1
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Barnett SC, Murray MM, Badger GJ, Yen YM, Kramer DE, Sanborn R, Kiapour A, Proffen B, Sant N, Fleming BC, Micheli LJ. Earlier Resolution of Symptoms and Return of Function After Bridge-Enhanced Anterior Cruciate Ligament Repair As Compared With Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:23259671211052530. [PMID: 34778483 PMCID: PMC8581796 DOI: 10.1177/23259671211052530] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Bridge-enhanced anterior cruciate ligament repair (BEAR) has noninferior
patient-reported outcomes when compared with autograft anterior cruciate
ligament reconstruction (ACLR) at 2 years. However, the comparison of BEAR
and autograft ACLR at earlier time points—including important outcomes such
as resolution of knee pain and symptoms, recovery of strength, and return to
sport—has not yet been reported. Hypothesis: It was hypothesized that the BEAR group would have higher outcomes on the
International Knee Documentation Committee and Knee injury and
Osteoarthritis Outcome Score, as well as improved muscle strength, in the
early postoperative period. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 patients aged 13 to 35 years with complete midsubstance
anterior cruciate ligament injuries were randomized to receive a suture
repair augmented with an extracellular matrix implant (n = 65) or an
autograft ACLR (n = 35). Outcomes were assessed at time points up to 2 years
postoperatively. Mixed-model repeated-measures analyses were used to compare
BEAR and ACLR outcomes. Patients were unblinded after their 2-year
visit. Results: Repeated-measures testing revealed a significant effect of group on the
International Knee Documentation Committee Subjective Score
(P = .015), most pronounced at 6 months after surgery
(BEAR = 86 points vs ACLR = 78 points; P = .001). There was
a significant effect of group on the Knee injury and Osteoarthritis Outcome
Score-Symptoms subscale scores (P = .010), largely
attributed to the higher BEAR scores at the 1-year postoperative time point
(88 vs 82; P = .009). The effect of group on hamstring
strength was significant in the repeated-measures analysis
(P < .001), as well as at all postoperative time
points (P < .001 for all comparisons). At 1 year after
surgery, approximately 88% of the patients in the BEAR group and 76% of the
ACLR group had been cleared for return to sport (P =
.261). Conclusion: Patients undergoing the BEAR procedure had earlier resolution of symptoms and
increased satisfaction about their knee function, as well as improved
resolution of hamstring muscle strength throughout the 2-year follow-up
period. Registration: NCT02664545 (ClinicalTrials.gov identifier)
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Affiliation(s)
- Samuel C Barnett
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - Yi-Meng Yen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan Sanborn
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ata Kiapour
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nicholas Sant
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,University of Vermont, Burlington, Vermont, USA.,Members of the BEAR Trial Team are listed in the Authors section at the end of this article.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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2
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Hackethal J, Weihs AM, Karner L, Metzger M, Dungel P, Hennerbichler S, Redl H, Teuschl-Woller AH. Novel Human Placenta-Based Extract for Vascularization Strategies in Tissue Engineering. Tissue Eng Part C Methods 2021; 27:616-632. [PMID: 34714165 DOI: 10.1089/ten.tec.2021.0173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
There is critical unmet need for new vascularized tissues to support or replace injured tissues and organs. Various synthetic and natural materials were already established for use of two-dimensional (2D) and three-dimensional (3D) in vitro neovascularization assays, however, they still cannot mimic the complex functions of the sum of the extracellular matrix (ECM) in native intact tissue. Currently, this issue is only addressed by artificial products such as Matrigel™, which comprises a complex mixture of ECM proteins, extracted from animal tumor tissue. Despite its outstanding bioactivity, the isolation from tumor tissue hinders its translation into clinical applications. Since nonhuman ECM proteins may cause immune reactions, as are frequently observed in clinical trials, human ECM proteins represent the best option when aiming for clinical applications. Here, we describe an effective method of isolating a human placenta substrate (hpS) that induces the spontaneous formation of an interconnected network of green fluorescence-labeled human umbilical vein endothelial cells (gfpHUVECs) in vitro. The substrate was biochemically characterized by using a combination of bicinchoninic acid (BCA) assay, DNA, and glycosaminoglycan (GAG) content assays, sodium dodecyl sulfate/polyacrylamide gel electrophoresis (SDS-PAGE) analysis and Western blot, angiogenesis arrays, chromatographic thrombin detection, high performance liquid chromatography (HPLC)-based amino acid quantification analysis, and assessment of antimicrobial properties. 2D in vitro cell culture experiments have been performed to determine the vasculogenic potential of hpS, which demonstrated that cell networks developed on hpS show a significantly higher degree of complexity (number of tubules/junctions; total/mean tube length) when compared with Matrigel. As 3D cell culture techniques represent a more accurate representation of the in vivo condition, the substrate was 3D solidified using various natural polymers. 3D in vitro vasculogenesis assays have been performed by seeding gfpHUVECs in an hpS-fibrinogen clot. In conclusion, hpS provides a potent human/material-based alternative to xenogenic-material-based biomaterials for vascularization strategies in tissue engineering.
