WO 2006/102457 PCT/US2006/010480
USE OF FIBROUS TISSUE INDUCING PROTEINS FOR HERNIA REPAIR
[0001] This application claims priority to U.S. Patent Application No.
60/664,933, filed on March 24, 2005, which is herein incorporated by reference in
its entirety.
Technical Field
[0002] This invention relates to the field of hernia repair and other
methods of strengthening or repairing the fascia tissue.
BACKGROUND
[0003] A hernia is a fascia defect in a structure, such as, for example,
the abdominal wall, through which an organ, part of an organ, a tissue, or part of a
tissue may protrude. Usually it involves the weakening, bulging, or actual tearing
of the fascia in a structure which normally contains an organ or tissue. There are
many types of hernias. For example, when in the lower abdominal area, a hernia
often involves intra-abdominal contents, such as the intestines or other tissue,
which pass into or through a defect in the abdominal wall. There are at least two
types of hernias that occur in the groin region, inguinal and femoral. A femoral
hernia, which is more common in women than men, involves penetration of a
tissue or an organ through the femoral ring. Inguinal hernia involves penetration
of an organ or a tissue through the superficial inguinal ring. An indirect inguinal
hernia leaves the abdominal cavity at the internal ring and passes down the
inguinal canal, whereas a direct hernia protrudes through the floor of the inguinal
canal in the Hesselbach's triangle. Hernias that occur in the abdominal wall at
sites other than the groin are referred to as ventral hernias. Examples of ventral
hernias include umbilical and incisional hernias. Other types of hernias are well
characterized in surgical texts.
[0004] Known causes of hernias include obesity, pregnancy, tight
clothing, sudden physical exertion, such as weight lifting, coughing, and
abdominal injury. According to the National Center for Health Statistics,
approximately five million Americans develop hernias each year. Inguinal hernias
are more common in men, primarily because of the unsupported space left in the
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groin after the testicles descend into the scrotum. Whereas hernias in the femoral
area, at the top of the thigh, are more common in women and commonly result
from pregnancy and childbirth.
[0005] Temporary relief from the symptoms of some hernias can be
obtained by the patient wearing a truss device that applies external pressure
against the abdomen in the region of the hernia. This well known and
long-established treatment rarely, if ever, provides more than temporary relief
from pain and can result in discomfort to the patient from wearing the device.
Permanent relief typically requires invasive surgery to return the offending organ
or tissue, if present, to its original and correct position, followed by the repair and
reinforcement of the fascia defect in the structure which normally contains the
organ or tissue.
[0006] Additionally, mesh-type patches have been used to repair
openings or holes formed in a structure through which interior organs or tissues
may protrude. Typically, these patches are permanently implanted in a patient's
body and may cause postoperative discomfort to the patient. Further, they have
been reported to have a likelihood of harboring bacteria, thereby leading to
infections.
[0007] Although mesh-type patches are widely used for hernia repair,
recurrence is a problem frequently associated with their use. Recurrence has
been attributed, at least in part, to the length of time required for hernia repair,
which often is not met, for example, either because the mesh-type patches are
displaced after a period of time after implantation in a patient, or they fail to remain
in the body long enough for adequate repair, such as in the case of bioabsorbable
meshes.
SUMMARY
[0008] The present invention is directed to methods of stimulating
growth of the fascia tissue in a subject. Fascia is a sheet or band of fibrous
connective tissue enveloping, separating, or binding together muscles, organs,
and other soft structures of the body. Stimulation of growth of fascia tissue is
important in, e.g., treating hernias, which often include damage to or a defect in
fascia tissue. Surgical implants and compositions described herein are especially
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useful for the repair of fascia tissue defects, such as hernias, in the abdominal
cavity, including inguinal (direct and indirect), femoral, incisional, and recurrent
hernias.
[0009] Specifically, the invention provides compositions and devices for
treating a fascia tissue defect and related methods that comprise fibrous tissue
inducing proteins, e.g., members of the bone morphogenetic protein (BMP) family
such as, e.g., BMP-12, BMP-13, or MP-52, Such compositions may further
comprise a tissue adhesive, e.g., fibrin. The use of such compositions will result
in faster and/or more effective repair of the fascia. A composition comprising one
or more fibrous tissue inducing proteins (and optionally one or more tissue
adhesives) may be delivered to the site of a fibrous tissue defect directly or by
using a surgical implant, such as, e.g., a mesh. Alternatively, a composition
comprising one or more fibrous tissue inducing proteins and a separate
composition comprising one or more tissue adhesives may be delivered directly to
the site of a fascia tissue defect or by using a surgical implant. Suitable fascia
tissue defect repair implants of varying sizes and shapes can be anchored to the
surrounding healthy tissue to prevent migration. Implants can also be configured
to substantially occlude and conform to the walls of a fascia defect, e.g., in a
hernia.
Methods of making and using the compositions and devices of the
invention are also provided.
Embodiments of the invention include, without limitation, the following.
