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Sun L, Zhou X, Wu B, Tian M. Inhibitory effect of synovial fluid on tendon-to-bone healing: an experimental study in rabbits. Arthroscopy 2012; 28:1297-305. [PMID: 22607829 DOI: 10.1016/j.arthro.2012.02.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Revised: 02/09/2012] [Accepted: 02/16/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to explore the effects of joint synovial fluid on tendon-to-bone healing in intra-articular ligament reconstruction of the knee. METHODS We divided 40 female New Zealand white rabbits into 4 groups randomly, with 10 animals in each group. Transfer of the semitendinosus tendon to the tibial bone tunnel was performed to create tendon-to-bone healing models. An intra-articular bone tunnel (IBT) was used on the left side and an extra-articular bone tunnel (EBT) on the right. Histologic evaluation was performed at 2, 4, and 8 weeks after the operation and biomechanical testing at 8 weeks. RESULTS On the basis of fibroblast proliferation, collagen fiber density, collagen fiber orientation, and tendon-to-bone connection, histologic scores were significantly lower in the IBT group than in the EBT group at 2, 4, and 8 weeks. Cell counts per high-power field at the tendon-bone interface were significantly lower in the IBT group than in the EBT group at 2 and 4 weeks. In addition, biomechanical testing showed that the IBT group was significantly inferior to the EBT group in terms of ultimate failure load, yield load, and stiffness. There was also a significant difference between the 2 groups in failure mode. CONCLUSIONS Joint synovial fluid appeared to have an inhibitory effect on tendon-to-bone healing in rabbits at an early stage. CLINICAL RELEVANCE Our findings imply that prevention of infiltration of joint synovial fluid into the bone tunnel might be beneficial in improving the clinical outcome of cruciate ligament reconstruction of the knee.
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Affiliation(s)
- Lei Sun
- Orthopaedic Center of PLA, The 88th Hospital of PLA, Tai'an, China.
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102
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Robertson CM, Chen CT, Shindle MK, Cordasco FA, Rodeo SA, Warren RF. Failed healing of rotator cuff repair correlates with altered collagenase and gelatinase in supraspinatus and subscapularis tendons. Am J Sports Med 2012; 40:1993-2001. [PMID: 22896627 DOI: 10.1177/0363546512456519] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite improvements in arthroscopic rotator cuff repair technique and technology, a significant rate of failed tendon healing persists. Improving the biology of rotator cuff repairs may be an important focus to decrease this failure rate. The objective of this study was to determine the mRNA biomarkers and histological characteristics of repaired rotator cuffs that healed or developed persistent defects as determined by postoperative ultrasound. HYPOTHESIS Increased synovial inflammation and tendon degeneration at the time of surgery are correlated with the failed healing of rotator cuff tendons. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Biopsy specimens from the subscapularis tendon, supraspinatus tendon, glenohumeral synovium, and subacromial bursa of 35 patients undergoing arthroscopic rotator cuff repair were taken at the time of surgery. Expression of proinflammatory cytokines, tissue remodeling genes, and angiogenesis factors was evaluated by quantitative real-time polymerase chain reaction. Histological characteristics of the affected tissue were also assessed. Postoperative (>6 months) ultrasound was used to evaluate the healing of the rotator cuff. General linear modeling with selected mRNA biomarkers was used to predict rotator cuff healing. RESULTS Thirty patients completed all analyses, of which 7 patients (23%) had failed healing of the rotator cuff. No differences in demographic data were found between the defect and healed groups. American Shoulder and Elbow Surgeons shoulder scores collected at baseline and follow-up showed improvement in both groups, but there was no significant difference between groups. Increased expression of matrix metalloproteinase 1 (MMP-1) and MMP-9 was found in the supraspinatus tendon in the defect group versus the healed group (P = .006 and .02, respectively). Similar upregulation of MMP-9 was also found in the subscapularis tendon of the defect group (P = .001), which was consistent with the loss of collagen organization as determined by histological examination. From a general linear model, the upregulation of MMP-1 and MMP-9 was highly correlated with failed healing of the rotator cuff (R(2) = .656). CONCLUSION The upregulation of tissue remodeling genes in the torn rotator cuff at the time of surgery provides a snapshot of the biological environment surrounding the torn rotator cuff that is closely related to the healing of repaired rotator cuffs.
