Enhanced tendon-to-bone repair through adhesive films

Dual-Targeted Metal Ion Network Hydrogel Scaffold for Promoting the Integrated Repair of Tendon-Bone Interfaces

The tendon-bone interface has a complex gradient structure vital for stress transmission and pressure buffering during movement. However, injury to the gradient tissue, especially the tendon and cartilage components, often hinders the complete restoration of the original structure. Here, a metal ion network hydrogel scaffold, with the capability of targeting multitissue, was constructed through the photopolymerization of the LHERHLNNN peptide-modified zeolitic imidazolate framework-8 (LZIF-8) and the WYRGRL peptide-modified magnesium metal-organic framework (WMg-MOF) within the hydrogel scaffold, which could facilitate the directional migration of metal ions to form a dynamic gradient, thereby achieving integrated regeneration of gradient tissues. LZIF-8 selectively migrated to the tendon, releasing zinc ions to enhance collagen secretion and promoting tendon repair. Simultaneously, WMg-MOF migrated to cartilage, releasing magnesium ions to induce cell differentiation and facilitating cartilage regeneration. Infrared spectroscopy confirmed successful peptide modification of nano ZIF-8 and Mg-MOF. Fluorescence imaging validated that LZIF-8/WMg-MOF had a longer retention, indirectly confirming their successful targeting of the tendon-bone interface. In summary, this dual-targeted metal ion network hydrogel scaffold has the potential to facilitate synchronized multitissue regeneration at the compromised tendon-bone interface, offering favorable prospects for its application in the integrated reconstruction characterized by the gradient structure.

Advancements in scaffold for treating ligament injuries; in vitro evaluation

Tendon/ligament (T/L) injuries are a worldwide health problem that affects millions of people annually. Due to the characteristics of tendons, the natural rehabilitation of their injuries is a very complex and lengthy process. Surgical treatment of a T/L injury frequently necessitates using autologous or allogeneic grafts or synthetic materials. Nonetheless, these alternatives have limitations in terms of mechanical properties and histocompatibility, and they do not permit the restoration of the original biological function of the tissue, which can negatively impact the patient's quality of life. It is crucial to find biological materials that possess the necessary properties for the successful surgical treatment of tissues and organs. In recent years, the in vitro regeneration of tissues and organs from stem cells has emerged as a promising approach for preparing autologous tissue and organs, and cell culture scaffolds play a critical role in this process. However, the biological traits and serviceability of different materials used for cell culture scaffolds vary significantly, which can impact the properties of the cultured tissues. Therefore, this review aims to analyze the differences in the biological properties and suitability of various materials based on scaffold characteristics such as cell compatibility, degradability, textile technologies, fiber arrangement, pore size, and porosity. This comprehensive analysis provides valuable insights to aid in the selection of appropriate scaffolds for in vitro tissue and organ culture.

Genetically Engineered Protein-Based Bioadhesives with Programmable Material Properties

Silk-amyloid-mussel foot protein (SAM) hydrogels made from recombinant fusion proteins containing β-amyloid peptide, spider silk domain, and mussel foot protein (Mfp) are attractive bioadhesives as they display a unique combination of tunability, biocompatibility, bioabsorbability, strong cohesion, and underwater adhesion to a wide range of biological surfaces. To design tunable SAM hydrogels for tailored surgical repair applications, an understanding of the relationships between protein sequence and hydrogel properties is imperative. Here, we fabricated SAM hydrogels using fusion proteins of varying lengths of silk-amyloid repeats and Mfps to characterize their structure and properties. We found that increasing silk-amyloid repeats enhanced the hydrogel's β-sheet content (r = 0.74), leading to higher cohesive strength and toughness. Additionally, increasing the Mfp length beyond the half-length of the full Mfp sequence (1/2 Mfp) decreased the β-sheet content (r = -0.47), but increased hydrogel surface adhesion. Among different variants, the hydrogel made of 16xKLV-2Mfp displayed a high ultimate strength of 3.0 ± 0.3 MPa, an ultimate strain of 664 ± 119%, and an attractive underwater adhesivity of 416 ± 20 kPa to porcine skin. Collectively, the sequence-structure-property relationships learned from this study will be useful to guide the design of future protein adhesives with tunable characteristics for tailored surgical applications.

