Tissue-engineering strategies for the tendon/ligament-to-bone insertion

Three-Dimensional Bioprinting Strategies for Tissue Engineering

Over the past decades, many approaches have been developed to fabricate biomimetic extracellular matrices of desired properties for engineering functional tissues. However, the inability of these techniques to precisely control the spatial architecture has posed a significant challenge in producing complex tissues. 3D bioprinting technology has emerged as a potential solution by bringing unprecedented freedom and versatility in depositing biological materials and cells in a well-controlled manner in the 3D volumes, therefore achieving precision engineering of functional tissues. In this article, we review the application of 3D bioprinting to tissue engineering. We first discuss the general strategies for printing functional tissue constructs. We next describe different types of bioprinting with a focus on nozzle-based techniques and their respective advantages. Finally, we summarize the limitations of current technologies and propose challenges for future development of bioprinting.

Growth factor delivery strategies for rotator cuff repair and regeneration

The high incidence of degenerative tears and prevalence of retears (20-95%) after surgical repair makes rotator cuff injuries a significant health problem. This high retear rate is attributed to the failure of the repaired tissue to regenerate the native tendon-to-bone insertion (enthesis). Biological augmentation of surgical repair such as autografts, allografts, and xenografts are confounded by donor site morbidity, immunogenicity, and disease transmission, respectively. In contrast, these risks may be alleviated via growth factor therapy, which can actively influence the healing environment to promote functional repair. Several challenges have to be overcome before growth factor delivery can translate into clinical practice such as the selection of optimal growth factor(s) or combination, identification of the most efficient stage and duration of delivery, and the design considerations for the delivery device. Emerging insight into the injury-repair microenvironment and our understanding of growth factor mechanisms in healing are informing the design of advanced delivery scaffolds to effectively treat rotator cuff tears. Here, we review potential growth factor candidates, design parameters and material selection for growth factor delivery, innovative and dynamic delivery scaffolds, and novel therapeutic targets from tendon and developmental biology for the structural and functional healing of rotator cuff repair.

Functional and Biomimetic Materials for Engineering of the Three-Dimensional Cell Microenvironment

The cell microenvironment has emerged as a key determinant of cell behavior and function in development, physiology, and pathophysiology. The extracellular matrix (ECM) within the cell microenvironment serves not only as a structural foundation for cells but also as a source of three-dimensional (3D) biochemical and biophysical cues that trigger and regulate cell behaviors. Increasing evidence suggests that the 3D character of the microenvironment is required for development of many critical cell responses observed in vivo, fueling a surge in the development of functional and biomimetic materials for engineering the 3D cell microenvironment. Progress in the design of such materials has improved control of cell behaviors in 3D and advanced the fields of tissue regeneration, in vitro tissue models, large-scale cell differentiation, immunotherapy, and gene therapy. However, the field is still in its infancy, and discoveries about the nature of cell-microenvironment interactions continue to overturn much early progress in the field. Key challenges continue to be dissecting the roles of chemistry, structure, mechanics, and electrophysiology in the cell microenvironment, and understanding and harnessing the roles of periodicity and drift in these factors. This review encapsulates where recent advances appear to leave the ever-shifting state of the art, and it highlights areas in which substantial potential and uncertainty remain.

Micro-mechanical properties of the tendon-to-bone attachment

The tendon-to-bone attachment (enthesis) is a complex hierarchical tissue that connects stiff bone to compliant tendon. The attachment site at the micrometer scale exhibits gradients in mineral content and collagen orientation, which likely act to minimize stress concentrations. The physiological micromechanics of the attachment thus define resultant performance, but difficulties in sample preparation and mechanical testing at this scale have restricted understanding of structure-mechanical function. Here, microscale beams from entheses of wild type mice and mice with mineral defects were prepared using cryo-focused ion beam milling and pulled to failure using a modified atomic force microscopy system. Micromechanical behavior of tendon-to-bone structures, including elastic modulus, strength, resilience, and toughness, were obtained. Results demonstrated considerably higher mechanical performance at the micrometer length scale compared to the millimeter tissue length scale, describing enthesis material properties without the influence of higher order structural effects such as defects. Micromechanical investigation revealed a decrease in strength in entheses with mineral defects. To further examine structure-mechanical function relationships, local deformation behavior along the tendon-to-bone attachment was determined using local image correlation. A high compliance zone near the mineralized gradient of the attachment was clearly identified and highlighted the lack of correlation between mineral distribution and strain on the low-mineral end of the attachment. This compliant region is proposed to act as an energy absorbing component, limiting catastrophic failure within the tendon-to-bone attachment through higher local deformation. This understanding of tendon-to-bone micromechanics demonstrates the critical role of micrometer scale features in the mechanics of the tissue.

