Characterization of the plasminogen activators and plasminogen activator inhibitors expressed by cells isolated from rabbit ligament and synovial tissues: evidence for unique cell populations

Mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation: a medium-term follow-up

BACKGROUND

Although recurrent patellar dislocations are not uncommon, their pathophysiology and treatment are controversial.

HYPOTHESIS

Stabilization of recurrent patellar dislocations can be successfully managed with a mini-open approach.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-two patients (23 knees) underwent a mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocations with an average follow-up of 4.4 years (range, 1.4-14 years). The average age at the first dislocation was 15 years (range, 5-26 years), and the average age at surgery was 23 years (range, 12-65 years).

RESULTS

There was 1 postoperative dislocation (4%) and 1 recurrent subluxation (4%). The average Kujala knee score was 88.2 +/- 13.5, with overall good scores in each category. The lowest scores involved squatting (5.7), abnormal painful kneecap movements (subluxations) (7.1), and jumping (7.9). Overall, there was a statistically significant improvement in the Tegner score from 3.7 +/- 1.8 before surgery to 6.9 +/- 2.0 after surgery (P < .001). Six knees (26%) were rated subjectively as excellent, 15 (65%) as good, 2 (9%) as fair, and 0 (0%) as poor. All 22 patients (100%) stated that the procedure was worthwhile. Radiographically, there was a statistically significant improvement in the congruence angle (normal, -8.0 degrees +/- 6.0 degrees) from 15.7 degrees +/- 12.6 degrees (range, 0.0 degrees to +44.0 degrees) before surgery to -11.5 degrees +/- 8.7 degrees (range, -20.0 degrees to +10.0 degrees) after surgery (P < .001) and in the lateral patellofemoral angle (normal, >0 degrees) from -0.2 degrees +/- 6.4 degrees (range, -10 degrees to +8 degrees) before surgery to 7.9 degrees +/- 2.6 degrees (range, 0.0 degrees to +11.0 degrees) after surgery (P < .001).

CONCLUSION

Our mini-open technique provides anatomical restoration with limited morbidity and cosmetically appealing results. Furthermore, our redislocation rates compare favorably with traditional, more extensile open approaches.

Animal models of tendon and ligament injuries for tissue engineering applications

Animal modeling continues to be an important component to the critical evaluation of new techniques to treat tendon and ligament injuries. Appropriate choice and analysis of these models is essential. Factors that should be considered in assessing a potential model include the tissue type (ligament versus tendon and intrasynovial versus extrasynovial), the type of injury to be modeled, the techniques of measuring the response to treatment, the ease of comparison to previously published models and finally, the ease of translation to human trials and eventually to clinical usage.

Techniques of medial retinacular repair and reconstruction

Insufficiency of the passive patellar restraints results in lateral patellar instability by allowing excessive lateral displacement of the patella. Although the surgical approach to patellar instability traditionally has been to realign the dynamic elements (muscle forces) that pull the patella laterally, newer techniques have sought to restore the integrity of key medial passive (ligamentous) stabilizers. An increasing body of evidence indicates that the chief medial ligamentous restraint is the medial patellofemoral ligament. The current authors examine the principles of medial retinacular repair and reconstruction as they relate to patellar stability. Individual techniques and approaches are discussed, including primary repair with or without augmentation, and reconstruction using autogenous tendon, allografts, and synthetic graft materials. These procedures share the common objective of addressing the essential lesion in lateral patellar instability to restore the normal passive restraints against lateral patellar displacement.

