nerves; the evidence remains that major segmental motor or mixed nerve injury is optimally treated with a cabled nerve autograft.
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Affiliation(s)
- Nadia Rbia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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36
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Costa Serrão de Araújo G, Couto Neto B, Harley Santos Botelho R, Carpi Malta M. Clinical Evaluation After Peripheral Nerve Repair With Caprolactone Neurotube. Hand (N Y) 2017; 12:168-174. [PMID: 28344529 PMCID: PMC5349409 DOI: 10.1177/1558944716643277] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background: Peripheral nerve injuries with substance loss are challenges to surgeons because direct suture repair may result in malfunction due to nerve suture tension. Autologous nerve grafts are alternatives for treating those lesions; however, harvesting grafts adds morbidity at donor sites. Synthetic substitutes are options to bridge the gaps in these situations. The caprolactone neurotubes are used to assist nerve regeneration, but the literature lacks studies that evaluate their results. Methods: This research was designed to clinically evaluate patients undergoing repair of peripheral nerves with that conduit. We described results of 12 case series consisting of operations with Neurolac®. All nerves severed were sensory and had small gaps (ie, less than 25 mm). Subjective and objective clinical evaluations were performed and registered. Results: Physical examination by monofilament testing and 2-point discrimination showed results rated as good or excellent. However, the patients had complaints regarding sensory changes. Conclusions: Synthetic bioabsorbable guides for nerve repair are promising. The caprolactone conduits were demonstrated to be a safe option treatment and with a simple technique. Although in our study there were some operative complications, they were in line with previous descriptions in the literature. This case series added information about the treatment prognosis, but a higher evidence level study is necessary for decision making.
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Affiliation(s)
- Gabriel Costa Serrão de Araújo
- Universidade Federal Fluminense, Niterói, Brazil,Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, Brazil,Gabriel Costa Serrão de Araújo, Hospital Universitário Antônio Pedro, Rua Marques de Paraná, 303-Centro, Niterói, Rio de Janeiro, CEP 24033-900, Brazil.
| | - Bernardo Couto Neto
- Universidade Federal Fluminense, Niterói, Brazil,Universidade do Estado do Rio de Janeiro, Brazil
| | - Renato Harley Santos Botelho
- Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, Brazil,Universidade do Estado do Rio de Janeiro, Brazil
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Yurie H, Ikeguchi R, Aoyama T, Kaizawa Y, Tajino J, Ito A, Ohta S, Oda H, Takeuchi H, Akieda S, Tsuji M, Nakayama K, Matsuda S. The efficacy of a scaffold-free Bio 3D conduit developed from human fibroblasts on peripheral nerve regeneration in a rat sciatic nerve model. PLoS One 2017; 12:e0171448. [PMID: 28192527 PMCID: PMC5305253 DOI: 10.1371/journal.pone.0171448] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/02/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Although autologous nerve grafting is the gold standard treatment of peripheral nerve injuries, several alternative methods have been developed, including nerve conduits that use supportive cells. However, the seeding efficacy and viability of supportive cells injected in nerve grafts remain unclear. Here, we focused on a novel completely biological, tissue-engineered, scaffold-free conduit. METHODS We developed six scaffold-free conduits from human normal dermal fibroblasts using a Bio 3D Printer. Twelve adult male rats with immune deficiency underwent mid-thigh-level transection of the right sciatic nerve. The resulting 5-mm nerve gap was bridged using 8-mm Bio 3D conduits (Bio 3D group, n = 6) and silicone tube (silicone group, n = 6). Several assessments were conducted to examine nerve regeneration eight weeks post-surgery. RESULTS Kinematic analysis revealed that the toe angle to the metatarsal bone at the final segment of the swing phase was significantly higher in the Bio 3D group than the silicone group (-35.78 ± 10.68 versus -62.48 ± 6.15, respectively; p < 0.01). Electrophysiological studies revealed significantly higher compound muscle action potential in the Bio 3D group than the silicone group (53.60 ± 26.36% versus 2.93 ± 1.84%; p < 0.01). Histological and morphological studies revealed neural cell expression in all regions of the regenerated nerves and the presence of many well-myelinated axons in the Bio 3D group. The wet muscle weight of the tibialis anterior muscle was significantly higher in the Bio 3D group than the silicone group (0.544 ± 0.063 versus 0.396 ± 0.031, respectively; p < 0.01). CONCLUSIONS We confirmed that scaffold-free Bio 3D conduits composed entirely of fibroblast cells promote nerve regeneration in a rat sciatic nerve model.
