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Bioinductive collagen implants facilitate tendon regeneration in rotator cuff tears. J Exp Orthop 2022; 9:53. [PMID: 35674990 PMCID: PMC9177905 DOI: 10.1186/s40634-022-00495-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/31/2022] [Indexed: 11/14/2022] Open
Abstract
Purpose To evaluate the clinical outcomes, MRI imaging and histological characteristics of biopsy samples of the tendon from patients in whom rotator cuff repair was previously performed with a bioinductive type I bovine collagen implants. Methods Prospective study of 30 patients with partial or complete rotator cuff tears who underwent arthroscopic repair and augmentation with a resorbable type I bovine collagen implant. Preoperatively and at 6 and 12 months after surgery, the VAS, ASES and Constant-Murley scores were evaluated and an MRI study was performed. At 6 months, biopsies of the resulting tissue were obtained and examined histologically. Results Patients experienced statistically significant and sustained improvement from baseline for all scores and the mean tendon thickness increased by 1.84 mm. Magnetic resonance imaging evidence of complete healing was found in 27 patients and a considerable reduction in defect size, greater than 50%, was shown in 3. In all samples obtained, the new tissue generated had the histological appearance of a tendon, and was indistinguishable from the native tendon. There was no evidence of any remaining collagen implant. Conclusions Biopsies of tissue formed from bioinductive type I bovine collagen implants showed, six months after surgery, the generation of a neotendon indistinguishable from the native one. Histology and MRI imaging, revealed complete integration of the implant and absence of inflammatory or foreign body reactions. The clinical parameters, thickness and MRI signal of the tendon improved significantly at 6 months, regardless of the type and size of the tear, and remained unchanged until 12 months. Level of evidence Level IV, case series.
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Findings from the patch augmented rotator cuff surgery (PARCS) feasibility study. Pilot Feasibility Stud 2021; 7:163. [PMID: 34416915 PMCID: PMC8377837 DOI: 10.1186/s40814-021-00899-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background A rotator cuff tear is a common disabling shoulder problem. Symptoms include pain, weakness, lack of mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a pressing need to improve the outcome of rotator cuff surgery. The use of patch augmentation to provide support to the healing process and improve patient outcomes holds new promise. Different materials (e.g. human/animal skin or intestine tissue, and completely synthetic materials) and processes (e.g. woven or a mesh) have been used to produce patches. However, clinical evidence on their use is limited. The patch augmented rotator cuff surgery (PARCS) feasibility study aimed to determine the design of a definitive randomised controlled trial (RCT) assessing the effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. Methods A mixed methods feasibility study of conducing a subsequent RCT. The project involved six stages: a systematic review of clinical evidence; a survey of the British Elbow and Shoulder Society’s (BESS) surgical membership; a survey of surgeon trialists; focus groups and interviews with stakeholders; a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. Results The BESS surgeons’ survey identified a variety of patches in use (105 (21%) responses received). Twenty-four surgeons (77%) completed the trialist survey relating to trial design. Four focus groups were conducted involving 24 stakeholders. Twenty-nine (67% of invited) individuals took part in the Delphi. Differing views were held on a number of aspects including the appropriate patient population for trial participation. Agreement on the key research questions and the outline of two potential RCTs were achieved through the Delphi study and the consensus meeting. Conclusions Randomised comparisons of on-lay patch use for completed rotator cuff repairs, and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. The main limitation was that the findings were influenced by the participants, who might not necessarily reflect all stakeholders.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospital NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Hao L, Chen J, Shang X, Chen S. Surface modification of the simvastatin factor-loaded silk fibroin promotes the healing of rotator cuff injury through β-catenin signaling. J Biomater Appl 2021; 36:210-218. [PMID: 33779364 DOI: 10.1177/0885328221995926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Rupture of the rotator cuff is a common injury of the shoulder joint in sports professionals. In addition, research on repair of the rotator cuff has gained popularity over the recent years. Given the high rate of re-tear after surgery, it is necessary to design and prepare biodegradable materials with good mechanical properties, for the management of the condition. Consequently, the present study conducted surface modification of the simvastatin factor-loaded silk fibroin for the repair of chronic rotator cuff injury in SD rats. The in vitro experiments were analyzed through scanning electron microscopy and the water contact angle. Additionally, the CCK-8 assay was used to observe the effect of the intervention on the proliferation of BMSCs. Moreover, the osteogenic differentiation of BMSCs was detected through the ALP and ARS assays while the expression of osteogenic genes was examined using qRT-PCR and Western blot analysis. Furthermore, a model for repairing chronic rotator cuff tears in SD rats was established in vivo. Thereafter, rotator cuff repair and healing were evaluated through HE staining while Masson and Sirius staining was used to detect the collagen formation ratio. Additionally, the study analyzed the mechanism underlying the effect of simvastatin-loaded silk fibroin. The results showed that the simvastatin-loaded silk fibroin membrane had better biocompatibility and the in vitro experiments confirmed that it could promote the proliferation and osteogenic differentiation of BMSCs. In addition, the in vivo HE staining experiments similarly confirmed that it could enhance tendon bone healing and alleviate inflammation in chronic rotator cuff injuries. On the other hand, Masson and Sirius staining showed that the simvastatin-loaded silk fibroin could promote the formation of collagen. Further analysis also revealed that it could promote the osteogenic differentiation of BMSCs by activating the β-catenin signaling pathway. In general, these findings suggested that surface modification of the simvastatin factor-loaded silk fibroin was a potential means of improving the healing of rotator cuff injuries and can be implemented in clinical practice in future.