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Affiliation(s)
- Catherine M Robertson
- Sports Medicine and Shoulder Service, The Hospital for Special Surgery, New York, New York, USA
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103
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Rotator cuff: biology and current arthroscopic techniques. Knee Surg Sports Traumatol Arthrosc 2012; 20:1003-11. [PMID: 22270674 DOI: 10.1007/s00167-012-1901-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 01/10/2012] [Indexed: 12/19/2022]
Abstract
UNLABELLED The present article summarizes current trends in arthroscopic rotator cuff repairs focusing on the used repair technique, potential influencing factors on the results, and long-term outcome after reconstruction of the rotator cuff. Moreover, different treatment options for the treatment for irreparable rotator cuff ruptures were described, and the results of additional augmentation of the repairs with platelet-rich plasma were critically analyzed. Based on the current literature, double-row repairs did not achieve superior clinical results compared to single-row repairs neither in the clinical results nor in the re-rupture rate. Multiple factors such as age, fatty infiltration, and initial rupture size might influence the results. If the rupture is not repairable, various options were described including cuff debridement, partial repair, tuberoplasty, or tendon transfers. The additional augmentation with platelet-rich plasma did not reveal any significant differences in the healing rate compared to conventional rotator cuff repairs. LEVEL OF EVIDENCE IV.
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Bedi A, Maak T, Walsh C, Rodeo SA, Grande D, Dines DM, Dines JS. Cytokines in rotator cuff degeneration and repair. J Shoulder Elbow Surg 2012; 21:218-27. [PMID: 22244065 DOI: 10.1016/j.jse.2011.09.020] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 08/29/2011] [Accepted: 09/06/2011] [Indexed: 02/01/2023]
Abstract
The pathogenesis of rotator cuff degeneration remains poorly defined, and the incidence of degenerative tears is increasing in the aging population. Rates of recurrent tear and incomplete tendon-to-bone healing after repair remain significant for large and massive tears. Previous studies have documented a disorganized, fibrous junction at the tendon-to-bone interface after rotator cuff healing that does not recapitulate the organization of the native enthesis. Many biologic factors have been implicated in coordinating tendon-to-bone healing and maintenance of the enthesis after rotator cuff repair, including the expression and activation of transforming growth factor-β, basic fibroblast growth factor, platelet-derived growth factor-β, matrix metalloproteinases, and tissue inhibitors of metalloproteinases. Future techniques to treat tendinopathy and enhance tendon-to-bone healing will be driven by our understanding of the biology of this healing process after rotator cuff repair surgery. The use of cytokines to provide important signals for tissue formation and differentiation, the use of gene therapy techniques to provide sustained cytokine delivery, the use of stem cells, and the use of transcription factors to modulate endogenous gene expression represent some of these possibilities.
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Affiliation(s)
- Asheesh Bedi
- MedSport, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48106, USA.
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106
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Del Buono A, Oliva F, Longo UG, Rodeo SA, Orchard J, Denaro V, Maffulli N. Metalloproteases and rotator cuff disease. J Shoulder Elbow Surg 2012; 21:200-8. [PMID: 22244063 DOI: 10.1016/j.jse.2011.10.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 10/22/2011] [Accepted: 10/24/2011] [Indexed: 02/07/2023]
Abstract
The molecular changes occurring in rotator cuff tears are still unknown, but much attention has been paid to better understand the role of matrix metalloproteinases (MMP) in the development of tendinopathy. These are potent enzymes that, once activated, can completely degrade all components of the connective tissue, modify the extracellular matrix (ECM), and mediatethe development of painful tendinopathy and tendon rupture. To control the local activity of activated proteinases, the same cells produce tissue inhibitors of metalloproteinases (TIMP) that bind to the enzymes and prevent degradation. The balance between the activities of MMPs and TIMPs regulates tendon remodeling, whereas an imbalance produces a collagen dis-regulation and disturbances intendons. ADAMs (a disintegrin and metalloproteinase) are cell membrane-linked enzymes with proteolytic and cell signaling functions. ADAMTSs (ADAM with thrombospondin motifs) are secreted into the circulation, and constitute a heterogenous family of proteases with both anabolic and catabolic functions. Biologic modulation of endogenous MMP activity to basal levels may reduce pathologic tissue degradation and favorably influence healing after rotator cuff repair. Further studies are needed to better define the mechanism of action, and whether these new strategies are safe and effective in larger models.