The subacromial bursa is a key regulator of the rotator cuff and a new therapeutic target for improving repair

Rotator cuff injuries result in over 500,000 surgeries performed annually, an alarmingly high number of which fail. These procedures typically involve repair of the injured tendon and removal of the subacromial bursa. However, recent identification of a resident population of mesenchymal stem cells and inflammatory responsiveness of the bursa to tendinopathy indicate an unexplored biological role of the bursa in the context of rotator cuff disease. Therefore, we aimed to understand the clinical relevance of bursa-tendon crosstalk, characterize the biologic role of the bursa within the shoulder, and test the therapeutic potential for targeting the bursa. Proteomic profiling of patient bursa and tendon samples demonstrated that the bursa is activated by tendon injury. Using a rat to model rotator cuff injury and repair, tenotomy-activated bursa protected the intact tendon adjacent to the injured tendon and maintained the morphology of the underlying bone. The bursa also promoted an early inflammatory response in the injured tendon, initiating key players in wound healing. In vivo results were supported by targeted organ culture studies of the bursa. To examine the potential to therapeutically target the bursa, dexamethasone was delivered to the bursa, prompting a shift in cellular signaling towards resolution of inflammation in the healing tendon. In conclusion, contrary to current clinical practice, the bursa should be retained to the greatest extent possible and provides a new therapeutically target for improving tendon healing outcomes.

One Sentence Summary

The subacromial bursa is activated by rotator cuff injury and regulates the paracrine environment of the shoulder to maintain the properties of the underlying tendon and bone.

A discrete shear lag model of the mechanics of hitchhiker plants, and its prospective application to tendon-to-bone repair

Tendon-to-bone repairs often fail when sutures pull through tendon, like a wire through cheese. Repair strength is maximized when loads are balanced equally among all sutures, relative to the pullout resistance of the tendon and the strength of the sutures. This problem of balancing loads across multiple, discrete attachment sites has been solved in nature by hitchhiker plants that proliferate by adhering relatively stiff fruit to relatively soft fur and fabrics through arrays of hooks. We, therefore, studied the fruits of such a plant, Harpagonella palmeri , and developed a discrete shear lag analysis of the force distributions in H. palmeri 's linear arrays of long, slender hooks of varied lengths and spacing. Results suggested that strategies were used by the plant to distribute loads, including variations in the spacing and stiffnesses of hooks that serve to equalize forces over attachment sites. When applying these models to suturing schemes for surgical reattachment of tendon to bone, results suggested that strategies exhibited by H. palmeri show promise for balancing forces over sutures, potentially doubling repair strength relative to what could be achieved with a uniform suture distribution. Results suggest a potential pathway for strengthening surgical repairs, and more broadly for optimizing fasteners for bi-material attachment.

Effects of tendon viscoelasticity on the distribution of forces across sutures in a model tendon-to-bone repair

Tears to the rotator cuff often require surgical repair. These repairs often culminate in re-tearing when sutures break through the tendon in the weeks following repair. Although numerous studies have been performed to identify suturing strategies that reduce this risk by balancing forces across sutures, none have accounted for how the viscoelastic nature of tendon influences load sharing. With the aim of providing insight into this problem, we studied how tendon viscoelasticity, tendon stiffness, and suture anchor spacing affect this balancing of forces across sutures. Results from a model of a three-row sutured re-attachment demonstrated that optimized distributions of suture stiffnesses and of the spacing of suture anchors can balance the forces across sutures to within a few percent, even when accounting for tendon viscoelasticity. Non-optimized distributions resulted in concentrated force, typically in the outermost sutures. Results underscore the importance of accounting for viscoelastic effects in the design of tendon to bone repairs.

Mechanically Competent Chitosan-Based Bioadhesive for Tendon-to-Bone Repair

Current suture-based surgical techniques used to repair torn rotator cuff tendons do not result in mechanically competent tendon-to-bone attachments, leading to high postoperative failure rates. Although adhesives have been proposed to protect against sutures tearing through tendon during healing, no currently available adhesive meets the clinical needs of adhesive strength, biocompatibility, and promotion of healing. Here, a biocompatible, graded, 3,4-dihydroxy phenyl chitosan (BGC) bioadhesive designed to meet these needs is presented. Although 3,4-dihydroxy phenyl chitosan (DP-chitosan) bioadhesives are biocompatible, their adhesion strength is low; soluble oxidants or cross-linking agents can be added for higher bonding strength, but this sacrifices biocompatibility. These challenges are overcome by developing a periodate-modified ion exchange resin-bead filtration system that oxidizes catechol moieties to quinones and filters off the activating agent and resin. The resulting BGC bioadhesive exhibited sixfold higher strength compared to commercially available tissue adhesives, with strength in the range necessary to improve tendon-to-bone repair (≈1MPa, ≈20% of current suture repair strength). The bioadhesive is biocompatible and promoted tenogenesis; cells exposed to the bioadhesive demonstrated enhanced expression of collagen I and the tenogenic marker Scx. Results demonstrated that the bioadhesive has the potential to improve the strength of a tendon-to-bone repair and promote healing.

