Semiquantitative reverse transcription-polymerase chain reaction analysis of mRNA for growth factors and growth factor receptors from normal and healing rabbit medial collateral ligament tissue

Current progress in growth factors and extracellular vesicles in tendon healing

Tendon injury healing is a complex process that involves the participation of a significant number of molecules and cells, including growth factors molecules in a key role. Numerous studies have demonstrated the function of growth factors in tendon healing, and the recent emergence of EV has also provided a new visual field for promoting tendon healing. This review examines the tendon structure, growth, and development, as well as the physiological process of its healing after injury. The review assesses the role of six substances in tendon healing: insulin-like growth factor-I (IGF-I), transforming growth factor β (TGFβ), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and EV. Different growth factors are active at various stages of healing and exhibit separate physiological activities. IGF-1 is expressed immediately after injury and stimulates the mitosis of various cells while suppressing the response to inflammation. VEGF, which is also active immediately after injury, accelerates local metabolism by promoting vascular network formation and positively impacts the activities of other growth factors. However, VEGF's protracted action could be harmful to tendon healing. PDGF, the earliest discovered cytokine to influence tendon healing, has a powerful cell chemotaxis and promotes cell proliferation, but it can equally accelerate the response to inflammation and relieve local adhesions. Also useful for relieving tendon adhesion is TGF- β, which is active almost during the entire phase of tendon healing. As a powerful active substance, in addition to its participation in the field of cardiovascular and cerebrovascular vessels, tumour and chronic wounds, TGF- β reportedly plays a role in promoting cell proliferation, activating growth factors, and inhibiting inflammatory response during tendon healing.

The Auxin-Response Repressor IAA30 Is Down-Regulated in Reproductive Tissues of Apomictic Paspalum notatum

The capacity for apomixis in Paspalum notatum is controlled by a single-dominant genomic region, which shows strong synteny to a portion of rice chromosome 12 long arm. The locus LOC_Os12g40890, encoding the Auxin/Indole-3-Acetic Acid (Aux/IAA) family member OsIAA30, is located in this rice genomic segment. The objectives of this work were to identify transcripts coding for Aux/IAA proteins expressed in reproductive tissues of P. notatum, detect the OsIAA30 putative ortholog and analyze its temporal and spatial expression pattern in reproductive organs of sexual and apomictic plants. Thirty-three transcripts coding for AUX/IAA proteins were identified. Predicted protein alignment and phylogenetic analysis detected a highly similar sequence to OsIAA30 (named as PnIAA30) present in both sexual and apomictic samples. The expression assays of PnIAA30 showed a significant down-regulation in apomictic spikelets compared to sexual ones at the stages of anthesis and post-anthesis, representation levels negatively correlated with apospory expressivity and different localizations in sexual and apomictic ovules. Several PnIAA30 predicted interactors also appeared differentially regulated in the sexual and apomictic floral transcriptomes. Our results showed that an auxin-response repressor similar to OsIAA30 is down-regulated in apomictic spikelets of P. notatum and suggests a contrasting regulation of auxin signaling during sexual and asexual seed formation.

No Treatment Benefits of Local Administration of Insulin-like Growth Factor-1 in Addition to Heavy Slow Resistance Training in Tendinopathic Human Patellar Tendons: A Randomized, Double-Blind, Placebo-Controlled Trial With 1-Year Follow-up

BACKGROUND

Heavy slow resistance (HSR) training is currently recommended as part of the treatment of patellar tendon tendinopathy. However, treatment success is not reached in all patients, and combinations of different treatments could be beneficial. Local administration of insulin-like growth factor-1 (IGF-1) in humans has been shown to quickly stimulate tendon collagen synthesis.

PURPOSE

To study whether IGF-1 injections combined with HSR training enhance tendon synthesis, tissue structure, and patient satisfaction versus saline injection combined with HSR training in patients with patellar tendinopathy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Forty patients (age 18-50 years) with unilateral patellar tendinopathy undertook HSR training (3 times a week for 12 weeks) and received intratendinous IGF-1 injections (1 mg IGF-1 per dose) or isotonic saline injections (sham injections) at baseline and after 1 and 2 weeks of training. The primary outcome was collagen synthesis parameters after 12 weeks (primary endpoint). The secondary outcomes were patient-reported outcomes (scores on the Victorian Institute of Sport Assessment-Patella [VISA-P] and visual analog scale [VAS] for pain) and structural changes before the initiation of treatment and at week 3, week 12, and 1 year after the initiation of treatment.

RESULTS

Analysis of the patellar tendon biopsy specimens at 12 weeks showed that collagen mRNA and total RNA were increased in the tendinopathic tendons compared with the contralateral healthy tendons regardless of treatment with IGF-1 or saline. Similarly, no difference between the groups was seen in tendon thickness and Doppler activity at week 12 or at 1-year follow-up. The combination of HSR training and IGF-1 injections significantly improved VISA-P and VAS pain scores after 3 weeks, whereas the overall responses after 12 weeks and at 1-year follow-up were identical in the 2 groups.

CONCLUSION

Although a small, immediate clinical response to IGF-1 injections was seen when combined with training, no additional long-term effect of intratendinous IGF-1 was observed on structural and clinical outcomes in patients with patellar tendinopathy.

REGISTRATION

NCT01834989 (ClinicalTrials.gov identifier).

Restoration of cartilage defects using a superparamagnetic iron oxide-labeled adipose-derived mesenchymal stem cell and TGF-β3-loaded bilayer PLGA construct

Aim: We aimed to evaluate the capacity of the bilayer polylactic-co-glycolic acid (PLGA)/TGF-β3/adipose-derived mesenchymal stem cell (ADSC) construct used to repair cartilage defects and the role of ADSCs in the repair process in vivo. Materials & methods: Defects were created surgically on the femoropatellar groove of knee joints in 64 rabbits. All the rabbits were randomly divided into four groups: defect group, PLGA group, PLGA/TGF-β3 group and PLGA/TGF-β3/ADSC group. In vivo MRI and Prussian blue staining were applied. Quantitative real-time PCR and western blot methods were used to analyze the gene and protein expression. Results & conclusion: The result showed that TGF-β3 could effectively stimulate the expressions of aggrecan, collagen type II and SRY-related HMG box 9 (SOX9). The bilayer PLGA/TGF-β3/ADSC construct showed a promising repair effect.

Mesenchymal Stem Cells Seeded Decellularized Tendon Scaffold for Tissue Engineering

Tendon is a collagenous tissue to connect bone and muscle. Healing of damaged/injured tendon is the primary clinical challenge in musculoskeletal regeneration because they often react poorly to treatment. Tissue engineering (a triad strategy of scaffolds, cells and growth factors) may have the potential to improve the quality of tendon tissue healing under such impaired situations. Tendon tissue engineering aims to synthesize graft alternatives to repair the injured tendon. Biological scaffolds derived from decellularized tissue may be a better option as their biomechanical properties are similar to the native tissue. This review is designed to provide background information on the current challenges in curing torn/worn out the tendon and the clinical relevance of decellularized scaffolds for such applications.

