Induction of tendon and ligament formation by carbon implants

Synthetic grafts for anterior cruciate ligament reconstructive surgery

The quest for a good and durable substitute to anterior cruciate ligament (ACL) is driving scientists to explore new promising areas of research. Autologous and allogenic ligament reconstruction bring satisfactory results in managing ACL surgery although their use is associated with significant drawbacks. To overcome the limitations of biologic grafts, many artificial devices have been developed and implanted as a substitute to the native ACL over the past decades. Although many synthetic grafts used in the past have been withdrawn from the market due to early mechanical failures ultimately leading to synovitis and osteoarthritis, there is recently a resurgence of interest in the use of synthetic ligaments for ACL reconstruction. However, this new generation of artificial ligaments, despite promising initial results, have shown to produce serious side effects such as high rupture rates, insufficient tendon-bone healing and loosening. For these reasons, recent advancements in biomedical engineering are focusing on improving technical features of artificial ligaments combining mechanical properties to biocompatibility. Bioactive coatings and surface modification methods have been proposed to enhance synthetic ligament biocompatibility and promote osseointegration. The path to the development of a safe and effective artificial ligament is still full of challenges, however recent advancements are leading the way towards a tissue-engineered substitute to the native ACL.

Reproduction of the Mechanical Behavior of Ligament and Tendon for Artificial Joint Using Bioinspired 3D Braided Fibers

The level of joint laxity, which is an indicator of accurate diagnosis for musculoskeletal conditions is manually determined by a physician. Studying joint laxity via artificial joints is an efficient and economical way to improve patient experience and joint proficiency. However, most of study focus on the joint geometry but are inadequate with regard to the tailored mechanical properties of soft tissues. On the basis of collagen fibril deformation, this study proposes bioinspired 3D fibers braided from polyethene multifilament for the reproduction of the controlled nonlinear behavior of ligaments and tendons. Four braided bands are designed, all showing biological behaviors. Two knot-based bands exhibit large toe strains of 10.98% and 5.33% but low linear modulus of 239.84 MPa and 826.05 MPa. The other two bands without knots exhibit lower toe strains of 1.61% and 1.52% but high linear modulus of 2605.27 MPa and 2050.74 MPa. Empirical formulas for braiding parameters (wales and courses) and mechanical properties are expressed to provide a theoretical basis for the mimicry of different tissues in the human body by artificial joints. All parameters have significant effects on the linear region of the load-displacement curve of a fiber due to braided structure, while changing the number of wales facilitates a major contribution to the toe region. A biofidelic human knee has been successfully reconstructed by using bioinspired 3D braided fibers. This study demonstrates that the nonlinear mechanical properties of soft tissues can be replicated by bioinspired 3D braided fibers, further yielding the design of more biomechanically realistic artificial joints.

Biocompatibility and Application of Carbon Fibers in Heart Valve Tissue Engineering

The success of tissue-engineered heart valves rely on a balance between polymer degradation, appropriate cell repopulation, and extracellular matrix (ECM) deposition, in order for the valves to continue their vital function. However, the process of remodeling is highly dynamic and species dependent. The carbon fibers have been well used in the construction industry for their high tensile strength and flexibility and, therefore, might be relevant to support tissue-engineered hearts valve during this transition in the mechanically demanding environment of the circulation. The aim of this study was to assess the suitability of the carbon fibers to be incorporated into tissue-engineered heart valves, with respect to optimizing their cellular interaction and mechanical flexibility during valve opening and closure. The morphology and surface oxidation of the carbon fibers were characterized by scanning electron microscopy (SEM). Their ability to interact with human adipose-derived stem cells (hADSCs) was assessed with respect to cell attachment and phenotypic changes. hADSCs attached and maintained their expression of stem cell markers with negligible differentiation to other lineages. Incorporation of the carbon fibers into a stand-alone tissue-engineered aortic root, comprised of jet-sprayed polycaprolactone aligned carbon fibers, had no negative effects on the opening and closure characteristics of the valve when simulated in a pulsatile bioreactor. In conclusion, the carbon fibers were found to be conducive to hADSC attachment and maintaining their phenotype. The carbon fibers were sufficiently flexible for full motion of valvular opening and closure. This study provides a proof-of-concept for the incorporation of the carbon fibers into tissue-engineered heart valves to continue their vital function during scaffold degradation.

Chitosan/hydroxyapatite modified carbon/carbon composites: synthesis, characterization and in vitro biocompatibility evaluation

Carbon/carbon composite (C/C), due to its bio-inert property, is prone to cause bone consolidation defects and bacterial infections in clinical applications. Therefore, there is a great demand in practical applications to prevent implant infections and enhance its bone consolidation capability. In this study, we have developed a facile approach to construct a chitosan/hydroxyapatite composite modified layer on C/C surface by electrochemical deposition and a covalent grafting technique, and the modified layer has both the antibacterial activity of chitosan (CS) and the bioactivity of hydroxyapatite (HAP). The microstructure and chemical composition of the modified layer were analyzed using scanning electron microscopy (SEM), Fourier transform infrared (FTIR) spectroscopy, X-ray photoelectron spectroscopy (XPS) and water contact angle measurements. The biological properties of the composites were evaluated using cell culture, antimicrobial test and real-time quantitative PCR in vitro. The results showed that the CS/HAP modified C/C exhibited excellent biocompatibility, bacteriostasis and osteoinductive ability. These properties are beneficial for the potential application of the modified C/C composite as a bone tissue replacement material.

Carbon/carbon composite (C/C), due to its bio-inert property, is prone to cause bone consolidation defects and bacterial infections in clinical applications.

