Development of antisense oligonucleotide (ASO) technology against Tgf-β signaling to prevent scarring during flexor tendon repair

Pathogenesis of fibrosis in patella-patellar tendon junction induced by jumping load in a rabbit model

The mechanism of fibrosis at the patella-patellar tendon junction (PPTJ) was investigated using a rabbit overuse jumping model. Thirty-two female New Zealand White rabbits were randomly divided into control and jumping groups, and each group was further divided into four groups at 2, 4, 6, and 8 wk. The rabbit in the jumping group jumped 150 times/day, 5 days/wk. The PPTJ was removed at the corresponding time point and subjected to hematoxylin and eosin, safranin O, and immunohistochemical staining. Significant differences were observed in histological changes and fibrosis-related factors between the jumping and control groups (P < 0.01). Comparison within the jumping group indicated that the changes in the fibrocartilage zone thickness and proteoglycan area were pronounced at week 6; the expressions of transforming growth factor β (TGF-β1), Smad3, CTGF, α-SMA, COL-I, and COL-III peaked at week 6 (P < 0.05). The jumping load can lead to morphological and fibrotic changes in the patella-patellar tendon junction, with peak changes occurring at week 6. The fibrosis in the patella-patellar tendon junction may be associated with increased secretion of TGF-β1 and Smad3 due to jump loading, which upregulates CTGF expression and thus promotes the synthesis of α-SMA, COL-I, and COL-III.NEW & NOTEWORTHY The temporal pattern of fibrosis in the patella-patellar tendon junction (PPTJ) was determined by observing changes in histology and fibrosis-related factors at different time points in an overused jumping rabbit model. The results revealed that 1) the peak fibrotic changes in the PPTJ occurred at week 6 of jump training; 2) fibrosis in PPTJ may be associated with the changes in TGF-β1/Smad3. This study contributes to the development of targeted early interventions.

Targeting delivery of a novel TGF-β type I receptor-mimicking peptide to activated hepatic stellate cells for liver fibrosis therapy via inhibiting the TGF-β1/Smad and p38 MAPK signaling pathways

Excessive transforming growth factor β1 (TGF-β1) secreted by activated hepatic stellate cells (aHSCs) aggravates liver fibrosis via over-activation of TGF-β1-mediated signaling pathways in a TGF-β type I receptor (TβRI) dependent manner. TβRI with the C-terminal valine truncated (RIPΔ), as a novel TβRI-mimicking peptide, is an appealing anti-fibrotic candidate by competitive binding of TGF-β1 to block TGF-β1 signal transduction. Platelet-derived growth factor receptor β (PDGFβR) is highly expressed on the surface of aHSCs in liver fibrosis. Herein, we designed a novel RIPΔ variant Z-RIPΔ (PDGFβR-specific affibody ZPDGFβR fused to the N-terminus of RIPΔ) for liver fibrosis therapy, and expect to improve the anti-liver fibrosis efficacy by specifically inhibiting the TGF-β1 activity in aHSCs. Target peptide Z-RIPΔ was prepared in Escherichia coli by SUMO fusion system. Moreover, Z-RIPΔ specifically bound to TGF-β1-activated aHSCs, inhibited cell proliferation and migration, and reduced the expression of fibrosis markers (α-SMA and FN) and TGF-β1 pathway-related effectors (p-Smad2/3 and p-p38) in vitro. Furthermore, Z-RIPΔ specifically targeted the fibrotic liver, alleviated the liver histopathology, mitigated the fibrosis responses, and blocked TGF-β1-mediated Smad and p38 MAPK cascades. More importantly, Z-RIPΔ exhibited a higher fibrotic liver-targeting capacity and stronger anti-fibrotic effects than its parent RIPΔ. Besides, Z-RIPΔ showed no obvious toxicity effects in treating both an in vitro cell model and an in vivo mouse model of liver fibrosis. In conclusion, Z-RIPΔ represents a promising targeted candidate for liver fibrosis therapy.

Antifibrotic and Pro-regenerative Effects of SMAD3 siRNA and Collagen I mRNA-Loaded Lipid Nanoparticles in Human Tenocytes

Tendinopathy involves the inflammation and degeneration of the tendon due to repetitive strain injury. Current treatments primarily target inflammation resolution, yet they do not aim at tissue regeneration. In this study, a microfluidics approach is harnessed to develop a platform of lipid nanoparticles (LNPs) loaded simultaneously with SMAD3 siRNA and collagen I mRNA, aiming to explore its potential dual antifibrotic and regenerative effects in human tenocytes. The developed LNPs displayed size homogeneity and colloidal stability and exhibited high cytocompatibility in human tenocytes. Moreover, LNPs allowed for efficient uptake and transfection efficiency of the RNAs. In the in vitro efficacy studies, the gene expression and production of SMAD3 and collagen I were tested by real-time quantitative chain polymerase reaction and immuno- and intracellular staining, revealing collagen I production enhancement, SMAD3 inhibition, and modulation of other tendon repair factors by the LNPs. Overall, the potential of this platform of RNA-loaded LNPs to be used as a dual therapeutic approach to prevent fibrosis and promote tissue remodeling in late stages of tendon diseases was confirmed.

TGF-β signaling in health, disease, and therapeutics

Transforming growth factor (TGF)-β is a multifunctional cytokine expressed by almost every tissue and cell type. The signal transduction of TGF-β can stimulate diverse cellular responses and is particularly critical to embryonic development, wound healing, tissue homeostasis, and immune homeostasis in health. The dysfunction of TGF-β can play key roles in many diseases, and numerous targeted therapies have been developed to rectify its pathogenic activity. In the past decades, a large number of studies on TGF-β signaling have been carried out, covering a broad spectrum of topics in health, disease, and therapeutics. Thus, a comprehensive overview of TGF-β signaling is required for a general picture of the studies in this field. In this review, we retrace the research history of TGF-β and introduce the molecular mechanisms regarding its biosynthesis, activation, and signal transduction. We also provide deep insights into the functions of TGF-β signaling in physiological conditions as well as in pathological processes. TGF-β-targeting therapies which have brought fresh hope to the treatment of relevant diseases are highlighted. Through the summary of previous knowledge and recent updates, this review aims to provide a systematic understanding of TGF-β signaling and to attract more attention and interest to this research area.

