Translation and validation of 'The Knee Society Clinical Rating System' into Spanish.

PURPOSE: The Knee Society Clinical Rating System (KSS) is a questionnaire evaluating knee function itself and the patient's ability to walk and climb stairs. The aim of our study is to present the validated translation of KSS into Spanish. METHODS: The validated method of translation-retrotranslation was used to translate KSS into Spanish. Three hundred and sixteen patients undergoing primary knee arthroplasty, before surgery and 6 months postoperative, completed the questionnaire (with an orthopedist's help). Psychometric properties of feasibility (percentage of no answers), validity and sensitivity to change (test's ability to detect change in patients' functional status over time) were assessed. In the second part of the study, the translated version of KSS was compared with two already validated questionnaires (SF-36 and WOMAC). RESULTS: During the translation process, item 3 (ROM) presented low appropriateness and null comprehensibility. The alternative writing proposed was 'for every 5°, we sum up 1 point, as if 8° were 1 point, to obtain the maximum scoring of 25 points you should bend more than 200°'. Feasibility: the item 'malalignment' obtained 15 % of missing item at visit 1. The percentage of invalid items was high in both visits (60 and 47 %). VALIDITY: the coefficients of convergent correlation with WOMAC and SF-36 scales confirm the questionnaire's validity. Sensitivity to change: significant differences were found in all cases between the mean scores comparing both visits. CONCLUSION: The translated version 1.1 of KSS (final version) has shown to be feasible, valid and sensible to changes within the clinical practice of patients undergoing primary knees arthroplasty.

Validation of the 1,4-butanediol thermoplastic polyurethane as a novel material for 3D bioprinting applications.

Tissue engineering (TE) seeks to fabricate implants that mimic the mechanical strength, structure, and composition of native tissues. Cartilage TE requires the development of functional personalized implants with cartilage-like mechanical properties capable of sustaining high load-bearing environments to integrate into the surrounding tissue of the cartilage defect. In this study, we evaluated the novel 1,4-butanediol thermoplastic polyurethane elastomer (b-TPUe) derivative filament as a 3D bioprinting material with application in cartilage TE. The mechanical behavior of b-TPUe in terms of friction and elasticity were examined and compared with human articular cartilage, PCL, and PLA. Moreover, infrapatellar fat pad-derived human mesenchymal stem cells (MSCs) were bioprinted together with scaffolds. in vitro cytotoxicity, proliferative potential, cell viability, and chondrogenic differentiation were analyzed by Alamar blue assay, SEM, confocal microscopy, and RT-qPCR. Moreover, in vivo biocompatibility and host integration were analyzed. b-TPUe demonstrated a much closer compression and shear behavior to native cartilage than PCL and PLA, as well as closer tribological properties to cartilage. Moreover, b-TPUe bioprinted scaffolds were able to maintain proper proliferative potential, cell viability, and supported MSCs chondrogenesis. Finally, in vivo studies revealed no toxic effects 21 days after scaffolds implantation, extracellular matrix deposition and integration within the surrounding tissue. This is the first study that validates the biocompatibility of b-TPUe for 3D bioprinting. Our findings indicate that this biomaterial can be exploited for the automated biofabrication of artificial tissues with tailorable mechanical properties including the great potential for cartilage TE applications.

Development of a Biomimetic Hydrogel Based on Predifferentiated Mesenchymal Stem-Cell-Derived ECM for Cartilage Tissue Engineering.

The use of decellularized extracellular matrix (dECM) as a biomaterial has been an important step forward for the development of functional tissue constructs. In addition to tissues and organs, cell cultures are gaining a lot of attention as an alternative source of dECM. In this work, a novel biomimetic hydrogel is developed based on dECM obtained from mesenchymal stem cells (mdECM) for cartilage tissue engineering. To this end, cells are seeded under specific culture conditions to generate an early chondrogenic extracellular matrix (ECM) providing cues and elements necessary for cartilage development. The composition is determined by quantitative, histological, and mass spectrometry techniques. Moreover, the decellularization process is evaluated by measuring the DNA content and compositional analyses, and the hydrogel is formulated at different concentrations (3% and 6% w/v). Results show that mdECM derived hydrogels possess excellent biocompatibility and suitable physicochemical and mechanical properties for their injectability. Furthermore, it is evidenced that this hydrogel is able to induce chondrogenesis of mesenchymal stem cells (MSCs) without supplemental factors and, furthermore, to form hyaline cartilage-like tissue after in vivo implantation. These findings demonstrate for the first time the potential of this hydrogel based on mdECM for applications in cartilage repair and regeneration.

