A comparative study of the effects of growth and differentiation factor 5 on muscle-derived stem cells and bone marrow stromal cells in an in vitro tendon healing model

Facile and rapid fabrication of a novel 3D-printable, visible light-crosslinkable and bioactive polythiourethane for large-to-massive rotator cuff tendon repair

Facile and rapid 3D fabrication of strong, bioactive materials can address challenges that impede repair of large-to-massive rotator cuff tears including personalized grafts, limited mechanical support, and inadequate tissue regeneration. Herein, we developed a facile and rapid methodology that generates visible light-crosslinkable polythiourethane (PHT) pre-polymer resin (∼30 min at room temperature), yielding 3D-printable scaffolds with tendon-like mechanical attributes capable of delivering tenogenic bioactive factors. Ex vivo characterization confirmed successful fabrication, robust human supraspinatus tendon (SST)-like tensile properties (strength: 23 MPa, modulus: 459 MPa, at least 10,000 physiological loading cycles without failure), excellent suture retention (8.62-fold lower than acellular dermal matrix (ADM)-based clinical graft), slow degradation, and controlled release of fibroblast growth factor-2 (FGF-2) and transforming growth factor-β3 (TGF-β3). In vitro studies showed cytocompatibility and growth factor-mediated tenogenic-like differentiation of mesenchymal stem cells. In vivo studies demonstrated biocompatibility (3-week mouse subcutaneous implantation) and ability of growth factor-containing scaffolds to notably regenerate at least 1-cm of tendon with native-like biomechanical attributes as uninjured shoulder (8-week, large-to-massive 1-cm gap rabbit rotator cuff injury). This study demonstrates use of a 3D-printable, strong, and bioactive material to provide mechanical support and pro-regenerative cues for challenging injuries such as large-to-massive rotator cuff tears.

Growth factors in the treatment of Achilles tendon injury

Achilles tendon (AT) injury is one of the most common tendon injuries, especially in athletes, the elderly, and working-age people. In AT injury, the biomechanical properties of the tendon are severely affected, leading to abnormal function. In recent years, many efforts have been underway to develop effective treatments for AT injuries to enable patients to return to sports faster. For instance, several new techniques for tissue-engineered biological augmentation for tendon healing, growth factors (GFs), gene therapy, and mesenchymal stem cells were introduced. Increasing evidence has suggested that GFs can reduce inflammation, promote extracellular matrix production, and accelerate AT repair. In this review, we highlighted some recent investigations regarding the role of GFs, such as transforming GF-β(TGF-β), bone morphogenetic proteins (BMP), fibroblast GF (FGF), vascular endothelial GF (VEGF), platelet-derived GF (PDGF), and insulin-like GF (IGF), in tendon healing. In addition, we summarized the clinical trials and animal experiments on the efficacy of GFs in AT repair. We also highlighted the advantages and disadvantages of the different isoforms of TGF-β and BMPs, including GFs combined with stem cells, scaffolds, or other GFs. The strategies discussed in this review are currently in the early stages of development. It is noteworthy that although these emerging technologies may potentially develop into substantial clinical treatment options for AT injury, definitive conclusions on the use of these techniques for routine management of tendon ailments could not be drawn due to the lack of data.

Growth and differentiation factor-7 immobilized, mechanically strong quadrol-hexamethylene diisocyanate-methacrylic anhydride polyurethane polymer for tendon repair and regeneration

Biological and mechanical cues are both vital for biomaterial aided tendon repair and regeneration. Here, we fabricated mechanically tendon-like (0 s UV) QHM polyurethane scaffolds (Q: Quadrol, H: Hexamethylene diisocyanate; M: Methacrylic anhydride) and immobilized them with Growth and differentiation factor-7 (GDF-7) to produce mechanically strong and tenogenic scaffolds. In this study, we assessed QHM polymer cytocompatibility, amenability to fibrin-coating, immobilization and persistence of GDF-7, and capability to support GDF-7-mediated tendon differentiation in vitro as well as in vivo in mouse subcutaneous and acute rat rotator cuff tendon resection models. Cytocompatibility studies showed that QHM facilitated cell attachment, proliferation, and viability. Fibrin-coating and GDF-7 retention studies showed that mechanically tendon-like 0 s UV QHM polymer could be immobilized with GDF-7 and retained the growth factor (GF) for at least 1-week ex vivo. In vitro differentiation studies showed that GDF-7 mediated bone marrow-derived human mesenchymal stem cell (hMSC) tendon-like differentiation on 0 s UV QHM. Subcutaneous implantation of GDF-7-immobilized, fibrin-coated, QHM polymer in mice for 2 weeks demonstrated de novo formation of tendon-like tissue while implantation of GDF-7-immobilized, fibrin-coated, QHM polymer in a rat acute rotator cuff resection injury model indicated tendon-like tissue formation in situ and the absence of heterotopic ossification. Together, our work demonstrates a promising synthetic scaffold with human tendon-like biomechanical attributes as well as immobilized tenogenic GDF-7 for tendon repair and regeneration. STATEMENT OF SIGNIFICANCE: Biological activity and mechanical robustness are key features required for tendon-promoting biomaterials. While synthetic biomaterials can be mechanically robust, they often lack bioactivity. To biologically augment synthetic biomaterials, numerous drug and GF delivery strategies exist but the large tissue space within the shoulder is constantly flushed with saline during arthroscopic surgery, hindering efficacious controlled release of therapeutic molecules. Here, we coated QHM polymer (which exhibits human tendon-to-bone-like biomechanical attributes) with fibrin for GF binding. Unlike conventional drug delivery strategies, our approach utilizes immobilized GFs as opposed to released GFs for sustained, localized tissue regeneration. Our data demonstrated that GF immobilization can be broadly applied to synthetic biomaterials for enhancing bioactivity, and GDF-7-immobilized QHM exhibit high clinical translational potential for tendon repair.

