Mechanical load and BMP signaling during tendon repair: a role for follistatin?

Recent Advances in the Use of Stem Cells in Tissue Engineering and Adjunct Therapies for Tendon Reconstruction and Future Perspectives

Due to their function, tendons are exposed to acute injuries. This type of damage to the musculoskeletal system represents a challenge for clinicians when natural regeneration and treatment methods do not produce the expected results. Currently, treatment is long and associated with long-term complications. In this review, we discuss the use of stem cells in the treatment of tendons, including how to induce appropriate cell differentiation based on gene therapy, growth factors, tissue engineering, proteins involved in regenerative process, drugs and three-dimensional (3D) structures. A multidirectional approach as well as the incorporation of novel components of the therapy will improve the techniques used and benefit patients with tendon injuries in the future.

BMP signaling in the development and regeneration of tooth roots: from mechanisms to applications

Short root anomaly (SRA), along with caries, periodontitis, and trauma, can cause tooth loss, affecting the physical and mental health of patients. Dental implants have become widely utilized for tooth restoration; however, they exhibit certain limitations compared to natural tooth roots. Tissue engineering-mediated root regeneration offers a strategy to sustain a tooth with a physiologically more natural function by regenerating the bioengineered tooth root (bio-root) based on the bionic principle. While the process of tooth root development has been reported in previous studies, the specific molecular mechanisms remain unclear. The Bone Morphogenetic Proteins (BMPs) family is an essential factor regulating cellular activities and is involved in almost all tissue development. Recent studies have focused on exploring the mechanism of BMP signaling in tooth root development by using transgenic animal models and developing better tissue engineering strategies for bio-root regeneration. This article reviews the unique roles of BMP signaling in tooth root development and regeneration.

Growth factors in the treatment of Achilles tendon injury

Achilles tendon (AT) injury is one of the most common tendon injuries, especially in athletes, the elderly, and working-age people. In AT injury, the biomechanical properties of the tendon are severely affected, leading to abnormal function. In recent years, many efforts have been underway to develop effective treatments for AT injuries to enable patients to return to sports faster. For instance, several new techniques for tissue-engineered biological augmentation for tendon healing, growth factors (GFs), gene therapy, and mesenchymal stem cells were introduced. Increasing evidence has suggested that GFs can reduce inflammation, promote extracellular matrix production, and accelerate AT repair. In this review, we highlighted some recent investigations regarding the role of GFs, such as transforming GF-β(TGF-β), bone morphogenetic proteins (BMP), fibroblast GF (FGF), vascular endothelial GF (VEGF), platelet-derived GF (PDGF), and insulin-like GF (IGF), in tendon healing. In addition, we summarized the clinical trials and animal experiments on the efficacy of GFs in AT repair. We also highlighted the advantages and disadvantages of the different isoforms of TGF-β and BMPs, including GFs combined with stem cells, scaffolds, or other GFs. The strategies discussed in this review are currently in the early stages of development. It is noteworthy that although these emerging technologies may potentially develop into substantial clinical treatment options for AT injury, definitive conclusions on the use of these techniques for routine management of tendon ailments could not be drawn due to the lack of data.

The tendon unit: biochemical, biomechanical, hormonal influences

The current literature has mainly focused on the biology of tendons and on the characterization of the biological properties of tenocytes and tenoblasts. It is still not understood how these cells can work together in homeostatic equilibrium. We put forward the concept of the "tendon unit" as a morpho-functional unit that can be influenced by a variety of external stimuli such as mechanical stimuli, hormonal influence, or pathological states. We describe how this unit can modify itself to respond to such stimuli. We evidence the capability of the tendon unit of healing itself through the production of collagen following different mechanical stimuli and hypothesize that restoration of the homeostatic balance of the tendon unit should be a therapeutic target.

External stimulation: A potential therapeutic strategy for tendon-bone healing

Injuries at the tendon-bone interface are very common in the field of sports medicine, and healing at the tendon-bone interface is complex. Injuries to the tendon-bone interface can seriously affect a patient’s quality of life, so it is essential to restore stability and promote healing of the tendon-bone interface. In addition to surgical treatment, the healing of tendons and bones can also be properly combined with extracorporeal stimulation therapy during the recovery process. In this review, we discuss the effects of extracorporeal shock waves (ESWs), low-intensity pulsed ultrasound (LIPUS), and mechanical stress on tendon-bone healing, focusing on the possible mechanisms of action of mechanical stress on tendon-bone healing in terms of transcription factors and biomolecules. The aim is to provide possible therapeutic approaches for subsequent clinical treatment.

Stem Cell Applications and Tenogenic Differentiation Strategies for Tendon Repair

Tendons are associated with a high injury risk because of their overuse and age-related tissue degeneration. Thus, tendon injuries pose great clinical and economic challenges to the society. Unfortunately, the natural healing capacity of tendons is far from perfect, and they respond poorly to conventional treatments when injured. Consequently, tendons require a long period of healing and recovery, and the initial strength and function of a repaired tendon cannot be completely restored as it is prone to a high rate of rerupture. Nowadays, the application of various stem cell sources, including mesenchymal stem cells (MSCs) and embryonic stem cells (ESCs), for tendon repair has shown great potential, because these cells can differentiate into a tendon lineage and promote functional tendon repair. However, the mechanism underlying tenogenic differentiation remains unclear. Moreover, no widely adopted protocol has been established for effective and reproducible tenogenic differentiation because of the lack of definitive biomarkers for identifying the tendon differentiation cascades. This work is aimed at reviewing the literature over the past decade and providing an overview of background information on the clinical relevance of tendons and the urgent need to improve tendon repair; the advantages and disadvantages of different stem cell types used for boosting tendon repair; and the unique advantages of reported strategies for tenogenic differentiation, including growth factors, gene modification, biomaterials, and mechanical stimulation.