Use of a therapeutically effective amount of a fibrous tissue inducing
protein in the manufacture of a medicament or a device for repair of fascia defects
in an mammal, wherein the fibrous tissue inducing protein is (1) at least 70%
identical to BMP-12, BMP-13, or MP-52, or (2) a fragment of (1) capable of
inducing fibrous tissue, wherein the fibrous tissue inducing protein is BMP-12,
wherein the fibrous tissue inducing protein is BMP-13, and/or wherein the fibrous
tissue inducing protein is MP-52.
Use of a therapeutically effective amount of a fibrous tissue inducing
protein in the manufacture of a medicament or a device for repair of fascia defects
in an mammal, wherein the fascia defect is associated with a wound and/or
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wherein the fascia defect is associated with a hernia, such as, e.g., an inguinal or
femoral hernia.
Use of a therapeutically effective amount of a fibrous tissue inducing
protein in the manufacture of a medicament or a device for repair of fascia defects
in a mammal, such as, e.g., a human, and optionally wherein the mammal has
diabetes.
Use of a therapeutically effective amount of a fibrous tissue inducing
protein in the manufacture of a medicament or a device for repair of fascia defects
in a mammal, wherein the medicament further comprises a tissue adhesive, such
as, e.g., fibrin, fibrinogen, thrombin, aprotinin, Factor VIII, and 2-octyl
cyanoacrylate.
Use of a therapeutically effective amount of a fibrous tissue inducing
protein in the manufacture of a medicament or a device for repair of fascia defects
in a mammal, wherein the device comprises an implant configured for hernia
repair, such as, e.g., a mesh that comprises, e.g., polypropylene,
polytetrafluoroethylene, polyurethane, or polyester, wherein the mesh comprises a
bioabsorbable material, wherein the bioabsorbable material is collagen, gelatin,
keratin, laminin, fibrin, fibronectin, alginate, hyaluronic acid, polyglycolic acid,
polylactic acid, polyglycolide, or combination thereof, and optionally wherein the
implant comprises an anti-adhesion compound or an adhesion barrier, such as,
e.g., chemically modified sodium hyaluronate and carboxymethylcellulose, or
hyaluronic acid, or collagen.
DETAILED DESCRIPTION OF THE INVENTION
[0010] Surgical implants, compositions, and methods described herein
generally relate to treating defects of fascia tissue, such as, e.g., in hernia repair.
More particularly, surgical implants, compositions, and methods employ fibrous
tissue inducing proteins, e.g., members of the bone morphogenetic protein (BMP)
family such as, e.g., BMP-12, BMP-13, or MP-52. Evidence suggests that a
defect in the metabolism of collagen is involved in the pathogenesis of certain
types of hernias, such as, for example, inguinal hernia in adults, leading to a
weakening of the transversalis fascia tissue, which poses a problem for effective
repair of hernias as well as increases the likelihood of recurrence following repair.
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When fascia has been traumatized, it heals with a special type of collagen fiber
called type III. Thus, by way of theory and not as a limitation, it is hypothesized
that the fibrous tissue inducing proteins of the inventions may contribute to
correction of the collagen metabolism, thereby treating a defect of fascia.
[0011] In general, the invention provides a method of treating a defect of
fascia tissue, comprising delivering a composition comprising a fibrous tissue
inducing protein to the site of the fascia defect. Such compositions may further
comprise a tissue adhesive, e.g., fibrin. Compositions may be delivered to the site
of a hernia directly or by using an implantable device such as, e.g., a surgical
implant suitable for repair of a fascia tissue defect. Surgical implants,
compositions, and methods are described in detail below.
Fibrous tissue inducing proteins
[0012] Fibrous tissue inducing proteins used in the compositions,
implants, and methods of the invention are selected from the family of proteins
known as the transforming growth factors beta (TGF-P) superfamily. This family
includes activins, inhibins, and bone morphogenetic proteins (BMPs). Certain
BMPs are particularly useful in inducing fibrous tissue growth. In preferred
embodiments, the fibrous tissue inducing protein is chosen from BMP-12, BMP-13
and MP-52 (also known as GDF-7, GDF-6, and GDF-5, respectively), which form
a subgroup of proteins in the BMP family. The nucleotide and protein sequences
of BMP-12, BMP-13 and MP-52 are disclosed in U.S. Patent No. 5,658,882 and
their database accession numbers are shown in Table 1.

Nucleotide and protein sequences for other BMP and TGF-p family members are
well known in the art.