Current concepts of lateral patella dislocation

Surgical treatment of patellar dislocations, acute and chronic, has evolved significantly over the past decade with the advance of biomechanical knowledge of patellofemoral restraints and injury patterns identified by physical examination and improved imaging techniques. There continues to be no consensus on treatment parameters. Despite the presence of predisposing factors, such as dysplasia or generalized hyperlaxity, medial retinacular injury associated with primary (first-time) patellar dislocations represents a ligament injury, which may result in residual laxity of the injured structure. This residual laxity is defined objectively by an increase in passive lateral excursion of the patella. Repair or reconstructive procedures to restore this medial constraint is considered paramount in any procedure to stabilize the patella against subsequent dislocations. How best to accomplish this continues to be a matter of debate. The establishment of a medial check-rein by either repairing or reconstructing the MPFL is the procedure of choice for stabilizing a kneecap after first-time dislocation, largely because the literature to date does not provide clear guidelines about when more extensive surgery is indicated. Whether or not all first-time dislocators have improved outcome after surgical repair remains speculative, however. Improved outcome would involve both the elimination of recurrent instability episodes and continued satisfactory function of this patella in activities-of-daily-living and sporting activities. These outcomes have not been studied critically in operative versus nonoperative treatment of first-time patellar dislocation. For the first-time dislocator, most investigators would agree that an arthroscopy should be performed if intra-articular chondral damage is suspected. Nonoperative management of first-time patellar dislocations continues to be the preferred practice pattern in the United States. If surgical management is elected, because of individual characteristics of the injury pattern or the patient's lifestyle, it is important to inspect the MPFL along its length and repair any or all ligamentous disruptions. If the ligament is avulsed from the medial epicondyle, reattachment to bone is necessary to restore passive restraint to lateral patella motion. MRI may be useful in order to identify the location and degree of medial soft tissue injury preoperatively. The establishment of a medial check-rein by either repairing or reconstructing the MPFL is a necessary component of all surgical procedures performed to correct objective lateral instability of the patella. The addition of a LRR should be additive to this procedure only when it facilitates other procedures to recenter the patella or when objective lateral tilt by physical examination measurements is present. A practical approach to surgery after patellar dislocation is the minimal amount of surgery necessary to re-establish objective constraints of the patella. Correcting dysplastic factors, in particular tibial tubercle transfers and trochleoplasties, are best reserved if more minimal surgery has failed. This failure is defined as continued functional instability of the kneecap.

Pregnancy induces complex changes in the the pattern of mRNA expression in knee ligaments of the adolescent rabbit

Knee laxity has been shown to increase during human pregnancy, and the laxity of the rabbit medial collateral ligament also increases during pregnancy. To determine whether the changes in tissue function could be related to alterations in the regulation of gene expression for a subset of relevant molecules in ligaments, RNA was isolated from the medial collateral(MCL) and anterior cruciate(ACL) ligaments of first time pregnant adolescent rabbits. Levels of mRNA for matrix molecules (collagen types I and III and the proteoglycans biglycan, decorin, versican and lumican), proteinases and inhibitors (collagenase, urokinase, PAI-1 and TIMP-1, -2 and -3), growth factors (bFGF, IGF-I, TGF-beta1 and ET-1), cytokines (IL-1beta and TNF) and enzymes responsible for important tissue mediators (COX-2 and iNOS) were assessed by semi-quantitative RT-PCR. In the MCL, levels of transcripts for all of the matrix molecules, growth factors and TIMPs 1 and 2 were significantly depressed at 29 days of pregnancy compared to age-matched non-pregnant controls. In contrast, transcripts for PAI-1 were elevated during pregnancy, while those for collagenase (MMP-1), urokinase, TIMP-3, IL-1beta, TNF, COX-2 and iNOS were not statistically altered. mRNA transcript levels rebounded by 7 days post-partum for most genes studied, indicating that the changes were rapidly reversible. For some molecules, transcript levels were again depressed at 18 days post-partum, indicating that regulatory mechanisms were still not stabilized. Analysis of mRNA from the ACL also revealed changes in the pattern of gene expression, with some similarities and differences from the MCL noted. These results indicate that pregnancy induces reversible changes in mRNA for matrix molecules in ligaments, but differences in responsiveness exist between different ligaments. The complexity of the changes observed indicates that there is probably no simple cause and effect relationship between laxity changes and the molecular alterations during pregnancy.

Independent regulation of matrix metalloproteinases and plasminogen activators in human fibrosarcoma cells

