Possible reparative effect of low-intensity pulsed ultrasound (LIPUS) on injured meniscus

Extracorporeal shockwave therapy for degenerative meniscal tears results in a decreased T2 relaxation time and pain relief: An exploratory randomized clinical trial

PURPOSE

The optimal management of degenerative meniscal tears remains controversial. Extracorporeal shockwave therapy (ESWT) has been shown to promote tissue repair in both preclinical and clinical studies; however, its effect on degenerative meniscal tears remains unknown. This study aimed to examine whether ESWT improves meniscal degeneration.

METHODS

This randomized trial was conducted between 2020 and 2022 and involved patients with degenerative medial meniscal tears. Patients were allocated to receive either focused ESWT (0.25 mJ/mm2, 2000 impulses, 3 sessions with a 1-week interval) or sham treatment. Patients were evaluated using magnetic resonance imaging (MRI) before treatment and at 12 months after treatment. The primary endpoint was improvement in meniscal degeneration, as assessed by the change in T2 relaxation time from baseline on MRI T2 mapping. Knee pain and clinical outcomes were also examined at the same time.

RESULTS

Of 29 randomized patients, 27 patients (mean age 63.9 ± 8.7 years; females 37%; ESWT group 14 patients; control group 13 patients) were included in the final analysis. At 12 months postintervention, patients in the ESWT group showed a greater decrease in the T2 relaxation time (ESWT group -2.9 ± 1.7 ms vs. control group 1.0 ± 1.9 ms; p < 0.001) and had less knee pain (p = 0.04). The clinical outcomes at 12 months post-treatment were not statistically significant. No adverse events were reported.

CONCLUSION

ESWT decreased the T2 relaxation time in the meniscus at 12 months post-treatment. ESWT also provided pain relief, but no differences were observed in clinical outcomes.

LEVEL OF EVIDENCE

Level II.

Current advances in engineering meniscal tissues: insights into 3D printing, injectable hydrogels and physical stimulation based strategies

The knee meniscus is the cushioning fibro-cartilage tissue present in between the femoral condyles and tibial plateau of the knee joint. It is largely avascular in nature and suffers from a wide range of tears and injuries caused by accidents, trauma, active lifestyle of the populace and old age of individuals. Healing of the meniscus is especially difficult due to its avascularity and hence requires invasive arthroscopic approaches such as surgical resection, suturing or implantation. Though various tissue engineering approaches are proposed for the treatment of meniscus tears, three-dimensional (3D) printing/bioprinting, injectable hydrogels and physical stimulation involving modalities are gaining forefront in the past decade. A plethora of new printing approaches such as direct light photopolymerization and volumetric printing, injectable biomaterials loaded with growth factors and physical stimulation such as low-intensity ultrasound approaches are being added to the treatment portfolio along with the contemporary tear mitigation measures. This review discusses on the necessary design considerations, approaches for 3D modeling and design practices for meniscal tear treatments within the scope of tissue engineering and regeneration. Also, the suitable materials, cell sources, growth factors, fixation and lubrication strategies, mechanical stimulation approaches, 3D printing strategies and injectable hydrogels for meniscal tear management have been elaborated. We have also summarized potential technologies and the potential framework that could be the herald of the future of meniscus tissue engineering and repair approaches.

Low-intensity pulsed ultrasound enhances the positive effects of high-intensity treadmill exercise on bone in rats

INTRODUCTION

Moderate exercise benefits bone health, but excessive loading leads to bone fatigue and a decline in mechanical properties. Low-intensity pulsed ultrasound (LIPUS) can stimulate bone formation. The purpose of this study was to explore whether LIPUS could augment the skeletal benefits of high-intensity exercise.