STATEMENT OF SIGNIFICANCE

The tendon-to-bone attachment (enthesis) is a complex hierarchical tissue with features at a numerous scales that dissipate stress concentrations between compliant tendon and stiff bone. At the micrometer scale, the enthesis exhibits gradients in collagen and mineral composition and organization. However, the physiological mechanics of the enthesis at this scale remained unknown due to difficulty in preparing and testing micrometer scale samples. This study is the first to measure the tensile mechanical properties of the enthesis at the micrometer scale. Results demonstrated considerably enhanced mechanical performance at the micrometer length scale compared to the millimeter tissue length scale and identified a high-compliance zone near the mineralized gradient of the attachment. This understanding of tendon-to-bone micromechanics demonstrates the critical role of micrometer scale features in the mechanics of the tissue.

Tissue-Engineered Tendon for Enthesis Regeneration in a Rat Rotator Cuff Model

Healing of rotator cuff (RC) injuries with current suture or augmented scaffold techniques fails to regenerate the enthesis and instead forms a weaker fibrovascular scar that is prone to subsequent failure. Regeneration of the enthesis is the key to improving clinical outcomes for RC injuries. We hypothesized that the utilization of our tissue-engineered tendon to repair either an acute or a chronic full-thickness supraspinatus tear would regenerate a functional enthesis and return the biomechanics of the tendon back to that found in native tissue. Engineered tendons were fabricated from bone marrow-derived mesenchymal stem cells utilizing our well-described fabrication technology. Forty-three rats underwent unilateral detachment of the supraspinatus tendon followed by acute (immediate) or chronic (4 weeks retracted) repair by using either our engineered tendon or a trans-osseous suture technique. Animals were sacrificed at 8 weeks. Biomechanical and histological analyses of the regenerated enthesis and tendon were performed. Statistical analysis was performed by using a one-way analysis of variance with significance set at p < 0.05. Acute repairs using engineered tendon had improved enthesis structure and lower biomechanical failures compared with suture repairs. Chronic repairs with engineered tendon had a more native-like enthesis with increased fibrocartilage formation, reduced scar formation, and lower biomechanical failure compared with suture repair. Thus, the utilization of our tissue-engineered tendon showed improve enthesis regeneration and improved function in chronic RC repairs compared with suture repair. Clinical Significance: Our engineered tendon construct shows promise as a clinically relevant method for repair of RC injuries.

bFGF- and CaPP-Loaded Fibrin Clots Enhance the Bioactivity of the Tendon-Bone Interface to Augment Healing

BACKGROUND

Tendon-to-bone healing is a complex and slow process, and the rate of poor healing remains high. In recent years, several new strategies have been developed that enhance tendon-to-bone healing by increasing the bioactivity. Fibrin clots have been widely used to improve tissue healing and tissue engineering,

HYPOTHESIS

Modified fibrin clots can improve the bioactivity of the tendon-bone interface and histological appearance.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 27 male New Zealand White rabbits were used. Of these, 3 were used for cell isolation, and the remaining 24 rabbits were divided into 2 groups (12 per group) for an in vivo partial patellectomy study. The setting time, degradation time, and basic fibroblast growth factor (bFGF) and ceramide-activated protein phosphatase (CaPP) release kinetics of bFGF- and CaPP-loaded fibrin clots were modified appropriately for early tendon-to-bone healing. In an in vitro experiment, the bFGF- and CaPP-loaded fibrin clots were assessed for cell migration and proliferation by microscopy, MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay, and DAPI (4',6-diamidino-2-phenylindole) assay. Quantitative real-time reverse transcription polymerase chain reaction and a Western blot assay were performed to test for an induction effect of the bFGF- and CaPP-loaded fibrin clots. Finally, for the in vivo experiment, the rabbits were divided into 2 treatment groups: one with bFGF- and CaPP-loaded fibrin clots and one without bFGF- and CaPP-loaded fibrin clots after partial patellectomy in patella-patellar tendon sutured sites. A histological evaluation was performed at 2, 4, and 6 weeks after surgery.

RESULTS

The sitting time and degradation time of the bFGF- and CaPP-loaded fibrin clots were set at 15 seconds and more than 2 weeks, respectively, and the porosity was minimized to achieve the highest levels of cell migration and growth. In the bFGF-CaPP group of the in vitro experiment, cell proliferation increased to a greater extent relative to the control group (P < .05); the mRNA expression of osteopontin, alkaline phosphatase, runt-related transcription factor 2, vascular endothelial growth factor, and collagen type I was upregulated (P < .05); and the relative protein expression of these factors was enhanced (P < .05). In vivo, hematoxylin and eosin staining showed that the tendon-to-bone connections were more mature and more arranged when treated with bFGF- and CaPP-loaded fibrin clots than when untreated, and the histological scores were higher.

CONCLUSION

bFGF- and CaPP-loaded fibrin clots enhanced cell migration and proliferation and the expression of related genes and proteins, which increased the bioactivity of the tendon-bone interface and resulted in the histological improvement of tendon-to-bone healing.

CLINICAL RELEVANCE

As fibrin clots have already been used in clinical practice, bFGF- and CaPP-loaded fibrin clots can be further used to augment healing in the early stages of tendon-to-bone healing.