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Affiliation(s)
- Johannes Hackethal
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in AUVA Trauma Research Center, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Anna Maria Weihs
- Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Department of Life Science Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
| | - Lisa Karner
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in AUVA Trauma Research Center, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Magdalena Metzger
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in AUVA Trauma Research Center, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Peter Dungel
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in AUVA Trauma Research Center, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Simone Hennerbichler
- Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Red Cross Blood Transfusion Service of Upper Austria, Linz, Austria
| | - Heinz Redl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in AUVA Trauma Research Center, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Andreas Herbert Teuschl-Woller
- Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Department of Life Science Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
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3
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Jo Y, Kim WJ, Lee H. Healing of partial tear of the supraspinatus tendon after atelocollagen injection confirmed by MRI: A case report. Medicine (Baltimore) 2020; 99:e23498. [PMID: 33285757 PMCID: PMC7717826 DOI: 10.1097/md.0000000000023498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Recently, collagen therapy has been made available for treating rotator cuff tendon injuries. However, to our knowledge, there are no clinical studies objectively investigating the effect of collagen therapy. PATIENT CONCERNS A 53-year-old female patient visited our pain clinic because of pain in the right shoulder. Although she had never experienced trauma and had not overused her shoulder and arm, the patient showed limited range of motion with painful arc syndrome. Moreover, the Neer test and Hawkins-Kennedy test were positive with subacromial tenderness. DIAGNOSES The MRI findings revealed partial tears on the articular surface of the anterior supraspinatus tendon in the rotator cuff. INTERVENTIONS The patient was treated with injections of exogenous collagen at the site of the partial tear under ultrasound guidance. OUTCOMES Follow-up MRI after injection of collagen revealed healing of the previous partial rupture of the tendon without any complications. Moreover, the patient reported reduction in pain and improvement in the movement of her shoulder during the follow-up period. LESSONS In this report, we demonstrate healing of a partial tear of the supraspinatus tendon in the rotator cuff after injection of exogenous collagen, as confirmed by MRI.
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Affiliation(s)
- Youbin Jo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, Republic of Korea
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4
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Lee DW, Jang HG, Lee YJ, Moon SG, Kim NR, Kim JG. Effect of atelocollagen on the healing status after medial meniscal root repair using the modified Mason-Allen stitch. Orthop Traumatol Surg Res 2020; 106:969-975. [PMID: 32753355 DOI: 10.1016/j.otsr.2020.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Addition of collagen during medial meniscal root repair (MMRR) may improve meniscal root healing minimising fibrous scar tissue formation. The purpose of this study was to verify the effect of atelocollagen on MMRR using the modified Mason-Allen stitch when compared with that of the conventional pullout repair by assessing the clinical and radiological outcomes. HYPOTHESIS It was hypothesised that atelocollagen would enhance the healing effect on the meniscal root following MMRR. Moreover, we presumed that MMRR with atelocollagen application might reduce meniscal extrusion by promoting healing. MATERIALS AND METHODS A total of 47 patients who underwent MMRR using the modified Mason-Allen stitch between 2015 and 2016 were included, and they were divided into group A (atelocollagen application; n=25) and group R (MMRR without atelocollagen application; n=22). The postoperative clinical outcomes, radiological outcomes, and meniscal root healing and medial compartment cartilage status on follow-up magnetic resonance imaging (MRI) were compared between the two groups. RESULTS Mean follow-up duration was 26.4±4.8 months in group A and 27.1±5.2 months in group R (p=0.598). Mean duration from surgery to follow-up MRI was 12.5±1.4 months in group A and 12.7±1.2 months in group R (p=0.604). The subjective knee scores improved significantly in both groups at the last follow-up (all, p<0.001). The Kellgren-Lawrence (K-L) grade progressed in 16% and 22.7% in group A and group R, respectively (p=0.351). Follow-up MRI showed progression of cartilage loss in the medial compartment in 28% and 40.9% in group A and group R, respectively (p=0.355). In terms of meniscal root healing, 18 (72%) and 12 (54.5%) patients had complete healing, and 6 (24%) and 8 (36.4%) patients had partial healing in groups A and R, respectively. The mean value of the intra-meniscal signal intensity (IMSI) of the meniscal root based on MRI in group A was significantly lower than that in group R (p<0.001). The medial meniscal extrusion in groups A and R decreased by 0.2±0.1mm and 0.1±0.3mm following MMRR without significant differences (p=0.056 and p=0.229, respectively). The IMSI presented significant negative correlations with the root healing status and significant positive correlations with K-L grade progression (p<0.05). DISCUSSION Atelocollagen application during MMRR yielded lower IMSIs, suggesting better healing, than did conventional pullout root repair. However, this technique could not demonstrate beneficial effects on meniscal extrusion. LEVEL OF EVIDENCE III, retrospective case-control study.