MATERIALS AND METHODS

MC3T3-E1 osteoblasts were treated with LIPUS at 80 mW/cm2 or 30 mW/cm2 for 20 min/day. Forty rats were divided into sham treatment normal control (Sham-NC), sham treatment high-intensity exercise (Sham-HIE), 80 mW/cm2 LIPUS (LIPUS80), and high-intensity exercise combined with 80 mW/cm2 LIPUS (LIPUS80-HIE). The rats in HIE group were subjected to 30 m/min slope treadmill exercise for 90 min/day, 6 days/week for 12 weeks. The LIPUS80-HIE rats were irradiated with LIPUS (1 MHz, 80 mW/cm2) for 20 min/day at bilateral hind limb after exercise.

RESULTS

LIPUS significantly accelerated the proliferation, differentiation, mineralization, and migration of MC3T3-E1 cells. Compared to 30 mW/cm2 LIPUS, 80 mW/cm2 LIPUS got better promotion effect. 12 weeks of high-intensity exercise significantly reduced the muscle force, which was significantly reversed by LIPUS. Compared with the Sham-NC group, Sham-HIE group significantly optimized bone microstructure and enhanced mechanical properties of femur, and LIPUS80-HIE further enhanced the improvement effect on bone. The mechanisms may be related to activate Wnt/β-catenin signal pathway and then up-regulate the protein expression of Runx2 and VEGF, the key factors of osteogenesis and angiogenesis.

CONCLUSION

LIPUS could augment the skeletal benefits of high-intensity exercise through Wnt/β-catenin signal pathway.

Stimulus-Responsive Drug Delivery Nanoplatforms for Osteoarthritis Therapy

Osteoarthritis (OA) is one of the most prevalent age-related degenerative diseases. With an increasingly aging global population, greater numbers of OA patients are providing clear economic and societal burdens. Surgical and pharmacological treatments are the most common and conventional therapeutic strategies for OA, but often fall considerably short of desired or optimal outcomes. With the development of stimulus-responsive nanoplatforms has come the potential for improved therapeutic strategies for OA. Enhanced control, longer retention time, higher loading rates, and increased sensitivity are among the potential benefits. This review summarizes the advanced application of stimulus-responsive drug delivery nanoplatforms for OA, categorized by either those that depend on endogenous stimulus (reactive oxygen species, pH, enzyme, and temperature), or those that depend on exogenous stimulus (near-infrared ray, ultrasound, magnetic fields). The opportunities, restrictions, and limitations related to these various drug delivery systems, or their combinations, are discussed in areas such as multi-functionality, image guidance, and multi-stimulus response. The remaining constraints and potential solutions that are represented by the clinical application of stimulus-responsive drug delivery nanoplatforms are finally summarized.

The Evaluation of Meniscus Regenerative Effects of LIPUS-Induced CCN Proteins: Induction by LIPUS of CCN2 and Meniscus-Related Genes in Cultured Meniscus Cells and Meniscus Tissues

Menisci are a pair of crescent-shaped fibrocartilages and composed primarily of type I collagen. Inner region of the meniscus has similar characteristics to articular cartilage. Low-intensity pulsed ultrasound (LIPUS) has been reported to have chondroprotective effects on chondrocytes by inducing the expression of chondrocyte differentiation markers and CCN2/CTGF production. Here, we describe an experimental approach that investigates the distinct cellular behavior of human inner and outer meniscus cells in response to LIPUS stimulation. Our experimental model can analyze the relationships between LIPUS-induced CCN2 and its repairing role in the meniscus.

The therapeutic effects of low-intensity pulsed ultrasound in musculoskeletal soft tissue injuries: Focusing on the molecular mechanism

Musculoskeletal soft tissue injuries are very common and usually occur during both sporting and everyday activities. The intervention of adjuvant therapies to promote tissue regeneration is of great importance to improving people's quality of life and extending their productive lives. Though many studies have focused on the positive results and effectiveness of the LIPUS on soft tissue, the molecular mechanisms standing behind LIPUS effects are much less explored and reported, especially the intracellular signaling pathways. We incorporated all research on LIPUS in soft tissue diseases since 2005 and summarized studies that uncovered the intracellular molecular mechanism. This review will also provide the latest evidence-based research progress in this field and suggest research directions for future experiments.

