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Tan X, Xiao H, Yan A, Li M, Wang L. Effect of Exosomes From Bone Marrow-Derived Mesenchymal Stromal Cells and Adipose-Derived Stromal Cells on Bone-Tendon Healing in a Murine Rotator Cuff Injury Model. Orthop J Sports Med 2024; 12:23259671231210304. [PMID: 38188618 PMCID: PMC10768594 DOI: 10.1177/23259671231210304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/06/2023] [Indexed: 01/09/2024] Open
Abstract
Background Bone-tendon injury is characterized by poor self-healing. It is established that exosomes are favorable for tissue repair and regeneration. However, their effect on bone-tendon healing has not yet been determined. Purpose To compare the effectiveness of exosomes derived from adipose-derived mesenchymal stromal cells (ADSC-Exos) and bone marrow-derived mesenchymal stromal cells (BMSC-Exos) on bone-tendon interface healing in murine rotator cuff injury model and explore the underlying mechanisms thereof. Study Design Controlled laboratory study. Methods A total of 63 male C57BL6 mice with rotator cuff injuries underwent surgery and were randomly assigned to a control group treated without exosomes (n = 21), an ADSC-Exos group (n = 21), or a BMSC-Exos group (n = 21). The mice were sacrificed 4 or 8 weeks after surgery, and tissues were collected for histologic examination and radiographic and biomechanical testing. For exosome tracing in vivo, mice were sacrificed 7 days after surgery. A series of functional assays (radiographic evaluation, proliferation assay, Alizarin Red staining, alkaline phosphatase staining and activity, Alcian blue staining, quantitative polymerase chain reaction analyses, and glycosaminoglycans quantification) were conducted to evaluate the effect of exosomes on the cellular behaviors of the BMSCs in vitro. A statistical analysis of multiple-group comparisons was performed by 1-way analysis of variance, followed by the Bonferroni post hoc test to assess the differences between the 2 groups. Results The ADSCs and BMSCs were positive for surface markers CD29 and CD90 and negative for surface markers CD34 and CD45 and could differentiate into osteoblasts, chondrocytes, and adipocytes. Exosomes showed a cup- or sphere-shaped morphology and were positive for CD63 and TGS101. Local injection of ADSC-Exos and BMSC-Exos could recruit BMSCs and promote osteogenesis, chondrogenesis, and bone-tendon healing. In vitro, ADSC-Exos and BMSC-Exos could significantly promote the proliferation, migration, osteogenic differentiation, and chondrogenic differentiation ability of BMSCs. In vivo, ADSC-Exos and BMSC-Exos significantly accelerated bone-tendon injury healing, with no significant statistical difference between them. Conclusion ADSC-Exos and BMSC-Exos exhibited similar therapeutic effects on bone-tendon healing in our murine animal model. Clinical Relevance ADSC-Exos and BMSC-Exos may be used to develop a new cell-free therapy method for promoting rotator cuff injury repair.
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Affiliation(s)
- Xiaoqian Tan
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, Hunan, China
- The School of Pediatrics, University of South China, Changsha, Hunan, China
- Hunan Provincial Key Laboratory of Pediatric Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Han Xiao
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, Hunan, China
- The School of Pediatrics, University of South China, Changsha, Hunan, China
- Hunan Provincial Key Laboratory of Pediatric Orthopedics, Hunan Children's Hospital, Hunan, China
| | - An Yan
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, Hunan, China
- The School of Pediatrics, University of South China, Changsha, Hunan, China
- Hunan Provincial Key Laboratory of Pediatric Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Miao Li
- Department of Pediatric Orthopedics, Hunan Children's Hospital, Changsha, Hunan, China
- The School of Pediatrics, University of South China, Changsha, Hunan, China
- Hunan Provincial Key Laboratory of Pediatric Orthopedics, Hunan Children's Hospital, Hunan, China
| | - Linfeng Wang
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, China
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Chatterjee M, Evans MK, Bell R, Nguyen PK, Kamalitdinov TB, Korntner S, Kuo CK, Dyment NA, Andarawis-Puri N. Histological and immunohistochemical guide to tendon tissue. J Orthop Res 2023; 41:2114-2132. [PMID: 37321983 DOI: 10.1002/jor.25645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/02/2023] [Accepted: 06/11/2023] [Indexed: 06/17/2023]
Abstract
Tendons are unique dense connective tissues with discrete zones having specific structure and function. They are juxtaposed with other tissues (e.g., bone, muscle, and fat) with different compositional, structural, and mechanical properties. Additionally, tendon properties change drastically with growth and development, disease, aging, and injury. Consequently, there are unique challenges to performing high quality histological assessment of this tissue. To address this need, histological assessment was one of the breakout session topics at the 2022 Orthopaedic Research Society (ORS) Tendon Conference hosted at the University of Pennsylvania. The purpose of the breakout session was to discuss needs from members of the ORS Tendon Section related to histological procedures, data presentation, knowledge dissemination, and guidelines for future work. Therefore, this review provides a brief overview of the outcomes of this discussion and provides a set of guidelines, based on the perspectives from our laboratories, for histological assessment to assist researchers in their quest to utilize these techniques to enhance the outcomes and interpretations of their studies.