Bio-inspired hydrogel composed of hyaluronic acid and alginate as a potential bioink for 3D bioprinting of articular cartilage engineering constructs.

Bioprinting is a promising tool to fabricate well-organized cell-laden constructs for repair and regeneration of articular cartilage. The selection of a suitable bioink, in terms of composition and mechanical properties, is crucial for the development of viable cartilage substitutes. In this study, we focused on the use of one of the main cartilage components, hyaluronic acid (HA), to design and formulate a new bioink for cartilage tissue 3D bioprinting. Major characteristics required for this application such as printability, biocompatibility, and biodegradability were analyzed. To produce cartilage constructs with optimal mechanical properties, HA-based bioink was co-printed with polylactic acid (PLA). HA-based bioink was found to improve cell functionality by an increase in the expression of chondrogenic gene markers and specific matrix deposition and, therefore, tissue formation. These results indicate that it is a promising bioink candidate for cartilage tissue engineering based in 3D bioprinting. STATEMENT OF SIGNIFICANCE: The recent appearance of 3D printing technology has enabled great advances in the treatment of osteochondral disorders by fabrication of cartilage tissue constructs that restore and/or regenerate damaged tissue. In this attempt, the selection of a suitable biomaterial, in terms of composition and mechanical properties, is crucial. In this study, we describe for first time the development of a bioink based on the main component of cartilage, HA, with suitable biological and mechanical properties, without involving toxic procedure, and its application  in cartilage tissue bioprinting. Hybrid constructs prepared by co-printing  this  bioink and thermoplastic polymer PLA provided an optimal niche for chondrocyte growth and maintenance as well as mechanical properties necessary to support load forces exerted in native tissue. We highlight the translation potential of this HA-based bioink in the clinical arena.

A soft 3D polyacrylate hydrogel recapitulates the cartilage niche and allows growth-factor free tissue engineering of human articular cartilage.

Cartilage degeneration or damage treatment is still a challenge, but, tissue engineering strategies, which combine cell therapy strategies, which combine cell therapy and scaffolds, and have emerged as a promising new approach. In this regard, polyurethanes and polyacrylates polymers have been shown to have clinical potential to treat osteochondral injuries. Here, we have used polymer microarrays technology to screen 380 different polyurethanes and polyacrylates polymers. The top polymers with potential to maintain chondrocyte viability were selected, with scale-up studies performed to evaluate their ability to support chondrocyte proliferation during long-term culture, while maintaining their characteristic phenotype. Among the selected polymers, poly (methylmethacrylate-co-methacrylic acid), showed the highest level of chondrogenic potential and was used to create a 3D hydrogel. Ultrastructural morphology, microstructure and mechanical testing of this novel hydrogel revealed robust characteristics to support chondrocyte growth. Furthermore, in vitro and in vivo biological assays demonstrated that chondrocytes cultured on the hydrogel had the capacity to produce extracellular matrix similar to hyaline cartilage, as shown by increased expression of collagen type II, aggrecan and Sox9, and the reduced expression of the fibrotic marker's collagen type I. In conclusion, hydrogels generated from poly (methylmethacrylate-co-methacrylic acid) created the appropriate niche for chondrocyte growth and phenotype maintenance and might be an optimal candidate for cartilage tissue-engineering applications. SIGNIFICANCE STATEMENT: Articular cartilage has limited self-repair ability due to its avascular nature, therefore tissue engineering strategies have emerged as a promising new approach. Synthetic polymers displaygreat potential and are widely used in the clinical setting. In our study, using the polymer microarray technique a novel type of synthetic polyacrylate was identified, that was converted into hydrogels for articular cartilage regeneration studies. The hydrogel based on poly (methylmethacrylate-co-methacrylic acid-co-PEG-diacrylate) had a controlable ultrastructural morphology, microstructure (porosity) and mechanical properties (stiffness) appropriate for cartilage engineering. Our hydrogel created the optimal niche for chondrocyte growth and phenotype maintenance for long-term culture, producing a hyaline-like cartilage extracellular matrix. We propose that this novel polyacrylate hydrogel could be an appropriate support to help in the treatment efficient cartilage regeneration.