An oriented-collagen scaffold including Wnt5a promotes osteochondral regeneration and cartilage interface integration in a rabbit model

Articular cartilage regeneration remains a major challenge in orthopedics. Noncanonical Wnt5a is a particularly attractive growth factor in this context; Wnt5a inhibits chondrocyte hypertrophy but maintains chondrogenesis. We designed a novel, vertically oriented-collagen scaffold. The effect of Wnt5a on MSCs and chondrocytes and the therapeutic effects of the Wnt5a/oriented-collagen scaffold in terms of osteochondral repair and cartilage integration were evaluated. In vitro, the proliferation, migration, and differentiation of MSCs and chondrocytes treated with Wnt5a, and the mechanisms thereof, were assessed. mRNA microarray analysis was performed to compare the expression profiles of MSCs before and after Wnt5a treatment. In vivo, full-thickness cylindrical osteochondral defects (4 mm in diameter, 3 mm in depth) were created in the patellar grooves of 24 New Zealand white rabbits and implanted with oriented-collagen scaffolds (n = 8), Wnt5a/oriented-collagen scaffolds (n = 8), or nothing (n = 8). After 6 and 12 weeks, integration and tissue responses were evaluated. The proliferation, migration, chondrogenic differentiation, and extracellular matrix formation of/by MSCs and chondrocytes improved greatly after treatment with Wnt5a. Western blotting showed that the PI3K/AKT/JNK signaling pathway was activated. Microarray analysis revealed that the Wnt5a group exhibited a significant upregulation of the PI3K pathway. Reactome GSEA pathway interaction analysis revealed that such upregulation was associated with collagen and extracellular matrix formation. In vivo, the Wnt5a/oriented-collagen scaffold group exhibited optimal interface integration, cartilage regeneration, and collagenous fiber arrangement, accompanied by significantly increased glycosaminoglycan and collagen accumulations in the zones of regeneration and integration, compared to the other groups. Gene expression analysis showed that the levels of mRNAs encoding genes involved in cartilage formation were significantly increased in the Wnt5a/oriented, collagen scaffold group (all P < .05). Wnt5a promoted the proliferation, migration, and chondrogenic differentiation of MSCs and chondrocytes via the activation of the PI3K/AKT/JNK signaling pathway. The Wnt5a/oriented-collagen constructs enhanced the structure-specific regeneration of hyaline cartilage in a rabbit model and may be a promising treatment for the repair of human cartilage defects.

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7-12, 2020.

Stem Cell Therapy for Tendon Regeneration: Current Status and Future Directions

In adults the healing tendon generates fibrovascular scar tissue and recovers never histologically, mechanically, and functionally which leads to chronic and to degenerative diseases. In this review, the processes and mechanisms of tendon development and fetal regeneration in comparison to adult defect repair and degeneration are discussed in relation to regenerative therapeutic options. We focused on the application of stem cells, growth factors, transcription factors, and gene therapy in tendon injury therapies in order to intervene the scarring process and to induce functional regeneration of the lesioned tissue. Outlines for future therapeutic approaches for tendon injuries will be provided.

Cell Therapies in Tendon, Ligament, and Musculoskeletal System Repair

In the last few decades, several techniques have been used to optimize tendon, ligament, and musculoskeletal healing. The evidence in favor of these techniques is still not proven, and level I studies are lacking. We performed an analysis of the therapeutic strategies and tissue engineering projects recently published in this field. Here, we try to give an insight into the current status of cell therapies and the latest techniques of bioengineering applied to the field of orthopedic surgery. The future areas for research in the management of musculoskeletal injuries are outlined. There are emerging technologies developing into substantial clinical treatment options that need to be critically evaluated. Mechanical stimulation of the constructs reproduces a more propitious environment for effective healing.

Rescue plan for Achilles: Therapeutics steering the fate and functions of stem cells in tendon wound healing

Due to the increasing age of our society and a rise in engagement of young people in extreme and/or competitive sports, both tendinopathies and tendon ruptures present a clinical and financial challenge. Tendon has limited natural healing capacity and often responds poorly to treatments, hence it requires prolonged rehabilitation in most cases. Till today, none of the therapeutic options has provided successful long-term solutions, meaning that repaired tendons do not recover their complete strength and functionality. Our understanding of tendon biology and healing increases only slowly and the development of new treatment options is insufficient. In this review, following discussion on tendon structure, healing and the clinical relevance of tendon injury, we aim to elucidate the role of stem cells in tendon healing and discuss new possibilities to enhance stem cell treatment of injured tendon. To date, studies mainly apply stem cells, often in combination with scaffolds or growth factors, to surgically created tendon defects. Deeper understanding of how stem cells and vasculature in the healing tendon react to growth factors, common drugs used to treat injured tendons and promising cellular boosters could help to develop new and more efficient ways to manage tendon injuries.

Regenerative Engineering of the Rotator Cuff of the Shoulder

Rotator cuff tears often heal poorly, leading to re-tears after repair. This is in part attributed to the low proliferative ability of the resident cells (tendon fibroblasts and tendon-stem cells) upon injury to the rotator cuff tissue and the low vascularity of the tendon insertion. In addition, surgical outcomes of current techniques used in clinical settings are often suboptimal, leading to the formation of neo-tissue with poor biomechanics and structural characteristics, which results in re-tears. This has prompted interest in a new approach, which we term as "Regenerative Engineering", for regenerating rotator cuff tendons. In the Regenerative Engineering paradigm, roles played by stem cells, scaffolds, growth factors/small molecules, the use of local physical forces, and morphogenesis interplayed with clinical surgery techniques may synchronously act, leading to synergistic effects and resulting in successful tissue regeneration. In this regard, various cell sources such as tendon fibroblasts and adult tissue-derived stem cells have been isolated, characterized, and investigated for regenerating rotator cuff tendons. Likewise, numerous scaffolds with varying architecture, geometry, and mechanical characteristics of biologic and synthetic origin have been developed. Furthermore, these scaffolds have been also fabricated with biochemical cues (growth factors and small molecules), facilitating tissue regeneration. In this Review, various strategies to regenerate rotator cuff tendons using stem cells, advanced materials, and factors in the setting of physical forces under the Regenerative Engineering paradigm are described.

Assessment of mRNA Levels for Matrix Molecules and TGF-β1 in Rabbit Flexor and Peroneus Tendons Reveals Regional Differences in Steady-State Expression

This study analysed the differences on a molecular level between two segments of the deep flexor tendon, and compared the intrasynovial flexor tendon with the tendon sheath and the extrasynovial peroneus tendon in a rabbit model. The TRIspin method of RNA extraction was combined with the reverse transcription polymerase chain reaction to assess mRNA levels in the tissue segments. Significant differences were detected for all genes studied. mRNA levels for aggrecan, biglycan and collagen III were significantly higher in the fibrocartilaginous proximal segment of the flexor tendon. Collagen I was higher in the flexor tendon than the sheath and the peroneus tendon, and TGF-β1 was significantly lower in the peroneus tendon. This study demonstrates differences at the mRNA level between different segments of tendon, indicating that the tendon tissue may be adapted to its environment.

Cytokine and Growth Factor mRNA Expression Patterns Associated with the Hypercontracted, Hyperpigmented Healing Phenotype of Red Duroc Pigs: A Model of Abnormal Human Scar Development?

Background:

Skin wounds in red Duroc pigs heal with the formation of hypercontractile, hyperpigmented scars, similar in some respects to human hypertrophic scars. ObjectiveThe goal of this study was to characterize the mRNA expression patterns for a subset of relevant cytokines, growth factors, receptors, and transcription factors involved in the red Duroc scarring phenotype.

Methods:

Full-thickness and deep dermal wounds were created on the backs of juvenile female red Duroc pigs. Samples were taken every two weeks postwounding and total RNA and DNA were extracted and quantified. RT-PCR was performed using porcine gene-specific primers for 15 relevant molecules.

Results:

The majority of molecules examined exhibited a biphasic pattern of expression, with peaks of expression at days 14 and 56 postinjury.

Conclusions:

The molecular expression pattern observed correlates well with the gross healing phenotype and matrix molecule expression patterns previously reported in red Duroc pigs. These findings enhance our understanding of the processes associated with fibroproliferative scar-formation.

