Tendon bone healing can be enhanced by demineralized bone matrix: a functional and histological study

Long Head of Biceps Tenodesis for Maintaining Inherent Length and Uniform Tension at the Bicipital Groove: Suprapectoral Double-Row Technique With All-Suture Anchors

The clinicopathologic conditions of the long head of the biceps tendon vary, encompassing tendinitis, peritendinous inflammation, hypertrophy, and partial or complete tears. These symptoms are typically linked with SLAP tears and instability of the long head of the biceps tendon, often resulting in partial displacement or complete dislocation. The choice between tenotomy and tenodesis depends on varied factors. The choice of suprapectoral or subpectoral tenodesis is a difficult decision and should be weighed on a tailored basis. Our approach to suprapectoral tenodesis presents a blend of factors, maintaining uniform tension in the bicipital groove, limiting the number of portals for arthroscopy, re-tensioning the tendon after initial anchor placement, and preserving the inherent length of the functional biceps tendon without compromising its quality.

The effects of heat and hydrogen peroxide treatment on the osteoinductivity of demineralized cortical bone: a potential method for preparing tendon/ligament repair scaffolds

Recent studies have indicated that demineralized cortical bone (DCB) may be used to repair tendons and ligaments, such as the patellar tendon and anterior cruciate ligament (ACL). Hydrogen peroxide (H2O2) has been shown to reduce the osteoinductivity of DCB, and heat treatment may also decrease the osteoinductivity of DCB. The purpose of this study was (i) to determine whether heat treatment reduces the osteoinductivity of DCB and (ii) to compare the effectiveness of heat treatment and H2O2 treatment on BMP-2 inactivation. DCB was prepared by immersion in 0.6 N hydrochloric acid, and DCB-H and DCB-HO were prepared by heat treatment (70°C for 8 h) and H2O2 treatment (3% H2O2 for 8 h), respectively. The surface topographies, elemental distributions and histological structures of the scaffolds were observed by scanning electron microscopy (SEM), Fourier transform infrared spectroscopy (FT-IR) and histological staining. The viability and osteogenic differentiation of TDSCs cultured on the scaffolds were evaluated via live/dead cell staining and Cell Counting Kit-8 (CCK-8) testing, real-time polymerase chain reaction (RT-PCR) and western bolt (WB) analysis, alkaline phosphatase activity (ALP) and alizarin red S (ARS) staining. The intramuscular implantation of the scaffolds in rats was also used to evaluate the effect of heat treatment and H2O2 treatment on the osteoinductivity of DCB. Our results demonstrated that both treatments removed BMP-2 and osteocalcin (OCN) within the DCB and that DCB-H and DCB-HO had good cytocompatibility and reduced the osteogenic differentiation of TDSCs. Moreover, the in vivo results indicated that the DCB-H and DCB-HO groups had smaller areas of osteoid formation than did the DCB group, and the DCB-HO group had the smallest area among the three groups. Our study demonstrated that heat treatment could reduce the osteoinductivity of DCB, and that H2O2 treatment was more effective than heat treatment.

Anterior Cruciate Ligament Reconstruction Augmentation With Bone Marrow Aspirate Concentrate, Demineralized Bone Matrix, and Suture Tape Shows No Difference in Outcomes-But Faster Functional Recovery-Versus Non-augmented Anterior Cruciate Ligament Reconstruction

PURPOSE

To compare outcomes after anterior cruciate ligament reconstruction (ACLR) with bone marrow aspirate concentrate (BMAC), demineralized bone matrix (DBM), and suture tape augmentation (STA) versus ACLR without biological augmentation or STA.

METHODS

We performed a prospective randomized controlled trial at a single institution to compare ACLR with BMAC, DBM, and STA (group A) versus ACLR without biological augmentation or STA (group NA). The study sought to include 100 patients. Skeletally mature patients younger than 25 years received quadriceps tendon autograft, whereas patients aged 25 years or older underwent allograft ACLR with an all-inside technique. Patients with concomitant meniscal pathologies were included. The primary outcomes compared were range of motion (ROM), limb symmetry, and patient-reported outcomes. Secondary outcomes included radiographic outcomes and surgical complications. Univariate and mixed-model regression analyses were used to compare outcomes.

RESULTS

Fifty-nine patients were included (29 patients in group A [11 female patients, 38%] and 30 patients in group NA [15 female patients, 50%]). Early ROM at 6 weeks (125° of flexion vs 109° of flexion, P < .0001) and limb symmetry at 12 weeks (80.6% vs 36.7% [delta, 43.9%], P < .001) were significantly improved in group A. At 2 years, International Knee Documentation Committee scores were similar (91.1 ± 12.7 vs 85.3 ± 10.8, P = .109). Quality-of-life subscores of the Knee Injury and Osteoarthritis Outcome Score were significantly enhanced in group A (85.2 ± 20.9 vs 72.1 ± 20.4, P = .042). In 22 patients (12 in group A and 10 in group NA), computed tomography scans were obtained at 6 months to compare bone tunnel healing. Overall, the mean increase in bone tunnel diameter was significantly smaller in group A than in group NA. No difference in graft rerupture or reoperation rate was observed. Reoperations were performed for stiffness in 7 of 59 patients (11.9%) (3 [10%] in group A vs 4 [13%] in group NA; P > .999).

CONCLUSIONS

There were no differences in International Knee Documentation Committee scores between groups at 2-year follow-up. Functional outcomes including early ROM and limb symmetry were significantly improved in patients who received ACLR with BMAC, DBM, and STA.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Inlay Scaffold Augmentation of Rotator Cuff Repairs Enhances Histologic Resemblance to Native Enthesis in Animal Studies: A Systematic Review

PURPOSE

To investigate the outcomes of inlay positioned scaffolds for rotator cuff healing and regeneration of the native enthesis after augmentation of rotator cuff tendon repairs in preclinical studies.

METHODS

A literature search was performed using the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Preclinical studies reporting on outcomes after inlay tendon augmentation in rotator cuff repair were included. Preclinical study quality was assessed using an adapted version of the Gold Standard Publication Checklist for animal studies. The level of evidence was defined based on the inclusion of clinical analyses (grade A), biomechanical analyses (grade B), biochemical analyses (grade C), semiquantitative analyses (grade D), and qualitative histologic analyses (grade E).

RESULTS

Thirteen preclinical studies met the inclusion criteria. Quality assessment scores ranged from 4 to 8 points, and level-of-evidence grades ranged from B to E. Sheep/ewes were the main animal rotator cuff tear model used (n = 7). Demineralized bone matrix or demineralized cortical bone was the most commonly investigated scaffold (n = 6). Most of the preclinical evidence (n = 10) showed qualitative or quantitative differences regarding histologic, biomechanical, and biochemical outcomes in favor of interpositional scaffold augmentation of cuff repairs in comparison to controls.

CONCLUSIONS

Inlay scaffold positioning in preclinical studies has been shown to enhance the healing biology of the enthesis while providing histologic similarities to its native 4-zone configuration.

CLINICAL RELEVANCE

Although onlay positioned grafts and scaffolds have shown mixed results in preclinical and early clinical studies, inlay scaffolds may provide enhanced healing and structural support in comparison owing to the ability to integrate with the bone-tendon interface.