The efficacy of low-intensity pulsed ultrasound on articular cartilage and clinical evaluations in patients with knee osteoarthritis

BACKGROUND

While a number of preclinical studies have examined the effectiveness of low-intensity pulsed ultrasound (LIPUS) as a potential treatment for knee osteoarthritis (OA), there have been few clinical studies which have indirectly confirmed cartilage regeneration by magnetic resonance imaging (MRI).

OBJECTIVE

The aim of this clinical trial was to investigate whether LIPUS effectively increased knee cartilage thickness and improved pain and function in knee OA patients.

METHODS

This study was a prospective, single-group, home-based self-therapy trial. We included patients (n= 20) with OA pain. Each patient used an ultrasonic stimulation device (BODITREK JOINT™) for more than 20 sessions. Outcomes were assessed by MRI, Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the 36-Item Short Form Survey (SF-36) for assessing quality of life.

RESULTS

Nineteen subjects completed this study. There was no significant increase in the cartilage thickness measured by MRI after LIPUS treatment. LIPUS therapy significantly decreased VAS score and WOMAC score, and significantly increased SF-36 score. The subgroup analysis in patients with knee OA showed that LIPUS treatment showed better for older patients with lower Kellgren-Lawrence grades.

CONCLUSION

Pain, function, and quality of life improved after LIPUS, but there was no significant increase in cartilage thickness through MRI.

Pulsed Electromagnetic Field Enhances Healing of a Meniscal Tear and Mitigates Posttraumatic Osteoarthritis in a Rat Model

BACKGROUND

Meniscal tears in the avascular region are thought to rarely heal and are a considerable challenge to treat. Although the therapeutic effects of a pulsed electromagnetic field (PEMF) have been extensively studied in a variety of orthopaedic disorders, the effect of a PEMF on meniscal healing has not been reported.

HYPOTHESIS

PEMF treatment would promote meniscal healing and prevent osteoarthritis progression.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 72 twelve-week-old male Sprague-Dawley rats with full-thickness longitudinal medial meniscal tears in the avascular region were divided into 3 groups: control (G_con), treatment with a classic signal PEMF (G_classic), and treatment with a high-slew rate signal PEMF (G_HSR). Macroscopic observation and histological analysis of the meniscus and articular cartilage were performed to evaluate the meniscal healing and progression of osteoarthritis. The synovium was harvested for histological and immunofluorescent analysis to evaluate the intra-articular inflammation. Meniscal healing, articular cartilage degeneration, and synovitis were quantitatively evaluated according to their scoring systems.

RESULTS

Dramatic degenerative changes of the meniscus and articular cartilage were noticed during gross observation and histological evaluation in G_con at 8 weeks. However, the menisci in the 2 treatment groups were restored to normal morphology, with a smooth surface and shiny white color. Particularly, the HSR signal remarkably enhanced the fibrochondrogenesis and accelerated the remodeling process of the regenerated tissue. The meniscal healing scores of the PEMF treatment groups were significantly higher than those in G_con at 8 weeks. Specifically, the HSR signal showed a significantly higher meniscal repair score than did the classic signal at week 8 (P < .01). Additionally, the HSR signal significantly downregulated the secretion levels of interleukin 1 beta (IL-1β) and tumor necrosis factor alpha (TNF-α) in the meniscus and synovium as compared with the control group. When compared with the 2 treatment groups, G_con had significantly higher degeneration scores (G_con vs G_classic, P < .0001; G_con vs G_HSR, P < .0001). The HSR signal also exhibited significantly lower synovitis scores compared with the other two groups (G_con vs G_classic, P < .0001; G_classic vs G_HSR, P = .0002).

CONCLUSION

A PEMF promoted the healing of meniscal tears in the avascular region and restored the injured meniscus to its structural integrity in a rat model. As compared with the classic signal, the HSR signal showed increased capability to promote fibrocartilaginous tissue formation and modulate the inflammatory environment, therefore protecting the knee joint from posttraumatic osteoarthritis development.

