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Amirhekmat A, Brown WE, Salinas EY, Hu JC, Athanasiou KA, Wang D. Mechanical Evaluation of Commercially Available Fibrin Sealants for Cartilage Repair. Cartilage 2024; 15:147-155. [PMID: 36974340 DOI: 10.1177/19476035231163273] [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: 03/29/2023] Open
Abstract
OBJECTIVE Fibrin sealants are routinely used for intra-articular surgical fixation of cartilage fragments and implants. However, the mechanical properties of fibrin sealants in the context of cartilage repair are unknown. The purpose of this study was to characterize the adhesive and frictional properties of fibrin sealants using an ex vivo model. DESIGN Native bovine cartilage-bone composites were assembled with a single application of Tisseel or Vistaseal. Composites were tested in tension and lap shear. In addition, the coefficient of friction (COF) was measured in a native cartilage annulus model alone and with minced cartilage. Finally, the effect of a double application of fibrin sealant was evaluated. RESULTS There were no significant differences in tensile modulus, ultimate tensile strength (UTS), shear modulus, or ultimate shear strength (USS) between the 2 fibrin sealants. Both fibrin sealants demonstrated a UTS and USS of <8 and <30 kPa, respectively. There were no differences in COF between the sealants when tested alone or with minced cartilage. A double application of fibrin sealant did not alter the mechanical properties compared with a single application of fibrin sealant. CONCLUSIONS Fibrin sealant adhesive properties are not affected by the sealant type studied or the number of applications in a bovine cartilage-bone model. Fibrin sealant tribological properties are not affected by sealant type or the addition of minced cartilage. The adhesive properties of Tisseel and Vistaseal were less than those desired for the in vivo fixation of cartilage repair implants. These findings motivate the development of an improved cartilage-specific adhesive for cartilage repair applications.
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Affiliation(s)
- Arya Amirhekmat
- School of Medicine, University of California, Irvine, Irvine, CA, USA
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA, USA
| | - Wendy E Brown
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Evelia Y Salinas
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Jerry C Hu
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Kyriacos A Athanasiou
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Dean Wang
- School of Medicine, University of California, Irvine, Irvine, CA, USA
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA, USA
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
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2
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Swonger RM, Bernstein JM, Perez OF, Syros A, Horowitz KS, Schreiber VM. Fibrin Glue is a Viable Alternative to Fat Graft for Interposition After Tarsal Coalition Resection. J Pediatr Orthop 2023; 43:e370-e373. [PMID: 36914259 DOI: 10.1097/bpo.0000000000002386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Tarsal coalition is one of the most common foot and ankle pathologies in children, yet there is no consensus regarding what to interpose after resection. Fibrin glue could be considered, but the literature comparing fibrin glue to other interposition types is sparse. The purpose of this study was to evaluate the effectiveness of fibrin glue for interposition compared with fat graft by analyzing the rate of coalition recurrence and wound complications. We hypothesized that fibrin glue would have similar rates of coalition recurrence and fewer wound complications compared with fat graft interposition. METHODS A retrospective cohort study was performed examining all patients who underwent a tarsal coalition resection at a free-standing children's hospital in the United States from 2000 to 2021. Only patients undergoing isolated primary tarsal coalition resection with interposition of fibrin glue or fat graft were included. Wound complications were defined as any concern for an incision site that prompted the use of antibiotics. Comparative analyses were conducted using χ 2 and Fisher exact test to examine relationships among interposition type, coalition recurrence, and wound complications. RESULTS One hundred twenty-two tarsal coalition resections met our inclusion criteria. Fibrin glue was used for interposition in 29 cases and fat graft was used in 93 cases. The difference in the coalition recurrence rate between fibrin glue and fat graft interposition was not statistically significant (6.9% vs. 4.3%, P =0.627). The difference in wound complication rate between fibrin glue and fat graft interposition was not statistically significant (3.4% vs 7.5%, P = 0.679). CONCLUSION Fibrin glue interposition after tarsal coalition resection is a viable alternative to fat graft interposition. Fibrin glue has similar rates of coalition recurrence and wound complications when compared with fat grafts. Given our results and the lack of tissue harvesting required with fibrin glue, fibrin glue may be superior to fat grafts for interposition after tarsal coalition resection. LEVEL OF EVIDENCE Level III, a retrospective comparative study between treatment groups.
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Affiliation(s)
| | | | | | | | - Kevin S Horowitz
- Department of Orthopaedic Surgery, Nicklaus Children's Hospital, Miami, FL
| | - Verena M Schreiber
- Department of Orthopaedic Surgery, Nicklaus Children's Hospital, Miami, FL
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3
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Xue YT, Chen MY, Cao JS, Wang L, Hu JH, Li SY, Shen JL, Li XG, Zhang KH, Hao SQ, Juengpanich S, Cheng SB, Wong TW, Yang XX, Li TF, Cai XJ, Yang W. Adhesive cryogel particles for bridging confined and irregular tissue defects. Mil Med Res 2023; 10:15. [PMID: 36949519 PMCID: PMC10035260 DOI: 10.1186/s40779-023-00451-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/05/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Reconstruction of damaged tissues requires both surface hemostasis and tissue bridging. Tissues with damage resulting from physical trauma or surgical treatments may have arbitrary surface topographies, making tissue bridging challenging. METHODS This study proposes a tissue adhesive in the form of adhesive cryogel particles (ACPs) made from chitosan, acrylic acid, 1-Ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC) and N-hydroxysuccinimide (NHS). The adhesion performance was examined by the 180-degree peel test to a collection of tissues including porcine heart, intestine, liver, muscle, and stomach. Cytotoxicity of ACPs was evaluated by cell proliferation of human normal liver cells (LO2) and human intestinal epithelial cells (Caco-2). The degree of inflammation and biodegradability were examined in dorsal subcutaneous rat models. The ability of ACPs to bridge irregular tissue defects was assessed using porcine heart, liver, and kidney as the ex vivo models. Furthermore, a model of repairing liver rupture in rats and an intestinal anastomosis in rabbits were established to verify the effectiveness, biocompatibility, and applicability in clinical surgery. RESULTS ACPs are applicable to confined and irregular tissue defects, such as deep herringbone grooves in the parenchyma organs and annular sections in the cavernous organs. ACPs formed tough adhesion between tissues [(670.9 ± 50.1) J/m2 for the heart, (607.6 ± 30.0) J/m2 for the intestine, (473.7 ± 37.0) J/m2 for the liver, (186.1 ± 13.3) J/m2 for muscle, and (579.3 ± 32.3) J/m2 for the stomach]. ACPs showed considerable cytocompatibility in vitro study, with a high level of cell viability for 3 d [(98.8 ± 1.2) % for LO2 and (98.3 ± 1.6) % for Caco-2]. It has comparable inflammation repair in a ruptured rat liver (P = 0.58 compared with suture closure), the same with intestinal anastomosis in rabbits (P = 0.40 compared with suture anastomosis). Additionally, ACPs-based intestinal anastomosis (less than 30 s) was remarkably faster than the conventional suturing process (more than 10 min). When ACPs degrade after surgery, the tissues heal across the adhesion interface. CONCLUSIONS ACPs are promising as the adhesive for clinical operations and battlefield rescue, with the capability to bridge irregular tissue defects rapidly.