Function of peripheral nerves in the development and healing of tendon and bone

Although the functions of the peripheral nervous system in whole body homeostasis and sensation have been understood for many years, recent investigation has uncovered new roles for innervation in the musculoskeletal system. This review centers on advances regarding the function of nerves in the development and repair of two connected tissues: tendon and bone. Innervation in healthy tendons is generally confined to the tendon sheaths, and tendon-bone attachment units are typically aneural. In contrast to tendon, bone is an innervated and vascularized structure. Historically, the function of abundant peripheral nerves in bone has been limited to pain and some non-painful sensory perception in disease and injury. Indeed, much of our understanding of peripheral nerves in tendons, bones, and entheses is limited to the source and type of innervation in healthy and injured tissues. However, more recent studies have made important observations regarding the appearance, type, and innervation patterns of nerves during embryonic and postnatal development and in response to injury, which suggest a more expansive role for peripheral nerves in the formation of musculoskeletal tissues. Indeed, tendons and bones develop in a close spatiotemporal relationship in the embryonic mesoderm. Models of limb denervation have shed light on the importance of sensory innervation in bone and to a lesser extent, tendon development, and more recent work has unraveled key nerve signaling pathways. Furthermore, loss of sensory innervation also impairs healing of bone fractures and may contribute to chronic tendinopathy. However, more study is required to translate our knowledge of peripheral nerves to therapeutic strategies to combat bone and tendon diseases.

Application of Stem Cell Therapy for ACL Graft Regeneration

Graft regeneration after anterior cruciate ligament (ACL) reconstruction surgery is a complex three-stage process, which usually takes a long duration and often results in fibrous scar tissue formation that exerts a detrimental impact on the patients' prognosis. Hence, as a regeneration technique, stem cell transplantation has attracted increasing attention. Several different stem cell types have been utilized in animal experiments, and almost all of these have shown good capacity in improving tendon-bone regeneration. Various differentiation inducers have been widely applied together with stem cells to enhance specific lineage differentiation, such as recombinant gene transfection, growth factors, and biomaterials. Among the various different types of stem cells, bone marrow-derived mesenchymal stem cells (BMSCs) have been investigated the most, while ligament stem progenitor cells (LDSCs) have demonstrated the best potential in generating tendon/ligament lineage cells. In the clinic, 4 relevant completed trials have been reported, but only one trial with BMSCs showed improved outcomes, while 5 relevant trials are still in progress. This review describes the process of ACL graft regeneration after implantation and summarizes the current application of stem cells from bench to bedside, as well as discusses future perspectives in this field.

Muscle-tendon Crosstalk During Muscle Wasting

In organisms from flies to mammals, the initial formation of a functional tendon is completely dependent on chemical signals from muscle (myokines). However, how myokines affect the maturation, maintenance, and regeneration of tendons as a function of age is completely unstudied. Here we discuss the role of four myokines - fibroblast growth factors (FGF), myostatin, the secreted protein acidic and rich in cysteine (SPARC), and miR-29 - in tendon development and hypothesize a role for these factors in the progressive changes in tendon structure and function as a result of muscle wasting (disuse, aging and disease). Because of the close relationship between mechanical loading and muscle and tendon regulation, disentangling muscle-tendon crosstalk from simple mechanical loading is experimentally quite difficult. Therefore, we propose an experimental framework that hopefully will be useful in demonstrating muscle-tendon crosstalk in vivo. Though understudied, the promise of a better understanding of muscle-tendon crosstalk is the development of new interventions that will improve tendon development, regeneration, and function throughout the lifespan.

Tenogenic adipose-derived stem cell sheets with nanoyarn scaffolds for tendon regeneration

Tissue engineering, especially cell sheets-based engineering, offers a promising approach to tendon regeneration; however, obtaining a sufficient source of cells for tissue engineering applications is challenging. Adipose-derived stem cells (ASCs) are essential sources for tissue regeneration and have been shown to have the potential for tenogenic differentiation in vitro via induction by growth differentiation factor 5 (GDF-5). In this study, we explored the feasibility of ASCs cell sheets stimulated by GDF-5 for engineered tendon repair. As shown by quantitative polymerase chain reaction and western blotting, tenogenesis-related markers (Col I&III, TNMD, biglycan, and tenascin C) were significantly increased in GDF-5-induced ASCs cell sheets compared with the uninduced. Moreover, the levels of SMAD2/3 proteins and phospho-SMAD1/5/9 were significantly enhanced, demonstrating that GDF-5 may exert its functions through phosphorylation of SMAD1/5/9. Furthermore, the cell sheets were combined with P(LLA-CL)/Silk fibroin nanoyarn scaffolds to form constructs for tendon tissue engineering. Terminal deoxynucleotidyl transferase dUTP nick end labeling and immunofluorescence assays demonstrated favorable cell viability and tenogenesis-related marker expression in GDF-5-induced constructs. In addition, the constructs showed the potential for tendon repair in rabbit models, as demonstrated by histological, immunohistochemical, and biomechanical analyses. In our study, we successfully produced a new tissue-engineered tendon by the combination of GDF-5-induced ASCs cell sheets and nanoyarn scaffold which is valuable for tendon regeneration.

The Effect of Growth Differentiation Factor 8 (Myostatin) on Bone Marrow-Derived Stem Cell-Coated Bioactive Sutures in a Rabbit Tendon Repair Model

Background: We have reported that bioactive sutures coated with bone marrow-derived mesenchymal stem cells (BMSCs) enhance tendon repair strength in an in vivo rat model. We have additionally shown that growth differentiation factor 8 (GDF-8, also known as myostatin) simulates tenogenesis in BMSCs in vitro. The purpose of this study was to determine the possibility of BMSC-coated bioactive sutures treated with GDF-8 to increase tendon repair strength in an in vivo rabbit tendon repair model. Methods: Rabbit BMSCs were grown and seeded on to 4-0 Ethibond sutures and treated with GDF-8. New Zealand white rabbits' bilateral Achilles tendons were transected and randomized to experimental (BMSC-coated bioactive sutures treated with GDF-8) or plain suture repaired control groups. Tendons were harvested at 4 and 7 days after the surgery and subjected to tensile mechanical testing and quantitative polymerase chain reaction. Results: There were distinguishing differences of collagen and matrix metalloproteinase RNA level between the control and experimental groups in the early repair periods (day 4 and day 7). However, there were no significant differences between the experimental and control groups in force to 1-mm or 2-mm gap formation or stiffness at 4 or 7 days following surgery. Conclusions: BMSC-coated bioactive sutures with GDF-8 do not appear to affect in vivo rabbit tendon healing within the first week following repair despite an increased presence of quantifiable RNA level of collagen. GDF-8's treatment efficacy of the early tendon repair remains to be defined.

The shift in macrophages polarisation after tendon injury: A systematic review

Background

The role of macrophages (Mφs) in tendon injury healing is controversy. The aims of this study were to determine whether there is a shift in Mφs polarisation after an acute and chronic tendon injury ​and to assess whether the Mφs polarisation between the partial and complete rupture is different.