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Affiliation(s)
- Dhong Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Centre, Seoul, Korea
| | - Han Gil Jang
- Department of Orthopaedic Surgery, KonKuk University Medical Centre, Seoul, Korea
| | - Young Jun Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Centre, Seoul, Korea
| | - Sung Gyu Moon
- Department of Radiology, KonKuk University Medical Centre, Seoul, Korea
| | - Na Ra Kim
- Department of Radiology, KonKuk University Medical Centre, Seoul, Korea
| | - Jin Goo Kim
- Department of Orthopaedic Surgery, Myongji Hospital, Goyang-si, Gyeonggi-do, Korea.
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5
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Barnett S, Murray MM, Liu S, Micheli LJ. Resolution of Pain and Predictors of Postoperative Opioid use after Bridge-Enhanced Anterior Cruciate Ligament Repair and Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2020; 2:e219-e228. [PMID: 32548587 PMCID: PMC7283945 DOI: 10.1016/j.asmr.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 02/12/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose To compare postoperative pain scores and opioid use between patients undergoing a standard arthroscopic anterior cruciate ligament reconstruction (ACLR) using hamstring autograft with those undergoing a suture repair augmented with an extracellular matrix scaffold (bridge-enhanced ACL repair) performed through an arthrotomy and to determine factors predictive of postoperative opioid use and levels of overprescription. Methods A nonrandomized controlled trial was conducted with 20 patients (10 ACLR, 10 bridge-enhanced ACL repair), aged 18 to 35 years. All surgeries were performed by a single surgeon. A pain medication log was provided to patients on discharge. No regional anesthesia was performed. Pain scores via a visual analog pain scale were recorded at each visit. Correlations between preoperative and intraoperative characteristics and postoperative opioid use were determined. Results The total morphine-equivalent dose ranged from 30 to 309 mg (4-42 pills oxycodone) for the ACLR group and 75 to 254 mg (10-34 pills oxycodone) for the bridge-enhanced ACL repair group. The average opioid use per day was 35.8 mg for the patients undergoing bridge-enhanced ACL repair and 44.2 mg for patients undergoing ACLR (P = .29). Pain scores at time points up to 2 years postoperatively were not significantly different between the 2 groups. Across both groups, the average oversupply of oxycodone was 46 pills per patient, a greater than 70% unused opiate rate. Preoperative body mass index and preoperative Knee Injury and Osteoarthritis Outcome Scores pain score were predictive of greater postoperative opioid use per day, whereas age, concurrent meniscal repair, and operative time were not. Conclusions Total overall opiate intake was not different between the patients undergoing bridge-enhanced ACL repair through an arthrotomy and those undergoing arthroscopic ACLR. Both groups had similar pain scores from 2 weeks to 2 years postoperatively. Greater body mass index and greater preoperative pain (lower Knee Injury and Osteoarthritis Outcome Scores pain score) correlated with greater postoperative opioid use per day. There was an overprescription of opioids across all patients. Level of Evidence Level III, case control study (therapeutic).