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Affiliation(s)
- Yao-Ting Xue
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
| | - Ming-Yu Chen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Jia-Sheng Cao
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Lei Wang
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
| | - Jia-Hao Hu
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Si-Yang Li
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
| | - Ji-Liang Shen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Xin-Ge Li
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
| | - Kai-Hang Zhang
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
| | - Shu-Qiang Hao
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
| | - Sarun Juengpanich
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Si-Bo Cheng
- Soft Intelligent Materials Co., Ltd, Suzhou, 215123, China
| | - Tuck-Whye Wong
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- School of Biomedical Engineering and Health Sciences and Advanced Membrane Technology Research Centre, Universiti Teknologi Malaysia, 81310, Skudai, Malaysia
| | - Xu-Xu Yang
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China.
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China.
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China.
| | - Tie-Feng Li
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
| | - Xiu-Jun Cai
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Wei Yang
- Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
- Key Laboratory of Soft Machines and Smart Devices of Zhejiang Province, Zhejiang University, Hangzhou, 310027, China
- Center for X-Mechanics, Department of Engineering Mechanics, Zhejiang University, Hangzhou, 310027, China
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Silk Fibroin as Adjuvant in the Fabrication of Mechanically Stable Fibrin Biocomposites. Polymers (Basel) 2022; 14:polym14112251. [PMID: 35683920 PMCID: PMC9183065 DOI: 10.3390/polym14112251] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022] Open
Abstract
Fibrin is a very attractive material for the development of tissue-engineered scaffolds due to its exceptional bioactivity, versatility in the fabrication, affinity to cell mediators; and the possibility to isolate it from blood plasma, making it autologous. However, fibrin application is greatly limited due to its low mechanical properties, fast degradation, and strong contraction in the presence of cells. In this study, we present a new strategy to overcome these drawbacks by combining it with another natural polymer: silk fibroin. Specifically, we fabricated biocomposites of fibrin (5 mg/mL) and silk fibroin (0.1, 0.5 and 1% w/w) by using a dual injection system, followed by ethanol annealing. The shear elastic modulus increased from 23 ± 5 Pa from fibrin alone, to 67 ± 22 Pa for fibrin/silk fibroin 0.1%, 241 ± 67 Pa for fibrin/silk fibroin 0.5% and 456 ± 32 Pa for fibrin/silk fibroin 1%. After culturing for 27 days with strong contractile cells (primary human arterial smooth muscle cells), fibrin/silk fibroin 0.5% and fibrin/silk fibroin 1% featured minimal cell-mediated contraction (ca. 15 and 5% respectively) in contrast with the large surface loss of the pure fibrin scaffolds (ca. 95%). Additionally, the composites enabled the formation of a proper endothelial cell layer after culturing with human primary endothelial cells under standard culture conditions. Overall, the fibrin/silk fibroin composites, manufactured within this study by a simple and scalable biofabrication approach, offer a promising avenue to boost the applicability of fibrin in tissue engineering.
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5
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Calcium peroxide aids tyramine-alginate gel to crosslink with tyrosinase for efficient cartilage repair. Int J Biol Macromol 2022; 208:299-313. [PMID: 35288166 DOI: 10.1016/j.ijbiomac.2022.03.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 12/14/2022]
Abstract
The innate cartilage extracellular matrix is avascular and plays a vital role in innate chondrocytes. Recapping the crucial components of the extracellular matrix in engineered organs via polymeric gels and bioinspired approaches is promising for improving the regenerative aptitude of encapsulated cartilage/chondrocytes. Conventional gel formation techniques for polymeric materials rely on employing oxidative crosslinking, which is constrained in this avascular environment. Further, poor mechanical properties limit the practical applications of polymeric gels and reduce their therapeutic efficacy. Herein, the purpose of this study was to develop a bioadhesive gel possessing dual crosslinking for engineering cartilage. Tyramine (TYR) was first chemically conjugated to the alginate (ALG) backbone to form an ALG-TYR precursor, followed by the addition of calcium peroxide (CaO2); calcium ions of CaO2 physically crosslink with ALG, and oxygen atoms of CaO2 chemically crosslink TYR with tyrosinase, thus enabling dual/enhanced crosslinking and possessing injectability. The ALG-TYR/tyrosinase/CaO2 gel system was chemically, mechanically, cellularly, and microscopically characterized. The gel system developed herein was biocompatible and showed augmented mechanical strength. The results showed, for the first time, that CaO2 supplementation preserved cell viability and enhanced the crosslinking ability, bioadhesion, mechanical strength, chondrogenesis, and stability for cartilage regeneration.
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6
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Zhu T, Wang H, Jing Z, Fan D, Liu Z, Wang X, Tian Y. High efficacy of tetra-PEG hydrogel sealants for sutureless dural closure. Bioact Mater 2021; 8:12-19. [PMID: 34541383 PMCID: PMC8424082 DOI: 10.1016/j.bioactmat.2021.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/07/2021] [Accepted: 06/20/2021] [Indexed: 01/01/2023] Open
Abstract
Advances in meticulous dural closure technique remain a great challenge for watertight dural closure in the aged society, because the cerebrospinal fluid (CSF) leakage after spinal surgery is often accompanied with the disgusting wound infection, meningitis and pseudomeningocele. Here, a tetra-poly (ethylene glycol) (PEG)-based hydrogel sealant is developed with collective advantages of facile operation, high safety, quick set time, easy injectability, favorable mechanical strength and powerful tissue adhesion for effective sutureless dural closure during the surgery procedure. Impressively, this tetra-PEG sealant can instantaneously adhere to the irregular tissue surfaces even in a liquid environment, and effectively prevent or block off the intraoperative CSF leakage for sutureless dural closure and dura regeneration. Together, this sutureless tetra-PEG adhesive can be utilized as a very promising alternative for high-efficient watertight dural closure of the clinical patients who incidentally or deliberately undergo the durotomy during the spinal surgery.
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Affiliation(s)
- Tengjiao Zhu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Hufei Wang
- Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China.,University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zehao Jing
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Daoyang Fan
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Zhongjun Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
| | - Xing Wang
- Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, China.,University of Chinese Academy of Sciences, Beijing 100049, China
| | - Yun Tian
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, China.,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, China
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7
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Koëter M, van Hugten PPW, Emans PJ, Ten Bosch JA. Treatment of a coronal shear injury of the trochlea using a modified hedgehog-based technique through an anterior neurovascular interval approach: A case report. Int J Surg Case Rep 2021; 85:106211. [PMID: 34293656 PMCID: PMC8319752 DOI: 10.1016/j.ijscr.2021.106211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Surgical treatment for dislocated trochlear shear injuries is recommended due to its articular nature. However, the surgical exposure is often limited and large cartilaginous fragments with lack of subchondral bone stock makes a stable fixation technically challenging. Rapid swelling of the traumatized cartilage induces a size misfit between the cartilage of the fragment and the defect site. The use of a "modified hedgehog"-based technique might be a solution in these cases. However, this technique has only been described in chondral shear lesions of the knee. CASE PRESENTATION A fifteen-year-old boy fell out of the still rings during gymnastics at school and suffered trauma to his elbow. A CT-scan of the right elbow showed a coronal shear injury of the trochlea with accompanied lateral condyle fracture of the humerus. The patient was treated throughout an anterior neurovascular approach with a modified hedgehog-based technique with triple fixation by creating an interlocking match of the cartilage, application of fibrin glue and additional screw fixation. CLINICAL DISCUSSION The anterior neurovascular interval approach provides a clear exposure of the fracture site which is useful for anatomic reduction and triple fixation. The subsequent modified hedgehog-based technique has only been described once in children with shear-off chondral fragments of the knee, without additional screw fixation. Adding a screw fixation of the fragment creates some collateral damage to the cartilage and might not be necessary in future cases. CONCLUSION The anterior neurovascular approach seems elegant and provides adequate exposure. Furthermore, a modified hedgehog-based technique delivers a stable triple fixation of the osteochondral fragment.