3D Biomimetic Scaffold for Growth Factor Controlled Delivery: An In-Vitro Study of Tenogenic Events on Wharton's Jelly Mesenchymal Stem Cells

The present work described a bio-functionalized 3D fibrous construct, as an interactive teno-inductive graft model to study tenogenic potential events of human mesenchymal stem cells collected from Wharton’s Jelly (hWJ-MSCs). The 3D-biomimetic and bioresorbable scaffold was functionalized with nanocarriers for the local controlled delivery of a teno-inductive factor, i.e., the human Growth Differentiation factor 5 (hGDF-5). Significant results in terms of gene expression were obtained. Namely, the up-regulation of Scleraxis (350-fold, p ≤ 0.05), type I Collagen (8-fold), Decorin (2.5-fold), and Tenascin-C (1.3-fold) was detected at day 14; on the other hand, when hGDF-5 was supplemented in the external medium only (in absence of nanocarriers), a limited effect on gene expression was evident. Teno-inductive environment also induced pro-inflammatory, (IL-6 (1.6-fold), TNF (45-fold, p ≤ 0.001), and IL-12A (1.4-fold)), and anti-inflammatory (IL-10 (120-fold) and TGF-β1 (1.8-fold)) cytokine expression upregulation at day 14. The presented 3D construct opens perspectives for the study of drug controlled delivery devices to promote teno-regenerative events.

The effect of fibrin formulation on cell migration in an in vitro tendon repair model

BACKGROUND

The purpose of this study was to determine the effect of fibrinogen concentration on cell viability and migration in a tissue culture tendon healing model.

METHODS

Forty-eight canine flexor digitorum profundus tendons were randomly divided into three groups. In each group the tendons were lacerated and repaired augmented with a canine bone marrow stromal cell seeded fibrin interposition patch using either 5 mg/ml fibrinogen and 25 U/ml thrombin (physiological as a control), 40 mg/ml fibrinogen and 250 U/ml thrombin (low adhesive), or 80 mg/ml fibrinogen and 250 U/ml thrombin (high adhesive). The sutured tendons were cultured for two or four weeks.

RESULTS

Failure load was not significantly different among the groups. Cell-labeling staining showed that the stromal cells migrated across the gap in the control and low adhesive groups, but there was no cell migration in the high adhesive group at two weeks.

CONCLUSION

A high fibrinogen concentration in a fibrin patch or glue may impede early cell migration.

LEVEL OF EVIDENCE

Not applicable because this study was a laboratory study.

A novel engineered purified exosome product patch for tendon healing: An explant in an ex vivo model

Reducing tendon failure after repair remains a challenge due to its poor intrinsic healing ability. The purpose of this study is to investigate the effect of a novel tissue-engineered purified exosome product (PEP) patch on tendon healing in a canine ex vivo model. Lacerated flexor digitorum profundus (FDP) tendons from three canines' paws underwent simulated repair with Tisseel patch alone or biopotentiated with PEP. For the ex vivo model, FDP tendons were randomly divided into three groups: FDP tendon repair alone group (Control), Tisseel patch alone group, and the Tisseel plus PEP (TEPEP) patch group. Following 4 weeks of tissue culture, the failure load, stiffness, histology, and gene expression of the healing tendon were evaluated. Transmission electron microscopy revealed that in exosomes of PEP the diameters ranged from 93.70 to 124.65 nm, and the patch release test showed this TEPEP patch could stably release the extracellular vesicle over 2 weeks. The failure strength of the tendon in the TEPEP patch group was significantly higher than that of the Control group and Tisseel alone group. The results of histology showed that the TEPEP patch group had the smallest healing gap and the largest number of fibroblasts on the surface of the injured tendon. Quantitative reverse transcription polymerase chain reaction showed that TEPEP patch increased the expression of collagen type III, matrix metallopeptidase 2 (MMP2), MMP3, MMP14, and reduced the expression of transforming growth factor β1, interleukin 6. This study shows that the TEPEP patch could promote tendon repair by reducing gap formation and inflammatory response, increasing the activity of endogenous cells, and formation of type III collagen.

