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Marshall BP, Ashinsky BG, Ferrer XE, Kunes JA, Innis AC, Luzzi AJ, Forrester LA, Burt KG, Lee AJ, Song L, Lisiewski LE, Soni RK, Hung CT, Levine WN, Kovacevic D, Thomopoulos S. The subacromial bursa modulates tendon healing after rotator cuff injury in rats. Sci Transl Med 2024; 16:eadd8273. [PMID: 38657023 DOI: 10.1126/scitranslmed.add8273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 04/03/2024] [Indexed: 04/26/2024]
Abstract
Rotator cuff injuries result in more than 500,000 surgeries annually in the United States, many of which fail. These surgeries typically involve repair of the injured tendon and removal of the subacromial bursa, a synovial-like tissue that sits between the rotator cuff and the acromion. The subacromial bursa has been implicated in rotator cuff pathogenesis and healing. Using proteomic profiling of bursa samples from nine patients with rotator cuff injury, we show that the bursa responds to injury in the underlying tendon. In a rat model of supraspinatus tenotomy, we evaluated the bursa's effect on the injured supraspinatus tendon, the uninjured infraspinatus tendon, and the underlying humeral head. The bursa protected the intact infraspinatus tendon adjacent to the injured supraspinatus tendon by maintaining its mechanical properties and protected the underlying humeral head by maintaining bone morphometry. The bursa promoted an inflammatory response in injured rat tendon, initiating expression of genes associated with wound healing, including Cox2 and Il6. These results were confirmed in rat bursa organ cultures. To evaluate the potential of the bursa as a therapeutic target, polymer microspheres loaded with dexamethasone were delivered to the intact bursae of rats after tenotomy. Dexamethasone released from the bursa reduced Il1b expression in injured rat supraspinatus tendon, suggesting that the bursa could be used for drug delivery to reduce inflammation in the healing tendon. Our findings indicate that the subacromial bursa contributes to healing in underlying tissues of the shoulder joint, suggesting that its removal during rotator cuff surgery should be reconsidered.
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Affiliation(s)
- Brittany P Marshall
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Beth G Ashinsky
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Xavier E Ferrer
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Jennifer A Kunes
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Astia C Innis
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Andrew J Luzzi
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Lynn Ann Forrester
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Kevin G Burt
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Andy J Lee
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Lee Song
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Lauren E Lisiewski
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Rajesh K Soni
- Proteomics and Macromolecular Crystallography Shared Resource, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY 10032, USA
| | - Clark T Hung
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - David Kovacevic
- New York Metropolitan Orthopaedics and Spine, New York, NY 10001, USA
| | - Stavros Thomopoulos
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
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Luzzi AJ, Ferrer X, Fang F, Golman M, Song L, Marshall BP, Lee AJ, Kim JJ, Hung CT, Thomopoulos S. Hedgehog Activation for Enhanced Rotator Cuff Tendon-to-Bone Healing. Am J Sports Med 2023; 51:3825-3834. [PMID: 37897335 PMCID: PMC10821775 DOI: 10.1177/03635465231203210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2023]
Abstract
BACKGROUND Rotator cuff repair is a common orthopaedic procedure, yet the rate of failure to heal after surgery is high. Repair site rupture is due to poor tendon-to-bone healing and lack of regeneration of the native fibrocartilaginous enthesis. During development, the enthesis is formed and mineralized by a pool of progenitors activated by hedgehog signaling. Furthermore, hedgehog signaling drives regenerative enthesis healing in young animals, in contrast to older animals, in which enthesis injuries heal via fibrovascular scar and without participation of hedgehog signaling. HYPOTHESIS Hedgehog activation improves tendon-to-bone healing in an animal model of rotator cuff repair. STUDY DESIGN Controlled laboratory study. METHODS A total of 78 adult Sprague-Dawley rats were used. Supraspinatus tendon injury and repair were completed bilaterally, with microsphere-encapsulated hedgehog agonist administered to right shoulders and control microspheres administered to left shoulders. Animals were sacrificed after 3, 14, 28, or 56 days. Gene expression and histological, biomechanical, and bone morphometric analyses were conducted. RESULTS At 3 days, hedgehog signaling pathway genes Gli1 (1.70; P = .029) and Smo (2.06; P = .0173), as well as Runx2 (1.69; P = .0386), a transcription factor of osteogenesis, were upregulated in treated relative to control repairs. At 14 days, transcription factors of tenogenesis, Scx (4.00; P = .041), and chondrogenesis, Sox9 (2.95; P = .010), and mineralized fibrocartilage genes Col2 (3.18; P = .031) and Colx (1.85; P = .006), were upregulated in treated relative to control repairs. Treatment promoted fibrocartilage formation at the healing interface by 28 days, with improvements in tendon-bone maturity, organization, and continuity. Treatment led to improved biomechanical properties. The material property strength (2.43 vs 1.89 N/m2; P = .046) and the structural property work to failure (29.01 vs 18.09 mJ; P = .030) were increased in treated relative to control repairs at 28 days and 56 days, respectively. Treatment had a marginal effect on bone morphometry underlying the repair. Trabecular thickness (0.08 vs 0.07 mm; P = .035) was increased at 28 days. CONCLUSION Hedgehog agonist treatment activated hedgehog signaling at the tendon-to-bone repair site and prompted increased mineralized fibrocartilage production. This extracellular matrix production and mineralization resulted in improved biomechanical properties, demonstrating the therapeutic potential of hedgehog agonism for improving tendon-to-bone healing after rotator cuff repair. CLINICAL RELEVANCE This study demonstrates the therapeutic potential of hedgehog agonist treatment for improving tendon-to-bone healing after rotator cuff injury and repair.