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Affiliation(s)
- M Koëter
- Departement of Trauma Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - P P W van Hugten
- Department of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - P J Emans
- Department of Orthopaedic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - J A Ten Bosch
- Departement of Trauma Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
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8
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Iordachescu A, Hughes EAB, Joseph S, Hill EJ, Grover LM, Metcalfe AD. Trabecular bone organoids: a micron-scale 'humanised' prototype designed to study the effects of microgravity and degeneration. NPJ Microgravity 2021; 7:17. [PMID: 34021163 PMCID: PMC8140135 DOI: 10.1038/s41526-021-00146-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/25/2021] [Indexed: 11/20/2022] Open
Abstract
Bone is a highly responsive organ, which continuously adapts to the environment it is subjected to in order to withstand metabolic demands. These events are difficult to study in this particular tissue in vivo, due to its rigid, mineralised structure and inaccessibility of the cellular component located within. This manuscript presents the development of a micron-scale bone organoid prototype, a concept that can allow the study of bone processes at the cell-tissue interface. The model is constructed with a combination of primary female osteoblastic and osteoclastic cells, seeded onto femoral head micro-trabeculae, where they recapitulate relevant phenotypes and functions. Subsequently, constructs are inserted into a simulated microgravity bioreactor (NASA-Synthecon) to model a pathological state of reduced mechanical stimulation. In these constructs, we detected osteoclastic bone resorption sites, which were different in morphology in the simulated microgravity group compared to static controls. Once encapsulated in human fibrin and exposed to analogue microgravity for 5 days, masses of bone can be observed being lost from the initial structure, allowing to simulate the bone loss process further. Constructs can function as multicellular, organotypic units. Large osteocytic projections and tubular structures develop from the initial construct into the matrix at the millimetre scale. Micron-level fragments from the initial bone structure are detected travelling along these tubules and carried to sites distant from the native structure, where new matrix formation is initiated. We believe this model allows the study of fine-level physiological processes, which can shed light into pathological bone loss and imbalances in bone remodelling.
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Affiliation(s)
- Alexandra Iordachescu
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, UK.
- Healthcare Technologies Institute, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Erik A B Hughes
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, UK
- Healthcare Technologies Institute, University of Birmingham, Edgbaston, Birmingham, UK
| | - Stephan Joseph
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, UK
- The Binding Site, Edgbaston, Birmingham, UK
| | - Eric J Hill
- School of Biosciences, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Liam M Grover
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, UK
- Healthcare Technologies Institute, University of Birmingham, Edgbaston, Birmingham, UK
| | - Anthony D Metcalfe
- School of Chemical Engineering, University of Birmingham, Edgbaston, Birmingham, UK
- Healthcare Technologies Institute, University of Birmingham, Edgbaston, Birmingham, UK
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9
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Chen K, Lin Q, Wang L, Zhuang Z, Zhang Y, Huang D, Wang H. An All-in-One Tannic Acid-Containing Hydrogel Adhesive with High Toughness, Notch Insensitivity, Self-Healability, Tailorable Topography, and Strong, Instant, and On-Demand Underwater Adhesion. ACS APPLIED MATERIALS & INTERFACES 2021; 13:9748-9761. [PMID: 33591721 DOI: 10.1021/acsami.1c00637] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hydrogels that are mechanically tough and capable of strong underwater adhesion can lead to a paradigm shift in the design of adhesives for a variety of biomedical applications. We hereby innovatively develop a facile but efficient strategy to prepare hydrogel adhesives with strong and instant underwater adhesion, on-demand detachment, high toughness, notch-insensitivity, self-healability, low swelling index, and tailorable surface topography. Specifically, a polymerization lyophilization conjugation fabrication method was proposed to introduce tannic acid (TA) into the covalent network consisting of polyethylene glycol diacrylate (PEGDA) of substantially high molecular weight. The presence of TA facilitated wet adhesion to various substrates by forming collectively strong noncovalent bonds and offering hydrophobicity to allow water repellence and also provided a reversible cross-link within the binary network to improve the mechanical performance of the gels. The long-chain PEGDA enhanced the efficacy and stability of TA conjugation and contributed to gel mechanics and adhesion by allowing chain diffusion and entanglement formation. Moreover, PEGDA/TA hydrogels were demonstrated to be biocompatible and capable of accelerating wound healing in a skin wound animal model as compared to commercial tissue adhesives and can be applied for the treatment of both epidermal and intracorporeal wounds. Our study provides new, critical insight into the design principle of all-in-one hydrogels with outstanding mechanical and adhesive properties and can potentially enhance the efficacy of hydrogel adhesives for wound healing.
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Affiliation(s)
- Kaiwen Chen
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
| | - Qiaoxia Lin
- Department of Biomedical Engineering, Research Center for Nano-biomaterials & Regenerative Medicine, College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, PR China
| | - Libin Wang
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
| | - Zhumei Zhuang
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
| | - Yang Zhang
- Laboratory of Regenerative Biomaterials, Department of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518037, P.R. China
| | - Di Huang
- Department of Biomedical Engineering, Research Center for Nano-biomaterials & Regenerative Medicine, College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, PR China
| | - Huanan Wang
- Key State Laboratory of Fine Chemicals, School of Bioengineering, Dalian University of Technology, No.2 Linggong Road, High-tech District, Dalian 116024, P.R. China
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10
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Abstract
Polymeric tissue adhesives provide versatile materials for wound management and are widely used in a variety of medical settings ranging from minor to life-threatening tissue injuries. Compared to the traditional methods of wound closure (i.e., suturing and stapling), they are relatively easy to use, enable rapid application, and introduce minimal tissue damage. Furthermore, they can act as hemostats to control bleeding and provide a tissue-healing environment at the wound site. Despite their numerous current applications, tissue adhesives still face several limitations and unresolved challenges (e.g., weak adhesion strength and poor mechanical properties) that limit their use, leaving ample room for future improvements. Successful development of next-generation adhesives will likely require a holistic understanding of the chemical and physical properties of the tissue-adhesive interface, fundamental mechanisms of tissue adhesion, and requirements for specific clinical applications. In this review, we discuss a set of rational guidelines for design of adhesives, recent progress in the field along with examples of commercially available adhesives and those under development, tissue-specific considerations, and finally potential functions for future adhesives. Advances in tissue adhesives will open new avenues for wound care and potentially provide potent therapeutics for various medical applications.