In Vitro Innovation of Tendon Tissue Engineering Strategies

Tendinopathy is the term used to refer to tendon disorders. Spontaneous adult tendon healing results in scar tissue formation and fibrosis with suboptimal biomechanical properties, often resulting in poor and painful mobility. The biomechanical properties of the tissue are negatively affected. Adult tendons have a limited natural healing capacity, and often respond poorly to current treatments that frequently are focused on exercise, drug delivery, and surgical procedures. Therefore, it is of great importance to identify key molecular and cellular processes involved in the progression of tendinopathies to develop effective therapeutic strategies and drive the tissue toward regeneration. To treat tendon diseases and support tendon regeneration, cell-based therapy as well as tissue engineering approaches are considered options, though none can yet be considered conclusive in their reproduction of a safe and successful long-term solution for full microarchitecture and biomechanical tissue recovery. In vitro differentiation techniques are not yet fully validated. This review aims to compare different available tendon in vitro differentiation strategies to clarify the state of art regarding the differentiation process.

Tenogenic adipose-derived stem cell sheets with nanoyarn scaffolds for tendon regeneration

Tissue engineering, especially cell sheets-based engineering, offers a promising approach to tendon regeneration; however, obtaining a sufficient source of cells for tissue engineering applications is challenging. Adipose-derived stem cells (ASCs) are essential sources for tissue regeneration and have been shown to have the potential for tenogenic differentiation in vitro via induction by growth differentiation factor 5 (GDF-5). In this study, we explored the feasibility of ASCs cell sheets stimulated by GDF-5 for engineered tendon repair. As shown by quantitative polymerase chain reaction and western blotting, tenogenesis-related markers (Col I&III, TNMD, biglycan, and tenascin C) were significantly increased in GDF-5-induced ASCs cell sheets compared with the uninduced. Moreover, the levels of SMAD2/3 proteins and phospho-SMAD1/5/9 were significantly enhanced, demonstrating that GDF-5 may exert its functions through phosphorylation of SMAD1/5/9. Furthermore, the cell sheets were combined with P(LLA-CL)/Silk fibroin nanoyarn scaffolds to form constructs for tendon tissue engineering. Terminal deoxynucleotidyl transferase dUTP nick end labeling and immunofluorescence assays demonstrated favorable cell viability and tenogenesis-related marker expression in GDF-5-induced constructs. In addition, the constructs showed the potential for tendon repair in rabbit models, as demonstrated by histological, immunohistochemical, and biomechanical analyses. In our study, we successfully produced a new tissue-engineered tendon by the combination of GDF-5-induced ASCs cell sheets and nanoyarn scaffold which is valuable for tendon regeneration.

Dose-Response Tendon-Specific Markers Induction by Growth Differentiation Factor-5 in Human Bone Marrow and Umbilical Cord Mesenchymal Stem Cells

Mesenchymal stem cells derived from human bone marrow (hBM-MSCs) are utilized in tendon tissue-engineering protocols while extra-embryonic cord-derived, including from Wharton's Jelly (hWJ-MSCs), are emerging as useful alternatives. To explore the tenogenic responsiveness of hBM-MSCs and hWJ-MSCs to human Growth Differentiation Factor 5 (hGDF-5) we supplemented each at doses of 1, 10, and 100 ng/mL of hGDF-5 and determined proliferation, morphology and time-dependent expression of tenogenic markers. We evaluated the expression of collagen types 1 (COL1A1) and 3 (COL3A1), Decorin (DCN), Scleraxis-A (SCX-A), Tenascin-C (TNC) and Tenomodulin (TNMD) noting the earliest and largest increase with 100 ng/mL. With 100 ng/mL, hBM-MSCs showed up-regulation of SCX-A (1.7-fold) at Day 1, TNC (1.3-fold) and TNMD (12-fold) at Day 8. hWJ-MSCs, at the same dose, showed up-regulation of COL1A1 (3-fold), DCN (2.7-fold), SCX-A (3.8-fold) and TNC (2.3-fold) after three days of culture. hWJ-MSCs also showed larger proliferation rate and marked aggregation into a tubular-shaped system at Day 7 (with 100 ng/mL of hGDF-5). Simultaneous to this, we explored the expression of pro-inflammatory (IL-6, TNF, IL-12A, IL-1β) and anti-inflammatory (IL-10, TGF-β1) cytokines across for both cell types. hBM-MSCs exhibited a better balance of pro-inflammatory and anti-inflammatory cytokines up-regulating IL-1β (11-fold) and IL-10 (10-fold) at Day 8; hWJ-MSCs, had a slight expression of IL-12A (1.5-fold), but a greater up-regulation of IL-10 (2.5-fold). Type 1 collagen and tenomodulin proteins, detected by immunofluorescence, confirming the greater protein expression when 100 ng/mL were supplemented. In the same conditions, both cell types showed specific alignment and shape modification with a length/width ratio increase, suggesting their response in activating tenogenic commitment events, and they both potential use in 3D in vitro tissue-engineering protocols.