The rat as a novel model for chronic rotator cuff injuries

Chronic rotator cuff injuries (CRCIs) still present a great challenge for orthopaedics surgeons. Many new therapeutic strategies are developed to facilitate repair and improve the healing process. However, there is no reliable animal model for chronic rotator cuff injury research. To present a new valuable rat model for future chronic rotator cuff injuries (CRCIs) repair studies, and describe the changes of CRCIs on the perspectives of histology, behavior and MRI. Sixty male Wistar rats were enrolled and underwent surgery of the left shoulder joint for persistent subacromial impingement. They were randomly divided into experimental group (n = 30, a 3D printed PEEK implant shuttled into the lower surface of the acromion) and sham operation group (n = 30, insert the same implant, but remove it immediately). Analyses of histology, behavior, MRI and inflammatory pain-related genes expression profiles were performed to evaluate the changes of CRCIs. After 2-weeks running, the rats in the experimental group exhibited compensatory gait patterns to protect the injured forelimb from loading after 2-weeks running. After 8-weeks running, the rats in the experimental group showed obvious CRCIs pathological changes: (1) acromion bone hyperplasia and thickening of the cortical bone; (2) supraspinatus muscle tendon of the humeral head: the bursal-side tendon was torn and layered with disordered structure, forming obvious gaps; the humeral-side tendon is partially broken, and has a neatly arranged collagen. Partial fat infiltration is found. The coronal T2-weighted images showed that abnormal tendon-to-bone junctions of the supraspinatus tendon. The signal intensity and continuity were destroyed with contracted tendon. At the nighttime, compared with the sham operation group, the expression level of IL-1β and COX-2 increased significantly (P = 0063, 0.0005) in the experimental group. The expression of COX-2 in experimental group is up-regulated about 1.5 times than that of daytime (P = 0.0011), but the expression of IL-1β, TNF-a, and NGF are all down-regulated (P = 0.0146, 0.0232, 0.0161). This novel rat model of chronic rotator cuff injuries has the similar characteristics with that of human shoulders. And it supplies a cost-effective, reliable animal model for advanced tissue engineered strategies and future therapeutic strategies.

Cryopreserved Adipose-Derived Stem Cell Sheets: An Off-the-Shelf Scaffold for Augmenting Tendon-to-Bone Healing in a Rabbit Model of Chronic Rotator Cuff Tear

BACKGROUND

Adipose-derived stem cell (ADSC) sheets have been shown to promote tendon-to-bone healing. However, conventional laboratory preparation methods for ADSC sheets are time-consuming and risky, which precludes their diverse clinical applications.

PURPOSE

To explore the utility of off-the-shelf cryopreserved ADSC sheets (c-ADSC sheets) for rotator cuff tendon-to-bone healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

The ADSC sheets were cryopreserved and thawed for live/dead double staining, TdT-mediated dUTP Nick-End Labeling (TUNEL) staining, scanning electron microscopy observation, and biomechanical testing. Clone formation, proliferative capacity, and multilineage differentiation of ADSCs within the c-ADSC sheets were assayed to explore the effect of cryopreservation on stem cell properties. A total of 67 rabbits were randomly divided into 4 groups: normal group (without supraspinatus tendon tears; n = 7), control group (repair alone; n = 20), fresh ADSC (f-ADSC) sheet group (repair; n = 20), and c-ADSC sheet group (repair; n = 20). Rabbit bilateral supraspinatus tendon tears were induced to establish a chronic rotator cuff tear model. Gross observation, micro-computed tomography analysis, histological or immunohistochemical tests, and biomechanical tests were conducted at 6 and 12 weeks after repair.

RESULTS

No significant impairment was seen in the cell viability, morphology, and mechanical properties of c-ADSC sheets when compared with f-ADSC sheets. The stem cell properties of ADSC sheets also were preserved by cryopreservation. At 6 and 12 weeks after the repair, the f-ADSC and c-ADSC sheet groups showed superior bone regeneration, higher histological scores, larger fibrocartilage areas, more mature collagen, and better biomechanical results compared with the control group. No obvious difference was seen between the f-ADSC and c-ADSC sheet groups in terms of bone regeneration, histological score, fibrocartilage formation, and biomechanical tests.

CONCLUSION

c-ADSC sheets, an off-the-shelf scaffold with a high potential for clinical translational application, can effectively promote rotator cuff tendon-to-bone healing.

CLINICAL RELEVANCE

Programmed cryopreservation of ADSC sheets is an efficient off-the-shelf scaffold for rotator cuff tendon-to-bone healing.

Fibrocartilage extracellular matrix augmented demineralized bone matrix graft repairs tendon-to-bone interface in a rabbit tendon reconstruction model

Current tendon/ligament reconstructions integrate via scar tissue rather than proper bone-tendon interface regeneration, which affects graft longevity, changes in bone tunnel size, and functional outcomes. The purpose of this study was to develop a functional demineralized bone matrix (DBM) + fibrocartilage extracellular matrix (FCECM) composite scaffold, characterize its physicochemical properties, and evaluate its efficacy in repairing tendon-bone interface in a rabbit tendon reconstruction model. Solubilized FCECM was loaded and crosslinked on to DBM scaffolds via gamma-irradiation to create DBM + FCECM scaffolds. The resulting scaffold showed interconnected pores coated with FCECM and protein cargo similar to FCECM. The addition of FCECM modified the physicochemical properties of the DBM scaffold, including microstructure, biochemical composition, mechanical strength, thermodynamic properties, and degradation period. The DBM + FCECM scaffold was biocompatible for mesenchymal stem cells (MSCs) and resulted in elevation of fibrochondrogenic gene markers compared to DBM scaffolds in vitro. In vivo implantation of DBM + FCECM scaffold resulted in neofibrocartilage formation, better pullout strength, and less bone tunnel widening compared to DBM only group in a rabbit tendon reconstruction model. In conclusion, the FCECM augmented DBM scaffold repairs the tendon-bone interface with osseous-fibrocartilage tissue, which may be utilized to improve current tendon reconstruction surgeries.

Clinical Outcomes following Biologically Enhanced Demineralized Bone Matrix Augmentation of Complex Rotator Cuff Repair

Complex rotator cuff tears provide a significant challenge for treating surgeons, given their high failure rate following repair and the associated morbidity. The purpose of this study is to evaluate the clinical outcomes of patients who underwent biologically enhanced demineralized bone matrix augmentation of rotator cuff repairs. Twenty patients with complex rotator cuff tears underwent arthroscopic rotator cuff repair by a single surgeon with demineralized bone matrix (DBM) augmentation that was biologically enhanced with platelet-rich plasma and concentrated bone marrow aspirate. Post-operative MRI was used to determine surgical success. Patient reported outcome measures and range of motion data were collected pre-operatively and at the final post-operative visit for each patient. Ten patients (50%) with DBM augmentation of their arthroscopic rotator cuff repair were deemed non-failures. The failure group had less improvement of visual analogue pain scale (p = 0.017), Simple Shoulder Test (p = 0.032), Single Assessment Numerical Evaluation (p = 0.006) and abduction (p = 0.046). There was no difference between the groups for change in American Shoulder and Elbow Society score (p = 0.096), Constant-Murley score (p = 0.086), forward elevation (p = 0.191) or external rotation (p = 0.333). The present study found that 50% of patients who underwent biologically enhanced DBM augmentation of their rotator cuff repair demonstrated MRI-determined failure of supraspinatus healing.

Segmentally Demineralized Cortical Bone With Stem Cell-Derived Matrix Promotes Proliferation, Migration and Differentiation of Stem Cells in vitro

A recent study has shown that demineralized cortical bone (DCB) did not improve the healing of tendon-bone interface. Considering that there is a gradient of mineral content in the tendon-bone interface, we designed a segmentally demineralized cortical bone (sDCB) scaffold with two different regions: undemineralized cortical bone section within the scaffold (sDCB-B) and complete demineralized cortical bone section within the scaffold (sDCB-D), to mimic the natural structure of the tendon-bone interface. Furthermore, the extracellular matrix (ECM) from tendon-derived stem cells (TDSCs) was used to modify the sDCB-D region of sDCB to construct a novel scaffold (sDCB-ECM) for enhancing the bioactivity of the sDCB-D. The surface topography, elemental distribution, histological structure, and surface elastic modulus of the scaffold were observed using scanning electron microscopy, energy-dispersive X-ray spectroscopy, Fourier transform infrared spectroscopy, histological staining and atomic force microscopy. Cell proliferation of bone marrow mesenchymal stem cells (BMSCs) and TDSCs cultured on scaffolds was evaluated using the Cell Counting kit-8, and cell viability was assessed by Live/Dead cell staining. Cell morphology was detected by fluorescent staining. The ability of the scaffolds to recruit stem cells was tested using transwell migration assay. The expression levels of bone-, cartilage- and tendon-related genes and proteins in stem cells were assessed by the polymerase chain reaction and western blotting. Our results demonstrated that there was a gradient of Ca and P elements in sDCB, and TDSC-derived ECM existed on the surface of the sDCB-D region of sDCB. The sDCB-ECM could promote stem cell proliferation and migration. Moreover, the sDCB-B region of sDCB-ECM could stimulate osteogenic and chondrogenic differentiation of BMSCs, and the sDCB-D-ECM region of sDCB-ECM could stimulate chondrogenic and tenogenic differentiation of TDSCs when compared to DCB. Our study indicated that sDCB-ECM might be a potential bioscaffold to enhance the tendon-bone interface regeneration.