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Affiliation(s)
- Sungmin Nam
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
| | - David Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02134, United States.,Wyss Institute for Biologically Inspired Engineering, Cambridge, Massachusetts 02115, United States
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11
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Öztürk E, Stauber T, Levinson C, Cavalli E, Arlov Ø, Zenobi-Wong M. Tyrosinase-crosslinked, tissue adhesive and biomimetic alginate sulfate hydrogels for cartilage repair. Biomed Mater 2020; 15:045019. [DOI: 10.1088/1748-605x/ab8318] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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12
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Pandey N, Soto-Garcia LF, Liao J, Zimmern P, Nguyen KT, Hong Y. Mussel-inspired bioadhesives in healthcare: design parameters, current trends, and future perspectives. Biomater Sci 2020; 8:1240-1255. [PMID: 31984389 PMCID: PMC7056592 DOI: 10.1039/c9bm01848d] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Mussels are well-known for their extraordinary capacity to adhere onto different surfaces in various hydrophillic conditions. Their unique adhesion ability under water or in wet conditions has generated considerable interest towards developing mussel inspired polymeric systems that can mimic the chemical mechanisms used by mussels for their adhesive properties. Catechols like 3,4-dihydroxy phenylalanine (DOPA) and their biochemical interactions have been largely implicated in mussels' strong adhesion to various substrates and have been the centerpoint of research and development efforts towards creating superior tissue adhesives for surgical and tissue engineering applications. In this article, we review bioadhesion and adhesives from an engineering standpoint, specifically the requirements of a good tissue glue, the relevance that DOPA and other catechols have in tissue adhesion, current trends in mussel-inspired bioadhesives, strategies to develop mussel-inspired tissue glues, and perspectives for future development of these materials.
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Affiliation(s)
- Nikhil Pandey
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX 76010, USA
| | - Luis F. Soto-Garcia
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX 76010, USA
| | - Jun Liao
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX 76010, USA
| | - Philippe Zimmern
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Kytai T. Nguyen
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX 76010, USA
| | - Yi Hong
- Department of Bioengineering, University of Texas at Arlington, Arlington, TX 76010, USA
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Dompé M, Cedano-Serrano FJ, Vahdati M, Hourdet D, van der Gucht J, Kamperman M, Kodger TE. Hybrid Complex Coacervate. Polymers (Basel) 2020; 12:E320. [PMID: 32033133 PMCID: PMC7077495 DOI: 10.3390/polym12020320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/14/2020] [Accepted: 01/22/2020] [Indexed: 12/13/2022] Open
Abstract
Underwater adhesion represents a huge technological challenge as the presence of water compromises the performance of most commercially available adhesives. Inspired by natural organisms, we have designed an adhesive based on complex coacervation, a liquid-liquid phase separation phenomenon. A complex coacervate adhesive is formed by mixing oppositely charged polyelectrolytes bearing pendant thermoresponsive poly(N-isopropylacrylamide) (PNIPAM) chains. The material fully sets underwater due to a change in the environmental conditions, namely temperature and ionic strength. In this work, we incorporate silica nanoparticles forming a hybrid complex coacervate and investigate the resulting mechanical properties. An enhancement of the mechanical properties is observed below the PNIPAM lower critical solution temperature (LCST): this is due to the formation of PNIPAM-silica junctions, which, after setting, contribute to a moderate increase in the moduli and in the adhesive properties only when applying an ionic strength gradient. By contrast, when raising the temperature above the LCST, the mechanical properties are dominated by the association of PNIPAM chains and the nanofiller incorporation leads to an increased heterogeneity with the formation of fracture planes at the interface between areas of different concentrations of nanoparticles, promoting earlier failure of the network-an unexpected and noteworthy consequence of this hybrid system.
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Affiliation(s)
- Marco Dompé
- Laboratory of Physical Chemistry and Soft Matter, Wageningen University & Research, 6708 WE Wageningen, The Netherlands; (M.D.); (J.v.d.G.); (M.K.)
| | - Francisco Javier Cedano-Serrano
- Soft Matter Sciences and Engineering, ESPCI Paris, PSL University, Sorbonne University, CNRS, F-75005 Paris, France; (F.J.C.-S.); (M.V.); (D.H.)
| | - Mehdi Vahdati
- Soft Matter Sciences and Engineering, ESPCI Paris, PSL University, Sorbonne University, CNRS, F-75005 Paris, France; (F.J.C.-S.); (M.V.); (D.H.)
| | - Dominique Hourdet
- Soft Matter Sciences and Engineering, ESPCI Paris, PSL University, Sorbonne University, CNRS, F-75005 Paris, France; (F.J.C.-S.); (M.V.); (D.H.)
| | - Jasper van der Gucht
- Laboratory of Physical Chemistry and Soft Matter, Wageningen University & Research, 6708 WE Wageningen, The Netherlands; (M.D.); (J.v.d.G.); (M.K.)
| | - Marleen Kamperman
- Laboratory of Physical Chemistry and Soft Matter, Wageningen University & Research, 6708 WE Wageningen, The Netherlands; (M.D.); (J.v.d.G.); (M.K.)
- Laboratory of Polymer Science, Zernike Institute for Advanced Materials, University of Groningen, 9747 AG Groningen, The Netherlands
| | - Thomas E. Kodger
- Laboratory of Physical Chemistry and Soft Matter, Wageningen University & Research, 6708 WE Wageningen, The Netherlands; (M.D.); (J.v.d.G.); (M.K.)
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Behrendt P, Ladner Y, Stoddart MJ, Lippross S, Alini M, Eglin D, Armiento AR. Articular Joint-Simulating Mechanical Load Activates Endogenous TGF-β in a Highly Cellularized Bioadhesive Hydrogel for Cartilage Repair. Am J Sports Med 2020; 48:210-221. [PMID: 31877102 DOI: 10.1177/0363546519887909] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The treatment of osteochondral defects (OCDs) constitutes a major problem for orthopaedic surgeons. The altered mechanics and the cell types, with associated soluble factors derived from the exposed subchondral bone, are likely responsible for the mechanically and structurally inferior articular cartilage subsequently obtained as a repair tissue. There is therefore an unmet clinical need for bioresponsive biomaterials that allow cell delivery, reduce cell infiltration from the bone marrow, and support chondrogenesis in the presence of joint mechanical loading. PURPOSE To develop a cell-laden injectable biomaterial, with bioadhesive properties, low cell invasion, and good mechanoresilience, in which simulated joint loading could induce tissue maturation through the production and activation of transforming growth factor beta 1 (TGF-β1). STUDY DESIGN Controlled laboratory study. METHODS Human bone marrow-derived mesenchymal stromal/stem cells were encapsulated in tyramine-modified hyaluronic acid (HA-Tyr) hydrogels, with crosslinking initiated by the addition of horseradish peroxidase (HRP) and various concentrations of hydrogen peroxide (H2O2; 0.3-2 mM). Cytocompatibility and biomechanical and adhesive properties were analyzed by live/dead staining, rheology, and push-out test, respectively. For multiaxial loading, cell-laden hydrogels were subjected to 10% compression superimposed onto a 0.5-N preload and shear loading (±25°) at 1 Hz for 1 hour per day and 5 times a week for 4 weeks. TGF-β1 production and activation were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS The viscoelastic properties of the cell-laden HA-Tyr hydrogels, as crosslinked with different ratios of HRP and H2O2, were demonstrated for a range of cell densities and HRP/H2O2 concentrations. In the absence of serum supplementation, cell invasion into HA-Tyr hydrogels was minimal to absent. The bonding strength of HA-Tyr to articular cartilage compared favorably with clinically used fibrin gel. CONCLUSION HA-Tyr hydrogels can be mechanically conditioned to induce activation of endogenous TGF-b1 produced by the embedded cells. HA-Tyr hydrogels function as cell carriers supporting biomechanically induced production and activation of TGF-β1 and as bioadhesive materials with low cell invasion, suggesting that they hold promise as a novel biomaterial for OCD repair strategies. CLINICAL RELEVANCE Leveraging physiological joint mechanics to support chondrogenic graft maturation in an optimized mechanosensitive hydrogel in the absence of exogenous growth factors is of highest interest for OCD repair.
