Evaluation of a new injury model to study medial collateral ligament healing: primary repair versus nonoperative treatment

Two-Year Functional Outcomes of Nonsurgical Treatment in Concomitant Anterior Cruciate Ligament and Medial Collateral Ligament Injuries: A Case-Control Study

The anterior cruciate ligament (ACL) is a common knee injury in high-intensity sports, which can cause early career loss in young athletes. Concomitant damage to other knee stabilizers may occur, such as the medial collateral ligament (MCL). Recent studies have shown that knee stability can increase without surgical intervention in patients with ACL and MCL injuries. Regarding the importance of functional tests in return to exercise prediction, this study aims to measure nonsurgical approach's long-term outcome for concomitant ACL and MCL injuries with a focus on functional tests. This is a case-control study with a 2-year follow-up. The case group consisted of patients who had provided written consent and completed their 2-year follow-up, and the control group was made up of healthy people who did not have any knee medical conditions and were matched by age, gender, and activity level. Physical examinations, Tegner and International Knee Documentation Committee questionnaires, and knee magnetic resonance imaging were conducted, and functional performance tests were performed after a 10-minute warm-up. Lody's index (the ratio of injured-to-uninjured knee results) was calculated. The data were analyzed using independent t-test, one-way analysis of variance, chi-squared test, and Fisher's exact test. The study involved 11 patients in each concomitant ACL and MCL injury cases and healthy control groups with a mean age of 32.4 and 28 years, respectively. None of the patients reported knee instability symptoms in the 2-year follow-up. More than half of the patients continued their sports field without reinjury, with no significant difference in activity levels between case and control groups. The 6-meter hop test and single-leg hop test showed no significant difference between case and control groups (p-value: 0.326, 0.859), and no significant difference was observed in the three Carioca, cocontraction, and Shuttle tests in the 2-year follow-up. Functional tests in ACL and MCL injuries revealed normal outcomes, implying a nonsurgical approach for patients with proximal ACL tears, better knee stability, and no significant differences between the injured and control groups.

Effects of simulated radioulnar synostosis on supination and pronation in cats. A cadaveric study

OBJECTIVE

To evaluate the effect of an induced synostosis with a screw on pronation and supination in cats.

STUDY DESIGN

Ex vivo biomechanical study.

SAMPLE POPULATION

A total of 58 feline forelimbs.

METHODS

A total of 58 cadaveric feline thoracic limbs were mounted on a custom-built jig with the elbow and carpus flexed at a 90° angle. To exclude any orthopedic disease, radiographs of the forelimbs were performed prior to the mechanical tests. Radioulnar synostosis was imitated with a 2 mm cortical screw through the radius into the ulna in the proximal (Group P; n = 54), middle (Group M; n = 52), and distal (Group D; n = 53) radial diaphysis. The angles of pronation and supination were recorded after manually applying a two-finger tight rotational force to the metacarpus. Rotational tests were performed without a screw (Group N) and with a screw in each of the aforementioned positions. Pairwise comparisons between the groups were performed based on their angles of rotation with a paired t-test with the Benjamini-Hochberg procedure and a mixed model ANOVA.

RESULTS

Mean angles of rotation decreased between Group N (129.5 ± 15.9°) and all groups with imitated radioulnar synostosis to a mean angle of 37.5 ± 14.5° (p < .0001). Mean angles of rotation did not differ between the groups with imitated radioulnar synostosis.

CONCLUSION

Induced radioulnar synostosis decreases antebrachial rotation by more than two-thirds, regardless of location.

CLINICAL SIGNIFICANCE

Implants fixating the radius to the ulna should be avoided in cats, regardless where they are located along the radial diaphysis.

Mechanical properties of animal ligaments: a review and comparative study for the identification of the most suitable human ligament surrogates

The interest in the properties of animal soft tissues is often related to the desire to find an animal model to replace human counterparts due to the unsteady availability of human tissues for experimental purposes. Once the most appropriate animal model is identified, it is possible to carry out ex-vivo and in-vivo studies for the repair of ligamentous tissues and performance testing of replacement and support healing devices. This work aims to present a systematic review of the mechanical properties of ligaments reported in the scientific literature by considering different anatomical regions in humans and several animal species. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. Moreover, considering the lack of a standard protocol for preconditioning of tissues, this aspect is also addressed. Ninety-six studies were selected for the systematic review and analysed. The mechanical properties of different animal species are reported and summarised in tables. Only results from studies reporting the strain rate parameter were considered for comparison with human ligaments, as they were deemed more reliable. Elastic modulus, ultimate tensile stress, and ultimate strain properties are graphically reported identifying the range of values for each animal species and to facilitate comparison between values reported in the scientific literature in animal and human ligaments. Useful similarities between the mechanical properties of swine, cow, and rat and human ligaments have been found.

Treating Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries Operatively in the Acute Setting Is Potentially Advantageous

Combined injury of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) remains among the most common knee injury patterns in orthopaedics. Optimal treatment of grade III MCL injuries is still debated, especially when combined with ACL injury. Most patients with these severe injuries are treated conservatively for at least 6 weeks to allow for MCL healing, followed by delayed ACL reconstruction. Although acute treatment of the MCL was common in the 1970s, postoperative stiffness was frequently reported. Moreover, studies of such treatment failed to show clinical benefits of surgical over conservative treatment, and the MCL exhibited intrinsic healing capacity, leading to the consensus that all MCL injuries are treated conservatively. The current delayed treatment algorithm for ACL-MCL injuries has several disadvantages. First, MCL healing may be incomplete, resulting in residual valgus laxity that places the ACL graft at greater risk of failure. Second, delayed treatment lengthens the overall rehabilitation period, thereby prolonging the presence of atrophy and delaying return to preinjury activity levels. Third, the initial healing period leaves the knee unstable for longer and risks further intra-articular damage. Acute simultaneous surgical treatment of both ligaments has the potential to avoid these shortcomings. This article will review the evolution of treatment of ACL-MCL injuries and explain how it shifted toward the current treatment algorithm. We will (1) discuss why the consensus shifted, (2) discuss the shortcomings of the current treatment plan, (3) discuss the potential advantages of acute simultaneous treatment, and (4) present an overview of the available literature.

The acromioclavicular ligament shows an early and dynamic healing response following acute traumatic rupture

Purpose

Symptomatic horizontal instability is clinically relevant following acute acromioclavicular joint dislocations. However, the intrinsic healing response is poorly understood. The present study sought to investigate time-dependent healing responses of the human acromioclavicular ligament following acute traumatic rupture.

Methods

Biopsies of the acromioclavicular ligament were obtained from patients undergoing surgical treatment for acute acromioclavicular joint dislocations. Specimens were stratified by time between trauma and surgery: group 1, 0–7 days (n = 5); group 2, 8–14 days (n = 6); and group 3, 15–21 days (n = 4). Time-dependent changes in cellularity, collagen (type 1 and 3) concentration, and histomorphological appearance were evaluated for the rupture and intact zone of the acromioclavicular ligament.

Results

Group 1 was characterized by cellular activation and early inflammatory response. The rupture zone exhibited a significantly higher count of CD68-positive cells than the intact zone (15.2 vs 7.4; P ≤ 0.05). Consistently, synovialization of the rupture end was observed. Within the second week, the rupture zone was subject to proliferation showing more fibroblast-like cells than the intact zone (66.8 vs 43.8; P ≤ 0.05) and a peak of collagen type 3 expression (group 1: 2.2 ± 0.38, group 2: 3.2 ± 0.18, group 3: 2.8 ± 0.57; P ≤ 0.05). Signs of consolidation and early remodeling were seen in the third week.

Conclusions

The acromioclavicular ligament exhibits early and dynamic healing responses following acute traumatic rupture. Our histological findings suggest that surgical treatment of acute ACJ dislocations should be performed as early as possible within a timeframe of 1 week after trauma to exploit the utmost biological healing potential. Prospective clinical studies are warranted to investigate whether early surgical treatment of ACJ dislocations translates into clinical benefits.

Comparison between Operative and Non-Operative Treatment of the Medial Collateral Ligament: Histological and Ultrastructural Findings during Early Healing in the Epiligament Tissue in a Rat Knee Model

The medial collateral ligament of the knee joint is one of the most commonly injured ligaments of the knee. Recent data have shown that the thin layer of connective tissue covering the ligament, known as the epiligament, is essential for its nutrition and normal function, as well as its healing after injury. The aim of the present study was to investigate and compare the changes in the epiligament of the medial collateral ligament which occurred during operative and non-operative treatment throughout the first month after injury. We used 27 male Wistar rats randomly allocated to three groups. In the 9 rats belonging to the first group, the medial collateral ligament was fully transected and left to heal spontaneously without suture. In the 9 rats belonging to the second group, the transected ends were marked with a 9–0 nylon monofilament suture. The 9 rats in the third group were used as normal controls. Three animals from each group were sacrificed on days 8, 16, and 30 after injury. Light microscopic analysis was performed on semi-thin sections stained with 1% methylene blue, azure II, and basic fuchsin. Transmission electron microscopy was used to study and compare the ultrastructural changes in the epiligament. The statistical analysis of the obtained data was performed using the Kruskal-Wallis H test and Mood’s median test. The normal structure of the epiligament of the medial collateral ligament was presented by fibroblasts, fibrocytes, adipose cells, mast cells, collagen fibers, and neuro-vascular bundles. On days 8 and 16 postinjury, the epiligament appeared hypercellular and returned to its normal appearance on the thirtieth day postinjury. The electron microscopic study revealed the presence of different types of fibroblasts with the typical ultrastructural features of collagen-synthetizing cells. The comparative statistical analysis on the respective day showed that there was no statistically significant difference in the number of cells between spontaneously healing animals and animals recovering with suture application. These data further prove that spontaneous healing of the medial collateral ligament yields similar results to surgical treatment and may be used as a basis for the development of treatment regimens with improved patient outcome.