Evaluation of hollow mesh augmentation on the biomechanical properties of the flexor tendon repaired with modified Kessler technique

Purpose

The aim of the study was to test flexor tendon repair with a novel hollow mesh suture augmentation served as a centre core cable [Triple-C (Tri-C)] in an in vitro study using a turkey model.

Methods

Forty long digits from white turkey feet were divided into the following four groups based on repair techniques: Group 0, intact tendon without repair; Group 1, modified Kessler (MK) repair only (MKo); Group 2, MK repair plus Tri-C (MK ​+ ​Tri-C); and Group 3, MK repair plus an additional outside knot plus Tri-C (MK-2knots ​+ ​Tri-C). Mechanical evaluations were performed for all groups.

Results

The frictions of the two groups with Tri-C were not significantly different than those of the MKo group. The ultimate tensile strength of the MK ​+ ​Tri-C group was not significantly different from that of the MKo group or the MK-2knots ​+ ​Tri-C group. In contrast, the MK-2knots ​+ ​Tri-C group had a significantly greater ultimate tensile strength compared with that of the MKo group. Forces at 2-mm gap formation in the groups with Tri-C were significantly stronger than that of MK alone.

Conclusion

Our data have demonstrated that MK repair augmented with the centre hollow mesh suture increased failure strength without inducing increased friction.

The translational potential of this article

Our study elucidates that a Tri-C augmentation designed in this study can achieve mechanical enhancements without increasing the repaired tendon friction. Hence, this novel technique has potential biological validity and clinical application.

A BMSCs-laden quercetin/duck's feet collagen/hydroxyapatite sponge for enhanced bone regeneration

Treating critical-sized bone defects is an important issue in the field of tissue engineering and bone regeneration. From the various biomaterials for bone regeneration, collagen is an important and widely used biomaterial in biomedical applications, hence, it has numerous attractive properties including biocompatibility, hyper elastic behavior, prominent mechanical properties, support cell adhesion, proliferation, and biodegradability. In the present study, collagen was extracted from duck's feet (DC) as a new collagen source and combined with quercetin (Qtn), a type of flavonoids found in apple and onions and has been reported to affect the bone metabolism, for increasing osteogenic differentiation. Further, improving osteoconductive properties of the scaffold hydroxyapatite (HAp) a biodegradable material was used. We prepared 0, 25, 50, and 100 μM Qtn/DC/HAp sponges using Qtn, DC, and HAp. Their physiochemical characteristics were evaluated using scanning electron microscopy, compressive strength, porosity, and Fourier transform infrared spectroscopy. To assess the effect of Qtn on osteogenic differentiation, we cultured bone marrow mesenchymal stem cells on the sponges and evaluated by alkaline phosphatase, 3-4-2, 5-diphenyl tetrazolium bromide assay, and real-time polymerase chain reaction. Additionally, they were studied implanting in rat, analyzed through Micro-CT and histological staining. From our in vitro and in vivo results, we found that Qtn has an effect on bone regeneration. Among the different experimental groups, 25 μM Qtn/DC/HAp sponge was found to be highly increased in cell proliferation and osteogenic differentiation compared with other groups. Therefore, 25 μM Qtn/DC/HAp sponge can be used as an alternative biomaterial for bone regeneration in critical situations.

Lateral slit delivery of bone marrow stromal cells enhances regeneration in the decellularized allograft flexor tendon

BACKGROUND/OBJECTIVE

Stem cell-based therapy has been applied to accelerate the revitalization of allograft tendon into a viable and functional tendon. Although many authors have proposed different methods to help the seeded stem cell distribution in the decellularized allograft, limited success has been achieved as tendon is a high dense connective tissue. We hypothesized that bone marrow stromal cells (BMSCs), seeded through the lateral slit, can regenerate the decellularized tendon (DCT) graft. The cell proliferation, cell viability, and tendon-specific gene expression are increased with the seeded cell density.

METHODS

Eighty-seven flexor digitorum profundus tendons were equally and randomly divided into 6 treatment groups that were seeded with low-density (2 × 107 cells/mL) and high-density (5 × 107 cells/mL) BMSCs through lateral slits cultured for 2 and 4 weeks, DCT without cells, and fresh live tendons. Tendons were evaluated for cell distribution, cell proliferation, cell viability, gene expression of Collagen I and Collagen III, tenogenic markers, and MMPs.