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Affiliation(s)
- Monideepa Chatterjee
- Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Mary K Evans
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Bell
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York, USA
| | - Phong K Nguyen
- Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
| | - Timur B Kamalitdinov
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stefanie Korntner
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland, USA
| | - Catherine K Kuo
- Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland, USA
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, New York, USA
- Department of Orthopaedics, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nathaniel A Dyment
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nelly Andarawis-Puri
- Nancy E. and Peter C. Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York, USA
- Hospital for Special Surgery, New York, New York, USA
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Assessing the biocompatibility of bovine tendon scaffold, a step forward in tendon tissue engineering. Cell Tissue Bank 2023; 24:11-24. [PMID: 35596907 DOI: 10.1007/s10561-022-10012-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 04/25/2022] [Indexed: 11/02/2022]
Abstract
Tendon is a collagen-enriched, tough, and intricately arranged connective tissue that connects muscle to the bone and transmits forces, resulting in joint movement. High mechanical demands can affect normal tissues and may lead to severe disorders, which usually require replacement of the damaged tendon. In recent decades, various decellularization methods have been studied for tissue engineering applications. One of the major challenges in tendon decellularization is preservation of the tendon extracellular matrix (ECM) architecture to maintain natural tissue characteristics. The aim of the present study was to create a decellularized bovine Achilles tendon scaffold to investigate its cytocompatibility with seeded hAd-MSCs (human adipose derived-mesenchymal stem cells) and blastema tissue in vitro. Here, we describe a reliable procedure to decellularize bovine Achilles tendon using a combination of physical and chemical treatments including repetitive freeze-thaw cycles and the ionic detergent SDS, respectively. The decellularization effectiveness and cytocompatibility of the tendon scaffolds were verified by histological studies and scanning electron microscopy for up to 30 days after culture. Histological studies revealed hAd-MSC attachment and penetration into the scaffolds at 5, 10, 15 and 20 days of culture. However, a decrease in cell number was observed on days 25 and 30 after culture in vitro. Moreover, migration of the blastema tissue cells into the scaffold were shown at 10 to 25 days post culture, however, destruction of the scaffolds and reduction in cell number were observed on 30th day after culture. Our results suggest that this decellularization protocol is an effective and biocompatible procedure which supports the maintenance and growth of both hAd-MSCs and blastema cells, and thus might be promising for tendon tissue engineering.
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Bono OJ, Jenkin B, Forlizzi J, Mousad A, Le Breton S, MacAskill M, Mandalia K, Mithoefer K, Ramappa A, Ross G, Shah SS. Evidence for Utilization of Injectable Biologic Augmentation in Primary Rotator Cuff Repair: A Systematic Review of Data From 2010 to 2022. Orthop J Sports Med 2023; 11:23259671221150037. [PMID: 36756167 PMCID: PMC9900676 DOI: 10.1177/23259671221150037] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/21/2022] [Indexed: 02/05/2023] Open
Abstract
Background Biologic healing after rotator cuff repair remains a significant challenge. Injectable biologic augmentation may improve tissue quality at the suture-tendon interface. Purpose To investigate the effect of injectable biologic supplementation in rotator cuff repair and to assess the quality and adherence to evolving reporting standards. Study Design Systematic review; Level of evidence, 3. Methods A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were 40 studies: 29 preclinical (in vivo animal models) and 11 clinical. Each clinical study was assessed for quality, risk of bias, and adherence to relevant MIBO (Minimum Information for Studies Evaluating Biologics in Orthopaedics) guidelines. The outcomes of interest were reported load to failure, load to gap, gap size, and stiffness in the preclinical studies, and healing rate and any patient-reported outcome measures in the clinical studies. Results Injectables reported included growth factors (eg, transforming growth factor-beta 3, erythropoietin), bone marrow-derived mesenchymal stem cells and adipose-derived mesenchymal stem cells (ADSCs), and other agents such as platelet-rich plasma (PRP) and hyaluronic acid. The most common findings for preclinical injectables were increased load to failure (16/29 studies; 55.2%) and improved collagen histological quality (11/29 studies; 37.9%). All 11 clinical studies (10 PRP, 1 ADSC) indicated no adverse events, with similar or improved patient-reported outcomes compared with repairs in the control groups. In 1 study utilizing an innovative delivery technique, a concentrated PRP globule with fibrin matrix was shuttled over a suture to maintain concentrated PRP at the repair site and demonstrated a significant decrease in retears (P = .03) at a 31-month follow-up. A matched-cohort study investigating augmentation with ADSCs demonstrated a significantly lower retear rate in the ADSC-augmented group than the control group at a 28-month follow-up (P < .001). On average, the clinical studies adhered to 66% of relevant MIBO reporting guidelines and had a low risk of bias. Conclusion Approximately 83% of preclinical studies found a positive biomechanical or histological effect, with no studies showing an overall negative effect. Clinically, utilization of innovative delivery techniques may reduce the risk of arthroscopic washout of PRP and improve retear rates. ADSCs were shown to reduce retear rates at a 28-month follow-up.