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[0013] Other candidate proteins that may be useful in repair of fascia
tissue defects can also be identified using one or more assays described herein to
evaluate hernia repair, for example, by measuring the tissue integration strength
in the presence of a candidate protein, or by measuring collagen (especially
collagen type III) section by cell in vitro or in vivo. BMP-13 and MP-52 are 86%
identical to each other, and 80% identical to BMP-12, whereas they are only 57%
identical to next most homologous member of the TGF- superfamily, BMP-2
(See, e.g., Fig. 4 of U.S. Patent No. 6,096,506). Thus, it is expected that a protein
that is a least about 70% identical to any one of BMP-12, BMP-13 and MP-52
would possess the required fibrous tissue inducing activity. Accordingly, some
embodiments include the use of a fibrous tissue inducing protein that is, for
example, 70%, 75%, 80%, 85%, 90%, 95%, 98%, 99% identical to BMP-12,
BMP-13 or MP-52. Such proteins can be engineered, for example, by mutating or
deleting a number of non-conserved amino acid residues, for example, those
residues that differ between the corresponding mouse and human sequences (or
other species) and or those residues that differ between any two of BMP-12,
BMP-13, and MP-52, when sequences are aligned. Conservative amino acid
substitutions in native sequences are also contemplated. Alternatively, fragments
of such homologous or modified proteins, as well as fragments of native fibrous
tissue inducing proteins, that retain fibrous tissue inducing activity may be used in
the methods of the invention.
[0014] Fibrous tissue inducing proteins may either be recombinantly
produced or be purified from natural sources, in the preferred embodiments, the
proteins are of the human origin and are recombinant. Methods for recombinant
production of proteins are well known and are described, for example, in U.S.
Patent No. 5,658,882.
[0015] In some embodiments, an effective amount of a fibrous tissue
inducing protein that may be used in the compositions and implants described
herein is that amount which is sufficient for repairing fascia in a subject at a rate
that is 10%, 20%, 30%, 50% faster or more than the corresponding repair in the
absence of the fibrous tissue inducing protein and will generally depend upon the
size and nature of the fascia defect being repaired and/or the surface area of the
implant being employed. In other embodiments, an effective amount of a fibrous
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tissue inducing protein is that amount which is sufficient for stimulating fascia
tissue growth at a rate that is 10%, 20%, 30%, 50% faster or more than the growth
in absence of the fibrous tissue inducing protein.
[0016] Generally, the amount of protein used for repairing a fascia
defect and/or for stimulating growth of fascia tissue is in a range of from 0.001 to
10 mg, 0.01 to 1 mg, or 0.1 to 0.5 mg per cubic centimeter of material required.
In some instances, dosages may be deduced from the concentration of protein in
the composition applied to the mesh. For example, a composition applied to the
mesh may contain from 0.001 to 10 mg/ml, from 0.01 to 1.0 mg/ml, or from 0.1 to
0.5 mg/ml of one or more fibrous tissue inducing proteins. For example, if a mesh
has a 1 cc volume and can absorb an equal amount of liquid, 1 ml of composition
is applied to the mesh, for a soak load of 100%. Soak loads can vary from 25% to
200%, from 50% to 150%, or from 75% to 100%. Particular dosage will be
determined by the clinical indication being addressed, as well as by various
patient variables (e.g., weight, age, sex) and clinical presentation (e.g., extent of
and/or site of the fascia defect, etc.).
Tissue adhesives
[0017] Tissue adhesives for use in the compositions and surgical
implants of the invention include fibrin, fibrinogen, thrombin, aprotinin, and Factor
VIII. Commercially available tissue adhesives include TISSEEL® (fibrinogen;
Baxter Healthcare Corp., Deerfield, IL) and DERMABOND™ (2-octyi
cyanoacrylate; Ethicon, Somerville, NJ). These adhesives may be combined
directly with a fibrous tissue inducing protein or applied to the site of a fascia
defect either before, after, or at the same time as the fibrous tissue inducing
protein. The adhesives may also be incorporated into a surgical implant in the
same ways as described for the fibrous tissue inducing proteins. Compositions
including tissue adhesives can also be used for stimulating growth of fascia tissue.
In some embodiments, tissue adhesives, alone or in combination with at least one
fibrous tissue inducing protein, are delivered in a composition in the form of a
paste or a gel.
Other Additives
[0018] Additives that may be useful in the compositions and surgical
implants described herein, include, without limitation, pharmaceutically acceptable
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salts, polysaccharides, peptides, proteins, amino acids, synthetic polymers,
natural polymers, and/or surfactants. Additives which help in reducing or
preventing the adhesion of surrounding tissue and organs to the surgical implant
are particularly useful and are referred to herein as anti-adhesion compounds.
Non-limiting examples of such additives include, for example, chemically modified
sodium hyaluronate and carboxymethylcellulose (modified with the activating
agent 1-(3-dimethylaminopropyl)-3-ethylcarbodimide hydrochloride (EDC) and
available commercially as SEPRAFILM® adhesion barrier (Genzyme Corp.,
Cambridge, MA)), hyaluronic acid, and collagen.
[0019] In some embodiments, compositions and surgical implants
described herein contain an antimicrobiotic agent, such as an antibiotic.
Administration of antibiotics serves to prevent infections. Examples of antibiotics
that may be used include, but are not limited to, TYGACIL® (tigecycline; Wyeth,
Madison, NJ), cephalosporins such as cephazolin and cephamandol, netilmycin,
penicillins such as oxacillin or mezlocillin, tetracycline, metronidazole or
aminoglycosides such as gentamycin or neomycin, and rifampicin. Generally, the
amount of antibiotic used is in a range of from 0.001 to 10 mg, 0.01 to 1 mg, or 0.1
to 0.5 mg per cubic centimeter of material required.