PDGFβ receptor-targeted delivery of truncated transforming growth factor β receptor type II for improving the in vitro and in vivo anti-renal fibrosis activity via strong inactivation of TGF-β1/Smad signaling pathway

Truncated transforming growth factor β receptor type II (tTβRII), serving as a trap for binding excessive transforming growth factor β1 (TGF-β1) by means of competing with wild-type TβRII, is a promising strategy for the treatment of kidney fibrosis. Platelet-derived growth factor β receptor (PDGFβR) is highly expressed in interstitial myofibroblasts in kidney fibrosis. This study identified the interaction between a novel tTβRII variant Z-tTβRII (PDGFβR-specific affibody ZPDGFβR fused to the N-terminus of tTβRII) and TGF-β1. Moreover, Z-tTβRII highly targeted to TGF-β1-activated NIH3T3 cells and UUO-induced fibrotic kidney, but less to normal cells, tissues, and organs. Furthermore, Z-tTβRII significantly inhibited cell proliferation and migration, and reduced fibrosis markers expression and phosphorylation level of Smad2/3 in activated NIH3T3 cells. Meanwhile, Z-tTβRII markedly alleviated the kidney histopathology and fibrotic responses, and inhibited the TGF-β1/Smad signaling pathway in UUO mice. Besides, Z-tTβRII showed good safety performance in the treatment of UUO mice. In conclusion, these results demonstrated that Z-tTβRII may be a potential candidate for a targeting therapy on renal fibrosis due to the high potential of fibrotic kidney-targeting and strong anti-renal fibrosis activity.

Interleukin-6 upregulates extracellular matrix gene expression and transforming growth factor β1 activity of tendon progenitor cells

BACKGROUND

Prolonged inflammation during tendon healing and poor intrinsic healing capacity of tendon are causal factors associated with tendon structural and functional degeneration. Tendon cells, consisting of mature tenocytes and tendon progenitor cells (TPC) function to maintain tendon structure via extracellular matrix (ECM) synthesis. Tendon cells can succumb to tissue cytokine/chemokine alterations during healing and consequently contribute to tendon degeneration. Interleukin-(IL-)1β, IL-6 and TNFα are key cytokines upregulated in injured tendons; the specific effects of IL-6 on flexor tendon-derived TPC have not been discerned.

METHODS

Passage 3 equine superficial digital flexor tendon (SDFT)-derived TPC were isolated from 6 horses. IL-6 impact on the viability (MMT assay with 0, 1, 5 and 10 ng/mL concentrations), migration (scratch motility assay at 0, 10ng/mL concentration) of TPC in monolayer culture were assessed. IL-6 effect on tendon ECM and chondrogenic gene expression (qRT-PCR), TGFβ1 gene expression and activity (ELISA), and MMP-1, -3 and - 13 gene expression of TPC was evaluated.

RESULTS

IL-6 decreased TPC viability and migration. IL-6 treatment at 10 ng/mL significantly up-regulated TGFβ1 gene expression (6.3-fold; p = 0.01) in TPC, and significantly increased the TGFβ1 concentration in cell culture supernates. IL-6 (at 10 ng/mL) significantly up-regulated both tendon ECM (COL1A1:5.3-fold, COL3A1:5.4-fold, COMP 5.5-fold) and chondrogenic (COL2A1:3.9-fold, ACAN:6.2-fold, SOX9:4.8-fold) mRNA expression in TPC. Addition of SB431542, a TGFβ1 receptor inhibitor, to TPC in the presence of IL-6, attenuated the up-regulated tendon ECM and chondrogenic genes.

CONCLUSION

IL-6 alters TPC phenotype during in vitro monolayer culture. Pro- and anti-inflammatory roles of IL-6 have been implicated on tendon healing. Our findings demonstrate that IL-6 induces TGFβ1 activity in TPC and affects the basal TPC phenotype (as evidenced via increased tendon ECM and chondrogenic gene expressions). Further investigation of this biological link may serve as a foundation for therapeutic strategies that modulate IL-6 to enhance tendon healing.

PAI-1 mediates TGF-β1-induced myofibroblast activation in tenocytes via mTOR signaling

Transforming growth factor-beta (TGF-β1) induces plasminogen activator inhibitor 1 (PAI-1) to effect fibrotic pathologies in several organs including tendon. Recent data implicated PAI-1 with inhibition of phosphatase and tensin homolog (PTEN) suggesting that PAI-1-induced adhesions involves phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin (mTOR) signaling. Ergo, we investigated effects of TGF-β1, PAI-1, and mTOR signaling crosstalk on myofibroblast activation, senescence, and proliferation in primary flexor tenocytes from wild-type (WT) and PAI-1 knockout (KO) mice. PAI-1 deletion blunted TGF-β1-induced myofibroblast activation in murine flexor tenocytes and increased the gene expression of Mmp-2 to confer protective effects against fibrosis. While TGF-β1 significantly reduced phosphorylation of PTEN in WT cells, PAI-1 deletion rescued the activation of PTEN. Despite that, there were no differences in TGF-β1-induced activation of mTOR signaling (AKT, 4EBP1, and P70S6K) in WT or KO tenocytes. Phenotypic changes in distinct populations of WT or KO tenocytes exhibiting high or low mTOR activity were then examined. TGF-β1 increased alpha-smooth muscle actin abundance in WT cells exhibiting high mTOR activity, but this increase was blunted in KO cells exhibiting high 4EBP1 activity but not in cells exhibiting high S6 activity. DNA damage (γH2AX) was increased with TGF-β1 treatment in WT tenocytes but was blunted in KO cells exhibiting high mTOR activity. Increased mTOR activity enhanced proliferation (Ki67) in both WT and KO tenocytes. These findings point to a complex nexus of TGF-β1, PAI-1, and mTOR signaling in regulating proliferation, myofibroblast differentiation, and senescence in tenocytes, which could define therapeutic targets for chronic tendon adhesions and other fibrotic pathologies.