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Affiliation(s)
- Olivia J. Bono
- Albany Medical College, Albany, New York, USA.,Olivia J. Bono, BA, Albany Medical College, 49 New Scotland
Avenue, Albany, NY 12208, USA (
)
| | - Bryan Jenkin
- Tufts University School of Medicine, Boston, Massachusetts,
USA
| | | | - Albert Mousad
- Tufts University School of Medicine, Boston, Massachusetts,
USA
| | | | | | | | - Kai Mithoefer
- New England Baptist Hospital, Boston, Massachusetts, USA
| | - Arun Ramappa
- Beth Israel Deaconess Medical Center, Boston, Massachusetts,
USA
| | - Glen Ross
- New England Baptist Hospital, Boston, Massachusetts, USA
| | - Sarav S. Shah
- New England Baptist Hospital, Boston, Massachusetts, USA
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Oda H, Kaizawa Y, Franklin A, Sanchez Rangel U, Storaci H, Min JG, Wang Z, Abrams GD, Chang J, Fox PM. Assessment of a Synergistic Effect of Platelet-Rich Plasma and Stem Cell-Seeded Hydrogel for Healing of Rat Chronic Rotator Cuff Injuries. Cell Transplant 2023; 32:9636897231190174. [PMID: 37592455 PMCID: PMC10467370 DOI: 10.1177/09636897231190174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/29/2023] [Accepted: 07/11/2023] [Indexed: 08/19/2023] Open
Abstract
Outcomes after repair of chronic rotator cuff injuries remain suboptimal. Type-1 collagen-rich tendon hydrogel was previously reported to improve healing in a rat chronic rotator cuff injury model. Stem cell seeding of the tendon hydrogel improved bone quality in the same model. This study aimed to examine whether there was a synergistic and dose-dependent effect of platelet-rich plasma (PRP) on tendon-bone interface healing by combining PRP with stem cell-seeded tendon hydrogel. Human cadaveric tendons were processed into a hydrogel. PRP was prepared at two different platelet concentrations: an initial concentration (initial PRP group) and a higher concentration (concentrated PRP group). Tendon hydrogel was mixed with adipose-derived stem cells and one of the platelet concentrations. Methylcellulose, as opposed to saline, was used as a negative control due to comparable viscosity. The supraspinatus tendon was detached bilaterally in 33 Sprague-Dawley rats (66 shoulders). Eight weeks later, each detached tendon was repaired, and a hydrogel mixture or control was injected at the repair site. Eight weeks after repair, shoulder samples were harvested and assigned for biomechanical testing (n = 42 shoulders) or a combination of bone morphological and histological assessment (n = 24 shoulders). Biomechanical testing showed significantly higher failure load and stiffness in the concentrated PRP group than in control. Yield load in the initial and concentrated PRP groups were significantly higher than that in the control. There were no statistically significant differences between the initial and concentrated PRP groups. The addition of the highly concentrated PRP to stem cells-seeded tendon hydrogel improved healing biomechanically after chronic rotator cuff injury in rats compared to control. However, synergistic and dose-dependent effects were not seen.