Tissue Engineering in Orthopaedics

➤It is important to carefully select the most appropriate combination of scaffold, signals, and cell types when designing tissue engineering approaches for an orthopaedic pathology.➤Although clinical studies in which the tissue engineering paradigm has been applied in the treatment of orthopaedic diseases are limited in number, examining them can yield important lessons.➤While there is a rapid rate of new discoveries in the basic sciences, substantial regulatory, economic, and clinical issues must be overcome with more consistency to translate a greater number of technologies from the laboratory to the operating room.

AAOS Research Symposium Updates and Consensus: Biologic Treatment of Orthopaedic Injuries

Strategies that seek to enhance musculoskeletal tissue regeneration and repair by modulating the biologic microenvironment at the site of injury have considerable therapeutic potential. Current and emerging biologic approaches include the use of growth factors, platelet-rich plasma, stem cell therapy, and scaffolds. The American Academy of Orthopaedic Surgeons hosted a research symposium in November 2015 to review the current state-of-the-art biologic treatments of articular cartilage, muscle, tendon, and bone injuries and identify knowledge gaps related to these emerging treatments. This review outlines the findings of the symposium and summarizes the consensus reached on how best to advance research on biologic treatment of orthopaedic injuries.

Current Status of Tissue-Engineered Scaffolds for Rotator Cuff Repair

Rotator cuff tears continue to be at significant risk for re-tear or for failure to heal after surgical repair despite the use of a variety of surgical techniques and augmentation devices. Therefore, there is a need for functionalized scaffold strategies to provide sustained mechanical augmentation during the critical first 12-weeks following repair, and to enhance the healing potential of the repaired tendon and tendon-bone interface. Tissue engineered approaches that combine the use of scaffolds, cells, and bioactive molecules towards promising new solutions for rotator cuff repair are reviewed. The ideal scaffold should have adequate initial mechanical properties, be slowly degrading or non-degradable, have non-toxic degradation products, enhance cell growth, infiltration and differentiation, promote regeneration of the tendon-bone interface, be biocompatible and have excellent suture retention and handling properties. Scaffolds that closely match the inhomogeneity and non-linearity of the native rotator cuff may significantly advance the field. While substantial pre-clinical work remains to be done, continued progress in overcoming current tissue engineering challenges should allow for successful clinical translation.

The concentration of stress at the rotator cuff tendon-to-bone attachment site is conserved across species

The tendon-to-bone attachment site integrates two distinct tissues via a gradual transition in composition, mechanical properties, and structure. Outcomes of surgical repair are poor, in part because surgical repair does not recreate the natural attachment, and in part because the mechanical features that are most critical to mechanical and physiological functions have not been identified. We employed allometric analysis to resolve a paradox about how the architecture of the rotator cuff contributes to load transfer: whereas published data suggest that the mean muscle stresses expected at the tendon-to-bone attachment are conserved across species, data also show that the relative dimensions of key anatomical features vary dramatically, suggesting that the amplification of stresses at the interface between tendon and bone should also vary widely. However, a mechanical model that enabled a sensitivity analysis revealed that the degree of stress concentration was in fact highly conserved across species: the factors that most affected stress amplification were most highly conserved across species, while those that had a lower effect showed broad variation across a range of relative insensitivity. Results highlight how micromechanical factors can influence structure-function relationships and cross-species scaling over several orders of magnitude in animal size, and provide guidance on physiological features to emphasize in surgical and tissue engineered repair of the rotator cuff.

Tunability of collagen matrix mechanical properties via multiple modes of mineralization

Functionally graded, mineralized collagen tissues exist at soft-to-hard material attachments throughout the body. However, the details of how collagen and hydroxyapatite mineral (HA) interact are not fully understood, hampering efforts to develop tissue-engineered constructs that can assist with repair of injuries at the attachments of soft tissues to bone. In this study, spatial control of mineralization was achieved in collagen matrices using simulated body fluids (SBFs). Based upon previous observations of poor bonding between reconstituted collagen and HA deposited using SBF, we hypothesized that mineralizing collagen in the presence of fetuin (which inhibits surface mineralization) would lead to more mineral deposition within the scaffold and therefore a greater increase in stiffness and toughness compared with collagen mineralized without fetuin. We tested this hypothesis through integrated synthesis, mechanical testing and modelling of graded, mineralized reconstituted collagen constructs. Results supported the hypothesis, and further suggested that mineralization on the interior of reconstituted collagen constructs, as promoted by fetuin, led to superior bonding between HA and collagen. The results provide us guidance for the development of mineralized collagen scaffolds, with implications for bone and tendon-to-bone tissue engineering.

Stimulation with bone morphogenetic protein-2 (BMP-2) enhances bone-tendon integration in vitro

PURPOSE

Preclinical studies have reported that bone morphogenetic protein (BMP)-2 promotes bone-tendon healing following anterior cruciate ligament reconstruction. We examined the region-specific effects of BMP-2 on osteoblast and fibroblast differentiation in a highly standardized murine in vitro co-culture model of bone-tendon integration.