Sheep condyle model evaluation of bone marrow cell concentrate combined with a scaffold for repair of large osteochondral defects

Aims

Minimally manipulated cells, such as autologous bone marrow concentrates (BMC), have been investigated in orthopaedics as both a primary therapeutic and augmentation to existing restoration procedures. However, the efficacy of BMC in combination with tissue engineering is still unclear. In this study, we aimed to determine whether the addition of BMC to an osteochondral scaffold is safe and can improve the repair of large osteochondral defects when compared to the scaffold alone.

Methods

The ovine femoral condyle model was used. Bone marrow was aspirated, concentrated, and used intraoperatively with a collagen/hydroxyapatite scaffold to fill the osteochondral defects (n = 6). Tissue regeneration was then assessed versus the scaffold-only group (n = 6). Histological staining of cartilage with alcian blue and safranin-O, changes in chondrogenic gene expression, microCT, peripheral quantitative CT (pQCT), and force-plate gait analyses were performed. Lymph nodes and blood were analyzed for safety.

Results

The results six months postoperatively showed that there were no significant differences in bone regrowth and mineral density between BMC-treated animals and controls. A significant upregulation of messenger RNA (mRNA) for types I and II collagens in the BMC group was observed, but there were no differences in the formation of hyaline-like cartilage between the groups. A trend towards reduced sulphated glycosaminoglycans (sGAG) breakdown was detected in the BMC group but this was not statistically significant. Functional weightbearing was not affected by the inclusion of BMC.

Conclusion

Our results indicated that the addition of BMC to scaffold is safe and has some potentially beneficial effects on osteochondral-tissue regeneration, but not on the functional endpoint of orthopaedic interest.

Cite this article: Bone Joint Res 2021;10(10):677–689.

Hierarchically Demineralized Cortical Bone Combined With Stem Cell-Derived Extracellular Matrix for Regeneration of the Tendon-Bone Interface

BACKGROUND

Poor healing of the tendon-bone interface after rotator cuff repair is one of the main causes of surgical failure. Previous studies demonstrated that demineralized cortical bone (DCB) could improve healing of the enthesis.

PURPOSE

To evaluate the outcomes of hierarchically demineralized cortical bone (hDCB) coated with stem cell-derived extracellular matrix (hDCB-ECM) in the repair of the rotator cuff in a rabbit model.

STUDY DESIGN

Controlled laboratory study.

METHODS

Tendon-derived stem cells (TDSCs) were isolated, cultured, and identified. Then, hDCB was prepared by the graded demineralization procedure. Finally, hDCB-ECM was fabricated via 2-week cell culture and decellularization, and the morphologic features and biochemical compositions of the hDCB-ECM were evaluated. A total of 24 rabbits (48 samples) were randomly divided into 4 groups: control, DCB, hDCB, and hDCB-ECM. All rabbits underwent bilateral detachment of the infraspinatus tendon, and the tendon-bone interface was repaired with or without scaffolds. After surgery, 8 rabbits were assessed by immunofluorescence staining at 2 weeks, and the others were assessed by micro-computed tomography (CT) examination, immunohistochemical staining, histological staining, and biomechanical testing at 12 weeks.

RESULTS

TDSCs were identified to have universal stem cell characteristics including cell markers, clonogenicity, and multilineage differentiation. The hDCB-ECM contained 3 components (bone, partial DCB, and DCB coated with ECM) with a gradient of calcium and phosphorus elements, and the ECM had stromal cell-derived factor 1, biglycan, and fibromodulin. Macroscopic observations demonstrated the absence of infection and rupture around the enthesis. The results of immunofluorescence staining showed that hDCB-ECM promoted stromal cell recruitment. Results of micro-CT analysis, immunohistochemical staining, and histological staining showed that hDCB-ECM enhanced bone and fibrocartilage formation at the tendon-bone interface. Biomechanical analysis showed that the hDCB-ECM group had higher ultimate tensile stress and Young modulus than the DCB group.

CONCLUSION

The administration of hDCB-ECM promoted healing of the tendon-bone interface.

CLINICAL RELEVANCE

hDCB-ECM could provide useful information for the design of scaffolds to repair the tendon-bone interface, and further studies are needed to determine its effectiveness.

Engineering multi-tissue units for regenerative Medicine: Bone-tendon-muscle units of the rotator cuff

Our body systems are comprised of numerous multi-tissue units. For the musculoskeletal system, one of the predominant functional units is comprised of bone, tendon/ligament, and muscle tissues working in tandem to facilitate locomotion. To successfully treat musculoskeletal injuries and diseases, critical consideration and thoughtful integration of clinical, biological, and engineering aspects are necessary to achieve translational bench-to-bedside research. In particular, identifying ideal biomaterial design specifications, understanding prior and recent tissue engineering advances, and judicious application of biomaterial and fabrication technologies will be crucial for addressing current clinical challenges in engineering multi-tissue units. Using rotator cuff tears as an example, insights relevant for engineering a bone-tendon-muscle multi-tissue unit are presented. This review highlights the tissue engineering strategies for musculoskeletal repair and regeneration with implications for other bone-tendon-muscle units, their derivatives, and analogous non-musculoskeletal tissue structures.

Biomimetic strategies for tendon/ligament-to-bone interface regeneration

Tendon/ligament-to-bone healing poses a formidable clinical challenge due to the complex structure, composition, cell population and mechanics of the interface. With rapid advances in tissue engineering, a variety of strategies including advanced biomaterials, bioactive growth factors and multiple stem cell lineages have been developed to facilitate the healing of this tissue interface. Given the important role of structure-function relationship, the review begins with a brief description of enthesis structure and composition. Next, the biomimetic biomaterials including decellularized extracellular matrix scaffolds and synthetic-/natural-origin scaffolds are critically examined. Then, the key roles of the combination, concentration and location of various growth factors in biomimetic application are emphasized. After that, the various stem cell sources and culture systems are described. At last, we discuss unmet needs and existing challenges in the ideal strategies for tendon/ligament-to-bone regeneration and highlight emerging strategies in the field.

Subacromial bursal preservation can enhance rotator cuff tendon regeneration: a comparative rat supraspinatus tendon defect model study

BACKGROUND

The role of subacromial bursa in rotator cuff surgery is unknown. This study aimed to assess the subacromial bursa's role in the healing of supraspinatus tendon injury in a rat model.

METHODS

Twenty-three male Sprague-Dawley rats (9 weeks old; weight, approximately 296 g) were used in this study. Three rats used as biomechanical study controls were killed at 12 weeks of age. A supraspinatus tendon defect was made bilaterally in 20 rats, whereas an additional subacromial bursa sectioning was performed on the left side. Six rats were killed for biomechanical testing and 4 were killed for histologic observation at 3 and 9 weeks, respectively.

RESULTS

The regenerated tendon in the bursal preservation group showed significantly superior biomechanical properties in maximum load to failure at 3 and 9 weeks and stiffness at 9 weeks after surgery compared with the bursal removal group. The modified Bonar scale scores showed better regenerated supraspinatus tendons in the bursal preservation group.

CONCLUSION

The present study found that the subacromial bursa plays an important role in rotator cuff regeneration in this rat supraspinatus injury model. Extensive bursectomy of the subacromial bursa may not be recommended in rotator cuff repair surgery, though future in vivo human studies are needed to confirm these observations.