The role of loading in murine models of rotator cuff disease

Rotator cuff disease pathogenesis is associated with intrinsic (e.g., age, joint laxity, muscle weakness) and extrinsic (e.g., mechanical load, fatigue) factors that lead to chronic degeneration of the cuff tissues. However, etiological studies are difficult to perform in patients due to the long duration of disease onset and progression. Therefore, the purpose of this study was to determine the effects of altered joint loading on the rotator cuff. Mice were subjected to one of three load-dependent rotator cuff tendinopathy models: underuse loading, achieved by injecting botulinum toxin-A into the supraspinatus muscle; overuse loading, achieved using downhill treadmill running; destabilization loading, achieved by surgical excision of the infraspinatus tendon. All models were compared to cage activity animals. Whole joint function was assessed longitudinally using gait analysis. Tissue-scale structure and function were determined using microCT, tensile testing, and histology. The molecular response of the supraspinatus tendon and enthesis was determined by measuring the expression of 84 wound healing-associated genes. Underuse and destabilization altered forepaw weight-bearing, decreased tendon-to-bone attachment strength, decreased mineral density of the humeral epiphysis, and reduced tendon strength. Transcriptional activity of the underuse group returned to baseline levels by 4 weeks, while destabilization had significant upregulation of inflammation, growth factors, and extracellular matrix remodeling genes. Surprisingly, overuse activity caused changes in walking patterns, increased tendon stiffness, and primarily suppressed expression of wound healing-related genes. In summary, the tendinopathy models demonstrated how divergent muscle loading can result in clinically relevant alterations in rotator cuff structure, function, and gene expression.

Pegylated insulin-like growth factor-1 biotherapeutic delivery promotes rotator cuff regeneration in a rat model

Tears in the rotator cuff are challenging to repair because of the complex, hypocellular, hypovascular, and movement-active nature of the tendon and its enthesis. Insulin-like Growth Factor-1 (IGF-1) is a promising therapeutic for this repair. However, its unstable nature, short half-life, and ability to disrupt homeostasis has limited its clinical translation. Pegylation has been shown to improve the stability and sustain IGF-1 levels in the systemic circulation without disrupting homeostasis. To provide localized delivery of IGF-1 in the repaired tendons, we encapsulated pegylated IGF-1 mimic and its controls (unpegylated IGF-1 mimic and recombinant human IGF-1) in polycaprolactone-based matrices and evaluated them in a pre-clinical rodent model of rotator cuff repair. Pegylated-IGF-1 mimic delivery reestablished the characteristic tendon-to-bone enthesis structure and improved tendon tensile properties within 8 weeks of repair compared to controls, signifying the importance of pegylation in this complex tissue regeneration. These results demonstrate a simple and scalable biologic delivery technology alternative to tissue-derived grafts for soft tissue repair.

Functional Macromolecular Adhesives for Bone Fracture Healing

Compared with traditional internal fixation devices, bone adhesives are expected to exhibit remarkable advantages, such as improved fixation of comminuted fractures and maintained spatial location of fractured scattered bone pieces in treating bone injuries. In this review, different bone adhesives are summarized from the aspects of bone tissue engineering, and the applications of bone adhesives are emphasized. The concepts of "liquid scaffold" and "liquid plate" are proposed to summarize two different research directions of bone adhesives. Furthermore, significant advances of bone adhesives in recent years in mechanical strength, osseointegration, osteoconductivity, and osteoinductivity are discussed. We conclude this topic by providing perspectives on the state-of-the-art research progress and future development trends of bone adhesives. We hope this review will provide a comprehensive summary of bone adhesives and inspire more extensive and in-depth research on this subject.