[0020] Like the adhesives, these additives may be combined directly
with the fibrous tissue inducing protein, or applied to the site of a fascia defect
either before, after, or at the same time as the fibrous tissue inducing protein. The
additives may also be incorporated into a surgical implant, in the same ways as
described for the fibrous tissue inducing proteins.
[0021] Compositions useful in the methods of the invention may be
delivered directly to a site of fascia defect. They may be applied (e.g., injected) to
the site, while the defect is otherwise repaired using traditional surgical
techniques. The compositions may also be used in conjunction with a surgical
implant that has not been treated with such a composition. Alternatively,
compositions described herein may be applied to the affected area either before
or after a surgical implant is put into place.
Surgical implants
[0022] Surgical implants for hernia repair typically include a mesh, or
other means of structural support. An implant has a structure that may serve to
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both release the protein in a time-dependent manner and provide structural
support for hernia repair. The surgical implant may comprise at least one fibrous
tissue inducing protein and, optionally, at least one tissue adhesive. The surgical
implant can be treated by any method, so long as the method allows the fibrous
tissue inducing protein(s) to be delivered to the site of a fascia defect in a subject.
For example, a mesh may be coated with a fibrous tissue inducing protein by
immersing or soaking it in a solution of fibrous tissue inducing protein(s), for
example, from 1 minute to 1 hour, 10 minutes to 45 minutes, or 15 minutes to 30
minutes. Coating may be also achieved by, for example, spraying the mesh with
such a solution. In yet other embodiments, a mesh may be impregnated with a
fibrous tissue inducing protein by the use of chemical cross-linking.
[0023] Meshes that can be employed as surgical implants include, for
example, polypropylene mesh (PPM) which has been used extensively in hernia
repair to provide the necessary strength and support for tissue growth for the
repair of abdominal defects in hernia. Other examples include expanded
polytetraflouroethylene (ePTFE), sepramesh biosurgical composite, polyethylene
terephthalate (PET), and titanium. Ideal mesh properties include, without
limitation, inertness, resistance to infection at the site where the mesh is
implanted, molecular permeability, pliability, transparency, mechanical integrity
and strength, and biocompatibility.
[0024] Implants may have a dorsal surface and a visceral surface. The
dorsal surface is the portion of the implant which faces outward away from a
fascia defect and the visceral surface is the portion which faces inward towards
the defect. Prior to implantation, some of the implants described herein may, in
an unstressed state, assume a flat or planar shape, or may assume a concave
and/or convex shape on one or more surfaces.
[0025]. In yet other embodiments, an implant comprises a mesh in the
form of a sponge, for example, which is soaked or immersed in a composition
comprising a fibrous tissue inducing protein and optionally a tissue adhesive, so
that the composition fully permeates the pores of the sponge. Such a sponge can
either be made from a synthetic material, such as polyvinyl alcohol, or from a
bioabsorbable material, such as collagen, gelatin, keratin, laminin, fibrin, or
fibronectin. Examples include HELISTAT®, HELITENE®, and VITAGUARD®
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(Integra Life Sciences, Plainsboro, NJ), and ULTRAFOAM® (Davol, Inc.,
Cranston, Rl). In certain instances, it is preferable to use a bioabsorbable sponge
that is only temporarily present in the body of a subject. Meshes and sponges
described herein may also be referred to by other terms, such as for example, a
pad or a gauze, etc.
[0026] In some embodiments, implants may be sufficiently flexible to
allow a surgeon to manipulate the implant to conform to the surgical site and/or
ease delivery during a laparoscopic procedure. However, in some circumstances,
a stiffer arrangement that limits compression and/or expansion of the implant may
be preferred. In certain embodiments, an implant may be collapsible, such as by
folding, rolling, or otherwise, into a slender configuration, so that it may be
delivered through a narrow lumen of a laparascopic device. Flexibility of the
implant is influenced by many factors, including, the materials from which the
implant is made, treatments applied to the implant or any other features of the
body of the implant.
[0027] A mesh implant may either include a single mesh or be formed
from two or more mesh segments that are joined or overlap. In some
embodiments, meshes are configured to continuously deliver at least one fibrous
tissue inducing protein and optionally at least one tissue adhesive at the site of a
fascia defect in a subject, thereby resulting in repair of the defect. It is
contemplated that meshes can be configured to deliver at least one fibrous tissue
inducing protein continuously, for example, for approximately 15 days, 20 days
and 30 days. The length of time, however, will vary depending on the extent and
site of the defect to repair, age of the patient and other clinical parameters that are
typically taken into consideration by surgeons.
[0028] Surgical implants for use in the methods of the invention may be
manufactured, sterilized, and contained in packages until opened for use in a
surgical procedure. Any appropriate sterilization process can be used, including
the conventional physical or chemical methods or treatment with ionizing radiation
such as, for example, gamma or beta rays.