Therapeutic role of mesenchymal stem cells and platelet-rich plasma on skin burn healing and rejuvenation: A focus on scar regulation, oxido-inflammatory stress and apoptotic mechanisms

Cell-based therapies have great promise in accelerating and improving burn wound healing. It is a growing need to scale their competence to meet the clinical demands. In this study, the bone marrow mesenchymal stem cells (BMSCs) and platelet-rich plasma (PRP) were tested on the repair of induced burn wounds in a murine model. After the induction of thermal injury, rats were injected with BMSCs and/or PRP in the burn area. After 4 weeks of post-burn, our findings revealed that local treatment of burnt skin with BMSCs and/or PRP offered substantial outcomes when compared with the untreated group. Injected burn with BMSCs and/or PRP enhanced the wound contraction rate and decreased the burn area and period of epithelization. Significant increases in VEGF together with declines in MMP-9 and TGF-β1 were observed in burnt areas after being treated with BMSCs and/or PRP therapy that indicated improved angiogenesis, and re-epithelization. Furthermore, both MSCs and PRP modulated the burn's oxidative and inflammatory microenvironment as indicated by increases in SOD, CAT, and GSH besides declines in MDA, IL-6, TNF-α, NF-κB, NO, and iNOS. Notable increases in Bcl-2 levels and decreases in Cas-3 and Bax levels were recorded in burnt skin that received both agents concomitantly. Interestingly, the histopathological examination validates the healing power of BMSCs and/or PRP. Collectively, BMSCs and PRP have pioneered therapeutics candidates for clinical application in burn healing possibly via antioxidant, anti-inflammatory, and anti-apoptotic mechanisms along with regulating angiogenesis and scar formation.

Non-Viral Delivery of Gene Therapy to the Tendon

The tendon, as a compact connective tissue, is difficult to treat after an acute laceration or chronic degeneration. Gene-based therapy is a highly efficient strategy for diverse diseases which has been increasingly applied in tendons in recent years. As technology improves by leaps and bounds, a wide variety of non-viral vectors have been manufactured that attempt to have high biosecurity and transfection efficiency, considered to be a promising treatment modality. In this review, we examine the unwanted biological barriers, the categories of applicable genes, and the introduction and comparison of non-viral vectors. We focus on lipid-based nanoparticles and polymer-based nanoparticles, differentiating between them based on their combination with diverse chemical modifications and scaffolds.

Transforming growth factor-β signalling pathway in tendon healing

Transforming growth factor-β(TGF-β) plays an important but diverse role in tendon injuries, such as collagen synthesis, cell proliferation, cell differentiation, and cell adhesion, leading to tendon healing and tendon fibrosis. In the well-known canonical TGF-β signalling pathway, TGF-β activates Smad signalling through its two cell surface receptors, which leads to Smad-mediated transcriptional regulation and is also regulated by inhibitory Smads, forming a negative feedback regulatory pathway. In the context of the canonical TGF-β signalling mechanism mediated by Smad, the activated receptors also send signals through other signal transducers, which in the backdrop of TGF-β signaling are collectively known as non-Smad signalling pathways. Activated TGF-β binds to the receptor and acts through these signalling pathways. Understanding the mechanism of the TGF-β signalling pathway and its role in tendon repair is of great significance for targeting the TGF-β signalling pathway to accelerate tendon healing and reduce tendon fibrosis.

Characterization of scar tissue biomechanics during adult murine flexor tendon healing

Tendon injuries are very common and result in significant impairments in mobility and quality of life. During healing, tendons produce a scar at the injury site, characterized by abundant and disorganized extracellular matrix and by permanent deficits in mechanical integrity compared to healthy tendon. Although a significant amount of work has been done to understand the healing process of tendons and to develop potential therapeutics for tendon regeneration, there is still a significant gap in terms of assessing the direct effects of therapeutics on the functional and material quality specifically of the scar tissue, and thus, on the overall tendon healing process. In this study, we focused on characterizing the mechanical properties of only the scar tissue in flexor digitorum longus (FDL) tendons during the proliferative and early remodeling healing phases and comparing these properties with the mechanical properties of the composite healing tissue. Our method was sensitive enough to identify significant differences in structural and material properties between the scar and tendon-scar composite tissues. To account for possible inaccuracies due to the small aspect ratio of scar tissue, we also applied inverse finite element analysis (iFEA) to compute mechanical properties based on simulated tests with accurate specimen geometries and boundary conditions. We found that the scar tissue linear tangent moduli calculated from iFEA were not significantly different from those calculated experimentally at all healing timepoints, validating our experimental findings, and suggesting the assumptions in our experimental calculations were accurate. Taken together, this study first demonstrates that due to the presence of uninjured stubs, testing composite healing tendons without isolating the scar tissue overestimates the material properties of the scar itself. Second, our scar isolation method promises to enable more direct assessment of how different treatment regimens (e.g., cellular ablation, biomechanical and/or biochemical stimuli, tissue engineered scaffolds) affect scar tissue function and material quality in multiple different types of tendons.