Does Demineralized Bone Matrix Enhance Tendon-to-Bone Healing after Rotator Cuff Repair in a Rabbit Model?

Backgroud

The purpose of this study was to compare the histologic outcomes of rotator cuff (RC) repair with demineralized bone matrix (DBM) augmentation and those without DBM augmentation and to evaluate the role of DBM for tendon-to-bone (TB) healing in a rabbit model.

Methods

Twenty-six adult male New Zealand white rabbits were randomly allocated to the control group (n = 13) or the DBM group (n = 13). Repair was performed 8 weeks after complete transection of the right supraspinatus tendon of all rabbits. In the control group, RC repair was achieved by a standard transosseous technique. In the DBM group, RC repair was achieved using the same technique, and DBM was interposed between the cuff and bone. After 8 weeks, the RC tendon entheses from all rabbits were processed for gross and histologic examination.

Results

On gross TB healing, 2 of 11 specimens in the control group were unhealed and no specimen was grossly unhealed in the DBM group (p = 0.421). In the control group, the tendon midsubstance was disorganized with randomly and loosely arranged collagen fibers and rounded fibroblastic nuclei. The TB interface was predominantly fibrous with small regions of fibrocartilage, especially mineralized fibrocartilage. In the DBM group, the tendon midsubstance appeared normal and comprised densely arranged collagen fibers, with orientated crimped collagen fibers running in the longitudinal direction of the tendon. These fibers were interspersed with elongated fibroblast nuclei. The TB interface consisted of organized collagen fibers with large quantities of fibrocartilage and mineralized fibrocartilage.

Conclusions

The use of DBM for TB interface healing in rabbit experiments showed good results in gross and histologic analysis. However, it is difficult to draw a solid conclusion because the sample size is small. Further evaluation in the in vivo setting is necessary to determine clinical recommendations.

Decellularized porcine xenograft for anterior cruciate ligament reconstruction: A histological study in sheep comparing cross-pin and cortical suspensory femoral fixation

Aims

To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements.

Methods

A total of 12 sheep underwent unilateral single-bundle ACL reconstruction using pSFT. Two femoral fixation devices were investigated: Group 1 (n = 6) used cortical suspensory fixation (Endobutton CL) and Group 2 (n = 6) used cross-pin fixation (Stratis ST). A soft screw was used for tibial fixation. Functional recovery was quantified using force plate analysis at weeks 5, 8, and 11. The sheep were euthanized after 12 weeks and comprehensive histological analysis characterized graft healing at the graft-bone interface and the intra-articular graft (ligamentization).

Results

The pSFT remodelled into a ligament-like structure and no adverse inflammatory reaction was seen. The ground reaction force in the operated leg of the Endobutton group was higher at 11 weeks (p < 0.05). An indirect insertion was seen at the graft-bone interface characterized by Sharpey-like fibres. Qualitative differences in tendon remodelling were seen between the two groups, with greater crimp-like organization and more aligned collagen fibres seen with Endobutton fixation. One graft rupture occurred in the cross-pin group, which histologically showed low collagen organization.

Conclusion

Decellularized pSFT xenograft remodels into a ligament-like structure after 12 weeks and regenerates an indirect-type insertion with Sharpey-like fibres. No adverse inflammatory reaction was observed. Cortical suspensory femoral fixation was associated with more enhanced graft remodelling and earlier functional recovery when compared with the stiffer cross-pin fixation.

Suprascapular nerve neuropathy leads to supraspinatus tendon degeneration

BACKGROUND

Nowadays most of attention regarding rotator cuff is payed to how to reduce the failure after rotator cuff surgical repair rather than how to prevent the rotator cuff tear before surgery. The etiologies of rotator cuff tear are still unclear. As we all know, the nerve system include brain, spinal cord, sensory organs and all the neurons allover our body coordinates the homoeostasis of our body. We hypothesis that the nerve injury proximal to suprascapular nerve can leads to rotator cuff degeneration even tear.

METHODS

Thirty-six SD rats were used. A defect on the suprascapular nerve was made on the right side and a sham surgery on the nerve (expose nerve only) at the left side. The insertion of supraspinatus tendon and supraspinatus muscle were harvested for testing. Twelve rats were sacrificed for biomechanical (six rats) and histological (six rats) properties were evaluated at 3, 6, and 9 weeks after surgery, respectively.

RESULTS

Significant inferior biomechanical properties of rotator cuff were found in nerve injured side compared to the nerve intact side at 6-9 weeks. Significant muscle atrophy was found at nerve injured side from 3 to 9 weeks. The enthesis of nerve injured side showed significant excessive cell maturity, reduced cellularity, smaller metachromasia area and more type-III collagen especially at 9 weeks after surgery.

CONCLUSIONS

The neuropathy proximal to suprascapular nerve can leads to rotator cuff degeneration even tear. The nerve dysfunction maybe an important etiology for rotator cuff tear.

Suprascapular nerve injury affects rotator cuff healing: A paired controlled study in a rat model

Purpose

We designed a paired controlled study to investigate the role of the suprascapular nerve (SSN) in rotator cuff healing using a rat tear model, and we hypothesised that rotator cuff healing is impaired in the absence of a healthy SSN.

Methods

Bilateral supraspinatus tenotomy from the great tuberosity was performed for 36 Wistar rats, which was then repaired immediately. A defect on the SSN was made on the right side, and a sham surgery was performed on the SSN at the left side. Twelve rats were sacrificed for biomechanical (six rats) and histological (six rats) testing, evaluated at 3, 6, and 9 weeks after surgery.

Results

The bone–tendon junction on the nerve-intact side showed significantly better biomechanical characteristics than the nerve-injured side in terms of maximum load, maximum stress over time, stiffness at 9 weeks, and Young's modulus at 3 and 9 weeks. On the nerve-injured side, significantly smaller fibrocartilage layers and muscle fibres could be obtained over time. In addition, on the nerve-injured side, inferior bone–tendon interface formation was obtained in terms of cell maturity, cell alignment, collagen orientation, and the occurrence of tidemark and Sharpey's fibres through 9 weeks. In addition, neuropeptide Y was secreted in the nerve-intact group at 6 and 9 weeks.

Conclusion

This study showed the inferior healing of the bone–tendon junction on the nerve-injured side compared with the nerve-intact side, which indicates that the SSN plays an important role in rotator cuff healing. Surgeons should pay more attention to SSN injury when treating patients with rotator cuff tear.

Bioresorbable Stent in Anterior Cruciate Ligament Reconstruction

The exact causes of failure of anterior cruciate ligament (ACL) reconstruction are still unknown. A key to successful ACL reconstruction is the prevention of bone tunnel enlargement (BTE). In this study, a new strategy to improve the outcome of ACL reconstruction was analyzed using a bioresorbable polylactide (PLA) stent as a catalyst for the healing process. The study included 24 sheep with 12 months of age. The animals were randomized to the PLA group (n = 16) and control group (n = 8), subjected to the ACL reconstruction with and without the implantation of the PLA tube, respectively. The sheep were sacrificed 6 or 12 weeks post-procedure, and their knee joints were evaluated by X-ray microcomputed tomography with a 50 μm resolution. While the analysis of tibial and femoral tunnel diameters and volumes demonstrated the presence of BTE in both groups, the enlargement was less evident in the PLA group. Also, the microstructural parameters of the bone adjacent to the tunnels tended to be better in the PLA group. This suggested that the implantation of a bioresorbable PLA tube might facilitate osteointegration of the tendon graft after the ACL reconstruction. The beneficial effects of the stent were likely associated with osteogenic and osteoconductive properties of polylactide.

