Collagen fibre implant for tendon and ligament biological augmentation. In vivo study in an ovine model

Collagen processing with mesoscale aggregates as templates and building blocks

Collagen presents a well-organized hierarchical multilevel structure. Microfibers, fibers, and fiber bundles are the aggregates of natural collagen; which achieve an ideal balance of mechanical strength and toughness at the mesoscopic scale for biological tissue. These mesostructured aggregates of collagen isolated from biological tissues retain these inherent organizational features to enable their use as building blocks for constructing new collagen materials with ideal mechanical performance, thermal and dimensional stability. This strategy is distinct from the more common bottom-up or molecular-level design and assembly approach to generating collagen materials. The present review introduces the hierarchical structure of biological collagen with a focus on mesostructural features. Isolation strategies for these collagen aggregates (CAs) are summarized. Recent progress in the use of these mesostructural components for the construction of new collagen materials with emerging applications is reviewed, including in catalysis, environmental applications, biomedicine, food packaging, electrical energy storage, and flexible sensors. Finally, challenges and prospects are assessed for controllable production of CAs as well as material designs.

Repair of tendons treated with peracetic acid-ethanol and gamma irradiation by EDC combined with NHS: a morphological, biochemical and biomechanical study in vitro

The purpose of this study was to investigate whether 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC) combined with n-hydroxysuccinimide (NHS) can repair tendon damage caused by peracetic acid-ethanol and gamma irradiation sterilization. The semitendinosus tendons of 15 New Zealand white rabbits were selected as experimental materials, and the tendons were sterilized in a solution containing 1% (v/w) peracetic acid and 24% (v/w) ethanol. After 15 kGy gamma irradiation sterilization, the tendons were randomly divided into three groups (n = 10). The tendons were repaired with EDCs of 0, 2.5 and 5 mM combined with 5 mM NHS for 6 h, the tendons were temporarily stored at - 80 ± °C. The arrangement and spatial structure of collagen fibers were observed by light microscopy and scanning electron microscopy, the collagen type and collagen crimp period were observed under a polarizing microscope, and the collagen fibril diameter and its distribution were measured by transmission electron microscopy, from which the collagen fibril index and mass average diameter were calculated. The resistance of collagen to enzymolysis was detected by the free hydroxyproline test, and tensile fracture and cyclic loading tests of each group of tendons were carried out, from which the elastic modulus, maximum stress, maximum strain, strain energy density and cyclic creep strain were calculated. The obtained results showed that the gap between loose collagen fibers in the 0 mM control group was wider, the parallel arrangement of tendons in the 2.5 and 5 mM groups was more uniform and regular and the fiber space decreased, the crimp period in the 5 mM group was lower than that in the 0 mM group (P < 0.05), and the concentration of hydroxyproline in the 5 mM group (711.64 ± 77.95 μg/g) was better than that in the control group (1150.57 ± 158.75 μg/g). The elastic modulus of the 5 mM group (424.73 ± 150.96 MPa) was better than that of the 0 mM group (179.09 ± 37.14 MPa). Our results show that EDC combined with NHS can repair damaged tendons after peracetic acid-ethanol and gamma radiation treatment, and 5 mM EDC has better morphological performance, anti-enzymolysis ability and biomechanical properties than 2.5 mM EDC.

Large animal models for the study of tendinopathy

Tendinopathy has a high incidence in athletes and the aging population. It can cause pain and movement disorders, and is one of the most difficult problems in orthopedics. Animal models of tendinopathy provide potentially efficient and effective means to develop understanding of human tendinopathy and its underlying pathological mechanisms and treatments. The selection of preclinical models is essential to ensure the successful translation of effective and innovative treatments into clinical practice. Large animals can be used in both micro- and macro-level research owing to their similarity to humans in size, structure, and function. This article reviews the application of large animal models in tendinopathy regarding injuries to four tendons: rotator cuff, patellar ligament, Achilles tendon, and flexor tendon. The advantages and disadvantages of studying tendinopathy with large animal models are summarized. It is hoped that, with further development of animal models of tendinopathy, new strategies for the prevention and treatment of tendinopathy in humans will be developed.