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Affiliation(s)
- Hirofumi Yurie
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
- * E-mail:
| | - Tomoki Aoyama
- Department of Physical Therapy, Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yukitoshi Kaizawa
- Department of Orthopaedic Surgery, Iseikai Yawata Chuo Hospital, Kyoto, Japan
| | - Junichi Tajino
- Department of Physical Therapy, Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akira Ito
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Souichi Ohta
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Oda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hisataka Takeuchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | | | - Koichi Nakayama
- Department of Regenerative Medicine and Biomedical Engineering Faculty of Medicine, Saga University, Saga, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Advances and Future Applications of Augmented Peripheral Nerve Regeneration. Int J Mol Sci 2016; 17:ijms17091494. [PMID: 27618010 PMCID: PMC5037771 DOI: 10.3390/ijms17091494] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 02/06/2023] Open
Abstract
Peripheral nerve injuries remain a significant source of long lasting morbidity, disability, and economic costs. Much research continues to be performed in areas related to improving the surgical outcomes of peripheral nerve repair. In this review, the physiology of peripheral nerve regeneration and the multitude of efforts to improve surgical outcomes are discussed. Improvements in tissue engineering that have allowed for the use of synthetic conduits seeded with neurotrophic factors are highlighted. Selected pre-clinical and available clinical data using cell based methods such as Schwann cell, undifferentiated, and differentiated stem cell transplantation to guide and enhance peripheral nerve regeneration are presented. The limitations that still exist in the utility of neurotrophic factors and cell-based therapies are outlined. Strategies that are most promising for translation into the clinical arena are suggested.
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Approaches to Peripheral Nerve Repair: Generations of Biomaterial Conduits Yielding to Replacing Autologous Nerve Grafts in Craniomaxillofacial Surgery. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3856262. [PMID: 27556032 PMCID: PMC4983313 DOI: 10.1155/2016/3856262] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/29/2016] [Indexed: 01/09/2023]
Abstract
Peripheral nerve injury is a common clinical entity, which may arise due to traumatic, tumorous, or even iatrogenic injury in craniomaxillofacial surgery. Despite advances in biomaterials and techniques over the past several decades, reconstruction of nerve gaps remains a challenge. Autografts are the gold standard for nerve reconstruction. Using autografts, there is donor site morbidity, subsequent sensory deficit, and potential for neuroma development and infection. Moreover, the need for a second surgical site and limited availability of donor nerves remain a challenge. Thus, increasing efforts have been directed to develop artificial nerve guidance conduits (ANCs) as new methods to replace autografts in the future. Various synthetic conduit materials have been tested in vitro and in vivo, and several first- and second-generation conduits are FDA approved and available for purchase, while third-generation conduits still remain in experimental stages. This paper reviews the current treatment options, summarizes the published literature, and assesses future prospects for the repair of peripheral nerve injury in craniomaxillofacial surgery with a particular focus on facial nerve regeneration.
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40
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Abstract
Manufactured conduits and allografts are viable alternatives to direct suture repair and nerve autograft. Manufactured tubes should have gaps less than 10 mm, and ideally should be considered as an aid to the coaptation. Processed nerve allograft has utility as a substitute for either conduit or autograft in sensory nerve repairs. There is also a growing body of evidence supporting their utility in major peripheral nerve repairs, gap repairs up to 70 mm in length, as an alternative source of tissue to bolster the diameter of a cable graft, and for the management of neuromas in non-reconstructable injuries.