CLINICAL RELEVANCE

Adjuvant PEMF therapy may offer a new approach for the treatment of meniscal tears attributed to the enhanced meniscal repair and ameliorated osteoarthritis progression.

Low-intensity pulsed ultrasound promotes angiogenesis via the AKT pathway and DNA methylation in human umbilical vein endothelial cells

Angiogenesis involves the activation of endothelial cells (ECs). Low-intensity pulsed ultrasound (LIPUS), which delivers ultrasound waves at a low intensity, can induce the angiogenic potential of ECs. However, the underlying cellular mechanisms remain to be elucidated. In this study, the LIPUS parameters were 1.5 MHz pulsed frequency, 200 us pulse duration, 1.0 kHz repetition rate, and 30 mW/cm² energy intensity. First, we evaluated the effects of LIPUS on the proliferation and angiogenic differentiation of the EC line EA.hy926. The results showed that LIPUS could induce cell proliferation, promote migration, and increase mRNA level inKDR and CD144.Also, the mRNA level and secretion of VEGF were enhanced. We then investigated the role of the AKT signaling pathway in this process. We observed that the expression of p-AKT was upregulated which means that the AKT signaling pathway could be activated by LIPUS, while inhibitor LY294002 of the AKT signaling pathway effectively blocked LIPUS-induced angiogenesis. Finally,we applied confocal Raman microscopy to track biomolecular changes in cells after LIPUS treatment. Spectral analysis showed DNA methylation changes. An Infinium Methylation assay suggested that399 sites were significantly different. After KEGG enrichment analysis, we found seven genes (IRS1, GNG7, COL4A1, FOXO3, COL4A2, CDK4 and EGF) which were closely related to AKT signaling pathway. We verified that AKT signaling pathway inhibition partially blocked LIPUS-induced DNA methylation changes. Ourstudy demonstrated that LIPUS couldpromote the proliferation and angiogenic differentiation of ECs via the AKT signaling pathway. LIPUS could also alter DNA methylation of ECs via the activation of AKT signal.

CTGF as a multifunctional molecule for cartilage and a potential drug for osteoarthritis

CTGF is a multifunctional protein and plays different roles in different cells and under different conditions. Pamrevlumab, a monoclonal antibody against CTGF, is an FDA approved drug for idiopathic pulmonary fibrosis (IPF) and Duchenne muscular dystrophy (DMD). Recent studies have shown that CTGF antibodies may potentially serve as a new drug for osteoarthritis (OA). Expression of CTGF is significantly higher in OA joints than in healthy counterparts. Increasing attention has been attracted due to its interesting roles in joint homeostasis. Joint homeostasis relies on normal cellular functions and cell-cell interactions. CTGF is essential for physiological activities of chondrocytes. Abnormal CTGF expression may cause cartilage degeneration. In this review, the physiological functions of CTGF in chondrocytes and related mechanisms are summarized. Changes in the related signaling pathways due to abnormal CTGF are discussed, which are contributing factors to inflammation, cartilage degeneration and synovial fibrosis in OA. The possibility of CTGF as a potential therapeutic target for OA treatment are reviewed.

Ex Vivo Imaging of Ultrasound-Stimulated Metabolic Activity in Rat Pancreatic Slices