Medial collateral ligament injuries of the knee in male professional football players: a prospective three-season study of 130 cases from the UEFA Elite Club Injury Study

PURPOSE

Medial collateral ligament (MCL) injury is the single most common traumatic knee injury in football. The purpose of this study was to study the epidemiology and mechanisms of MCL injury in men's professional football and to evaluate the diagnostic and treatment methods used.

METHODS

Fifty-one teams were followed prospectively between one and three full seasons (2013/2014-2015/2016). Individual player exposure and time-loss injuries were recorded by the teams' medical staffs. Moreover, details on clinical grading, imaging findings and specific treatments were recorded for all injuries with MCL injury of the knee as the main diagnosis. Agreement between magnetic resonance imaging (MRI) and clinical grading (grades I-III) was described by weighted kappa.

RESULTS

One hundred and thirty of 4364 registered injuries (3%) were MCL injuries. Most MCL injuries (98 injuries, 75%) occurred with a contact mechanism, where the two most common playing situations were being tackled (38 injuries, 29%) and tackling (15 injuries, 12%). MRI was used in 88 (68%) of the injuries, while 33 (25%) were diagnosed by clinical examination alone. In the 88 cases in which both MRI and clinical examination were used to evaluate the grading of MCL injury, 80 (92% agreement) were equally evaluated with a weighted kappa of 0.87 (95% CI 0.77-0.96). Using a stabilising knee brace in players who sustained a grade II MCL injury was associated with a longer lay-off period compared with players who did not use a brace (41.5 (SD 13.2) vs. 31.5 (SD 20.3) days, p = 0.010).

CONCLUSION

Three-quarter of the MCL injuries occurred with a contact mechanism. The clinical grading of MCL injuries showed almost perfect agreement with MRI grading, in cases where the MCL injury is the primary diagnosis. Not all grade II MCL injuries were treated with a brace and may thus indicate that routine bracing should not be necessary in milder cases.

LEVEL OF EVIDENCE

Prospective cohort study, II.

Cell Therapies in Tendon, Ligament, and Musculoskeletal System Repair

In the last few decades, several techniques have been used to optimize tendon, ligament, and musculoskeletal healing. The evidence in favor of these techniques is still not proven, and level I studies are lacking. We performed an analysis of the therapeutic strategies and tissue engineering projects recently published in this field. Here, we try to give an insight into the current status of cell therapies and the latest techniques of bioengineering applied to the field of orthopedic surgery. The future areas for research in the management of musculoskeletal injuries are outlined. There are emerging technologies developing into substantial clinical treatment options that need to be critically evaluated. Mechanical stimulation of the constructs reproduces a more propitious environment for effective healing.

Biomechanical study of the effect of platelet rich plasma on the treatment of medial collateral ligament lesion in rabbits

PURPOSE

To evaluate the use of platelet-rich plasma in the early stages of healing of traumatic injury of the medial collateral ligament in the knee of rabbits.

METHODS

Thirty rabbits were subjected to surgical lesion of the medial collateral ligament. Of these, 16 were treated with platelet-rich plasma and 14 with saline (control). After 3 and 6 weeks of treatment, 50% of the animals from each group were sacrificed, and biomechanical tests were performed on the injured ligament to compare the tensile strength between the two groups.

RESULTS

Platelet-rich plasma significantly increased the tensile strength of the ligament in the groups treated after3 and 6 weeks. In the group treated with platelet-rich plasma vs. saline, the tensile strength values were 3192.5 ± 189.7 g/f vs. 2851.1 ± 193.1 g/f at3 weeks (p = 0.005) and 5915.6 ± 832.0 g/f vs. 4187.6 ± 512.9 g/f at 6 weeks (p = 0.0001).

CONCLUSION

The use of platelet-rich plasma at the injury site accelerated ligament healing in an animal model, demonstrated by an increase in the tensile strength of the medial collateral ligament.

Feline talocrural luxation: A cadaveric study of repair using ligament prostheses

Currently recommended surgical techniques to treat severe biaxial feline talocrural soft-tissue injuries commonly lead to unsatisfactory outcome. Data relating to canine talocrural stabilisation may not be useful in cats due to major differences in tarsal anatomy between the species. This experimental biomechanical cadaveric study used specimens (n = 10) prepared from the distal pelvic limbs of five adult cats. The aim was to design a technique for treating talocrural luxation using suture prostheses and bone tunnels, and to investigate its suitability for use in clinical cases. Four prosthetic ligaments were placed through a series of five 1.5 mm bone tunnels. Two prostheses, the caudoproximal pair, were taut in talocrural flexion and two prostheses, the craniodistal pair, were taut in extension. The intact specimens had their range-of-motion (ROM) and stability tested, after which they were transected at the talocrural joint (simulated luxation) and repaired using the technique described. The ROM and stability of the repaired specimens were tested and compared to the intact specimens. The repaired specimens had comparable stability to the intact specimens, although the ROM was different (p <0.05) in six of 16 positions (p <0.003125). These corresponded to the positions where the lateral prostheses were taut. The repair technique described may be useful in the treatment of talocrural luxation, as it is lowprofile in an area of limited soft-tissue cover, allows anatomic reduction, restores normal talocrural joint stability and near-normal tarsal ROM.

Nanoscale Imaging of Collagen Gels with Focused Ion Beam Milling and Scanning Electron Microscopy

In vitro polymerized type I collagen hydrogels have been used extensively as a model system for three-dimensional (3D) cell and tissue culture, studies of fibrillogenesis, and investigation of multiscale force transmission within connective tissues. The nanoscale organization of collagen fibrils plays an essential role in the mechanics of these gels and emergent cellular behavior in culture, yet quantifying 3D structure with nanoscale resolution to fully characterize fibril organization remains a significant technical challenge. In this study, we demonstrate that a new imaging modality, focused ion beam scanning electron microscopy (FIB-SEM), can be used to generate 3D image datasets for visualizing and quantifying complex nanoscale organization and morphometry in collagen gels. We polymerized gels at a number of concentrations and conditions commonly used for in vitro models, stained and embedded the samples, and performed FIB-SEM imaging. The resulting image data had a voxel size of 25 nm, which is the highest resolution 3D data of a collagen fibril network ever obtained for collagen gels. This resolution was essential for discerning individual fibrils, fibril paths, and their branching and grouping. The resulting volumetric images revealed that polymerization conditions have a significant impact on the complex fibril morphology of the gels. We segmented the fibril network and demonstrated that individual collagen fibrils can be tracked in 3D space, providing quantitative analysis of network descriptors such as fibril diameter distribution, length, branch points, and fibril aggregations. FIB-SEM 3D reconstructions showed considerably less lateral grouping and overlap of fibrils than standard 2D SEM images, likely due to artifacts in SEM introduced by dehydration. This study demonstrates the utility of FIB-SEM for 3D imaging of collagen gels and quantitative analysis of 3D fibril networks. We anticipate that the method will see application in future studies of structure-function relationships in collagen gels as well as native collagenous tissues.

Comparison of ACL Strain in the MCL-Deficient and MCL-Reconstructed Knee During Simulated Landing in a Cadaveric Model

BACKGROUND

Noncontact anterior cruciate ligament (ACL) injury after valgus landing has been reported and studied biomechanically. However, the role of the medial collateral ligament (MCL) in dissipating these forces has not been fully elucidated. Purpose/Hypothesis: The purpose of this study was to investigate the role that the MCL plays in ACL strain during simulated landing. The hypothesis was that ACL strain would increase significantly in MCL-incompetent knees compared with the native knee and that reconstructing the MCL would return the values to those of the intact knee.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen human cadaveric knees were used in this study. A materials testing machine applied a force of 2× body weight over 60 milliseconds to simulate landing after a jump. The knees were tested in 12 loading conditions, consisting of full extension or 15° of flexion combined with 7° of valgus or neutral alignment while the tibia was in external rotation, neutral rotation, or internal rotation. This test procedure was repeated on each specimen with the MCL transected and reconstructed. The superficial and deep MCL was transected along with the posterior oblique ligament, which was thought to simulate a worst case scenario. The MCL was reconstructed by use of semitendinosus and gracilis tendon grafts.

RESULTS

During internal rotation at 0° of flexion and 0° of valgus, both the intact ( P = .005) and the reconstructed ( P = .004) MCL states placed significantly lower strain on the ACL than did the transected MCL. The reconstructed MCL state at 0° of flexion and 7° of valgus ( P = .049) along with 15° of flexion and 0° of valgus ( P = .020) also placed significantly lower strain on the ACL than did the transected MCL. For external rotation testing at 0° of flexion and 7° of valgus, the reconstructed MCL state placed significantly lower strain on the ACL than did the transected MCL ( P = .039). Finally, during neutral rotation, the ACL strain at 0° of valgus and 0° of flexion, and at 7° of valgus and 0° of flexion was significantly lower for the MCL-intact groups ( P < .028) and MCL-reconstructed groups ( P < .016) than the MCL-transected groups.

CONCLUSION

The current findings demonstrate that during valgus landing, a knee with an incompetent MCL puts the ACL under increased strain. These values are highest in full extension with the tibia in internal and neutral rotation. This increased strain can be reduced to baseline levels with reconstruction.

CLINICAL RELEVANCE

A knee with an incompetent MCL puts the ACL under increased strain. Once the MCL has healed in an elongated manner, MCL reconstruction should be considered.