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Affiliation(s)
- Hiroki Oda
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Yukitoshi Kaizawa
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Austin Franklin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Uriel Sanchez Rangel
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Hunter Storaci
- Department of Orthopedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - Jung Gi Min
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Zhen Wang
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Geoffrey D. Abrams
- Department of Orthopedic Surgery, Stanford University School of Medicine, Redwood City, CA, USA
| | - James Chang
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Paige M. Fox
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Lebaschi A, Kriscenski DE, Tamburini LM, McCarthy MB, Obopilwe E, Uyeki CL, Cote MP, Rodeo SA, Kumbar SG, Mazzocca AD. Subacromial bursa increases the failure force in a mouse model of supraspinatus detachment and repair. J Shoulder Elbow Surg 2022; 31:e519-e533. [PMID: 35690347 DOI: 10.1016/j.jse.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/28/2022] [Accepted: 05/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND It has been shown that subacromial bursa (SAB) harbors connective tissue progenitor cells. The purpose of this study was to evaluate the effects of implantation of SAB-derived cells (SBCs) suspended in a fibrin sealant bead and implantation of SAB tissue at rotator cuff repair site on biomechanical properties of the repair in a mouse (C57Bl/6) model of supraspinatus tendon (ST) detachment and repair. METHODS Part 1: Murine SAB tissue was harvested and cultured. Viability of SBCs suspended in 10 μL of fibrin sealant beads was confirmed in vitro and in vivo. Eighty mice underwent right ST detachment and repair augmented with either fibrin sealant bead (control group) or fibrin sealant bead with 100,000 SBCs (study group) applied at the repair site. Part 2: 120 mice underwent right ST detachment and repair and were randomized equally into 4 groups: (1) a tissue group, which received a piece of freshly harvested SAB tissue; (2) a cell group, which received SBCs suspended in fibrin sealant bead; (3) a fibrin sealant group, which received plain fibrin sealant bead without cells; and (4) a control group, which received nothing at the ST repair site. An equal number of mice in each group were killed at 2 and 4 weeks. Specimens underwent biomechanical testing to evaluate failure force (part 1 and 2) and histologic analysis of the repair site (part 1 only). RESULTS Part 1: The mean failure force in the study group was significantly higher than controls at 2 and 4 weeks (3.25 ± 1.03 N vs. 2.43 ± 0.56 N, P = .01, and 4.08 ± 0.99 N vs. 3.02 ± 0.8 N, P = .004, respectively). Mean cell density of the ST at the repair site was significantly lower in the study group at 2 weeks than in controls (18,292.13 ± 1706.41 vs. 29,501.90 ± 3627.49, P = .001). Study group specimens had lower proteoglycan contents than controls, but this difference was not statistically significant. Part 2: There was no difference in failure force between cell and tissue groups at the 2- and 4-week time points (P = .994 and P = .603, respectively). There was no difference in failure force between fibrin sealant bead and control groups at the 2- and 4-week time points (P = .978 and P = .752, respectively). CONCLUSION This study shows that the application of SBCs and SAB tissue at the rotator cuff repair site increases the strength of repair in a murine model of rotator cuff detachment and repair.
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Affiliation(s)
- Amir Lebaschi
- Department of Orthopedics and Sports Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Danielle E Kriscenski
- Department of Orthopedics and Sports Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Lisa M Tamburini
- Department of Orthopedics and Sports Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Mary Beth McCarthy
- Department of Orthopedics and Sports Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Elifho Obopilwe
- Department of Orthopedics and Sports Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Colin L Uyeki
- Department of Orthopedics and Sports Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopedics and Sports Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Scott A Rodeo
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Sangamesh G Kumbar
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
| | - Augustus D Mazzocca
- Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Shoulder and Elbow Surgery, Harvard Medical School, Boston, MA, USA.
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7
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Zhang G, Zhou X, Hu S, Jin Y, Qiu Z. Large animal models for the study of tendinopathy. Front Cell Dev Biol 2022; 10:1031638. [PMID: 36393858 PMCID: PMC9640604 DOI: 10.3389/fcell.2022.1031638] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022] Open
Abstract
Tendinopathy has a high incidence in athletes and the aging population. It can cause pain and movement disorders, and is one of the most difficult problems in orthopedics. Animal models of tendinopathy provide potentially efficient and effective means to develop understanding of human tendinopathy and its underlying pathological mechanisms and treatments. The selection of preclinical models is essential to ensure the successful translation of effective and innovative treatments into clinical practice. Large animals can be used in both micro- and macro-level research owing to their similarity to humans in size, structure, and function. This article reviews the application of large animal models in tendinopathy regarding injuries to four tendons: rotator cuff, patellar ligament, Achilles tendon, and flexor tendon. The advantages and disadvantages of studying tendinopathy with large animal models are summarized. It is hoped that, with further development of animal models of tendinopathy, new strategies for the prevention and treatment of tendinopathy in humans will be developed.