Toughening mechanisms for the attachment of architectured materials: The mechanics of the tendon enthesis

Architectured materials offer tailored mechanical properties but are limited in engineering applications due to challenges in maintaining toughness across their attachments. The enthesis connects tendon and bone, two vastly different architectured materials, and exhibits toughness across a wide range of loadings. Understanding the mechanisms by which this is achieved could inform the development of engineered attachments. Integrating experiments, simulations, and previously unexplored imaging that enabled simultaneous observation of mineralized and unmineralized tissues, we identified putative mechanisms of enthesis toughening in a mouse model and then manipulated these mechanisms via in vivo control of mineralization and architecture. Imaging uncovered a fibrous architecture within the enthesis that controls trade-offs between strength and toughness. In vivo models of pathology revealed architectural adaptations that optimize these trade-offs through cross-scale mechanisms including nanoscale protein denaturation, milliscale load-sharing, and macroscale energy absorption. Results suggest strategies for optimizing architecture for tough bimaterial attachments in medicine and engineering.

A Biosynthetic Hybrid Spidroin-Amyloid-Mussel Foot Protein for Underwater Adhesion on Diverse Surfaces

Strong underwater adhesives are attractive materials for biomedical healing and underwater repair, but their success in applications has been limited, owing to challenges with underwater setting and with balancing surface adhesion and cohesion. Here, we applied synthetic biology approaches to overcome these challenges through design and synthesis of a novel hybrid protein consisting of the zipper-forming domains of an amyloid protein, flexible spider silk sequences, and a dihydroxyphenylalanine (DOPA)-containing mussel foot protein (Mfp). This partially structured, hybrid protein can self-assemble into a semi-crystalline hydrogel that exhibits high strength and toughness as well as strong underwater adhesion to a variety of surfaces, including difficult-to-adhere plastics, tendon, and skin. The hydrogel allows selective debonding by oxidation or iron-chelating treatments. Both the material design and the biosynthetic approach explored in this study will inspire future work for a wide range of hybrid protein-based materials with tunable properties and broad applications.

Chitosan/gelatin-tannic acid decorated porous tape suture with multifunctionality for tendon healing

The inferior tendon healing after surgery is inextricably linked to the surgical suture. Poor load transfer along the suture often results in a high tendon re-tear rate. Besides, the severe inflammation and infection induced by sutures even cause a second surgery. Herein, to alleviate the above-mentioned issues, a multifunctional suture was fabricated by decorating chitosan/gelatin-tannic acid (CS/GE-TA) on the porous tape suture. The porous tape suture ensured the required mechanical properties and sufficient space for tissue integration. Compared to the pristine suture, the CS/GE-TA decorated suture (TA100) presented a 332% increase in pull-out force from the tendon, indicating potentially decreased re-tear rates. Meanwhile, TA100 showed superior anti-inflammatory and antibacterial performances. In vivo experiments further proved that TA100 could not only reduce inflammatory action but also facilitate collagen deposition and blood vessel formation. These results indicate that the multifunctional sutures are promising candidates for accelerating tendon healing.

Patch Augmentation in Rotator Cuff Repair

PURPOSE OF THE REVIEW

Rotator cuff repair has excellent outcomes for many patients but continues to be suboptimal for large, retracted tears, and revision procedures. In these situations, patch augmentation may be considered in order to improve healing. The purpose of this article is to review the history, graft options, indications, surgical technique, outcomes, and complications associated with arthroscopic patch augmentation for rotator cuff repair.

RECENT FINDINGS

Patch augmentation has been shown in several studies to improve healing rates. After multiple investigations into different materials available for patch augmentation, acellular dermal allograft seems to be the graft with the best scientific support. While multiple techniques have been presented, few studies have compared their performance. While the arthroscopic technique for patch augmentation can be challenging, we present a systematic approach to this procedure with the potential to reliably and predictably perform patch augmentation. This technique is a valuable tool for surgeons that treat rotator cuff pathology.