A discrete spectral analysis for determining quasi-linear viscoelastic properties of biological materials

The viscoelastic behaviour of a biological material is central to its functioning and is an indicator of its health. The Fung quasi-linear viscoelastic (QLV) model, a standard tool for characterizing biological materials, provides excellent fits to most stress-relaxation data by imposing a simple form upon a material's temporal relaxation spectrum. However, model identification is challenging because the Fung QLV model's 'box'-shaped relaxation spectrum, predominant in biomechanics applications, can provide an excellent fit even when it is not a reasonable representation of a material's relaxation spectrum. Here, we present a robust and simple discrete approach for identifying a material's temporal relaxation spectrum from stress-relaxation data in an unbiased way. Our 'discrete QLV' (DQLV) approach identifies ranges of time constants over which the Fung QLV model's typical box spectrum provides an accurate representation of a particular material's temporal relaxation spectrum, and is effective at providing a fit to this model. The DQLV spectrum also reveals when other forms or discrete time constants are more suitable than a box spectrum. After validating the approach against idealized and noisy data, we applied the methods to analyse medial collateral ligament stress-relaxation data and identify the strengths and weaknesses of an optimal Fung QLV fit.

Positive effects of an extracellular matrix hydrogel on rat anterior cruciate ligament fibroblast proliferation and collagen mRNA expression

Background/Objective

We have previously shown that an extracellular matrix (ECM) bioscaffold derived from porcine small intestine submucosa (SIS) enhanced the healing of a gap injury of the medial collateral ligament as well as the central third defect of the patellar tendon. With the addition of a hydrogel form of SIS, we found that a transected goat anterior cruciate ligament (ACL) could also be healed. The result begs the research question of whether SIS hydrogel has positive effects on ACL fibroblasts (ACLFs) and thus facilitates ACL healing.

Methods

In the study, ECM-SIS hydrogel was fabricated from the digestion of decellularised and sterilised sheets of SIS derived from αGal-deficient (GalSafe) pigs. As a comparison, a pure collagen hydrogel was also fabricated from commercial collagen type I solution. The morphometrics of hydrogels was assessed with scanning electron microscopy. The ECM-SIS and collagen hydrogels had similar fibre diameters (0.105 ± 0.010 μm vs. 0.114 ± 0.004 μm), fibre orientation (0.51 ± 0.02 vs. 0.52 ± 0.02), and pore size (0.092 ± 0.012 μm vs. 0.087 ± 0.008 μm). The preservation of bioactive properties of SIS hydrogel was assessed by detecting bioactive molecules sensitive to processing and enzyme digestion, such as growth factors fibroblast growth factor-2 (FGF-2) and transforming growth factor-beta 1 (TGF-β1), with enzyme-linked immunosorbent assay. ACLFs were isolated and expanded in culture from explants of rat ACLs (n = 3). The cells were then seeded on the hydrogels and cultured with 0%, 1%, and 10% foetal bovine serum (FBS) for 3 days and 7 days. Cell attachment was observed using a light microscope and scanning electron microscopy, whereas cell proliferation and matrix production (collagen types I and III) were examined with bromodeoxyuridine assays and reverse transcription-polymerase chain reaction, respectively.

Results

The results showed that FGF-2 and TGF-β1 in the SIS hydrogel were preserved by 50% (65.9 ± 26.1 ng/g dry SIS) and 90% (4.4 ± 0.6 ng/g dry SIS) relative to their contents in ECM-SIS sheets, respectively. At Day 3 of culture, ACLFs on the SIS hydrogel were found to proliferate 39%, 31%, and 22% more than those on the pure collagen hydrogel at 0%, 1%, and 10% FBS, respectively (p < 0.05). Collagen type I mRNA expression was increased by 150%, 207%, and 100%, respectively, compared to collagen hydrogel (p < 0.05), whereas collagen type III mRNA expression was increased by 123% and 132% at 0% and 1% FBS, respectively (all p < 0.05) but not at 10% FBS. By Day 7, collagen type I mRNA expression was still elevated by 137% and 100% compared to collagen hydrogel at 1% and 10% FBS, respectively (p < 0.05). Yet, collagen type III mRNA levels were not significantly different between the two groups at any FBS concentrations.

Conclusion

Our data showed that the ECM-SIS hydrogel not only supported the growth of ACLFs, but also promoted their proliferation and matrix production relative to a pure collagen hydrogel. As such, ECM-SIS hydrogel has potential therapeutic value to facilitate ACL healing at the early stage after injury.

The effects of plasma rich in growth factors (PRGF-Endoret) on healing of medial collateral ligament of the knee

PURPOSE

Platelet-rich plasma (PRP) has been increasingly used in sports-related injuries for therapeutic applications. However, there are numerous manufacturing procedures and treatment protocols of PRP use, which make difficult to assess its real efficacy for tissue healing. This study addressed to evaluate the therapeutic effects of locally delivered plasma rich in growth factors (PRGF-Endoret) on the early healing of medial collateral ligament (MCL) in rabbit knees.

METHODS

Thirty-one Japanese white rabbits were subjected to a mop-end tear in the MCL of the left knee. PRGF-Endoret was prepared using Anitua's technique. Two groups were set up. In 17 knees, prepared 1.0 ml of PRGF-Endoret after clotting was applied on the tear site, while in 14 knees the tear site was untreated serving as a control. Quantitative aspects of PRGF-Endoret, the concentration of platelets, leukocytes and erythrocytes and therapeutic growth factors such as PDGF-BB and TGF-β1 were measured. Rabbits were sacrificed at 3 and 6 weeks after the operation and histological and biomechanical evaluation were performed.

RESULTS

No leukocytes were measured and certain amount of growth factors such as PDGF-BB and TGF-β1 were confirmed in the PRGF-Endoret. PRGF-Endoret stimulated proliferation of fibroblasts and neovascularization, and induced statistically better structural properties in repaired MCL.

CONCLUSIONS

Our findings provide evidence that local administration of PRGF-Endoret promotes early steps in ligament healing and the repair of structural properties in a rabbit model. PRGF-Endoret would be a useful product in clinical treatment of ligament injuries.

Cellular senescence occurring in the rabbit medial collateral ligament during healing

Medial collateral ligament (MCL) healing proceeds in a temporally ordered fashion after injury. Despite the critical roles of fibroblasts during ligament repair, the phenotypic features of these healing fibroblasts have not been well characterized. Here, we show that healing MCL fibroblasts obtained from rabbits at 3-week postinjury exhibited higher rates of senescent phenotypes and produced higher levels of TGF-β1, collagens, α-SMA, and matrix metalloproteinases (MMPs), than the corresponding fibroblasts from sham-operated MCLs. Mechanical stretch further enhanced the cellular senescence and the expression of TGF-β1, collagens, α-SMA, and MMPs in both sham and healing MCL fibroblasts. In addition to MCL fibroblasts at 3-week postinjury, the increased cellular senescence was also detected in healing MCL fibroblasts obtained at 4- and 6-week postinjury. Most importantly, the association between the cellular senescence and ligament healing was confirmed in tissue sections by the senescence-associated β-galactosidase (SA-β-gal) staining. Using a recombinant TGF-β1 and a neutralizing antibody, we found that those phenotypic changes, such as cellular senescence and the expression of collagens and MMPs, in MCL fibroblasts under mechanical loading conditions were regulated through TGF-β1. Taken together, our results propose that cellular senescence and turnover of extracellular matrixes regulated by TGF-β1 in MCL fibroblasts are critical for ligament healing.

Therapeutic potential of anterior cruciate ligament-derived stem cells for anterior cruciate ligament reconstruction

We recently reported that the ruptured regions of the human anterior cruciate ligament (ACL) contained vascular-derived stem cells, which showed the potential for high expansion and multilineage differentiation. In this study, we performed experiments to test the hypothesis that ACL-derived CD34(+) cells could contribute to tendon-bone healing. ACL-derived cells were isolated from the rupture site of human ACL by fluorescence-activated cell sorting. Following ACL reconstruction, immunodeficient rats received intracapsular administration of either ACL-derived CD34(+) cells, nonsorted (NS) cells, CD34(+) cells, or phosphate-buffered saline (PBS). We also performed in vitro cell proliferation assays and enzyme-linked immunosorbent assays for vascular endothelial growth factor (VEGF) secretion. We confirmed the recruitment of the transplanted cells into the perigraft site after intracapuslar injection by immunohistochemical staining at week 1. Histological evaluation showed a greater area of collagen fiber formation and more collagen type II expression in the CD34(+) group than the other groups at the week 2 time point. Immunostaining with isolectin B4 and rat osteocalcin demonstrated enhanced angiogenesis and osteogenesis in the CD34(+) group at week 2. Moreover, double immunohistochemical staining for human-specific endothelial cell (EC) and osteoblast (OB) markers at week 2 demonstrated a greater ability of differentiation into ECs and OBs in the CD34(+) group. Microcomputerized tomography showed the greatest healing of perigraft bone at week 4 in the CD34(+) cell group, and the failure load of tensile test at week 8 demonstrated the greatest biomechanical strength in the CD34(+) group. Furthermore, the in vitro studies indicated that the CD34(+) group was superior to the other groups in their cell proliferation and VEGF secretion capacities. We demonstrated that ACL-derived CD34(+) cells contributed to the tendon-bone healing after ACL reconstruction via the enhancement of angiogenesis and osteogenesis, which also contributed to an increase in biomechanical strength.

Autologous transplantation of culture-born myofibroblasts into intact and injured rabbit ligaments

PURPOSE

The myofibroblast, a contractile fibroblastic cell expressing α-smooth muscle actin (α-SMA), has been reported to play a role in ligament healing. The aim of this study was to evaluate the feasibility of transplanting culture-derived myofibroblasts in injured rabbit medial collateral ligaments (MCL) and in intact anterior cruciate ligaments (ACL).