Biologic Treatments for Sports Injuries II Think Tank-Current Concepts, Future Research, and Barriers to Advancement, Part 2: Rotator Cuff

Rotator cuff tears are common and result in considerable morbidity. Tears within the tendon substance or at its insertion into the humeral head represent a considerable clinical challenge because of the hostile local environment that precludes healing. Tears often progress without intervention, and current surgical treatments are inadequate. Although surgical implants, instrumentation, and techniques have improved, healing rates have not improved, and a high failure rate remains for large and massive rotator cuff tears. The use of biologic adjuvants that contribute to a regenerative microenvironment have great potential for improving healing rates and function after surgery. This article presents a review of current and emerging biologic approaches to augment rotator cuff tendon and muscle regeneration focusing on the scientific rationale, preclinical, and clinical evidence for efficacy, areas for future research, and current barriers to advancement and implementation.

In vivo vascularization of MSC-loaded porous hydroxyapatite constructs coated with VEGF-functionalized collagen/heparin multilayers

Rapid and adequate vascularization is vital to the long-term success of porous orbital enucleation implants. In this study, porous hydroxyapatite (HA) scaffolds coated with vascular endothelial growth factor (VEGF)-functionalized collagen (COL)/heparin (HEP) multilayers (porosity 75%, pore size 316.8 ± 77.1 μm, VEGF dose 3.39 ng/mm³) were fabricated to enhance vascularization by inducing the differentiation of mesenchymal stem cells (MSCs) to endothelial cells. The in vitro immunofluorescence staining, quantitative real-time polymerase chain reaction (qRT-PCR), and western blotting results demonstrated that the expression of the endothelial differentiation markers CD31, Flk-1, and von Willebrand factor (vWF) was significantly increased in the HA/(COL/HEP)₅/VEGF/MSCs group compared with the HA/VEGF/MSCs group. Moreover, the HA/(COL/HEP)₅ scaffolds showed a better entrapment of the MSCs and accelerated cell proliferation. The in vivo assays showed that the number of newly formed vessels within the constructs after 28 d was significantly higher in the HA/(COL/HEP)₅/VEGF/MSCs group (51.9 ± 6.3/mm²) than in the HA (26.7 ± 2.3/mm²) and HA/VEGF/MSCs (38.2 ± 2.4/mm²) groups. The qRT-PCR and western blotting results demonstrated that the HA/(COL/HEP)₅/VEGF/MSCs group also had the highest expression of CD31, Flk-1, and vWF at both the mRNA and protein levels.

Recent Scientific Advances Towards the Development of Tendon Healing Strategies

There exists a range of surgical and non-surgical approaches to the treatment of both acute and chronic tendon injuries. Despite surgical advances in the management of acute tears and increasing treatment options for tendinopathies, strategies frequently are unsuccessful, due to impaired mechanical properties of the treated tendon and/or a deficiency in progenitor cell activities. Hence, there is an urgent need for effective therapeutic strategies to augment intrinsic and/or surgical repair. Such approaches can benefit both tendinopathies and tendon tears which, due to their severity, appear to be irreversible or irreparable. Biologic therapies include the utilization of scaffolds as well as gene, growth factor, and cell delivery. These treatment modalities aim to provide mechanical durability or augment the biologic healing potential of the repaired tissue. Here, we review the emerging concepts and scientific evidence which provide a rationale for tissue engineering and regeneration strategies as well as discuss the clinical translation of recent innovations.

Biologics for tendon repair

Tendon injuries are common and present a clinical challenge to orthopedic surgery mainly because these injuries often respond poorly to treatment and require prolonged rehabilitation. Therapeutic options used to repair ruptured tendons have consisted of suture, autografts, allografts, and synthetic prostheses. To date, none of these alternatives has provided a successful long-term solution, and often the restored tendons do not recover their complete strength and functionality. Unfortunately, our understanding of tendon biology lags far behind that of other musculoskeletal tissues, thus impeding the development of new treatment options for tendon conditions. Hence, in this review, after introducing the clinical significance of tendon diseases and the present understanding of tendon biology, we describe and critically assess the current strategies for enhancing tendon repair by biological means. These consist mainly of applying growth factors, stem cells, natural biomaterials and genes, alone or in combination, to the site of tendon damage. A deeper understanding of how tendon tissue and cells operate, combined with practical applications of modern molecular and cellular tools could provide the long awaited breakthrough in designing effective tendon-specific therapeutics and overall improvement of tendon disease management.

Tendon and ligament regeneration and repair: clinical relevance and developmental paradigm

As dense connective tissues connecting bone to muscle and bone to bone, respectively, tendon and ligament (T/L) arise from the somitic mesoderm, originating in a recently discovered somitic compartment, the syndetome. Inductive signals from the adjacent sclerotome and myotome upregulate expression of Scleraxis, a key transcription factor for tenogenic and ligamentogenic differentiation. Understanding T/L development is critical to establishing a knowledge base for improving the healing and repair of T/L injuries, a high-burden disease due to the intrinsically poor natural healing response. Current treatment of the three most common tendon injuries-tearing of the rotator cuff of the shoulder, flexor tendon of the hand, and Achilles tendon-include mostly surgical repair and/or conservative approaches, including biophysical modalities such as rehabilitation and cryotherapy. Unfortunately, the fibrovascular scar formed during healing possesses inferior mechanical and biochemical properties, resulting in compromised tissue functionality. Regenerative approaches have sought to augment the injured tissue with cells, scaffolds, bioactive agents, and mechanical stimulation to improve the natural healing response. The key challenges in restoring full T/L function following injury include optimal combination of these biological agents as well as their delivery to the injury site. A greater understanding of the molecular mechanisms involved in T/L development and natural healing, coupled with the capability of producing complex biomaterials to deliver multiple biofactors with high spatiotemporal resolution and specificity, should lead to regenerative procedures that more closely recapitulate T/L morphogenesis, thereby offering future patients the prospect of T/L regeneration, as opposed to simple tissue repair.

Influence of the molecular weight of poly(lactide-co-glycolide) on the in vivo cartilage repair by a construct of poly(lactide-co-glycolide)/fibrin gel/mesenchymal stem cells/transforming growth factor-β1

The poly(lactide-co-glycolide) (PLGA, LA/GA 75/25) sponges with different weight average molecular weights (Mw 52, 122, and 177 kDa) were fabricated and were used to build the constructs of PLGA/fibrin gel/mesenchymal stem cells (MSCs)/transforming growth factor-β1 (TGF-β1). The PLGA 177 with the highest Mw (177 kDa) had the fastest degradation rate at the initial stage, whereas the PLGA 122 had the moderate degradation rate and smallest mass loss. After implantation in rabbit knees for 12 weeks, the full-thickness defects (both cartilage and subchondral bone were destroyed with a diameter and depth of 4 mm) repaired by the PLGA 122 group had formed a hyaline cartilage-like tissue with abundant glycosaminoglycans on the top layer and subchondral bone on the bottom layer. The group also achieved the best macroscopic (11.3 ± 0.8) and histological scoring (Wakitani, 0.5 ± 0.6). To unveil the mechanism of the cartilage repair outcome and the PLGA degradation behaviors, the chondrogenesis-related genes, inflammatory cytokines, and matrix metalloproteinase (MMP) activity were analyzed by quantitative reverse transcription-polymerase chain reaction at week 1, 3, and 6 postsurgery. At each time point, the regenerated tissues by the PLGA 122 group had the highest mRNA expression of SOX9 and collagen type II, but the smallest mRNA expression of interleukin-1β and tumor necrosis factor α, and MMP-13 and MMP-3. In summary, as a scaffolding matrix, the PLGA with different Mw shows a huge difference in cartilage regeneration in vivo. The one with a moderate Mw (122 kDa) causes the weakest inflammatory response and results in the best cartilage regeneration.