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Affiliation(s)
- Angelo Del Buono
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico, University of Rome, Rome, Italy
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107
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Nixon AJ, Watts AE, Schnabel LV. Cell- and gene-based approaches to tendon regeneration. J Shoulder Elbow Surg 2012; 21:278-94. [PMID: 22244071 DOI: 10.1016/j.jse.2011.11.015] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 11/14/2011] [Accepted: 11/15/2011] [Indexed: 02/06/2023]
Abstract
Repair of rotator cuff tears in experimental models has been significantly improved by the use of enhanced biologic approaches, including platelet-rich plasma, bone marrow aspirate, growth factor supplements, and cell- and gene-modified cell therapy. Despite added complexity, cell-based therapies form an important part of enhanced repair, and combinations of carrier vehicles, growth factors, and implanted cells provide the best opportunity for robust repair. Bone marrow-derived mesenchymal stem cells provide a stimulus for repair in flexor tendons, but application in rotator cuff repair has not shown universally positive results. The use of scaffolds such as platelet-rich plasma, fibrin, and synthetic vehicles and the use of gene priming for stem cell differentiation and local anabolic and anti-inflammatory impact have both provided essential components for enhanced tendon and tendon-to-bone repair in rotator cuff disruption. Application of these research techniques in human rotator cuff injury has generally been limited to autologous platelet-rich plasma, bone marrow concentrate, or bone marrow aspirates combined with scaffold materials. Cultured mesenchymal progenitor therapy and gene-enhanced function have not yet reached clinical trials in humans. Research in several animal species indicates that the concept of gene-primed stem cells, particularly embryonic stem cells, combined with effective culture conditions, transduction with long-term integrating vectors carrying anabolic growth factors, and development of cells conditioned by use of RNA interference gene therapy to resist matrix metalloproteinase degradation, may constitute potential advances in rotator cuff repair. This review summarizes cell- and gene-enhanced cell research for tendon repair and provides future directions for rotator cuff repair using biologic composites.
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Affiliation(s)
- Alan J Nixon
- Comparative Orthopaedics Laboratory, College of Veterinary Medicine, Cornell University, Ithaca, New York 14853, USA.
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Chaudhury S, Carr AJ. Lessons we can learn from gene expression patterns in rotator cuff tears and tendinopathies. J Shoulder Elbow Surg 2012; 21:191-9. [PMID: 22244062 DOI: 10.1016/j.jse.2011.10.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 10/22/2011] [Accepted: 10/23/2011] [Indexed: 02/06/2023]
Abstract
Persistently high failure rates that are reported after rotator cuff repairs have encouraged greater understanding of the pathophysiology that underlies rotator cuff tears. Biologic changes that contribute to the pathogenesis of rotator cuff tears and tendinopathies, as well as adaptation after these changes, have been well described. A subset of patients with a genetic predisposition to early onset of rotator cuff tears and earlier symptom and disease progression have been identified. Many biologic changes occurring at the gene level have been identified. Pathways that are believed to contribute to rotator cuff tendinopathies include extracellular matrix remodeling, angiogenesis, changes in metabolism, apoptosis, and stress-related genes. Metaplasia of rotator cuff cells is contributed to by changes in gene expression. Modification of these gene changes may be possible through mechanical loading, drugs, or cellular manipulation. Gene changes may offer greater insight into why certain tears fail to heal and help to identify therapeutic targets.
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Affiliation(s)
- Salma Chaudhury
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Musculoskeletal Biomedical Research Unit, National Institute for Health Research, University of Oxford, Oxford, UK.