Targeted truncated TGF-β receptor type II delivery to fibrotic liver by PDGFβ receptor-binding peptide modification for improving the anti-fibrotic activity against hepatic fibrosis in vitro and in vivo

Truncated transforming growth factor-β receptor type II (tTβRII) is a promising anti-fibrotic candidate because it attenuates excessive transforming growth factor-β1 (TGF-β1) and then blocks TGF-β1 activity in hepatic fibrosis. However, its use has been greatly limited due to the fact that it is expensive to chemically synthesize and it does not specifically target to the lesion site. In this study, we describe that platelet- derived growth factor β receptor (PDGFβR)-binding peptide BiPPB modified tTβRII (BiPPB-tTβRII) was prepared from the cleavage of SUMO-BiPPB-tTβRII by digestion with SUMO-specific protease. Moreover, compared to the unmodified tTβRII, the target protein BiPPB-tTβRII not only highly specific targeted activated hepatic stellate cells (HSCs) and fibrotic liver tissue, but also significantly inhibited the protein levels of fibrosis-related genes in TGF-β1-induced HSC-T6 cells and CCl₄-induced liver fibrosis in mice. Furthermore, BiPPB-tTβRII markedly ameliorated liver morphology, fibrotic responses and the damage of liver function in fibrosis animal. More importantly, BiPPB-tTβRII showed a much lesser extent in binding to quiescent HSCs and non-fibrotic liver tissue. Taken together, our results suggested that the target protein BiPPB-tTβRII, with its high specific fibrotic liver-targeting potential and its improved anti-fibrotic activity in liver fibrosis, may be a potential therapeutic agent for liver fibrosis.

Effects of low-density pulsed ultrasound treatment on transforming growth factor-beta, collagen level, histology, biomechanics, and function in repaired rat tendons

Objectives

The aim of this study is to compare the effects of low-density pulsed ultrasound (LIPUS) treatment on growth factors/collagen production, histological, biomechanical, and function of rats with Achilles tendon injury.

Materials and methods

A total of 44 Wistar Albino rats were used in the study between April 2017 and June 2018. The rats were randomized to two treatment groups. Group 1 (n=6) received LIPUS treatment (0.3 Watt/cm2; 1 MHz, 1:5 pulse mode) and Group 2 (n=6)received sham ultrasound (US) treatment following Achilles tendon surgery. Transforming growth factor-beta 1 (TGF-β1) and collagen gene expression levels were evaluated using polymerase chain reaction. The histological evaluation was performed with the Bonar scoring system. The tensile strength was measured by biomechanical testing and the function was evaluated with the Achilles Functional Index (AFI).

Results

Although TGF-β1 expression and tensile strength evaluation showed a tendency to improve in favor of the LIPUS group, no statistically significant difference was found (p=0.065 and p=0.053, respectively). The COL3 gene expression in the LIPUS group and the COL1 expression in the sham US group were significantly higher. Bonar scores and AFI scores showed a statistically significant improvement in the LIPUS group, compared to the sham US group.

Conclusion

Our study results show that LIPUS yields positive effects on tendon histology and functional status in repaired Achilles tendon in rats.

Advanced technology-driven therapeutic interventions for prevention of tendon adhesion: Design, intrinsic and extrinsic factor considerations

Tendon adhesion formation describes the development of fibrotic tissue between the tendon and its surrounding tissues, which commonly occurs as a reaction to injury or surgery. Its impact on function and quality of life varies from negligible to severely disabling, depending on the affected area and extent of adhesion formed. Thus far, treatment options remain limited with prophylactic anti-inflammatory medications and revision surgeries constituting the only tools within the doctors' armamentarium - neither of which provides reliable outcomes. In this review, the authors aim to collate the current understanding of the pathophysiological mechanisms underlying tendon adhesion formation, highlighting the significant role ascribed to the inflammatory cascade in accelerating adhesion formation. The bulk of this article will then be dedicated to critically appraising different therapeutic structures like nanoparticles, hydrogels and fibrous membranes fabricated by various cutting-edge technologies for adhesion formation prophylaxis. Emphasis will be placed on the role of the fibrous membranes, their ability to act as drug delivery vehicles as well as the combination with other therapeutic structures (e.g., hydrogel or nanoparticles) or fabrication technologies (e.g., weaving or braiding). Finally, the authors will provide an opinion as to the future direction of the prevention of tendon adhesion formation in view of scaffold structure and function designs.

Inhibition of Smad3 promotes the healing of rotator cuff injury in a rat model

To investigate the effect of inhibiting transforming growth factor-β (TGF-β1)/Smad2/3 signaling on rotator cuff (RC) healing. A bilateral supraspinatus tendon detachment-repair model of Sprague-Dawley (SD) rats was utilized. A total of 120 SD rats were randomly assigned to six groups and each group received the subacromial injection of normal saline, empty vectors, or lentiviral vectors containing small interfering RNA against TGF-β1, Smad2, Smad3 at the bone-tendon junction. Biomechanical and histological analyses were performed to evaluate bone-tendon junction healing quality at 8 weeks after repair. Histologically, scar healing was found in all surgical groups. Animals with inhibited Smad3 exhibited better bone-tendon junction structures with higher density, parallel orientation, and collagen fiber continuity than other surgical group animals. Immunohistochemistry revealed that the protein expression level of collagen I in animals with inhibited Smad3 was more prominent compared with all other surgical groups. Biomechanically, Animals with inhibited Smad3 showed better results in the maximum load at 4, 6, and 8 weeks after surgery compared with other surgical groups. Besides, C3H10T1/2 (Smad3-) cells increased TT-D6 cell migration and tendon-associated genes expression (scleraxis, tenascin C, collagen I) in coculture system. We conclude that inhibition of Smad3 promotes RC tendon healing in the rat supraspinatus model.

Pathogenesis and Development of Patellar Tendon Fibrosis in a Rabbit Overuse Model

BACKGROUND

The pathogenesis of patellar tendon fibrosis caused by overuse remains unclear. In an effort to further investigate effective treatments for patellar tendon fibrosis attributed to overuse, it is necessary to construct a reliable animal model.