Augmenting tendon and ligament repair with platelet-rich plasma (PRP)

Tendon and ligament injuries (TLI) commonly occur in athletes and non-athletes alike, and remarkably debilitate patients' athletic and personal abilities. Current clinical treatments, such as reconstruction surgeries, do not adequately heal these injuries and often result in the formation of scar tissue that is prone to re-injury. Platelet-rich plasma (PRP) is a widely used alternative option that is also safe because of its autologous nature. PRP contains a number of growth factors that are responsible for its potential to heal TLIs effectively. In this review, we provide a comprehensive report on PRP. While basic science studies in general indicate the potential of PRP to treat TLIs effectively, a review of existing literature on the clinical use of PRP for the treatment of TLIs indicates a lack of consensus due to varied treatment outcomes. This suggests that current PRP treatment protocols for TLIs may not be optimal, and that not all TLIs may be effectively treated with PRP. Certainly, additional basic science studies are needed to develop optimal treatment protocols and determine those TLI conditions that can be treated effectively.

Cellular distribution and gene expression profile during flexor tendon graft repair: A novel tissue engineering approach(*)

To understand scar and adhesion formation during postsurgical period of intrasynovial tendon graft healing, a murine model of flexor digitorum longus tendon graft repair was developed, by utilizing flexor digitorum longus tendon allograft from donor Rosa26/+ mouse, and the healing process at days 3, 7, 14, 21, 28, and 35 post surgery of host wild-type mouse was followed. Using X-gal staining, β-galactosidase positive cells of allograft origin were detectable in tissue sections of grafted tendon post surgery. Graft healing was assessed for the cellular density, scar and adhesion formation, and their interaction with surrounding tissue. From histological analysis, it was evident that the healing of intrasynovial flexor digitorum longus tendon graft takes place in an interactive environment of donor graft, host tendon, and host surrounding tissue. A total of 32 genes, analyzed by RNA analysis, expressed during healing process. Particularly, Alk1, Postn, Tnc, Tppp3, and Mkx will be further investigated for therapeutical value in reducing scars and adhesions.

Fabrication of poly(lactide-co-glycolide) scaffold filled with fibrin gel, mesenchymal stem cells, and poly(ethylene oxide)-b-poly(L-lysine)/TGF-β1 plasmid DNA complexes for cartilage restoration in vivo

A poly (lactide-co-glycolide) (PLGA) scaffold filled with fibrin gel, mesenchymal stem cells (MSCs) and poly(ethylene oxide)-b-poly (L-lysine) (PEO-b-PLL)/pDNA-TGF-β1 complexes was fabricated and applied in vivo for synchronized regeneration of cartilage and subchondral bone. The PEO-b-PLL/pDNA-TGF-β1 complexes could transfect MSCs in vitro to produce TGF-β1 in situ and up regulate the expression of chondrogenesis-related genes in the construct. The expression of heterogeneous TGF-β1 in vivo declined along with the prolongation of implantation time, and lasted for 3 and 6 weeks in the mRNA and protein levels, respectively. The constructs (Experimental group) of PLGA/fibrin gel/MSCs/(PEO-b-PLL/pDNA-TGF-β1 complexes) were implanted into the osteochondral defects of rabbits to restore the functional cartilages, with gene-absent constructs as the Control. After 12 weeks, the Experimental group regenerated the neo-cartilage and subchondral bone with abundant deposition of glycosaminoglycans (GAGs) and type II collagen. The regenerated tissues had good integration with the host tissues too. By contrast, the defects were only partially repaired by the Control constructs. qRT-PCR results demonstrated that expression of the chondrogenesis-marker genes in the Experimental group was significantly higher than that of the Control group, and was very close to that of the normal cartilage tissue.

Tenocytes of chronic rotator cuff tendon tears can be stimulated by platelet-released growth factors

BACKGROUND

Bone-to-tendon healing after rotator cuff repairs is mainly impaired by poor tissue quality. The tenocytes of chronic rotator cuff tendon tears are not able to synthesize normal fibrocartilaginous extracellular matrix (ECM). We hypothesized that in the presence of platelet-released growth factors (PRGF), tenocytes from chronically retracted rotator cuff tendons proliferate and synthesize the appropriate ECM proteins.

MATERIALS AND METHODS

Tenocytes from 8 patients with chronic rotator cuff tears were cultured for 4 weeks in 2 different media: standard medium (Iscove's Modified Dulbecco's Media + 10% fetal calf serum + 1% nonessential amino acids + 0.5 μg/mL ascorbic acid) and media with an additional 10% PRGF. Cell proliferation was assessed at 7, 14, 21, and 28 days. Messenger (m)RNA levels of collagens I, II, and X, decorin, biglycan, and aggrecan were analyzed using real time reverse-transcription polymerase chain reaction. Immunocytochemistry was also performed.

RESULTS

The proliferation rate of tenocytes was significantly higher at all time points when cultured with PRGF. At 21 days, the mRNA levels for collagens I, II, and X, decorin, aggrecan, and biglycan were significantly higher in the PRGF group. The mRNA data were confirmed at protein level by immunocytochemistry.

CONCLUSIONS

PRGFs enhance tenocyte proliferation in vitro and promote synthesis of ECM to levels similar to those found with insertion of the normal human rotator cuffs.

CLINICAL RELEVANCE

Biologic augmentation of repaired rotator cuffs with PRGF may enhance the properties of the repair tissue. However, further studies are needed to determine if application of PRGF remains safe and effective in long-term clinical studies.

LEVEL OF EVIDENCE

Basic Science Study, Cell Biology.

Effect of therapeutic ultrasound on human periodontal ligament cells for dental and periodontal tissue engineering

The objective of this study was to investigate whether low intensity pulsed ultrasound (LIPUS) has anabolic effects on human periodontal ligament (PDL) cells. The PDL cells were plated in 48-well plates and cultured at 37°C in an atmosphere of 5% CO2 in air, in a humidified incubator until confluent. The cells were divided into three groups including control, 5 min and 10 min ultrasound application. The LIPUS was applied using a 2.5 transducer that produces an incident intensity of 30 mW/cm2 of the transducer's surface area. The results from the quantitative polymerase chain reaction (PCR) indicates that expression levels of alkaline phosphatase (ALP),cyclin D1 (CYC), nucleostemin (NCT) were increased after four weeks of 10 minutes of daily ultrasound treatment. The increased ALP/DNA by LIPUS shows a time dependent pattern with the highest activity occurring after four weeks of treatment. These results demonstrate that LIPUS has an anabolic effect on PDL cells and suggest that LIPUS may enhance the pluripotent characteristics of PDL cells as indicated by the up-regulation of NCT, a stem marker. These results also may explain the potential role of LIPUS in periodontal tissue regeneration.

The effect of growth factors on both collagen synthesis and tensile strength of engineered human ligaments

Growth factors play a central role in the development and remodelling of musculoskeletal tissues. To determine which growth factors optimized in vitro ligament formation and mechanics, a Box-Behnken designed array of varying concentrations of growth factors and ascorbic acid were applied to engineered ligaments and the collagen content and mechanics of the grafts were determined. Increasing the amount of transforming growth factor (TGF) β1 and insulin-like growth factor (IGF)-1 led to an additive effect on ligament collagen and maximal tensile load (MTL). In contrast, epidermal growth factor (EGF) had a negative effect on both collagen content and MTL. The predicted optimal growth media (50 μg/ml TGFβ, IGF-1, and GDF-7 and 200 μM ascorbic acid) was then validated in two separate trials: showing a 5.7-fold greater MTL and 5.2-fold more collagen than a minimal media. Notably, the effect of the maximized growth media was scalable such that larger constructs developed the same material properties, but larger MTL. These results show that optimizing the interactions between growth factors and engineered ligament volume results in an engineered ligament of clinically relevant function.