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Affiliation(s)
- Samuel Barnett
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, U.S.A
| | - Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, U.S.A
| | - Shanshan Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital Boston, Massachusetts, U.S.A
| | | | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, U.S.A
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6
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Jung KH. Does Atelocollagen Actually Help the Rotator Cuff Healing and Pain Control? Clin Shoulder Elb 2019; 22:171-172. [PMID: 33330215 PMCID: PMC7714308 DOI: 10.5397/cise.2019.22.4.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kyu-Hak Jung
- Department of Orthopaedic Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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7
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Rieu C, Parisi C, Mosser G, Haye B, Coradin T, Fernandes FM, Trichet L. Topotactic Fibrillogenesis of Freeze-Cast Microridged Collagen Scaffolds for 3D Cell Culture. ACS APPLIED MATERIALS & INTERFACES 2019; 11:14672-14683. [PMID: 30913387 DOI: 10.1021/acsami.9b03219] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Type I collagen is the main component of the extracellular matrix (ECM). In vitro, under a narrow window of physicochemical conditions, type I collagen self-assembles to form complex supramolecular architectures reminiscent of those found in native ECM. Presently, a major challenge in collagen-based biomaterials is to couple the delicate collagen fibrillogenesis events with a controlled shaping process in non-denaturating conditions. In this work, an ice-templating approach promoting the structuration of collagen into macroporous monoliths is used. Instead of common solvent removal procedures, a new topotactic conversion approach yielding self-assembled ordered fibrous materials is implemented. These collagen-only, non-cross-linked scaffolds exhibit uncommon mechanical properties in the wet state, with a Young's modulus of 33 ± 12 kPa, an ultimate tensile stress of 33 ± 6 kPa, and a strain at failure of 105 ± 28%. With the help of the ice-patterned microridge features, normal human dermal fibroblasts and C2C12 murine myoblasts successfully migrate and form highly aligned populations within the resulting three-dimensional (3D) collagen scaffolds. These results open a new pathway to the development of new tissue engineering scaffolds ordered across various organization levels from the molecule to the macropore and are of particular interest for biomedical applications where large-scale 3D cell alignment is needed such as for muscular or nerve reconstruction.
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Affiliation(s)
- Clément Rieu
- Sorbonne Université, CNRS, Laboratoire de Chimie de la Matière Condensée de Paris, Pierre and Marie Curie Campus , 4 place Jussieu , 75252 Paris Cedex 05 , France
| | - Cleo Parisi
- Sorbonne Université, CNRS, Laboratoire de Chimie de la Matière Condensée de Paris, Pierre and Marie Curie Campus , 4 place Jussieu , 75252 Paris Cedex 05 , France
| | - Gervaise Mosser
- Sorbonne Université, CNRS, Laboratoire de Chimie de la Matière Condensée de Paris, Pierre and Marie Curie Campus , 4 place Jussieu , 75252 Paris Cedex 05 , France
| | - Bernard Haye
- Sorbonne Université, CNRS, Laboratoire de Chimie de la Matière Condensée de Paris, Pierre and Marie Curie Campus , 4 place Jussieu , 75252 Paris Cedex 05 , France
| | - Thibaud Coradin
- Sorbonne Université, CNRS, Laboratoire de Chimie de la Matière Condensée de Paris, Pierre and Marie Curie Campus , 4 place Jussieu , 75252 Paris Cedex 05 , France
| | - Francisco M Fernandes
- Sorbonne Université, CNRS, Laboratoire de Chimie de la Matière Condensée de Paris, Pierre and Marie Curie Campus , 4 place Jussieu , 75252 Paris Cedex 05 , France
| | - Léa Trichet
- Sorbonne Université, CNRS, Laboratoire de Chimie de la Matière Condensée de Paris, Pierre and Marie Curie Campus , 4 place Jussieu , 75252 Paris Cedex 05 , France
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8
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Murray MM, Kalish LA, Fleming BC, Flutie B, Freiberger C, Henderson RN, Perrone GS, Thurber LG, Proffen BL, Ecklund K, Kramer DE, Yen YM, Micheli LJ. Bridge-Enhanced Anterior Cruciate Ligament Repair: Two-Year Results of a First-in-Human Study. Orthop J Sports Med 2019; 7:2325967118824356. [PMID: 30923725 PMCID: PMC6431773 DOI: 10.1177/2325967118824356] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background Bridge-enhanced anterior cruciate ligament repair (BEAR) combines suture repair of the anterior cruciate ligament (ACL) with a specific extracellular matrix scaffold (the BEAR scaffold) that is placed in the gap between the torn ends of the ACL to facilitate ligament healing. Purpose/Hypothesis The purpose of this study was to report the 12- and 24-month outcomes of patients who underwent the BEAR procedure compared with a nonrandomized concurrent control group who underwent ACL reconstruction (ACLR) with an autograft. We hypothesized that the BEAR group would have physical examination findings, patient-reported outcomes, and adverse events that were similar to those of the ACLR group. Study Design Cohort study; Level of evidence, 2. Methods Ten patients underwent BEAR, and 10 underwent ACLR with a 4-stranded hamstring autograft. At 24 months, 9 of the 10 BEAR patients and 7 of the 10 