PURPOSE

A rabbit patellar tendon fibrosis model was developed with the use of electrical stimulation to induce jumping. The pathogenesis and development of patellar tendon fibrosis were subsequently investigated with this model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 32 New Zealand White rabbits were randomly divided into a jumping group and a control group. Rabbits in the control group did not receive any treatment, while those in the jumping group jumped 150 times daily, 5 days per week. At 2, 4, 6, and 8 weeks after the initiation of treatment, the patellar tendons of 4 rabbits from each group were harvested and subjected to hematoxylin and eosin staining, immunohistochemical staining, and real-time polymerase chain reaction. The influence of jumping training on the expressions of histology- and fibrosis-related factors in the patellar tendon was assessed.

RESULTS

The histological changes of patellar tendon fibrosis in the jumping group were most pronounced at 4 weeks. When compared with the control group at corresponding time points, the mRNA and protein expressions of TGF-β1, CTGF, COL-I, and COL-III were upregulated significantly in the patellar tendon after jumping training for 4 weeks (P < .05). Intragroup comparison at different time points indicated that the mRNA and protein expressions of TGF-β1, COL-I, and COL-III were the highest at 4 weeks in the jumping group (P < .01).

CONCLUSION

It was found that patellar tendon fibrosis occurred because of overuse and the peak changes occurred at 4 weeks. Jumping load increased the secretions of TGF-β1 and Smad3 in the patellar tendon, with CTGF upregulation and higher synthesis of COL-I and COL-III, which were considered the pathogenesis of fibrosis.

CLINICAL RELEVANCE

This study simulated the effects of jumping load on tendon fibrosis at different time points. Moreover, the time course relationship between jumping training and patellar tendon fibrosis in the rabbit model was determined, which provided a new animal model for the study of patellar tendon fibrosis.

Stem Cell Therapy for Tendon Regeneration: Current Status and Future Directions

In adults the healing tendon generates fibrovascular scar tissue and recovers never histologically, mechanically, and functionally which leads to chronic and to degenerative diseases. In this review, the processes and mechanisms of tendon development and fetal regeneration in comparison to adult defect repair and degeneration are discussed in relation to regenerative therapeutic options. We focused on the application of stem cells, growth factors, transcription factors, and gene therapy in tendon injury therapies in order to intervene the scarring process and to induce functional regeneration of the lesioned tissue. Outlines for future therapeutic approaches for tendon injuries will be provided.

The cellular basis of fibrotic tendon healing: challenges and opportunities

Tendon injuries are common and can dramatically impair patient mobility and productivity, resulting in a significant socioeconomic burden and reduced quality of life. Because the tendon healing process results in the formation of a fibrotic scar, injured tendons never regain the mechanical strength of the uninjured tendon, leading to frequent reinjury. Many tendons are also prone to the development of peritendinous adhesions and excess scar formation, which further reduce tendon function and lead to chronic complications. Despite this, there are currently no treatments that adequately improve the tendon healing process due in part to a lack of information regarding the contributions of various cell types to tendon healing and how their activity may be modulated for therapeutic value. In this review, we summarize recent efforts to identify and characterize the distinct cell populations involved at each stage of tendon healing. In addition, we examine the mechanisms through which different cell populations contribute to the fibrotic response to tendon injury, and how these responses can be affected by systemic factors and comorbidities. We then discuss gaps in our current understanding of tendon fibrosis and highlight how new technologies and research areas are shedding light on this clinically important and intractable challenge. A better understanding of the complex cellular environment during tendon healing is crucial to the development of new therapies to prevent fibrosis and promote tissue regeneration.

Kartogenin and Its Application in Regenerative Medicine

Regenerative medicine refers to the possibility of replacing aged/damaged cells with genetically similar young and functional cells to restore or establish normal function. Kartogenin (KGN), a small heterocyclic, drug-like compound was discovered in 2012, which is strongly associated with regenerative medicine. KGN has been applied in many regenerative fields, including cartilage regeneration and protection, tendon-bone healing, wound healing, and limb development. KGN could facilitate cartilage repair, promote formation of cartilage-like transition zone in tendon-bone junctions, stimulate collagen synthesis for wound healing, and regulate limb development in a coordinated manner. Considering the related mechanism, filamin A/CBFβ/RUNX1, Ihh, and TGFβ/Smad pathways have been reported to involve KGN. Therefore, KGN is proven a promising agent in regenerative medicine; however, studies conducted on the effect of KGN are limited to date and not convictive for long-term use. Further studies are recommended to explore the long-term effect and potential molecular mechanisms of KGN. Our investigations may motivate researchers to expand its applications in different forms and fields.

Battling adhesions: from understanding to prevention

Adhesions represent a major burden in clinical practice, particularly following abdominal, intrauterine, pericardial and tendon surgical procedures. Adhesions are initiated by a disruption in the epithelial or mesothelial layer of tissue, which leads to fibrin adhesion sites due to the downregulation of fibrinolytic activity and an increase in fibrin deposition. Hence, the metabolic events involved in tissue healing, coagulation, inflammation, fibrinolysis and angiogenesis play a pivotal role in adhesion formation. Understanding these events, their interactions and their influence on the development of post-surgical adhesion is crucial for the development of effective therapies to prevent them. Mechanical barriers, antiadhesive agents and combination thereof are customarily used in the battle against adhesions. Although these systems seem to be effective at reducing adhesions in clinical procedures, their prevention remains still elusive, imposing the need for new antiadhesive strategies.

Biologic and mechanical aspects of tendon fibrosis after injury and repair

Tendon injuries of the hand that require surgical repair often heal with excess scarring and adhesions to adjacent tissues. This can compromise the natural gliding mechanics of the flexor tendons in particular, which operate within a fibro-osseous tunnel system similar to a set of pulleys. Even combining the finest suture repair techniques with optimal hand therapy protocols cannot ensure predictable restoration of hand function in these cases. To date, the majority of research regarding tendon injuries has revolved around the mechanical aspects of the surgical repair (i.e. suture techniques) and postoperative rehabilitation. The central principles of treatment gleaned from this literature include using a combination of core and epitendinous sutures during repair and initiating motion early on in hand therapy to improve tensile strength and limit adhesion formation. However, it is likely that the best clinical solution will utilize optimal biological modulation of the healing response in addition to these core strategies and, recently, the research in this area has expanded considerably. While there are no proven additive biological agents that can be used in clinical practice currently, in this review, we analyze the recent literature surrounding cytokine modulation, gene and cell-based therapies, and tissue engineering, which may ultimately lead to improved clinical outcomes following tendon injury in the future.