Effects of hydrogen peroxide on biological characteristics and osteoinductivity of decellularized and demineralized bone matrices

Due to the similar collagen composition and closely physiological relationship with soft connective tissues, demineralized bone matrices (DBMs) were used to repair the injured tendon or ligament. However, the osteoinductivity of DBMs would be a huge barrier of these applications. Hydrogen peroxide (H₂ O₂ ) has been proved to reduce the osteoinductivity of DBMs. Nevertheless, the biological properties of H₂ O₂ -treated DBMs have not been evaluated completely, while the potential mechanism of H₂ O₂ compromising osteoinductivity is also unclear. Hence, the purpose of this study was to characterize the biological properties of H₂ O₂ -treated DBMs and search for the proof that H₂ O₂ could compromise osteoinductivity of DBMs. Decellularized and demineralized bone matrices (DCDBMs) were washed by 3% H₂ O₂ for 12 h to fabricate the H₂ O₂ -treated DCDBMs (HPTBMs). Similar biological properties including collagen, biomechanics, and biocompatibility were observed between DCDBMs and HPTBMs. The immunohistochemistry staining of bone morphogenetic protein 2 (BMP-2) was negative in HPTBMs. Furthermore, HPTBMs exhibited significantly reduced osteoinductivity both in vitro and in vivo. Taken together, these findings suggest that the BMP-2 in DCDBMs could be the target of H₂ O₂ . HPTBMs could be expected to be used as a promising scaffold for tissue engineering. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part A, 2019.

Use of stem cells and growth factors in rotator cuff tendon repair

The management of rotator cuff tears continues to prove challenging for orthopaedic surgeons. Such tears affect most age groups and can lead to significant morbidity in patients. The aetiology of these tears is likely to be multifactorial; however, an understanding of the mechanisms involved is still under review. Despite advancements in surgical operative techniques and the materials used, post-operative recurrence rates after surgical repair remain high. A growing area of research surrounds biological adjuncts used to improve the healing potential of the repaired tissues. This review of recent publications focuses on the strengths and limitations of using stem cells and growth factors in rotator cuff repair.

Integrating soft and hard tissues via interface tissue engineering

The enthesis, or interface between bone and soft tissues such as ligament and tendon, is prone to injury and often does not heal, even post surgical intervention. Interface tissue engineering represents an integrative strategy for regenerating the native enthesis by functionally connecting soft and hard tissues and thereby improving clinical outcome. This review focuses on integrative and cell-instructive scaffold designs that target the healing of the two most commonly injured soft tissue-bone junctions: tendon-bone interface (e.g., rotator cuff) and ligament-bone interface (e.g., anterior cruciate ligament). The inherent connectivity between soft and hard tissues is instrumental for musculoskeletal motion and is therefore a key design criterion for soft tissue regeneration. To this end, scaffold design for soft tissue regeneration have progressed from single tissue systems to the emerging focus on pre-integrated and functional composite tissue units. Specifically, a multifaceted, bioinspired approach has been pursued wherein scaffolds are tailored to stimulate relevant cell responses using spatially patterned structural and chemical cues, growth factors, and/or mechanical stimulation. Moreover, current efforts to elucidate the essential scaffold design criteria via strategic biomimicry are emphasized as these will reduce complexity in composite tissue regeneration and ease the related burden for clinical translation. These innovative studies underscore the clinical relevance of engineering connective tissue integration and have broader impact in the formation of complex tissues and total joint regeneration. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1069-1077, 2018.

Bone Marrow-Derived Mesenchymal Stromal Cells Enhanced by Platelet-Rich Plasma Maintain Adhesion to Scaffolds in Arthroscopic Simulation

PURPOSE

To assess the response of bone marrow-derived mesenchymal stromal cells (bMSCs) enhanced by platelet-rich plasma (PRP) in the setting of a normal human tendon (NHT), a demineralized bone matrix (DBM), and a fibrin scaffold (FS) with simulated arthroscopic mechanical washout stress.

METHODS

Bone marrow was aspirated from the humeral head and concentrated. BMSCs were counted, plated, and grown to confluence. Cells were seeded onto 3 different scaffolds: (1) NHT, (2) DBM, and (3) FS. Each scaffold was treated with a combination of (+)/(-) PRP and (+)/(-) arthroscopic washout simulation. A period of 60 minutes was allotted before arthroscopic washout. Adhesion, proliferation, and differentiation assays were performed to assess cellular activity in each condition.

RESULTS

Significant differences were seen in mesenchymal stromal cell adhesion, proliferation, and differentiation among the scaffolds. DBM and FS showed superior results to NHT for cell adhesion, proliferation, and differentiation. PRP significantly enhanced cellular adhesion, proliferation, and differentiation. Arthroscopic simulation did not significantly decrease bMSC adhesion.

CONCLUSIONS

We found that the type of scaffold impacts bMSCs' behavior. Both scaffolds (DBM and FS) were superior to NHT. The use of an arthroscopic simulator did not significantly decrease the adhesion of bMSCs to the scaffolds nor did it decrease their biologic differentiation potential. In addition, PRP enhanced cellular adhesion, proliferation, and differentiation.

CLINICAL RELEVANCE

Improved healing after tendon repair can lead to better clinical outcomes. BMSCs are attractive for enhancing healing given their accessibility and regenerative potential. Application of bMSCs using scaffolds as cell carriers relies on arthroscopic feasibility.

Biological augmentation of graft healing in anterior cruciate ligament reconstruction: a systematic review

Aims

The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR.

Materials and Methods

In all, 1879 studies were identified across three databases. Following assessment against strict criteria, 112 studies were included (20 clinical studies; 92 animal studies).

Results

Seven categories of biological interventions were identified: growth factors, biomaterials, stem cells, gene therapy, autologous tissue, biophysical/environmental, and pharmaceuticals. The methodological quality of animal studies was moderate in 97%, but only 10% used clinically relevant outcome measures. The most interventions in clinical trials target the graft-tunnel interface and are applied intraoperatively. Platelet-rich plasma is the most studied intervention, but the clinical outcomes are mixed, and the methodological quality of studies was suboptimal. Other biological therapies investigated in clinical trials include: remnant-augmented ACLR; bone substitutes; calcium phosphate-hybridized grafts; extracorporeal shockwave therapy; and adult autologus non-cultivated stem cells.

Conclusion

There is extensive preclinical research supporting the use of biological therapies to augment ACLR. Further clinical studies that meet the minimum standards of reporting are required to determine whether emerging biological strategies will provide tangible benefits in patients undergoing ACLR. Cite this article: Bone Joint J 2018;100-B:271-84.

Application of a Demineralized Cortical Bone Matrix and Bone Marrow-Derived Mesenchymal Stem Cells in a Model of Chronic Rotator Cuff Degeneration

BACKGROUND

The success of rotator cuff repair is primarily dependent on tendon-bone healing. Failure is common because weak scar tissue replaces the native enthesis, rendering it prone to reruptures. A demineralized bone matrix (DBM) consists of a network of collagen fibers that provide a sustained release of growth factors such as bone morphogenetic proteins. Previous studies have demonstrated that it can regenerate a fibrocartilaginous enthesis.

HYPOTHESIS

The use of a DBM and mesenchymal stem cells (MSCs) at the healing enthesis will result in a higher bone mineral density at the tendon insertion and will enhance the regeneration of a morphologically superior enthesis when compared with an acellular human dermal matrix.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Three weeks later, tendon repair was carried out in animals randomized into 3 groups: group 1 received augmentation of the repair with a cortical allogenic DBM (n = 6); group 2 received augmentation with a nonmeshed, ultrathick, acellular human dermal matrix (n = 6); and group 3 underwent tendon-bone repair without a scaffold (n = 6). All animals received 1 × 10⁶ MSCs delivered in fibrin glue to the repair site. Specimens were retrieved at 6 weeks postoperatively for histological analysis and the evaluation of bone mineral density.

RESULTS

All groups demonstrated closure of the tendon-bone gap with a fibrocartilaginous enthesis. Although there were no significant differences in the enthesis maturation and modified Movin scores, repair augmented with a dermal matrix + MSCs exhibited a disorganized enthesis, abnormal collagen fiber arrangement, and greater cellularity compared with other MSC groups. Only repairs augmented with a DBM + MSCs reached a bone mineral density not significantly lower than nonoperated controls.

CONCLUSION

A DBM enhanced with MSCs can augment rotator cuff healing at 6 weeks and restore bone mineral density at the enthesis to its preinjury levels.