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Affiliation(s)
- Peter Behrendt
- Department of Orthopaedic and Trauma Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Yann Ladner
- AO Research Institute Davos, Davos Platz, Switzerland.,Institute for Biomechanics, ETH Zürich, Zürich, Switzerland
| | | | - Sebastian Lippross
- Department of Orthopaedic and Trauma Surgery, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Mauro Alini
- AO Research Institute Davos, Davos Platz, Switzerland
| | - David Eglin
- AO Research Institute Davos, Davos Platz, Switzerland
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Cravens MG, Behn AW, Dragoo JL. Comparison of mechanical compressive properties of commercial and autologous fibrin glues for tissue engineering applications. Clin Biomech (Bristol, Avon) 2017; 49:34-39. [PMID: 28863319 DOI: 10.1016/j.clinbiomech.2017.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/17/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fibrin glues are widely used in orthopedic surgery as adhesives and hemostatic agents. We evaluated the compressive properties of selected fibrin glues in order to identify which are appropriate for tissue regeneration applications subject to compression. METHODS Uniaxial unconfined compression tests were performed on fibrin gels prepared from commercial and autologous products: (1) Evicel (Ethicon), (2) Tisseel (Baxter), (3) Angel (Arthrex), and (4) ProPlaz (Biorich). Cyclic loads were applied from 0 to 30% strain for 100cycles at 0.5Hz. Following cyclic testing, specimens were subjected to ramp displacement of 1% strain per second to 80% strain. FINDINGS Throughout cyclic loading, Evicel and Tisseel deformed (shortened) less than Angel at all but one time point, and deformed less than ProPlaz at cycles 10 and 20. The dynamic moduli, peak stress, and strain energy were significantly greater in Tisseel than all other groups. Evicel displayed significantly greater dynamic moduli, peak stress, and strain energy than Angel and ProPlaz. Following cyclic testing, Tisseel and Evicel were significantly less deformed than Angel. No specimens exhibited gross failure during ramp loading to 80% strain. Ramp loading trends mirrored those of cyclic loading. INTERPRETATION The tested commercial glues were significantly more resistant to compression than the autologous products. The compressive properties of Tisseel were approximately twice those of Evicel. All preparations displayed moduli multiple orders of magnitude less than that of native articular cartilage. We conclude that in knee surgeries requiring fibrin glue to undergo compression of daily activity, commercial products are preferable to autologous preparations from platelet-poor plasma, though both will deform significantly.
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Affiliation(s)
- Matthew G Cravens
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Anthony W Behn
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jason L Dragoo
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Comparison of healing intra-articular fracture of distal femur using a Kirschner wire and autologous fibrin glue in an animal model. J Pediatr Orthop B 2017; 26:454-457. [PMID: 28277417 DOI: 10.1097/bpb.0000000000000444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Considering different surgical techniques for the fixation of osteochondral intra-articular fracture, the present study aimed to compare the efficacy of autologous fibrin glue and Kirschner wire (KW) on an osteochondral fracture in the left lateral condyle of Dutch rabbits with a control group. After 6 weeks, macroscopic and microscopic evaluation showed that autologous fibrin glue is easier and faster with a higher number of bone trabecula (P<0.05), whereas the healing rate and cellularity of the healing site were not different between the two groups (KW and glue). The use of autologous fibrin glue can be an alternative to KW fixation in the fixation of osteochondral fractures. LEVEL OF EVIDENCE Level II.
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Broguiere N, Cavalli E, Salzmann GM, Applegate LA, Zenobi-Wong M. Factor XIII Cross-Linked Hyaluronan Hydrogels for Cartilage Tissue Engineering. ACS Biomater Sci Eng 2016; 2:2176-2184. [DOI: 10.1021/acsbiomaterials.6b00378] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Nicolas Broguiere
- ETH Zürich, Cartilage Engineering and
Regeneration Laboratory, HPL J20, Otto-Stern-Weg 7, 8093 Zürich, Switzerland
| | - Emma Cavalli
- ETH Zürich, Cartilage Engineering and
Regeneration Laboratory, HPL J20, Otto-Stern-Weg 7, 8093 Zürich, Switzerland
| | | | - Lee Ann Applegate
- Department
of Musculoskeletal Medicine, Regenerative Therapy Unit, University Hospital of Lausanne, 1011 Lausanne, Switzerland
| | - Marcy Zenobi-Wong
- ETH Zürich, Cartilage Engineering and
Regeneration Laboratory, HPL J20, Otto-Stern-Weg 7, 8093 Zürich, Switzerland
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Fujioka-Kobayashi M, Mottini M, Kobayashi E, Zhang Y, Schaller B, Miron RJ. An in vitro study of fibrin sealant as a carrier system for recombinant human bone morphogenetic protein (rhBMP)-9 for bone tissue engineering. J Craniomaxillofac Surg 2016; 45:27-32. [PMID: 27840120 DOI: 10.1016/j.jcms.2016.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/27/2016] [Accepted: 10/04/2016] [Indexed: 01/29/2023] Open
Abstract
In the craniofacial bone field, fibrin sealants are used as coagulant and adhesive tools to stabilize grafts during surgery. Despite this, their exact role in osteogenesis is poorly characterized. In the present study, we aimed to characterize the osteogenic potential of TISSEEL fibrin sealant and used its technology to incorporate growth factors within its matrix. We focused on recombinant human bone morphogenetic protein (rhBMP)-9, which has previously been characterized as one of the strongest osteogenetic inducers in the BMP family. TISSEEL displayed an excellent ability to retain rhBMP9, which was gradually released over a 10-day period. Although TISSEEL decreased bone stromal ST2 cell attachment at 8 h, it displayed normal cell proliferation at 1, 3, and 5 days when compared to tissue culture plastic. Interestingly, TISSEEL had little influence on osteoblast differentiation; however its combination with rhBMP9 significantly increased ALP activity at 7 days, Alizarin Red staining at 14 days, and mRNA levels of osteoblast differentiation markers ALP, bone sialoprotein, and osteocalcin. In summary, although fibrin sealants were shown to have little influence on osteogenesis, their combination with bone-inducing growth factors such as rhBMP9 may serve as an attractive carrier/scaffold for future bone regenerative strategies. Future animal studies are now necessary.