Expression, purification, and evaluation of in vivo anti-fibrotic activity for soluble truncated TGF-β receptor II as a cleavable His-SUMO fusion protein

Excessive production of transforming growth factor-β1 (TGF-β1) and its binding to transforming growth factor-β receptor type II (TGF-βRII) promotes fibrosis by activation of the TGF-β1-mediated signaling pathway. Thus, the truncated extracellular domain of TGF-βRII (tTβRII) is a promising anti-fibrotic candidate, as it lacks the signal transduction domain. In this work, the native N-terminal tTβRII was prepared as a His-SUMO fusion protein (termed His-SUMO-tTβRII) in Escherichia coli strain BL21 (DE3). His-SUMO-tTβRII was expressed as a soluble protein under optimal conditions (6 h of induction with 0.5 mM IPTG at 37 °C). His-SUMO-tTβRII was purified by Ni-NTA resin chromatography, and then cleaved with SUMO protease to release native tTβRII, which was re-purified using a Ni-NTA column. Approximately 12 mg of native tTβRII was obtained from a one liter fermentation culture with no less than 95% purity. In vivo studies demonstrated that tTβRII prevented CCl₄-induced liver fibrosis, as evidenced by the inhibition of fibrosis-related Col I and α-SMA protein expression in C57BL/6 mice. In addition, tTβRII downregulated phosphorylation of SMAD2/3, which partly repressed TGF-β1-mediated signaling. These data indicate that the His-SUMO expression system is an efficient approach for preparing native tTβRII that possesses anti-liver fibrotic activity, allowing for the large-scale production of tTβRII, which potentially could serve as an anti-fibrotic candidate for treatment of TGF-β1-related diseases.

Preparation and evaluation of anti-renal fibrosis activity of novel truncated TGF-β receptor type II

Production of excessive transforming growth factor-beta 1 (TGF-β1) with elevated TGF-β1 activity has been implicated in renal fibrosis via renal epithelial cells activation and collagen deposition. As such, attenuating the binding of TGF-β1 to its receptor TGF-beta receptor type II (TGF-βRII) in TGF-β1-dependent signaling is an attractive target for the control of renal fibrosis. Here, we verified the interaction between novel truncated human TGF-βRII (thTβRII, Thr23-Gln166) and TGF-β1, prepared thTβRII in Escherichia coli, and assessed the effects of thTβRII on TGF-β1-induced human kidney epithelial cells (HK-2) and unilateral ureteral obstruction (UUO) model of renal fibrosis. Our data showed that thTβRII accounted for up to 20% of the total protein and 40% of the inclusion bodies of whole cell lysates under the optimal conditions (0.8 mM IPTG and 25°C for 6 H). Most of the expressed protein in inclusion body was refolded by dialysis refolding procedures and purified by Ni²⁺ -IDA affinity chromatography. Furthermore, thTβRII decreased type I collagen and α-smooth muscle actin protein expression in TGF-β1-induced HK-2 cells, and ameliorated kidney morphology and fibrotic responses in fibrosis animal. These findings indicate that thTβRII holds great promise for developing new treatments for renal fibrosis.

Biomaterials in Tendon and Skeletal Muscle Tissue Engineering: Current Trends and Challenges

Tissue engineering is a promising approach to repair tendon and muscle when natural healing fails. Biohybrid constructs obtained after cells&rsquo; seeding and culture in dedicated scaffolds have indeed been considered as relevant tools for mimicking native tissue, leading to a better integration in vivo. They can also be employed to perform advanced in vitro studies to model the cell differentiation or regeneration processes. In this review, we report and analyze the different solutions proposed in literature, for the reconstruction of tendon, muscle, and the myotendinous junction. They classically rely on the three pillars of tissue engineering, i.e., cells, biomaterials and environment (both chemical and physical stimuli). We have chosen to present biomimetic or bioinspired strategies based on understanding of the native tissue structure/functions/properties of the tissue of interest. For each tissue, we sorted the relevant publications according to an increasing degree of complexity in the materials&rsquo; shape or manufacture. We present their biological and mechanical performances, observed in vitro and in vivo when available. Although there is no consensus for a gold standard technique to reconstruct these musculo-skeletal tissues, the reader can find different ways to progress in the field and to understand the recent history in the choice of materials, from collagen to polymer-based matrices.

Targeting TGFβ Signaling to Address Fibrosis Using Antisense Oligonucleotides

Fibrosis results from the excessive accumulation of extracellular matrix in chronically injured tissue. The fibrotic process is governed by crosstalk between many signaling pathways. The search for an effective treatment is further complicated by the fact that there is a degree of tissue-specificity in the pathways involved, although the process is not completely understood for all tissues. A plethora of drugs have shown promise in pre-clinical models, which is not always borne out translationally in clinical trial. With the recent approvals of two antisense oligonucleotides for the treatment of the genetic diseases Duchenne muscular dystrophy and spinal muscular atrophy, we explore here the potential of antisense oligonucleotides to knockdown the expression of pro-fibrotic proteins. We give an overview of the generalized fibrotic process, concentrating on key players and highlight where antisense oligonucleotides have been used effectively in cellular and animal models of different fibrotic conditions. Consideration is given to the advantages antisense oligonucleotides would have as an anti-fibrotic therapy alongside factors that would need to be addressed to improve efficacy. A prospective outlook for the development of antisense oligonucleotides to target fibrosis is outlined.