CLINICAL RELEVANCE

Biological augmentation of rotator cuff repair with a DBM and MSCs may reduce the incidence of retears, although further studies are required to determine its effectiveness.

Demineralized Bone Matrix to Augment Tendon-Bone Healing: A Systematic Review

Background:

Following injury to the rotator cuff and anterior cruciate ligament, a direct enthesis is not regenerated, and healing occurs with biomechanically inferior fibrous tissue. Demineralized bone matrix (DBM) is a collagen scaffold that contains growth factors and is a promising biological material for tendon and ligament repair because it can regenerate a direct fibrocartilaginous insertion via endochondral ossification.

Purpose:

To provide a comprehensive review of the literature investigating the use of DBM to augment tendon-bone healing in tendon repair and anterior cruciate ligament reconstruction (ACLR).

Study Design:

Systematic review.

Methods:

Electronic databases (MEDLINE and EMBASE) were searched for preclinical and clinical studies that evaluated the use of DBM in tendon repair and ACLR. Search terms included the following: (“demineralized bone matrix” OR “demineralized cortical bone”) AND (“tissue scaffold” OR “tissue engineering” OR “ligament” OR “tendon” OR “anterior cruciate ligament” OR “rotator cuff”). Peer-reviewed articles written in English were included, and no date restriction was applied (searches performed February 10, 2017). Methodological quality was assessed with peer-reviewed scoring criteria.

Results:

The search strategy identified 339 articles. After removal of duplicates and screening according to inclusion criteria, 8 studies were included for full review (tendon repair, n = 4; ACLR, n = 4). No human clinical studies were identified. All 8 studies were preclinical animal studies with good methodological quality. Five studies compared DBM augmentation with non-DBM controls, of which 4 (80%) reported positive findings in terms of histological and biomechanical outcomes.

Conclusion:

Preclinical evidence indicates that DBM can improve tendon-bone healing, although clinical studies are lacking. A range of animal models of tendon repair and ACLR showed that DBM can re-create a direct fibrocartilaginous enthesis, although the animal models are not without limitations. Before clinical trials are justified, research is required that determines the best source of DBM (allogenic vs xenogenic) and the best form of DBM (demineralized cortical bone vs DBM paste) to be used in them.

Next Generation Tissue Engineering of Orthopedic Soft Tissue-to-Bone Interfaces

Soft tissue-to-bone interfaces are complex structures that consist of gradients of extracellular matrix materials, cell phenotypes, and biochemical signals. These interfaces, called entheses for ligaments, tendons, and the meniscus, are crucial to joint function, transferring mechanical loads and stabilizing orthopedic joints. When injuries occur to connected soft tissue, the enthesis must be re-established to restore function, but due to structural complexity, repair has proven challenging. Tissue engineering offers a promising solution for regenerating these tissues. This prospective review discusses methodologies for tissue engineering the enthesis, outlined in three key design inputs: materials processing methods, cellular contributions, and biochemical factors.

Supraspinatus detachment causes musculotendinous degeneration and a reduction in bone mineral density at the enthesis in a rat model of chronic rotator cuff degeneration

BACKGROUND

To evaluate biological strategies that enhance tendon-bone healing in humans, it is imperative that suitable animal models accurately reproduce the pathological changes observed in the clinical setting following a tear. The purpose of the present study was to investigate rotator cuff degeneration in a rat, as well as assess the development of osteopenia at the enthesis following tendon detachment.

METHODS

Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Specimens were retrieved at 4 weeks (n = 6), 6 weeks (n = 6) and 9 weeks (n = 6) postoperatively for histological analysis and peripheral quantitative computer tomography.

RESULTS

Three weeks following tendon detachment, there was a significant increase in the modified Movin score, characterized by a loss of muscle mass, fatty infiltration, an increase in musculotendinous cellularity, loss of normal collagen fibre structure/arrangement, rounded tenocyte nuclei and an increase in the number of vascular bundles. This was accompanied by a reduction in bone mineral density at the tendon insertion site. After 3 weeks however, these changes were less prominent.

CONCLUSIONS

The rotator cuff tendon-muscle-bone unit in a rat model 3 weeks after detachment of supraspinatus represents a valid model for investigating rotator cuff degeneration.

The effectiveness of demineralized cortical bone matrix in a chronic rotator cuff tear model

BACKGROUND

The purpose of this study was to assess the effect of demineralized bone matrix (DBM) on rotator cuff tendon-bone healing. The hypothesis was that compared with a commercially available dermal matrix scaffold, DBM would result in a higher bone mineral density and regenerate a morphologically superior enthesis in a rat model of chronic rotator cuff degeneration.

METHODS

Eighteen female Wistar rats underwent unilateral detachment of the supraspinatus tendon. Three weeks later, tendon repair was carried out in animals randomized into 3 groups: group 1 animals were repaired with DBM (n = 6); group 2 received augmentation with the dermal scaffold (n = 6); and group 3 (controls) underwent nonaugmented tendon-bone repair (n = 6). Specimens were retrieved at 6 weeks postoperatively for histologic analysis and evaluation of bone mineral density.

RESULTS

No failures of tendon-bone healing were noted throughout the study. All groups demonstrated closure of the tendon-bone gap with a fibrocartilaginous interface. Dermal collagen specimens exhibited a disorganized structure with significantly more abnormal collagen fiber arrangement and cellularity than in the DBM-based repairs. Nonaugmented repairs exhibited a significantly higher bone mineral density than in DBM and the dermal collagen specimens and were not significantly different from control limbs that were not operated on.

CONCLUSION

The application of DBM to a rat model of chronic rotator cuff degeneration did not improve the composition of the healing enthesis compared with nonaugmented controls and a commercially available scaffold. However, perhaps the most important finding of this study was that the control group demonstrated a similar outcome to augmented repairs.

Augmentation and repair of tendons using demineralised cortical bone

BACKGROUND

In severe injuries with loss of tendon substance a tendon graft or a synthetic substitute is usually used to restore functional length. This is usually associated with donor site morbidity, host tissue reactions and lack of remodelling of the synthetic substitutes, which may result in suboptimal outcome. A biocompatible graft with mechanical and structural properties that replicate those of normal tendon and ligament has so far not been identified. The use of demineralised bone for tendon reattachment onto bone has been shown to be effective in promoting the regeneration of a normal enthesis. Because of its properties, we proposed that Demineralised Cortical Bone (DCB) could be used in repair of a large tendon defect.

METHODS

Allogenic DCB grafts in strip form were prepared from sheep cortical bone by acid decalcification and used to replace the enthesis and distal 1 cm of the ovine patellar tendon adjacent to the tibial tuberosity. In 6 animals the DCB strip was used to bridge the gap between the resected end of the tendon and was attached with bone anchors. Force plate analysis was done for each animal preoperatively and at weeks 3, 9, and 12 post operatively. At week 12, after euthanasia x-rays were taken and range of movements were recorded for hind limbs of each animal. Patella, patellar tendon - DCB and proximal tibia were harvested as a block and pQCT scan was done prior to histological analysis.

RESULTS

Over time functional weight bearing significantly increased from 44% at 3 weeks post surgery to 79% at week 12. On retrieval none of the specimens showed any evidence of ossification of the DCB. Histological analysis proved formation of neo-enthesis with presence of fibrocartilage and mineralised fibrocartilage in all the specimens. DCB grafts contained host cells and showed evidence of vascularisation. Remodelling of the collagen leading to ligamentisation of the DCB was proved by the presence of crimp in the DCB graft on polarized microscopy.

CONCLUSION

Combined with the appropriate surgical techniques, DCB can be used to achieve early mobilization and regeneration of a tendon defect which may be applicable to the repair of chronic rotator cuff injury in humans.