MATERIALS AND METHODS

We used quantitative PCR to measure the dose- and time-dependent influence of BMP-2 on the expression of alkaline phosphatase, osteocalcin, collagen type 1 (alpha 1 chain), runt-related transcription factor 2, osteopontin, collagen type 1 (alpha 2 chain), collagen type 5 (alpha 1 chain), decorin, fibromodulin, mohawk homeobox, bone morphogenetic protein receptor, type 1A, bone morphogenetic protein receptor, type 2, and Noggin in the osteoblast, interface, and fibroblast regions of a co-culture model of the murine preosteoblast cell line MC3T3-E1 and the fibroblast cell line 3T6.

RESULTS

Stimulation with BMP-2 resulted in a significant upregulation of alkaline phosphatase (p < 0.001), osteocalcin (p < 0.001), collagens (p < 0.001), runt-related transcription factor 2 (p < 0.05), and osteopontin (p < 0.001) expression in the osteoblast region. In the interface region, BMP-2 exposure led to dose- and time-dependent upregulation of alkaline phosphatase (p < 0.001), osteocalcin (p < 0.001), osteopontin (p < 0.001), runt-related transcription factor 2 (p < 0.001), and markers of extracellular matrix production (p < 0.001). Both BMP receptors showed a significant BMP-2-dependent upregulation at the interface region, and Noggin was downregulated at the osteoblast and interface region following BMP-2 exposure.

CONCLUSIONS

Exposure to BMP-2 upregulated the expression of genes associated with bone-tendon integration in vitro, suggesting the stimulation of transdifferentiation processes at the interface and fibroblast regions as well as the induction of positive feedback mechanisms. Further studies will be needed to establish BMP-2 dose and treatment algorithms following tendon reinsertion and reconstruction.

Strategies to engineer tendon/ligament-to-bone interface: Biomaterials, cells and growth factors

Integration between tendon/ligament and bone occurs through a specialized tissue interface called enthesis. The complex and heterogeneous structure of the enthesis is essential to ensure smooth mechanical stress transfer between bone and soft tissues. Following injury, the interface is not regenerated, resulting in high rupture recurrence rates. Tissue engineering is a promising strategy for the regeneration of a functional enthesis. However, the complex structural and cellular composition of the native interface makes enthesis tissue engineering particularly challenging. Thus, it is likely that a combination of biomaterials and cells stimulated with appropriate biochemical and mechanical cues will be needed. The objective of this review is to describe the current state-of-the-art, challenges and future directions in the field of enthesis tissue engineering focusing on four key parameters: (1) scaffold and biomaterials, (2) cells, (3) growth factors and (4) mechanical stimuli.

Diffusion chamber system for testing of collagen-based cell migration barriers for separation of ligament enthesis zones in tissue-engineered ACL constructs

A temporary barrier separating scaffold zones seeded with different cell types prevents faster growing cells from overgrowing co-cultured cells within the same construct. This barrier should allow sufficient nutrient diffusion through the scaffold. The aim of this study was to test the effect of two variants of collagen-based barriers on macromolecule diffusion, viability, and the spreading efficiency of primary ligament cells on embroidered scaffolds. Two collagen barriers, a thread consisting of a twisted film tape and a sponge, were integrated into embroidered poly(lactic-co-caprolactone) and polypropylene scaffolds, which had the dimension of lapine anterior cruciate ligaments (ACL). A diffusion chamber system was designed and established to monitor nutrient diffusion using fluorescein isothiocyanate-labeled dextran of different molecular weights (20, 40, 150, 500 kDa). Vitality of primary lapine ACL cells was tested at days 7 and 14 after seeding using fluorescein diacetate and ethidium bromide staining. Cell spreading on the scaffold surface was measured using histomorphometry. Nuclei staining of the cross-sectioned scaffolds revealed the penetration of ligament cells through both barrier types. The diffusion chamber was suitable to characterize the diffusivity of dextran molecules through embroidered scaffolds with or without integrated collagen barriers. The diffusion coefficients were generally significantly lower in scaffolds with barriers compared to those without barriers. No significant differences between diffusion coefficients of both barrier types were detected. Both barriers were cyto-compatible and prevented most of the ACL cells from crossing the barrier, whereby the collagen thread was easier to handle and allowed a higher rate of cell spreading.

Accelerating the Translation of Nanomaterials in Biomedicine

Due to their size and tailorable physicochemical properties, nanomaterials are an emerging class of structures utilized in biomedical applications. There are now many prominent examples of nanomaterials being used to improve human health, in areas ranging from imaging and diagnostics to therapeutics and regenerative medicine. An overview of these examples reveals several common areas of synergy and future challenges. This Nano Focus discusses the current status and future potential of promising nanomaterials and their translation from the laboratory to the clinic, by highlighting a handful of successful examples.

Generation of electrospun nanofibers with controllable degrees of crimping through a simple, plasticizer-based treatment

Electrospun nanofibers with controllable degrees of crimping are fabricated by simply exposing the samples to a plasticizer at preset shrinkage ratios. Compared with their straight counterparts, the crimped nanofibers are able to mechanically mimic native tendon tissue and better protect tendon fibroblasts under uniaxial strains.

