Soft bioreactor systems: a necessary step toward engineered MSK soft tissue?

A key objective of tissue engineering (TE) is to produce in vitro funcional grafts that can replace damaged tissues or organs in patients. TE uses bioreactors, which are controlled environments, allowing the application of physical and biochemical cues to relevant cells growing in biomaterials. For soft musculoskeletal (MSK) tissues such as tendons, ligaments and cartilage, it is now well established that applied mechanical stresses can be incorporated into those bioreactor systems to support tissue growth and maturation via activation of mechanotransduction pathways. However, mechanical stresses applied in the laboratory are often oversimplified compared to those found physiologically and may be a factor in the slow progression of engineered MSK grafts towards the clinic. In recent years, an increasing number of studies have focused on the application of complex loading conditions, applying stresses of different types and direction on tissue constructs, in order to better mimic the cellular environment experienced in vivo. Such studies have highlighted the need to improve upon traditional rigid bioreactors, which are often limited to uniaxial loading, to apply physiologically relevant multiaxial stresses and elucidate their influence on tissue maturation. To address this need, soft bioreactors have emerged. They employ one or more soft components, such as flexible soft chambers that can twist and bend with actuation, soft compliant actuators that can bend with the construct, and soft sensors which record measurements in situ. This review examines types of traditional rigid bioreactors and their shortcomings, and highlights recent advances of soft bioreactors in MSK TE. Challenges and future applications of such systems are discussed, drawing attention to the exciting prospect of these platforms and their ability to aid development of functional soft tissue engineered grafts.

Advanced Robotics to Address the Translational Gap in Tendon Engineering

Tendon disease is a significant and growing burden to healthcare systems. One strategy to address this challenge is tissue engineering. A widely held view in this field is that mechanical stimulation provided to constructs should replicate the mechanical environment of native tissue as closely as possible. We review recent tendon tissue engineering studies in this article and highlight limitations of conventional uniaxial tensile bioreactors used in current literature. Advanced robotic platforms such as musculoskeletal humanoid robots and soft robotic actuators are promising technologies which may help address translational gaps in tendon tissue engineering. We suggest the proposed benefits of these technologies and identify recent studies which have worked to implement these technologies in tissue engineering. Lastly, key challenges to address in adapting these robotic technologies and proposed future research directions for tendon tissue engineering are discussed.

Motion preservation surgery for scoliosis with a vertebral body tethering system: a biomechanical study

PURPOSE

There is a paucity of studies on new vertebral body tethering (VBT) surgical constructs especially regarding their potentially motion-preserving ability. This study analyses their effects on the ROM of the spine.

METHODS

Human spines (T10-L3) were tested under pure moment in four different conditions: (1) native, (2) instrumented with one tether continuously connected in all vertebrae from T10 to L3, (3) additional instrumented with a second tether continuously connected in all vertebrae from T11 to L3, and (4) instrumented with one tether and one titanium rod (hybrid) attached to T12, L1 and L2. The instrumentation was inserted in the left lateral side. The intersegmental ROM was evaluated using a magnetic tracking system, and the medians were analysed. Please check and confirm the author names and initials are correct. Also, kindly confirm the details in the metadata are correct. The mentioned information is correct RESULTS: Compared to the native spine, the instrumented spine presented a reduction of less than 13% in global ROM considering flexion-extension and axial rotation. For left lateral bending, the median global ROM of the native spine (100%) significantly reduced to 74.6%, 66.4%, and 68.1% after testing one tether, two tethers and the hybrid construction, respectively. In these cases, the L1-L2 ROM was reduced to 68.3%, 58.5%, and 38.3%, respectively. In right lateral bending, the normalized global ROM of the spine with one tether, two tethers and the hybrid construction was 58.9%, 54.0%, and 56.6%, respectively. Considering the same order, the normalized L1-L2 ROM was 64.3%, 49.9%, and 35.3%, respectively.

CONCLUSION

The investigated VBT techniques preserved global ROM of the spine in flexion-extension and axial rotation while reduced the ROM in lateral bending.

Material failure in dynamic spine implants: are the standardized implant tests before market launch sufficient?

PURPOSE

International Standards Organization (ISO) 12189 and American Society for Testing and Materials F2624 are two standard material specification and test methods for spinal implant devices. The aim of this study was to assess whether the existing and required tests before market launch are sufficient.

METHODS

In three prospective studies, patients were treated due to degenerative disease of the lumbar spine or spondylolisthesis with lumbar interbody fusion and dynamic stabilization of the cranial adjacent level. The CD HORIZON BalanC rod and S⁴ Dynamic rod were implanted in 45 and 11 patients, respectively.

RESULTS

A fatigue fracture of the material of the topping off system has been found in five cases (11%) for the group fitted with the CD HORIZON BalanC rod. In the group using the S⁴ Dynamic rod group, a material failure of the dynamic part was demonstrated in seven patients (64%). All three studies were interrupted due to these results, and a report to the Federal Institute for Drugs and Medical Devices was generated.

CONCLUSION

Spinal implants have to be checked by a notified body before market launch. The notified body verifies whether the implants fulfil the requirements of the current standards. These declared studies suggest that the current standards for the testing of load bearing capacity and stand ability of dynamic spine implants might be insufficient. Revised standards depicting sufficient deformation and load pattern have to be developed and counted as a requirement for the market launch of an implant. These slides can be retrieved under Electronic Supplementary Material.

Biomechanical testing of a PEEK-based dynamic instrumentation device in a lumbar spine model

BACKGROUND

The purpose of this study was to investigate the range-of-motion after posterior polyetheretherketone-based rod stabilisation combined with a dynamic silicone hinge in order to compare it with titanium rigid stabilisation.

METHODS

Five human cadaveric lumbar spines with four vertebra each (L2 to L5) were tested in a temperature adjustable spine-testing set-up in four trials: (1) native measurement; (2) kinematics after rigid monosegmental titanium rod instrumentation with anterior intervertebral bracing of the segment L4/5; (3) kinematics after hybrid posterior polyetheretherketone rod instrumentation combined with a silicone hinge within the adjacent level (L3/4) and (4) kinematics after additional decompression with laminectomy of L4 and bilateral resection of the inferior articular processes (L3). During all steps, the specimens were loaded quasi-statically with 1°/s with pure moment up to 7.5Nm in flexion/extension, lateral bending and axial rotation.

FINDINGS

In comparison to the native cadaveric spine, both the titanium device and polyetheretherketone-based device reduce the range-of-motion within the level L4/5 significantly (flexion/extension: reduction of 77%, p<0.001; lateral bending: reduction of 62%, p<0.001; axial rotation: reduction of 71%, p<0.001). There was a clear stabilisation effect after hybrid-instrumentation within the level L3/4, especially in flexion/extension (64%, p<0.001) and lateral bending (62%, p<0.001) but without any effect on the axial rotation. Any temperature dependency has not been observed.

INTERPRETATION

Surprisingly, the hybrid device compensates for laminectomy L4 and destabilising procedure within the level L3/4 in comparison to other implants. Further studies must be performed to show its effectiveness regarding the adjacent segment instability.