RESULTS

Histologic evaluation revealed BMSCs distributed from the lateral slit to the whole DCT. BMSCs were proliferated and kept viable in lateral slit decellularized tendon (LSDCT) in both seeded cell density groups after 2 and 4 weeks of culture. However, no significant differences in the cell proliferation between both cell density groups at 2 and 4 weeks of culture were observed. The lowest cell viability was found in the high-density group after 4 weeks of culture. BMSCs in LSDCT showed a significant tendency of higher gene expression of Collagen I, Collagen III, tenascin C, MMP2, MMP9, and MMP13 compared to normal tendons in both cell density groups at 2 and 4 weeks of culture.

CONCLUSION

BMSCs proliferated and remained viable after 2 and 4 weeks of culture with distribution throughout the lateral slits. Lateral slit preparation allows for the effective delivery and maintenance of mesenchymal cells with proliferation and generating a tenogenic behaviour of DCT in both the low and high cell densities in an in vitro model.

THE TRANSLATION POTENTIAL OF THIS ARTICLE

Revitalizing the implanted decellularized allograft is important for clinical application. In this study, we demonstrated that the DCT, with lateral slits, could harbour the seeded stem cell and stimulate proliferation with collagen synthesis. This evidence was presented for clinical application of the lateral slit technique, in DCT grafts, which would repopulate the seeded BMSCs during tendon and ligament reconstruction.

A modified preplate technique for efficient isolation and proliferation of mice muscle-derived stem cells

We modified an existing protocol to develop a more efficient method to acquire and culture muscle-derived stem cells (MDSCs) and compared the characteristics of cells obtained from the two methods. This method is based on currently used multistep enzymatic digestion and preplate technique. During the replating process, we replaced the traditional medium with isolation medium to promote fibroblast-like cell adherence at initial replating step, which shortened the purifying duration by up to 4 days. Moreover, we modified the culture container to provide a stable microenvironment that promotes MDSC adherence. We compared the cell morphology, growth curve and the expression of specific markers (Sca-1, CD34, PAX7 and Desmin) between the two cell groups separately obtained from the two methods. Afterwards, we compared the neural differentiation capacity of MDSCs with other muscle-derived cell lineages. The protocol developed here is a fast and effective method to harvest and purify MDSCs from mice limb skeletal muscle.

BMP14 induces tenogenic differentiation of bone marrow mesenchymal stem cells in vitro

Bone marrow mesenchymal stem cells (BMSCs) are pluripotent cells, which have the capacity to differentiate into various types of mesenchymal cell phenotypes, including osteoblasts, chondroblasts, myoblasts and tendon fibroblasts (TFs). The molecular mechanism for tenogenic differentiation of BMSCs is still unknown. The present study investigated the effects of bone morphogenetic protein (BMP) 14 on BMSC differentiation in vitro. It was revealed that BMP14 significantly increased the expression of tendon markers (scleraxis and tenomodulin) at the mRNA and protein level, which led to the upregulation of sirtuin 1 (Sirt1) expression. The gain or loss of Sirt1 function may promote or inhibit tenogenic differentiation by deacetylating the peroxisome proliferator-activated receptor (PPAR)-γ. BMP14 also triggered the phosphorylation of c-Jun N-terminal kinase (JNK) and Smad1; overexpression of Sirt1 significantly increased the phosphorylation and knockdown of Sirt1 significantly decreased the phosphorylation. The inhibition of JNK and Smad significantly increased the acetylation of PPARγ and inhibited the expression of tenogenic differentiation markers. These results suggest that BMP14 may induce the tenogenic differentiation of BMSCs via the Sirt1-JNK/Smad1-PPARγ signaling pathway. The present study provided a cellular and molecular basis for the development of novel therapeutic strategies for tendon healing.

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.

Revitalized and synovialized allograft for intrasynovial flexor tendon reconstruction in an in vivo canine model