Comprehensive collagen crosslinking comparison of microfluidic wet-extruded microfibers for bioactive surgical suture development

Collagen microfiber-based constructs have garnered considerable attention for ligament, tendon, and other soft tissue repairs, yet with limited clinical translation due to strength, biocompatibility, scalable manufacturing, and other challenges. Crosslinking collagen fibers improves mechanical properties; however, questions remain regarding optimal crosslinking chemistries, biocompatibility, biodegradation, long-term stability, and potential for biotextile assemble at scale, limiting their clinical usefulness. Here, we assessed over 50 different crosslinking chemistries on microfluidic wet-extruded collagen microfibers made with clinically relevant collagen to optimize collagen fibers as a biotextile yarn for suture or other medical device manufacture. The endogenous collagen crosslinker, glyoxal, provides extraordinary fiber ultimate tensile strength near 300MPa, and Young's modulus of over 3GPa while retaining 50% of the initial load-bearing capacity through 6 months as hydrated. Glyoxal crosslinked collagen fibers further proved cytocompatible and biocompatible per ISO 10993-based testing, and further elicits a predominantly M2 macrophage response. Remarkably these strong collagen fibers are amenable to industrial braiding to form strong collagen fiber sutures. Collagen microfluidic wet extrusion with glyoxal crosslinking thus progress bioengineered, strong, and stable collagen microfibers significantly towards clinical use for potentially promoting efficient healing compared to existing suture materials. STATEMENT OF SIGNIFICANCE: Towards improving clinical outcomes for over 1 million ligament and tendon surgeries performed annually, we report an advanced microfluidic extrusion process for type I collagen microfiber manufacturing for biological suture and other biotextile manufacturing. This manuscript reports the most extensive wet-extruded collagen fiber crosslinking compendium published to date, providing a tremendous recourse to the field. Collagen fibers made with clinical-grade collagen and crosslinked with glyoxal, exhibit tensile strength and stability that surpasses all prior reports. This is the first report demonstrating that glyoxal, a native tissue crosslinker, has the extraordinary ability to produce strong, cytocompatible, and biocompatible collagen microfibers. These collagen microfibers are ideal for advanced research and clinical use as surgical suture or other tissue-engineered medical products for sports medicine, orthopedics, and other surgical indications.

Light Cross-Linkable Marine Collagen for Coaxial Printing of a 3D Model of Neuromuscular Junction Formation

Collagen is a major component of the extracellular matrix (ECM) that modulates cell adhesion, growth, and migration, and has been utilised in tissue engineering applications. However, the common terrestrial sources of collagen carry the risk of zoonotic disease transmission and there are religious barriers to the use of bovine and porcine products in many cultures. Marine based collagens offer an attractive alternative and have so far been under-utilized for use as biomaterials for tissue engineering. Marine collagen can be extracted from fish waste products, therefore industry by-products offer an economical and environmentally sustainable source of collagen. In a handful of studies, marine collagen has successfully been methacrylated to form collagen methacrylate (ColMA). Our work included the extraction, characterization and methacrylation of Red Snapper collagen, optimisation of conditions for neural cell seeding and encapsulation using the unmodified collagen, thermally cross-linked, and the methacrylated collagen with UV-induced cross-linking. Finally, the 3D co-axial printing of neural and skeletal muscle cell cultures as a model for neuromuscular junction (NMJ) formation was investigated. Overall, the results of this study show great potential for a novel NMJ in vitro 3D bioprinted model that, with further development, could provide a low-cost, customizable, scalable and quick-to-print platform for drug screening and to study neuromuscular junction physiology and pathogenesis.

Periorbital Reconstruction by "Periorbital Patch" Technique Using a Pericardium-Based Collagen Membrane and Titanium Mesh

OBJECTIVE

Titanium mesh is a commonly used material for the reconstruction of orbital floor fractures. However, in some instances, a subsequent inflammatory reaction can occur that causes the adhesion of orbital tissue to the titanium mesh. The adhesion of the orbital soft tissue to the mesh causes diplopia, lid rigidity and extraocular movements restriction. This study was performed to determine if the placement of a collagen membrane over a titanium mesh can prevent the adhesion of orbital soft tissue for an improved clinical outcome. Clinical considerations: A case study was performed investigating 106 patients undergoing a periorbital restoration. Seventy-two patients received a titanium mesh without a barrier membrane, 12 patients received a barrier membrane composed of autologous auricular cartilage to provide a barrier function and 22 patients received a pericardium collagen membrane and titanium mesh.