METHODS

Fibroblasts isolated from the iliotibial band were cultured in the presence of transforming growth factor beta-1 (TGF-β1) for five days and analysed for α-SMA expression. In a concentration of TGF-β1 ≥ 10 ng/ml, the differentiation rate into myofibroblast was 90%. After labelling with PKH26, α-SMA -positive cells were transplanted in intact ACL and in injured MCL of ten rabbits.

RESULTS

Survival of PKH-26+ cells was seen in all intact and damaged ligaments one day after injection. The density of PKH-26+ cells had decreased at seven days postinjection in both ligaments. Double-positive PKH-26+/α-SMA+ cells were only observed in injured MCL at seven days postinjection. Moreover, we found that genetically modified fibroblasts differentiate into myofibroblasts and can be transplanted into ligaments.

CONCLUSIONS

Our data demonstrate that culture-born myofibroblasts survive and maintain α-SMA expression up to one week after transplantation. This study provides the first insight into the feasibility of transplanted mechanically active cells for ligament reconstruction.

Effect of anterior cruciate healing on the uninjured ligament insertion site

The effect of anterior cruciate healing on the uninjured ligament insertion site after enhanced suture repair with collagen-platelet composites (CPC) has not yet been defined. In this study, we hypothesized that fibroblasts and osteoclasts would participate in generating histologic changes in insertion site morphology after transection and bioenhanced repair of the ACL, and that these changes would be age-dependent. Skeletally immature, adolescent, and adult Yucatan mini-pigs underwent ACL transection and bioenhanced suture repair. The histologic response to repair of the insertion site was evaluated at 1, 2, 4, and 15 weeks. In young and adolescent animals treated with bioenhanced suture repair with CPC, changes in the insertion site included: (1) fibroblastic proliferation with loss and return of collagen alignment in the fibrous zone; (2) osteoclastic resorption within fibrocartilage zones at 2-4 weeks; and (3) partial reappearance of fibrocartilage zones at 15 weeks. In adult animals; however, degenerative changes were noted by 15 weeks: (1) loss of parallel arrangement of collagen fibers in the fibrous zone; and (2) increasing disorganization and loss of columnation of chondrocytes in the fibrocartilage zone. These results suggest that fibroblasts and osteoclasts mediate histologic changes at the insertion site during bioenhanced suture repair of the ACL which may prevent insertion site degeneration, and that the magnitude of these changes may be a function of skeletal maturity.

Wound healing differences between Yorkshire and red Duroc porcine medial collateral ligaments identified by biomechanical assessment of scars

BACKGROUND

Currently, there are no large animal models to assess potential genetic contributions to ligament biomechanics during an injury repair response. Yorkshire and red Duroc pigs display phenotypically and genetically different skin wound healing responses; red Duroc skin scars were hyper-contracted and hyper-pigmented, whereas Yorkshire skin scars were not. Such findings raise the question whether connective tissues of synovial joints display a similar differential healing response in these pig breeds. This study assessed medial collateral ligament healing in Yorkshire and red Duroc pigs at the functional (biomechanical) level.

METHODS

Surgical injury was created in the right hind limb medial collateral ligament of Yorkshire and red Duroc pigs. After 10 weeks of healing, low-load (laxity and creep) and high-load (failure) mechanical properties were measured.

FINDINGS

Large, complete ligament scars formed by 10 weeks post-injury. A differential healing response was observed between the breeds, where red Duroc ligament scars had larger cross-sectional areas, exhibited greater static and total creep responses, failed at greater deformations and strains (P ≤ 0.05), and failed with strong trends for higher loads and lower moduli (P=0.06) than Yorkshire ligament scars.

INTERPRETATION

The ligament healing response of red Duroc pigs differs from Yorkshire pigs. Previously observed breed differences in dorsal skin wound healing are not restricted to skin. Such findings support a genetic basis for breed differences in response to connective tissue injury. Since this animal model is physiologically comparable to humans, these findings could provide further insight into identification of specific genetic contributions to ligament repair in human populations.

Isolation and characterization of human anterior cruciate ligament-derived vascular stem cells

The anterior cruciate ligament (ACL) usually fails to heal after rupture mainly due to the inability of the cells within the ACL tissue to establish an adequate healing process, making graft reconstruction surgery a necessity. However, some reports have shown that there is a healing potential of ACL with primary suture repair. Although some reports showed the existence of mesenchymal stem cell-like cells in human ACL tissues, their origin still remains unclear. Recently, blood vessels have been reported to represent a rich supply of stem/progenitor cells with a characteristic expression of CD34 and CD146. In this study, we attempted to validate the hypothesis that CD34- and CD146-expressing vascular cells exist in hACL tissues, have a potential for multi-lineage differentiation, and are recruited to the rupture site to participate in the intrinsic healing of injured ACL. Immunohistochemistry and flow cytometry analysis of hACL tissues demonstrated that it contains significantly more CD34 and CD146-positive cells in the ACL ruptured site compared with the noninjured midsubstance. CD34+CD45- cells isolated from ACL ruptured site showed higher expansionary potentials than CD146+CD45- and CD34-CD146-CD45- cells, and displayed higher differentiation potentials into osteogenic, adipogenic, and angiogenic lineages than the other cell populations. Immunohistochemistry of fetal and adult hACL tissues demonstrated a higher number of CD34 and CD146-positive cells in the ACL septum region compared with the midsubstance. In conclusion, our findings suggest that the ACL septum region contains a population of vascular-derived stem cells that may contribute to ligament regeneration and repair at the site of rupture.

α-Smooth muscle actin and TGF-β receptor I expression in the healing rabbit medial collateral and anterior cruciate ligaments

The aim of our study was to advance the knowledge about the biological differences in the healing of the anterior cruciate ligament (ACL) versus the medial collateral ligament (MCL). We quantified α-smooth muscle actin (α-SMA) expression and TGF-β receptor I (TGF-βRI) expression in experimentally injured rabbit ligaments (from day 3 to 12 weeks post-injury). Myofibroblasts (α-SMA positive cells) were identified as early as the third day post-injury in MCL and their density increased steadily up to day 21. Myofibroblasts were also detected in injured ACL but their density remained very low at all time points. The percentage of positive TGF-βRI area significantly increased in both injured ligaments compared to controls, with a peak expression at day 21; however, it remained constantly lower in ACL compared to MCL. A significant correlation was found between the percentage of TGF-βRI positive cells and the percentage of α-SMA expression only in injured MCL. These results provide evidence that myofibroblasts are important players in MCL remodelling after injury. The combined presence of myofibroblasts and TGF-βRI in the first 3 weeks post-MCL injury may partially explain the difference in the MCL and ACL healing process.

Molecular events surrounding collagen fibril assembly in the early healing rabbit medial collateral ligament--failure to recapitulate normal ligament development

??Although injuries to the medial collateral ligament (MCL) can heal functionally without surgical intervention, the collagen fibers in the healing tissue remain compromised. The molecular basis for this poor healing potential was investigated by examining extracellular matrix-modifying molecules such as bone morphogenetic protein 1 (BMP-1), procollagen C proteinase enhancer (PCOLCE), lysyl oxidase (LOX), and transforming growth factor beta 1 (TGF-β1) involved in collagen fibrillogenesis during normal early postnatal ligament maturation and at comparable intervals after MCL injury. Samples of midsections of rabbit MCLs were collected from 3-, 6-, 14-, and 52-week-old normal animals and at 3, 6, and 14 weeks postinjury. Harvested midsubstance tissues were analyzed for collagen fibril diameter by transmission electron microscopy (TEM), and mRNA levels were assessed by reverse transcription-polymerase chain reaction (RT-PCR). Results showed different patterns of expression between normal MCL maturation and during scar maturation. BMP-1 and PCOLCE mRNA levels were upregulated in the 3?14-week period during maturation of normal ligaments but decreased at skeletal maturity. The scar tissue exhibited a 3.5-fold increase in PCOLCE mRNA levels during the early healing phase, but these decreased with time. After injury, BMP-1 mRNA levels in scars were low and did not change during healing. Both LOX and TGF-β1 mRNA levels were low during normal MCL development compared with levels at maturity and exhibited elevated mRNA levels during early healing that decreased with time postinjury. These results suggest that gene expression in scars during MCL healing does not recapitulate expression in normal ligament fibroblasts during maturation.

Functional tissue engineering of ligament healing

Ligaments and tendons are dense connective tissues that are important in transmitting forces and facilitate joint articulation in the musculoskeletal system. Their injury frequency is high especially for those that are functional important, like the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) of the knee as well as the glenohumeral ligaments and the rotator cuff tendons of the shoulder. Because the healing responses are different in these ligaments and tendons after injury, the consequences and treatments are tissue- and site-specific. In this review, we will elaborate on the injuries of the knee ligaments as well as using functional tissue engineering (FTE) approaches to improve their healing. Specifically, the ACL of knee has limited capability to heal, and results of non-surgical management of its midsubstance rupture have been poor. Consequently, surgical reconstruction of the ACL is regularly performed to gain knee stability. However, the long-term results are not satisfactory besides the numerous complications accompanied with the surgeries. With the rapid development of FTE, there is a renewed interest in revisiting ACL healing. Approaches such as using growth factors, stem cells and scaffolds have been widely investigated. In this article, the biology of normal and healing ligaments is first reviewed, followed by a discussion on the issues related to the treatment of ACL injuries. Afterwards, current promising FTE methods are presented for the treatment of ligament injuries, including the use of growth factors, gene delivery, and cell therapy with a particular emphasis on the use of ECM bioscaffolds. The challenging areas are listed in the future direction that suggests where collection of energy could be placed in order to restore the injured ligaments and tendons structurally and functionally.