Use of intramedullary carbon fiber nail in hindfoot fusion: A small cohort study

BACKGROUND

Current literature on carbon fiber implant use in foot and ankle surgery is scant. The purpose of this paper is to report medium-term outcomes of hindfoot fusion using a carbon fiber intramedullary nail.

METHODS

We retrospectively reviewed 30 cases of hindfoot fusion using carbon fiber intramedullary nail fixation between 2014 and 2017. We excluded revisions and cases with bulk allograft or ankle infection prior to surgery. We reviewed charts for length of followup, radiographic union, and complications.

RESULTS

Eleven patients were included (6 females, 5 males; mean age=52±15years; mean BMI=29.0±6.4kg/m²). Mean followup was 20 (range, 1.5-107) months. Nine of eleven cases achieved radiographic union while one case developed a complication requiring surgery. The mean time to union was 3 (range, 1.5-6) months.

CONCLUSIONS

Carbon fiber implants offer several theoretical advantages over traditional metallic implants. They can be used safely in foot and ankle surgery without concern for high failure or complication rate. Larger scale studies with longer followup are needed on this topic.

Carbon Nanofiber Reinforced Nonmulberry Silk Protein Fibroin Nanobiocomposite for Tissue Engineering Applications

Natural silk protein fibroin based biomaterial are exploited extensively in tissue engineering due to their aqueous preparation, slow biodegradability, mechanical stability, low immunogenicity, dielectric properties, tunable properties, sufficient and easy availability. Carbon nanofibers are reported for their conductivity, mechanical strength and as delivery vehicle of small molecules. Limited evidence about their cytocompatibility and their poor dispersibility are the key issues for them to be used as successful biomaterials. In this study, carbon nanofiber is functionalized and dispersed using the green aqueous-based method within the regenerated nonmulberry (tropical tasar: Antheraea mylitta) silk fibroin (AmF), which contains inherent - R-G-D- sequences. Carbon nanofiber (CNF) reinforced silk films are fabricated using solvent evaporation technique. Different biophysical characterizations and cytocompatibility of the composite matrices are assessed. The investigations show that the presence of the nanofiber greatly influence the property of the composite films in terms of excellent conductivity (up to 6.4 × 10^-6 Mho cm, which is 3 orders of magnitude of pure AmF matrix), and superior tensile modulus (up to 1423 MPa, which is 12.5 times more elastic than AmF matrix). The composite matrices (composed of up to 1 mg of CNF per mL of 2% AmF) also support better fibroblast cell growth and proliferation. The fibroin-carbon nanofiber matrices can lead to a novel multifunctional biomaterial platform, which will support conductive as well as load bearing tissue (such as, muscle, bone, and nerve tissue) regenerations.

Efficacy of brow suspension with autogenous fascia lata in simple congenital ptosis

Objective:

To assess the mean change in interpalpebral fissure height and marginal reflex distance after brow suspension with autogenous fascia lata sling in patients of ptosis.

Methods:

This was a Quasi experimental study conducted at Department of Ophthalmology, Mayo Hospital, King Edwards Medical University Lahore, from Jan 2013 to June 2016. Included were the patients who had unilateral or bilateral ptosis with poor levator function (< 5 mm). Informed consent was obtained from all patients after explaining about the research project. Patients were admitted in ward and all of them underwent surgery by a single surgical team. The surgical procedure was performed in supine position under general anesthesia in children and uncooperative patients. Patients were followed at week 4, 8, 12 and 24 to observe vertical interpalpebral fissure height and marginal reflex distance.

Results:

The mean age of the patients was 9.03 ± 5.26 years. The mean Inter palpebral fissure height (IPFH) was 4.40±0.91 mm and mean MRD was 0.50 ± 1.00 mm before surgery while after surgery it was 7.41±0.76 mm and 3.10 ± 1.50 mm respectively at 04 weeks. The mean IPFH and MRD at 24 weeks postoperatively were 8.43±0.98 mm and 3.60 + 1.50 mm respectively. The mean change in IPFH and MRD at 24^th week, were 3.90 ± 0.34 mm and 3.50 ± 1.00 mm.

Conclusion:

Brow suspension with fascia lata sling is safe and effective technique for correction of ptosis with poor levator function.

Long-term clinical and experimental/surface analytical studies of carbon/carbon maxillofacial implants

Background

Over the past 30–40 years, various carbon implant materials have become more interesting, because they are well accepted by the biological environment. The traditional carbon-based polymers give rise to many complications. The polymer complication may be eliminated through carbon fibres bound by pyrocarbon (carbon/carbon). The aim of this study is to present the long-term clinical results of carbon/carbon implants, and the results of the scanning electron microscope and energy dispersive spectrometer investigation of an implant retrieved from the human body after 8 years.

Methods

Mandibular reconstruction (8–10 years ago) was performed with pure (99.99 %) carbon implants in 16 patients (10 malignant tumours, 4 large cystic lesions and 2 augmentative processes). The long-term effect of the human body on the carbon/carbon implant was investigated by comparing the structure, the surface morphology and the composition of an implant retrieved after 8 years to a sterilized, but not implanted one.

Results

Of the 16 patients, the implants had to be removed earlier in 5 patients because of the defect that arose on the oral mucosa above the carbon plates. During the long-term follow-up, plate fracture, loosening of the screws, infection or inflammations around the carbon/carbon implants were not observed. The thickness of the carbon fibres constituting the implants did not change during the 8-year period, the surface of the implant retrieved was covered with a thin surface layer not present on the unimplanted implant. The composition of this layer is identical to the composition of the underlying carbon fibres. Residual soft tissue penetrating the bulk material between the carbon fibre bunches was found on the retrieved implant indicating the importance of the surface morphology in tissue growth and adhering implants.