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Affiliation(s)
- Bauback Safa
- The Buncke Clinic, 45 Castro Street #121, San Francisco, CA 94114, USA.
| | - Gregory Buncke
- The Buncke Clinic, 45 Castro Street #121, San Francisco, CA 94114, USA
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Henry M. Management of Iatrogenic Ulnar Nerve Transection. J Hand Microsurg 2015; 7:173-6. [PMID: 26078536 DOI: 10.1007/s12593-014-0141-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022] Open
Abstract
A case of iatrogenic ulnar nerve laceration at the elbow is presented. Five subsequent surgeries over the course of the ensuing 20 months were performed to address this complication. The article examines the scientific basis for the various decisions needed to formulate a strategy that effectively addresses the problem. Emphasis is placed on the microsurgery of nerve topics: direct nerve repair, autogenous cable nerve grafting, biodegradable conduits, decellularized nerve allograft, and transfer of the anterior interosseous nerve to the ulnar motor branch. The discussion covers the relationship between choices made at the level of the original injury at the cubital tunnel to the timing and selection of distal reconstructive efforts, with specific attention to the distinction between end-to-end anterior interosseous to ulnar motor branch transfer as opposed to the supercharged end-to-side variation of this procedure.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, 1200 Binz Street, 13th Floor, 77004 Houston, TX USA
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Hohman MH, Kleiss IJ, Knox CJ, Weinberg JS, Heaton JT, Hadlock TA. Functional recovery after facial nerve cable grafting in a rodent model. JAMA FACIAL PLAST SU 2015; 16:20-4. [PMID: 24232003 DOI: 10.1001/jamafacial.2013.1431] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Cable grafting is widely considered to be the preferred alternative to primary repair of the injured facial nerve; however, quantitative comparison of the 2 techniques has not been previously undertaken in a rodent model. OBJECTIVE To establish functional recovery parameters after interposition autografting in a rodent facial nerve model. DESIGN, SETTING, AND PARTICIPANTS Prospective randomized animal study at a tertiary care facial nerve center using 16 female Wistar Hannover rats. INTERVENTION The experimental group received reversed autograft reconstruction of a 20-mm neural gap, and the control group received facial nerve transection and primary repair. MAIN OUTCOME AND MEASURE Whisker excursion was measured weekly for 70 postoperative days using laser micrometers. RESULTS The control group exhibited the most rapid recovery, with substantial return of whisker movement occurring during the third postoperative week. The experimental group demonstrated return of function beginning in the fourth postoperative week, eventually achieving a degree of function comparable to that of the control group by the sixth postoperative week (P = .68). CONCLUSIONS AND RELEVANCE Recovery of facial function after cable grafting seems to be slower than, but eventually similar to, recovery after primary neurorrhaphy in a rodent model. In the present study we have established a benchmark for recovery of whisker movement across a 20-mm rodent facial nerve gap, which will be used for comparison of different facial nerve gap bridging materials in future studies. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Marc H Hohman
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts2Division of Facial Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Ingrid J Kleiss
- Division of Facial Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts3Department of Otolaryngology/Head and Neck Surgery, Radboud University, Nijmegen, the Netherlands
| | - Christopher J Knox
- Division of Facial Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Julie S Weinberg
- Division of Facial Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - James T Heaton
- Division of Laryngeal Surgery, Department of Surgery, Massachusetts General Hospital, Boston
| | - Tessa A Hadlock
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts2Division of Facial Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
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Kaushik AP, Hammert WC. Options for digital nerve gap. J Hand Surg Am 2015; 40:141-4. [PMID: 25446411 DOI: 10.1016/j.jhsa.2014.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 09/25/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Anjan P Kaushik
- Department of Orthopaedics and Rehabilitation, Strong Memorial Hospital, University of Rochester, Rochester, NY
| | - Warren C Hammert
- Department of Orthopaedics and Rehabilitation, Strong Memorial Hospital, University of Rochester, Rochester, NY.