Delivery Methods
[0029] Surgical implants and compositions described herein can be
used in any of the surgical procedures that are used by surgeons for repair of a
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fascia tissue defect. In some embodiments, an incision is made at the site of a
hernia in a subject and a surgical implant described herein is inserted to cover the
area of the defect. In other embodiments, a laparoscopic method is used to
deploy a surgical implant in the patient. Fascia tissue defect repair may be
performed using general, regional, or local anesthesia. Some of the advantages
of local anesthesia include a short recovery time and ability to test the repair
intra-operatively. Further, local anesthesia avoids the respiratory and immune
depressive effects of general anesthesia.
[0030] As previously noted, compositions described herein may be
applied directly to the site of a fascia defect, injected at the site of the defect, or
applied to a surgical implant before or after it is placed at the site of the fascia
defect. In some embodiments, compositions described herein may be used in
conjunction with a mesh which covers a fascia defect in a structure which normally
contains an organ or a tissue, such as, for example, the abdominal wall. For
example, compositions comprising a fibrous tissue inducing protein and optionally
a tissue adhesive may be delivered to the site of a hernia using a device, suitable
for administering the composition to or near the site of the hernia. Such a method
of delivery would eliminate the need to treat or soak a mesh, or other surgical
implant, in the composition prior to its implantation in a subject.
[0031] Various methods of hernia repair and implants suitable for use in
hernia repair are known and described, for example, in U.S. Patent Nos.
5,176,692; 5,569,273; 6,800,0825,824,082; 6,166,286; 5,290,217; and 5,356,432.
Generally, such devices include (a) a mesh-like member configured for repairing
a fascia defect in a subject; and optionally (b) a means for securing the
mesh-like member to the site of the fascia. The devices of the invention are
distinct in that the surgical implant or mesh-like member contains a
therapeutically effective amount of one or more fibrous tissue inducing proteins
and optionally, one or more tissue adhesives.
Uses
[0032] Compositions and surgical implants described herein may be
tested in a wide variety of well known and available animal models for repair of
fascia tissue defects. For example, the strength of hernia repair can be tested
according to porcine groin hernia repair stress-loading tests taught in Uen,
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"Comparative Laparoscopic Evaluation of the PROLENE polypropylene hernia
system vs. the PerFix plug repair in a porcine groin hernia repair model," J.
Laparoendosc. Adv. Surg. Tech. 14(6):368-73 (2004). Light microscopy can also
be used to evaluate the health of other structures near a hernia, as taught in
Berndsen et al., "Does mesh implantation affect the spermatic cord structures
after inguinal hernia surgery? An experimental study in rats," Eur. Surg. Res.
36(5):318-22 (2004).
[0033] It is contemplated that in addition to repairing hernias and
stimulating growth of fascia tissue, the methods of the invention may also be
applied to repairing damage to fascia tissue associated with, for example, colon
surgery, rectal surgery, plastic surgery, trauma, surgery, vascular surgery, pelvic
floor repair, or a wound, as well as fascia defects caused by chronic strain and
immobility.
[0034] Accordingly, this invention may be used to treat various types of
fascia defects, including for example, serious hernias, recurrent hernias, hernias
in patients with diabetes or other conditions that are associated with impaired
wound healing, or any other fascia defects in patients with diabetes or other
conditions that are associated with impaired wound healing.
[0035] The following examples are illustrative of the present invention
and are not limiting in any manner. Modifications, variations and minor
enhancements are contemplated and are within the scope of the present
invention.
EXAMPLES
[0036] The following materials and methods are used in the subsequent
Examples. It will be appreciated by those of skill in the art that while the
Examples employ BMP-12, they can be performed in a similar manner with
BMP-13, MP-52, or any another fibrous tissue inducing protein. Similarly, other
tissue adhesives and surgical implants may be substituted for those described in
the Examples.
[0037] Various meshes employed as surgical implants in the following
Examples include the Bard mesh which is a polypropylene mesh (PPM) and the
Bard Composix mesh, which has two layers of PPM and a layer of expanded
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polytetraflouroethylene to minimize tissue adhesion to the mesh (Davol, Inc.,
Cranston, Rl).
[0038] Additionally, the sepramesh biosurgical composite (Genzyme
Surgical Products, Cambridge, MA) is also used, which includes PPM coated with
chemically modified sodium hyaluronate/carboxymethylcellulose (HA/CMC).
Examples of bioabsorbable meshes that may be used in the surgical implants
described herein include the polyglactin vicryl mesh (Ethicon, Somerville, NJ).
[0039] Various bioabsorbable sponges that may be employed as
surgical implants include collagen sponges HELISTAT®and HELITENE® (Integra,
Plainsboro, NJ), and ULTRAFOAM®(Davol, Inc., Cranston, Rl).