Tendon Reattachment to Bone in an Ovine Tendon Defect Model of Retraction Using Allogenic and Xenogenic Demineralised Bone Matrix Incorporated with Mesenchymal Stem Cells

Background

Tendon-bone healing following rotator cuff repairs is mainly impaired by poor tissue quality. Demineralised bone matrix promotes healing of the tendon-bone interface but its role in the treatment of tendon tears with retraction has not been investigated. We hypothesized that cortical demineralised bone matrix used with minimally manipulated mesenchymal stem cells will result in improved function and restoration of the tendon-bone interface with no difference between xenogenic and allogenic scaffolds.

Materials and Methods

In an ovine model, the patellar tendon was detached from the tibial tuberosity and a complete distal tendon transverse defect measuring 1 cm was created. Suture anchors were used to reattach the tendon and xenogenic demineralised bone matrix + minimally manipulated mesenchymal stem cells (n = 5), or allogenic demineralised bone matrix + minimally manipulated mesenchymal stem cells (n = 5) were used to bridge the defect. Graft incorporation into the tendon and its effect on regeneration of the enthesis was assessed using histomorphometry. Force plate analysis was used to assess functional recovery.

Results

Compared to the xenograft, the allograft was associated with significantly higher functional weight bearing at 6 (P = 0.047), 9 (P = 0.028), and 12 weeks (P = 0.009). In the allogenic group this was accompanied by greater remodeling of the demineralised bone matrix into tendon-like tissue in the region of the defect (p = 0.015), and a more direct type of enthesis characterized by significantly more fibrocartilage (p = 0.039). No failures of tendon-bone healing were noted in either group.

Conclusion

Demineralised bone matrix used with minimally manipulated mesenchymal stem cells promotes healing of the tendon-bone interface in an ovine model of acute tendon retraction, with superior mechanical and histological results associated with use of an allograft.

Augmentation of Rotator Cuff Repair With Soft Tissue Scaffolds

Background

Tears of the rotator cuff are one of the most common tendon disorders. Treatment often includes surgical repair, but the rate of failure to gain or maintain healing has been reported to be as high as 94%. This has been substantially attributed to the inadequate capacity of tendon to heal once damaged, particularly to bone at the enthesis. A number of strategies have been developed to improve tendon-bone healing, tendon-tendon healing, and tendon regeneration. Scaffolds have received considerable attention for replacement, reconstruction, or reinforcement of tendon defects but may not possess situation-specific or durable mechanical and biological characteristics.

Purpose

To provide an overview of the biology of tendon-bone healing and the current scaffolds used to augment rotator cuff repairs.

Study Design

Systematic review; Level of evidence, 4.

Methods

A preliminary literature search of MEDLINE and Embase databases was performed using the terms rotator cuff scaffolds, rotator cuff augmentation, allografts for rotator cuff repair, xenografts for rotator cuff repair, and synthetic grafts for rotator cuff repair.

Results

The search identified 438 unique articles. Of these, 214 articles were irrelevant to the topic and were therefore excluded. This left a total of 224 studies that were suitable for analysis.

Conclusion

A number of novel biomaterials have been developed into biologically and mechanically favorable scaffolds. Few clinical trials have examined their effect on tendon-bone healing in well-designed, long-term follow-up studies with appropriate control groups. While there is still considerable work to be done before scaffolds are introduced into routine clinical practice, there does appear to be a clear indication for their use as an interpositional graft for large and massive retracted rotator cuff tears and when repairing a poor-quality degenerative tendon.

Scaffolds for tendon and ligament repair and regeneration

Enhanced tendon and ligament repair would have a major impact on orthopedic surgery outcomes, resulting in reduced repair failures and repeat surgeries, more rapid return to function, and reduced health care costs. Scaffolds have been used for mechanical and biologic reinforcement of repair and regeneration with mixed results. This review summarizes efforts made using biologic and synthetic scaffolds using rotator cuff and ACL as examples of clinical applications, discusses recent advances that have shown promising clinical outcomes, and provides insight into future therapy.

Engineering complex orthopaedic tissues via strategic biomimicry

The primary current challenge in regenerative engineering resides in the simultaneous formation of more than one type of tissue, as well as their functional assembly into complex tissues or organ systems. Tissue-tissue synchrony is especially important in the musculoskeletal system, wherein overall organ function is enabled by the seamless integration of bone with soft tissues such as ligament, tendon, or cartilage, as well as the integration of muscle with tendon. Therefore, in lieu of a traditional single-tissue system (e.g., bone, ligament), composite tissue scaffold designs for the regeneration of functional connective tissue units (e.g., bone-ligament-bone) are being actively investigated. Closely related is the effort to re-establish tissue-tissue interfaces, which is essential for joining these tissue building blocks and facilitating host integration. Much of the research at the forefront of the field has centered on bioinspired stratified or gradient scaffold designs which aim to recapitulate the structural and compositional inhomogeneity inherent across distinct tissue regions. As such, given the complexity of these musculoskeletal tissue units, the key question is how to identify the most relevant parameters for recapitulating the native structure-function relationships in the scaffold design. Therefore, the focus of this review, in addition to presenting the state-of-the-art in complex scaffold design, is to explore how strategic biomimicry can be applied in engineering tissue connectivity. The objective of strategic biomimicry is to avoid over-engineering by establishing what needs to be learned from nature and defining the essential matrix characteristics that must be reproduced in scaffold design. Application of this engineering strategy for the regeneration of the most common musculoskeletal tissue units (e.g., bone-ligament-bone, muscle-tendon-bone, cartilage-bone) will be discussed in this review. It is anticipated that these exciting efforts will enable integrative and functional repair of soft tissue injuries, and moreover, lay the foundation for the development of composite tissue systems and ultimately, total limb or joint regeneration.

Demineralized bone matrix in extraction sockets: a clinical and histologic case series

PURPOSE

To evaluate its efficacy and predictability in immediate extraction sockets, this case series used demineralized bone matrix in a puttylike carrier (DBM putty) with and without mineralized bone chips. Each preparation was made from the long bones of the same tissue donor; the only excipient material was water.

MATERIAL AND METHODS

A single failing tooth was atraumatically extracted from each study subject, and the socket was debrided. Intact sockets were grafted with DBM putty (n = 6), and sockets with buccal defects were grafted with DBM putty with bone chips (n = 6). A bovine pericardium membrane was draped over the graft site, and tension-free primary closure was obtained. After 6 months of healing, a trephine biopsy was taken from the center of each graft, and then, a dental implant was placed. Two subjects were withdrawn, and histologic data could not be obtained from 2 other patients.

RESULTS

Mean new bone fill was 40.28% for DBM putty (n = 5) and 44.60% for DBM putty with bone chips (n = 4).

CONCLUSIONS

Both preparations maintained ridge dimensions and, despite ongoing bone turnover, produced adequate mineralized tissue that enabled implant placement at 6 months. This finding warrants further research.

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.

Effects of demineralized bone matrix on tendon-bone healing in an intra-articular rodent model

BACKGROUND

Techniques to improve and accelerate tendon-bone healing could be advantageous in anterior cruciate ligament (ACL) reconstruction. Effects of demineralized bone matrix (DBM) on intra-articular tendon-bone healing have not been examined.

HYPOTHESIS

Demineralized bone matrix has the potential to convey osteoinductive growth proteins to the site of healing at the tendon-bone interface. We hypothesized that the presence of DBM will result in more bone formation and hasten tendon-bone healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifty-six female athymic rnu/rnu (nude) rats were used. Rats were randomly allocated into 2 groups (control or treatment). The control group underwent an ACL reconstruction, while the treatment group had human DBM implanted in the tendon graft and bone tunnel before reconstruction. Rats were sacrificed at 2 (n = 8), 4 (n = 24), and 6 (n = 24) weeks for histological, and immunohistochemical (t = 2, 4, and 6 weeks), and biomechanical testing and micro-computed tomography (t = 4 and 6 weeks) end points.

RESULTS

Our findings suggest that in the presence of DBM, tendon-bone healing is augmented by increased woven bone formation and enhanced bone remodeling as indicated by histology and micro-computed tomography. This ultimately resulted in a statistically significant increase in peak load to failure of the tendon-bone interface at 4 weeks (DBM group: 5.96 ± 1.36 N; control group: 2.86 ± 0.7 N) and 6 weeks (DBM group: 9.13 ± 0.97 N; control group: 5.81 ± 1.1 N).