Conclusions

The surface morphology and the structure were not changed after 8 years. The two main components of the implant retrieved from the human body are still carbon and oxygen, but the amount of oxygen is 3–4 times higher than on the surface of the reference implant, which can be attributed to the oxidative effect of the human body, consequently in the integration and biocompatibility of the implant. The clinical conclusion is that if the soft part cover is appropriate, the carbon implants are cosmetically and functionally more suitable than titanium plates.

Surface analytical studies of maxillofacial implants: influence of the preoperational treatment and the human body on the surface properties of retrieved implants

In the present work, surface analytical investigation of unimplanted as well as retrieved pyrolytic carbon-covered carbon/carbon composite implants and Ti osteosynthesis plates is reported. The Ti plates were covered by a 200-nm-thick, anodically and thermally formed TiO2 layer. Our results suggest that although the oxide layer on the Ti miniplates remained stable during the time spent in the human body, there is still material transport between the implant and the human body. In case of the carbon/carbon composite implants, damage of the carbon fibers constituting the material was found on one side of the sterile implant and attributed to the manufacturing process. The NaCl crystals originally present on the surface of the sterile material disappeared during the time spent in the human body. As a result of the interaction with the human body, a new surface layer (mainly constituted of carbon) appeared on the implant. The results indicate that both the time spent in the human organism and the preparation of the implants before operation can have detectable effects on the investigated surface properties. Surface analytical investigations could therefore provide information not only about the biocompatibility of these materials but also about the effect of their treatment before operation.

History and performance of implant materials applied as peritendinous antiadhesives

Peritendinous fibrotic adhesions after tendon surgery are still a problem up-to-date. Approaches to overcome or at least minimize adhesion formation include implantation of barrier materials, application of lubricants or combinations of materials and functionalized drugs that are controllably released and support the healing tendon to glide and achieve the full range of motion after regeneration. Although a huge amount of different materials have been experimentally tested, the optimal strategy with respect to material and method has not yet been determined. In this review, we present a historical overview of physical barriers as well as liquid agents that have been used in order to prevent peritendinous adhesion formation. The materials are divided according to their first publication into two time frames; before and after 1980. There is no claim to include all materials tested neither will the "best" material be chosen; however, we present several materials that were experimentally tested in different animal trials as well as in clinical trials in contrast to other materials that were only tested once and disappeared from the assortment of anti-adhesives; which as such is a valuable information about its applicability for this purpose.

SEM and EDS investigation of a pyrolytic carbon covered C/C composite maxillofacial implant retrieved from the human body after 8 years

The long term effect of the human body on a pyrolytic carbon covered C/C composite maxillofacial implant (CarBulat(Tm)) was investigated by comparing the structure, the surface morphology and composition of an implant retrieved after 8 years to a sterilized, but not implanted one. Although the thickness of the carbon fibres constituting the implants did not change during the 8 year period, the surface of the implant retrieved was covered with a thin surface layer not present on the unimplanted implant. The composition of this layer is identical to the composition of the underlying carbon fibres. Calcium can only be detected on the surface as a trace element implying that the new layer is not formed by bone tissue. Residual soft tissue penetrating the bulk material between the carbon fibre bunches was found on the retrieved implant indicating the importance of the surface morphology in tissue growth and adhering to implants.

Microbial fuel cell as power supply for implantable medical devices: a novel configuration design for simulating colonic environment

This study focused on providing power for implantable medical devices (IMDs) using a microbial fuel cell (MFC) implanted in human transverse colon. Considering the condition of colonic environment, a continuous-flow single-chamber MFC without membrane was set up. The performance of the MFC was investigated. The power output of 1.6 mW under the steady state was not rich enough for some high energy-consuming IMDs. Moreover, the parameters of the simulated colonic environment, such as pH and ORP value, varied along with the time. Hence, a new MFC configuration was developed. In this novel model, pH transducers were placed in cathodic and anodic areas, so as to regulate the reactor operation timely via external intervention. And two ORP transducers were inserted next to the pH transducers, for monitoring and adjusting the MFC operation efficiently. Besides, colonic haustra were designed in order to increase the difference between cathodic and anodic areas.

Regeneration and repair of tendon and ligament tissue using collagen fibre biomaterials

Collagen fibres are ubiquitous macromolecular assemblies in nature, providing the structures that support tensile mechanical loads within the human body. Aligned type I collagen fibres are the primary structural motif for tendon and ligament, and therefore biomaterials based on these structures are considered promising candidates for mediating regeneration of these tissues. However, despite considerable investigation, there remains no collagen-fibre-based biomaterial that has undergone clinical evaluation for this application. Recent research in this area has significantly enhanced our understanding of these complex and challenging biomaterials, and is reinvigorating interest in the development of such structures to recapitulate mechanical function. In this review we describe the progress to date towards a ligament or tendon regeneration template based on collagen fibre scaffolds. We highlight reports of particular relevance to the development of the underlying biomaterials science in this area. In addition, the potential for tailoring and manipulating the interactions between collagen fibres and biological systems, as hybrid biomaterial-biological ensembles, is discussed in the context of developing novel tissue engineering strategies for tendon and ligament.