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Affiliation(s)
- Andrew J. Luzzi
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
| | - Xavier Ferrer
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
| | - Fei Fang
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
| | - Mikhail Golman
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Lee Song
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
| | - Brittany P. Marshall
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Andy J. Lee
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Jieon J. Kim
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
| | - Clark T. Hung
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Stavros Thomopoulos
- Department of Orthopaedic Surgery, Columbia University, New York, New York, USA
- Department of Biomedical Engineering, Columbia University, New York, New York, USA
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Marshall BP, Ferrer XE, Kunes JA, Innis AC, Luzzi AJ, Forrester LA, Burt KG, Lee AJ, Song L, Hung CT, Levine WN, Kovacevic D, Thomopoulos S. The subacromial bursa is a key regulator of the rotator cuff and a new therapeutic target for improving repair. bioRxiv 2023:2023.07.01.547347. [PMID: 37425730 PMCID: PMC10327214 DOI: 10.1101/2023.07.01.547347] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
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.
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Marshall BP, Levine WN, Thomopoulos S. The Role of the Subacromial Bursa in Rotator Cuff Healing: Friend or Foe? J Bone Joint Surg Am 2023; 105:417-425. [PMID: 36575165 PMCID: PMC10353884 DOI: 10.2106/jbjs.22.00680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Golman M, Abraham AC, Kurtaliaj I, Marshall BP, Hu YJ, Schwartz AG, Guo XE, Birman V, Thurner PJ, Genin GM, Thomopoulos S. Toughening mechanisms for the attachment of architectured materials: The mechanics of the tendon enthesis. Sci Adv 2021; 7:eabi5584. [PMID: 34826240 PMCID: PMC8626067 DOI: 10.1126/sciadv.abi5584] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 10/06/2021] [Indexed: 05/09/2023]
Abstract
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.
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Affiliation(s)
- Mikhail Golman
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Adam C. Abraham
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
| | - Iden Kurtaliaj
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Brittany P. Marshall
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Yizhong Jenny Hu
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Andrea G. Schwartz
- NSF Science and Technology Center for Engineering Mechanobiology, Washington University, St. Louis, MO 63130, USA
| | - X. Edward Guo
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
| | - Victor Birman
- Missouri University of Science and Technology, Rolla, MO 65409, USA
| | - Philipp J. Thurner
- Institute of Lightweight Design and Structural Biomechanics, Vienna University of Technology, Vienna, Austria
| | - Guy M. Genin
- NSF Science and Technology Center for Engineering Mechanobiology, Washington University, St. Louis, MO 63130, USA
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY 10027, USA
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Kim D, Lee B, Marshall BP, Jang E, Thomopoulos S, Jun YS. Pulsed Electrical Stimulation Enhances Body Fluid Transport for Collagen Biomineralization. ACS Appl Bio Mater 2019; 3:902-910. [DOI: 10.1021/acsabm.9b00979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Doyoon Kim
- Department of Energy, Environmental & Chemical Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
| | - Byeongdu Lee
- X-ray Science Division, Argonne National Laboratory, Argonne, Illinois 60439, United States
| | - Brittany P. Marshall
- Department of Orthopedic Surgery, Department of Biomedical Engineering, Columbia University, New York, New York 10032-3072, United States
| | - Eunyoung Jang
- Department of Energy, Environmental & Chemical Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Department of Biomedical Engineering, Columbia University, New York, New York 10032-3072, United States
| | - Young-Shin Jun
- Department of Energy, Environmental & Chemical Engineering, Washington University in St. Louis, St. Louis, Missouri 63130, United States
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