Ultrasound has previously been reported to produce a reversible stimulatory effect in cultured rat beta cells. Here, we quantified and assessed dynamic metabolic changes in an in situ pancreatic slice model evoked by ultrasound application. After plating, pancreas slices were imaged using a confocal microscope at 488 and 633 nm to image lipodamine dehydrogenase (Lip-DH) autofluorescence and a far red fluorescence, respectively. Ultrasound was applied at intensities of 0.5 and 1 W/cm2 at both 800 kHz and 1 MHz. Additionally, 800 kHz at 1 W/cm2 was applied in a pulsing scheme. No ultrasound (control) and glucose application experiments were performed. A difference in fluorescence signal before and after treatment application was the metric for analysis. Comparison of experimental groups using far red fluorescence revealed significant differences between all experimental groups and control in the islet (p < 0.05) and between all ultrasound experimental groups and control (p < 0.05) in pancreatic exocrine tissue. However, this difference in response between control and glucose did not exist in the exocrine tissue. We also observed using Lip-DH autofluorescence that glucose produces a significantly increased metabolic response in islet tissue compared with exocrine tissue (p < 0.05). Pulsed ultrasound appeared to increase metabolic activity in the pancreatic slice in a more consistent manner compared with continuous ultrasound application. Our results indicate that therapeutic ultrasound may have a stimulatory metabolic effect on the pancreatic islets similar to that of glucose.

Suppression of adipocyte differentiation by low-intensity pulsed ultrasound via inhibition of insulin signaling and promotion of CCN family protein 2

Adipocyte differentiation is regulated by several transcription factors such as the CCAAT/enhancer-binding proteins (C/EBPs) and peroxisome proliferator-activated receptor-γ (PPARγ). Here, we demonstrate that low-intensity pulsed ultrasound (LIPUS) suppressed differentiation into mature adipocytes via multiple signaling pathways. When C3H10T1/2, a mesenchymal stem cell line, was treated with LIPUS (3.0 MHz, 60 mW/cm2 ) for 20 minutes once a day for 4 days during adipogenesis, and both the number of lipid droplets and the gene expression of PPARγ and C/EBPα were significantly decreased. Furthermore, LIPUS treatment decreased the phosphorylation of the insulin receptor and also that of Akt and ERK1/2, which are located downstream of this receptor. Next, we showed that LIPUS suppressed the gene expression of angiotensinogen (AGT), which is an adipokine produced by mature adipocytes, as well as that of angiotensin-converting enzyme 1 (ACE1) and angiotensin receptor type 1 (AT1 R) during adipogenesis of pre-adipogenic 3T3-L1 cells. Next, the translocation of Yes-associated protein (YAP) into the nucleus of 3T3-L1 cells was promoted by LIPUS, leading to upregulation of CCN family protein 2 (CCN2), a cellular communication network factor. Moreover, forced expression of CCN2 in 3T3-L1 cells decreased PPARγ gene expression, but it did not increase alkaline phosphatase and osterix gene expression. Finally, gene silencing of CCN2 in C3H10T1/2 cells diminished the effect of LIPUS on the gene expression of PPARγ and C/EBPα. These findings suggest that LIPUS suppressed adipogenesis through inhibition of insulin signaling and decreased PPARγ expression via increased CCN2 production, resulting in a possible decrease of mature adipocytes.

Roles of CCN2 as a mechano-sensing regulator of chondrocyte differentiation

Cellular communication network factor 2 (CCN2) is a cysteine-rich secreted matricellular protein that regulates various cellular functions including cell differentiation. CCN2 is highly expressed under several types of mechanical stress, such as stretch, compression, and shear stress, in mesenchymal cells including chondrocytes, osteoblasts, and fibroblasts. In particular, CCN2 not only promotes cell proliferation and differentiation of various cells but also regulates the stability of mRNA of TRPV4, a mechanosensitive ion channel in chondrocytes. Of note, CCN2 behaves like a biomarker to sense suitable mechanical stress, because CCN2 expression is down-regulated when chondrocytes are subjected to excessive mechanical stress. These findings suggest that CCN2 is a mechano-sensing regulator. CCN2 expression is regulated by the activation of various mechano-sensing signaling pathways, e.g., mechanosensitive ion channels, integrin-focal adhesion-actin dynamics, Rho GTPase family members, Hippo-YAP signaling, and G protein-coupled receptors. This review summarizes the characterization of mechanoreceptors involved in CCN2 gene regulation and discusses the role of CCN2 as a mechano-sensing regulator of mesenchymal cell differentiation, with particular focus on chondrocytes.