Bone marrow-derived mesenchymal stem cells obtained during arthroscopic rotator cuff repair surgery show potential for tendon cell differentiation after treatment with insulin

PURPOSE

The purpose of this study was to determine whether a one-time physiologic dose of insulin when compared with the growth factors insulin-like growth factor 1, β-fibroblastic growth factor, and growth differentiation factor 5 is capable of differentiating bone marrow-derived mesenchymal stem cells (MSCs) into tendon.

METHODS

Eleven patients undergoing arthroscopic rotator cuff repair consented to undergo aspiration of bone marrow. A dose-response curve was calculated to determine the optimal dose of insulin needed to differentiate MSCs into tendon. After purification of bone marrow in the operating room, MSCs were exposed to either insulin or tendon-inducing growth factors or were left untreated to serve as a control. The potential for MSCs in each of these groups to differentiate into tendon was evaluated with a multistep process that included determination of the genetic upregulation for tendon-specific proteins, confirmation that the levels of these proteins were actually increased, staining of the MSCs with antibodies for these proteins to ensure that they were expressed on the cell surface, and finally, evaluation of cell morphology to verify the MSCs' tendon-like appearance.

RESULTS

MSCs treated with insulin showed increased gene expression of tendon-specific markers (P < .05), increased content of tendon-specific proteins (P < .05), and increased receptors on the cell surface (P < .05) compared with control cells. Histologic analysis showed a tendon-like appearance compared with the control cells.

CONCLUSIONS

Bone marrow-derived MSCs treated with a single physiologic dose of insulin differentiated into cells with characteristics consistent with tendon.

CLINICAL RELEVANCE

The potential for MSCs to differentiate into tendon after a 1-time dose of insulin may assist in developing practical biologic options for augmentation of rotator cuff repairs.

The restoration of full-thickness cartilage defects with BMSCs and TGF-beta 1 loaded PLGA/fibrin gel constructs

Poly(lactide-co-glycolide) (PLGA) sponge was filled with fibrin gel, bone marrow mesenchymal stem cells (BMSCs) and transforming growth factor-β1 (TGF-β1) to obtain a construct for cartilage restoration in vivo. The PLGA sponge lost its weight steadily in vitro, but degraded much faster in the construct of PLGA/fibrin gel/BMSCs implanted in the full-thickness cartilage defects. The in vivo degradation of the fibrin gel inside the construct was prolonged to 12 wk too. The CM-DiI labeled allogenic BMSCs were detectable after transplantation (implantation) into the defects for 12 wk by small animal in vivo fluorescence imaging and confocal laser scanning microscopy. In vivo repair experiments were firstly performed by implantation of the PLGA/fibrin gel/BMSCs and PLGA/BMSCs constructs into full-thickness cartilage defects (3 mm in diameter and 4 mm in depth) of New Zealand white rabbits for 12 wk. The defects implanted with the PLGA/fibrin gel/BMSCs constructs were filled with cartilage-like tissue containing collagen type II and glycosaminoglycans (GAGs), while those by the PLGA/BMSCs constructs were filled with fibrous-like tissues. To repair the defects of larger size (4 mm in diameter), addition of growth factors was mandatory as exemplified here by further loading of TGF-β1. Implantation of the PLGA/fibrin gel/BMSCs/TGF-β1 constructs into the full-thickness cartilage defects for 12 wk resulted in full restoration of the osteochondral tissue. The neo-cartilage integrated well with its surrounding cartilage and subchondral bone. Immunohistochemical and GAGs staining confirmed the similar distribution of collagen type II and GAGs in the regenerated cartilage as that of hyaline cartilage. The quantitative reverse transcription-polymerase chain reaction (qRT-PCR) revealed that the cartilage special genes were significantly up-regulated compared with those of the TGF-β1 absent constructs.

Temporal and spatial expression of TGF-beta1 in an Achilles tendon section model after application of platelet-rich plasma

BACKGROUND

To investigate the effect of platelet-rich plasma (PRP) on TGF-beta1 expression during tendon healing.

METHODS

We used 48 skeletally mature New Zealand White rabbits. 24 rabbits received the PRP, and 24 rabbits served as an untreated control group. Equal numbers of animals were sacrificed at 1st, 2nd, 3rd, and 4th week. The surgical procedure involved a transverse incision to transect the Achilles tendon. A volume of 1ml of PRP was then injected into the tendon mass in the PRP group. Histological and immunohistochemical evaluations with an anti-TGF-beta primary antibody were performed.

RESULTS

The pattern of expression of TGF-beta1 in the PRP group was characterized by a significant upregulation during the first 2 weeks and subsequently significant downregulation in the 3rd and 4th week in comparison with the controls.

CONCLUSIONS

Our results suggest that PRP may affect the tendon healing process by altering the expression of TGF-beta1.

In vivo restoration of full-thickness cartilage defects by poly(lactide-co-glycolide) sponges filled with fibrin gel, bone marrow mesenchymal stem cells and DNA complexes

A composite construct comprising of bone marrow mesenchymal stem cells (BMSCs), plasmid DNA encoding transforming growth factor-beta1 (pDNA-TGF-beta1), fibrin gel and poly (lactide-co-glycolide) (PLGA) sponge was designed and employed to repair articular cartilage defects. To improve the gene transfection efficiency, a cationized chitosan derivative N,N,N-trimethyl chitosan chloride (TMC) was employed as the vector. The TMC/DNA complexes had a transfection efficiency of 9% to BMSCs and showed heterogeneous TGF-beta1 expression in a 10-day culture period in vitro. In vivo culture of the composite constructs was performed by implantation into full-thickness cartilage defects of New Zealand white rabbit joints, using the constructs absence of pDNA-TGF-beta1 or BMSCs as controls. Heterogeneous expression of TGF-beta1 in vivo was detected at 4 weeks, but its level was decreased in comparison with that of 2 weeks. After implantation for 12 weeks, the cartilage defects were successfully repaired by the composite constructs of the experimental group, and the neo-cartilage integrated well with its surrounding tissue and subchondral bone. Immunohistochemical and glycosaminoglycans (GAGs) staining confirmed the similar amount and distribution of collagen type II and GAGs in the regenerated cartilage as that of hyaline cartilage. The cartilage special genes expressed in the neo-tissue were closer to those of the normal cartilage. An overall score of 2.83 was obtained according to Wakitani's standard. By contrast, only part of the defects was repaired by the pDNA-TGF-beta1 absence constructs, and no cartilage repair but fibrous tissue was found for the BMSCs absence constructs. Therefore, combination of the PLGA sponge/fibrin gel scaffold with BMSCs and gene therapy is an effective method to restore cartilage defects and may have a great potential for practical applications in the near future.

Functional tissue engineering of ligament healing

Ligaments and tendons are dense connective tissues that are important in transmitting forces and facilitate joint articulation in the musculoskeletal system. Their injury frequency is high especially for those that are functional important, like the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) of the knee as well as the glenohumeral ligaments and the rotator cuff tendons of the shoulder. Because the healing responses are different in these ligaments and tendons after injury, the consequences and treatments are tissue- and site-specific. In this review, we will elaborate on the injuries of the knee ligaments as well as using functional tissue engineering (FTE) approaches to improve their healing. Specifically, the ACL of knee has limited capability to heal, and results of non-surgical management of its midsubstance rupture have been poor. Consequently, surgical reconstruction of the ACL is regularly performed to gain knee stability. However, the long-term results are not satisfactory besides the numerous complications accompanied with the surgeries. With the rapid development of FTE, there is a renewed interest in revisiting ACL healing. Approaches such as using growth factors, stem cells and scaffolds have been widely investigated. In this article, the biology of normal and healing ligaments is first reviewed, followed by a discussion on the issues related to the treatment of ACL injuries. Afterwards, current promising FTE methods are presented for the treatment of ligament injuries, including the use of growth factors, gene delivery, and cell therapy with a particular emphasis on the use of ECM bioscaffolds. The challenging areas are listed in the future direction that suggests where collection of energy could be placed in order to restore the injured ligaments and tendons structurally and functionally.