ACLR patients completed a study visit. Outcomes reported included International Knee Documentation Committee (IKDC) subjective and objective results, knee anteroposterior (AP) laxity findings via an arthrometer, and functional outcomes. Results There were no graft or repair failures in the first 24 months after surgery. The IKDC subjective scores in both groups improved significantly from baseline (P < .0001) at 12 and 24 months, to 84.6 ± 17.2 in the ACLR group and to 91.7 ± 11.7 in the BEAR group. An IKDC objective grade of A (normal) was found in 44% of patients in the BEAR group and in 29% of patients in the ACLR group at 24 months; no patients in either group had C (abnormal) or D (severely abnormal) grades. Arthrometer testing demonstrated mean side-to-side differences in AP laxity that were similar in the 2 groups at 24 months (BEAR, 1.94 ± 2.08 mm; ACLR, 3.14 ± 2.66 mm). Functional hop testing results were similar in the 2 groups at 12 and 24 months after surgery. Hamstring strength indices were significantly higher in the BEAR group compared with the ACLR group (P = .0001). Conclusion In this small, first-in-human study, BEAR produced similar outcomes to ACLR with a hamstring autograft. BEAR may result in knee stability and patient-reported outcomes at 2 years sufficient to warrant longer term studies of efficacy in larger groups of patients.
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Affiliation(s)
- Martha M Murray
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Leslie A Kalish
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Brett Flutie
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christina Freiberger
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael N Henderson
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gabriel S Perrone
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Laura G Thurber
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benedikt L Proffen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yi-Meng Yen
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
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9
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Li Y, Fu SC, Cheuk YC, Song G, Feng H, Yung SH. The non-reconstructive treatment of complete ACL tear with biological enhancement in clinical and preclinical studies: A systematic review. Asia Pac J Sports Med Arthrosc Rehabil Technol 2018; 14:10-16. [PMID: 30302314 PMCID: PMC6170796 DOI: 10.1016/j.asmart.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/28/2018] [Accepted: 04/09/2018] [Indexed: 01/15/2023] Open
Abstract
Introduction There is still controversy regarding the bio-enhanced non-reconstructive ACL treatment. Materials and methods A search for articles in databases was performed in February 2017. The objective and subjective evaluations of clinical studies and biomechanical and histological data of preclinical studies were extracted. Results Eighteen articles were included for analysis. In clinical studies, although subjective scores were significantly improved, the rate of re-operation rate was high. In preclinical studies, bio-enhancing techniques demonstrated promotion of the healing of ACL. Conclusions The efficacy of biological enhancement cannot be validated in clinical studies. Preclinical studies showed improved biomechanical and healing potential.
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Affiliation(s)
- Yue Li
- Sports Medicine Service, Beijing Jishuitan Hospital, China
| | - Sai Cheun Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, China.,Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Yau Chuk Cheuk
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, China.,Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Guanyang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, China
| | - Shu-Hang Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, China.,Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong, China
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10
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van Eck CF, Limpisvasti O, ElAttrache NS. Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review. Am J Sports Med 2018; 46:2291-2298. [PMID: 28783472 DOI: 10.1177/0363546517717956] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Renewed interest has arisen in arthroscopic anterior cruciate ligament (ACL) repair techniques. HYPOTHESIS ACL repair with or without some form of internal bracing could lead to good outcomes in a carefully selected subset of patients. STUDY DESIGN Systematic review. METHODS An electronic database search was performed to identify 89 papers describing preclinical and clinical studies on the outcome of ACL repair. RESULTS Proximal ACL tear patterns showed a better healing potential with primary repair than distal or midsubstance tears. Some form of internal bracing increased the success rate of ACL repair. Improvement in the biological characteristics of the repair was obtained by bone marrow access by drilling tunnels or microfracture. Augmentation with platelet-rich plasma was beneficial only in combination with a structural scaffold. Skeletally immature patients had the best outcomes. Acute repair offered improved outcomes with regard to load, stiffness, laxity, and rerupture. CONCLUSION ACL repair may be a viable option in young patients with acute, proximal ACL tears. The use of internal bracing, biological augmentation, and scaffold tissue may increase the success rate of repair.