CONCLUSIONS

Titanium has been shown to generate an intense inflammatory reaction in host tissues, which can cause fibrosis to adjacent structures. Fibrosis is an essential factor in the repair of fracture sites, however this can lead to adverse effects in the orbital socket. Fibrosis can cause cicatrization and lower eyelid retraction when induced along the lower orbital rim. An improved outcome can be achieved by using a barrier between the titanium mesh and the soft tissue, such as autogenous auricular cartilage, however, only patients treated with a resorbable collagen membrane to act as a soft tissue barricade during site regeneration, prevented the fibrosis reaction and related problems from occurring.

The Collagen Suprafamily: From Biosynthesis to Advanced Biomaterial Development

Collagen is the oldest and most abundant extracellular matrix protein that has found many applications in food, cosmetic, pharmaceutical, and biomedical industries. First, an overview of the family of collagens and their respective structures, conformation, and biosynthesis is provided. The advances and shortfalls of various collagen preparations (e.g., mammalian/marine extracted collagen, cell-produced collagens, recombinant collagens, and collagen-like peptides) and crosslinking technologies (e.g., chemical, physical, and biological) are then critically discussed. Subsequently, an array of structural, thermal, mechanical, biochemical, and biological assays is examined, which are developed to analyze and characterize collagenous structures. Lastly, a comprehensive review is provided on how advances in engineering, chemistry, and biology have enabled the development of bioactive, 3D structures (e.g., tissue grafts, biomaterials, cell-assembled tissue equivalents) that closely imitate native supramolecular assemblies and have the capacity to deliver in a localized and sustained manner viable cell populations and/or bioactive/therapeutic molecules. Clearly, collagens have a long history in both evolution and biotechnology and continue to offer both challenges and exciting opportunities in regenerative medicine as nature's biomaterial of choice.

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.

Emerging Concepts in Treating Cartilage, Osteochondral Defects, and Osteoarthritis of the Knee and Ankle

The management and treatment of cartilage lesions, osteochondral defects, and osteoarthritis remain a challenge in orthopedics. Moreover, these entities have different behaviors in different joints, such as the knee and the ankle, which have inherent differences in function, biology, and biomechanics. There has been a huge development on the conservative treatment (new technologies including orthobiologics) as well as on the surgical approach. Some surgical development upraises from technical improvements including advanced arthroscopic techniques but also from increased knowledge arriving from basic science research and tissue engineering and regenerative medicine approaches. This work addresses the state of the art concerning basic science comparing the knee and ankle as well as current options for treatment. Furthermore, the most promising research developments promising new options for the future are discussed.

Fish scale-derived collagen patch promotes growth of blood and lymphatic vessels in vivo

In this study, Type I collagen was extracted from fish scales asa potential alternative source of collagen for tissue engineering applications. Since unmodified collagen typically has poor mechanical and degradation stability both in vitro and in vivo, additional methylation modification and 1,4-butanediol diglycidyl ether (BDE) crosslinking steps were used to improve the physicochemical properties of fish scale-derived collagen. Subsequently, in vivo studies using a murine model demonstrated the biocompatibility of the different fish scale-derived collagen patches. In general, favorable integration of the collagen patches to the surrounding tissues, with good infiltration of cells, blood vessels (BVs) and lymphatic vessels (LVs) were observed under growth factor-free conditions. Interestingly, significantly higher (p<0.05) number of LVs was found to be more abundant around collagen patches with methylation modification and BDE crosslinking. Overall, we have demonstrated the potential application of fish scale-derived collagen as a promising scaffolding material for various biomedical applications.

STATEMENT OF SIGNIFICANCE

Currently the most common sources of collagen are of bovine and porcine origins, although the industrial use of collagen obtained from non-mammalian species is growing in importance, particularly since they have a lower risk of disease transmission and are not subjected to any cultural or religious constraints. However, unmodified collagen typically has poor mechanical and degradation stability both in vitro and in vivo. Hence, in this study, Type I collagen was successfully extracted from fish scales and chemically modified and crosslinked. In vitro studies showed overall improvement in the physicochemical properties of the material, whilst in vivo implantation studies showed improvements in the growth of blood and lymphatic host vessels in the vicinity of the implants.