Methods

This systematic review of the scientific literature was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane guidelines. PubMed database and Excerpta Medica Database (EMBASE) were used for specific search criteria. Only studies measuring Mφs using specific cell markers in Achilles tendon tissue and rotator cuff tendon tissue were included, respectively.

Results

Five Achilles tendon injury studies and four rotator cuff injury studies were included. Expression of the pan Mϕs marker Cluster of Differentiation (CD) 68 was significantly upregulated in acute Achilles tendon ruptures compared to intact tendons, while no significant changes were found in Mφs polarisation markers CD80 (M1 Mφs) and CD206 (M2 Mφs). High levels of CD86 (M1 Mφs) and CD206 were observed in acute partial rupture. Expression of CD68 and CD206 were significantly upregulated in chronic rotator cuff tendinopathy and downregulated as structural failure increases. A low level of CD206 was observed in complete tendon rupture regardless of acute or chronic injury.

Discussion and conclusion

In spite of the limited number of articles included, findings from this study suggested that the process of inflammation plays an important role in acute Achilles tendon injuries, indicated by the increased expression of CD68+ Mφs. Low levels of CD206+ Mφs were constantly observed in complete Achilles tendon rupture, while high levels of CD80+ Mφs and CD206+ Mφs were observed in partial Achilles tendon rupture, which suggested the potential correlation between M2 Mφs and tendon structure. For chronic rotator cuff injury, CD68+ Mφs and CD206+ Mφs were higher in tendinopathic tissues in comparison to the intact control tissues. Both CD68+ Mφs and CD206+ Mφs has an inverse relation to the structural failure in the torn rotator cuff tendon. After tendon rupture, the time point of biopsy specimen collection is an important factor, which could occur in the acute phase or chronic phase. Collectively, the understanding of the roles in Mφs after tendon injury is inadequate, and more research efforts should be devoted to this direction.

The translational potential of this article

This article provided a potential implication on how pan Mφs or M2 Mφs might be associated with ruptured or torn tendon structure. Managing Mφs numbers and phenotypes may lead to possible novel therapeutic approaches to the management of early tendinopathy, early acute tendon rupture, hence, promote healing after restoration surgery.

Transcriptome profiles of isolated murine Achilles tendon proper- and peritenon-derived progenitor cells

Progenitor cells of the tendon proper and peritenon have unique properties that could impact their utilization in tendon repair strategies. While a few markers have been found to aid in distinguishing progenitors cells from each region, there is great value in identifying more markers. In this study, we hypothesized that RNAseq could be used to improve our understanding of those markers that define these cell types. Transcriptome profiles were generated for pools of mouse Achilles tendon progenitor cells from both regions and catalogues of potential markers were generated. Moreover, common (e.g., glycoprotein, signaling, and proteinaceous extracellular matrix) and unique (e.g., cartilage development versus angiogenesis and muscle contraction) biological processes and molecular functions were described for progenitors from each region. Real-time quantitative PCR of a subset of genes was used to gain insight into the heterogeneity amongst individual progenitor colonies from each region. Markers like Scx, Mkx, Thbs4, and Wnt10a were consistently able to distinguish tendon proper progenitors from peritenon progenitors; expression variability for other genes suggested greater cell type complexity for potential peritenon progenitor markers. This is the first effort to define Achilles tendon progenitor markers by region. Further efforts to investigate the value of these cataloged markers are required by screening more individual colonies of progenitors for more markers. Clinical Significance: Findings from this study advance efforts in the discernment of cell type specific markers for tendon proper and peritenon progenitor cells; insight into marker sets could improve tracking and sorting strategies for these cells for future therapeutic strategies. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1409-1418, 2019.

Tendon healing in the context of complex fractures

Tendons connect muscle to bone and play an integral role in bone and joint alignment and loading. Tendons act as pulleys that provide anchorage of muscle forces for joint motion and stability, as well as for fracture reduction and realignment. Patients that experience complex fractures also have concomitant soft tissue injuries, such as tendon damage or rupture. Tendon injuries that occur at the time of bone fracture have long-term ramifications on musculoskeletal health, yet these injuries are often disregarded in clinical treatment and diagnosis for patients with bone fractures as well as in basic science approaches for understanding bone repair processes. Delayed assessment of soft tissue injuries during evaluation of trauma can lead to chronic pain, dysfunction, and delayed bone healing even following successful fracture repair, highlighting the importance of identifying and treating damaged tendons early. Treatment strategies for bone repair, such as mechanical stabilization and biological therapeutics, can impact tendon healing and function. Because poor tendon healing following complex fracture can significantly impact the function of tendon during bone fracture healing, a need exists to understand the healing process of complex fractures more broadly, beyond the healing of bone. In this review, we explored the mechanical and biological interaction of bone and tendon in the context of complex fracture, as well as the relevance and potential ramifications of tendon damage following bone fracture, which has particular impact on patients that experience complex fractures, such as from combat, automobile accidents, and other trauma.

Side-to-side differences in Achilles tendon geometry and mechanical properties following achilles tendon rupture

Background

Recovery of tendon structure has been suggested to play a role in clinical success following Achilles tendon rupture. The purpose of this study was to identify side-to-side differences in tendon geometry and mechanical properties following Achilles tendon rupture and investigate the relationship of tendon structure with clinical outcomes.

Methods

Participants within 1 year post complete rupture were included. Tendon geometry and mechanical properties were quantified using B-mode ultrasound imaging and continuous shear wave elastography (cSWE). Clinical outcomes included the heel-rise test. Participant self-reported function was measured using the Achilles tendon Total Rupture Score, Foot and Ankle Outcome Score - quality of life subscale, and the Physical Activity Scale.

Results

Twenty participants [mean (SD) age: 42.7(13.6) years, 13 managed surgically] were included. Tendon thickness was greater on the ruptured side (p <0.001) [median (IQR) rupture: 1.38(1.21-1.56) cm, non-rupture: 0.49(0.40-0.52)]. Tendon length to the gastrocnemius was longer (p <0.001) on ruptured [22.8 (21.71-24.31) cm] than non-ruptured [21.66(20.74-23.62) cm] sides. Viscosity was lower on the ruptured side (p <0.001) [median (IQR) rupture: 37.7(30.6-43.3) Pa*s, non-rupture: 53.5(48.4-59.6) Pa*s]. Shear modulus was not different between sides. Tendon thickness (rho = 0.675, p = 0.002) and shear modulus (rho = -0.791, p = 0.001) related to total work on the heel-rise test.

Conclusion

Ultrasound imaging, including cSWE, can be used to detect side-to-side differences in tendon structure in individuals with Achilles tendon rupture and tendon structure relates to clinical performance.