[0040] Finally, the tissue adhesive TISSEEL® (Baxter Healthcare Corp.,
Deerfield, IL) is used to prepare a composition comprising TISSEEL® and
rhBMP-12,
A. Preparation of Surgical Implants For Use In Hernia Repair
[0041] It is understood that any of the meshes and/or sponges that are
currently available can be used as surgical implants. In the case of a mesh, the
mesh is either coated with a composition including at least one fibrous tissue
inducing protein, e.g., rhBMP-12, or it is impregnated with a composition
comprising at least one fibrous tissue inducing protein.
[0042] Each of Bard mesh, Bard composix mesh, sepramesh
biosurgical composite and the polyglactin vicryl mesh, following receipt from the
manufacturer, are coated with a composition including rhBMP-12. Either both
surfaces of the mesh or only one surface may be coated, such as the surface that
faces outward from the defect after implantation, i.e., the dorsal surface.
Additionally, the meshes are coated with an antibiotic to prevent infections in the
area where the meshes are implanted. A suitable antibiotic can either be included
in the same composition as the fibrous tissue inducing protein or it can be coated
separately onto the mesh.
[0043] In some instances, the meshes are impregnated with a
composition including a fibrous tissue inducing protein, e.g., rhBMP-12. This is
achieved by cross-linking the fibrous tissue inducing protein to the fibers of the
mesh before the fibers are interwoven into a mesh. However, it is expected that
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there will be no difference in hernia repair whether the meshes are coated or
impregnated with a fibrous tissue inducing protein.
[0044] The sponges used in the surgical implant are either soaked in a
composition including at least one fibrous tissue inducing protein or at least one
fibrous tissue inducing protein can be cross-linked to the sponge material, for
example, collagen. Cross-linking may be achieved using any suitable
cross-linking agent.
B. Generation of an Animal Model for Hernia
[0045] An animal model for hernia is generated as follows. The
guidelines for the animal study are in accordance with the NIH guidelines
described in Guide for the Care of Laboratory Animals (National Academy Press,
1996). Mature female New Zealand white rabbits (Oryctolagus cuniculuc), each
weighing about 3.5-4.5 kg, are preanesthetized with acepromazine (0.5 mg/kg,
sc). Ten to thirty minutes after administering the preanesthetic, animals are
anesthetized with ketamine hydrochloride (30 mg/kg, im) and xylazine
hydrochloride (10 mg/kg, im). The animals are intubated and fully anesthetized
with isoflurane (1.0-3.0%) and oxygen (1.5-2.0 liters/min) followed by
administration of buprenorphine (0.02-0.05 mg/kg, sc) as an analgesic.
[0046] The abdomen of each animal is shaved and prepped with a
povidone/iodine scrub and successive alcohol wipes. A 10 to 12 cm skin incision
is made beginning approximately 2 cm caudal to the xyphoid process and a 5 to 7
cm full-thickness muscular peritoneal abdominal wall defect is created by excising
a segment around the linea alba. If necessary, the arteries are clamped for
hemostatsis. The cecum of the animals is externalized from the abdominal cavity
and abraded with a sterile nylon surgeon's brush. The cecum is visually divided
into four sections and each section is abraded with 15 strokes such that punctate .
bleeding develops. The cecum is subsequently returned to the abdominal cavity
and the animals are ready for implantation of a surgical implant and fibrous tissue
inducing protein composition.
C. Histology
[0047] To evaluate fascia defect repair, the entire tissue area
surrounding the original defect from each of the animal groups is excised and
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fixed in 4% paraformaldehyde (Polysciences, Warrington, PA) in PBS. The tissue
specimens are embedded in paraffin and 5 m thick sections are cut and stained
with hematoxylin and eosin, and subject to a blind analysis. Morphologic
characterization of cellular responses and tissue ingrowth is noted for each of the
meshes.
D. Tissue Integration Strength Assay
[0048] A tissue integration assay is used to assess the strength of the
tissue following hernia repair using the various methods described herein. Strips
about 2 X 5 cm are cut parallel to the transverse axis of an implant, which includes
the implant, the tissue/implant interface as well as normal tissue following
recovery of the animals. The tensile strength of each tissue sample is measured
using a tensiometer using a load cell. The maximum load at which the
tissue/implant interface fails for each sample is recorded.
EXAMPLE 1: A MESH COATED WITH A COMPOSITION CONTAINING A
FIBROUS TISSUE INDUCING PROTEIN DESIGNED FOR MORE
EFFECTIVE AND STRONGER HERNIA REPAIR IN AN ANIMAL
MODEL
[0049] Rabbits are prepared as described above and are divided into
two groups for each of the meshes: Bard mesh; Bard composix mesh and the
sepramesh biosurgical composite. In each case, one group is implanted with the
mesh prehydrated in sterile saline the other group is implanted with the mesh
coated with a composition including a fibrous tissue inducing protein, rhBMP-12,
as described above,
[0050] In each case, the mesh is secured to the 5 X 7 cm defect margin
created as described above, with 3-0 Prolene in a simple continuous pattern. The
subcutaneous tissue is closed with absorbable suture in a continuous subcuticular
pattern. The animals are exbubated and allowed to recover in an incubator. In
each of the six groups (i.e., Bard mesh and Bard mesh + rhBMP; Bard composix
mesh and Bard composix mesh + rhBMP-12; and sepramesh biosurgical
composite and sepramesh biosurgical composite + rhBMP-12), some of the
animals are euthanized at about 15 days, some of the animals are euthanized at
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WO 2006/102457 PCT/US2006/010480
about 20 days and others are euthanized at approximately one-month after the
surgery to monitor the overall performance of the treated and untreated meshes
over time. The repair of the abdominal defect in each group is evaluated using
the histological protocol and the tissue integration strength assays described
above.