Effect of platelet-rich plasma and bioactive glass powder for the improvement of rotator cuff tendon-to-bone healing in a rabbit model

To test the hypothesis that a platelet-rich plasma (PRP) plus bioactive glass (BG) mixture could shorten the tendon-bone healing process in rotator cuff tendon repair, thirty mature male New Zealand white rabbits were randomly divided into three groups, Control, PRP, and PRP + BG. All groups underwent a surgical procedure to establish a rotator cuff tendon healing model. Mechanical examinations and histological assays were taken to verify the adhesion of the tendon-bone. Real-time PCR was adopted to analyze Bone Morphogenetic Protein-2 (BMP-2). The maximum load-to-failure value in mechanical examinations was significantly higher in the PRP + BG group than that in the control group after six weeks (Control 38.73 ± 8.58, PRP 54.49 ± 8.72, PRP + BG 79.15 ± 7.62, p < 0.001), but it was not significantly different at 12 weeks (PRP 74.27 ± 7.74, PRP + BG 82.57 ± 6.63, p = 0.145). In histological assays, H&E (hematoxylin-eosin) staining showed that the interface between the tendon-bone integration was much sturdier in the PRP + BG group compared to the other two groups at each time point, and more ordered arranged tendon fibers can be seen at 12 weeks. At six weeks, the mRNA expression levels of BMP-2 in the PRP + BG group were higher than those in the other groups (PRP + BG 0.65 ± 0.11, PRP 2.284 ± 0.07, Control 0.12 ± 0.05, p < 0.05). However, there was no significant difference in the mRNA expression levels of BMP-2 among the three groups at 12 weeks (p = 0.922, 0.067, 0.056). BMP-2 levels in PRP and PRP+BG groups were significantly lower at 12 weeks compared to six weeks (p = 0.006, <0.001).We found that the PRP + BG mixture could enhance tendon-bone healing in rotator cuff tendon repair.

Stress amplification during development of the tendon-to-bone attachment

Mechanical stress is necessary to sustain the mineral content of bone in adults. However, in a developing neonatal mouse, the mineralization of soft tissues progresses despite greatly reduced average mechanical stresses. In adults, these reduced loads would likely lead to bone loss. Although biochemical factors may partly explain these different responses, it is unclear how mineralization is initiated in low load environments. We present here the effect of morphometric data and initial modeling supporting a hypothesis that mechanical factors across several length scales amplify stresses, and we suggest that these stresses are of a level adequate to contribute to mechanical signaling for initiation of mineralization at the developing tendon-to-bone enthesis. A mineral gradient is evident across the insertion from the onset of mineralization. This grading maintains a constant size from early postnatal time points to adulthood. At the tissue level, this grading contributes to reduced stresses in an adult animal and to a minor elevation of stresses in a neonatal animal. At the cellular level, stress concentrations around mineralizing chondrocytes are enhanced in neonatal animals compared with adult animals. The enhancement of stresses around cells at early time points may serve to amplify and transduce low loads in order to initiate mineralization.

In vitro characterization of self-assembled anterior cruciate ligament cell spheroids for ligament tissue engineering

Tissue engineering of an anterior cruciate ligament (ACL) implant with functional enthesis requires site-directed seeding of different cell types on the same scaffold. Therefore, we studied the suitability of self-assembled three-dimensional spheroids generated by lapine ACL ligament fibroblasts for directed scaffold colonization. The spheroids were characterized in vitro during 14 days in static and 7 days in dynamic culture. Size maintenance of self-assembled spheroids, the vitality, the morphology and the expression pattern of the cells were monitored. Additionally, we analyzed the total sulfated glycosaminoglycan, collagen contents and the expression of the ligament components type I collagen, decorin and tenascin C on protein and for COL1A1, DCN and TNMD on gene level in the spheroids. Subsequently, the cell colonization of polylactide-co-caprolactone [P(LA-CL)] and polydioxanone (PDS) polymer scaffolds was assessed in response to a directed, spheroid-based seeding technique. ACL cells were able to self-assemble spheroids and survive over 14 days. The spheroids decreased in size but not in cellularity depending on the culture time and maintained or even increased their differentiation state. The area of P[LA-CL] scaffolds, colonized after 14 days by the cells of one spheroid, was in average 4.57 ± 2.3 mm(2). Scaffolds consisting of the polymer P[LA-CL] were more suitable for colonization by spheroids than PDS embroideries. We conclude that ACL cell spheroids are suitable as site-directed seeding strategy for scaffolds in ACL tissue engineering approaches and recommend the use of freshly assembled spheroids for scaffold colonization, due to their balanced proliferation and differentiation.