Level of evidence

III b.

Profibrotic mediators in tendon disease: a systematic review

Background

Tendon disease is characterized by the development of fibrosis. Transforming growth factor beta (TGF-β), bone morphogenic proteins (BMPs) and connective tissue growth factor (CTGF) are key mediators in the pathogenesis of fibrotic disorders. The aim of this systematic review was to investigate the evidence for the expression of TGF-β, BMPs and CTGF along tendon disease progression and the response of tendon cells to these growth factors accordingly.

Method

We conducted a systematic screen of the scientific literature using the Medline database. The search terms used were “tendon AND TGF-β,” “tendon AND BMP” or “tendon AND CTGF.” Studies of human samples, animal tendon injury and overuse models were included.

Results

Thirty-three studies were included. In eight studies the expression of TGF-β, BMPs or CTGF was dysregulated in chronic tendinopathy and tendon tear patient tissues in comparison with healthy control tissues. The expression of TGF-β, BMPs and CTGF was increased and showed temporal changes in expression in tendon tissues from animal injury or overuse models compared with the healthy control (23 studies), but the pattern of upregulation was inconsistent between growth factors and also the type of animal model. No study investigated the differences in the effect of TGF-β, BMPs or CTGF treatment between patient-derived cells from healthy and diseased tendon tissues. Tendon cells derived from animal models of tendon injury showed increased expression of extracellular matrix protein genes and increased cell signaling response to TGF-β and BMP treatments compared with the control cells (two studies).

Conclusion

The expression of TGF-β, BMPs and CTGF in tendon tissues is altered temporally during healing in animal models of tendon injury or overuse, but the transition during the development of human tendon disease is currently unknown. Findings from this systematic review suggest a potential and compelling role for TGF-β, BMPs and CTGF in tendon disease; however, there is a paucity of studies analyzing their expression and stimulated cellular response in well-phenotyped human samples. Future work should investigate the dynamic expression of these fibrotic growth factors and their interaction with tendon cells using patient samples at different stages of human tendon disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1165-0) contains supplementary material, which is available to authorized users.

Tendon development and musculoskeletal assembly: emerging roles for the extracellular matrix

Tendons and ligaments are extracellular matrix (ECM)-rich structures that interconnect muscles and bones. Recent work has shown how tendon fibroblasts (tenocytes) interact with muscles via the ECM to establish connectivity and strengthen attachments under tension. Similarly, ECM-dependent interactions between tenocytes and cartilage/bone ensure that tendon-bone attachments form with the appropriate strength for the force required. Recent studies have also established a close lineal relationship between tenocytes and skeletal progenitors, highlighting the fact that defects in signals modulated by the ECM can alter the balance between these fates, as occurs in calcifying tendinopathies associated with aging. The dynamic fine-tuning of tendon ECM composition and assembly thus gives rise to the remarkable characteristics of this unique tissue type. Here, we provide an overview of the functions of the ECM in tendon formation and maturation that attempts to integrate findings from developmental genetics with those of matrix biology.

A Comparative Study on the Biomechanical and Histological Properties of Bone-to-Bone, Bone-to-Tendon, and Tendon-to-Tendon Healing: An Achilles Tendon-Calcaneus Model in Goats

BACKGROUND

Surgical repair around the bone-tendon insertion (BTI) may involve bone-to-bone (BB), bone-to-tendon (BT), or tendon-to-tendon (TT) reattachment with varying healing outcome.

HYPOTHESIS

The repair of Achilles tendon-calcaneus (ATC) by reattachment of homogeneous tissue (BB or TT) would heal faster, with respect to tensile properties at the healing complex, than those of reattachment of heterogeneous tissues (BT) over time.

STUDY DESIGN

Controlled laboratory study.

METHODS

Forty-seven adolescent male Chinese goats were divided into BB, BT, and TT groups. Osteotomy of the calcaneus, reattachment of Achilles tendon to the calcaneus after removal of the insertion, and tenotomy of the Achilles tendon were performed to simulate BB, BT, and TT repair, respectively. The ATC healing complexes were harvested at 6, 12, or 24 weeks postoperatively. Mechanical and morphological properties of the healing ATC complexes were assessed by tensile testing and qualitative histology, respectively. The contralateral intact ATC complex was used as the control.

RESULTS

Failure load of BT was 33.4% lower than that of TT (P = .0243) at week 12. Ultimate strength of BT was 50.2% and 45.3% lower than that of TT at weeks 12 (P = .0002) and 24 (P = .0001), respectively. Tissue morphological characteristics of the BB and TT groups showed faster remodeling. The BT group showed limited regeneration of fibrocartilage zone and excessive formation of fibrous tissue at the healing interface.

CONCLUSION

BTI repair between homogeneous tissues (BB and TT healing) showed better healing quality with respect to mechanical and histological assessments than did healing between heterogeneous tissues (BT healing).

CLINICAL RELEVANCE

Anatomic reconstruction of ATC complex injury may be a primary concern when selecting the proper surgical approach. However, it is recommended to select fracture fixation (BB) or tendon repair (TT) instead of bone-tendon reattachment (BT) if possible to ensure better outcome at the healing interface.

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.

Gene therapy approaches to regenerating the musculoskeletal system

Injuries to the musculoskeletal system are common, debilitating and expensive. In many cases, healing is imperfect, which leads to chronic impairment. Gene transfer might improve repair and regeneration at sites of injury by enabling the local, sustained and potentially regulated expression of therapeutic gene products; such products include morphogens, growth factors and anti-inflammatory agents. Proteins produced endogenously as a result of gene transfer are nascent molecules that have undergone post-translational modification. In addition, gene transfer offers particular advantages for the delivery of products with an intracellular site of action, such as transcription factors and noncoding RNAs, and proteins that need to be inserted into a cell compartment, such as a membrane. Transgenes can be delivered by viral or nonviral vectors via in vivo or ex vivo protocols using progenitor or differentiated cells. The first gene transfer clinical trials for osteoarthritis and cartilage repair have already been completed. Various bone-healing protocols are at an advanced stage of development, including studies with large animals that could lead to human trials. Other applications in the repair and regeneration of skeletal muscle, intervertebral disc, meniscus, ligament and tendon are in preclinical development. In addition to scientific, medical and safety considerations, clinical translation is constrained by social, financial and logistical issues.