Mechanical Actuation Systems for the Phenotype Commitment of Stem Cell-Based Tendon and Ligament Tissue Substitutes

High tensile forces transmitted by tendons and ligaments make them susceptible to tearing or complete rupture. The present standard reparative technique is the surgical implantation of auto- or allografts, which often undergo failure.Currently, different cell types and biomaterials are used to design tissue engineered substitutes. Mechanical stimulation driven by dedicated devices can precondition these constructs to a remarkable degree, mimicking the local in vivo environment. A large number of dynamic culture instruments have been developed and many appealing results collected. Of the cells that have been used, tendon stem cells are the most promising for a reliable stretch-induced tenogenesis, but their reduced availability represents a serious limitation to upscaled production. Biomaterials used for scaffold fabrication include both biological molecules and synthetic polymers, the latter being improved by nanotechnologies which reproduce the architecture of native tendons. In addition to cell type and scaffold material, other variables which must be defined in mechanostimulation protocols are the amplitude, frequency, duration and direction of the applied strain. The ideal conditions seem to be those producing intermittent tension rather than continuous loading. In any case, all physical parameters must be adapted to the specific response of the cells used and the tensile properties of the scaffold. Tendon/ligament grafts in animals usually have the advantage of mechanical preconditioning, especially when uniaxial cyclic forces are applied to cells engineered into natural or decellularized scaffolds. However, due to the scarcity of in vivo research, standard protocols still need to be defined for clinical applications.

Tendon injuries: Basic science and new repair proposals

Tendons connect muscles to bones, ensuring joint movement. With advanced age, tendons become more prone to degeneration followed by injuries. Tendon repair often requires lengthy periods of rehabilitation, especially in elderly patients. Existing medical and surgical treatments often fail to regain full tendon function.

The development of novel treatment methods has been hampered due to limited understanding of basic tendon biology. Recently, it was discovered that tendons, similar to other mesenchymal tissues, contain tendon stem/progenitor cells (TSPCs) which possess the common stem cell properties.

The current strategies for enhancing tendon repair consist mainly of applying stem cells, growth factors, natural and artificial biomaterials alone or in combination. In this review, we summarise the basic biology of tendon tissues and provide an update on the latest repair proposals for tendon tears.

Cite this article: EFORT Open Rev 2017;2:332-342. DOI: 10.1302/2058-5241.2.160075

Preparation of collagen/polyurethane/knitted silk as a composite scaffold for tendon tissue engineering

The main objective of this study was to prepare a hybrid three-dimensional scaffold that mimics natural tendon tissues. It has been found that a knitted silk shows good mechanical strength; however, cell growth on the bare silk is not desirable. Hence, electrospun collagen/polyurethane combination was used to cover knitted silk. A series of collagen and polyurethane solutions (4%-7% w/v) in aqueous acetic acid were prepared and electrospun. According to obtained scanning electron microscopy images from pure collagen and polyurethane nanofibers, concentration was set constant at 5% (w/v) for blend solutions of collagen/polyurethane. Afterward, blend solutions with the weight ratios of 75/25, 50/50 and 25/75 were electrospun. Scanning electron microscopy images demonstrated the smooth and uniform morphology for the optimized nanofibers. The least fibers diameter among three weight ratios was found for collagen/polyurethane (25/75) which was 100.86 ± 40 nm and therefore was selected to be electrospun on the knitted silk. Attenuated total reflectance-Fourier transform infrared spectra confirmed the chemical composition of obtained electrospun nanofibers on the knitted silk. Tensile test of the specimens including blend nanofiber, knitted silk and commercial tendon substitute examined and indicated that collagen/polyurethane-coated knitted silk has appropriate mechanical properties as a scaffold for tendon tissue engineering. Then, Alamar Blue assay of the L929 fibroblast cell line seeded on the prepared scaffolds demonstrated appropriate viability of the cells with a significant proliferation on the scaffold containing more collagen content. The results illustrate that the designed structure would be promising for being used as a temporary substitute for tendon repair.

Collagen: a network for regenerative medicine

The basic building block of the extra-cellular matrix in native tissue is collagen. As a structural protein, collagen has an inherent biocompatibility making it an ideal material for regenerative medicine. Cellular response, mediated by integrins, is dictated by the structure and chemistry of the collagen fibers. Fiber formation, via fibrillogenesis, can be controlled in vitro by several factors: pH, ionic strength, and collagen structure. After formation, fibers are stabilized via cross-linking. The final bioactivity of collagen scaffolds is a result of both processes. By considering each step of fabrication, scaffolds can be tailored for the specific needs of each tissue, improving their therapeutic potential.