In vitro and in vivo studies on biocompatibility of carbon fibres

In the present study we focused on the in vitro and in vivo evaluation of two types of carbon fibres (CFs): hydroxyapatite modified carbon fibres and porous carbon fibres. Porous CFs used as scaffold for tissues regeneration could simultaneously serve as a support for drug delivery or biologically active agents which would stimulate the tissue growth; while addition of nanohydroxyapatite to CFs precursor can modify their biological properties (such as bioactivity) without subsequent surface modifications, making the process cost and time effective. Presented results indicated that fibre modification with HAp promoted formation of apatite on the fibre surface during incubation in simulated body fluid. The materials biocompatibility was determined by culturing human osteoblast-like cells of the line MG 63 in contact with both types of CFs. Both tested materials gave good support to adhesion and growth of bone-derived cells. Materials were implanted into the skeletal rat muscle and a comparative analysis of tissue reaction to the presence of the two types of CFs was done. Activities of marker metabolic enzymes: cytochrome c oxidase (CCO) and acid phosphatase were examined to estimate the effect of implants on the metabolic state of surrounding tissues. Presented results evidence the biocompatibility of porous CFs and activity that stimulates the growth of connective tissues. In case of CFs modified with hydroxyapatite the time of inflammatory reaction was shorter than in case of traditional CFs.

Anterior cruciate ligament reconstruction with synthetic grafts. A review of literature

Anterior cruciate ligament (ACL) rupture, one of the most common knee injuries in sports, results in anteroposterior laxity, which often leads to an unstable knee. Traditional ACL reconstruction is performed with autograft; disadvantages of this technique are donor site morbidity and a long rehabilitation period. In the 1980s, artificial ligaments became an attractive alternative to biological grafts. The initial enthusiasm surrounding their introduction stemmed from their lack of donor morbidity, their abundant supply and significant strength, immediate loading and reduced postoperative rehabilitation. Synthetic grafts made of different materials such as carbon fibers, polypropylene, Dacron and polyester have been utilised either as a prosthesis or as an augmentation for a biological ACL graft substitute. Nevertheless, every material presented serious drawbacks: cross-infections, immunological responses, breakage, debris dispersion leading to synovitis, chronic effusions, recurrent instability and knee osteoarthritis. Recently, a resurgence of interest in the use of synthetic prostheses has occurred and studies regarding new artificial grafts have been reported. Although many experimental studies have been made and much effort has been put forth, currently no ideal prosthesis mimicking natural human tissue has been found.

Use of soft tissue matrices as an adjunct to achilles repair and reconstruction

The Achilles tendon is the thickest and strongest tendon in the human body. In spite of this, it is also one of the most frequently ruptured tendons. This article reviews the history of and debate about the appropriate course of treatment. A case study of an Achilles repair illustrates that the use soft tissue matrices is a successful adjunct to both the primary repair and gastrocnemius recession, with full return to activity and no inflammatory response at long-term follow up. The authors anticipate that the use of soft tissue matrices for the repair of tendon and soft tissue defects will expand over time as this material has distinct advantages over synthetics and highly crosslinked biologic materials.

Alignment of Osteoblast-Like Cells and Cell-Produced Collagen Matrix Induced by Nanogrooves

Alignment of bone cells and collagen matrix is closely related to the anisotropic mechanical properties of bone. Intact scaffolds that promote osteoblast differentiation and mineralization in the preferred direction offer promise in the generation of biomimetic bone tissue. In this study, we examined the alignment of osteoblast-like cells and collagen fibers guided by nanogrooves. Nanoscale groove-ridge patterns (approximately 300 nm in periodicity, 60-70 nm in depth) on the surface of polystyrene (PS) were made by polarized Nd:YAG laser irradiation, at a wavelength of 266 nm. The influence of such "nanoscale features" on the orientation and alignment of cells and their mineralized collagen matrix was investigated, using rabbit mesenchymal stem cell (MSC)-derived osteoblast-like cells. The cells and actin stress fibers were aligned and elongated along the direction of the nanogrooves. In addition, the alignment of collagen matrix was also influenced by underlying nanogrooves. The results suggested that nanoscale fibrous cues in the longitudinal direction might contribute to the aligned formation of bone tissue. This may provide an effective approach for constructing biomimetic bone tissue.

Long-term local effects of carbon fibre in the knee

A radiological and histological analysis of five knee joints after a minimum of 15 years following the implanting of carbon fibre, which had been used as a treatment for knee instability, was undertaken. All patients underwent total knee replacement for secondary osteoarthritis. Histological analysis demonstrated a variable amount of macroscopically visible carbon particles in the synovium, hyaline cartilage and menisci. At microscopy these particles were found in association with fibrous tissue adjacent to bone with no acute inflammatory changes. No intact carbon fibre ligament was noted within the joint, small portions of the old ligament were covered with a thin fibrous layer but there was no evidence of any structure resembling neo-ligament. Extra articularly the carbon fibre was covered with a thick fibrous sheath with no active inflammation changes inflammation. In the bone tunnels, the carbon fibre-bone interface showed an apposition of the bone to the carbon fibre without any interposing fibrous sheath. Carbon fibre bonds directly with the bone without fibrous interposition.

Novel system for engineering bioartificial tendons and application of mechanical load