Bone morphogenetic protein-7 enhances bone-tendon integration in a murine in vitro co-culture model

PURPOSE

Bone-tendon healing following anterior cruciate ligament reconstruction is reportedly enhanced by bone morphogenetic protein (BMP)-7. To improve our understanding of the underlying biologic processes, we examined the effects of BMP-7 on region-specific gene expression in vitro.

METHODS

A murine in vitro co-culture model simulating the osteoblast, interface and fibroblast regions was established. The dose- and time-dependent region-specific effects of BMP-7 exposure on gene expression of Alpl, Bglap, Col1a1, Runx2 and Spp1 were analysed by quantitative PCR.

RESULTS

At the osteoblast region, BMP-7 significantly increased Alp, Bglap, Col1a1, and Runx2 expression, while Spp1 expression was suppressed. At the interface region, BMP-7 exposure resulted in a trend towards increased expression rates of Alpl and Col1a1, whereas Bglap (P < 0.001) and Runx2 (P < 0.01) were significantly upregulated without any detectable effect on Spp1 expression. At the fibroblast region, BMP-7 increased Alpl (P < 0.001), Bglap (P < 0.001) and Runx2 (P < 0.001) expression, but no significant effects were seen on Col1a1 or Spp1. Exposure to BMP-7 (100 ng/ml) had its most pronounced biologic impact on day ten.

CONCLUSION

BMP-7 stimulation showed beneficial region-specific effects on bone-tendon healing in vitro, such as enhanced expression of parameters for ossification and fibroblast transdifferentiation, both key processes during successful graft integration.

A comparative study of the effects of growth and differentiation factor 5 on muscle-derived stem cells and bone marrow stromal cells in an in vitro tendon healing model

PURPOSE

To investigate the ability of muscle-derived stem cells (MDSCs) supplemented with growth and differentiation factor-5 (GDF-5) to improve tendon healing compared with bone marrow stromal cells (BMSCs) in an in vitro tendon culture model.

METHODS

Eighty canine flexor digitorum profundus tendons were assigned into 5 groups: repaired tendon (1) without gel patch interposition (no cell group), (2) with BMSC-seeded gel patch interposition (BMSC group), (3) with MDSC-seeded gel patch interposition (MDSC group), (4) with GDF-5-treated BMSC-seeded gel patch interposition (BMSC+GDF-5 group), and (5) with GDF-5-treated MDSC-seeded gel patch interposition (MDSC+GDF-5 group). After culturing for 2 or 4 weeks, the failure strength of the healing tendons was measured. The tendons were also evaluated histologically.

RESULTS

The failure strength of the repaired tendon in the MDSC+GDF-5 group was significantly higher than that of the non-cell and BMSC groups. The stiffness of the repaired tendons in the MDSC+GDF-5 group was significantly higher than that of the non-cell group. Histologically, the implanted cells became incorporated into the original tendon in all 4 cell-seeded groups.

CONCLUSIONS

Interposition of a multilayered GDF-5 and MDSC-seeded collagen gel patch at the repair site enhanced tendon healing compared with a similar patch using BMSC. However, this increase in vitro was relatively small. In the clinical setting, differences between MDSC and BMSC may not be substantially different, and it remains to be shown that such methods might enhance the results of an uncomplicated tendon repair clinically.

CLINICAL RELEVANCE

Muscle-derived stem cell implantation and administration of GDF-5 may improve the outcome of tendon repair.

BMP growth factor signaling in a biomechanical context

Bone Morphogenetic Proteins (BMPs) are members of the transforming growth factor-β superfamily of secreted polypeptide growth factors and are important regulators in a multitude of cellular processes. To ensure the precise and balanced propagation of their pleiotropic signaling responses, BMPs and their corresponding signaling pathways are subject to tight control. A large variety of regulatory mechanisms throughout different biological levels combines into a complex network and provides the basis for physiological BMP function. This regulatory network not only includes biochemical factors but also mechanical cues. Both BMP signaling and mechanotransduction pathways are tightly interconnected and represent an elaborate signaling network active during development but also during organ homeostasis. Moreover, its dysregulation is associated with a number of human pathologies. A more detailed understanding of this crosstalk in respect to molecular interactions will be indispensable in the future, in particular to understand BMP-related diseases as well as with regard to an efficient clinical application of BMP ligands.

The genetics of sports injuries and athletic performance

PURPOSE

in the last two decades, several evidences have been provided to support the relationship between single nucleotide polymorphisms and the susceptibility to develop injuries participating in sport and performance related to sports activity. We report up-to-date review of the genetics factors involved in tendon injuries and athletic performance.

METHODS

we searched PubMed using the terms "sports injuries", "athletic performance" and "genetics" over the period 1990 to the present day. We also included non-English journals.

RESULTS

most of the currently established or putative tendinopathy susceptibility loci have been analyzed by candidate gene studies. The genes currently associated with tendon injuries include gene encoding for collagen, matrix metallopeptidase, tenascin and growth factors. Several genes have been related to the physical performance phenotypes affecting endurance capacity and muscle performance. The most studied include ACE and ACTN3 genes.

CONCLUSIONS

genetics determines the response of an individual to the surrounding environment. Recently, some of the individual genetic variations contributing to the athletic performance and the onset of musculoskeletal injuries, particularly in tendon and ligament tissues, have been identified. However, the identification of the genetic background related to susceptibility to injuries and physical performance of the athletes is challenging yet and further studies must be performed to establish the specific role of each gene and the potential effect of the interaction of these.

Force and scleraxis synergistically promote the commitment of human ES cells derived MSCs to tenocytes

As tendon stem/progenitor cells were reported to be rare in tendon tissues, tendons as vulnerable targets of sports injury possess poor self-repair capability. Human ESCs (hESCs) represent a promising approach to tendon regeneration. But their teno-lineage differentiation strategy has yet to be defined. Here, we report that force combined with the tendon-specific transcription factor scleraxis synergistically promoted commitment of hESCs to tenocyte for functional tissue regeneration. Force and scleraxis can independently induce tendon differentiation. However, force alone concomitantly activated osteogenesis, while scleraxis alone was not sufficient to commit, but augment tendon differentiation. Scleraxis synergistically augmented the efficacy of force on teno-lineage differentiation and inhibited the osteo-lineage differentiation by antagonized BMP signaling cascade. The findings not only demonstrated a novel strategy of directing hESC differentiation to tenocyte for functional tendon regeneration, but also offered insights into understanding the network of force, scleraxis and bmp2 controlling tendon-lineage differentiation.