[0051] In each of the groups, it is predicted that the hernia repair will be
stronger in the animal group which is implanted with the mesh coated with
rhBMP-12, relative to the animals which are implanted with the meshes alone.
EXAMPLE 2: A SURGICAL IMPLANT TREATED WITH A COMPOSITION
CONTAINING A FIBROUS TISSUE INDUCING PROTEIN
DESIGNED FOR FASTER REPAIR OF HERNIA IN AN ANIMAL
MODEL
[0052] Rabbits are prepared as discussed above, and are divided into
two groups. One group of rabbits is implanted with a PPM mesh and the other
group of rabbits is implanted with a bioabsorbable sponge. Specifically, in one
group, a hernia defect is covered with a PPM mesh coated with a composition
including a fibrous tissue inducing protein, e.g., rhBMP-12, or a hernia defect is
covered with a PPM mesh treated with a sterile saline solution, as discussed
above. In the second group or rabbits, a hernia defect is either covered using a
collagen sponge immersed in a composition including a fibrous tissue inducing
protein, e.g., rhBMP-12, or it is covered with the sponge immersed in a sterile
saline solution.
[0053] In each group of animals, the surgical implant, i.e., PPM mesh or
the bioabsorbable sponge is secured to the 5 X 7 cm defect margin created using
the method described above. The animals are allowed to recover and some of
the animals from each group are euthanized at approximately one-month to
evaluate the hernia repair.
[0054] In each of the groups, it is predicted that the hernia repair will be
faster in the animal group which is implanted with the mesh coated with
rhBMP-12, relative to the animals which are implanted with the meshes alone.
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EXAMPLE 3: A COMPOSITION COMPRISING BMP-12 AND A TISSUE
ADHESIVE DESIGNED TO BE EFFECTIVE ALONE OR WHEN
COATED ON A MESH
[0055] Rabbits are prepared as described above and are divided into
three groups: mesh alone, composition comprising rhBMP-12 and TISSEEL®,
and the composition comprising rhBMP-12 and TISSEEL® applied to the mesh.
[0056] In the groups with a mesh, the mesh is secured to the 5 X 7 cm
defect margin created as described above, with 3-0 Prolene in a simple
continuous pattern. The subcutaneous tissue is closed with absorbable suture in
a continuous subcuticular pattern. The animals are extubated and allowed to
recover in an incubator.
[0057] In the group with a composition comprising rhBMP-12 and
TISSEEL®, the hernia is repaired surgically as described above and the rhBMP-12
and TISSEEL® composition is injected at the site of the hernia. The subcutaneous
tissue is closed with absorbable suture in a continuous subcuticular pattern. The
animals are extubated and allowed to recover in an incubator.
[0058] In each of the three groups, some of the animals are euthanized
at about 15 days, some of the animals are euthanized at about 20 days and
others are euthanized at approximately one-month after the surgery to monitor the
overall performance of the treatments over time. The repair of the abdominal
defect in each group is evaluated using the histological protocol and the tissue
integration strength assays described above.
[0059] It is predicted that the hernia repair will be faster in the animal
group which is implanted with the mesh coated with rhBMP-12 and TISSEEL®,
followed by the composition containing rhBMP-12 and TISSEEL®, relative to the
animals which are implanted with the mesh alone.
[0060] The specification is most thoroughly understood in light of the
teachings of the references cited within the specification which are hereby
incorporated by reference. The embodiments within the specification provide an
illustration of embodiments of the invention and should not be construed to limit
the scope of the invention. The skilled artisan readily recognizes that many other
embodiments are encompassed by this specification. All publications, patents,
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and sequences cited are incorporated by reference in their entirety. To the extent
the material incorporated by reference contradicts or is inconsistent with the
present specification, the present specification will supercede any such material.
The citation of any references herein is not an admission that such references are
prior art.
[0061] Unless otherwise indicated, all numbers expressing quantities of
ingredients, treatment conditions, and so forth used in the specification, including
claims, are to be understood as being modified in all instances by the term
"about." Accordingly, unless otherwise indicated to the contrary, the numerical
parameters are approximations and may vary depending upon the desired
properties sought to be obtained. Unless otherwise indicated, the term "at least"
preceding a series of elements is to be understood to refer to every element in the
series. Those skilled in the art will recognize, or be able to ascertain using no
more than routine experimentation, many equivalents to the specific embodiments
described herein. Such equivalents are intended to be encompassed by the
following claims.