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Affiliation(s)
- Masako Fujioka-Kobayashi
- Department of Cranio-Maxillofacial Surgery (Chair: Prof. Tateyuki Iizuka, MD, DDS, PhD), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland; Department of Oral Surgery, Institute of Biomedical Sciences, Tokushima University Graduate School, Kuramoto-cho 3-18-15, Tokushima, Japan.
| | - Matthias Mottini
- Department of Cranio-Maxillofacial Surgery (Chair: Prof. Tateyuki Iizuka, MD, DDS, PhD), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Eizaburo Kobayashi
- Department of Cranio-Maxillofacial Surgery (Chair: Prof. Tateyuki Iizuka, MD, DDS, PhD), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Yufeng Zhang
- Department of Oral Implantology, School of Stomatology, Wuhan University, Wuhan 430079, China
| | - Benoit Schaller
- Department of Cranio-Maxillofacial Surgery (Chair: Prof. Tateyuki Iizuka, MD, DDS, PhD), Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Richard J Miron
- Department of Periodontology, College of Dental Medicine Nova Southeastern University, 3301 College Avenue, Fort Lauderdale, Florida, USA
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Stack JD, Levingstone TJ, Lalor W, Sanders R, Kearney C, O'Brien FJ, David F. Repair of large osteochondritis dissecans lesions using a novel multilayered tissue engineered construct in an equine athlete. J Tissue Eng Regen Med 2016; 11:2785-2795. [DOI: 10.1002/term.2173] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/08/2016] [Accepted: 02/15/2016] [Indexed: 11/07/2022]
Affiliation(s)
- J. David Stack
- University College Dublin Veterinary Hospital, University College Dublin; Ireland
| | - Tanya J. Levingstone
- Tissue Engineering Research Group, Department of Anatomy; Royal College of Surgeons in Ireland; Dublin Ireland
- Trinity Centre for Bioengineering; Trinity College Dublin; Ireland
- Advanced Materials and Bioengineering Research (AMBER) Centre; RCSI & TCD; Dublin Ireland
| | - William Lalor
- W. Lalor Equine Sports Medicine; Clonmel, Co. Tipperary; Ireland
| | - Ruth Sanders
- Chiltern Equine Clinic, Blueberry Farm Hospital; Warfield Berkshire UK
| | - Clodagh Kearney
- University College Dublin Veterinary Hospital, University College Dublin; Ireland
| | - Fergal J. O'Brien
- Tissue Engineering Research Group, Department of Anatomy; Royal College of Surgeons in Ireland; Dublin Ireland
- Trinity Centre for Bioengineering; Trinity College Dublin; Ireland
- Advanced Materials and Bioengineering Research (AMBER) Centre; RCSI & TCD; Dublin Ireland
| | - Florent David
- Bjerke Dyrehospital - En Rikstotoklinikk; Oslo Norway
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20
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Choufani C, Barbier O, Bajard X, Ollat D, Versier G. [Medical and economic impact of a haemostatic sealant on the rate of transfusion after total knee arthroplasty]. Transfus Clin Biol 2015; 22:22-9. [PMID: 25684620 DOI: 10.1016/j.tracli.2015.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/13/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Blood loss reduction in total knee arthroplasty (TKA) contributes to the prevention of morbidity and mortality and in the management of health care costs. Fibrin haemostatic sealant have controversial effectiveness in reducing postoperative blood loss and transfusion requirements. Our study evaluated the medical and economic benefits of this treatment with the assumption that it decreases the frequency of blood transfusion after TKA. METHODS AND PATIENTS Our single-center and randomized study included 60 patients pose unilateral primary TKA for osteoarthritis. Distribution was done in 2 groups of 30 patients each. Group 1 patients treated with a dose of 5 mL Evicel®, compared to untreated group 2. Were collected the number of patients transfused. The treatment cost was compared to the sealant cost. RESULTS Results are not statistically significant. Two patients were transfused in group 1 and 3 in group 2 (P=0.64). The treatment cost for 30 patients is 13,500 €, for a savings of cells packed at 187 €, an additional cost of 13,313 € in group 1. CONCLUSION The use of fibrin haemostatic sealant in TKA did not induce a significant difference in terms of blood or transfusion savings, with a significant cost. We do not recommend its routine use in TKA.
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Affiliation(s)
- C Choufani
- Service de chirurgie orthopédique et traumatologique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France.
| | - O Barbier
- Service de chirurgie orthopédique et traumatologique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - X Bajard
- Service de chirurgie orthopédique et traumatologique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - D Ollat
- Service de chirurgie orthopédique et traumatologique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - G Versier
- Service de chirurgie orthopédique et traumatologique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
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Saleh A, Hebeish M, Farias-Kovac M, Klika AK, Patel P, Suarez J, Barsoum WK. Use of Hemostatic Agents in Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2014; 2:01874474-201401000-00001. [PMID: 27490809 DOI: 10.2106/jbjs.rvw.m.00061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anas Saleh
- Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue, A41, Cleveland, OH 44195
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Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey). Arch Orthop Trauma Surg 2014; 134:15-20. [PMID: 24276360 DOI: 10.1007/s00402-013-1893-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. This survey was conducted to assess the current use of perioperative blood-saving measures and to compare it with prior results. MATERIALS AND METHODS All departments of orthopaedic surgery at Dutch hospitals were sent a follow-up survey on perioperative blood-saving measures, and data were compared to the results of two surveys conducted 5 and 10 years earlier. RESULTS The response rate was 94 out of 108 departments (87%). Most departments used erythropoietin prior to hip and knee replacements at the expense of preoperative autologous blood donation. The use of intraoperative autologous retransfusion in revision hip (56 vs. 54%) as well as revision knee arthroplasty (26 vs. 24%), was virtually unchanged. Postoperative autologous retransfusion is still used by the majority of departments after both primary arthroplasty and revision of hip (58/53%) and knee (65/61%). CONCLUSIONS Currently, just as in 2007, the majority of Dutch orthopaedic departments uses erythropoietin, normothermia and postoperative autologous retransfusion with hip and knee arthroplasty. Intraoperative retransfusion is used mainly with hip revision arthroplasty. Other effective blood management modalities such as tranexamic acid have not been widely implemented.