Rational design of nanofiber scaffolds for orthopedic tissue repair and regeneration

This article reviews recent significant advances in the design of nanofiber scaffolds for orthopedic tissue repair and regeneration. It begins with a brief introduction on the limitations of current approaches for orthopedic tissue repair and regeneration. It then illustrates that rationally designed scaffolds made up of electrospun nanofibers could be a promising solution to overcome the problems that current approaches encounter. The article also discusses the intriguing properties of electrospun nanofibers, including control of composition, structures, orders, alignments and mechanical properties, use as carriers for topical drug and/or gene sustained delivery, and serving as substrates for the regulation of cell behaviors, which could benefit musculoskeletal tissue repair and regeneration. It further highlights a few of the many recent applications of electrospun nanofiber scaffolds in repairing and regenerating various orthopedic tissues. Finally, the article concludes with perspectives on the challenges and future directions for better design, fabrication and utilization of nanofiber scaffolds for orthopedic tissue engineering.

Nanofiber scaffolds with gradients in mineral content for spatial control of osteogenesis

Reattachment of tendon to bone has been a challenge in orthopedic surgery. The disparate mechanical properties of the two tissues make it difficult to achieve direct surgical repair of the tendon-to-bone insertion. Healing after surgical repair typically does not regenerate the natural attachment, a complex tissue that connects tendon and bone across a gradient in both mineral content and cell phenotypes. To facilitate the regeneration of the attachment, our groups have developed a nanofiber-based scaffold with a graded mineral coating to mimic the mineral composition of the native tendon-to-bone insertion. In the present work, we evaluated the ability of this scaffold to induce graded osteogenesis of adipose-derived mesenchymal stem cells (ASCs). Results from 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and proliferating cell nuclear antigen staining indicated that cell proliferation was negatively correlated with the mineral content. In contrast, alkaline phosphatase staining, an indicator of osteogenesis, was positively correlated with the mineral content. Likewise, runt-related transcription factor 2 (an early marker of osteoblast differentiation) and osteocalcin (a late marker of osteoblast differentiation) immunostaining were both positively correlated with the mineral content. These results indicate that a gradient in mineral content on the surface of a nanofiber scaffold is capable of inducing graded differentiation of ASCs into osteoblasts for enthesis repair.

Scaffold-mediated lentiviral transduction for functional tissue engineering of cartilage

The ability to develop tissue constructs with matrix composition and biomechanical properties that promote rapid tissue repair or regeneration remains an enduring challenge in musculoskeletal engineering. Current approaches require extensive cell manipulation ex vivo, using exogenous growth factors to drive tissue-specific differentiation, matrix accumulation, and mechanical properties, thus limiting their potential clinical utility. The ability to induce and maintain differentiation of stem cells in situ could bypass these steps and enhance the success of engineering approaches for tissue regeneration. The goal of this study was to generate a self-contained bioactive scaffold capable of mediating stem cell differentiation and formation of a cartilaginous extracellular matrix (ECM) using a lentivirus-based method. We first showed that poly-L-lysine could immobilize lentivirus to poly(ε-caprolactone) films and facilitate human mesenchymal stem cell (hMSC) transduction. We then demonstrated that scaffold-mediated gene delivery of transforming growth factor β3 (TGF-β3), using a 3D woven poly(ε-caprolactone) scaffold, induced robust cartilaginous ECM formation by hMSCs. Chondrogenesis induced by scaffold-mediated gene delivery was as effective as traditional differentiation protocols involving medium supplementation with TGF-β3, as assessed by gene expression, biochemical, and biomechanical analyses. Using lentiviral vectors immobilized on a biomechanically functional scaffold, we have developed a system to achieve sustained transgene expression and ECM formation by hMSCs. This method opens new avenues in the development of bioactive implants that circumvent the need for ex vivo tissue generation by enabling the long-term goal of in situ tissue engineering.

Reconstruction of the tendon-bone insertion with decellularized tendon-bone composite grafts: comparison with conventional repair

PURPOSE

Injuries involving the tendon-bone interface (TBI) are difficult to address. Standard techniques typically lead to diminished strength of the healed insertion site. We hypothesized that these injuries would benefit from being reconstructed with decellularized composite grafts replacing both tendon and bone. To test this hypothesis, decellularized grafts were compared with conventional pullout repairs in an in vivo animal model.

METHODS

We harvested 48 Achilles TBI grafts from rats and decellularized them. Tendon-bone interface graft reconstruction and pullout repairs were compared using a pair-matched design. Biomechanical properties were evaluated at 2, 4, 8, and 12 weeks. We evaluated histological analysis of insertion morphology and collagen type I/III content.

RESULTS

There was a significant increase in ultimate failure load (35 ± 11 vs 24 ± 7 N) and ultimate tensile stress (1.5 ± 0.3 vs 1.0 ± 0.4 N/mm(2)) of the TBI grafts compared with pullout repairs at 2 weeks. These differences remained at 4 weeks. At 12 weeks, both TBI grafts and pullout repairs were as strong as native tissue and not significantly different from each other. Histology showed a more organized extracellular matrix in the TBI graft group at the early time points. Repopulation of the decellularized grafts increased over time. At 12 weeks, the insertion points of both groups were richly populated with cells that possessed morphologies similar to those found in native TBI.

