CORR Insights®: Tendon Collagen Crosslinking Offers Potential to Improve Suture Pullout in Rotator Cuff Repair: An Ex Vivo Sheep Study CORR Insights 1 : Tendon Collagen Crosslinking Offers Potential to Improve Suture Pullout in Rotator Cuff Repair: An Ex Vivo Sheep Study Joseph A. Abboud MD Where Are We Now? R otator cuff disease in patients older than 50 years of age remains both common and therapeutically challenging. Various forms of treatment, both nonoperative and operative, have been extensively explored. No single solution has emerged as dominant, and none is curative. In the hope of changing that, biologics in rotator cuff surgery have become something of a hot topic, as surgical success may be more depen- dent upon biologic healing than on the technical aspects of tendon fixation. The current authors set out to use an exogenous collagen crosslinking agent, genipin, to augment tendon repairs. The use of this agent to augment tendon healing has not been explored before. The study, conducted in a cadaveric (ex vivo) sheep model, allows us to make two conclusions pertaining to suture pullout strength: (1) Pullout strength is enhanced after tendon incu- bation in genipin for 24 hours when utilizing the simple suture configuration repair technique, and (2) incubation of the tendon in genipin for 4 or 24 hours did not make a difference in the pullout strength of tendons repaired using a modified Mason-Allen suture configuration. This suggests that the suture configuration may be the most important aspect of this repair model as opposed to the exposure to the exoge- nous crosslinking agent genipin. Where Do We Need To Go? What we really need to know is whether genipin has any real clinical utility. In other words, can we use genipin in humans with rotator cuff tears? Does its mode of activation lend itself to uti- lization in vivo at the time of surgery? Will its method of delivery allow for safe and effective clinical treatment in a timely fashion? Will this provide any clinically enhanced levels of healing after surgical repair? While this study does not allow us to answer any of these questions, as a proof-of-concept effort, it paves the way for future studies that should be able to do so. How Do We Get There? Future in-vivo rotator cuff animal studies in rats or sheep utilizing this This CORR Insights 1 is a commentary on the article ‘‘Tendon Collagen Crosslinking Offers Potential to Improve Suture Pullout in Rotator Cuff Repair: An Ex Vivo Sheep Study’’ by Camenzind and colleagues available at: DOI: 10.1007/s11999-016-4838-8 The author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR 1 or The Association of Bone and Joint Surgeons 1 . This CORR Insights 1 comment refers to the article available at DOI: 10.1007/s11999-016- 4838-8 J. A. Abboud MD (&) Thomas Jefferson University Hospital, The Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107, USA e-mail: abboudj@gmail.com CORR Insights Published online: 31 May 2016 � The Association of Bone and Joint Surgeons1 2016 123 Clin Orthop Relat Res (2016) 474:1786–1787 / DOI 10.1007/s11999-016-4914-0 Clinical Orthopaedics and Related Research® A Publication of The Association of Bone and Joint Surgeons® http://dx.doi.org/10.1007/s11999-016-4838-8 http://dx.doi.org/10.1007/s11999-016-4838-8 http://dx.doi.org/10.1007/s11999-016-4838-8 http://crossmark.crossref.org/dialog/?doi=10.1007/s11999-016-4914-0&domain=pdf http://crossmark.crossref.org/dialog/?doi=10.1007/s11999-016-4914-0&domain=pdf agent should look to quantify the level of improved crosslinking demonstrated at the collagen level. Additionally, delivery vehicles such as liposomes or exosomes, which are anchor or suture based, may be designed to allow for local application in vivo of the genipin at the time of surgery. 123 Volume 474, Number 8, August 2016 CORR Insights 1 1787 CORR Insights CORR Insightsreg: Tendon Collagen Crosslinking Offers Potential to Improve Suture Pullout in Rotator Cuff Repair: An Ex Vivo Sheep Study Where Are We Now? Where Do We Need To Go? How Do We Get There?