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Affiliation(s)
| | - Orr Limpisvasti
- Kerlan Jobe Orthopaedic Clinic, Los Angeles, California, USA
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Hackethal J, Mühleder S, Hofer A, Schneider KH, Prüller J, Hennerbichler S, Redl H, Teuschl A. An Effective Method ofAtelocollagenType 1/3 Isolation from Human Placenta and ItsIn VitroCharacterization in Two-Dimensional and Three-Dimensional Cell Culture Applications. Tissue Eng Part C Methods 2017; 23:274-285. [DOI: 10.1089/ten.tec.2017.0016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Johannes Hackethal
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Severin Mühleder
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Alexandra Hofer
- Research Area Biochemical Engineering, Institute of Chemical Engineering, Vienna University of Technology, Vienna, Austria
| | - Karl Heinrich Schneider
- Center of Biomedical Research, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
| | - Johanna Prüller
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Department of Biochemical Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
| | - Simone Hennerbichler
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Red Cross Blood Transfusion Service of Upper Austria, Linz, Austria
| | - Heinz Redl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Andreas Teuschl
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Department of Biochemical Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
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Murray MM, Flutie BM, Kalish LA, Ecklund K, Fleming BC, Proffen BL, Micheli LJ. The Bridge-Enhanced Anterior Cruciate Ligament Repair (BEAR) Procedure: An Early Feasibility Cohort Study. Orthop J Sports Med 2016; 4:2325967116672176. [PMID: 27900338 PMCID: PMC5120682 DOI: 10.1177/2325967116672176] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: This study assessed the safety of the newly developed bridge-enhanced anterior cruciate ligament (ACL) repair (BEAR), which involves suture repair of the ligament combined with a bioactive scaffold to bridge the gap between the torn ligament ends. As the intra-articular environment is complex in its response to implanted materials, this study was designed to determine whether there would be a significant rate of adverse reaction to the implanted scaffold. Hypothesis: The primary hypothesis was that the implanted scaffold would not result in a deep joint infection (arthrocentesis with positive culture) or significant inflammation (clinical symptoms justifying arthrocentesis but negative culture). The secondary hypotheses were that patients treated with BEAR would have early postoperative outcomes that were similar to patients treated with ACL reconstruction with an autologous hamstring graft. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 20 patients were enrolled in this nonrandomized, first-in-human study. Ten patients received BEAR treatment and 10 received a hamstring autograft ACL reconstruction. The BEAR procedure was performed by augmenting a suture repair with a proprietary scaffold, the BEAR scaffold, placed in between the torn ends of the ACL at the time of suture repair. The BEAR scaffold is to our knowledge the only device that fills the gap between the torn ligament ends to have current Investigational Device Exemption approval from the Food and Drug Administration. Ten milliliters of autologous whole blood were added to the scaffold prior to wound closure. Outcomes were assessed at 3 months postoperatively. The outcomes measures included postoperative pain, muscle atrophy, loss of joint range of motion, and implant failure (designated by an International Knee Documentation Committee grade C or D Lachman test and/or an absence of continuous ACL tissue on magnetic resonance images). Results: There were no joint infections or signs of significant inflammation in either group. There were no differences between groups in effusion or pain, and no failures by Lachman examination criteria (BEAR, 8 grade A and 2 grade B; ACL reconstruction, 10 grade A). Magnetic resonance images from all of the BEAR and ACL-reconstructed patients demonstrated a continuous ACL or intact graft. In addition, hamstring strength at 3 months was significantly better in the BEAR group than in the hamstring autograft group (mean ± SD: 77.9% ± 14.6% vs 55.9% ± 7.8% of the contralateral side; P < .001). Conclusion: The results of this study suggest that the BEAR procedure may have a rate of adverse reactions low enough to warrant a study of efficacy in a larger group of patients.