Cells cultured in three-dimensional collagen gels express a more native state phenotype because they form a syncytial network that can be mechanically loaded. Moreover, cells remodel their matrix by eliminating water, and by reorganizing and aligning the collagen fibrils. Last, the ability to subject cells to mechanical loading in a native matrix is desirable because cells, in tissues as well as the matrix, bear strains and alter their expression profile consistent with either immobilization, moderate activity, or repetitive loading. This is the first report of a model bioreactor system to fabricate and culture tendon cell-populated, linear, tethered matrix constructs that can be mechanically loaded by a computer-driven, pressure-controlled system. Bioartificial tissues (BATs) as tendon constructs were molded in a novel, rubber bottom Tissue Train culture plate bearing nonwoven nylon mesh anchors at the east and west poles of each culture well. Mechanical loading was achieved by placing an Arctangle loading post (an Arctangle is a rectangle with curved short ends) beneath each well of the six-well culture plate and using vacuum to displace the flexible membrane downward, resulting in uniaxial strain on the BAT. BATs populated with avian flexor tendon cells expressed collagen genes I, III, and XII as well as aggrecan, fibronectin, prolyl hydroxylase, and tenascin, consistent with expression levels of cells grown on collagen-bonded two-dimensional surfaces or in native, whole, avian flexor tendon. Likewise, cells in BATs established a morphology of linearly arranged cells aligned with the principal strain direction as in fasicles of whole tendons. Last, BATs that were mechanically loaded had an ultimate tensile strength that was nearly 3-fold greater than that of nonloaded BATs in the first week of culture. Taken together, these results indicate that tendon cells fabricated in a mechanically loaded, linear collagen gel construct assume a phenotype that is similar to that of a native tendon in terms of appearance and expression and are stronger than nonexercised counterparts yet far weaker than native adult tendons. This technique represents a novel approach to culturing cells in a mechanically active, three-dimensional culture environment that can be readily used for the fabrication of tissue simulates for drug testing or tissue engineering.

Surface pretreatments for medical application of adhesion

Medical implants and prostheses (artificial hips, tendono- and ligament plasties) usually are multi-component systems that may be machined from one of three material classes: metals, plastics and ceramics. Typically, the body-sided bonding element is bone. The purpose of this contribution is to describe developments carried out to optimize the techniques, connecting prosthesis to bone, to be joined by an adhesive bone cement at their interface. Although bonding of organic polymers to inorganic or organic surfaces and to bone has a long history, there remains a serious obstacle in realizing long-term high-bonding strengths in the in vivo body environment of ever present high humidity. Therefore, different pretreatments, individually adapted to the actual combination of materials, are needed to assure long term adhesive strength and stability against hydrolysis. This pretreatment for metal alloys may be silica layering; for PE-plastics, a specific plasma activation; and for bone, amphiphilic layering systems such that the hydrophilic properties of bone become better adapted to the hydrophobic properties of the bone cement. Amphiphilic layering systems are related to those developed in dentistry for dentine bonding. Specific pretreatment can significantly increase bond strengths, particularly after long term immersion in water under conditions similar to those in the human body. The bond strength between bone and plastic for example can be increased by a factor approaching 50 (pealing work increasing from 30 N/m to 1500 N/m). This review article summarizes the multi-disciplined subject of adhesion and adhesives, considering the technology involved in the formation and mechanical performance of adhesives joints inside the human body.

Achilles rupture in the athlete. Current science and treatment

Achilles tendon ruptures became increasingly common in the latter half of the 20th century. Once the diagnosis is made, the patient's goals and objectives should be clearly stated. The treatment choice should incorporate the patient's needs, desires, objectives, and functional goals to assure an optimal result.

Carbon fibres and plasma-preserved tendon allografts for gap repair of flexor tendon in bovines: clinical, radiological and angiographical observations

Twenty-four tenorrhaphies were performed at the mid-metatarsal region in 12 crossbred calves under xylazine-ketamine spinal analgesia. A 2.5-cm long gap was created in the superficial digital flexor (SDF) tendon and immediately repaired with carbon fibres in the animals of group I and with plasma-preserved tendon allografts in group II. Clinical examination revealed a slight increase (P > 0.05) in rectal temperature, heart and respiratory rate for 2-4 days postoperation in both groups. Milder pain and exudation as well as earlier restoration of tendon gliding movements and weight bearing were observed in group I as compared to group II. Air-tendogram in the carbon fibre group on day 30 revealed restoration of continuity across the defect of the tendon. whereas, in the allograft group, a dense homogeneous swelling was seen along the flexors. Regression of peritendinous adhesions and swelling at the reconstructed site at later stages was seen in both groups. Angiography showed hypervascularization at the reconstructed site on day 14 in the carbon fibre group, however, in the allograft group the site appeared to be relatively avascular. On days 30 and 90, blood vessels were normally organized in both groups.

Tissue engineering: the biophysical background

Tissue engineering is the construction, repair or replacement of damaged or missing tissue in humans and other animals. This engineering may take place within the animal body or as tissue constructs to be made in a bioreactor for later grafting into the animal. The minimal set of materials for this are the appropriate types of cell. Usually, however, non-living substrata are used as well. These substrata may be nothing more than materials that bulk up any voids in the damaged tissue and provide the mechanical strength that has been lost when the tissue is damaged or removed. They may serve a similar pair of functions in the bioreactor. They can do much more in terms of pattern formation. The orientations and morphology of the cells, the arrangement of intercellular material as it is laid down and the relationships between different cell types in the repairing or construct tissue are all of importance, for these should resemble the correct normal tissue as closely as possible. Most of these requirements are ones involving pattern formation. This review discusses the various ways in which tissue pattern can be engineered chiefly from a biophysical standpoint. Unpatterned cells are effectively not tissue. This engineering includes the use of topography on the substrata, chemical patterning of adhesive and other cues for the cells, mechanical force application to cause cell orientation and appropriate synthetic responses and electrical fields. The review also discusses the methods used to impart the appropriate cues to and through the materials which are often biodegradable polymers. The article gives particular attention to regions of research and practice where the involvement of the physicist or biophysicist is of importance.