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Healing of the rotator cuff. CURRENT ORTHOPAEDIC PRACTICE 2012. [DOI: 10.1097/bco.0b013e3182410e91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
As rotator cuff repair techniques have improved, failure of the tendon to heal to the proximal humerus is less likely to occur from weak tendon-to-bone fixation. More likely causes of failure include biologic factors such as intrinsic tendon degeneration, fatty atrophy, fatty infiltration of muscle, and lack of vascularity of the tendons. High failure rates have led to the investigation of biologic augmentation to potentially enhance the healing response. Histologic studies have shown that restoration of the rotator cuff footprint during repair can help reestablish the enthesis. In animal models, growth factors and their delivery scaffolds as well as tissue engineering have shown promise in decreasing scar tissue while maintaining biomechanical strength. Platelet-rich plasma may be a safe adjuvant to rotator cuff repair, but it has not been shown to improve healing or function. Many of these strategies need to be further defined to permit understanding of, and to optimize, the biologic environment; in addition, techniques need to be refined for clinical use.
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Cenni E, Scioscia L, Baldini N. Orthopaedic research in italy: state of the art. Int J Immunopathol Pharmacol 2011; 24:157-78. [PMID: 21669157 DOI: 10.1177/03946320110241s230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The most significant results in experimental and clinical orthopaedic research in Italy within the last three years have been primarily in major congenital diseases, bone tumors, regenerative medicine, joint replacements, spine, tendons and ligaments. The data presented in the following discussion is comparable with leading international results, highlighting Italian orthopaedic research excellemce as well as its shortcomings.
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Affiliation(s)
- E Cenni
- Istituto Ortopedico Rizzoli, Bologna, Italy
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112
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Miller BS, Downie BK, Kohen RB, Kijek T, Lesniak B, Jacobson JA, Hughes RE, Carpenter JE. When do rotator cuff repairs fail? Serial ultrasound examination after arthroscopic repair of large and massive rotator cuff tears. Am J Sports Med 2011; 39:2064-70. [PMID: 21737833 DOI: 10.1177/0363546511413372] [Citation(s) in RCA: 221] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite advances in arthroscopic repair of rotator cuff tears, recurrent tears after repair of large and massive tears remain a significant clinical problem. The primary objective of this study was to define the timing of structural failure of surgically repaired large and massive rotator cuff tears by serial imaging with ultrasound. The secondary objective of this study was to investigate the association between recurrent tears and clinical outcome after rotator cuff repair. HYPOTHESIS Recurrent tear after arthroscopic repair of large rotator cuff tears is more likely to occur late (>3 months) in the postoperative period and will be associated with inferior clinical outcome scores. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Twenty-two consecutive patients with large (>3 cm) rotator cuff tears underwent arthroscopic repair with a standardized technique. Serial ultrasound examinations were performed at 2 days, 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. Western Ontario Rotator Cuff (WORC) Index scores were also collected at these time points. RESULTS Nine (41%) of the 22 arthroscopically repaired rotator cuff tears demonstrated recurrent tears. Seven of the 9 retears occurred within 3 months of surgery, and the other 2 occurred between 3 and 6 months. No retears occurred after 6 months. At 24-month follow-up, WORC scores favoring intact rotator cuffs over retears approached statistical significance (mean WORC intact 123.9 vs retear 659.8; P = .07). CONCLUSION Recurrent rotator cuff tears are not uncommon after arthroscopic repair of large and massive tears. These recurrent tears appear to occur more frequently in the early postoperative period (within the first 3 months) and are associated with inferior clinical outcomes.
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Affiliation(s)
- Bruce S Miller
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48105, USA.
