Ryan P. Russell

Platelet-Rich Plasma: The PAW Classification System

Platelet-rich plasma (PRP) has been the subject of hundreds of publications in recent years. Reports of its effects in tissue, both positive and negative, have generated great interest in the orthopaedic community. Protocols for PRP preparation vary widely between authors and are often not well documented in the literature, making results difficult to compare or replicate. A classification system is needed to more accurately compare protocols and results and effectively group studies together for meta-analysis. Although some classification systems have been proposed, no single system takes into account the multitude of variables that determine the efficacy of PRP. In this article we propose a simple method for organizing and comparing results in the literature. The PAW classification system is based on 3 components: (1) the absolute number of Platelets, (2) the manner in which platelet Activation occurs, and (3) the presence or absence of White cells. By analyzing these 3 variables, we are able to accurately compare publications.

Rotational and Translational Stability of Different Methods for Direct Acromioclavicular Ligament Repair in Anatomic Acromioclavicular Joint Reconstruction

Background: Many reconstructions of acromioclavicular (AC) joint dislocations have focused on the coracoclavicular (CC) ligaments and neglected the functional contribution of the AC ligaments and the deltotrapezial fascia. Purpose: To compare the modifications of previously published methods for direct AC reconstruction in addition to a CC reconstruction. The hypothesis was that there would be significant differences within the variations of surgical reconstructions. Study Design: Controlled laboratory study. Methods: A total of 24 cadaveric shoulders were tested with a servohydraulic testing system. Two digitizing cameras evaluated the 3-dimensional movement. All reconstructions were based on a CC reconstruction using 2 clavicle tunnels and a tendon graft. The following techniques were used to reconstruct the AC ligaments: a graft was shuttled underneath the AC joint back from anterior and again sutured to the acromial side of the joint (group 1), a graft was fixed intramedullary in the acromion and distal clavicle (group 2), a graft was passed over the acromion and into an acromial tunnel (group 3), and a FiberTape was fixed in a cruciate configuration (group 4). Anterior, posterior, and superior translation, as well as anterior and posterior rotation, were tested. Results: Group 1 showed significantly less posterior translation compared with the 3 other groups (P < .05) but did not show significant differences compared with the native joint. Groups 3 and 4 demonstrated significantly more posterior translation than the native joint. Group 1 showed significantly less anterior translation compared with groups 2 and 3. Group 3 demonstrated significantly more anterior translation than the native joint. Group 1 demonstrated significantly less superior translation compared with the other groups and with the native joint. The AC joint of group 1 was pulled apart less compared with all other reconstructions. Only group 1 reproduced the native joint for the anterior rotation at the posterior marker. Group 4 showed significantly increased distances for all 3 measure points when the clavicle was rotated posteriorly. Conclusion: Reconstruction of the AC ligament by direct wrapping and suturing of the remaining graft around the AC joint (group 1) was the most stable method and was the only one to show anterior rotation comparable with the native joint. In contrast, the transacromial technique (group 3) showed the most translation and rotation. Clinical Relevance: An anatomic repair should address both the CC ligaments and the AC ligaments to control the optimal physiologic function (translation and rotation).

Variability of platelet-rich plasma preparations.

Platelet-rich plasma (PRP) as a clinical treatment for bone, muscle, tendon, and cartilage injury has gained popularity in the field of orthopedic sports medicine. The use of a patient’s own blood is an appealing aspect of PRP treatment, as the resulting plasma preparation is considered relatively benign in comparison with more common, potentially caustic treatments such as corticosteroids and anesthetics. Although appealing, the autologous nature of PRP introduces variability to plasma preparations, creating challenges for both the researcher and the clinician. Differences in patients at the time of blood draw result in plasma preparations that vary within as well as between patients. This variability is compounded by the multitude of protocols and devices available for procuring PRP. The variability of components and its effects on dosage should be considered in single or consecutive treatments of PRP.