Accelerated Achilles tendon healing by PDGF gene delivery with mesoporous silica nanoparticles

We report the ability of amino- and carboxyl-modified MCM-41 mesoporous silica nanoparticles (MSN) to deliver gene in vivo in rat Achilles tendons, despite their inefficiency to transfect primary tenocytes in culture. We show that luciferase activity lasted for at least 2 weeks in tendons injected with these MSN and a plasmid DNA (pDNA) encoding the luciferase reporter gene. By contrast, in tendons injected with naked plasmid, the luciferase expression decreased as a function of time and became hardly detectable after 2 weeks. Interestingly, there were neither signs of inflammation nor necrosis in tendon, kidney, heart and liver of rat weekly injected with pDNA/MSN formulation during 1.5 months. Our main data concern the acceleration of Achilles tendons healing by PDGF-B gene transfer using MSN. Biomechanical properties and histological analyses clearly indicate that tendons treated with MSN and PDGF gene healed significantly faster than untreated tendons and those treated with pPDGF alone.

Ligament regeneration using a knitted silk scaffold combined with collagen matrix

This study was aimed to develop a new practical ligament scaffold by synergistic incorporation of silk fibers, a knitted structure, and a collagen matrix. The efficacy for ligament tissue engineering was investigated in vitro and in animal models. Cells cultured on a collagen substrate expressed ligament matrix genes at higher levels than those on a silk substrate. The silk scaffold elicited little inflammatory reaction and degraded slowly after subcutaneous implantation in a mouse model. In the rabbit MCL defect model, MCLs treated with a silk+collagen scaffold deposited more collagen, had better mechanical properties, and showed more native microstructure with larger diameter collagen fibrils and stronger scaffold-ligament interface healing than untreated MCLs and those treated with silk scaffolds. These results demonstrated that the knitted silk+collagen sponge scaffold improves structural and functional ligament repair by regulating ligament matrix gene expression and collagen fibril assembly. The findings are the first to highlight the important roles of biomaterials in ligament regeneration biology. Also, the concept of an "internal-space-preservation" scaffold is proposed for the tissue repair under physical loading.

Genetic engineering for skeletal regenerative medicine

The clinical challenges of skeletal regenerative medicine have motivated significant advances in cellular and tissue engineering in recent years. In particular, advances in molecular biology have provided the tools necessary for the design of gene-based strategies for skeletal tissue repair. Consequently, genetic engineering has emerged as a promising method to address the need for sustained and robust cellular differentiation and extracellular matrix production. As a result, gene therapy has been established as a conventional approach to enhance cellular activities for skeletal tissue repair. Recent literature clearly demonstrates that genetic engineering is a principal factor in constructing effective methods for tissue engineering approaches to bone, cartilage, and connective tissue regeneration. This review highlights this literature, including advances in the development of efficacious gene carriers, novel cell sources, successful delivery strategies, and optimal target genes. The current status of the field and the challenges impeding the clinical realization of these approaches are also discussed.

Temporal extracellular matrix adaptations in ligament during wound healing and hindlimb unloading

Previous data from spaceflight studies indicate that injured muscle and bone heal slowly and abnormally compared with ground controls, strongly suggesting that ligaments or tendons may not repair optimally as well. Thus the objective of this study was to investigate the biochemical and molecular gene expression of the collagen extracellular matrix in response to medial collateral ligament (MCL) injury repair in hindlimb unloaded (HLU) rodents. Male rats were assigned to 3- and 7-wk treatment groups with three subgroups each: sham control, ambulatory healing (Amb-healing), and HLU-healing groups. Amb- and HLU-healing animals underwent bilateral surgical transection of their MCLs, whereas control animals were subjected to sham surgeries. All surgeries were performed under isoflurane anesthesia. After 3 wk or 7 wk of HLU, rats were euthanized and MCLs were surgically isolated and prepared for molecular or biochemical analyses. Hydroxyproline concentration and hydroxylysylpyridinoline collagen cross-link contents were measured by HPLC and showed a substantial decrement in surgical groups. MCL tissue cellularity, quantified by DNA content, remained significantly elevated in all HLU-healing groups vs. Amb-healing groups. MCL gene expression of collagen type I, collagen type III, collagen type V, fibronectin, decorin, biglycan, lysyl oxidase, matrix metalloproteinase-2, and tissue inhibitor of matrix metalloproteinase-1, measured by real-time quantitative PCR, demonstrated differential expression in the HLU-healing groups compared with Amb-healing groups at both the 3- and 7-wk time points. Together, these data suggest that HLU affects dense fibrous connective tissue wound healing and confirms previous morphological and biomechanical data that HLU inhibits the ligament repair processes.

Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold

The anterior cruciate ligament (ACL) of the knee is an intra-articular ligament that fails to heal after primary repair. The medial collateral ligament (MCL) of the knee is an extra-articular ligament that heals uneventfully in the majority of cases. Why these two ligaments have such different responses to injury remains unclear. In this article, we address two hypotheses: first, that the histologic response to injury is different in intra-articular and extra-articular ligaments, and second, that the response of the intra-articular ligaments can be altered by placing a collagen-platelet-rich plasma (collagen-PRP) hydrogel in the wound site. Wounds were created in extra-articular ligaments (MCL and/or patellar ligament) and an intra-articular ligament (ACL) in canine knees, and the histologic response to injury evaluated at 3 days (n = 3), 7 days (n = 4), 3 weeks (n = 5), and 6 weeks (n = 5). In the 3-week (n = 5) and 6-week (n = 5) animals, bilateral central wounds were made in the ACLs and the wounds in one knee of each animal treated with a collagen-PRP hydrogel while the contralateral side was untreated. Extra-articular ligament wounds had greater filling of the wound site and increased presence in the wound site of fibrinogen, fibronectin, PDGF-A, TGF-beta1, FGF-2, and von Willebrand's factor when compared to intra-articular ligament wounds. Treatment of the intra-articular wound with a collagen-PRP hydrogel resulted in increased filling of the wound site with repair tissue that had similar profiles of growth factor and protein expression to the extra-articular ligament wounds. The use of a collagen-PRP scaffold can ameliorate histologic differences noted between healing extra-articular ligamentous wounds and nonhealing intra-articular ligamentous wounds. This study supports the hypothesis that premature scaffold failure may play a key role in the normally expected failure of the ACL to heal after injury.

Systemic administration of IGF-I enhances healing in collagenous extracellular matrices: evaluation of loaded and unloaded ligaments

BACKGROUND

Insulin-like growth factor-I (IGF-I) plays a crucial role in wound healing and tissue repair. We tested the hypotheses that systemic administration of IGF-I, or growth hormone (GH), or both (GH+IGF-I) would improve healing in collagenous connective tissue, such as ligament. These hypotheses were examined in rats that were allowed unrestricted activity after injury and in animals that were subjected to hindlimb disuse. Male rats were assigned to three groups: ambulatory sham-control, ambulatory-healing, and hindlimb unloaded-healing. Ambulatory and hindlimb unloaded animals underwent surgical disruption of their knee medial collateral ligaments (MCLs), while sham surgeries were performed on control animals. Healing animals subcutaneously received systemic doses of either saline, GH, IGF-I, or GH+IGF-I. After 3 weeks, mechanical properties, cell and matrix morphology, and biochemical composition were examined in control and healing ligaments.