Mechanically-enhanced three-dimensional scaffold with anisotropic morphology for tendon regeneration

Tissue engineering has showed promising results in restoring diseased tendon tissue functions. Herein, a hybrid three-dimensional (3D) porous scaffold comprising an outer portion rolled from an electrohydrodynamic jet printed poly(ɛ-caprolactone) (PCL) fiber mesh, and an inner portion fabricated from uniaxial stretching of a heat-sealed PCL tube, was developed for tendon tissue engineering (TE) application. The outer portion included three layers of micrometer-scale fibrous bundles (fiber diameter: ~25 µm), with an interconnected spacing and geometric anisotropy along the scaffold length. The inner portion showed orientated micro-ridges/grooves in a parallel direction to that of the outer portion. Owning to the addition of the inner portion, the as-fabricated scaffold exhibited comparable mechanical properties to those of the human patellar tendon in terms of Young's modulus (~227 MPa) and ultimate tensile stress (~50 MPa). Compared to the rolled electrospun fibers, human tenocytes cultured in the tendon scaffolds showed increased cellular metabolism. Furthermore, the 3D tendon scaffold resulted in up-regulated cell alignment, cell elongation and formation of collagen type I. These results demonstrated the potential of mechanically-enhanced 3D fibrous scaffold for applications in tendon TE, with desired cell alignment and functional differentiation.

The influence of anisotropic nano- to micro-topography on in vitro and in vivo osteogenesis

AIM

Topographically modified substrates are increasingly used in tissue engineering to enhance biomimicry. The overarching hypothesis is that topographical cues will control cellular response at the cell-substrate interface.

MATERIALS & METHODS

The influence of anisotropically ordered poly(lactic-co-glycolic acid) substrates (constant groove width of ~1860 nm; constant line width of ~2220 nm; variable groove depth of ~35, 306 and 2046 nm) on in vitro and in vivo osteogenesis were assessed.

RESULTS & DISCUSSION

We demonstrate that substrates with groove depths of approximately 306 and 2046 nm promote osteoblast alignment parallel to underlined topography in vitro. However, none of the topographies assessed promoted directional osteogenesis in vivo.

CONCLUSION

2D imprinting technologies are useful tools for in vitro cell phenotype maintenance.

Anterior Cruciate Ligament: Structure, Injuries and Regenerative Treatments

Anterior cruciate ligament (ACL) is one of the most vulnerable ligaments of the knee. ACL impairment results in episodic instability, chondral and meniscal injury and early osteoarthritis. The poor self-healing capacity of ACL makes surgical treatment inevitable. Current ACL reconstructions include a substitution of torn ACL via biological grafts such as autograft, allograft. This review provides an insight of ACL structure, orientation and properties followed by comparing the performance of various constructs that have been used for ACL replacement. New approaches, undertaken to induce ACL regeneration and fabricate biomimetic scaffolds, are also discussed.

Textile cell-free scaffolds for in situ tissue engineering applications

In this article, the benefits offered by micro-fibrous scaffold architectures fabricated by textile manufacturing techniques are discussed: How can established and novel fiber-processing techniques be exploited in order to generate templates matching the demands of the target cell niche? The problems related to the development of biomaterial fibers (especially from nature-derived materials) ready for textile manufacturing are addressed. Attention is also paid on how biological cues may be incorporated into micro-fibrous scaffold architectures by hybrid manufacturing approaches (e.g. nanofiber or hydrogel functionalization). After a critical review of exemplary recent research works on cell-free fiber based scaffolds for in situ TE, including clinical studies, we conclude that in order to make use of the whole range of favors which may be provided by engineered fibrous scaffold systems, there are four main issues which need to be addressed: (1) Logical combination of manufacturing techniques and materials. (2) Biomaterial fiber development. (3) Adaption of textile manufacturing techniques to the demands of scaffolds for regenerative medicine. (4) Incorporation of biological cues (e.g. stem cell homing factors).