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Affiliation(s)
- Liang Hao
- 159397Huashan Hospital Fudan University, Shanghai, China
| | - Jun Chen
- 159397Huashan Hospital Fudan University, Shanghai, China
| | - Xiliang Shang
- 159397Huashan Hospital Fudan University, Shanghai, China
| | - Shiyi Chen
- 159397Huashan Hospital Fudan University, Shanghai, China
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Ezagüi Bentolila L. Surgical Technique for Arthroscopic Rotator Cuff Augmentation With Human Acellular Dermal Matrix. Arthrosc Tech 2021; 10:e1025-e1032. [PMID: 33981546 PMCID: PMC8085310 DOI: 10.1016/j.eats.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/01/2020] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic repair is probably the gold standard for treating large rotator cuff tears. Although positive, the results of this type of intervention depend on many factors such as the size of the tear, the age of the patient, and the number of previous surgeries. To decrease the rate of recurrence, we propose a surgical technique for augmenting the repair using an acellular dermal matrix (ArthroFlex, LifeNet Health). Our technique allows the surgeon to initially suture the tear in a regular fashion without visual interference. Once the tear is repaired, the augmentation is performed in a simple, all-arthroscopic, reproducible, and safe way. Also, we do not use extra implants for the fixation of the graft, so it does not increase the cost of the procedure (leaving aside the cost of the matrix itself).
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Affiliation(s)
- León Ezagüi Bentolila
- Address correspondence to León Ezagüi Bentolila, M.D., Hospital El Pilar, Barcelona, Spain.
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Cook JA, Baldwin M, Cooper C, Nagra NS, Crocker JC, Glaze M, Greenall G, Rangan A, Kottam L, Rees JL, Farrar-Hockley D, Merritt N, Hopewell S, Beard D, Thomas M, Dritsaki M, Carr AJ. Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study. Health Technol Assess 2021; 25:1-138. [PMID: 33646096 PMCID: PMC7958078 DOI: 10.3310/hta25130] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh). OBJECTIVES The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible. DESIGN A mixed-methods feasibility study of a randomised controlled trial. DATA SOURCES MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018. METHODS The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6. RESULTS The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended. LIMITATIONS The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups. CONCLUSION The need for further clinical studies was clear, particularly given the range and number of different patches available. FUTURE WORK Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study. STUDY REGISTRATION The systematic review is registered as PROSPERO CRD42017057908. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Navraj S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joanna C Crocker
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jonathan L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dair Farrar-Hockley
- Patient representative, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Baldwin M, Nagra NS, Greenall G, Carr AJ, Beard D, Rees JL, Rangan A, Merritt N, Dritsaki M, Hopewell S, Cook JA. Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis. BMJ Open 2020; 10:e039552. [PMID: 33293307 PMCID: PMC7722806 DOI: 10.1136/bmjopen-2020-039552] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 09/03/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs). DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020. ELIGIBILITY CRITERIA All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions. DATA EXTRACTION AND SYNTHESIS Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane). RESULTS We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%). CONCLUSIONS While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations. PROSPERO REGISTRATION NUMBER CRD42017057908.
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Affiliation(s)
- Mathew Baldwin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - N S Nagra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Gemma Greenall
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - J L Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
- Department of Orthopaedics, James Cook University Hospital, Middlesbrough, Middlesbrough, UK
| | - Naomi Merritt
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
| | - Melina Dritsaki
- Centre for Statistics in Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Sally Hopewell
- Centre for Statistics in Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Jonathan Alistair Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, Oxfordshire, UK
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