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Affiliation(s)
- Guorong Zhang
- School of Clinical Medicine, Changchun University of Chinese Medicine, Changchun, China
- School of Pharmacy, Changchun University of Chinese Medicine, Changchun, China
| | - Xuyan Zhou
- School of Pharmacy, Changchun University of Chinese Medicine, Changchun, China
| | - Shuang Hu
- School of Pharmacy, Changchun University of Chinese Medicine, Changchun, China
| | - Ye Jin
- School of Pharmacy, Changchun University of Chinese Medicine, Changchun, China
- *Correspondence: Ye Jin, ; Zhidong Qiu,
| | - Zhidong Qiu
- School of Pharmacy, Changchun University of Chinese Medicine, Changchun, China
- *Correspondence: Ye Jin, ; Zhidong Qiu,
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Chen C, Shi Q, Li M, Chen Y, Zhang T, Xu Y, Liao Y, Ding S, Wang Z, Li X, Zhao C, Sun L, Hu J, Lu H. Engineering an enthesis-like graft for rotator cuff repair: An approach to fabricate highly biomimetic scaffold capable of zone-specifically releasing stem cell differentiation inducers. Bioact Mater 2022; 16:451-471. [PMID: 35386315 PMCID: PMC8965727 DOI: 10.1016/j.bioactmat.2021.12.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/29/2021] [Accepted: 12/19/2021] [Indexed: 02/09/2023] Open
Abstract
Rotator cuff (RC) attaches to humerus across a triphasic yet continuous tissue zones (bone-fibrocartilage-tendon), termed "enthesis". Regrettably, rapid and functional enthesis regeneration is challenging after RC tear. The existing grafts bioengineered for RC repair are insufficient, as they were engineered by a scaffold that did not mimic normal enthesis in morphology, composition, and tensile property, meanwhile cannot simultaneously stimulate the formation of bone-fibrocartilage-tendon tissues. Herein, an optimized decellularization approach based on a vacuum aspiration device (VAD) was developed to fabricate a book-shaped decellularized enthesis matrix (O-BDEM). Then, three recombinant growth factors (CBP-GFs) capable of binding collagen were synthesized by fusing a collagen-binding peptide (CBP) into the N-terminal of BMP-2, TGF-β3, or GDF-7, and zone-specifically tethered to the collagen of O-BDEM to fabricate a novel scaffold (CBP-GFs/O-BDEM) satisfying the above-mentioned requirements. After ensuring the low immunogenicity of CBP-GFs/O-BDEM by a novel single-cell mass cytometry in a mouse model, we interleaved urine-derived stem cell-sheets into this CBP-GFs/O-BDEM to bioengineer an enthesis-like graft. Its high-performance on regenerating enthesis was determined in a canine model. These findings indicate this CBP-GFs/O-BDEM may be an excellent scaffold for constructing enthesis-like graft to patch large/massive RC tears, and provide breakthroughs in fabricating graded interfacial tissue.
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Affiliation(s)
- Can Chen
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, 410008, China
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Qiang Shi
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Muzhi Li
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Rehabilitation, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
| | - Yang Chen
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Tao Zhang
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Yan Xu
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Yunjie Liao
- Department of Radiology, The Third Xiangya Hospital, Central South University, Changsha, 410013, China
| | - Shulin Ding
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Zhanwen Wang
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Xing Li
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Chunfeng Zhao
- Division of Orthopedic Research and Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, 55905, United States
| | - Lunquan Sun
- Center for Molecular Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Jianzhong Hu
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Spine Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
- Corresponding author. Xiangya Hospital, Central South University, No. 87, Xiangya Road, Changsha, 410008, Hunan, China.
| | - Hongbin Lu
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, 410008, China
- Hunan Engineering Research Center of Sports and Health, Changsha, 410008, China
- Xiangya Hospital-International Chinese Musculoskeletal Research Society Sports Medicine Research Centre, Changsha, 410008, China
- Department of Sports Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
- Corresponding author. Xiangya Hospital, Central South University, No. 87, Xiangya Road, Changsha, 410008, Hunan, China.