Study of Medical Ultrasound for Rhizarthrosis (SUR): study protocol for a randomized controlled single-center pilot-trial

BACKGROUND

Rhizarthrosis (trapeziometacarpal osteoarthritis) is the second most common site of osteoarthritis in the hand affecting 10-30% of adults over the age of 50. Up to four times as many women as men have rhizarthrosis. Clinical symptoms include functional disability of the thumb, pain, joint swelling, and reduced strength. The first carpometacarpal joint is pivotal in the opposition of the thumb and allows a high degree in flexibility to humans. Current therapies focus mainly on surgical strategies, which should be considered in advanced, therapy-resistant stages to relieve pain and improve function. However, conservative treatment methods are urgently required in presurgical stages. The efficacy of conservative treatment options for rhizarthrosis, which are intended to preserve function, joint integrity and to relieve pain, has not been adequately studied. In the clinical study protocol presented here, we investigate the efficacy of multimodal hand therapy versus therapeutic ultrasound versus combination therapy with both hand therapy and therapeutic ultrasound.

METHODS

This study is a single-center, randomized, controlled, parallel-group pilot trial. One hundred fifty patients with rhizarthrosis and current disease activity will be randomized to one of three conservative interventions over 6 months. Interventions are (1) multimodal hand therapy (2) therapeutic ultrasound, and (3) combination therapy with both hand therapy and ultrasound therapy. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score after 6 months. Secondary endpoints are changes in pain, quality of life, disability progression, and changes of hand function. Safety will also be assessed.

DISCUSSION

Clinical data suggest that multimodal hand therapy may improve functionality and reduce pain in rhizarthrosis. Clinical data regarding therapeutic ultrasound are not available. Clinical evidence is lacking. This study is the first clinical study investigating the effects of multimodal hand therapy in direct comparison to therapeutic ultrasound and to a combination therapy with both hand therapy and ultrasound therapy for rhizarthrosis.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04115085; Registered on September 30, 2019.

Roles of Interaction between CCN2 and Rab14 in Aggrecan Production by Chondrocytes

To identify proteins that cooperate with cellular communication network factor 2 (CCN2), we carried out GAL4-based yeast two-hybrid screening using a cDNA library derived from the chondrocytic cell line HCS-2/8. Rab14 GTPase (Rab14) polypeptide was selected as a CCN2-interactive protein. The interaction between CCN2 and Rab14 in HCS-2/8 cells was confirmed using the in situ proximity ligation assay. We also found that CCN2 interacted with Rab14 through its IGFBP-like domain among the four domains in CCN2 protein. To detect the colocalization between CCN2 and Rab14 in the cells in detail, CCN2, wild-type Rab14 (Rab14WT), a constitutive active form (Rab14CA), and a dominant negative form (Rab14DN) of Rab14 were overexpressed in monkey kidney-tissue derived COS7 cells. Ectopically overexpressed Rab14 showed a diffuse cytosolic distribution in COS7 cells; however, when Rab14WT was overexpressed with CCN2, the Rab14WT distribution changed to dots that were evenly distributed within the cytosol, and both Rab14 and CCN2 showed clear colocalization. When Rab14CA was overexpressed with CCN2, Rab14CA and CCN2 also showed good localization as dots, but their distribution was more widespread within cytosol. The coexpression of Rab14DN and CCN2 also showed a dotted codistribution but was more concentrated in the perinuclear area. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) analysis revealed that the reduction in RAB14 or CCN2 mRNA by their respective siRNA significantly enhanced the expression of ER stress markers, BIP and CHOP mRNA in HCS-2/8 chondrocytic cells, suggesting that ER and Golgi stress were induced by the inhibition of membrane vesicle transfer via the suppression of CCN2 or Rab14. Moreover, to study the effect of the interaction between CCN2 and its interactive protein Rab14 on proteoglycan synthesis, we overexpressed Rab14WT or Rab14CA or Rab14DN in HCS-2/8 cells and found that the overexpression of Rab14DN decreased the extracellular proteoglycan accumulation more than the overexpression of Rab14WT/CA did in the chondrocytic cells. These results suggest that intracellular CCN2 is associated with Rab14 on proteoglycan-containing vesicles during their transport from the Golgi apparatus to endosomes in chondrocytes and that this association may play a role in proteoglycan secretion by chondrocytes.