This study was to test our hypothesis that flexor tendon reconstruction with an allograft revitalized with bone marrow stromal cells (BMSCs) and synovialized with carbodiimide derivatized autologous synovial fluid (cd-SYN) would result in better digit functional restoration than the conventional allograft tendon. A total of 32 flexor digital profundus tendons from the second and fifth digit of 16 dogs were created a repair failure model first. Then, failed-repaired tendons were reconstructed with either a revitalized-synovialized allograft tendon or a clinical standard autograft tendon (control group). The allograft tendon was seeded with autologous BMSCs in multiple slits and the graft surface was coated with cd-SYN. A 6 weeks after tendon reconstruction, the digits were harvested and evaluated for digit function, adhesion status, tendon gliding resistance, attachment strength, cell viability, and histologic factors. The allograft group had significantly improved digit function compared with the control group through decreased work of flexion, increased digit range of motion under 2-Newton force, and less adhesion score (p < .05). However, the distal attachment-site strength and stiffness in the allograft tendon were significantly weaker than the autografts (p < .05). No significant difference was found for gliding resistance. Histologically, allograft tendons coated with allograft had smoother surfaces and showed tendon-to-bone and tendon-to-tendon incorporation. Viable BMSCs were found in the tendon slits 6 weeks after the graft. In conclusion, cellular lubricant-based modification of allograft tendons improved digit function and reduced the adhesions compared with autograft for flexor tendon reconstruction. However, improvement of graft-to-host tendon healing is still challenging. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Therapeutic Effects of Doxycycline on the Quality of Repaired and Unrepaired Achilles Tendons

BACKGROUND

Achilles tendon tears are devastating injuries, especially to athletes. Elevated matrix metalloproteinase (MMP) activity after a tendon injury has been associated with deterioration of the collagen network and can be inhibited with doxycycline (Doxy).

HYPOTHESIS

Daily oral administration of Doxy will enhance the histological, molecular, and biomechanical quality of transected Achilles tendons. Additionally, suture repair will further enhance the quality of repaired tendons.

STUDY DESIGN

Controlled laboratory study.

METHODS

Randomized unilateral Achilles tendon transection was performed in 288 adult male Sprague-Dawley rats. The injured tendons were either unrepaired (groups 1 and 2) or surgically repaired (groups 3 and 4). Animals from groups 2 and 4 received Doxy daily through oral gavage, and animals from groups 1 and 3 served as controls (no Doxy). Tendons were harvested at 1.5, 3, 6, and 9 weeks after the injury (n = 18 per group and time point). The quality of tendon repair was evaluated based on the histological grading score, collagen fiber orientation, gene expression, and biomechanical properties.

RESULTS

In surgically repaired samples, Doxy enhanced the quality of tendon repair compared with no Doxy ( P = .0014). Doxy had a significant effect on collagen fiber dispersion, but not principal fiber angle. There was a significant effect of time on the gene expression of MMP-3, MMP-9 and TIMP1, and Doxy significantly decreased MMP-3 expression at 9 weeks. Doxy treatment with surgical repair increased the dynamic modulus at 6 weeks but not at 9 weeks after the injury ( P < .001). Doxy also increased the equilibrium modulus and decreased creep strain irrespective of the repair group. Doxy did not have a significant effect on the histology or biomechanics of unrepaired tendons.

CONCLUSION

The findings indicate that daily oral administration of Doxy accelerated matrix remodeling and the dynamic and equilibrium biomechanics of surgically repaired Achilles tendons, although such enhancements were most evident at the 3- to 6-week time points.

CLINICAL RELEVANCE

The inhibition of MMPs at the optimal stage of the repair process may accelerate Achilles tendon repair and improve biomechanical properties, especially when paired with surgical management.

* An Engineered Multiphase Three-Dimensional Microenvironment to Ensure the Controlled Delivery of Cyclic Strain and Human Growth Differentiation Factor 5 for the Tenogenic Commitment of Human Bone Marrow Mesenchymal Stem Cells

At present, injuries or rupture of tendons are treated by surgical repair or conservative approaches with unpredictable clinical outcome. Alternative strategies to repair tendon defects without the undesirable side effects associated with the current options are needed. With this in mind, a tissue engineering approach has gained considerable attention as a promising strategy. Here we investigated a synthetic three-dimensional (3D) microenvironment able to interact with stem cells and inducing, via coupled biochemical and physical signals, their early commitment toward the tenogenic lineage. This multiphase 3D construct consisted of a braided hyaluronate elastic band merged with human bone marrow mesenchymal stem cells (hBMSCs) and poly-lactic-co-glycolic acid microcarriers loaded with human growth differentiation factor 5 (hGDF-5) by means of fibrin hydrogel. The multiphase structure allowed hBMSC culture under cyclic strain within a microenvironment where a controlled amount of hGDF-5 was regularly delivered. The cooperative biochemical and physical stimuli induced significantly increased expression of tenogenic markers, such as collagen type I and III, decorin, scleraxis, and tenascin-C, within only 3 days of dynamic hBMSC culture. This approach opens exciting perspectives for future development of engineered tendon tissue substitutes.

From skeletal muscle to stem cells: an innovative and minimally-invasive process for multiple species

Bone marrow and adipose tissue represent the two most commonly exploited sources of adult mesenchymal stem cells for musculoskeletal applications. Unfortunately the sampling of bone marrow and fat tissue is invasive and does not always lead to a sufficient number of cells. The present study describes a novel sampling method based on microbiopsy of skeletal muscle in man, pigs, dogs and horses. The process includes explant of the sample, Percoll density gradient for isolation and subsequent culture of the cells. We further characterized the cells and identified their clonogenic and immunomodulatory capacities, their immune-phenotyping behavior and their capability to differentiate into chondroblasts, osteoblasts and adipocytes. In conclusion, this report describes a novel and easy-to-use technique of skeletal muscle-derived mesenchymal stem cell harvest, culture, characterization. This technique is transposable to a multitude of different animal species.