RESULTS

Tissues from ambulatory animals receiving only saline had significantly greater strength than tissue from saline receiving hindlimb unloaded animals. Addition of IGF-I significantly improved maximum force and ultimate stress in tissues from both ambulatory and hindlimb unloaded animals with significant increases in matrix organization and type-I collagen expression. Addition of GH alone did not have a significant effect on either group, while addition of GH+IGF-I significantly improved force, stress, and modulus values in MCLs from hindlimb unloaded animals. Force, stress, and modulus values in tissues from hindlimb unloaded animals receiving IGF-I or GH+IGF-I exceeded (or were equivalent to) values in tissues from ambulatory animals receiving only saline with greatly improved structural organization and significantly increased type-I collagen expression. Furthermore, levels of IGF-receptor were significantly increased in tissues from hindlimb unloaded animals treated with IGF-I.

CONCLUSION

These results support two of our hypotheses that systemic administration of IGF-I or GH+IGF-I improve healing in collagenous tissue. Systemic administration of IGF-I improves healing in collagenous extracellular matrices from loaded and unloaded tissues. Growth hormone alone did not result in any significant improvement contrary to our hypothesis, while GH + IGF-I produced remarkable improvement in hindlimb unloaded animals.

Myofibroblast upregulators are elevated in joint capsules in posttraumatic contractures

We hypothesized specific growth factors are increased in the elbow capsules of patients with post traumatic elbow contractures. A model of surgically induced joint contracture in rabbit knees was developed to study the growth factor expression in joint contractures. This study demonstrates this model mimics the human condition and analyzes how the growth factor levels decrease with time in rabbit knees with contractures. Reverse transcription polymerase chain reaction was used to measure mRNA levels of transforming growth factor-beta1, connective tissue growth factor, ED-A of fibronectin, and alpha-smooth muscle actin normalized to a housekeeping gene, glyceraldehyde-3-phosphate dehydrogenase. In the joint capsules of patients with elbow contractures, mRNA levels were increased for transforming growth factor- beta1, connective tissue growth factor, and alpha-smooth muscle actin. In the joint capsules of rabbit knees with contractures, mRNA levels were increased for transforming growth factor- beta1, connective tissue growth factor, ED-A of fibronectin, and alpha-smooth muscle actin. The mRNA levels for transforming growth factor-beta1, connective tissue growth factor, and alpha-smooth muscle actin decreased with time in rabbit knees. The elevated levels of these myofibroblast up-regulators and fibrogenic growth factors could explain the previously reported increase in myofibroblasts and collagen mRNA levels. The rabbit knee model correlated well with the human post traumatic elbow contractures.

Genetic Involvement in Skin Wound Healing and Scarring in Domestic Pigs: Assessment of Molecular Expression Patterns in (Yorkshire × Red Duroc) × Yorkshire Backcross Animals

Yorkshire, red Duroc, and F1 (first-generation cross) pigs heal with normal, fibroproliferative/hypercontractile, and intermediate levels of scarring, respectively. The purpose of this study was to evaluate the healing phenotype of Yorkshire x F1 backcross animals, to address the molecular basis for genetic transmission of the red Duroc scarring phenotype. Macroscopically and histologically, full-thickness wounds on backcross animals followed the Yorkshire phenotype, with one exception; the backcross wounds exhibited contraction following re-epithelialization. The molecular expression patterns in the backcross animals generally correlated with the macroscopic and histologic findings. Compared to Yorkshire, red Duroc, and F1 wounds, the backcross wounds demonstrated a diminished initial inflammatory phase, followed by a prolonged expression of several relevant growth factors. Additionally, collagen expression was prolonged, expression of matrix metalloproteinases was increased, and alterations in tissue inhibitor of metalloproteinase expression were detected. Moreover, a subset of molecules still followed the red Duroc pattern of mRNA expression, a finding that allows for correlations between the scarring phenotype and the molecular expression patterns to be made in this model. The results indicate that a number of genes are likely involved in the red Duroc healing phenotype and that identification of the specific genes involved will require a more detailed genomic analysis.

Patterns of mRNA expression for matrix molecules and growth factors in flexor tendon injury: differences in the regulation between tendon and tendon sheath

PURPOSE

Injuries to tendons, particularly flexor tendons, can lead to loss of function after healing due to adhesion formation and other complications. The aim of this study was to increase our understanding of the healing process in tendons and tendon sheaths to develop methods to affect the healing process and improve the outcome of tendon repair in the future.

METHODS

In a rabbit model of flexor tendon injury, tissues were harvested 3, 6, 12, and 24 days after surgery (n = 6 for each group). After RNA extraction, messenger RNA (mRNA) levels for relevant genes in tendon and tendon sheaths were measured using the reverse transcription polymerase chain reaction. Messenger RNA levels for a subset of relevant molecules at different time points after injury were compared with those of uninjured controls for tendons and tendon sheaths.

RESULTS

Initially after injury, there was a shift in collagen expression with a marked increase in type III mRNA levels in both the tendon and tendon sheath, whereas those for collagen I increased only in the sheath at later time points. Aggrecan and versican mRNA levels were increased in both tissues, but temporal aspects of the changes were different. The mRNA levels for biglycan and lumican were all upregulated throughout the healing interval examined, whereas those for decorin were significantly decreased throughout in the tendon more so than the sheath. The mRNA levels for basic fibroblastic growth factor and transforming growth factor beta were elevated after injury in the tendon but not in the sheath. In contrast, mRNA levels for connective tissue growth factor were unaltered or decreased in both tissues throughout the interval assessed.

CONCLUSIONS

Healing after injury to the rabbit flexor tendon and tendon sheath follow a reproducible pattern of gene expression; however, the pattern in the tendon is very different from that in the sheath. These findings indicate that interventions developed to improve healing of these tissues will have to address these differences, because they will likely affect the outcomes.

Clinical Applications of Bioactive Factors in Sports Medicine

The ability to biologically manipulate musculoskeletal healing and augment bone and soft tissue repair and regeneration holds great promise. Advances in the basic science study and clinical application of bioactive proteins and growth factors continues to evolve. Improvement in the surgical resurfacing of articular cartilage defects and tendon and ligament repair through the addition of bioactive polypeptides is currently underway. The purpose of this article is to review the present array of biologically active materials that may be clinically applicable in sports medicine and arthroscopy. Mechanisms for biologic augmentation of tissue repair and regeneration will be discussed. Current limitations and future considerations will be reviewed particularly as they relate to practical clinical approaches.

The effects of G-CSF and naproxen sodium on the serum TGF-beta1 level and fracture healing in rat tibias

Local and systemic release of transforming growth factor beta 1 (TGF-beta1) is known to increase during the process of fracture healing and this cytokine stimulates bone healing. The majority of the non steroidal anti inflammatory drugs (NSAIDs) inhibit fracture healing. Granulocyte colony stimulating factor (G-CSF) is a hematopoietic growth factor that stimulates bone marrow. In this study, the effects of the NSAID naproxen sodium, G-CSF, and both of them in combination on the TGF-beta1 serum level in rats with tibia fractures were measured and fracture healing was evaluated by histopathologic and radiologic examination. The TGF-beta1 serum levels obtained on day one (24 h after fracture but before administration of naproxen or G-CSF) were found to be similar in all of the five groups (p > 0.05). At the end of the first week, TGF-beta1 levels were significantly lower in naproxen-treated rats than those of the other groups excluding control (p = 0.002). Similar changes in TGF-beta1 levels were found at the end of the second and fourth weeks. TGF-beta1 levels were significantly higher in G-CSF-treated rats at the end of the first, second and fourth weeks (p < 0.05). Fracture healing scores measured with histopathological and radiological methods were higher in G-CSF-treated rats than in naproxen-treated ones. When both naproxen and G-CSF were given, the scores resumed to normal. The results point to the negative effect of naproxen sodium on fracture healing is due to its decreasing effect on the level of TGF-beta1, which may be a new possible mechanism. Moreover, this negative effect can be inhibited by the use of G-CSF.