Fluid pressure induces osteoclast differentiation comparably to titanium particles but through a molecular pathway only partly involving TNFα

In contrast to the well-understood inflammatory pathway driven by TNFα, by which implant-derived particles induce bone resorption, little is known about the process in which loosening is generated as a result of force-induced mechanical stimulus at the bone-implant interface. Specifically, there is no knowledge as to what cells or signaling pathways couple mechanical stimuli to bone resorption in context of loosening. We hypothesized that different stimuli, i.e., fluid flow versus wear particles, act through different cytokine networks for activation and localization of osteoclasts. By using an animal model in which osteoclasts and bone resorption were induced by fluid pressure or particles, we were able to detect distinct differences in osteoclast localization and inflammatory gene expression between fluid pressure and titanium particles. Fluid pressure recruits and activates osteoclasts with bone marrow contact away from the fluid pressure exposure zone, whereas titanium particles recruit and activate osteoclasts in areas in direct contact to particles. Fluid pressure induced weaker expression of the selected inflammatory related genes, although the eventual degree of osteoclast induction was similar in both models. Using TNFαRa (4 mg/kg) (Enbrel) and dexamethasone (2 mg/kg) as specific and more general suppressors of inflammation we showed that the TNFαRa failed to generate statistically impaired osteoclast generation while dexamethasone was much more potent. These results demonstrate that fluid pressure induces osteoclasts at a different localization than titanium particles by a molecular pathway less associated with TNFα and the innate system, which open up for other pathways controlling pressure induced osteoclastogenesis.

Synergy of tendon stem cells and platelet-rich plasma in tendon healing

Injured rat Achilles tendons were treated with botulism toxin to create a mechanically unloaded condition (unloaded) or left untreated (loaded), and then treated with phosphate-buffered saline (PBS), platelet-rich plasma (PRP), tendon stem cells (TSCs), or a combination (TSCs + PRP). mRNA and protein expression of collagen I, collagen III, tenascin C, and Smad 8 were determined by real time PCR and immunostaining, respectively. Loaded tendons treated with PBS, PRP, or TSCs for 3 or 14 days had higher collagen I mRNA expression than unloaded tendons. Loaded tendons treated with PBS for 3 or 14 days or with PRP for 3 days had higher collagen I protein levels than unloaded tendons. Loaded tendons treated for 3 days with PBS, for 14 days with PRP or TSCs or TSCs + PRP for 3 or 14 days had higher collagen III protein levels than unloaded tendons. Collagen I mRNA levels were higher in TSCs + PRP-treated loaded tendons compared to PBS-treated loaded tendons on day 3 of treatment. Based on changes in the expression of tendon-healing genes, our data suggest that the combination of TSCs and PRP has synergistic effects on tendon healing under both loaded and unloaded conditions, and loaded conditions improve tendon healing.

BMP2 and mechanical loading cooperatively regulate immediate early signalling events in the BMP pathway

Background

Efficient osteogenic differentiation is highly dependent on coordinated signals arising from growth factor signalling and mechanical forces. Bone morphogenetic proteins (BMPs) are secreted proteins that trigger Smad and non-Smad pathways and thereby influence transcriptional and non-transcriptional differentiation cues. Crosstalk at multiple levels allows for promotion or attenuation of signalling intensity and specificity. Similar to BMPs, mechanical stimulation enhances bone formation. However, the molecular mechanism by which mechanical forces crosstalk to biochemical signals is still unclear.

Results

Here, we use a three-dimensional bioreactor system to describe how mechanical forces are integrated into the BMP pathway. Time-dependent phosphorylation of Smad, mitogen-activated protein kinases and Akt in human fetal osteoblasts was investigated under loading and/or BMP2 stimulation conditions. The phosphorylation of R-Smads is increased both in intensity and duration under BMP2 stimulation with concurrent mechanical loading. Interestingly, the synergistic effect of both stimuli on immediate early Smad phosphorylation is reflected in the transcription of only a subset of BMP target genes, while others are differently affected. Together this results in a cooperative regulation of osteogenesis that is guided by both signalling pathways.

Conclusions

Mechanical signals are integrated into the BMP signalling pathway by enhancing immediate early steps within the Smad pathway, independent of autocrine ligand secretion. This suggests a direct crosstalk of both mechanotransduction and BMP signalling, most likely at the level of the cell surface receptors. Furthermore, the crosstalk of both pathways over longer time periods might occur on several signalling levels.

Role of growth factors in rotator cuff healing

The histologic lesion underlying overuse rotator cuff tendinopathy is a failed healing response, with haphazard proliferation of tenocytes, disruption of tendon cells and collagen fibers, and increased noncollagenous extracellular matrix. Recent attention has focused on the biological pathways by which tendons heal, leading to the identification of several growth factors (GFs) involved in this process. No studies have been published on the time course of the various GFs during rotator cuff healing process in vivo, in humans. We review what is known about these GFs and their role in rotator cuff healing.

Influence of a single loading episode on gene expression in healing rat Achilles tendons

Mechanical loading stimulates tendon healing via mechanisms that are largely unknown. Genes will be differently regulated in loaded healing tendons, compared with unloaded, just because of the fact that healing processes have been changed. To avoid such secondary effects and study the effect of loading per se, we therefore studied the gene expression response shortly after a single loading episode in otherwise unloaded healing tendons. The Achilles tendon was transected in 30 tail-suspended rats. The animals were let down from the suspension to load their tendons on a treadmill for 30 min once, 5 days after tendon transection. Gene expression was studied by Affymetrix microarray before and 3, 12, 24, and 48 h after loading. The strongest response in gene expression was seen 3 h after loading, when 150 genes were up- or downregulated (fold change ≥2, P ≤ 0.05). Twelve hours after loading, only three genes were upregulated, whereas 38 were downregulated. Fewer than seven genes were regulated after 24 and 48 h. Genes involved in the inflammatory response were strongly regulated at 3 and 12 h after loading; this included upregulation of iNOS, PGE synthase, and IL-1β. Also genes involved in wound healing/coagulation, angiogenesis, and production of reactive oxygen species were strongly regulated by loading. Microarray results were confirmed for 16 selected genes in a repeat experiment (N = 30 rats) using real-time PCR. It was also confirmed that a single loading episode on day 5 increased the strength of the healing tendon on day 12. In conclusion, the fact that there were hardly any regulated genes 24 h after loading suggests that optimal stimulation of healing requires a mechanical loading stimulus every day.