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113
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Reider B. Of cuffs and cones. Am J Sports Med 2011; 39:2061-3. [PMID: 22003210 DOI: 10.1177/0363546511424268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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114
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Lakemeier S, Braun J, Efe T, Foelsch C, Archontidou-Aprin E, Fuchs-Winkelmann S, Paletta JRJ, Schofer MD. Expression of matrix metalloproteinases 1, 3, and 9 in differing extents of tendon retraction in the torn rotator cuff. Knee Surg Sports Traumatol Arthrosc 2011; 19:1760-5. [PMID: 21222105 DOI: 10.1007/s00167-010-1367-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE Differing extents of tendon retraction are found in full-thickness rotator cuff tears. The pathophysiologic context of tendon degeneration and the extent of tendon retraction are unclear. Tendon integrity depends on the extracellular matrix, which is regulated by matrix metalloproteinases (MMP). It is unknown which enzymes play a role in tendon degeneration. The hypotheses are that (1) the expression of MMPs 1, 3, and 9 is altered in the torn rotator cuff when compared with healthy tendon samples; and (2) that there is a relationship between MMP expression and the extent of tendon retraction in the torn cuff. METHODS Rotator cuff tendon samples of 33 patients with full-thickness rotator cuff tears (Bateman grade III) were harvested during reconstructive surgery. Samples were dehydrated and paraffin-embedded. Immunohistologic determination of MMP 1, 3, and 9 expression was performed by staining sample slices with MMP antibody. The extent of tendon retraction was determined intraoperatively according to Patte's classification and patients were assigned to 4 groups (control group, and by tendon retraction grade Patte I-III). The control group consisted of six healthy tendon samples. RESULTS Expression of MMPs 1 and 9 was significantly higher in torn cuff samples than in healthy tendons whereas MMP 3 expression was significantly decreased (P < 0.05). MMP 9 expression significantly increased with rising extent of tendon retraction in the torn cuff (P < 0.05). No significant association was found between expression of MMPs 1 and 3 and the rising extent of tendon retraction by Patte's classification. CONCLUSION Elevated expression of MMPs 1 and 9 as well as decreased MMP 3 expression can be detected in torn rotator cuff tendon tissue. There is a significant association between the extent of tendon retraction and MMP 9 expression. The results of this study give evidence that early surgical treatment of small and partial-thickness rotator cuff tears is required.
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Affiliation(s)
- Stefan Lakemeier
- Department of Orthopedics and Rheumatology, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany.
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Chamberlain CS, Leiferman EM, Frisch KE, Wang S, Yang X, Brickson SL, Vanderby R. The influence of interleukin-4 on ligament healing. Wound Repair Regen 2011; 19:426-35. [PMID: 21518087 DOI: 10.1111/j.1524-475x.2011.00682.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Despite a complex cascade of cellular events to reconstruct the damaged extracellular matrix, ligament healing results in a mechanically inferior scarred ligament. During normal healing, granulation tissue expands into any residual normal ligamentous tissue (creeping substitution), resulting in a larger region of healing, greater mechanical compromise and an inefficient repair process. To control creeping substitution and possibly enhance the repair process, the antiinflammatory cytokine, interleukin-4 (IL-4), was administered to rats before and after rupture of their medial collateral ligaments. In vitro experiments showed a time-dependent effect on fibroblast proliferation after IL-4 treatment. In vivo treatments with IL-4 (100 ng/mL IV) for 5 days resulted in decreased wound size and type III collagen and increased type I procollagen, indicating a more regenerative early healing in response to the IL-4 treatment. However, continued treatment of IL-4 to day 11 antagonized this early benefit and slowed healing. Together, these results suggest that IL-4 not only influences the macrophages and T lymphocytes but also stimulates fibroblasts associated with the proliferative phase of healing in a dose-, cell-, and time-dependent manner. Although treatment significantly influenced healing in the first week after injury, IL-4 alone was unable to maintain this early regenerative response.
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Affiliation(s)
- Connie S Chamberlain
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin 53705, USA
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Affiliation(s)
- Marc Tompkins
- Department of Orthopaedics, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22908, USA
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Chaudhury S, Murphy R, Carr A. Tendon Tissue Engineering: The Potential Application of Stem Cells, Biological Factors, and Repair Scaffolds to Improve Rotator Cuff Tendon Tears. COMPREHENSIVE BIOTECHNOLOGY 2011:252-269. [DOI: 10.1016/b978-0-444-64046-8.00297-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
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Chaudhury S, Murphy R, Carr A. Tendon Tissue Engineering. COMPREHENSIVE BIOTECHNOLOGY 2011:291-310. [DOI: 10.1016/b978-0-08-088504-9.00511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
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Rodeo SA, Delos D, Weber A, Ju X, Cunningham ME, Fortier L, Maher S. What's new in orthopaedic research. J Bone Joint Surg Am 2010; 92:2491-501. [PMID: 20962201 DOI: 10.2106/jbjs.j.01174] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Scott A Rodeo
- The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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