Serpine1 Knockdown Enhances MMP Activity after Flexor Tendon Injury in Mice: Implications for Adhesions Therapy

Injuries to flexor tendons can be complicated by fibrotic adhesions, which severely impair the function of the hand. Adhesions have been associated with TGF-β1, which causes upregulation of PAI-1, a master suppressor of protease activity, including matrix metalloproteinases (MMP). In the present study, the effects of inhibiting PAI-1 in murine zone II flexor tendon injury were evaluated utilizing knockout (KO) mice and local nanoparticle-mediated siRNA delivery. In the PAI-1 KO murine model, reduced adherence of injured tendon to surrounding subcutaneous tissue and accelerated recovery of normal biomechanical properties compared to wild type controls were observed. Furthermore, MMP activity was significantly increased in the injured tendons of the PAI-1 KO mice, which could explain their reduced adhesions and accelerated remodeling. These data demonstrate that PAI-1 mediates fibrotic adhesions in injured flexor tendons by suppressing MMP activity. In vitro siRNA delivery to silence Serpine1 expression after treatment with TGF-β1 increased MMP activity. Nanoparticle-mediated delivery of siRNA targeting Serpine1 in injured flexor tendons significantly reduced target gene expression and subsequently increased MMP activity. Collectively, the data demonstrate that PAI-1 can be a druggable target for treating adhesions and accelerating the remodeling of flexor tendon injuries.

Rescue plan for Achilles: Therapeutics steering the fate and functions of stem cells in tendon wound healing

Due to the increasing age of our society and a rise in engagement of young people in extreme and/or competitive sports, both tendinopathies and tendon ruptures present a clinical and financial challenge. Tendon has limited natural healing capacity and often responds poorly to treatments, hence it requires prolonged rehabilitation in most cases. Till today, none of the therapeutic options has provided successful long-term solutions, meaning that repaired tendons do not recover their complete strength and functionality. Our understanding of tendon biology and healing increases only slowly and the development of new treatment options is insufficient. In this review, following discussion on tendon structure, healing and the clinical relevance of tendon injury, we aim to elucidate the role of stem cells in tendon healing and discuss new possibilities to enhance stem cell treatment of injured tendon. To date, studies mainly apply stem cells, often in combination with scaffolds or growth factors, to surgically created tendon defects. Deeper understanding of how stem cells and vasculature in the healing tendon react to growth factors, common drugs used to treat injured tendons and promising cellular boosters could help to develop new and more efficient ways to manage tendon injuries.

Biomechanic and histologic analysis of fibroblastic effects of tendon-to-bone healing by transforming growth factor β1 (TGF-β1) in rotator cuff tears

PURPOSE

To evaluate the effect of transforming growth factor β1 (TGF-β1) on tendon-to-bone reconstruction of rotator cuff tears.

METHODS

Seventy-two rat supraspinatus tendons were transected and reconstructed in situ. At 8 and 16 weeks, specimens of three groups; that is control, L-dose (low dose), and H-dose (high dose) were harvested and underwent a biomechanical test to evaluate the maximum load and stiffness values. Histology sections of the tendon-to-bone interface were identified by hematoxylin-eosin or Masson trichrome stain. Collagen type III was observed by picric acid sirius red staining under polarized light. The level of insulin-like growth factor 1 (IGF-1) and vascular endothelial growth factor (VEGF) was measured by the enzyme-linked immunosorbent assay (ELISA) method.

RESULTS

Collagen type III of the H-dose group had a significant difference in histology structure compared with the L-dose group (P<0.05). The maximum load and stiffness decreased significantly in the control group compared with the values of the L-dose and H-dose groups. The stiffness among the three groups differed significantly at the same postoperative time (P<0.05). Interestingly, progressive reestablishment of collagen type III affected tendon-to-bone healing significantly in the later stages.

CONCLUSION

The H-dose was associated with an increased collagen type III morphology stimulated by TGF-β1.

Flexor Tendon Injuries

Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.

Cellular and Molecular Factors Influencing Tendon Repair

Tendons are complex connective tissues that transmit tensile forces between muscles and tendons. Tendon injuries are among the most common orthopedic problems with long-term disability as a frequent consequence due to prolonged healing time. Furthermore, the repair tissue is of inferior quality, predisposing patients to high rates of recurrence following initial injury. Coordinated cellular processes and biological factors under the influence of mechanical loading are involved in tendon healing and our understanding of these events lags behind other musculoskeletal tissues. Tendons are relatively hypocellular and hypovascular, with little or no intrinsic regenerative capacity. Studies have documented fatty degeneration, chondrogenic dysplasia, and ectopic ossification within tendon repair tissue. The underlying pathogenesis for these metaplastic changes that compromise the quality of tendon repair tissue is poorly understood. The purpose of this review is to compile literature reporting molecular processes that regulate/control the phenotype of cells responsible for abnormal matrix deposition at repair site. In addition, recent studies reporting the interplay of mechanotransduction and cellular responses during tendon repair are summarized. Identifying the links between cellular, biological, and mechanical parameters involved in tendon repair is paramount to develop successful therapies for tendon healing.

Murine Flexor Tendon Injury and Repair Surgery

Tendon connects skeletal muscle and bone, facilitating movement of nearly the entire body. In the hand, flexor tendons (FTs) enable flexion of the fingers and general hand function. Injuries to the FTs are common, and satisfactory healing is often impaired due to excess scar tissue and adhesions between the tendon and surrounding tissue. However, little is known about the molecular and cellular components of FT repair. To that end, a murine model of FT repair that recapitulates many aspects of healing in humans, including impaired range of motion and decreased mechanical properties, has been developed and previously described. Here an in-depth demonstration of this surgical procedure is provided, involving transection and subsequent repair of the flexor digitorum longus (FDL) tendon in the murine hind paw. This technique can be used to conduct lineage analysis of different cell types, assess the effects of gene gain or loss-of-function, and to test the efficacy of pharmacological interventions in the healing process. However, there are two primary limitations to this model: i) the FDL tendon in the mid-portion of the murine hind paw, where the transection and repair occur, is not surrounded by a synovial sheath. Therefore this model does not account for the potential contribution of the sheath to the scar formation process. ii) To protect the integrity of the repair site, the FT is released at the myotendinous junction, decreasing the mechanical forces of the tendon, likely contributing to increased scar formation. Isolation of sufficient cells from the granulation tissue of the FT during the healing process for flow cytometric analysis has proved challenging; cytology centrifugation to concentrate these cells is an alternate method used, and allows for generation of cell preparations on which immunofluorescent labeling can be performed. With this method, quantification of cells or proteins of interest during FT healing becomes possible.