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Affiliation(s)
- Martha M Murray
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, USA
| | - Brett M Flutie
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, USA
| | - Leslie A Kalish
- Clinical Research Center, Boston Children's Hospital Boston, Massachusetts, USA
| | - Kirsten Ecklund
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Benedikt L Proffen
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, USA
| | - Lyle J Micheli
- Division of Sports Medicine, Department of Orthopaedic Surgery, Boston Children's Hospital Boston, Massachusetts, USA
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13
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Taylor SA, Khair MM, Roberts TR, DiFelice GS. Primary Repair of the Anterior Cruciate Ligament: A Systematic Review. Arthroscopy 2015; 31:2233-47. [PMID: 26165465 DOI: 10.1016/j.arthro.2015.05.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 04/13/2015] [Accepted: 05/13/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the clinical and preclinical research conducted on primary repair of the anterior cruciate ligament (ACL) during the past 10 years. METHODS A systematic search of PubMed, the Cochrane Central Register of Controlled Trials, and Embase was performed for all English-language studies published between 2003 and April 2014 on primary repair of the ACL. RESULTS Twenty-six studies met the inclusion and exclusion criteria. In the clinical research group, 8 studies (166 patients; age range, 10 to 71 years) met the inclusion and exclusion criteria and were largely long-term clinical outcome studies, based on the original cohorts from the 1970s and 1980s, and suggested high failure rates, additional surgery, and revision for instability. A subset of patients, however, achieved good to excellent subjective and objective long-term outcomes. In the preclinical research group, 18 studies met the inclusion and exclusion criteria and were based on an ACL transection model; they suggested that (1) stabilization of the knee with an internal suture strut improved the healing and biomechanical properties of the repaired ACL, (2) "enhancing" the repair with biological collagen-platelet composite augmentation improved healing and mechanical strength, (3) younger age and skeletal immaturity seem to correlate with improved histologic healing and biomechanical properties, (4) enhanced primary repair of the ACL may reduce post-traumatic osteoarthritis, and (5) the native ACL biomechanically outperformed the repaired ACL. CONCLUSIONS Although long-term human studies suggest collectively unacceptable outcomes for open primary repair of the ACL, a subset of patients achieved acceptable long-term results. ACL transection model animal studies showed improved healing and biomechanics with primary suture repair stabilization, early intervention, biological augmentation techniques, and younger age. Primary repair of the ACL may be an effective treatment modality for an appropriately selected subset of patients. LEVEL OF EVIDENCE Level IV, systematic review of preclinical and clinical Level IV studies.
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Affiliation(s)
- Samuel A Taylor
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A
| | - M Michael Khair
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A
| | - Timothy R Roberts
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A
| | - Gregory S DiFelice
- Orthopaedic Trauma and Sports Medicine Services, Hospital for Special Surgery, New York, New York, U.S.A..
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Fleming BC, Proffen BL, Vavken P, Shalvoy MR, Machan JT, Murray MM. Increased platelet concentration does not improve functional graft healing in bio-enhanced ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23:1161-70. [PMID: 24633008 PMCID: PMC4167989 DOI: 10.1007/s00167-014-2932-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 03/04/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE The use of an extracellular matrix scaffold (ECM) combined with platelets to enhance healing of an anterior cruciate ligament (ACL) graft ("bio-enhanced ACL reconstruction") has shown promise in animal models. However, the effects of platelet concentration on graft healing remain unknown. The objectives of this study were to determine whether increasing the platelet concentration in the ECM scaffold would (1) improve the graft biomechanical properties and (2) decrease cartilage damage after surgery. METHODS Fifty-five adolescent minipigs were randomized to five treatment groups: untreated ACL transection (n = 10), conventional ACL reconstruction (n = 15) and bio-enhanced ACL reconstruction using 1× (n = 10), 3× (n = 10) or 5× (n = 10) platelet-rich plasma. The graft biomechanical properties, anteroposterior (AP) knee laxity, graft histology and macroscopic cartilage integrity were measured at 15 weeks. RESULTS The mean linear stiffness of the bio-enhanced ACL reconstruction procedure using the 1× preparation was significantly greater than traditional reconstruction, while the 3× and 5× preparations were not. The failure loads of all the ACL-reconstructed groups were equivalent but significantly greater than untreated ACL transection. There were no significant differences in the Ligament Maturity Index or AP laxity between reconstructed knees. Macroscopic cartilage damage was relatively minor, though significantly less when the ECM-platelet composite was used. CONCLUSIONS Only the 1× platelet concentration improved healing over traditional ACL reconstruction. Increasing the platelet concentration from 1× to 5× in the ECM scaffold did not further improve the graft mechanical properties. The use of an ECM-platelet composite decreased the amount of cartilage damage seen after ACL surgery.