Characterization of the Fatigue Behavior of the Medial Collateral Ligament Utilizing Traditional and Novel Mechanical Variables for the Assessment of Damage Accumulation

Ligaments are regularly subjected to repetitive loading in vivo. Typically, mechanical studies focus on repetitive loading protocols of short duration, while those characterizing damage accumulation over a longer duration (i.e., fatigue studies) are lacking. The aims of this study were as follows: (a) to demonstrate that damage does accumulate in ligament tissue subjected to repetitive loading and (b) to evaluate existing and new methods for characterizing fatigue damage accumulation. It was hypothesized that ligaments would accumulate damage with repetitive loading as evidenced by failure at stresses well below ultimate tensile strength, creep curve discontinuities, and by reductions in stiffness during loading. Eight normal medial collateral ligaments from female New Zealand white rabbits were cycled in tension, between 0 MPa and 28 MPa, to failure or until 259,200 cycles, whichever came first. Medial collateral ligaments that did not fail were subsequently loaded to failure. Displacement rates (dlmax/dt) as well as primary, secondary, and tertiary creeps were monitored as indices of damage accumulation and impending mechanical failure. Additionally, the relative utilities of tangent, secant, and chord stiffness parameters were critically evaluated. Finally, new uses for the second derivative of force-displacement data were explored. Three out of eight ligaments failed during testing, demonstrating that ligaments can fail in fatigue under moderate tensile stress in vitro. The evaluation of displacement rates (dlmax/dt), as well as primary through tertiary creep patterns, were not well suited to predicting failure in normal ligaments until rupture was all but imminent. Tangent stiffness, which was calculated from a mathematically defined start of the “linear region,” was surprisingly constant throughout testing. Secant stiffness dropped in a predictable fashion, providing a global indicator of tissue stiffness, but did not provide any insight into fiber mechanics. Chord stiffness, on the other hand, appeared to be sensitive to fiber recruitment patterns. The second derivative of force-displacement data proved to be a useful means of (a) objectively defining the start of the linear region and (b) inferring changes in fiber recruitment patterns within ligament tissue. Tangent, secant, and chord stiffnesses highlight different attributes of ligament responses to loading; hence these parameters cannot be used interchangeably. Additionally, the second derivative of the force-displacement curve was introduced as a useful descriptive and analytical tool.

Microporous pure beta-tricalcium phosphate implants for press-fit fixation of anterior cruciate ligament grafts: strength and healing in a sheep model

PURPOSE

A sheep study was conducted to test a press-fit technique using microporous pure beta-tricalcium phosphate (beta-TCP) dowels for fixation of the anterior cruciate ligament (ACL) graft.

METHODS

Microporous (5 mum) cylindrical plugs of beta-TCP (diameter, 7 mm; length, 25 mm) with interconnecting pores were used. The material featured a novel configuration of structure and surface geometry. Implants were tested by use of press-fit fixation of ACL grafts with and without bone blocks in 42 sheep over a period of 24 weeks. Biomechanical, radiologic, histologic, and immunohistochemical evaluations were performed.

RESULTS

In load-to-failure tests at 6, 12, and 24 weeks after surgery, the intra-articular graft always failed, not the fixation. Grafts showed bony fixation in the tunnel at 6 weeks and primary healing at the junction of the tunnel and joint after 24 weeks. Tricalcium phosphate was resorbed and simultaneously replaced by bone. Remodeling was still incomplete at 24 weeks.

CONCLUSIONS

In the sheep model microporous beta-TCP implants used with press-fit fixation of ACL grafts permit early functional rehabilitation. After 6 weeks, the graft is fixed by woven bone or bony integration. Implanted microporous tricalcium phosphate is resorbed and replaced by bone.

CLINICAL RELEVANCE

In a sheep model we showed that primary healing of ACL grafts with resorption and bony replacement of the fixating implant can be achieved by means of press-fit fixation with pure beta-TCP.

Instrument-assisted cross-fiber massage accelerates knee ligament healing

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To investigate the effects of instrument-assisted cross-fiber massage (IACFM) on tissue-level healing of knee medial collateral ligament (MCL) injuries.

BACKGROUND

Ligament injuries are common and significant clinical problems for which there are few established interventions. IACFM represents an intervention that may mediate tissue-level healing following ligament injury.

METHODS

Bilateral knee MCL injuries were created in 51 rodents, while 7 rodents were maintained as ligament-intact, control animals. IACFM was commenced 1 week following injury and introduced 3 sessions per week for 1 minute per session. IACFM was introduced unilaterally (IACFM-treated), with the contralateral, injured MCL serving as an internal control (nontreated). Thirty-one injured animals received 9 ACFM treatments, while the remaining 20 injured animals received 30 treatments. Ligament biomechanical properties and morphology were assessed at either 4 or 12 weeks postinjury.

RESULTS

IACFM-treated ligaments were 43.1% stronger (P<.05), 39.7% stiffer (P<.01), and could absorb 57.1% more energy before failure (P<.05) than contralateral, injured, nontreated ligaments at 4 weeks postinjury. On histological and scanning electron microscopy assessment, IACFM-treated ligaments appeared to have improved collagen fiber bundle formation and orientation within the scar region than nontreated ligaments. There were minimal differences between IACFM-treated and contralateral, nontreated ligaments at 12 weeks postinjury, although IACFM-treated ligaments were 15.4% stiffer (P<.05).

CONCLUSION

IACFM-accelerated ligament healing, possibly via favorable effects on collagen formation and organization, but had minimal effect on the final outcome of healing. These findings are clinically interesting, as there are few established interventions for ligament injuries, and IACFM is a simple and practical therapy technique. J Orthop Sports Phys Ther 2009;39(7):506-514, Epub 24 February 2009. doi:10.2519/jospt.2009.2997.

Role of biomechanics in the understanding of normal, injured, and healing ligaments and tendons

Ligaments and tendons are soft connective tissues which serve essential roles for biomechanical function of the musculoskeletal system by stabilizing and guiding the motion of diarthrodial joints. Nevertheless, these tissues are frequently injured due to repetition and overuse as well as quick cutting motions that involve acceleration and deceleration. These injuries often upset this balance between mobility and stability of the joint which causes damage to other soft tissues manifested as pain and other morbidity, such as osteoarthritis.

The healing of ligament and tendon injuries varies from tissue to tissue. Tendinopathies are ubiquitous and can take up to 12 months for the pain to subside before one could return to normal activity. A ruptured medial collateral ligament (MCL) can generally heal spontaneously; however, its remodeling process takes years and its biomechanical properties remain inferior when compared to the normal MCL. It is also known that a midsubstance anterior cruciate ligament (ACL) tear has limited healing capability, and reconstruction by soft tissue grafts has been regularly performed to regain knee function. However, long term follow-up studies have revealed that 20–25% of patients experience unsatisfactory results. Thus, a better understanding of the function of ligaments and tendons, together with knowledge on their healing potential, may help investigators to develop novel strategies to accelerate and improve the healing process of ligaments and tendons.

With thousands of new papers published in the last ten years that involve biomechanics of ligaments and tendons, there is an increasing appreciation of this subject area. Such attention has positively impacted clinical practice. On the other hand, biomechanical data are complex in nature, and there is a danger of misinterpreting them. Thus, in these review, we will provide the readers with a brief overview of ligaments and tendons and refer them to appropriate methodologies used to obtain their biomechanical properties. Specifically, we hope the reader will pay attention to how the properties of these tissues can be altered due to various experimental and biologic factors. Following this background material, we will present how biomechanics can be applied to gain an understanding of the mechanisms as well as clinical management of various ligament and tendon ailments. To conclude, new technology, including imaging and robotics as well as functional tissue engineering, that could form novel treatment strategies to enhance healing of ligament and tendon are presented.

The effects of bone marrow or periosteum on tendon-to-bone tunnel healing in a rabbit model

The purpose of this study was to investigate whether a grafting technique using either periosteum or bone marrow as an adjunct, would reconstitute more favorable tendon anchorage morphology with improved tensile strength in a bone tunnel model. We hypothesized that autogenous bone marrow aspirate can enhance the tendon-bone attachment as well as a freshly harvested periosteum, because both tissues contain pluripotent cells. Thirty-six skeletally mature New Zealand white rabbits were utilized. For the tendon graft healing in a bone tunnel model, the extensor digitorum longus tendon was detached from its femoral insertion and transplanted through a bone tunnel into the proximal tibia. Three groups were compared. For the group P (periosteum), a periosteum-wrapped tendon was fixed into the tunnel through the proximal tibial metaphysis. For the group BM (bone marrow), instead of periosteum augmentation, fresh bone marrow was injected into the tendon graft that would sit inside the tunnel. For the group C (control), the limb underwent a similar operation with neither the periosteum enveloping nor bone marrow injecting the tendon. At 6 and 12 weeks after surgery, two rabbits were used for light and electron microscopic examinations, and ten rabbits were used for biomechanical tests in each group. The interface tissue between bone and tendon was thicker and less organized in group C compared to groups P and BM at 6 weeks. Ultra-structurally, the interface tissue was loosely organized in group C, compared to others. Bone ingrowth into tendon was more obvious in groups P and BM, compared to group C. The proliferation of cartilage islands was observed within bone tunnels of both groups P and BM; but a well-defined fibrocartilage zone was noted only in group BM at the interface at week 12. Biomechanical findings: (1) at 6 weeks, the average failure load of group P was significantly higher than the others (P < 0.01). At same time point, in terms of stiffness, while group P was significantly higher than the other groups (P < 0.01), group BM was also significantly higher than that of group C (P < 0.05); (2) at 12 weeks, in terms of failure loads, there was a statistical significant difference only between groups BM and C (P < 0.05). At the same time point, stiffness values were not statistically different among the three groups. Based on the histological and biomechanical findings, the present study demonstrated that periosteum had a positive effect when compared to bone marrow and control groups on the tendon-to-bone healing at an early time point (6 weeks), and bone marrow was also effective at 12 weeks time point compared to the control group in an extra-articular bone tunnel in rabbits. The presence of pluripotent cells in both the bone marrow and the periosteum may be the possible mechanism for enhanced healing. Periosteum had a positive effect at an early time point (6 weeks). Bone marrow was more effective at 12 weeks. Therefore, it is possible that a combination of wrapping periosteum and injecting bone marrow to the tendon graft would have a synergistic effect (early and strong). To prove this hypothesis, future studies which would combine both methods are needed.