Harnessing Hierarchical Nano- and Micro-Fabrication Technologies for Musculoskeletal Tissue Engineering

Cells within a tissue are able to perceive, interpret and respond to the biophysical, biomechanical, and biochemical properties of the 3D extracellular matrix environment in which they reside. Such stimuli regulate cell adhesion, metabolic state, proliferation, migration, fate and lineage commitment, and ultimately, tissue morphogenesis and function. Current scaffold fabrication strategies in musculoskeletal tissue engineering seek to mimic the sophistication and comprehensiveness of nature to develop hierarchically assembled 3D implantable devices of different geometric dimensions (nano- to macrometric scales) that will offer control over cellular functions and ultimately achieve functional regeneration. Herein, advances and shortfalls of bottom-up (self-assembly, freeze-drying, rapid prototype, electrospinning) and top-down (imprinting) scaffold fabrication approaches, specific to musculoskeletal tissue engineering, are discussed and critically assessed.

Scaffold and scaffold-free self-assembled systems in regenerative medicine

Self-assembly in tissue engineering refers to the spontaneous chemical or biological association of components to form a distinct functional construct, reminiscent of native tissue. Such self-assembled systems have been widely used to develop platforms for the delivery of therapeutic and/or bioactive molecules and various cell populations. Tissue morphology and functional characteristics have been recapitulated in several self-assembled constructs, designed to incorporate stimuli responsiveness and controlled architecture through spatial confinement or field manipulation. In parallel, owing to substantial functional properties, scaffold-free cell-assembled devices have aided in the development of functional neotissues for various clinical targets. Herein, we discuss recent advancements and future aspirations in scaffold and scaffold-free self-assembled devices for regenerative medicine purposes. Biotechnol. Bioeng. 2016;113: 1155-1163. © 2015 Wiley Periodicals, Inc.

Substrate topography: A valuable in vitro tool, but a clinical red herring for in vivo tenogenesis

Controlling the cell-substrate interactions at the bio-interface is becoming an inherent element in the design of implantable devices. Modulation of cellular adhesion in vitro, through topographical cues, is a well-documented process that offers control over subsequent cellular functions. However, it is still unclear whether surface topography can be translated into a clinically functional response in vivo at the tissue/device interface. Herein, we demonstrated that anisotropic substrates with a groove depth of ∼317nm and ∼1988nm promoted human tenocyte alignment parallel to the underlying topography in vitro. However, the rigid poly(lactic-co-glycolic acid) substrates used in this study upregulated the expression of chondrogenic and osteogenic genes, indicating possible tenocyte trans-differentiation. Of significant importance is that none of the topographies assessed (∼37nm, ∼317nm and ∼1988nm groove depth) induced extracellular matrix orientation parallel to the substrate orientation in a rat patellar tendon model. These data indicate that two-dimensional imprinting technologies are useful tools for in vitro cell phenotype maintenance, rather than for organised neotissue formation in vivo, should multifactorial approaches that consider both surface topography and substrate rigidity be established.

STATEMENT OF SIGNIFICANCE

Herein, we ventured to assess the influence of parallel groves, ranging from nano- to micro-level, on tenocytes response in vitro and on host response using a tendon and a subcutaneous model. In vitro analysis indicates that anisotropically ordered micro-scale grooves, as opposed to nano-scale grooves, maintain physiological cell morphology. The rather rigid PLGA substrates appeared to induce trans-differentiation towards chondrogenic and/or steogenic lineage, as evidence by TILDA gene analysis. In vivo data in both tendon and subcutaneous models indicate that none of the substrates induced bidirectional host cell and tissue growth. Collective, these observations indicate that two-dimensional imprinting technologies are useful tools for in vitro cell phenotype maintenance, rather than for directional neotissue formation, should multifactorial approaches that consider both surface topography and substrate rigidity be established.

Effect of 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide and N-hydroxysuccinimide concentrations on the mechanical and biological characteristics of cross-linked collagen fibres for tendon repair

Reconstituted type I collagen fibres have received considerable interest as tendon implant materials due to their chemical and structural similarity to the native tissue. Fibres produced through a semi-continuous extrusion process were cross-linked with different concentrations of the zero-length cross-linker 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (EDC) in combination with N-hydroxysuccinimide (NHS). Tensile properties of the fibres were considered, along with imaging of both surface structure and fibrillar alignment. Resistance of the fibres to bacterial collagenase was investigated and fibre sections seeded with human tendon cells for biological characterization, including cell adhesion and proliferation. The work clearly demonstrated that whilst the concentration of EDC and NHS had no significant effect on the mechanics, a higher concentration was associated with higher collagenase resistance, but also provided a less attractive surface for cell adhesion and proliferation. A lower cross-linking concentration offered a more biocompatible material without reduction in mechanics and with a potentially more optimal degradability.