CONCLUSIONS

This study showed that decellularized TBI grafts were stronger compared with conventional pullout repairs at 2 and 4 weeks but were comparable at 12 weeks. A more organized extracellular matrix and different collagen composition in the early time points may explain the observed differences in strength.

CLINICAL RELEVANCE

In the future, decellularized TBI grafts may be used to reconstruct tendon-bone insertion tears in multiple areas including the flexor tendon system.

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

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

Modelling the mechanics of partially mineralized collagen fibrils, fibres and tissue

Progressive stiffening of collagen tissue by bioapatite mineral is important physiologically, but the details of this stiffening are uncertain. Unresolved questions about the details of the accommodation of bioapatite within and upon collagen's hierarchical structure have posed a central hurdle, but recent microscopy data resolve several major questions. These data suggest how collagen accommodates bioapatite at the lowest relevant hierarchical level (collagen fibrils), and suggest several possibilities for the progressive accommodation of bioapatite at higher hierarchical length scales (fibres and tissue). We developed approximations for the stiffening of collagen across spatial hierarchies based upon these data, and connected models across hierarchies levels to estimate mineralization-dependent tissue-level mechanics. In the five possible sequences of mineralization studied, percolation of the bioapatite phase proved to be an important determinant of the degree of stiffening by bioapatite. The models were applied to study one important instance of partially mineralized tissue, which occurs at the attachment of tendon to bone. All sequences of mineralization considered reproduced experimental observations of a region of tissue between tendon and bone that is more compliant than either tendon or bone, but the size and nature of this region depended strongly upon the sequence of mineralization. These models and observations have implications for engineered tissue scaffolds at the attachment of tendon to bone, bone development and graded biomimetic attachment of dissimilar hierarchical materials in general.

Advances in regenerative orthopedics

Orthopedic injuries are common and a source of much misery and economic stress. Several relevant tissues, such as cartilage, meniscus, and intra-articular ligaments, do not heal. And even bone, which normally regenerates spontaneously, can fail to mend. The regeneration of orthopedic tissues requires 4 key components: cells, morphogenetic signals, scaffolds, and an appropriate mechanical environment. Although differentiated cells from the tissue in question can be used, most cellular research focuses on the use of mesenchymal stem cells. These can be retrieved from many different tissues, and one unresolved question is the degree to which the origin of the cells matters. Embryonic and induced pluripotent stem cells are also under investigation. Morphogenetic signals are most frequently supplied by individual recombinant growth factors or native mixtures provided by, for example, platelet-rich plasma; mesenchymal stem cells are also a rich source of trophic factors. Obstacles to the sustained delivery of individual growth factors can be addressed by gene transfer or smart scaffolds, but we still lack detailed, necessary information on which delivery profiles are needed. Scaffolds may be based on natural products, synthetic materials, or devitalized extracellular matrix. Strategies to combine these components to regenerate tissue can follow traditional tissue engineering practices, but these are costly, cumbersome, and not well suited to treating large numbers of individuals. More expeditious approaches make full use of intrinsic biological processes in vivo to avoid the need for ex vivo expansion of autologous cells and multiple procedures. Clinical translation remains a bottleneck.

Comparative transcriptional analysis of three human ligaments with distinct biomechanical properties

One major aim of regenerative medicine targeting the musculoskeletal system is to provide complementary and/or alternative therapeutic approaches to current surgical therapies, often involving the removal and prosthetic substitution of damaged tissues such as ligaments. For these approaches to be successful, detailed information regarding the cellular and molecular composition of different musculoskeletal tissues is required. Ligaments have often been considered homogeneous tissues with common biomechanical properties. However, advances in tissue engineering research have highlighted the functional relevance of the organisational and compositional differences between ligament types, especially in those with higher risks of injury. The aim of this study was to provide information concerning the relative expression levels of a subset of key genes (including extracellular matrix components, transcription factors and growth factors) that confer functional identity to ligaments. We compared the transcriptomes of three representative human ligaments subjected to different biomechanical demands: the anterior cruciate ligament (ACL); the ligamentum teres of the hip (LT); and the iliofemoral ligament (IL). We revealed significant differences in the expression of type I collagen, elastin, fibromodulin, biglycan, transforming growth factor β1, transforming growth interacting factor 1, hypoxia-inducible factor 1-alpha and transforming growth factor β-induced gene between the IL and the other two ligaments. Thus, considerable molecular heterogeneity can exist between anatomically distinct ligaments with differing biomechanical demands. However, the LT and ACL were found to show remarkable molecular homology, suggesting common functional properties. This finding provides experimental support for the proposed role of the LT as a hip joint stabiliser in humans.