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9
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Wang HN, Rong X, Yang LM, Hua WZ, Ni GX. Advances in Stem Cell Therapies for Rotator Cuff Injuries. Front Bioeng Biotechnol 2022; 10:866195. [PMID: 35694228 PMCID: PMC9174670 DOI: 10.3389/fbioe.2022.866195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Rotator cuff injury is a common upper extremity musculoskeletal disease that may lead to persistent pain and functional impairment. Despite the clinical outcomes of the surgical procedures being satisfactory, the repair of the rotator cuff remains problematic, such as through failure of healing, adhesion formation, and fatty infiltration. Stem cells have high proliferation, strong paracrine action, and multiple differentiation potential, which promote tendon remodeling and fibrocartilage formation and increase biomechanical strength. Additionally, stem cell-derived extracellular vesicles (EVs) can increase collagen synthesis and inhibit inflammation and adhesion formation by carrying regulatory proteins and microRNAs. Therefore, stem cell-based therapy is a promising therapeutic strategy that has great potential for rotator cuff healing. In this review, we summarize the advances of stem cells and stem cell-derived EVs in rotator cuff repair and highlight the underlying mechanism of stem cells and stem cell-derived EVs and biomaterial delivery systems. Future studies need to explore stem cell therapy in combination with cellular factors, gene therapy, and novel biomaterial delivery systems.
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Affiliation(s)
- Hao-Nan Wang
- School of Sport Medicine and Rehabilitation, Beijing Sport University, Beijing, China
| | - Xiao Rong
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Lu-Ming Yang
- Musculoskeletal Sonography and Occupational Performance Lab, Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, United States
| | - Wei-Zhong Hua
- School of Sport Medicine and Rehabilitation, Beijing Sport University, Beijing, China
| | - Guo-Xin Ni
- School of Sport Medicine and Rehabilitation, Beijing Sport University, Beijing, China
- *Correspondence: Guo-Xin Ni,
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10
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Liu Q, Tang Q, Liao L, Li D, Zhu W, Zhao C. Translational therapy from preclinical animal models for muscle degeneration after rotator cuff injury. J Orthop Translat 2022; 35:13-22. [PMID: 35846726 PMCID: PMC9260436 DOI: 10.1016/j.jot.2022.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
Chronic rotator cuff tears are debilitating diseases which significantly affect patients’ quality of life and pose substantial financial burden to the society. The intraoperative reparability of injured tendon and postoperative probability of tendon retear are highly associated with the quality of torn muscles, specifically, the severity of muscle atrophy and fatty infiltration. Animal models that reproduce the characteristic muscle pathology after rotator cuff injury have been developed and used to provide insight into the underlying biology and pathophysiology. In this review, we briefly summarize the current information obtained from preclinical animal studies regarding the degenerative change of cuff muscle subsequent to tendon release and/or suprascapular nerve denervation. Importantly, we focus on the potential translational therapeutic targets or agents for the prevention or reversal of muscle atrophy and fatty infiltration. While further studies are warranted to assess the safety and efficacy of novel therapies derived from these preclinical animal research, we believe that their clinical translation for the treatment of rotator cuff disorders is on the horizon. The Translational potential of this article Novel therapeutic strategies described in this review from preclinical animal studies hold a great translational potential for preventing or reversing rotator cuff muscle pathology, while further assessments on their safety and efficacy are warranted.
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11
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Jiang X, Wojtkiewicz M, Patwardhan C, Greer S, Kong Y, Kuss M, Huang X, Liao J, Lu Y, Dudley A, Gundry RL, Fuchs M, Streubel P, Duan B. The effects of maturation and aging on the rotator cuff tendon-to-bone interface. FASEB J 2021; 35:e22066. [PMID: 34822203 DOI: 10.1096/fj.202101484r] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/29/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
Rotator cuff tendon injuries often occur at the tendon-to-bone interface (i.e., enthesis) area, with a high prevalence for the elderly population, but the underlying reason for this phenomenon is still unknown. The objective of this study is to identify the histological, molecular, and biomechanical alterations of the rotator cuff enthesis with maturation and aging in a mouse model. Four different age groups of mice (newborn, young, adult, and old) were studied. Striking variations of the entheses were observed between the newborn and other matured groups, with collagen content, proteoglycan deposition, collagen fiber dispersion was significantly higher in the newborn group. The compositional and histological features of young, adult, and old groups did not show significant differences, except having increased proteoglycan deposition and thinner collagen fibers at the insertion sites in the old group. Nanoindentation testing showed that the old group had a smaller compressive modulus at the insertion site when compared with other groups. However, tensile mechanical testing reported that the old group demonstrated a significantly higher failure stress when compared with the young and adult groups. The proteomics analysis detected dramatic differences in protein content between newborn and young groups but minor changes among young, adult, and old groups. These results demonstrated: (1) the significant alterations of the enthesis composition and structure occur from the newborn to the young time period; (2) the increased risk of rotator cuff tendon injuries in the elderly population is not solely because of old age alone in the rodent model.