CONCLUSION

Demineralized bone matrix at the tendon-bone interface promotes healing between the tendon and bone in a rodent ACL model.

CLINICAL RELEVANCE

Introduction of osteoinductive DBM at the tendon-bone interface during ACL reconstructive surgery may improve short-term outcomes.

Reconstruction of the extensor mechanism after major knee resection

In periarticular knee resections, the relative lack of soft tissue coverage and need to reattach the extensor mechanism after en bloc resection of the tibial tuberosity with the tumor specimen complicate reconstructions and decrease postoperative function and stability of the knee joint. Distal femoral reconstructions are less problematic; muscular attachments are relatively few, neurovascular structures are not immediately adjacent to bone, and the knee extensor mechanism is usually not compromised from bone tumors. In the proximal tibia, the close proximity of the neurovascular structures in the popliteal fossa and peroneal nerve at the lateral aspect of the leg make reconstruction more difficult. Poor function is mostly related to unreliable options for knee extensor mechanism reattachment and poor soft tissue coverage. Successful and reliable attachment of the soft tissues has been a significant advance that improved functional outcomes.This article describes techniques for the reconstruction of the extensor mechanism of the knee after proximal tibia resections. Combined reconstruction techniques using direct reattachment of the patellar tendon with synthetic materials to megaprosthetic or allograft reconstructions for immediate stability, augmentation with autologous bone graft or substitutes at the attachment site, and coverage with the medial gastrocnemius muscle flap and supplementary flaps for long-term stability of the reattachment are currently considered the gold standard.

Platelet-rich plasma reverses the inhibition of tenocytes and osteoblasts in tendon-bone healing

The purpose of this study was to investigate the effect of platelet-rich plasma on the proliferation of osteoblasts and tenocytes in tendon-bone healing. We cultured osteoblasts and tenocytes in an indirect coculture system with Transwell filters (Merck Millipore, Billerica, Massachusetts). The proliferation was examined using Cell Counting Kit-8 (Dojindo Chemistry Research Institute, Kumamoto, Japan).Four groups were studied: group 1, one cell type cultured without platelet-rich plasma; group 2, two cell types cultured together in an indirect coculture system without platelet-rich plasma; group 3, cells in the outer chamber and platelet-rich plasma in the inner chamber; and group 4, two different cell types in each of the 2 chambers with platelet-rich plasma in the inner chamber. The proliferation rates of groups 3 and 4 were the highest, followed by group 1 and then group 2, which was the lowest.Platelet-rich plasma abolishes the inhibition of osteoblasts or tenocytes in an indirect coculture system and improves the cell proliferation rate.

Biomimetic scaffold design for functional and integrative tendon repair

Rotator cuff tears represent the most common shoulder injuries in the United States. The debilitating effect of this degenerative condition coupled with the high incidence of failure associated with existing graft choices underscores the clinical need for alternative grafting solutions. The 2 critical design criteria for the ideal tendon graft would require the graft to not only exhibit physiologically relevant mechanical properties but also be able to facilitate functional graft integration by promoting the regeneration of the native tendon-to-bone interface. Centered on these design goals, this review will highlight current approaches to functional and integrative tendon repair. In particular, the application of biomimetic design principles through the use of nanofiber- and nanocomposite-based scaffolds for tendon tissue engineering will be discussed. This review will begin with nanofiber-based approaches to functional tendon repair, followed by a section highlighting the exciting research on tendon-to-bone interface regeneration, with an emphasis on implementation of strategic biomimicry in nanofiber scaffold design and the concomitant formation of graded multi-tissue systems for integrative soft-tissue repair. This review will conclude with a summary and discussion of future directions.

Augmentation of bone tunnel healing in anterior cruciate ligament grafts: application of calcium phosphates and other materials

Bone tunnel healing is an important consideration after anterior cruciate ligament (ACL) replacement surgery. Recently, a variety of materials have been proposed for improving this healing process, including autologous bone tissue, cells, artificial proteins, and calcium salts. Amongst these materials are calcium phosphates (CaPs), which are known for their biocompatibility and are widely commercially available. As with the majority of the materials investigated, CaPs have been shown to advance the healing of bone tunnel tissue in animal studies. Mechanical testing shows fixation strengths to be improved, particularly by the application of CaP-based cement in the bone tunnel. Significantly, CaP-based cements have been shown to produce improvements comparable to those induced by potentially more complex treatments such as biologics (including fibronectin and chitin) and cultured cells. Further investigation of CaP-based treatment in the bone tunnels during ACL replacement is therefore warranted in order to establish what improvements in healing and resulting clinical benefits may be achieved through its application.

Engineering an in vitro model of a functional ligament from bone to bone

For musculoskeletal tissues that transmit loads during movement, the interfaces between tissues are essential to minimizing injury. Therefore, the reproduction of functional interfaces within engineered musculoskeletal tissues is critical to the successful transfer of the technology to the clinic. The goal of this work was to rapidly engineer ligament equivalents in vitro that contained both the soft tissue sinew and a hard tissue bone mimetic. This goal was achieved using cast brushite (CaHPO(4)·2H(2)O) anchors to mimic bone and a fibrin gel embedded with fibroblasts to create the sinew. The constructs formed within 7 days. Fourteen days after seeding, the interface between the brushite and sinew could withstand a stress of 9.51 ± 1.7  kPa before failure and the sinew reached a Young's modulus value of 0.16 ± 0.03  MPa. Treatment with ascorbic acid and proline increased the collagen content of the sinew (from 1.34% ± 0.2% to 8.34% ± 0.37%), strength of the interface (29.24 ± 6  kPa), and modulus of the sinew (2.69 ± 0.25  MPa). Adding transforming growth factor-β resulted in a further increase in collagen (11.25% ± 0.39%), interface strength (42 ± 8  kPa), and sinew modulus (5.46 ± 0.68  MPa). Both scanning electron and Raman microscopy suggested that the interface between the brushite and sinew mimics the in vivo tidemark at the enthesis. This work describes a major step toward the development of tissue-engineered ligaments for the repair of ligament ruptures in humans.

Graft healing in anterior cruciate ligament reconstruction

Successful anterior cruciate ligament reconstruction with a tendon graft necessitates solid healing of the tendon graft in the bone tunnel. Improvement of graft healing to bone is crucial for facilitating an early and aggressive rehabilitation and ensuring rapid return to pre-injury levels activity. Tendon graft healing in a bone tunnel requires bone ingrowth into the tendon. Indirect Sharpey fiber formation and direct fibrocartilage fixation confer different anchorage strength and interface properties at the tendon-bone interface. For enhancing tendon graft-to-bone healing, we introduce a strategy that includes the use of periosteum, hydrogel supplemented with periosteal progenitor cells and bone morphogenetic protein-2, and a periosteal progenitor cell sheet. Future studies include the use of cytokines, gene therapy, stem cells, platelet-rich plasma, and mechanical stress for tendon-to-bone healing. These strategies are currently under investigation, and will be applied in the clinical setting in the near future.

Tendon re-attachment to metal prostheses in an in vivo animal model using demineralised bone matrix

We used demineralised bone matrix (DBM) to augment re-attachment of tendon to a metal prosthesis in an in vivo ovine model of reconstruction of the extensor mechanism at the knee. We hypothesised that augmentation of the tendon-implant interface with DBM would enhance the functional and histological outcomes as compared with previously reported control reconstructions without DBM. Function was assessed at six and 12 weeks postoperatively, and histological examination was undertaken at 12 weeks. A significant increase of 23.5% was observed in functional weight-bearing at six weeks in the DBM-augmented group compared with non-augmented controls (p = 0.004). By 12 weeks augmentation with DBM resulted in regeneration of a more direct-type enthesis, with regions of fibrocartilage, mineralised fibrocartilage and bone. In the controls the interface was predominantly indirect, with the tendon attached to the bone graft-hydroxyapatite base plate by perforating collagen fibres.