Treatment with rhBMP12 or rhBMP13 increase the rate and the quality of rat Achilles tendon repair

Tendon injuries that result in partial or complete tears often come from chronic, repetitive use, or from sudden trauma. In some cases, torn tendons can be repaired, but such repairs often fail to completely restore tendon function. We used global gene expression profiling and histological examination to study tendon repair to elucidate key molecular processes that regulate the rate and quality of tissue restoration. Using a rat Achilles tendon transection model, tissue was collected at 3, 7, 10, and 15 days postinjury. The pattern of gene expression in the repairing tissue paralleled the healing phases of inflammation, matrix formation, and matrix reorganization. Newly formed repaired tissue is characterized by cells expressing many genes associated with tendon formation, thereby potentially distinguishing this repair tissue from other types of repair or scar tissue. Addition of recombinant human bone morphogenic protein (rhBMP)12 or rhBMP13, also known as growth and differentiation factors (GDFs) 6 and 7, 1 day after injury yielded increases in tissue volume, rate of cellular infiltration, and in changes in levels of key mRNAs involved in tendon repair. Altogether, our results indicate that rhBMP12 or rhBMP13 enhance the rate of tendon repair. A better understanding of the key molecular regulators of tendon repair could lead to the development of new therapies for tendon injuries and the identification of diagnostic markers that indicate the status of tendon repair after injury.

Tenogenic differentiation of stem cells for tendon repair-what is the current evidence?

Tendon/ligament injuries are very common in sports and other rigorous activities. Tendons regenerate and repair slowly and inefficiently in vivo after injury. The limited ability of tendon to self-repair and the general inefficiencies of current treatment regimes have hastened the motivation to develop tissue-engineering strategies for tissue repair. Of particular interest in recent years has been the use of adult mesenchymal stem cells (MSCs) to regenerate functional tendons and ligaments. Different sources of MSCs have been studied for their effects on tendon repair. However, ectopic bone and tumour formation has been reported in some special circumstances after transplantation of MSCs. The induction of MSCs to differentiate into tendon-forming cells in vitro prior to transplantation is a possible approach to avoid ectopic bone and tumour formation while promoting tendon repair. While there are reports about the factors that might promote tenogenic differentiation, the study of tenogenic differentiation is hampered by the lack of definitive biomarkers for tendons. This review aims to summarize the cell sources currently used for tendon repair as well as their advantages and limitations. Factors affecting tenogenic differentiation were summarized. Molecular markers currently used for assessing tenogenic differentiation or neotendon formation are summarized and their advantages and limitations are commented upon. Finally, further directions for promoting and assessing tenogenic differentiation of stem cells for tendon repair are discussed.

Augmentation of zone II flexor tendon repair using growth differentiation factor 5 in a rabbit model

PURPOSE

Modulation of zone II flexor tendon repair healing using growth factors may reduce the incidence of complications, such as rupture and fibrosis. We hypothesized that sutures coated with growth differentiation factor 5 (GDF5) will stimulate the healing of zone II flexor tendon repairs.

METHODS

We created and immediately repaired zone II flexor tendon lacerations in the second and fourth toe of the right forepaw of 44 New Zealand White rabbits. One tendon was repaired with suture coated with GDF5, whereas the other tendon was repaired with suture without GDF5 (control). We randomized the allocation of GDF5 and control suture to either toe. A proximal tenotomy of the flexor digitorum profundus at the level of the wrist was performed to relieve tension on the more distal repairs. Rabbits were euthanized at 21 or 42 days after repair. Four rabbits (8 tendons) underwent histological analysis at each time point; the remaining repairs were tested biomechanically in a blinded fashion.

RESULTS

Control tendons demonstrated distinct borders at the transection site and less endogenous repair at 3 weeks. The Soslowsky histological score for collagen was better in the GDF5 group at both time points (p≤.003). All tendons failed at the repair site. The maximum load was significantly greater (p=.04) in the GDF5 group (11.6 ± 3.5 N) compared with control tendons (8.6 ± 3.0 N) at 3 weeks. The maximum load was not significantly different (p=.12) at 6 weeks. We observed no significant differences in stiffness at either time point (p>.11).

CONCLUSIONS

The results demonstrate that GDF5 has an early beneficial effect on tendon healing in zone II flexor tendon repairs in a rabbit flexor tendon injury model.

Role of myostatin (GDF-8) signaling in the human anterior cruciate ligament

Myostatin, also referred to as growth and differentiation factor-8 (GDF-8), is expressed in muscle tissue where it functions to suppress myoblast proliferation and myofiber hypertrophy. Recently, myostatin and its receptor, the type IIB activin receptor (ActRIIB), were detected in the leg tendons of mice, and recombinant myostatin was shown to increase cellular proliferation and the expression of type 1 collagen in primary fibroblasts from mouse tendons. We sought to determine whether myostatin and its receptor were present in human anterior cruciate ligament (ACL) tissue, and if myostatin treatment had any effect on primary ACL fibroblasts. ACL tissue samples were obtained from material discarded during ACL reconstruction surgery. Real-time PCR and immunohistochemistry demonstrate that both myostatin and its receptor are abundant in the human ACL. Primary fibroblasts isolated from human ACL specimens were treated with recombinant myostatin, and myostatin treatment increased fibroblast proliferation as well as the expression of tenascin C (TNC), type 1 collagen, and transforming growth factor-beta1. Real-time PCR analysis of TNC and type 1 collagen expression in ACL specimens from normal mice and mice lacking myostatin supported these findings by showing that both TNC and type 1 collagen were downregulated in ACL tissue from myostatin-deficient mice. Together, these data suggest that myostatin is a pro-fibrogenic factor that enhances cellular proliferation and extracellular matrix synthesis by ACL fibroblasts. Recombinant myostatin may therefore have therapeutic applications in the area of tendon and ligament engineering and regeneration.

BMPs: from bone to body morphogenetic proteins

The family of bone morphogenetic proteins (BMPs) comprises approximately 30 secreted cytokines that signal through transmembrane serine/threonine kinase receptors. The BMP signaling pathways are fine-tuned on multiple levels: Extracellular antagonists modify ligand activity; several co-receptors enhance or inhibit downstream signaling events through multiple mechanisms; and intracellular molecules further regulate the signaling outcome and mediate crosstalk with other pathways. BMPs affect structures and processes throughout the entire body, ranging from embryonic patterning and development through stem cells and their niches, to tissue homeostasis and regeneration. This comprehensive involvement in various tissues had not been expected by Marshall Urist, who initially discovered the ability of an unknown factor in bone to induce bone growth in muscle and subsequently suggested the name "bone morphogenetic protein." Today, recombinant BMPs are used in clinical practice for the treatment of bone and kidney disorders, and new genetically modified BMPs are emerging as promising tools in regenerative medicine and tissue engineering. Clearly, the functions of BMPs within the body are more versatile than initially suspected. To discuss modern trends in BMP signaling, leaders in the field met for the First International BMP Workshop in Berlin in September 2009. Here, we summarize new insights on the roles of BMPs in various tissues and highlight recent findings in cell, structural, and developmental biology as well as the therapeutic potential of BMPs. Finally, we conclude that BMPs today deserve to be called body morphogenetic proteins.

