Hyaluronan induces scarless repair in mouse limb organ culture

COX-2 inhibitors prolong trauma-induced elevations of iris hyaluronan

PURPOSE

To investigate whether and how treatment with COX-2 inhibitors influences hyaluronan responses to a standardized trauma, argon laser induced iritis, in rabbits.

METHODS

Two different COX-2 inhibitors were used, SC-236 and rofecoxib. The drugs were administered orally, 6 mg/kg/day and 1.5 mg/kg/day respectively. Iris and aqueous humor hyaluronan concentrations were measured with a radiometric assay at different time points after laser irradiation.

RESULTS

The hyaluronan concentration in the iris increased 3-4-fold with a peak concentration of 129.1 microg/g wet weight 2 days after laser irradiation. It then decreased to normal values after 1 week. In eyes treated with either of the COX-2 inhibitors, iris hyaluronan concentrations did not decrease as rapidly and were significantly higher at day 4 and 7 when compared to drug untreated eyes.

CONCLUSION

Treatment with COX-2 inhibitors prolongs trauma induced elevation of iris content of endogenous hyaluronan. This may be, at least partly, due to an inhibition of interstitial fluid pressure regulation.

Modulation of human fibroblast gap junction intercellular communication by hyaluronan

The composition of the extracellular matrix changes during dermal repair. Initially, hyaluronan (HA) concentration is high, however, by day 3, HA is eliminated. HA optimizes collagen organization within granulation tissue. One possible mechanism of HA modulation of collagen packing is through the promotion of gap junction intercellular communication (GJIC). Gap junctions are gated channels that allow rapid intercellular communication and synchronization of coupled cell activities. The gap junction channel is composed of connexin (Cx) proteins that form a gated channel between coupled cells. HA is reported to enhance Cx43 expression in transformed fibroblasts. GJIC was quantified by the scrape loading technique and reported as a coupling index. The coupling index for human dermal fibroblasts was 4.6 +/- 0.2, while the coupling index for fibroblasts treated with HA more than doubled to 10.6 +/- 0.7. By Western blot analysis no differences were appreciated in the protein levels of Cx43 or beta-catenin, a protein involved in the translocation of Cx to the cell surface. By immuno-histology Cx43 and beta-catenin were evenly distributed throughout the cell in controls, but in cells treated with HA these proteins were co-localized to the cell surface. Coupled fibroblasts are reported to enhance the organization of collagen fibrils. It is proposed that HA increases the accumulation of Cx43 and beta-catenin on the cell surface, leading to greater GJIC and enhanced collagen organization.

The Clinical Effects of Hyaluronic Acid Ester Nasal Dressing (Merogel) on Intranasal Wound Healing after Functional Endoscopic Sinus Surgery

OBJECTIVES: We sought to determine the efficacy of MeroGel, an absorbable hyaluronic acid nasal dressing (HA) in reducing synechia after functional endoscopic sinus surgery (FESS) compared with Merocel, a nonabsorbable packing (NAP) requiring removal.

METHODS: We conducted a blinded, randomized, controlled trial of 37 patients requiring bilateral FESS for chronic sinusitis. Patients were randomized to placement of HA within the right or left middle meatus and NAP on the other side. Patients were evaluated at 2, 4, 6, and 8 weeks postoperatively.

RESULTS: Blinded evaluation revealed 5 patients (14%) with synechia at last follow-up: 3 sides (8%) with HA and 3 (8%) with NAP. Thirteen patients (35%) had synechia at any visit, 10 sides (27%) with HA and 9 (24%) with NAP. Seven patients (19%) required lysis of synechia, 5 sides (14%) with HA and 3 (8%) with NAP.

CONCLUSION: We found no statistically significant difference between HA and NAP dressings.