GDF5 PROGENITORS GIVE RISE TO FIBROCARTILAGE CELLS THAT MINERALIZE VIA HEDGEHOG SIGNALING TO FORM THE ZONAL ENTHESIS

The sequence of events that leads to the formation of a functionally graded enthesis is not clearly defined. The current study demonstrates that clonal expansion of Gdf5 progenitors contributes to linear growth of the enthesis. Prior to mineralization, Col1+ cells in the enthesis appose Col2+ cells of the underlying primary cartilage. At the onset of enthesis mineralization, cells at the base of the enthesis express alkaline phosphatase, Indian hedgehog, and ColX as they mineralize. The mineralization front then extends towards the tendon midsubstance as cells above the front become encapsulated in mineralized fibrocartilage over time. The hedgehog (Hh) pathway regulates this process, as Hh-responsive Gli1+ cells within the developing enthesis mature from unmineralized to mineralized fibrochondrocytes in response to activated signaling. Hh signaling is required for mineralization, as tissue-specific deletion of its obligate transducer Smoothened in the developing tendon and enthesis cells leads to significant reductions in the apposition of mineralized fibrocartilage. Together, these findings provide a spatiotemporal map of events - from expansion of the embryonic progenitor pool to synthesis of the collagen template and finally mineralization of this template - that leads to the formation of the mature zonal enthesis. These results can inform future tendon-to-bone repair strategies to create a mechanically functional enthesis in which tendon collagen fibers are anchored to bone through mineralized fibrocartilage.

The Future Role of Mesenchymal Stem Cells in the Management of Shoulder Disorders

PURPOSE Biologics may help to optimize the healing environment after rotator cuff repair. Mesenchymal stem cells (MSCs) may have the potential to regenerate a physiological enthesis, thereby improving healing at the repair site after rotator cuff repair. METHODS The PubMed database was searched in May 2013. Only in vivo and in vitro studies reporting on stem cell use in the rotator cuff of humans or animals were included. Exclusion criteria consisted of the following: Level V evidence, systematic reviews, and studies reporting preliminary results. RESULTS This query resulted in 141 citations. Of these, 90 were excluded based on the title of the study. A final group of 17 studies was included in this review (9 in vivo animal studies, 5 in vitro human studies, 1 in vitro animal study, 1 study reporting in vitro human and in vivo animal results, and 1 study reporting on clinical outcomes of human patients). CONCLUSIONS The current literature regarding therapeutic use of MSCs in shoulder surgery is limited. Although in vivo animal studies have shown some promising approaches to enhance tendon-to-bone healing, the use of MSCs for shoulder surgery should still be regarded as an experimental technique. Further basic and clinical research is needed until a procedure can be defined for the routine use of these cells in shoulder surgery.

Stability of Double-Row Rotator Cuff Repair Is Not Adversely Affected by Scaffold Interposition Between Tendon and Bone