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Affiliation(s)
- Xiping Jiang
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Molecular Genetics and Cell Biology Program, Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Melinda Wojtkiewicz
- CardiOmics Program, Center for Heart and Vascular Research, Division of Cardiovascular Medicine, and Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Chinmay Patwardhan
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas, USA
| | - Sydney Greer
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Molecular Genetics and Cell Biology Program, Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Yunfan Kong
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mitchell Kuss
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Xi Huang
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Jun Liao
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas, USA
| | - Yongfeng Lu
- Department of Electrical and Computer Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Andrew Dudley
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Molecular Genetics and Cell Biology Program, Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Rebekah L Gundry
- CardiOmics Program, Center for Heart and Vascular Research, Division of Cardiovascular Medicine, and Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthias Fuchs
- Department of Physics and Astronomy, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Philipp Streubel
- Department of Orthopedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bin Duan
- Mary & Dick Holland Regenerative Medicine Program, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Surgery, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Department of Mechanical and Materials Engineering, University of Nebraska-Lincoln, Lincoln, Nebraska, USA
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12
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Morikawa D, LeVasseur MR, Luczak SB, Mancini MR, Bellas N, McCarthy MBR, Cote MP, Berthold DP, Muench LN, Mazzocca AD. Decreased Colony-Forming Ability of Subacromial Bursa-Derived Cells During Revision Arthroscopic Rotator Cuff Repair. Arthrosc Sports Med Rehabil 2021; 3:e1047-e1054. [PMID: 34430884 PMCID: PMC8365201 DOI: 10.1016/j.asmr.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/14/2021] [Indexed: 02/06/2023] Open
Abstract
Purpose To compare the cellular viability and differentiation potential of subacromial bursa-derived cells (SBDCs) located over the rotator cuff muscle and tendon of patients undergoing primary versus revision arthroscopic rotator cuff repair (ARCR). Methods Subacromial bursa was harvested from 18 primary (57.1 ± 4.6 years) and 12 revision ARCRs (57.3 ± 6.7 years). Bursa was collected from 2 sites (over rotator cuff tendon and muscle), digested with collagenase, and grown in culture. The number of nucleated cells, colony-forming units (CFUs), differentiation potential, and mesenchymal stem cell surface markers were compared in primary and revision cases. Results There was no difference in the number of nucleated cells between primary and revision ARCR harvested from the subacromial bursa overlying the tendon (3019.3 ± 1420.6 cells/mg and 3541.7 ± 2244.2 cells/mg, respectively; P = .912) or muscle (2753.5 ± 1547.1 cells/mg and 2989.0 ± 2231.4 cells/mg, respectively; P = .777). There was no difference in the number of CFUs between primary and revision ARCR over the rotator cuff tendon (81.5 ± 49.5 CFUs and 53.0 ± 36.9 CFUs, respectively; P = .138), but there were significantly fewer CFUs over the muscle in revision cases (28.1 ± 22.7 CFUs) compared with primary cases (55.7 ± 34.5 CFUs) (P = .031). SBDCs from revision ARCR expressed characteristic mesenchymal stem cell surface epitopes and had multidifferentiation potentials for chondrogenesis, osteogenesis, and adipogenesis. Conclusions SBDCs harvested over the rotator cuff muscle demonstrated significantly decreased colony-forming abilities in revision arthroscopic rotator cuff repairs compared with primary repairs. However, the subacromial bursa retains its pluripotent differentiation potential for chondrogenic, osteogenic, and adipogenic lineages in the revision setting. Clinical Relevance The subacromial bursa may play a role in the healing response of the repaired rotator cuff. This capacity is not necessarily diminished in the revision setting and may be harnessed as an orthobiologic.