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Arslantunali D, Dursun T, Yucel D, Hasirci N, Hasirci V. Peripheral nerve conduits: technology update. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2014; 7:405-24. [PMID: 25489251 PMCID: PMC4257109 DOI: 10.2147/mder.s59124] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Peripheral nerve injury is a worldwide clinical problem which could lead to loss of neuronal communication along sensory and motor nerves between the central nervous system (CNS) and the peripheral organs and impairs the quality of life of a patient. The primary requirement for the treatment of complete lesions is a tension-free, end-to-end repair. When end-to-end repair is not possible, peripheral nerve grafts or nerve conduits are used. The limited availability of autografts, and drawbacks of the allografts and xenografts like immunological reactions, forced the researchers to investigate and develop alternative approaches, mainly nerve conduits. In this review, recent information on the various types of conduit materials (made of biological and synthetic polymers) and designs (tubular, fibrous, and matrix type) are being presented.
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Affiliation(s)
- D Arslantunali
- BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering, Middle East Technical University (METU), Ankara, Turkey ; Department of Biotechnology, METU, Ankara, Turkey ; Department of Bioengineering, Gumushane University, Gumushane, Turkey
| | - T Dursun
- BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering, Middle East Technical University (METU), Ankara, Turkey ; Department of Biotechnology, METU, Ankara, Turkey
| | - D Yucel
- BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering, Middle East Technical University (METU), Ankara, Turkey ; Faculty of Engineering, Department of Medical Engineering, Acibadem University, Istanbul, Turkey ; School of Medicine, Department of Histology and Embryology, Acibadem University, Istanbul, Turkey
| | - N Hasirci
- BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering, Middle East Technical University (METU), Ankara, Turkey ; Department of Biotechnology, METU, Ankara, Turkey ; Department of Chemistry, Faculty of Arts and Sciences, METU, Ankara, Turkey
| | - V Hasirci
- BIOMATEN, Center of Excellence in Biomaterials and Tissue Engineering, Middle East Technical University (METU), Ankara, Turkey ; Department of Biotechnology, METU, Ankara, Turkey ; Department of Biological Sciences, Faculty of Arts and Sciences, METU, Ankara, Turkey
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Isaacs J, Mallu S, Yan W, Little B. Consequences of oversizing: nerve-to-nerve tube diameter mismatch. J Bone Joint Surg Am 2014; 96:1461-7. [PMID: 25187585 DOI: 10.2106/jbjs.m.01420] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although commercially available nerve conduits are an accepted tool for overcoming short gaps in peripheral nerve repair, unexplained inconsistencies in clinical outcomes are not uncommon. Although exceeding the critical gap size and nerve caliber are most frequently cited as the source of these failures, oversizing of the nerve conduit in relation to the nerve diameter may be a previously unrecognized factor as well. METHODS Sixty female Sprague-Dawley rats underwent excision of a 10-mm section midway between the sciatic notch and the sciatic nerve division of one hindlimb. The defect was immediately repaired by reversing the resected nerve section and suturing it back in place (reverse autograft) (group A, n = 13) or it was repaired with a 14-mm nerve tube of 3 mm in diameter (group B, n = 12), 2 mm in diameter (group C, n = 15), or 1.5 mm in diameter (group D, n = 15). At twelve weeks, the rodents underwent muscle strength testing before harvest of muscle and nerve (including the conduit) for histomorphologic assessment. RESULTS Most conduits from group B were collapsed at final inspection and demonstrated diminished nerve regenerate. Muscle atrophy was most pronounced in groups B and C (p < 0.05), although normalized muscle contraction force was weakest in group B (p < 0.05), indicating inferior reinnervation. The axon counts, axon diameter, and G-ratios at the midpart of the conduit or graft demonstrated more axons and lower G-ratios in the autologous graft group. Among the conduit groups, the axon counts were lowest in group B (p < 0.05) followed by group C (p < 0.05). The G-ratio was highest in group B (p < 0.05), although the axon diameter was highest in group B (p < 0.05) as well. CONCLUSIONS Repair of a 10-mm gap in a rodent nerve with an oversized, poorly fitted nerve conduit resulted in tube collapse, poor nerve regenerate, and decreased muscle reinnervation compared with the findings in the animals treated with more accurately fitted nerve conduits. CLINICAL RELEVANCE Accurate sizing of nerve conduits to the nerve-stump diameter improves nerve recovery.