Reconstruction of rabbit Achilles tendon with three bioabsorbable materials: histological and biomechanical studies

This study investigated whether three biodegradable materials, poly-N-acetyl-D-glucosamine (chitin), poly-epsilon-caprolactone (p-CL), polylactic acid (PLA), and chitin/p-CL composite could be used as scaffold implants in the reconstruction of extra-articular ligaments or tendons. Braided artificial tendons made from these materials were soaked in phosphate-buffered saline or implanted in the subcutaneous tissue of 31 Japanese white rabbits and then subjected to load at failure testing. There was no significant loss of load at failure when chitin tendons were soaked in saline for 26 weeks, but a rapid decrease occurred in vivo. The other two types of tendons showed significant loss of strength after 26 weeks both in vitro and in vivo. Another 111 rabbits were used to assess Achilles tendon reconstruction with the braided tendon implants. The tendon regeneration process was assessed macroscopically, histologically, immunohistochemically, and mechanically (maximum load at failure). Chitin showed more rapid degradation than the other materials on histological examination. There was good formation of fibrous tissue composed of type I and type III collagen around the chitin, PLA, and chitin/p-CL fibers in comparison with p-CL fibers, but chitin tendons showed more rapid loss of strength after implantation. Both PLA and the chitin/p-CL composite tendons had good initial strength and showed increased ingrowth of fibrous tissue, suggesting that these materials are promising as artificial tendons.

Achilles tendon repair using a bone-tendon graft harvested from the knee extensor system: three cases

The authors describe a new surgical technique of Achilles tendon reconstruction using bone-tendon graft from the knee extensor system. This technique is for those unusual cases of neglected or partial Achilles tendon rupture with distal tendon-substance loss at calcaneal insertion level, requiring transbone plasty fixation. Three cases are reported; the first two, followed up over a 5-year period, had excellent functional, morphological, and clinical outcomes. This new technique is compared with other available solutions: triceps plasty, other local tendon plasty, artificial plasty, and allograft.

Reactions of cells to topography

Though contact guidance has been known since the very early days of cell culture very little quantitative examination of the reaction of cells to topography has been made. Exceptions to this subjective approach are given prominence below. Yet if we are to understand how cells react and if we are to be able to design ideal substrata for particular cells we need this information. Precision and quantitation are required both of the methods of examination of the cells but also in the definition of that topography. Recently it has become clear that the these reactions occur at the nanometric scale and have importance for use in cellular engineering and tissue repair. Topography appears to provide a set of very powerful signals for cells.

Total Achilles tendon rupture. A review

There are only a few epidemiological studies on the incidence of Achilles tendon (AT) ruptures. These show an increase in incidence in the West during the past few decades. The main reason is probably the increased popularity of recreational sports among middle-aged people. Ball games constitute the cause of over 60% of AT ruptures in many series. The 2 most frequently discussed pathophysiological theories involve chronic degeneration of the tendon and failure of the inhibitory mechanism of the musculotendinous unit. There are reports of AT ruptures related to the use of corticosteroids, either systemically or locally, but the role of corticosteroids in large patient series is marginal. In addition, recent studies do not confirm earlier findings of blood group O dominance in patients with AT rupture. Comparable series have been published with surgical versus nor surgical treatment and postoperative cast immobilisation versus early functional treatment. Although conservative treatment has its own supporters, surgical treatment seems to have been the method of choice in the late 1980s and the 1990s in athletes and young people and in cases of delayed ruptures. Early ruptures in non-athletes can also be treated conservatively. In small series of compliant, well motivated patients, functional postoperative treatment has been reported to be well tolerated, safe and effective. The lack of a universal, consistent protocol for subjective and objective evaluation of AT ruptures has prevented any direct comparison of the results. The results have been often assessed according to the criteria of Lindholm or Percy and Conochie, but no scoring is available for the analysis. We assessed a new scoring method and analysed the prognostic factors related to the results. There is also no single, uniformly accepted surgical technique. Although early ruptures have been treated successfully with simple end-to-end suture, many authors have combined simple tendon suture with plastic procedures of various types. No randomised study comparing simple suture technique and repair with augmentation could be found in the literature. The major complaint against surgical treatment has been the high rate of complications. Most are minor wound complications, which delay improvement but do not influence the final outcome. Major complications are rare, but often difficult to treat with minor procedures. For instance, large postoperative skin and soft tissue defects in the Achilles region can be treated successfully with a microvascular free flap reconstruction. The complications of conservative treatment include mostly reruptures and residual lengthening of the tendon, which may result in significant calf muscle weakness. It has been postulated that a physically inactive lifestyle leads to a decrease in tendon vascularisation, while maintenance of a continuous level of activity counteracts the structural changes within the musculotendinous unit induced by inactivity and aging. Proper warm-up and stretching are essential for preventing musculotendinous injuries, but improper or excessive stretching or warming-up can predispose to these injuries.

Topographical control of cells

We review the literature on the reaction of cells to their surrounding topography. The topography may be that of surrounding cells, intercellular materials or biomaterials. The reactions include cell orientation, rates of movement, and activations of the cells. We concentrate on those papers where quantitative measurements of the reactions have been made and largely ignore those on subjective impressions. A wide range of topographies are considered but special attention is given to results on groove-ridge topographies. The question of whether the cells are reacting to the topography directly or to patterned substratum chemistry formed on the topography is discussed. The review ends with a summary of the types of prosthesis where advantage has been taken of the ability to fabricate topography.

Phagocytosis of chemically modified carbon materials

An oxidizing treatment of carbon fibres in boiling nitric acid leads to significant changes in the chemical state of their surface. As a result of the chemical treatment on a hydrophobic carbon surface, hydrophilic domains are formed and phenolic, carbonyl and carboxyl groups appear. In this work the intensity of phagocytosis of carbon fibres obtained by carbonization of polyacrylonitrile was studied both for HNO3 etched and non-etched fibres. Part of the powdered material studied was placed in plasma before it was contacted with cells. To study the material, which was first placed in plasma and then contacted with cells, X-ray photoelectron spectroscopy and Fourier transform infrared spectroscopy were used. It was found that the powders made from the etched fibres are phagocytized more intensively. It was also found that the absorption of plasma proteins enhances the phagocytosis only for the fibres oxidized in HNO3 and has no influence in the case of powders obtained from non-etched fibres.