Metalloproteinases and their inhibitors-diagnostic and therapeutic opportunities in orthopedics

Matrix metalloproteinases (MMPs) and related enzymes (ADAMs, ADAMTS) and their inhibitors control matrix turnover and function. Recent advances in our understanding of musculoskeletal conditions such as tendinopathy, arthritis, Dupuytren's disease, degenerative disc disease, and bone and soft tissue healing suggest that MMPs have prominant roles. Importantly, MMPs are amenable to inhibition by cheap, safe, and widely available drugs such as the tetracycline antibiotics and the bisphosphonates. This indicates that these MMP inhibitors, if proven effective for any novel indication, may be quickly brought into clinical practice.

Sexual dimorphism in the effect of GDF-6 deficiency on murine tendon

Three members of the growth/differentiation factor (GDF) subfamily of bone morphogenetic proteins (BMPs), GDFs-5, -6, and -7, have demonstrated the potential to augment tendon and ligament repair. To gain further insight into the in vivo role of these molecules, previous studies have characterized intact and healing tendons in mice with functional null mutations in GDF-5 and -7. The primary goal of the present study was to perform a detailed characterization of the intact tendon phenotype in 4- and 16-week-old male and female GDF6-/- mice and their +/+ littermates. The results demonstrate that GDF6 deficiency was associated with an altered tendon phenotype that persisted into adulthood. Among males, GDF6-/- tail tendon fascicles had significantly less collagen and glycosaminoglycan content, and these compositional differences were associated with compromised material properties. The effect of GDF6 deficiency on tendon was sexually dimorphic, however, for among female GDF6-/- mice, neither differences in tendon composition nor in material properties were detected. The tendon phenotype that was observed in males appeared to be stronger in the tail site than in the Achilles tendon site, where some compositional differences were present, but no material property differences were detected. These data support existing in vitro studies, which suggest a potential role for BMP-13 (the human homologue to GDF-6) in tendon matrix modeling and/or remodeling.

Bone morphogenetic proteins in soft-tissue reconstruction

Different options are reviewed in the field of musculoskeletal tissue reconstruction, from the addition of biological actors (cells, growth factors, biological or artificial scaffolds) to the application of gene therapy or tissue engineering. Growth factors can enable innovative solutions to treat such disease if we can extrapolate to soft tissue the promising results obtained in bone reconstruction with bone morphogenetic proteins. However, as in bone reconstruction, soft-tissue regeneration will depend on the drug delivery carrier, the scaffold for the newly formed tissue, the dose of growth factor and the animal model, which must all be explored before extrapolation to clinical problems.

Myostatin in tendon maintenance and repair

Myostatin, a negative regulator of muscle growth, has recently been found to be expressed in tendons. Myostatin-deficient mice have weak and brittle tendons, which suggest that myostatin could be important for tendon maintenance. Follistatin expression in the callus tissue after tendon transection is influenced by loading. We found that follistatin antagonises myostatin, but not GDF-5 or OP-1 in vitro. To study if myostatin might play a physiological role in soft tissue, we transected 64 rat Achilles tendons and studied the gene expression for myostatin and its receptors at four different time-points during healing. Intact tendons were also studied. All samples were studied with or without mechanical loading. Unloading was achieved with botulinum toxin injections in the calf muscles. The expression of the myostatin gene was more than 40 times higher in intact tendons than in the callus tissue during tendon healing. The expression of myostatin was also influenced by loading status in both intact and healing tendons. Thereafter, we measured the mechanical properties of healing tendons after local myostatin administration. This treatment increased the volume and the contraction of the callus after 8 days, but did not improve its strength. Our results indicate that myostatin plays a positive role in tendon maintenance and that exogenous protein administration stimulates proliferation and growth of early repair tissue. However, no effect on further development towards connective tissue formation was found.

Rat Achilles tendon healing: mechanical loading and gene expression

Injured tendons require mechanical tension for optimal healing, but it is unclear which genes are upregulated and responsible for this effect. We unloaded one Achilles tendon in rats by Botox injections in the calf muscles. The tendon was then transected and left to heal. We studied mechanical properties of the tendon calluses, as well as mRNA expression, and compared them with loaded controls. Tendon calluses were studied 3, 8, 14, and 21 days after transection. Intact tendons were studied similarly for comparison. Altogether 110 rats were used. The genes were chosen for proteins marking inflammation, growth, extracellular matrix, and tendon specificity. In intact tendons, procollagen III and tenascin-C were more expressed in loaded than unloaded tendons, but none of the other genes was affected. In healing tendons, loading status had small effects on the selected genes. However, TNF-alpha, transforming growth factor-beta1, and procollagens I and III were less expressed in loaded callus tissue at day 3. At day 8 procollagens I and III, lysyl oxidase, and scleraxis had a lower expression in loaded calluses. However, by days 14 and 21, procollagen I, cartilage oligomeric matrix protein, tenascin-C, tenomodulin, and scleraxis were all more expressed in loaded calluses. In healing tendons, the transverse area was larger in loaded samples, but material properties were unaffected, or even impaired. Thus mechanical loading is important for growth of the callus but not its mechanical quality. The main effect of loading during healing might thereby be sought among growth stimulators. In the late phase of healing, tendon-specific genes (scleraxis and tenomodulin) were upregulated with loading, and the healing tissue might to some extent represent a regenerate rather than a scar.

Identification of a tendon phenotype in GDF6 deficient mice

Increasing evidence suggests that the growth/differentiation factors, GDFs 5, 6, and 7 in particular, may play a role in tendon and ligament biology. Mice with genetic mutations in Gdf5 have altered tendon composition and mechanical behavior, whereas animals with functional null mutations in Gdf7 have a more subtle tendon phenotype. The present study demonstrates for the first time that a null mutation in Gdf6 is associated with substantially lower levels of tail tendon collagen content (-33%) in 4-week-old male mice, which has direct functional consequences for the mechanical integrity of the tissue (45-50% reduction in material properties). These data support a role for GDF6 in tendon matrix modeling.