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Affiliation(s)
- Jonathan Isaacs
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, 1200 East Broad Street, P.O. Box 980153, Richmond, VA 23298. E-mail address for J. Isaacs:
| | - Satya Mallu
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, 1200 East Broad Street, P.O. Box 980153, Richmond, VA 23298. E-mail address for J. Isaacs:
| | - Wo Yan
- Departments of Plastic and Reconstructive Surgery and Anatomy, Shanghai JiaoTong University School of Medicine, Shanghai Ninth People's Hospital, Shanghai 200025, China
| | - Barrett Little
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Medical Center, 1200 East Broad Street, P.O. Box 980153, Richmond, VA 23298. E-mail address for J. Isaacs:
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Abstract
Nerve conduits and acellular nerve allograft offer efficient and convenient tools for overcoming unexpected gaps during nerve repair. Both techniques offer guidance for migrating Schwann cells and axonal regeneration though utilizing very different scaffolds. The substantially greater amount of animal and clinical data published on nerve conduits is marked by wide discrepancies in results that may be partly explained by a still poorly defined critical repair gap and diameter size. The available information on acellular allografts appears more consistently positive though this tool is also hampered by a longer but also limited critical length. This article reviews the current relative literature and examines pertinent parameters for application of both acellular allograft and nerve conduits in overcoming short nerve gaps.
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Rinker B, Vyas KS. Clinical applications of autografts, conduits, and allografts in repair of nerve defects in the hand: current guidelines. Clin Plast Surg 2014; 41:533-50. [PMID: 24996470 DOI: 10.1016/j.cps.2014.03.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Traumatic nerve injuries are common conditions treated by hand surgeons, and the optimal treatment of a severed nerve requires providing a healthy wound bed, generous trimming to healthy nerve substance, and a minimal-tension approximation. The gold standard for repair of a critical nerve gap has been the nerve autograft. However, results are generally less favorable than direct suture. Autogenous and synthetic conduits and processed nerve allografts have been developed as less morbid and more convenient alternatives to autografts, but the reported outcomes have been uneven. Engineered neural tissues show great promise in inducing nerve regeneration across a gap.
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Affiliation(s)
- Brian Rinker
- Division of Plastic Surgery, Department of Surgery, University of Kentucky, K454 740 S. Limestone Street, Lexington, KY 40536-0284, USA.