Low-intensity pulsed ultrasound inhibits VEGFA expression in chondrocytes and protects against cartilage degeneration in experimental osteoarthritis

Low-intensity pulsed ultrasound (LIPUS), a noninvasive physical therapy, was recently demonstrated to be an effective treatment for osteoarthritis (OA). Vascular endothelium growth factor A (VEGFA) has been found to be upregulated in the articular cartilage, synovium and subchondral bone of OA patients, leading to cartilage degeneration, synovitis and osteophyte formation. However, the functions and mechanisms of LIPUS in regulating chondrocyte-derived VEGFA expression are still unclear. In this study, we investigated whether LIPUS attenuated OA progression by (a) decreasing the percentage of VEGFA-positive cells in mouse articular cartilage destabilised through medial meniscus surgery and (b) relieving interleukin-1β-induced VEGFA expression in mouse primary chondrocytes. However, this function was negated by a p38 mitogen-activated protein kinase (p38 MAPK) inhibitor. In addition, we found that LIPUS ameliorated VEGFA-mediated disorders in cartilage extracellular matrix metabolism and chondrocyte hypertrophy during OA development. In conclusion, our data indicate a novel effect of LIPUS in regulating the expression of osteoarthritic chondrocyte-derived VEGFA through the suppression of p38 MAPK activity.

Extracorporeal Shockwave Therapy Accelerates the Healing of a Meniscal Tear in the Avascular Region in a Rat Model

BACKGROUND

The treatment of meniscal tears in the avascular region remains a clinical challenge. Extracorporeal shockwave therapy (ESWT) is a minimally invasive, safe, and effective therapy for various orthopaedic disorders. However, the therapeutic effect of ESWT on meniscal tears has not been reported.

PURPOSE

To evaluate the therapeutic effect of ESWT in the treatment of meniscal tears.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve-week-old male Wistar rats were divided into 3 groups (normal, ESWT-, and ESWT+). The authors made a full-thickness 2-mm longitudinal tear in the avascular region of the anterior horn in the latter 2 groups. At 1 week after surgery, the ESWT+ group received 800 impulses of shockwave at 0.22-mJ/mm² energy flux density in a single session. The authors performed a histological examination to evaluate meniscal healing (n = 10 for each group) and immunohistochemistry to analyze the expression of bromodeoxyuridine (BrdU; n = 5 for each group) and CCN family member 2/connective tissue growth factor (CCN2/CTGF; n = 5 for each group) at 2, 4, and 8 weeks after ESWT. The mRNA levels of CCN2, SOX 9, VEGF-a, aggrecan, Col1a2, and Col2a1 at the site of the meniscal tear at 4 weeks after ESWT were quantitatively evaluated by a real-time polymerase chain reaction (n = 5 for each group).

RESULTS

The meniscus healing scores in the ESWT+ group were significantly higher than those in the ESWT- group at 4 weeks and 8 weeks. The ratio of BrdU-positive cells was the highest in the ESWT+ group at all observation periods. The ratio of CCN2-positive cells was highest in the ESWT+ group at 4 and 8 weeks. In the ESWT+ group, real-time polymerase chain reaction revealed that the levels of CCN2, SOX9, aggrecan, and Col2a1 were upregulated (All significant data were P < .05).

CONCLUSION

ESWT promoted the healing of meniscal tears in the avascular area. ESWT stimulated proliferation of meniscal cells and the upregulation of cartilage-repairing factors such as CCN2, with the upregulation of cartilage-specific extracellular matrix expression.

CLINICAL RELEVANCE

ESWT may be an effective therapeutic option that promotes meniscal healing in the avascular region.