Static and dynamic fatigue properties of carbon ligament prosthesis

The aim of the present paper was to characterize the static and dynamic mechanical properties of carbon braids used in medicine as prostheses of ligaments and tendons. A computing system (PC software) was used to register and analyze the data of mechanical tests. Tensile static tests (creep testing) were utilized to determine the failure-free value of static force. Fatigue dynamic properties of carbon braids in tensile-tensile cyclic tests including the effect of simulated body conditions were analyzed. The braids were immersed in isotonic solution at 37 degrees C. Fatigue life was markedly lowered in air in comparison with simulated body conditions. For a given value of maximum cyclic force, decreasing the minimum/maximum force ratio decreased the number of cycles to failure. The mechanical approach of fatigue behavior based on approximately maximum fatigue force and number of cycles to failure by analytical expression was given. Energy dissipation due to the hysteresis loop was considered.

Historical overview of operations for anterior cruciate ligament rupture

The evolution of the surgical management of anterior cruciate ligament rupture is critically reviewed. Special attention is paid to obsolete techniques or concepts which were once accepted with enthusiasm and important work that passed unnoticed.

Reconstruction of the anterior cruciate ligament with carbon fibres: unsatisfactory results after 8 years

A total of 37 patients were operated on for anterior cruciate ligament (ACL) insufficiency between 1980 and 1989 using two types of carbon fibre ligament substitutes. The average age of the population was 23.6 years. The carbon fibre prostheses were covered with either a strip of medial joint capsule or lyophilized dura. Follow-up averaged 8.1 years (range 4-13 years), most of the operations being done from 1983 to 1985. Evaluation included a questionnaire, physical examination, Lysholm scoring, radiographs and cruciometer testing. The operated ACLs were looser than those in the contralateral healthy knees. The Lysholm scoring system gave acceptable results (excellent and good) in 43.5%, fair in 31.4% and poor in 24.1% of cases. Acceptable results provided better stability and muscle strength. During the follow-up there was an evident deterioration in stability as well as in Lysholm score. The results between the two types of ligaments did not become statistically different. Osteoarthrosis increased in all the knees examined radiographically (28/37). The results indicate that the ACL reconstructions using these types of carbon fibre prostheses lead to unacceptable results in the long-term follow-up.

Neglected rupture of the Achilles tendon

Delayed treatment of a rupture of the Achilles tendon is a challenge. Operative treatment is generally recommended, with a variety of techniques being described to appose the tendinous ends and augment the repair.

Anterior cruciate ligament reconstruction using cryopreserved irradiated bone-ACL-bone-allograft transplants

Bone-ACL-bone allograft transplantation has been investigated as a potential solution to reconstruction of the anterior cruciate ligament (ACL). To minimize disease transmission (e.g. the acquired immuno deficiency syndrome), bony and collagenous tissues should be sterilized. Recent animal studies indicate that gamma irradiation and ethylene oxide sterilization result in diminished histological and biomechanical properties. The purpose of the present study was biomechanical and histological determination of the fate of deep-frozen gamma-irradiated (2.5 Mrad) canine bone-ACL-bone allografts with argon gas protection. Particular attention was paid to collagenous and neuroanatomical morphology 3, 6 and 12 months after implantation, by comparison to a non-irradiated control group. Sixty skeletally mature foxhounds were operated on in this study, divided up in two groups of 30 dogs each. In group A animals the ACL was replaced by a deep-frozen (-80 degrees C) bone-ACL-bone LAD-augmented allograft subjected to 2.5 Mrad gamma irradiation with argon gas protection. The animals in group B received an LAD-augmented ACL-allograft transplant without gamma irradiation. All knees from both groups were evaluated 3, 6 and 12 months after implantation in regard to biomechanical properties, collagen morphology and routine histology (haematoxylin and eosin stain, polarization microscopy), neuroanatomical morphology (silver and gold chloride stain) and microvasculature (modified Spalteholz technique). The irradiated ACL allografts withstood a maximum load that was 63.8% (718.3 N) of the maximum load of normal ACLs after 12 months. By contrast, the non-irradiated allografts failed at 69.1% (780.1 N) of the maximum load of normal control ACLs.(ABSTRACT TRUNCATED AT 250 WORDS)

Development of the Apex polyester fibre cruciate ligament implant

This paper describes the work done in developing the Apex polyester fibre cruciate ligament implant. A series of animal experiments showed that the material was the basis for good collagenous tissue ingrowth at the calcaneal tendon and within the knee joint. The rate of increase of strength of ingrowth at the calcaneal tendon was investigated. The slow maturation led to the development of a stainless steel screw and grommet anchorage system, which was also tested in vitro. A long-term animal study of the clinical implant and anchor system showed the implant fibres spaced apart by prolific ingrowth, while no implant particles were found, and there was no evidence of synovitis. The tissue reactions in human use have been found to be the same as in the animals, while ultrastructural study of retrieved specimens has given evidence of long-term collagen maturation.

The repair of inguinal hernias using carbon fibre patches--a five-year follow-up

One hundred and eight inguinal hernias were treated following a standard surgical technique, using 3-mm thick loosely woven carbon-fibre patches. The average follow-up was five and a half years. There was one recurrence. Otherwise, excellent clinical results without pain were found in all but one patient and only a further three experienced a slight discomfort in the area of the implant, without any restriction on function. The technique is simple and permeation of the carbon-fibre patch by fibrous tissue showed a lasting repair.