Cell and Biologic-Based Treatment of Flexor Tendon Injuries

The two primary factors leading to poor clinical results after intrasynovial tendon repair are adhesion formation within the digital sheath and repair-site elongation and rupture. As the outcomes following modern tendon multi-strand repair and controlled rehabilitation techniques are often unsatisfactory, alternative approaches, such as the application of growth factors and mesenchymal stem cells (MSCs), have become increasingly attractive treatment options. Successful biological therapies require carefully controlled spatiotemporal delivery of cells, growth factors, and biocompatible scaffold matrices in order to simultaneously (1) promote matrix synthesis at the tendon repair site leading to increased biomechanical strength and stiffness and (2) suppress matrix synthesis along the tendon surface and synovial sheath preventing adhesion formation. This review summarizes recent cell and biologic-based experimental treatments for flexor tendon injury, with an emphasis on large animal translational studies.

TGF-β1 promotes scar fibroblasts proliferation and transdifferentiation via up-regulating MicroRNA-21

TGF-β1, upregulated in keloid tissue, promotes the proliferation, collagen formation and differentiation of dermal fibroblasts. miR-21 is one of microRNAs first found in human genome. The aim of our study is to explore the mechanisms of miR-21 in TGF-β1-induced scar fibroblasts proliferation and transdifferentiation. In the present study, first we found that TGF-β1 promoted scar fibroblasts proliferation and transdifferentiation via up-regulating miR-21 expression, which could be attenuated when miR-21 was inhibited. Overexpression of miR-21 had similar effect as TGF-β1 on proliferation and transdifferentiation. Additionally, TGF-β1 increased the expressions and activities of MMP2 and MMP9 in keloid fibroblasts, which was suppressed by miR-21 inhibition. Finally, the results demonstrated that PTEN/AKT signaling pathway played important role in TGF-β1-induced transdifferentiation. In conclusion, our study suggests that TGF-β1 promotes keloid fibroblasts proliferation and transdifferentiation via up-regulation of miR-21 and PTEN/AKT signalling pathway plays important role in this process, which provides a potential theoretical basis for clinical treatment of skin scars.

Signalling by Transforming Growth Factor Beta Isoforms in Wound Healing and Tissue Regeneration

Transforming growth factor beta (TGFβ) signalling is essential for wound healing, including both non-specific scar formation and tissue-specific regeneration. Specific TGFβ isoforms and downstream mediators of canonical and non-canonical signalling play different roles in each of these processes. Here we review the role of TGFβ signalling during tissue repair, with a particular focus on the prototypic isoforms TGFβ1, TGFβ2, and TGFβ3. We begin by introducing TGFβ signalling and then discuss the role of these growth factors and their key downstream signalling mediators in determining the balance between scar formation and tissue regeneration. Next we discuss examples of the pleiotropic roles of TGFβ ligands during cutaneous wound healing and blastema-mediated regeneration, and how inhibition of the canonical signalling pathway (using small molecule inhibitors) blocks regeneration. Finally, we review various TGFβ-targeting therapeutic strategies that hold promise for enhancing tissue repair.

Gene therapy strategies to improve strength and quality of flexor tendon healing

INTRODUCTION

Rupture of the repair and adhesion around a tendon are two major problems after tendon surgery. Novel biological therapies which enhance healing and reduce adhesions are goals of many investigations. Gene therapy offers a new and promising approach to tackle these difficult problems. In the past decade, we sought to develop methods to augment tendon healing and reduce tendon adhesion through gene therapy.

AREAS COVERED

This review discusses the methods and results of adeno-associated viral (AAV) type 2 vector gene therapy to increase tendon healing strength and reduce adhesions in a chicken model. Micro-RNA related gene therapy is also discussed. We also developed a controlled release system, which incorporates nanoparticles to deliver micro-RNAs to regulate tendon healing.

EXPERT OPINION

We obtained promising results of enhancement of tendon healing strength in a chicken model using AAV2-mediated gene transfer. AAV2-mediated micro-RNA transfer also limited adhesions around the tendon. Controlled release systems incorporating nanoparticles have ideally delivered genes to the healing tendons and resulted in a moderate (but incomplete) reduction of adhesions. It remains to be determined what the best doses are and what other factors are in play in adhesion formation. These are two targets in our future investigations.

Biological Augmentation of Flexor Tendon Repair: A Challenging Cellular Landscape

Advances in surgical technique and rehabilitation have transformed zone II flexor tendon injuries from an inoperable no-man's land to a standard surgical procedure. Despite these advances, many patients develop substantial range of motion-limiting adhesions after primary flexor tendon repair. These suboptimal outcomes may benefit from biologic augmentation or intervention during the flexor tendon healing process. However, there is no consensus biological approach to promote satisfactory flexor tendon healing; we propose that insufficient understanding of the complex cellular milieu in the healing tendon has hindered the development of successful therapies. This article reviews recent advances in our understanding of the cellular components of flexor tendon healing and adhesion formation, including resident tendon cells, synovial sheath, macrophages, and bone marrow-derived cells. In addition, it examines molecular approaches that have been used in translational animal models to improve flexor tendon healing and gliding function, with a specific focus on progress made using murine models of healing. This information highlights the importance of understanding and potentially exploiting the heterogeneity of the cellular environment during flexor tendon healing, to define rational therapeutic approaches to improve healing outcomes.