The revitalisation of flexor tendon allografts with bone marrow stromal cells and mechanical stimulation: An ex vivo model revitalising flexor tendon allografts

Objectives

The present study describes a novel technique for revitalising allogenic intrasynovial tendons by combining cell-based therapy and mechanical stimulation in an ex vivo canine model.

Methods

Specifically, canine flexor digitorum profundus tendons were used for this study and were divided into the following groups: (1) untreated, unprocessed normal tendon; (2) decellularised tendon; (3) bone marrow stromal cell (BMSC)-seeded tendon; and (4) BMSC-seeded and cyclically stretched tendon. Lateral slits were introduced on the tendon to facilitate cell seeding. Tendons from all four study groups were distracted by a servohydraulic testing machine. Tensile force and displacement data were continuously recorded at a sample rate of 20 Hz until 200 Newton of force was reached. Before testing, the cross-sectional dimensions of each tendon were measured with a digital caliper. Young’s modulus was calculated from the slope of the linear region of the stress-strain curve. The BMSCs were labeled for histological and cell viability evaluation on the decellularized tendon scaffold under a confocal microscope. Gene expression levels of selected extracellular matrix tendon growth factor genes were measured. Results were reported as mean ± SD and data was analyzed with one-way ANOVAs followed by Tukey’s post hoc multiple-comparison test.

Results

We observed no significant difference in cross-sectional area or in Young’s modulus among the four study groups. In addition, histological sections showed that the BMSCs were aligned well and viable on the tendon slices after two-week culture in groups three and four. Expression levels of several extracellular matrix tendon growth factors, including collagen type I, collagen type III, and matrix metalloproteinase were significantly higher in group four than in group three (p < 0.05).

Conclusion

Lateral slits introduced into de-cellularised tendon is a promising method of delivery of BMSCs without compromising cell viability and tendon mechanical properties. In addition, mechanical stimulation of a cell-seeded tendon can promote cell proliferation and enhance expression of collagen types I and III in vitro.

Cite this article: J. H. Wu, A. R. Thoreson, A. Gingery, K. N. An, S. L. Moran, P. C. Amadio, C. Zhao. The revitalisation of flexor tendon allografts with bone marrow stromal cells and mechanical stimulation: An ex vivo model revitalising flexor tendon allografts. Bone Joint Res 2017;6:179–185. DOI: 10.1302/2046-3758.63.BJR-2016-0207.R1.

Effectiveness of Biologic Factors in Shoulder Disorders

Background:

Shoulder pathology can cause significant pain, discomfort, and loss of function that all interfere with activities of daily living and may lead to poor quality of life. Primary osteoarthritis and rotator cuff diseases with its sequalae are the main culprits. Management of shoulder disorders using biological factors gained an increasing interest over the last years. This interest reveals the need of effective treatments for shoulder degenerative disorders, and highlights the importance of a comprehensive and detailed understanding of the rapidly increasing knowledge in the field.

Methods:

This study will describe most of the available biology-based strategies that have been recently developed, focusing on their effectiveness in animal and clinical studies.

Results:

Data from in vitro work will also be briefly presented; in order to further elucidate newly acquired knowledge regarding mechanisms of tissue degeneration and repair that would probably drive translational work in the next decade. The role of platelet rich-plasma, growth factors, stem cells and other alternative treatments will be described in an evidence-based approach, in an attempt to provide guidelines for their clinical application. Finally, certain challenges that biologic treatments face today will be described as an initiative for future strategies.

Conclusion:

The application of different growth factors and mesenchymal stem cells appears as promising approaches for enhancing biologic repair. However, data from clinical studies are still limited, and future studies need to improve understanding of the repair process in cellular and molecular level and evaluate the effectiveness of biologic factors in the management of shoulder disorders.