Reconstruction of the anterior cruciate ligament

Ligaments are strong collagenous structures that act as constraints on joint motion, thus confining the articular surfaces to more or less the same paths. In so doing they prevent arbitrary apposition of these surfaces from occurring and resulting in abnormal stresses which may damage the joint surfaces. Ligaments rupture due to excessive loads, particularly those resulting from trauma occurring during sporting events or motor vehicle accidents. Knee and ankle joints have the highest frequency of ligamentous injuries. This paper is a brief review of the current approaches to the reconstruction of the knee ligaments with specific reference to the anterior cruciate ligament (ACL) being the most frequently reconstructed. This is not only because it is frequently injured but also because of the debilitating consequences of such an injury. Approaches ranging from the conservative to those that advocate the use of frank prosthetic replacement have been adopted by surgeons at both ends of the spectrum. Following a discussion of the rationale for reconstruction of the ACL, the mechanical and biological considerations of the reconstructive procedure are discussed. The different methods of ACL reconstruction are reviewed. These include: (a) primary repair, (b) reconstruction with different tissues, including autogenous allografts and xenografts, (c) reconstruction employing different synthetic devices. A brief discussion of the procedures used for reconstruction with different types of tissue and of the surviving examples of the synthetic devices will follow.

Anterior cruciate ligament allograft transplantation for intraarticular ligamentous reconstruction

A multiplicity of surgical operations have been developed in an attempt to achieve satisfactory function after anterior cruciate ligament (ACL) repair. None of these procedures have been able to reproduce the fiber organization anatomy of attachment site, vascularity, or function of the ACL. Twenty-nine foxhounds received a deep-frozen bone-ACL-bone allograft and a ligament augmentation device (LAD). Biomechanical, microvascular, and histological changes were evaluated 3, 6, and 12 months following implantation. The maximum loads of the allograft/LADs were 34.3% (387.2 N) after 3 months, 49.3% (556.6 N) after 6 months, and 61.1% (698.8 N) after a year. The maximum load was 69.1% (780 N). In general, after 6 months the allografts showed normal collagen orientation. The allografts demonstrated no evidence of infection or immune reaction. No bone ingrowth into the LAD was observed. Polarized light microscopy and periodic acid-schiff staining showed that the new bone-ligament substance interface had intact fiber orientation at the area of the ligament insertion. Microvascular examination using the Spalteholtz technique revealed revascularization and the importance of an infrapatellar fat pad for the nourishment of ACL allografts.

Repair of fibular ligaments: comparison of reconstructive techniques using plantaris and peroneal tendons

The results of treatment of chronic ligamentous insufficiency of the lateral hindfoot using plantaris tendon grafting (52 ankles) or peroneal tenodesis (128 ankles) were compared with an average followup of 66 months. In two-thirds of all cases an instability of the subtalar joint was present, isolated or combined with an instability of the talocrural joint. The overall outcome with both methods was good, but the results after plantaris repair were slightly more favorable. This fact is underlined by the frequency of reoperations: 1.9% after plantaris repair compared with 9.4% after peroneal tenodesis. We conclude that plantaris repair is the method of choice.

In vitro tendon cell growth rates on a synthetic fiber scaffold material and on standard culture plates

Growth rates of rat tendon fibroblasts cultured in a three-dimensional carbon fiber matrix were compared with those of cells cultured on standard flat culture plates. The carbon fiber has been used as a tissue scaffold for tendon and ligament repair in animal and clinical studies. While cell growth on the culture plates appears to follow a growth curve containing a lag phase, a log phase, and plateau phase of growth, cell growth in the fiber matrix was characterized by a suppressed log phase of growth. SEM and cytotoxicity studies indicated that this effect was not caused by growth-inhibiting or cytotoxic substances from the carbon fiber. While we cannot rule out the possibility that cell growth was influenced by the surface chemistry of the carbon substrate, evidence from this and other studies suggests that the observed effect was caused by a lack of readily available surface area for cell attachment and growth on the small fibers. Because cell colonies growing on individual fibers are limited (at least in theory) to growing in two directions only, they enjoy limited opportunities for cell migration and growth--in contrast with cell colonies on flat culture plates. These results suggest fundamental differences in the mechanisms controlling cell growth on planar vs. three-dimensional fiber substrates.

Cellular events in the mechanisms of prosthesis loosening

The functional restoration of a joint damaged by trauma or disease is obtained by prosthetic surgery. In particular the implantation of hip prostheses is regarded as routine in orthopedic surgery and thorough research has been developed in this field. The prosthetic replacement of the knee and even more so the ankle and elbow occurs less frequently in clinical practice and has been studied less intensively. The results of artifical hip replacement are generally good, both in terms of pain relief and the restoration of satisfactory joint function. Nevertheless, as time passes, a high rate of failures have been recorded due to prosthesis infections, fracture and wearing of the prosthetic components and prosthesis loosening by various causes. The use of ultra-filtered air and laminar flow in operating theatres and antibiotic prophylaxis have dramatically reduced the incidence of infections in total hip arthroplasty. Thanks to the setting up of new stem configurations and the use of superalloys that are highly resistant to fatigue failure, the fracture of the femoral component has been virtually eliminated as a complication of total hip arthroplasty replacements. Loosening is thus the most frequent complication in total hip replacement.

Utilization of composite laminate theory in the design of synthetic soft tissues for biomedical prostheses

There are several advantages of using composite design considerations for the preparation of biomedical soft tissues. Using a composite laminate design, a wide range for compliance results, proving that the prosthesis compliance can be altered without a concomitant variation of other properties. The trend of compliance as a function of the reinforcement angle is discussed for an angle-ply composite of low compliance constituents, as well as the implications for stress-strain behaviour. Experimental examples pertinent to prosthetic arterial design are presented.