GDFs promote tenogenic characteristics on human periodontal ligament-derived cells in culture at late passages

Tendon/ligament injures are leading disabilities worldwide. The periodontal ligament (PDL) connects teeth to bone, and is comparable to a tendon/ligament-to-bone insertion. PDL-derived cells (PDLCs) express both osteo/cementogenesis and teno/ligamentogenesis genes. However, an efficient method to induce a tenogenic differentiation of PDLCs has not been thoroughly examined. Therefore, this study tested if growth/differentiation factors (GDFs) enhanced tenogenic characteristics of human PDLCs, as a potential cell source for tendon/ligament engineering. Results demonstrated recombinant GDF-5/GDF-7 inhibited alkaline phosphatase (ALP) activity of PDLCs from passage 3 to 6, while GDF-5 enhanced ALP in dental pulp-derived cells and mesenchymal stem cells. GDF-5 (particularly at 10 ng/ml concentration) induced high expression of both early (scleraxis) and mature (tenomodulin, aggrecan, collagen3) tenogenic genes in P4-6 PDLCs, while inhibiting expression of specific transcription-factors for osteogenic, chondrogenic and adipogenic differentiation. Exogenous GDFs might lead PDLCs being expanded in culture during several passages to highly useful cell source for tendon/ligament engineering.

Biological and biomechanical evaluation of the ligament advanced reinforcement system (LARS AC) in a sheep model of anterior cruciate ligament replacement: a 3-month and 12-month study

PURPOSE

The purposes of this study were to assess tissue ingrowth within the Ligament Advanced Reinforcement System (LARS) artificial ligament (LARS AC; LARS, Arc sur Tille, France) and to study the biomechanical characteristics of the reconstructed knees in a sheep model of anterior cruciate ligament (ACL) replacement.

METHODS

Twenty-five female sheep underwent excision of the proximal third of the left ACL and intra-articular joint stabilization with a 44-strand polyethylene terephthalate ligament (mean ultimate tensile failure load, 2,500 N). Animals were killed either 3 or 12 months after surgery. Explanted knees were processed for histology (n = 10) or mechanical tests including tests of laxity and loading to failure in tension (n = 15).

RESULTS

Well-vascularized tissue ingrowth within the artificial ligament was only observed in the portions of the ligament in contact with the host's tissues (native ligament and bone tunnels). Ligament wear was observed in 40% of explanted knees. The ultimate tensile failure loads of the operated knees at both time points were inferior to those of the contralateral, intact knees (144 ± 69 N at 3 months and 260 ± 126 N at 12 months versus 1,241 ± 270 N and 1,218 ± 189 N, respectively) (P < .01). In specimens with intact artificial ligaments, failure occurred by slippage from the bone tunnels in all specimens explanted 3 months postoperatively and in half of the specimens explanted 12 months postoperatively.

CONCLUSIONS

This study provides evidence that the LARS AC has a satisfactory biointegration but that it is not suitable for ACL replacement if uniform tissue ingrowth is contemplated. Despite good clinical performance up to 1 year after implantation, none of the reconstructions approached the mechanical performance of the normal ACL in the ovine model. Partial tearing of the artificial ligament, which led to a significant decrease in ultimate tensile strength, was observed in 40% of cases in the ovine model.

CLINICAL RELEVANCE

The LARS is not a suitable scaffold for ACL replacement. Further animal studies are needed to evaluate its potential for augmentation of ligament repair.

Functional attachment of soft tissues to bone: development, healing, and tissue engineering

Connective tissues such as tendons or ligaments attach to bone across a multitissue interface with spatial gradients in composition, structure, and mechanical properties. These gradients minimize stress concentrations and mediate load transfer between the soft and hard tissues. Given the high incidence of tendon and ligament injuries and the lack of integrative solutions for their repair, interface regeneration remains a significant clinical challenge. This review begins with a description of the developmental processes and the resultant structure-function relationships that translate into the functional grading necessary for stress transfer between soft tissue and bone. It then discusses the interface healing response, with a focus on the influence of mechanical loading and the role of cell-cell interactions. The review continues with a description of current efforts in interface tissue engineering, highlighting key strategies for the regeneration of the soft tissue-to-bone interface, and concludes with a summary of challenges and future directions.

Biologics in the management of rotator cuff surgery

The rotator cuff enthesis is not reestablished after a rotator cuff repair. Instead, a scar-mediated healing response occurs at the tendon-bone interface, which is notably weaker than the native enthesis and thus more prone to failure. Biological augmentation through growth factors, AASs, biomimetic scaffolds, or siRNA therapy has the potential to enhance the healing response. The ultimate key, however, is in determining which of these enables a more regenerative healing response of the native tissue rather than enhanced production of scar tissue. In addition, the optimal combination of factors, dosing, and delivery methods remains to be clearly elucidated. Biological augmentation and tissue engineering for tendon healing remains promising, but much work still needs to be done.

Fabrication of nanofiber scaffolds with gradations in fiber organization and their potential applications

A new and simple method for fabrication of nanofiber scaffolds with gradations in fiber organization is reported. The nanofiber organization, achieved by deposition of random fibers on the uniaxially aligned nanofiber mat in a gradient manner, directed morphological changes of applied adipose-derived stem cells. These morphological changes and resultant biochemical changes can help mimic the structural orientation of complex biomechanical structures like the collagen fiber structure at the tendon-to-bone insertion site. In addition, chemical gradients can be established through nanoencapsulation in this novel scaffold allowing for enhanced biomedical applications.