| | - Krishna S Vyas
- Division of Plastic Surgery, Department of Surgery, University of Kentucky, K454 740 S. Limestone Street, Lexington, KY 40536-0284, USA
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Boeckstyns MEH, Sørensen AI, Viñeta JF, Rosén B, Navarro X, Archibald SJ, Valss-Solé J, Moldovan M, Krarup C. Collagen conduit versus microsurgical neurorrhaphy: 2-year follow-up of a prospective, blinded clinical and electrophysiological multicenter randomized, controlled trial. J Hand Surg Am 2013; 38:2405-11. [PMID: 24200027 DOI: 10.1016/j.jhsa.2013.09.038] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 09/24/2013] [Accepted: 09/26/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare repair of acute lacerations of mixed sensory-motor nerves in humans using a collagen tube versus conventional repair. METHODS In a prospective randomized trial, we repaired the ulnar or the median nerve with a collagen nerve conduit or with conventional microsurgical techniques. We enrolled 43 patients with 44 nerve lacerations. We performed electrophysiological tests and hand function using a standardized clinical evaluation instrument, the Rosen scoring system, after 12 and 24 months. RESULTS Operation time using the collagen conduit was significantly shorter than for conventional neurorrhaphy. There were no complications in terms of infection, extrusion of the conduit, or other local adverse reaction. Thirty-one patients with 32 nerve lesions, repaired with collagen conduits or direct suture, attended the 24-month follow-up. There was no difference between sensory function, discomfort, or total Rosen scores. Motor scores were significantly better for the direct suture group after 12 months, but after 24 months, there were no differences between the treatment groups. There was a general further recovery of both motor and sensory conduction parameters at 24 months compared with 12 months. There were no statistically significant differences in amplitudes, latencies, or conduction velocities between the groups. CONCLUSIONS Use of a collagen conduit produced recovery of sensory and motor functions that were equivalent to direct suture 24 months after repair when the nerve gap inside the tube was 6 mm or less, and the collagen conduit proved to be safe for these nerve lacerations in the forearm. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Michel E H Boeckstyns
- Clinic of Hand Surgery, Gentofte Hospital, University of Copenhagen; Section of Hand Surgery, Rigshospitalet, University of Copenhagen; Department of Clinical Neurophysiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen; Institute of Neuroscience and Pharmacology, University of Copenhagen, Denmark; Department of Orthopedic Surgery, Hospital Clínic, University of Barcelona; Department of Cell Biology, Physiology, and Immunology, and Institute of Neurosciences, Universitat Autònoma de Barcelona; Institute of Biomedical Investigations August Pi i Sunyer, Barcelona, Spain; Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden; Integra LifeSciences, Plainsboro, New Jersey.
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Fernández J, Larrañaga A, Etxeberria A, Wang W, Sarasua JR. A new generation of poly(lactide/ε-caprolactone) polymeric biomaterials for application in the medical field. J Biomed Mater Res A 2013; 102:3573-84. [PMID: 24243562 DOI: 10.1002/jbm.a.35036] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 11/08/2022]
Abstract
Thermoplastic biodegradable polymers displaying an elastomeric behavior are greatly valued for the regeneration of soft tissues and for various medical devices. In this work, terpolymers composed of ε-caprolactone (CL), D-lactide (D-LA), and L-lactide (L-LA) were synthesized. These poly(lactide-ε-caprolactone) (PLCLs) presented an elevated randomness character (R∼1), glass transition temperatures (Tg ) higher than 20°C and adjusted L-LA content. In this way, the L-LA average sequence length (/L-LA ) was reduced to below 3.62 and showed little or no crystallization capability during in vitro degradation. As a result, the obtained materials underwent homogenous degradation exhibiting KMw ranging from 0.030 to 0.066 d(-1) and without generation of crystalline remnants in advanced stages of degradation. Mechanical performance was maintained over a period of 21 days for a rac-lactide-ε-caprolactone copolymer composed of ∼85% D,L-LA and ∼15% CL and also for a terpolymer composed of ∼72% L-LA, ∼12% D-LA and ∼16% CL. Terpolymers having L-LA content from ∼60 to 70% and CL content from ∼10 to 27% were also studied. In view of the results, those materials having CL and D-LA units disrupting the microstructural arrangement of the L-LA crystallizable chains, an L-LA content <72% and a random distribution of sequences, may display proper and tunable mechanical behavior and degradation performance for a large number of medical applications. Those with a CL content from 15 to 30% will fulfill the demand of elastomeric materials of Tg higher than 20°C whereas those with a CL content from 5 to 15% might be applied as ductile stiff materials.
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Affiliation(s)
- J Fernández
- Department of Mining-Metallurgy Engineering and Materials Science, POLYMAT, University of the Basque Country (UPV/EHU), School of Engineering, Alameda de Urquijo s/n., 48013, Bilbao, Spain
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