Myostatin promotes tenogenic differentiation of C2C12 myoblast cells through Smad3

Myostatin, a member of the transforming growth factor-β (TGF-β) superfamily, is expressed in developing and adult skeletal muscle and negatively regulates skeletal muscle growth. Recently, myostatin has been found to be expressed in tendons and increases tendon fibroblast proliferation and the expression of tenocyte markers. C2C12 is a mouse myoblast cell line, which has the ability to transdifferentiate into osteoblast and adipocyte lineages. We hypothesized that myostatin is capable of inducing tenogenic differentiation of C2C12 cells. We found that the expression of scleraxis, a tendon progenitor cell marker, is much higher in C2C12 than in the multipotent mouse mesenchymal fibroblast cell line C3H10T1/2. In comparison with other growth factors, myostatin significantly up-regulated the expression of the tenogenic marker in C2C12 cells under serum-free culture conditions. Immunohistochemistry showed that myostatin inhibited myotube formation and promoted the formation of spindle-shaped cells expressing tenomodulin. We examined signaling pathways essential for tenogenic differentiation to clarify the mechanism of myostatin-induced differentiation of C2C12 into tenocytes. The expression of tenomodulin was significantly suppressed by treatment with the ALK inhibitor SB341542, in contrast to p38MAPK (SB203580) and MEK1 (PD98059) inhibitors. RNAi silencing of Smad3 significantly suppressed myostatin-induced tenomodulin expression. These results indicate that myostatin has a potential role in the induction of tenogenic differentiation of C2C12 cells, which have tendon progenitor cell characteristics, through activation of Smad3-mediated signaling.

Rotator cuff repair augmentation in a rat model that combines a multilayer xenograft tendon scaffold with bone marrow stromal cells

HYPOTHESIS

A composite of multilayer tendon slices (COMTS) seeded with bone marrow stromal cells (BMSCs) may impart mechanical and biologic augmentation effects on supraspinatus tendon repair under tension, thereby improving the healing process after surgery in rats.

METHODS

Adult female Lewis rats (n = 39) underwent transection of the supraspinatus tendon and a 2-mm tendon resection at the distal end, followed by immediate repair to its bony insertion site under tension. Animals received 1 of 3 treatments at the repair site: (1) no augmentation, (2) COMTS augmentation alone, or (3) BMSC-seeded COMTS augmentation. BMSCs were labeled with a fluorescent cell marker. Animals were euthanized 6 weeks after surgery, and the extent of healing of the repaired supraspinatus tendon was evaluated with biomechanical testing and histologic analysis.

RESULTS

Histologic analysis showed gap formation between the repaired tendon and bone in all specimens, regardless of treatment. Robust fibrous tissue was observed in rats with BMSC-seeded COMTS augmentation; however, fibrous tissue was scarce within the gap in rats with no augmentation or COMTS-only augmentation. Labeled transplanted BMSCs were observed throughout the repair site. Biomechanical analysis showed that the repairs augmented with BMSC-seeded COMTS had significantly greater ultimate load to failure and stiffness compared with other treatments. However, baseline (time 0) data showed that COMTS-only augmentation did not increase mechanical strength of the repair site.

CONCLUSION

Although the COMTS scaffold did not increase the initial repair strength, the BMSC-seeded scaffold increased healing strength and stiffness 6 weeks after rotator cuff repair in a rat model.

Effect of Fibrin Formulation on Initial Strength of Tendon Repair and Migration of Bone Marrow Stromal Cells in Vitro

BACKGROUND

Cell-based tissue engineering techniques have been introduced to improve tendon repair outcomes. The purpose of this study was to determine optimal concentrations of fibrinogen and thrombin for use as a scaffold to deliver stromal cells to the tendon repair site.

METHODS

Lacerated flexor digitorum profundus tendons from forty canine forepaws underwent simulated repair with fibrin gel interposition. The tendons were divided into five groups with different ratios of fibrinogen (mg/mL) to thrombin (NIH units/mL) used to form the gels. These ratios, which ranged from those found in normal hemostasis to those used clinically as adhesives, were 5:25 (the physiological ratio, used as a control), 40:250 (a low adhesive concentration of fibrinogen and a low adhesive concentration of thrombin [low-low group]), 80:250 (high-low group), 40:500 (low-high group), and 80:500 (high-high group). The failure load and tensile stiffness at time zero, compressive stiffness of the fibrin gel, and cell viability and migration were evaluated.

RESULTS

The failure loads of the high-low and high-high groups were significantly higher than that of the control group. The tensile stiffness of the high-high group was significantly higher than that of the control group. The high-low and high-high groups had significantly higher compressive stiffness than the other groups. While there was no significant difference among the groups regarding cell viability, the cells in the control, low-low, and low-high gels were spindle-shaped whereas those in the high-low and high-high groups were rounded. Cells migrated across scratch gaps within twenty-four hours in the control, low-low, and low-high groups, but not in the high-low and high-high groups.

CONCLUSIONS

Higher concentrations of fibrinogen resulted in stronger and stiffer gels, but the strength was far less than that of a tendon suture and these gels were associated with a more rounded cell morphology and reduced cell migration. Therefore, lower concentrations of fibrinogen should be used if a fibrin gel is employed to deliver cells for tendon repair.

CLINICAL RELEVANCE

Concentrations of fibrinogen lower than those used in fibrin glue may be more appropriate if fibrin is employed to create a cell delivery matrix for tendon repair.