Background: Rotator cuff reconstructions may be improved by adding growth factors, cells, or other biologic factors into the repair zone. This usually requires a biological carrier (scaffold) to be integrated into the construct and placed in the area of tendon-to-bone healing. This needs to be done without affecting the constructs mechanics. Hypothesis/Purpose: The hypothesis was that scaffold placement, as an interposition, has no adverse effects on biomechanical properties of double-row rotator cuff repair. The purpose of this study was to examine the effect of scaffold interposition on the initial strength of rotator cuff repairs. Study Design: Controlled laboratory study. Methods: Twenty-five fresh-frozen shoulders (mean age: 65.5 ± 8.9 years) were randomly assigned to 5 groups. Groups were chosen to represent a broad spectrum of commonly used scaffold types: (1) double-row repair without augmentation, (2) double-row repair with interposition of a fibrin clot (Viscogel), (3) double-row repair with interposition of a collagen scaffold (Mucograft) between tendon and bone, (4) double-row repair with interposition of human dermis patch (ArthroFlex) between tendon and bone, and (5) double-row repair with human dermis patch (ArthroFlex) placed on top of the repair. Cyclic loading to measure displacement was performed to 3000 cycles at 1 Hz with an applied 10- to 100-N load. The ultimate load to failure was determined at a rate of 31 mm/min. Results: There were no significant differences in mean displacement under cyclic loading, slope, or energy absorbed to failure between all groups (P = .128, P = .981, P = .105). Ultimate load to failure of repairs that used the collagen patch as an interposition (573.3 ± 75.6 N) and a dermis patch on top of the reconstruction (575.8 ± 22.6 N) was higher compared with the repair without a scaffold (348.9 ± 98.8 N; P = .018 and P = .025). No significant differences were found for repairs with the fibrin clot as an interposition (426.9 ± 103.6 N) and the decellularized dermis patch as an interposition (469.9 ± 148.6 N; P = .73 and P = .35). Conclusion: Scaffold augmentation did not adversely affect the zero time strength of the tested standard double-row rotator cuff repairs. An increased ultimate load to failure was observed for 2 of the augmentation methods (collagen patch as an interposition and decellularized dermis patch on top of the reconstruction) compared with the nonaugmented repairs. Clinical Relevance: Scaffolds intended for application of growth factors or cellular components in a repair situation did not adversely jeopardize the stability of the operative construct.

Inverse agonism of retinoic acid receptors directs epiblast cells into the paraxial mesoderm lineage

We have investigated the differentiation of paraxial mesoderm from mouse embryonic stem cells utilizing a Tbx6-EYFP/Brachyury (T)-Ckerry dual reporter system. Differentiation from the mouse ESC state directly into mesoderm via Wnt pathway activation was low, but augmented by treatment with AGN193109, a pan-retinoic acid receptor inverse agonist. After five days of differentiation, T+ cells increased from 12.2% to 18.8%, Tbx6+ cells increased from 5.8% to 12.7%, and T+/Tbx6+ cells increased from 2.4% to 14.1%. The synergism of AGN193109 with Wnt3a/CHIR99021 was further substantiated by the increased expression of paraxial mesoderm gene markers Tbx6, Msgnl, Meoxl, and Hoxbl. Separate to inverse agonist treatment, when mouse ESCs were indirectly differentiated into mesoderm via a transient epiblast step the efficiency of paraxial mesoderm formation markedly increased. Tbx6+ cells represented 65–75% of the total cell population after just 3 days of differentiation and the expression of paraxial mesoderm marker genes Tbx6 and Msgn increased over 100-fold and 300-fold, respectively. Further evaluation of AGN193109 treatment on the indirect differentiation protocol suggested that RARs have two distinct roles. First, AGN193109 treatment at the epiblast step and mesoderm step promoted paraxial mesoderm formation over other mesoderm and endoderm lineage types. Second, continued treatment during mesoderm formation revealed its ability to repress the maturation of presomitic mesoderm into somitic paraxial mesoderm. Thus, the continuous treatment of AGN193109 during epiblast and mesoderm differentiation steps yielded a culture where —90% of the cells were Tbx6+. The surprisingly early effect of inverse agonist treatment at the epiblast step of differentiation led us to further examine the effect of AGN193109 treatment during an extended epiblast differentiation protocol. Interestingly, while inverse agonist treatment had no impact on the conversion of ESCs into epiblast cells based on the expression of Rexl, Fgf5, and pluripotency marker genes Oct4, Nanog, and Sox2, after three days of differentiation in the presence of AGN193109 caudal epiblast and early paraxial mesoderm marker genes, T, Cyp26al, Fgf8, Tbx6 and Msgn were all highly up-regulated. Collectively, our studies reveal an earlier than appreciated role for RARs in epiblast cells and the modulation of their function via inverse agonist treatment can promote their differentiation into the paraxial mesoderm lineage.