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WO 2006/102457 PCT/US2006/010480
WHAT IS CLAIMED IS:
1. A method of treating a fascia defect in a mammal, the method
comprising administering to a site of the fascia defect a composition comprising a
therapeutically effective amount of a fibrous tissue inducing protein.
2. The method of claim 1, wherein the fibrous tissue inducing protein is
(1) at least 70% identical to BMP-12, BMP-13, or MP-52, or (2) a fragment of (1)
capable of inducing fibrous tissue.
3. The method of claim 1, wherein the fibrous tissue inducing protein is
BMP-12.
4. The method of claim 1, wherein the fibrous tissue inducing protein is
BMP-13.
5. The method of claim 1, wherein the fibrous tissue inducing protein is
MP-52.
6. The method of claim 1, wherein the fascia defect is associated with
a wound.
7. The method of claim 1, wherein the fascia defect is associated with
a hernia.
8. The method of claim 7, wherein the hernia is inguinal or femoral.
9. The method of claim 1, wherein the mammal is human.
10. The method of claim 1, wherein the mammal has diabetes.
11. The method of claim 1, wherein the composition further comprises a
tissue adhesive.
12. The method of claim 11, wherein the tissue adhesive is selected
from the group consisting of fibrin, fibrinogen, thrombin, aprotinin, Factor VIII, and
2-octyl cyanoacryiate.
13. The method claim 1, wherein the composition is delivered using a
surgical implant configured for hernia repair.
14. The method of claim 13, wherein the surgical implant comprises a
mesh.
15. The method of claim 14, wherein the mesh comprises
polypropylene, polytetrafluoroethylene, polyurethane, or polyester.
16. The method of claim 14, wherein the mesh comprises a
bioabsorbable material.
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17. The method of claim 16, wherein the bioabsorbable material is
collagen, gelatin, keratin, laminin, fibrin, fibronectin, alginate, hyaluronic acid,
polyglycolic acid, polylactic acid, polyglycolide, or combination thereof.
18. The method of claim 13, wherein the surgical implant comprises an
anti-adhesion compound or an adhesion barrier.
19. The method of claim 18, wherein the anti-adhesion compound is
chemically modified sodium hyaluronate and carboxymethylcellulose, or
hyaluronic acid, or collagen.
20. A hernia repair device, comprising:

(a) a mesh-like member configured for repairing a fascia defect in a
subject and comprising a therapeutically effective amount of a fibrous
tissue inducing protein; and optionally
(b) a means for securing the mesh-like member to the. site of the
fascia.

21. The device of claim 20, wherein the fibrous tissue inducing protein is
(1) at least 70% identical to BMP-12, BMP-13, or MP-52, or (2) a fragment of (1)
capable of inducing fibrous tissue.
22. Use of a therapeutically effective amount of a fibrous tissue inducing
protein in the manufacture of a medicament or a device for repair of fascia defects
in a mammal.
23. The use of claim 22, wherein the fibrous tissue inducing protein is
(1) at least 70% identical to BMP-12, BMP-13, or MP-52, or (2) a fragment of (1)
capable of inducing fibrous tissue. .
24. The use of claim 22, wherein the fibrous tissue inducing protein is
BMP-12.
25. The use of claim 22, wherein the fibrous tissue inducing protein is
BMP-13.
26. The use of claim 22, wherein the fibrous tissue inducing protein is
MP-52.
27. The use of claim 22, wherein the fascia defect is associated with a
wound.
28. The use of claim 22, wherein the fascia defect is associated with a
hernia.
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29. The use of claim 28, wherein the hernia is inguinal or femoral.
30. The use of claim 22, wherein the mammal is human.
31. The use of claim 22, wherein the mammal has diabetes.
32. The use of claim 22, wherein the medicament further comprises a
tissue adhesive.
33. The use of claim 32, wherein the tissue adhesive is selected from
the group consisting of fibrin, fibrinogen, thrombin, aprotinin, Factor VIII, and
2-octyl cyanoacrylate.
34. The use of claim 22, wherein the device comprises an implant
configured for hernia repair.
35. The use of claim 34, wherein the implant comprises a mesh.
36. The use of claim 35, wherein the mesh comprises polypropylene,
polytetrafluoroethylene, polyurethane, or polyester.
37. The use of claim 35, wherein the mesh comprises a bioabsorbable
material.
38. The use of claim 37, wherein the bioabsorbable material is collagen,
gelatin, keratin, laminin, fibrin, fibronectin, alginate, hyaluronic acid, poiyglycolic
acid, polylactic acid, polyglycolide, or combination thereof.
39. The use of claim 34, wherein the implant comprises an
anti-adhesion compound or an adhesion barrier.
21

The present disclosure relates to hernia repair and methods for stimulating growth of fascia tissue employing compositions comprising fibrous tissue inducing proteins. In a preferred embodiment, a surgical hernia mesh is impregnated with
rhBMP-12.