Expression of growth factors in the early phase of supraspinatus tendon healing in rabbits

Growth factors are known to appear during wound healing. We hypothesized that growth factors would also appear during the healing process of a rotator cuff tear. We determined the expression of various growth factors during healing of acute rotator cuff tears in the rabbit. We made a full-thickness defect in the supraspinatus tendon of 27 Japanese white rabbits. The shoulders were harvested on days 1, 3, 5, 7, 9, 11, 14, 21, and 28 postoperatively (n = 3 at each time point). We assessed the expression of basic fibroblast growth factor, insulin-like growth factor 1, platelet-derived growth factor, and transforming growth factor beta. Basic fibroblast growth factor appeared with its peak on days 7 and 9, insulin-like growth factor 1 appeared with its peak on day 5, platelet-derived growth factor appeared with a mild expression between days 7 and 14, and transforming growth factor beta appeared with constant mild expression throughout the observation period. It is likely that each of these growth factors plays a role in the early phase of healing of the supraspinatus tendon in rabbits.

Tissue engineering for anterior cruciate ligament reconstruction: a review of current strategies

The anterior cruciate ligament (ACL) is one the most commonly injured ligaments of the knee. Chronic ACL insufficiency can result in episodic instability, chondral and meniscal injury, and early osteoarthritis. The intra-articular environment of the ligament precludes normal healing and surgical replacement of the injured ligament is often mandated to restore stability. Current surgical strategies include the use of local autograft or allograft tissues for ligament reconstruction. These procedures have yielded superior long-term clinical results yet have the potential for serious associated morbidities. Existing limitations have prompted ongoing research designed to engineer a replacement ligament that will parallel the native ACL in both its biologic properties and mechanical durability. Ligament engineering necessitates the use of appropriate source cells and a growth matrix to support cell proliferation and collagen synthesis. The identification of appropriate growth modulators including both biochemical factors and mechanical stimuli are requisites for successful tissue growth. The characterization of the elements essential for successful graft development represents a significant challenge for investigators. This review examines the current literature regarding the potential and limitations of ligament engineering and describes the development of a novel 3-dimensional scaffold and bioreactor system at our institution.

Influence of mechanical and biological signals on gene expression in human MG-63 cells: evidence for a complex interplay between hydrostatic compression and vitamin D3 or TGF-beta1 on MMP-1 and MMP-3 mRNA levels

Biological mediators can influence the activity and differentiation of bone cells. 1,25-dihydroxy-vitamin D3 (1,25-(OH)2D3) is known to induce differentiation of precursors into mature osteoblasts, and transforming growth factor-beta1 (TGF-beta1) can modulate the activity of bone cells leading to alterations in proliferation and gene expression patterns. Bone-derived cells were loaded via intermittent cyclic hydrostatic pressure (icHP) on cells under basal conditions and in the presence of 1,25-(OH)2D3 or TGF-beta1. Evaluating the effects of loading on the cells allowed for a comparison to be made between responsiveness to biomechanical and biochemical stimuli and their potential interplay. The effects of icHP on mRNA levels for the specific genes involved in bone remodelling and differentiation were measured in MG-63 cells using reverse transcription-polymerase chain reaction (RT-PCR). The mRNA levels for matrix metalloproteinase-1 and -3 (MMP-1 and MMP-3) were significantly, and uniquely, increased (p < 0.001) in cells exposed to icHP under serum-free conditions for 4-12 h. However, mRNA levels for MMP-3, but not MMP-1, were significantly enhanced in cells subjected to static hydrostatic pressure (HP). Treatment of cells with 1,25-(OH)2D3 resulted in increased (p < 0.001) mRNA levels for osteocalcin and decreased (p < 0.001) mRNA levels for both MMP-1 and MMP-3. In cells exposed to icHP and 1,25-(OH)2D3, the mRNA levels for both MMP-1 and MMP-3 were elevated (p < 0.001) compared with hormone alone, but not to the same degree (p < 0.01) as cells subjected to icHP alone. Addition of TGF-beta1 to cells led to increases in cell proliferation and expression of collagen I, as well as decreases in expression of osteocalcin and MMP-1 and MMP-3. Exposure of cells to icHP and TGF-beta1 again led to unique and significant increases in expression of MMP-1 and MMP-3. No changes in mRNA levels for glyceraldehyde-3-phosphate dehydrogenase (GAPDH) or any of the other 9 genes assessed, including those for MMP-2 and MMP-13, were detected under any of the conditions described. Therefore, icHP can induce alterations in mRNA levels for a specific subset of genes in both premature and mature osteoblasts. Such stimuli can modulate the impact of potent biological mediators in defining patterns of gene expression by bone cells and potentially modify function in vivo.

The healing rabbit medial collateral ligament of the knee responds to systemically administered glucocorticoids differently than the uninjured tissues of the same joint or the uninjured MCL: a paradoxical shift in impact on specific mRNA levels and MMP-13 protein expression in injured tissues

The impact and molecular mechanism of action of glucocorticoids in connective tissues is largely unclear, even though widely used, and whether factors such as injury and inflammation modulate this response has not been elucidated. This study describes the role of glucocorticoids in the regulation of mRNA levels for collagens I and III, MMP-13, biglycan, decorin, COX-2 and the glucocorticoid receptor in connective tissues of normal and injured joints in an established rabbit in vivo MCL scar model, and examines the potential mechanism(s) involved. In vitro promoter studies were performed using an MMP-13 promoter-luciferase expression construct in transient transfection assays with a rabbit synovial cell line (HIG-82) to identify sites of glucocorticoid-mediated transcriptional regulation and the promoter elements involved. The in vivo results indicate that scar tissue from different phases of healing (early inflammatory, granulation tissue and neovascular, and later remodelling phases, respectively) displays a different pattern of responsiveness to glucocorticoid treatment than uninjured tissue and that this responsiveness is gene dependent. The most significant impact was seen for genes such as collagen I, collagen III and MMP-13, all of which are involved in connective tissue structure and remodelling. The in vitro studies confirmed the apparent in vivo glucocorticoid-mediated response of MMP-13 mRNA and implicated the AP-1 site of the MMP-13 promoter in this regulation. Immunohistochemistry studies showed increased MMP-13 protein expression, consistent with the mRNA findings, following glucocorticoid treatment in injured tissue but not normal tissues. In conclusion, connective tissue responsiveness to glucocorticoid treatment varies depending on injury and the stage of healing of the tissue, and consequently, glucocorticoid-responsiveness may be modulated differently in states of injury and inflammation.

Cytokine and Growth Factor mRNA Expression Patterns Associated with the Hypercontracted, Hyperpigmented Healing Phenotype of Red Duroc Pigs: A Model of Abnormal Human Scar Development?

BACKGROUND

Skin wounds in red Duroc pigs heal with the formation of hypercontractile, hyperpigmented scars, similar in some respects to human hypertrophic scars.

OBJECTIVE

The goal of this study was to characterize the mRNA expression patterns for a subset of relevant cytokines, growth factors, receptors, and transcription factors involved in the red Duroc scarring phenotype.

METHODS

Full-thickness and deep dermal wounds were created on the backs of juvenile female red Duroc pigs. Samples were taken every two weeks postwounding and total RNA and DNA were extracted and quantified. RT-PCR was performed using porcine gene-specific primers for 15 relevant molecules.

RESULTS

The majority of molecules examined exhibited a biphasic pattern of expression, with peaks of expression at days 14 and 56 postinjury.

CONCLUSIONS

The molecular expression pattern observed correlates well with the gross healing phenotype and matrix molecule expression patterns previously reported in red Duroc pigs. These findings enhance our understanding of the processes associated with fibroproliferative scar-formation.