Adhesive-based tendon-to-bone repair: failure modelling and materials selection

Surgical reattachment of tendon to bone is a procedure marked by high failure rates. For example, nearly all rotator cuff repairs performed on elderly patients with massive tears ultimately result in recurrence of tearing. These high failure rates have been attributed to stress concentrations that arise due to the mechanical mismatch between tendon and bone. Although recent studies have identified potential adhesives with mechanical properties tuned to alleviate these stress concentrations, and thereby delay the onset of failure, resistance to the progression of failure has not been studied. Here, we refined the space of adhesive material properties that can improve surgical attachment by considering the fracture process. Using cohesive zone modelling and physiologically relevant values of mode I and mode II adhesive fracture toughnesses, we predicted the maximum displacement and strength at failure of idealized, adhesively bonded tendon-to-bone repairs. Repair failure occurred due to excessive relative displacement of the tendon and bone tissues for strong and compliant adhesives. The failure mechanism shifted to rupture of the entire repair for stiffer adhesives below a critical shear strength. Results identified a narrow range of materials on an Ashby chart that are suitable for adhesive repair of tendon to bone, including a range of elastomers and porous solids.

Current State of Bone Adhesives-Necessities and Hurdles

The vision of gluing two bone fragments with biodegradable and biocompatible adhesives remains highly fascinating and attractive to orthopedic surgeons. Possibly shorter operation times, better stabilization, lower infection rates, and unnecessary removal make this approach very appealing. After 30 years of research in this field, the first adhesive systems are now appearing in scientific reports that may fulfill the comprehensive requirements of bioadhesives for bone. For a successful introduction into clinical application, special requirements of the musculoskeletal system, challenges in the production of a bone adhesive, as well as regulatory hurdles still need to be overcome. In this article, we will give an overview of existing synthetic polymers, biomimetic, and bio-based adhesive approaches, review the regulatory hurdles they face, and discuss perspectives of how bone adhesives could be efficiently introduced into clinical application, including legal regulations.

Influence of sutures configuration on the strength of tendon-patch joints for rotator cuff tears treatment

PURPOSE

Massive rotator cuff tears are common in the aging population. The incidence of failed rotator cuff repairs is still quite high, especially in the treatment of full-thickness tears or revision repairs. In this context, natural and synthetic meshes can be used as augmentation scaffolds or as devices to close the gap between a retracted tendon and the bone. The purpose of this work is to evaluate the ultimate tensile strength of different tendon-patch joints in order to consider their use in the treatment of massive cuff tears.

MATERIALS AND METHODS

Porcine tendons and a synthetic low-density polypropylene mesh have been used. A preliminary study on the tensile strength of tendons and patches has been performed. Different patch-tendon joints have been studied by modifying the number and the layout of the sutures. For every joint, the tensile test, performed through an electromechanical machine, has been repeated at least twice to obtain reliable data.

RESULTS

Experimental tensile tests on tendons and patches have given good results with very low dispersion data. Mean values of the calculated ultimate tensile stresses are, respectively, about 34 MPa and 16 MPa for tendons and patches. As regards the sutures arrangement, the staggered layout gave, for all joints, a higher tensile strength than the regular (aligned) one. Different ultimate tensile stress values, depending on the sutures number and layout, have been calculated for the joints.

CONCLUSION

Synthetic patches could be an interesting option to repair massive cuff tears and to improve, in a significant way, pain, range of motion and strength at time 0, so reducing the rehabilitation time. Obtained results demonstrated that joints with a suitable number and layout of sutures could ensure very good mechanical performances. The failure load of the tendon-patch joint, in fact, is higher than the working load on a healthy tendon.

Engineering the hard-soft tissue interface with random-to-aligned nanofiber scaffolds

Tendon injuries can be difficult to heal and have high rates of relapse due to stress concentrations caused by scar formation and the sutures used in surgical repair. Regeneration of the tendon/ligament-to-bone interface is critical to provide functional graft integration after injury. The objective of this study is to recreate the tendon-to-bone interface using a gradient scaffold which is fabricated by a one-station electrospinning process. Two cell phenotypes were grown on a poly-ε-caprolactone nanofiber scaffold which possesses a gradual transition from random to aligned nanofiber patterns. We assessed the effects of the polymer concentration, tip-to-collector distance, and electrospinning time on the microfiber diameter and density. Osteosarcoma and fibroblast cells were seeded on the random and aligned sections of scaffolds, respectively. A random-to-aligned cocultured tissue interface which mimicked the native transition in composition of enthesis was created after 96 h culturing. The results showed that the microstructure gradient influenced the cell morphology, tissue topology, and promoted enthesis formation. This study demonstrates a heterogeneous nanofiber scaffold strategy for interfacial tissue regeneration. It provides a potential solution for mimicking transitional interface between distinct tissues, and can be further developed as a heterogeneous cellular composition platform to facilitate the formation of multi-tissue complex systems.