Positive changes in bone marrow-derived cells in response to culture on an aligned bioscaffold

Previous studies have shown that cultured cells align with the local topography of their substrate following a concept called "contact guidance." Additionally, if the topography is highly aligned, the cells produce newly synthesized matrix that is also aligned. The objective of this study was to elucidate the positive effect of cell seeding on an elongated porcine small intestinal submucosa (SIS), which has been shown to improve ligament and tendon healing, by measuring the cellular response as a result of the changes in alignment. Because elongation is known to align the fibers of SIS through recruitment along the direction of elongation, we hypothesized that rabbit bone marrow-derived cells (BMDCs) seeded on SIS with improved fiber alignment would increase the expression and production of collagen following the concept of contact guidance. Using the small-angle light-scattering technique, it was found that a 15% elongation together with BMDC seeding on SIS (elongated, seeded group) improved its alignment of collagen fibers up to 16 times more than no elongation and no BMDC seeding (non-elongated, non-seeded group). Furthermore, BMDCs were also aligned along the direction of elongation and showed 200% greater collagen type I gene expression in the elongated, seeded group than in Petri dish controls. More importantly, the production of collagen was also 24% greater. The results of this study demonstrate that alignment of a bioscaffold can result in positive changes in cellular response, making the bioscaffold more attractive for functional tissue engineering to potentially enhance healing of ligaments and tendons.

Fetal ACL fibroblasts exhibit enhanced cellular properties compared with adults

Fetal tendons and skin heal regeneratively without scar formation. Cells isolated from these fetal tissues exhibit enhanced cellular migration and collagen production in comparison to cells from adult tissue. We determined whether fetal and adult fibroblasts isolated from the anterior cruciate ligament (ACL), a tissue that does not heal regeneratively, exhibit differences in cell migration rates and collagen elaboration. An in vitro migration assay showed fetal ACL fibroblasts migrated twice as fast as adult ACL fibroblasts at a rate of 38.90 +/- 7.69 microm per hour compared with 18.88 +/- 4.18 microm per hour, respectively. Quantification of Type I collagen elaboration by enzyme-linked immunosorbent assay showed fetal ACL fibroblasts produced four times the amount of Type I collagen compared with adult ACL fibroblasts after 7 days in culture. We observed no differences in Type III collagen with time for adult or fetal ACL fibroblasts. Our findings indicate fetal ACL fibroblasts are intrinsically different from adult ACL fibroblasts, suggesting the healing potential of the ACL may be age-dependent.

Ultrasound phonophoresis of panax notoginseng improves the strength of repairing ligament: a rat model

This study examined the phonophoretic effect of a therapeutic ultrasound coupled with a Panax notoginseng (PN) gel and compared it with a therapeutic ultrasound alone for medial collateral ligament repair in rats. Twenty mature male Sprague-Dawley rats receiving surgical transection to the left medial collateral ligament (MCL) were divided randomly into three groups: ultrasound (US, n = 7), ultrasound with PN coupling gel (PNUS, n = 7) and control (n = 6). The treatments started on day 3 after surgery for six days per week over a two-week period. The US group received 4 min of pulsed ultrasound (1 MHz) at the intensity of 0.5W/cm(2) with a normal ultrasonic coupling gel. The PNUS group received the same ultrasound treatment, but with a coupling gel that contained PN extract. The control group received a placebo ultrasound treatment similar to the other two groups. On day 17, the ligaments were mechanically tested for load-relaxation, stiffness and ultimate tensile strength (UTS). Values of the left side were normalized against that of the right side of each animal for analysis. Results revealed significantly higher normalized stiffness (p = 0.009) and UTS (p = 0.022) in the PNUS group than the other two groups, but insignificant difference in load-relaxation among all groups. This study reveals a positive ultrasonic phonophoretic effect of Panax notoginseng extract for improving the strength of ligament repair than ultrasound therapy alone.

Twenty-five years of tendon and ligament research

Twenty-five years ago, the Journal of Orthopaedic Research published its first volume, which included five articles covering topics in tendon and ligament research. Since then, the body of tendon and ligament research has continued to increase exponentially. This review summarizes major advancements in tendon and ligament research since the initial publication of this journal. The purpose of this article is not to provide an in-depth review of all of tendon and ligament research, but instead to provide a concise literature review of some of the major and recurring areas of research. The general topics covered over the last 25 years include tissue properties, tendinopathy, healing, and engineered scaffolds.

Effects of a bioscaffold on collagen fibrillogenesis in healing medial collateral ligament in rabbits

Bioscaffolds have been successfully used to improve the healing of ligaments and tendons. In a rabbit model, the application of porcine small intestine submucosa (SIS) to the healing medial collateral ligament (MCL) resulted in improved mechanical properties with the formation of larger collagen fibrils. Thus, the objective of the study was to find out whether the SIS bioscaffold could improve the gene expressions of fibrillogenesis-related molecules, specifically, collagen types I, III, V, and small leucine-rich proteoglycans including decorin, biglycan, lumican, and fibromodulin, as well as collagen fibril morphology and organization, in the healing rabbit MCL at an early time point (6 weeks postinjury). Twenty skeletally mature rabbits were equally divided into two groups. In the SIS-treated group, a 6-mm gap was surgically created and a layer of SIS was sutured to cover the gap, whereas the gap was left open in the nontreated group. At 6 weeks postinjury, Masson's trichrome staining showed that the SIS-treated group had more regularly aligned collagen fibers and cells. Transmission electron microscopy revealed that the SIS-treated group had larger collagen fibrils with a diameter distribution from 24 to 120 nm, whereas the nontreated group had only small collagen fibrils (ranging from 26 to 87 nm, p < 0.05). Finally, the quantitative real-time PCR showed that the mRNAs of collagen type V, decorin, biglycan, and lumican in the SIS-treated group were 41, 58, 51, and 43% lower than those in the nontreated group, respectively (p < 0.05). Such significant reduction in the gene expressions are closely related to the improved morphological characteristics, which are known to be coupled with better mechanical properties, as previously reported in longer term studies.

Administrations of peripheral blood CD34-positive cells contribute to medial collateral ligament healing via vasculogenesis

Neoangiogenesis is a key process in the initial phase of ligament healing. Adult human circulating CD34+ cells, an endothelial/hematopoietic progenitor-enriched cell population, have been reported to contribute to neoangiogenesis; however, the therapeutic potential of CD34+ cells for ligament healing is still unclear. Therefore, we performed a series of experiments to test our hypothesis that ligament healing is supported by CD34+ cells via vasculogenesis. Granulocyte colony-stimulating factor-mobilized peripheral blood (GM-PB) CD34+ cells with atelocollagen (CD34+ group), GM-PB mononuclear cells (MNCs) with atelocollagen (MNC group), or atelocollagen alone (control group) was locally transplanted after the creation of medial collateral ligament injury in immunodeficient rats. Reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemical staining at the injury site demonstrated that molecular and histological expression of human-specific markers for endothelial cells was higher in the CD34+ group compared with the other groups at week 1. Endogenous effect, assessed by capillary density and mRNA expression of vascular endothelial growth factor, was significantly higher in CD34+ cell group than the other groups. In addition to the observation that, as assessed by real-time RT-PCR, gene expression of ligament-specific marker was significantly higher in the CD34+ group than in the other groups, ligament healing assessed by macroscopic, histological, and biomechanical examination was significantly enhanced by CD34+ cell transplantation compared with the other groups. Our data strongly suggest that local transplantation of circulating human CD34+ cells may augment the ligament healing process by promoting a favorable environment through neovascularization.

Effect of osteogenic protein-1 on the matrix metabolism of bovine tendon cells

Tendon rupture is a common sports injury in adults. However, the mechanical properties of repair tissue are inferior to those of normal tissue. To accelerate tendon healing, an in vivo approach using growth factors has been applied and has shown evidence for the efficacy of biological stimulation of the repair process. Recombinant human osteogenic protein-1 (rhOP-1) has been shown to be effective in stimulating matrix production by various connective tissues. To test the effect of rhOP-1 on the matrix metabolism of tendon cells in vitro, bovine tendon cells were cultured in monolayer with various doses of rhOP-1 for 7 days. The addition of rhOP-1 to cell culture media resulted in significant increases in cell proliferation, DNA content, and the synthesis of proteoglycans (PGs) and collagen, compared to control cultures. The relative percentage of large PGs in the OP-1 culture was higher than that in the control culture. In conclusion, we show for the first time that rhOP-1 stimulates the proliferation of tendon cells and their ability to synthesize and accumulate PGs and collagen in their extracellular matrix. These biological properties may be used in the tissue-engineering of tendon tissues.

Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold

The anterior cruciate ligament (ACL) of the knee is an intra-articular ligament that fails to heal after primary repair. The medial collateral ligament (MCL) of the knee is an extra-articular ligament that heals uneventfully in the majority of cases. Why these two ligaments have such different responses to injury remains unclear. In this article, we address two hypotheses: first, that the histologic response to injury is different in intra-articular and extra-articular ligaments, and second, that the response of the intra-articular ligaments can be altered by placing a collagen-platelet-rich plasma (collagen-PRP) hydrogel in the wound site. Wounds were created in extra-articular ligaments (MCL and/or patellar ligament) and an intra-articular ligament (ACL) in canine knees, and the histologic response to injury evaluated at 3 days (n = 3), 7 days (n = 4), 3 weeks (n = 5), and 6 weeks (n = 5). In the 3-week (n = 5) and 6-week (n = 5) animals, bilateral central wounds were made in the ACLs and the wounds in one knee of each animal treated with a collagen-PRP hydrogel while the contralateral side was untreated. Extra-articular ligament wounds had greater filling of the wound site and increased presence in the wound site of fibrinogen, fibronectin, PDGF-A, TGF-beta1, FGF-2, and von Willebrand's factor when compared to intra-articular ligament wounds. Treatment of the intra-articular wound with a collagen-PRP hydrogel resulted in increased filling of the wound site with repair tissue that had similar profiles of growth factor and protein expression to the extra-articular ligament wounds. The use of a collagen-PRP scaffold can ameliorate histologic differences noted between healing extra-articular ligamentous wounds and nonhealing intra-articular ligamentous wounds. This study supports the hypothesis that premature scaffold failure may play a key role in the normally expected failure of the ACL to heal after injury.

In Vitro Validation of a Technique for Assessment of Canine and Feline Elbow Joint Collateral Ligament Integrity and Description of a New Method for Collateral Ligament Prosthetic Replacement

OBJECTIVE

To assess the ability of an operator to differentiate intact from transected canine and feline elbow joint collateral ligaments (CL) using a reported manipulative test (Campbell's test) and to determine the potential for elbow joint luxation in canine and feline elbows with intact, transected, and surgically stabilized CL.

STUDY DESIGN

In vitro biomechanical study.

SAMPLE POPULATION

Canine (n=6) and feline cadavers (n=3).

METHODS

Thoracic limb specimens were mounted on a custom-built jig with the elbows and carpi fixed in 90 degrees of flexion. Angles of pronation and supination were recorded after applying rotational forces to the manus. Attempts were made to manually luxate each elbow with intact CL. Constructs were re-evaluated after sequential sectioning of the medial (MCL) and lateral (LCL) collateral ligaments and after insertion of a new CL prosthesis.

RESULTS

Mean (+/-SD) angles of rotation in dogs increased from 27.3+/-8 degrees (range, 16.7-41.3 degrees ) in pronation to 58.9+/-9.2 degrees (range, 38-88.3 degrees ) after sectioning the MCL and from 45.5+/-10.8 degrees (range, 30.7-67.3 degrees ) in supination to 68.9+/-17.2 degrees (range, 45-94 degrees ) after sectioning the LCL. Angles of pronation and supination were subject to significant interanimal variability, with a strong correlation between increasing animal weight and smaller angles of rotation. Elbow luxation in dogs was not possible unless at least the LCL was transected. In cats, mean angles of rotation increased from 49.8+/-14.9 degrees (range, 30.7-70 degrees ) in pronation to 99.1+/-17.6 degrees (range, 79-111.7 degrees ) after sectioning the MCL and from 128.7+/-18.8 degrees (range, 108.3-151.7 degrees ) in supination to 166.7+/-13.1 degrees (range, 157.3-181.7 degrees ) after sectioning the LCL. Luxation in cats was not possible unless both CL were cut. Use of the ligament prosthesis without primary CL repair reliably prevented reluxation in all canine and feline elbows.

CONCLUSIONS

Campbell's test allowed reliable differentiation of intact, transected and surgically stabilized canine and feline elbow joint CL in a cadaveric model. Luxation could not be performed by application of rotational forces to specimens with intact CL.

CLINICAL RELEVANCE

Clinical examination findings, specifically Campbell's test, can be used to determine elbow CL integrity in dogs and cats. The contralateral elbow should be used as a control, because of interanimal variability in angles of rotation.

Translation from Research to Applications

The article summarizes the collective views expressed at the fourth session of the workshop Tissue Engineering--the Next Generation, which was devoted to the translation of results of tissue engineering research into applications. Ernst Hunziker described the paradigm of a dual translational approach, and argued that tissue engineering should be guided by the dimensions and physiological setting of the bodily compartment to be repaired. Myron Spector discussed collagen-glycosaminoglycan (GAG) scaffolds for musculoskeletal tissue engineering. Jeanette Libera focused on the biological and clinical aspects of cartilage tissue engineering, and described a completely autologous procedure for engineering cartilage using the patient's own chondrocytes and blood serum. Arthur Gertzman reviewed the applications of allograft tissues in orthopedic surgery, and outlined the potential of allograft tissues as models for biological and medical studies. Savio Woo discussed a list of functional tissue engineering approaches designed to restore the biochemical and biomechanical properties of injured ligaments and tendons to be closer to that of the normal tissues. Specific examples of using biological scaffolds that have chemoattractants as well as growth factors with unique contact guidance properties to improve their healing process were shown. Anthony Ratcliffe discussed the translation of the results of research into products that are profitable and meet regulatory requirements. Michael Lysaght challenged the proposition that commercial and clinical failures of early tissue engineering products demonstrate a need for more focus on basic research. Arthur Coury described the evolution of tissue engineering products based on the example of Genzyme, and how various definitions of success and failure can affect perceptions and policies relative to the status and advancement of the field of tissue engineering.

An in vivo injury model of posterolateral knee instability

BACKGROUND

Posterolateral knee instability is a difficult clinical problem to diagnose and treat. To best evaluate its natural history and the effects of interventional treatments, it is important to develop an in vivo model in an attempt to validate human cadaveric and clinical observational studies.

PURPOSE

To develop an in vivo model of posterolateral knee instability in the rabbit and to determine the natural history of untreated posterolateral knee injuries at 6 months postoperatively.

STUDY DESIGN

Controlled laboratory study.

METHODS

The fibular collateral ligament and popliteus tendon were surgically transected in 1 knee in each of 10 skeletally mature New Zealand White rabbits, with the contralateral knee serving as a control knee. At 6 months postoperatively, the rabbits were euthanized, the knees were removed, and biomechanical testing of knee joint stability was performed. After biomechanical testing, histological sections of each proximal tibia and distal femur were evaluated, and each proximal tibia was graded using an osteoarthritis grading scheme.

RESULTS

Biomechanical testing revealed a statistically significant difference in amount of rotation in the operated knees compared with the unoperated control knees to varus moments at 30 degrees , 60 degrees , and 90 degrees and to external rotation torques at 30 degrees and 60 degrees . Morphological analysis revealed no significant difference in lesions of osteoarthritis in the medial compartment of the operated knees compared with the unoperated knees.

CONCLUSIONS

Although the presence of posterolateral knee instability was validated 6 months after surgery in this model, the authors did not identify significant differences in lesions of osteoarthritis in the operated knees compared with the unoperated control knees.

CLINICAL SIGNIFICANCE

This study confirms that posterolateral knee instability can be created in an animal model. It also recapitulates the clinical observation in humans that untreated posterolateral knee injuries do not heal. Similar to animal models of medial collateral ligament sectioning, further studies to validate a posterolateral instability knee model may lead to interventional studies to determine the best way to treat this complex knee instability pattern.

Vanadate ingestion enhances the organization and collagen fibril diameters of rat healing medical collateral ligaments

Although an injured medial collateral ligament (MCL) will naturally heal, the quality of healing tissue is inferior to the uninjured MCL tissue. Previous studies have shown promising results of sodium orthovanadate (vanadate) in enhancing the quality of rat skin wounds. This study therefore investigated whether vanadate enhances the quality of the rat healing MCL in terms of the collagen fibril organization and diameter. Six mature male Sprague-Dawley rats, with weight ranges of 475-505 g and ages of 25 weeks, were used in this study. Three rats in the experimental group received vanadate (0.2 mg/ml) in their saline drinking water (150 mM NaCl), whereas three rats in the control group were only given saline water. Three weeks after transection, the rat MCLs were harvested for hematoxylin and eosin (H&E) staining and transmission electron microscopy. It was found that vanadate promoted organization of collagen fibrils and significantly increased the diameters of collagen fibrils by 14% in healing MCL (P<0.001). These results indicate that application of vanadate may be a promising tissue engineering approach to enhance the quality of healing tissues such as injured MCLs.

Conservative and Postoperative Rehabilitation of Isolated and Combined Injuries of the Medial Collateral Ligament

Injuries to the medial collateral ligament (MCL) are very common and there seems to be a consensus supporting the conservative management of grade I and II tears. Grade III tears are also usually treated conservatively unless associated with injuries to the anterior cruciate ligament or posterior cruciate ligament. This article outlines rehabilitation programs for conservative treatment of MCL injuries, and postoperative programs after anterior cruciate ligament or multiple ligament reconstruction. In addition, the use of functional and prophylactic bracing for injuries of the MCL is reviewed.

Effects of ligament repair on laxity and creep behavior of an early healing ligament scar

BACKGROUND

Previous clinical studies have reported that conservatively managed medial collateral ligament (MCL) injuries remained unstable 9 years post injury with subjective complaints of muscle weakness, reinjuries, and post-traumatic osteoarthritis. Animal studies have also reported that healing MCLs were weaker and more lax than controls. Therefore, our purpose was to study the early effects of ligament repair on scar laxity, creep, and creep recovery in a rabbit model of bilateral medial collateral ligament (MCL) injury.

METHODS

Each rabbit had one MCL cut in midsubstance which was not repaired, while the other MCL had a sagittal Z-plasty repair. Six weeks after surgery, isolated bone-MCL-bone complexes were biomechanically tested for MCL laxity, cyclic creep, creep recovery, and then loaded to ultimate failure.