Serine proteases and matrix metalloproteinases have been shown to often cooperate in multiple physiological and pathological processes associated with changes in the extracellular matrix (ECM). We have examined the interaction between the plasminogen activator (PA)-plasmin system and matrix metalloproteinases (MMPs) in HT1080 human fibrosarcoma cells treated with 12-O-tetradecanoyl-phorbol-13-acetate (TPA). While TPA treatment evoked a temporary increased expression of urokinase type PA (uPA), the production of both types of human plasminogen activator inhibitors (PAI) was induced and sustained over 12 h by TPA treatment shifting the protease-protease inhibitors balance in favor of the inhibitors. TPA treatment of HT1080 cells induced the expression of interstitial collagenase (MMP-1) and increased the expression of gelatinase B (MMP-9), tissue inhibitor of metalloproteinases-1 (TIMP-1), and MT-MMP, a membrane-bound activator of progelatinase A (proMMP-2), while MMP-2 and TIMP-2 expression were decreased. Increased MT-MMP expression by TPA treatment was associated with increased activation of proMMP-2. These data show that the regulation of PA-plasmin and metalloproteinase and their specific inhibitors is uncoordinated. In addition, inhibition of the PA-plasmin system by PAI-2 or aprotinin did not prevent the activation of proMMP-2 by TPA, suggesting that plasmin is not involved in MT-MMP-mediated activation of proMMP-2.

Influence of exogenous growth factors on the expression of plasminogen activators and plasminogen activator inhibitors by cells isolated from normal and healing rabbit ligaments

In this investigation, we demonstrate that cells from normal and healing rabbit ligaments are selective in their responsiveness to various growth factors. The cells analyzed included fibroblasts isolated from the synovium, the anterior cruciate ligament, and the medial collateral ligament (midsubstance and epiligament). Fibroblasts isolated from scar tissue of medial collateral ligament that had been allowed to heal for 3 weeks also were analyzed. The addition of insulin-like growth factor-2 or transforming growth factor-beta 1 was observed to alter, in a dose-dependent manner, the expression of plasminogen activator and plasminogen activator inhibitor by connective tissue cells. However, the response to these growth factors was cell specific. Fibroblasts isolated from the midsubstance, epiligament, and scar tissue of the medial collateral ligament were responsive to these growth factors; fibroblasts isolated from the anterior cruciate ligament and synovium did not have a detectable response. The cells from the normal and healing medial collateral ligament responded to both growth factors by increasing plasminogen activator inhibitor activity. This was observed at both the protein and RNA level. In contrast, the addition of insulin-like growth factor-1 or acidic or basic fibroblast growth factor to cells derived from normal or healing ligament did not result in any detectable alteration of plasminogen activator or plasminogen activator inhibitor activity. These results are similar to those observed with an explant system and indicate that cells isolated from ligament tissue maintain their responsiveness to these growth factors in the absence of matrix. As the major effect of insulin-like growth factor-2 and transforming growth factor-beta 1 on the cells tested was to increase plasminogen activator inhibitor activity, such an alteration should diminish the activity of plasminogen activator, an enzyme capable of directly and indirectly proteolyzing matrix molecules, and thus contribute to a more anabolic environment.

Plasminogen activators and plasminogen activator inhibitors in connective tissues and connective tissue cells: influence of the neuropeptide substance P on expression

Tissue segments isolated from ligament, epiligament, and synovial tissues from mature female New Zealand White Rabbits were demonstrated to constitutively secrete a plasminogen activator. Several tissues were also observed to constitutively secrete a plasminogen activator inhibitor which was detected in the form of a PA-PAI complex. Heterogeneity was observed in PA and PAI activity between the different connective tissues. Heterogeneity also existed between and within the medial collateral (MCL), lateral collateral (LCL), and the anterior cruciate (ACL) ligaments. In addition to the differences in constitutive expression of PA and PAI activity, differences in the responsiveness to the neuropeptide substance P (10(-5)-10(-9) M) were also detected. This responsiveness to substance P was displayed by an increase in PA and PAI activity in the conditioned medium. The pattern of responsiveness reflected the degree of innervation of these tissues. That is, synovium and epiligament tissue were the most responsive tissues to substance P while the MCL, LCL and ACL were less responsive to the neuropeptide. Parallel results were obtained using cell culture with fibroblasts isolated from the above mentioned tissues. That is, the pattern of responsiveness was similar between cells and tissue segments. More specifically, cells isolated from both synovium and epiligament increased their both their PA (slightly) and PAI activity following exposure to substance P. This was demonstrated at both the protein and RNA level. Thus, cells within a tissue maintain their phenotype when removed from their three-dimensional matrix. These results are unique in demonstrating that normal ligament and synovial cells and tissue respond to substance P by altering the expression of PA and PAI activity. This investigation further supports the concept that innervation may be important in normal connective tissue function.