Outcomes of hyaluronan therapy in diabetic foot wounds

The purpose of this study was to evaluate outcomes of persons with neuropathic diabetic foot wounds treated with a hyaluronan-containing dressing. Data were abstracted for 36 patients with diabetes, 72.2% male, aged 60.0+/-10.7 years and a mean glycated hemoglobin (HbA(1c)) of 9.5+/-2.5% presenting for care at two large, multidisciplinary wound care centers. All patients received surgical debridement for their diabetic foot wounds and were placed on therapy consisting of hyaluronan dressing (Hyalofill, Convatec, USA) with dressing changes taking place every other day. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks. Hyalofill therapy was used until the wound bed achieved 100% granulation tissue. Therapy was then followed by a moisture-retentive dressing until complete epithelialization. In total, 75.0% of wounds measuring a mean 2.2+/-2.2 cm(2) healed in the 20-week evaluation period. Of those that healed in this period, healing took place in a mean 10.0+/-4.8 weeks. The average duration of Hyalofill therapy in all patients was 8.6+/-4.2 weeks. Deeper (UT Grade 2A) wounds were over 15 times less likely to heal than superficial (1A) wounds (94.7 vs. 52.9%, Odds Ratio=15.9, 95% Confidence Interval=1.7-142.8, P=0.006). We conclude that a regimen consisting of moist wound healing using hyaluronan-containing dressings may be a useful adjunct to appropriate diabetic foot ulcer care. We await the completion of a multicenter randomized controlled trial in this area to either support or refute this initial assessment.

Hyaluronan enhances contraction of collagen by smooth muscle cells and adventitial fibroblasts: Role of CD44 and implications for constrictive remodeling

Remodeling contributes to restenosis when cells shrink the artery wall at sites of injury. This may be analogous to wound healing, where tissue remodeling achieves wound contraction. Hyaluronan (HA) is prominent in wound matrix and inhibits fetal scarring. HA is also produced in the artery wall after angioplasty, where it may inhibit constrictive remodeling. This hypothesis was tested in vitro using a model of matrix contraction. Primate aortic smooth muscle cells and adventitial fibroblasts were seeded into collagen I gels containing increasing amounts of HA (0% to 50%, wt/wt). Both cell types reduced the diameter of collagen alone approximately 65% at 18 hours. HA significantly increased gel contraction (diameter in mm: 0% HA, 7. 7+/-0.9; 2%, 7.1+/-0.7; 10%, 6.7+/-0.5; 50%, 5.6+/-0.9; P<0.05 for >/=10%), cell spreading and telopodia, and pericellular accumulation of collagen fibrils. These effects were mediated in part by cellular HA binding, because an antibody against CD44 receptors blocked pericellular collagen accumulation and enhanced gel contraction without altering cell shape. The role of CD44 was specific, because inhibiting receptor for hyaluronic acid-mediated motility (RHAMM) had no effect. Blocking ss(1)-integrins completely inhibited contraction of collagen, but gels containing HA required CD44 and ss(1)-integrin blockade for complete inhibition. Enhanced collagen reorganization and contraction were not attributable to increased collagenase activity, because the metalloproteinase inhibitor batimastat had no effect. In summary, HA enhanced collagen reorganization by the cell types most likely to mediate constrictive remodeling after angioplasty. These effects were CD44-dependent, thus providing a potential target for therapies to prevent constrictive remodeling and restenosis.

Optimisation of the biology of soft tissue repair

As identified in this review, over the past twenty years there have been a number of very exciting new developments in the quest to optimise soft tissue repair. Comparing fetal soft tissue injuries, which heal by regeneration, to the adult processes of healing by inflammation-induced scar formation has led to a number of insights into how the latter may be improved. Seeding wounds with embryonic stem cells, bridging gaps with cell-derived "engineered tissues", addition of exogenous hyaluronic acid and modification of wounds to either enhance the growth factors which have been implicated in regeneration (e.g. TGF-B3) or block those implicated in scar formation (eg. TGF-B1) have all shown promise. Our group has quantified numerous cellular, molecular, biomechanical and matrix abnormalities of scar in a rabbit model of ligament healing. Based on these studies which we review here, three matrix deficiencies have been identified which appear to have specific implications to scar weakness: organisational "flaws", abnormal hydroxypyridinoline collagen cross-link densities and abnormally small, slow-maturing collagen fibrils. In tests aimed at finding therapeutic solutions in this model, the addition of a 7ug bolus of TGF-B1 at day 21 or 2.5ng/day of TGF-B1 being pumped into a wound x 21 days increased the size of ligament scars but did not improve their material strength. It also did not alter any of the above-noted matrix deficiencies. A liposome-mediated anti-sense gene therapy approach aimed at decreasing the expression of the proteoglycan decorin in 21-day scars, however, has significantly increased the size of scar collagen fibrils as well as improved these scars mechanically. Based on these positive results from a single dose of only one targeted molecule, we believe that this gene therapy approach has great potential for further scar improvement. If combined with some of the other biological strategies reviewed above, a repair which is closer to true regenerative healing of ligaments, and all soft tissues, may eventually be achieved.