Assessment of stem cell carriers for tendon tissue engineering in pre-clinical models

Tendon injuries are prevalent and problematic, especially among young and otherwise healthy individuals. The inherently slow innate healing process combined with the inevitable scar tissue formation compromise functional recovery, imposing the need for the development of therapeutic strategies. The limited number of low activity/reparative capacity tendon-resident cells has directed substantial research efforts towards the exploration of the therapeutic potential of various stem cells in tendon injuries and pathophysiologies. Severe injuries require the use of a stem cell carrier to enable cell localisation at the defect site. The present study describes advancements that injectable carriers, tissue grafts, anisotropically orientated biomaterials, and cell-sheets have achieved in preclinical models as stem cell carriers for tendon repair.

The past, present and future in scaffold-based tendon treatments

Tendon injuries represent a significant clinical burden on healthcare systems worldwide. As the human population ages and the life expectancy increases, tendon injuries will become more prevalent, especially among young individuals with long life ahead of them. Advancements in engineering, chemistry and biology have made available an array of three-dimensional scaffold-based intervention strategies, natural or synthetic in origin. Further, functionalisation strategies, based on biophysical, biochemical and biological cues, offer control over cellular functions; localisation and sustained release of therapeutics/biologics; and the ability to positively interact with the host to promote repair and regeneration. Herein, we critically discuss current therapies and emerging technologies that aim to transform tendon treatments in the years to come.

The process of EDC-NHS Cross-linking of reconstituted collagen fibres increases collagen fibrillar order and alignment

We describe the production of collagen fibre bundles through a multi-strand, semi-continuous extrusion process. Cross-linking using an EDC (1-ethyl-3-(3-dimethylaminopropyl)carbodiimide), NHS (N-hydroxysuccinimide) combination was considered. Atomic Force Microscopy (AFM) and Raman spectroscopy focused on how cross-linking affected the collagen fibrillar structure. In the cross-linked fibres, a clear fibrillar structure comparable to native collagen was observed which was not observed in the non-cross-linked fibre. The amide III doublet in the Raman spectra provided additional evidence of alignment in the cross-linked fibres. Raman spectroscopy also indicated no residual polyethylene glycol (from the fibre forming buffer) or water in any of the fibres.

In vitro characterization of a novel tissue engineered based hybridized nano and micro structured collagen implant and its in vivo role on tenoinduction, tenoconduction, tenogenesis and tenointegration

Surgical reconstruction of large tendon defects is technically demanding. Tissue engineering is a new option. We produced a novel tissue engineered, collagen based, bioimplant and in vitro characterizations of the implant were investigated. In addition, we investigated role of the collagen implant on the healing of a large tendon defect model in rabbits. A two cm length of the left rabbit's Achilles tendon was transected and discarded. The injured tendons of all the rabbits were repaired by Kessler pattern to create and maintain a 2 cm tendon gap. The collagen implant was inserted in the tendon defect of the treatment group (n = 30). The defect area was left intact in the control group (n = 30). The animals were euthanized at 60 days post injury (DPI) and the macro- micro- and nano- morphologies and the biomechanical characteristics of the tendon samples were studied. Differences of P < 0.05 were considered significant. The host graft interaction was followed at various stages of tendon healing, using pilot animals. At 60 DPI, a significant increase in number, diameter and density of the collagen fibrils, number and maturity of tenoblasts and tenocytes, alignment of the collagen fibrils and maturity of the elastic fibers were seen in the treated tendons when compared to the control ones (P < 0.05). Compared to the control lesions, number of inflammatory cells, amount of peritendinous adhesions and muscle fibrosis and atrophy, were significantly lower in the treated lesions (P < 0.05). Treatment also significantly increased load to failure, tensile strength and elastic modulus of the samples as compared with the control ones. The collagen implant properly incorporated with the healing tissue and was replaced by the new tendinous structure which was superior both ultra-structurally and physically than the loose areolar connective tissue regenerated in the control lesions. The results of this study may be valuable in the clinical practice.