RESULTS

Nonrepaired scars were significantly more lax than both repaired Z-plasty scars and normal controls. In contrast, there was no significant difference in MCL laxity between repaired scars and normal controls. There were no significant differences between nonrepaired or repaired scars for either cyclic creep and creep recovery. Both crept significantly more and recovered significantly less than normal controls after the same load history. There were no significant differences in the failure load, stiffness, and tensile strength between gap scars and Z-plasty scars. All healing ligaments had significantly lower failure load, stiffness, and tensile strength than normal controls.

CONCLUSIONS

The present study demonstrates that ligament repair is effective in decreasing short-term laxity of ligament scars. These 6-week scars would be prone to abnormal creep if loaded excessively.

Long-term effects of porcine small intestine submucosa on the healing of medial collateral ligament: a functional tissue engineering study

Porcine small intestinal submucosa (SIS) was previously shown to enhance the mechanical properties of healing medial collateral ligaments (MCL), and the histomorphological appearance and collagen type V/I ratio were found to be close to those of normal MCL. We hypothesized that at a longer term, 26 weeks, SIS could guide a better organized neo-ligament formation, increasing mechanical properties and increasing collagen fibril diameters mediated by a reduction in collagen type V. A 6 mm gap injury in the right MCL was surgically created in 38 rabbits, while the contralateral intact MCL served as a sham-operated control. In half the animals, a strip of SIS was sutured onto the severed ends. In the other half, no SIS was applied. The cross-sectional area (CSA) was determined with a laser micrometer system. The femur-MCL-tibia complex was mechanically tested in uniaxial tension. Histomorphology was determined through H&E and immunofluorescent staining and transmission electron microscopy (TEM). Sodium-dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) was used to determine collagen type V/I ratio. SIS-treated MCLs displayed a 28% reduction in CSA, a 33% increase in tangent modulus, and a 50% increase in tensile strength compared with the nontreated group (p < 0.05). TEM showed groups of collagen fibrils with larger diameters in the SIS-treated ligaments in comparison with uniformly small fibrils for the nontreated group. H&E staining showed more densely stained collagen fibers in the SIS-treated group aligned along the longitudinal axis with more interspersed spindle-shaped cells. Immunofluorescent staining showed less collagen type V signals, confirmed by a 5% lower ratio of collagen type V/I compared with the nontreated controls (p < 0.05). The findings extend the shorter term 12-week results, and support the potential of porcine SIS as a bioscaffold to enhance ligament healing.

Regulation of mesenchymal stem cell adhesion and orientation in 3D collagen scaffold by electrical stimulus

Cell adhesion and orientation are important for both natural and engineered tissues to fully achieve physiologic functions. Based on diverse cellular responses induced by electrical stimulus on 2D substrate, we applied non-invasive electrical stimulus to regulate cell adhesion and orientation of bone marrow-derived mesenchymal stem cells (MSCs) and fibroblasts in a reconstituted 3D collagen-based scaffold. While fibroblasts were induced to reorient perpendicularly in response to direct current electrical stimulus, rat MSCs showed only slight changes in cell reorientation. Multiphoton microscopy revealed that rat MSCs exhibited much stronger 3D adhesion, which appears to resist cell reorientation. Only in response to a large electrical stimulus (e.g., 10 V/cm), collagen fibers around rat MSCs became disconnected and loosely reorganized. In contrast, the collagen fibers surrounding the fibroblasts were entangled in a random network and became preferentially aligned in the direction of the electrical stimulus. When incubated with integrin antibodies, both fibroblasts and rat MSCs failed to respond to electrical stimulus, providing evidence that integrin-dependent molecular mechanisms are involved in 3D cell adhesion and orientation. Elucidation of physical regulation of 3D cell adhesion and orientation may offer a novel approach in controlling cell growth and differentiation and could be useful for stem cell-based therapeutic application and engineering tissue constructs.

Treatment with Bioscaffold Enhances the the Fibril Morphology and the Collagen Composition of Healing Medial Collateral Ligament in Rabbits

Porcine small intestinal submucosa (SIS) was shown to be an effective bioscaffold in enhancing the mechanical properties of healing medial collateral ligaments (MCL). The purpose of this study was to investigate whether there are corresponding improvements in morphology and tissue compositions. Fourteen rabbits were equally divided into two groups. In the SIS-treated group, a 6 mm gap was surgically created in the right MCL and a layer of SIS was sutured covering the gap. For the nontreated group, the gap-injured MCLs remained untreated. All the left MCLs were sham operated and used as controls. At 12 weeks, the status of collagen types I and V was evaluated with immunofluorescent staining. The collagen type V/I ratios were obtained using SDS-PAGE. Collagen fibril diameters were calculated from the transmission electron micrographs. The results revealed that in the SIS-treated group, the collagen fibers were more regularly aligned as were the cell nuclei. The collagen fibril diameters were 22.2% larger and the ratio of collagen type V/I was 28.4% lower than those for the nontreated group (p < 0.05). These improvements in the morphological characteristics and biochemical constituents of healing MCLs following SIS treatment are the likely reasons for improved mechanical properties.

The effects of refreezing on the viscoelastic and tensile properties of ligaments

Biomechanical testing protocols for ligaments can be extensive and span two or more days. During this time, a specimen may have to undergo more than one cycle of freezing and thawing. Thus, the objective of this study was to evaluate the effects of refreezing on the viscoelastic and tensile properties of ligaments. The femur-medial collateral ligament-tibia complexes (FMTC) from six pairs of rabbit knees were used for this study. Following sacrifice, one leg in each pair was assigned to the fresh group and the FMTC was immediately dissected and prepared for testing. The contralateral knees were fresh-frozen at -20 degrees C for 3 weeks, thawed, dissected and then refrozen for one additional week before being tested as the refrozen group. The cross-sectional area and shape of the medial collateral ligament (MCL) was measured using a laser micrometer system. Stress relaxation and cyclic stress-relaxation tests in uniaxial tension were performed followed by a load to failure test. When the viscoelastic behavior of the MCL was described by the quasi-linear viscoelastic (QLV) theory, no statistically significant differences could be detected for the five constants (A, B, C, tau1, and tau2) between the fresh and refrozen groups (p > or = 0.07) based on our sample size. In addition, the structural properties of the FMTCs and the mechanical properties of the MCLs were also found to be similar between the two groups (p > or = 0.68). These results suggest that careful refreezing of the specimens had little or no effect on the biomechanical properties measured.

Ligament cells stretch-adapted on a microgrooved substrate increase intercellular communication in response to a mechanical stimulus

An in vitro model was used to investigate the effect of mechanical stimuli on adaptation to load and calcium signaling in aligned medial collateral ligament cells (MCL). This model used a patterned silicone membrane to align the cells parallel with the direction of the microgrooves. Alignment created an architecture that simulated a degree of cell orientation in native ligament tissue. It was hypothesized that aligned ligament cells would be more efficient at calcium wave propagation than cells that were randomly oriented. It was further hypothesized that calcium wave propagation would be greater among cells that were both aligned and subjected to mechanical stretch compared to cells that were aligned but not stretched. Rat MCL cells were loaded with Fura-2AM, a calcium-binding dye, and mechanically indented using a micropipette tip. A ratio-imaging fluorescence technique was used to quantitate the calcium (Ca2+) response. It was concluded that stretching ligament cells prior to stimulation increased their sensitivity to load and their ability to propagate a calcium wave. However, the ability of aligned cells to propagate this wave was not significantly different when compared to nonaligned cells. Treatment of cultures with inhibitors such as apyrase and suramin significantly reduced the number of cells recruited in the calcium response. Hence, it was concluded that ATP released from mechanically stimulated cells was a principal mediator responsible for the rise in intracellular calcium in ligament cells. Further, purinoceptor activation may amplify the signal to alert and recruit more cells in a response to mechanical stimulation.

Strength of medial structures of the knee joint are decreased by isolated injury to the medial collateral ligament and subsequent joint immobilization

Past studies of the healing of the medial collateral ligament (MCL) in animal models have been conducted over a variety of healing intervals, some as early as 1 week. One concern with testing at early healing intervals is the difficulty in identifying and isolating the tissues that carry load. The purpose of this study was to determine if isolation of the MCL and healing time are critical factors in the assessment of structural strength in this model. Furthermore, the effect of immobilization on these critical factors was investigated. Our approach was to calculate the load-sharing ratio between the MCL and the MCL plus capsule. A 4 mm gap was created in the midsubstance of both hindlimb MCLs of 52 female New Zealand White rabbits (n=104). Of these, 29 rabbits had their right hindlimb pin immobilized (immobilized group), leaving the left hindlimb non-immobilized. Testing was performed at 3 (n=12), 6 (n=22), and 14 (n=24) weeks. The remaining 23 rabbits, which had both limbs non-immobilized (non-immobilized group), were tested at 3 (n=10), 6 (n=12), 14 (n=12), and 40 (n=12) weeks. For both groups, half of the specimens at each healing interval were used to test the MCL alone and half to test the MCL plus capsule, except for 3 week immobilized joints where only the MCL plus capsule was tested. Additionally, MCL (n=12), MCL plus capsule (n=6), and capsule alone (n=5) were tested from normal animals. The load-sharing ratio at MCL failure for the normal joint was 89%, suggesting an MCL-dominated response. For the non-immobilized group, the load-sharing ratio was 24% at 3 weeks of healing, suggesting a capsule-dominated response. At and after 6 weeks of healing, an MCL-dominated response was observed, with the ratio being 68% or greater. Thus, at less than 6 weeks of healing, the structural strength capabilities of the joint may be better represented by the medial structures rather than the isolated MCL. Immobilization delayed the transition from a capsule-dominated response to an MCL-dominated response in this model.