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Abstract
Bone and tissue adhesives are common and beneficial supplements to standard methods of musculoskeletal tissue suture repair. Knowledge and development of biologically derived or inspired adhesives useful in orthopedic surgery are rapidly advancing. Recent literature demonstrates the increased adjunct or primary use of biological adhesives in the repair of musculoskeletal soft tissues, chondral fractures, and osteochondral fractures. Adhesives offer more benefits and enhancements to tissue healing than current fixation methods afford, including improved biocompatibility, resorbability, and non-immunogenicity. Further investigation is required to determine the extent of the role that these bioadhesives can play in orthopedic surgery. The largest group of biologically derived adhesives and sealants is fibrin sealants, which include first- and second-generation commercially available fibrin sealants, autologous fibrin sealants, and variants. Other groups include gelatin-resorcin aldehydes, protein-aldehyde systems, collagen-based adhesives, polysaccharide- based adhesives, mussel adhesive proteins, and various biologically inspired or biomimetic glues. Potential uses include applications in orthopedic-related blood conservation, arthroplasty, articular cartilage disorders, sports medicine, spine surgery, trauma, and tumors. The development of an adhesive with universal application is likely unfeasible, given the unique characteristics of various musculoskeletal tissues. However, the literature demonstrates the overall underuse of adhesives and indicates the rising probability of the development of a successful variety of bioadhesives for use in orthopedic surgery. As a result of reading this article, physicians should be able to: 1. Describe the difference between adhesives and sealants. 2. Recognize fibrin adhesives commonly used in practice today and identify other biological adhesives with rising potential. 3. Analyze how fibrin sealants work relative to fibrin and fibrinogen. 4. Identify anatomical areas and techniques in which fibrin sealants are used.
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Comprehensive evaluation of fibrin glue as a local drug-delivery system—efficacy and safety of sustained release of vancomycin by fibrin glue against local methicillin-resistant Staphylococcus aureus infection. J Artif Organs 2013; 17:42-9. [DOI: 10.1007/s10047-013-0746-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 11/08/2013] [Indexed: 10/26/2022]
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Rajangam T, An SSA. Fibrinogen and fibrin based micro and nano scaffolds incorporated with drugs, proteins, cells and genes for therapeutic biomedical applications. Int J Nanomedicine 2013; 8:3641-62. [PMID: 24106425 PMCID: PMC3792008 DOI: 10.2147/ijn.s43945] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Over the past two decades, many types of natural and synthetic polymer-based micro- and nanocarriers, with exciting properties and applications, have been developed for application in various types of tissue regeneration, including bone, cartilage, nerve, blood vessels, and skin. The development of suitable polymers scaffold designs to aid the repair of specific cell types have created diverse and important potentials in tissue restoration. Fibrinogen (Fbg)- and fibrin (Fbn)-based micro- and nanostructures can provide suitable natural matrix environments. Since these primary materials are abundantly available in blood as the main coagulation proteins, they can easily interact with damaged tissues and cells through native biochemical interactions. Fbg- and Fbn-based micro and nanostructures can also be consecutively furnished/or encapsulated and specifically delivered, with multiple growth factors, proteins, and stem cells, in structures designed to aid in specific phases of the tissue regeneration process. The present review has been carried out to demonstrate the progress made with micro and nanoscaffold applications and features a number of applications of Fbg- and Fbn-based carriers in the field of biomaterials, including the delivery of drugs, active biomolecules, cells, and genes, that have been effectively used in tissue engineering and regenerative medicine.
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Affiliation(s)
- Thanavel Rajangam
- Department of Bionanotechnology, Gachon University, Seongnam-Si, Republic of Korea
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Use of bovine thrombin to reduce blood loss in primary total knee arthroplasty: a controlled randomized trial. J Arthroplasty 2013; 28:1278-81. [PMID: 23518431 DOI: 10.1016/j.arth.2012.12.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 12/03/2012] [Accepted: 12/25/2012] [Indexed: 02/01/2023] Open
Abstract
Reducing blood loss during primary total knee arthroplasty (TKA) can improve outcomes by reducing transfusion requirements and wound complications. We examined the use of bovine thrombin to augment hemostasis during primary TKA. A double-blinded randomized trial was performed with 80 primary TKA patients. Half received intraarticular bovine thrombin at the time of wound closure, and half did not. Hemoglobin levels in the study group did decline less than the control group, but no statistically significant difference was found in rates of transfusion, drain outputs, length of stay, or Knee Society scores. This agent does appear to slightly reduce blood loss, but routine use is not cost effective. Thrombin may be considered for patients who would benefit more from greater blood conservation.
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Pillar 2: Minimising bleeding and blood loss. Best Pract Res Clin Anaesthesiol 2013; 27:99-110. [DOI: 10.1016/j.bpa.2012.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 12/17/2012] [Indexed: 01/21/2023]
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Hwang CM, Ay B, Kaplan DL, Rubin JP, Marra KG, Atala A, Yoo JJ, Lee SJ. Assessments of injectable alginate particle-embedded fibrin hydrogels for soft tissue reconstruction. Biomed Mater 2013; 8:014105. [PMID: 23353697 DOI: 10.1088/1748-6041/8/1/014105] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Soft tissue reconstruction is often needed after massive traumatic damage or cancer removal. In this study, we developed a novel hybrid hydrogel system consisting of alginate particles and a fibrin matrix that could maintain tissue volume long term. Alginate particles were fabricated by mixing 5% alginate with a 20 mM calcium solution. Cells and these alginate particles were then embedded in fibrin (alginate-fibrin) hydrogels using a dual syringe mixer. Cell-hydrogel constructs were evaluated in terms of cell survival and proliferation in the constructs in vitro. The results indicated that cellular viability, spreading and proliferation in the alginate-fibrin hydrogels were significantly higher compared to constructs fabricated with fibrin or alginate only. In vivo explants showed that cells contained within fibrin-only hydrogels did not contribute to neo-tissue formation, and the fibrin was fully degraded within a 12 week period. In the alginate-fibrin system, higher cellularity and vascular ingrowth were observed in vivo. This resulted in neo-tissue formation in the alginate-fibrin hydrogels. These results demonstrate that fibrin may enhance cell proliferation and accelerate the formation of extracellular matrix proteins in the alginate-fibrin system, while the alginate particles could contribute to volume retention. This injectable hybrid system composed of degradable and non-degradable hydrogels may be a preferable approach to the repair of soft tissue defects.
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Affiliation(s)
- C M Hwang
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Trajkovski B, Petersen A, Strube P, Mehta M, Duda GN. Intra-operatively customized implant coating strategies for local and controlled drug delivery to bone. Adv Drug Deliv Rev 2012; 64:1142-51. [PMID: 22664228 DOI: 10.1016/j.addr.2012.05.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 04/26/2012] [Accepted: 05/29/2012] [Indexed: 11/30/2022]
Abstract
Bone is one of the few tissues in the human body with high endogenous healing capacity. However, failure of the healing process presents a significant clinical challenge; it is a tremendous burden for the individual and has related health and economic consequences. To overcome such healing deficits, various concepts for a local drug delivery to bone have been developed during the last decades. However, in many cases these concepts do not meet the specific requirements of either surgeons who must use these strategies or individual patients who might benefit from them. We describe currently available methods for local drug delivery and their limitations in therapy. Various solutions for drug delivery to bone focusing on clinical applications and intra-operative constraints are discussed and drug delivery by implant coating is highlighted. Finally, a new set of design and performance requirements for intra-operatively customized implant coatings for controlled drug delivery is proposed. In the future, these requirements may improve approaches for local and intra-operative treatment of patients.