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Affiliation(s)
- Braden C Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI, USA,
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Embroidered polymer-collagen hybrid scaffold variants for ligament tissue engineering. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2014; 43:290-9. [PMID: 25175216 DOI: 10.1016/j.msec.2014.07.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 05/03/2014] [Accepted: 07/02/2014] [Indexed: 01/14/2023]
Abstract
Embroidery techniques and patterns used for scaffold production allow the adaption of biomechanical scaffold properties. The integration of collagen into embroidered polylactide-co-caprolactone [P(LA-CL)] and polydioxanone (PDS) scaffolds could stimulate neo-tissue formation by anterior cruciate ligament (ACL) cells. Therefore, the aim of this study was to test embroidered P(LA-CL) and PDS scaffolds as hybrid scaffolds in combination with collagen hydrogel, sponge or foam for ligament tissue engineering. ACL cells were cultured on embroidered P(LA-CL) and PDS scaffolds without or with collagen supplementation. Cell adherence, vitality, morphology and ECM synthesis were analyzed. Irrespective of thread size, ACL cells seeded on P(LA-CL) scaffolds without collagen adhered and spread over the threads, whereas the cells formed clusters on PDS and larger areas remained cell-free. Using the collagen hydrogel, the scaffold colonization was limited by the gel instability. The collagen sponge layers integrated into the scaffolds were hardly penetrated by the cells. Collagen foams increased scaffold colonization in P(LA-CL) but did not facilitate direct cell-thread contacts in the PDS scaffolds. The results suggest embroidered P(LA-CL) scaffolds as a more promising basis for tissue engineering an ACL substitute than PDS due to superior cell attachment. Supplementation with a collagen foam presents a promising functionalization strategy.
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Jeong IH, Shetty AA, Kim SJ, Jang JD, Kim YJ, Chung YG, Choi NY, Liu CH. Autologous Collagen-Induced Chondrogenesis Using Fibrin and Atelocollagen Mixture. Cells Tissues Organs 2013; 198:278-88. [DOI: 10.1159/000356488] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2013] [Indexed: 11/19/2022] Open
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Fleming BC, Magarian EM, Harrison SL, Paller DJ, Murray MM. Collagen scaffold supplementation does not improve the functional properties of the repaired anterior cruciate ligament. J Orthop Res 2010; 28:703-9. [PMID: 20058276 PMCID: PMC2858260 DOI: 10.1002/jor.21071] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Primary suture anterior cruciate ligament (ACL) repair was abandoned in favor of reconstruction due to a high rate of clinical failures. However, the insertion of a collagen scaffold loaded with platelets into the wound at the time of suture repair ("enhanced primary repair") has been shown to improve functional healing in animal models. Our objectives were to determine if using a collagen scaffold alone (without platelets) would be sufficient to increase the structural properties of the repaired ACL and decrease postoperative knee laxity compared to suture repair without the scaffold. Eight Yucatan minipigs underwent bilateral ACL transection and suture repair. In one knee, the repair was augmented with a collagen scaffold (SCAFFOLD group) while the other had suture alone (SUTURE group). After 13 weeks of healing, knee joint laxity and the structural properties of the ACL were measured. The addition of the collagen scaffold to suture repair of a transected ACL did not significantly improve the mean anteroposterior knee laxity [SCAFFOLD vs. SUTURE: 6.1 +/- 1.4 vs. 4.4 +/- 2.0 mm (p = 0.07), 8.1 +/- 2.0 vs. 7.6 +/- 2.0 mm (p = 0.66), and 6.2 +/- 1.2 vs. 6.1 +/- 1.8 mm (p = 0.85) at 30 degrees, 60 degrees, and 90 degrees flexion, respectively]. Likewise, there were no significant differences in the structural properties [SCAFFOLD vs. SUTURE: 367 +/- 185.9 vs. 322 +/- 122.0N (p = 0.66) and 90.7 +/- 29.5 vs. 85.0 +/- 30.3N/mm (p = 0.74) for the yield load and linear stiffness, respectively]. The use of a collagen scaffold alone to enhance suture repair of the ACL was ineffective in this animal model. Future work will be directed at stimulating biological activity in the scaffold.
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Affiliation(s)
- Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI 02903
| | - Elise M. Magarian
- Department of Orthopaedic Surgery, Children’s Hospital of Boston, Harvard Medical School, Boston, MA 02115
| | - Sophia L. Harrison
- Department of Orthopaedic Surgery, Children’s Hospital of Boston, Harvard Medical School, Boston, MA 02115
| | - David J. Paller
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, RI 02903
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Children’s Hospital of Boston, Harvard Medical School, Boston, MA 02115
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