Current concepts: tissue engineering and regenerative medicine applications in the ankle joint

Tissue engineering and regenerative medicine (TERM) has caused a revolution in present and future trends of medicine and surgery. In different tissues, advanced TERM approaches bring new therapeutic possibilities in general population as well as in young patients and high-level athletes, improving restoration of biological functions and rehabilitation. The mainstream components required to obtain a functional regeneration of tissues may include biodegradable scaffolds, drugs or growth factors and different cell types (either autologous or heterologous) that can be cultured in bioreactor systems (in vitro) prior to implantation into the patient. Particularly in the ankle, which is subject to many different injuries (e.g. acute, chronic, traumatic and degenerative), there is still no definitive and feasible answer to ‘conventional’ methods. This review aims to provide current concepts of TERM applications to ankle injuries under preclinical and/or clinical research applied to skin, tendon, bone and cartilage problems. A particular attention has been given to biomaterial design and scaffold processing with potential use in osteochondral ankle lesions.

Implantation of a novel biologic and hybridized tissue engineered bioimplant in large tendon defect: an in vivo investigation

Surgical reconstruction of large Achilles tendon defects is technically demanding. There is no standard method, and tissue engineering may be a valuable option. We investigated the effects of 3D collagen and collagen-polydioxanone sheath (PDS) implants on a large tendon defect model in rabbits. Ninety rabbits were divided into three groups: control, collagen, and collagen-PDS. In all groups, 2 cm of the left Achilles tendon were excised and discarded. A modified Kessler suture was applied to all injured tendons to retain the gap length. The control group received no graft, the treated groups were repaired using the collagen only or the collagen-PDS prostheses. The bioelectrical characteristics of the injured areas were measured at weekly intervals. The animals were euthanized at 60 days after the procedure. Gross, histopathological and ultrastructural morphology and biophysical characteristics of the injured and intact tendons were investigated. Another 90 pilot animals were also used to investigate the inflammatory response and mechanism of graft incorporation during tendon healing. The control tendons showed severe hyperemia and peritendinous adhesion, and the gastrocnemius muscle of the control animals showed severe atrophy and fibrosis, with a loose areolar connective tissue filling the injured area. The tendons receiving either collagen or collagen-PDS implants showed lower amounts of peritendinous adhesion, hyperemia and muscle atrophy, and a dense tendon filled the defect area. Compared to the control tendons, application of collagen and collagen-PDS implants significantly improved water uptake, water delivery, direct transitional electrical current and tissue resistance to direct transitional electrical current. Compared to the control tendons, both prostheses showed significantly increased diameter, density and alignment of the collagen fibrils and maturity of the tenoblasts at ultrastructure level. Both prostheses influenced favorably tendon healing compared to the control tendons, with no significant differences between collagen and collagen-PDS groups. Implantation of the 3D collagen and collagen-PDS implants accelerated the production of a new tendon in the defect area, and may become a valuable option in clinical practice.

Novel application of a tissue-engineered collagen-based three-dimensional bio-implant in a large tendon defect model: a broad-based study with high value in translational medicine

This study was designed to investigate the effectiveness of a novel tissue-engineered three-dimensional collagen implant on healing of a large tendon-defect model, in vivo. Forty rabbits were divided into two equal groups: treated and control. A 2cm full-thickness gap was created in the left Achilles tendons of all the rabbits. To maintain the gap at the desired length (2cm), a Kessler suture was anchored within the proximal and distal ends of the remaining tendon. In the treated group a collagen implant was inserted in the gap while in the control group the gap was left unfilled. At weekly intervals the animals were examined clinically and their Achilles tendons tested bioelectrically. The hematological parameters and the serum Platelet-Derived Growth Factor of the animals were analyzed at 60 days post injury (DPI) immediately prior to euthanasia. Their injured (left) and normal contralateral Achilles tendons were harvested and examined at gross morphologic level before being subjected to biomechanical testing, and biophysical and biochemical analysis. The treated animals showed superior weight-bearing and greater physical activity than their controls. New dense tendinous tissue with a transverse diameter comparable to that of intact tendons filled the defect area of the treated tendons and had entirely replaced the collagen implant, at 60 DPI. In control lesions the defect was filled with loose areolar connective tissue similar to subcutaneous fascia. Treatment significantly improved the electrical resistance, dry matter, hydroxyproline content, water uptake and water delivery characteristics, of the healing tissue, as well as maximum load, yield load, maximum stress, yield stress and modulus of elasticity of the injured treated tendons compared to those of the control tendons (P<0.05). Use of this three-dimensional collagen implant improved the healing of large tendon defects in rabbits.