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Affiliation(s)
- Branko Trajkovski
- Julius Wolff Institute, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Comadoll JL, Comadoll S, Hutchcraft A, Krishnan S, Farrell K, Kreuwel HTC, Bechter M. Comparison of hemostatic matrix and standard hemostasis in patients undergoing primary TKA. Orthopedics 2012; 35:e785-93. [PMID: 22691647 DOI: 10.3928/01477447-20120525-14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Bleeding after total knee arthroplasty increases the risk of pain, delayed rehabilitation, blood transfusion, and transfusion-associated complications. The authors compared pre- and postoperative decreases in hemoglobin as a surrogate for blood loss in consecutive patients treated at a single institution by the same surgeon (J.L.C.) using conventional hemostatic methods (electrocautery, suturing, or manual compression) or a gelatin and thrombin-based hemostatic matrix during total knee arthroplasty. Data were collected retrospectively by chart review. The population comprised 165 controls and 184 patients treated with hemostatic matrix. Median age was 66 years (range, 28-89 years); 66% were women. The arithmetic mean ± SD for the maximal postoperative decrease in hemoglobin was 3.18 ± 0.94 g/dL for controls and 2.19 ± 0.83 g/dL for the hemostatic matrix group. Least squares means estimates of the group difference (controls-hemostatic matrix) in the maximal decrease in hemoglobin was 0.96 g/dL (95% confidence interval, 0.77-1.14 mg/dL; P<.0001). Statistically significant covariate effects were observed for preoperative hemoglobin level (P<.0001) and body mass index (P=.0029). Transfusions were infrequent in both groups. The frequency of acceptable range of motion was high (control, 88%; hemostatic matrix, 84%). In both groups, overall mean tourniquet time was approximately 1 hour, and the most common length of stay was 3 to 5 days. No serious complications related to the hemostatic agent were observed. These data demonstrate that the use of a flowable hemostatic matrix results in less reduction in hemoglobin than the use of conventional hemostatic methods in patient undergoing total knee arthroplasty.
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Sabatini L, Trecci A, Imarisio D, Uslenghi MD, Bianco G, Scagnelli R. Fibrin tissue adhesive reduces postoperative blood loss in total knee arthroplasty. J Orthop Traumatol 2012; 13:145-51. [PMID: 22588333 PMCID: PMC3427699 DOI: 10.1007/s10195-012-0198-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 04/18/2012] [Indexed: 11/24/2022] Open
Abstract
Background Blood transfusion is often required in total knee replacement; various methods of blood preservation have been studied. The best solution is to reduce the loss of blood during and after surgery. Materials and methods We designed this study to evaluate the hemostatic efficacy and safety of fibrin tissue adhesive (Quixil) in patients receiving total knee arthroplasty [low contact stress (LCS, DePuy, Warsaw, IN, US) cementless total knee replacement (TKR)] with a prospective, randomized, standard treatment controlled study. Thirty-five patients were randomized to receive treatment with fibrin tissue adhesive (treatment group), and 35 were randomized to be managed with postoperative blood recovery and reinfusion (control group). Blood loss in suction drain, decrease in hemoglobin values, and transfusions were recorded. Results A significant reduction in apparent total blood loss was detected in the treatment group compared with the control group. There was also a lower decrease in hemoglobin level, although this difference was not significant. When fibrin tissue adhesive was administered, the need for transfusions was lower. No major adverse events were recorded in our series. Conclusions Fibrin tissue adhesive reduced blood loss in TKR and seemed to significantly reduce the need for blood transfusion. Fibrin tissue adhesive can be an appropriate solution to enhance hemostasis and vessel sealing at the operative site in TKR, in order to reduce blood loss after surgery and the risk of complications.
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Affiliation(s)
- Luigi Sabatini
- Orthopedics and Traumatology Department, Ospedale Civile di Saluzzo, Via Spielberg 58, 12037, Saluzzo, CN, Italy.
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van der Vijver RJ, van Laarhoven CJHM, de Man BM, Lomme RMLM, Hendriks T. The effect of fibrin glue on the early healing phase of intestinal anastomoses in the rat. Int J Colorectal Dis 2012; 27:1101-7. [PMID: 22398458 PMCID: PMC3401510 DOI: 10.1007/s00384-012-1435-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2012] [Indexed: 02/04/2023]
Abstract
PURPOSE Protecting the anastomotic integrity using suture or staple line reinforcement remains an important goal for ongoing research. The present comprehensive study aims to establish the effects of fibrin glue on the early phase of anastomotic healing in the rat intestine. METHODS One hundred and eight young adult male Wistar rats underwent resection and anastomosis of both the ileum and colon. In half, fibrin glue was applied around the anastomoses. Parameters for repair included wound strength, both bursting pressure and breaking strength at days 1, 3, and 5 after operation; hydroxyproline content; and histology, the latter also after 7 days. RESULTS A transient colonic ileus was observed in the experimental group. Anastomotic breaking strength was always similar in both the control and fibrin glue groups. Anastomotic bursting pressures remained low at days 1 and 3, without any differences between the groups. In both groups, the bursting pressure increased sharply (p < 0.001) between days 3 and 5. At day 5, the bursting pressure in the fibrin glue group remained below than that in the controls, although only significantly (p = 0.0138) so in the ileum. At day 5, but not at day 7, the wounds in the fibrin glue group contained less collagen. Other aspects of microscopic wound architecture appeared to be the same. CONCLUSIONS There is no justification for using fibrin glue on patent anastomoses constructed under low-risk conditions. Its potential benefit under conditions where chances for anastomotic leakage are enhanced needs further investigation.
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Affiliation(s)
- Rozemarijn J. van der Vijver
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Cees J. H. M. van Laarhoven
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Ben M. de Man
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Roger M. L. M. Lomme
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Thijs Hendriks
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Abstract
If continuous prophylaxis is not feasible due to expense or lack of venous access, we must aggressively treat major haemarthroses (including arthrocentesis) to prevent progression to synovitis, recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy). For the treatment of chronic haemophilic synovitis, radiosynovectomy should always be indicated as the first procedure. If, after three procedures with 6-month interval, radiosynovectomy fails, an arthroscopic synovectomy must be indicated. Between the second and fourth decades, many haemophilic patients develop joint destruction (arthropathy). At this stage possible treatments include alignment osteotomy, arthroscopic joint debridement, arthrodesis (joint fusion) and total joint arthroplasty. For the hip press-fit uncemented components (hemispherical acetabulum, flanged femoral stem, metal-to-polyethylene) are recommended whilst for the knee a posterior-stabilized (PS) cemented design is advised. Muscular problems must not be underestimated in haemophilia due to their risk of developing compartment syndromes (which will require surgical decompression) and pseudotumours (which will require surgical removal or percutaneous treatment). Regarding patients with inhibitors, the advent of APCCs and rFVIIa has made major orthopaedic surgery possible, leading to an improved quality of life for haemophilia patients. Concerning local fibrin seal, it is not always necessary to achieve haemostasis in all surgical procedures performed in persons with haemophilia. However, it could be a good adjunct therapy, mainly when a surgical field potentially will bleed more than expected (i.e. patients with inhibitors), and also in some orthopaedic procedures (mainly the surgical removal of pseudotumours).
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Affiliation(s)
- E C Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital, Madrid and Autónoma University, Madrid, Spain.
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