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Affiliation(s)
- Daichi Morikawa
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.,Department of Orthopaedic Surgery, Juntendo University, Tokyo, Japan
| | - Matthew R LeVasseur
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - S Brandon Luczak
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Michael R Mancini
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Nicholas Bellas
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Mary Beth R McCarthy
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Daniel P Berthold
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Lukas N Muench
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.,Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
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13
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Xu Y, Zhang WX, Wang LN, Ming YQ, Li YL, Ni GX. Stem cell therapies in tendon-bone healing. World J Stem Cells 2021; 13:753-775. [PMID: 34367476 PMCID: PMC8316867 DOI: 10.4252/wjsc.v13.i7.753] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/08/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Tendon-bone insertion injuries such as rotator cuff and anterior cruciate ligament injuries are currently highly common and severe. The key method of treating this kind of injury is the reconstruction operation. The success of this reconstructive process depends on the ability of the graft to incorporate into the bone. Recently, there has been substantial discussion about how to enhance the integration of tendon and bone through biological methods. Stem cells like bone marrow mesenchymal stem cells (MSCs), tendon stem/progenitor cells, synovium-derived MSCs, adipose-derived stem cells, or periosteum-derived periosteal stem cells can self-regenerate and potentially differentiate into different cell types, which have been widely used in tissue repair and regeneration. Thus, we concentrate in this review on the current circumstances of tendon-bone healing using stem cell therapy.
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Affiliation(s)
- Yue Xu
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Wan-Xia Zhang
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Li-Na Wang
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Yue-Qing Ming
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Yu-Lin Li
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
| | - Guo-Xin Ni
- School of Sports Medicine and Rehabilitation, Beijing Sport University, Beijing 100084, China
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14
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Zhang C, Wu J, Li X, Wang Z, Lu WW, Wong TM. Current Biological Strategies to Enhance Surgical Treatment for Rotator Cuff Repair. Front Bioeng Biotechnol 2021; 9:657584. [PMID: 34178957 PMCID: PMC8226184 DOI: 10.3389/fbioe.2021.657584] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023] Open
Abstract
Rotator cuff tear is one of the most common shoulder problems encountered by orthopedic surgeons. Due to the slow healing process and high retear rate, rotator cuff tear has distressed millions of people all around the world every year, especially for the elderly and active athletes. This disease significantly impairs patients' motor ability and reduces their quality of life. Besides conservative treatment, open and arthroscopic surgery contributes a lot to accelerate the healing process of rotator cuff tear. Currently, there are many emerging novel treatment methods to promote rotator cuff repair. A variety of biological stimulus has been utilized in clinical practice. Among them, platelet-rich plasma, growth factors, stem cells, and exosomes are the most popular biologics in laboratory research and clinical trials. This review will focus on the biologics of bioaugmentation methods for rotator cuff repair and tendon healing, including platelet-rich plasma, growth factors, exosomes and stem cells, etc. Relevant studies are summarized in this review and future research perspectives are introduced.
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Affiliation(s)
- Cheng Zhang
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jun Wu
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xiang Li
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zejin Wang
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Weijia William Lu
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Center for Human Tissues and Organs Degeneration, Shenzhen Institutes of Advanced Technology (CAS), Shenzhen, China
| | - Tak-Man Wong
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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15
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Lakhani A, Sharma E, Kapila A, Khatri K. Known data on applied regenerative medicine in tendon healing. Bioinformation 2021; 17:514-527. [PMID: 34602779 PMCID: PMC8450149 DOI: 10.6026/97320630017514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/31/2021] [Accepted: 04/29/2021] [Indexed: 12/03/2022] Open
Abstract
Tendons and ligaments are important structures in the musculoskeletal system. Ligaments connect various bones and provide stability in complex movements of joints in the knee. Tendon is made of dense connective tissue and transmits the force of contraction from muscle to bone. They are injured due to direct trauma in sports or roadside accidents. Tendon healing after repair is often poor due to the formation of fibro vascular scar tissues with low mechanical property. Regenerative techniques such as PRP (platelet-rich plasma), stem cells, scaffolds, gene therapy, cell sheets, and scaffolds help augment repair and regenerate tissue in this context. Therefore, it is of interest to document known data (repair process, tissue regeneration, mechanical strength, and clinical outcome) on applied regenerative medicine in tendon healing.
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Affiliation(s)
- Amit Lakhani
- Dr Br Ambedkar State Institute of Medical Sciences, Mohali Punjab, India
| | - Ena Sharma
- Maharishi Markandeshwar College of Dental Sciences and Hospital Mullana, Ambala, Haryana, India
| | | | - Kavin Khatri
- All India Institute of Medical Sciences, Bathinda, Punjab, India
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16
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He SK, Ning LJ, Yao X, Hu RN, Cui J, Zhang Y, Ding W, Luo JC, Qin TW. Hierarchically Demineralized Cortical Bone Combined With Stem Cell-Derived Extracellular Matrix for Regeneration of the Tendon-Bone Interface. Am J Sports Med 2021; 49:1323-1332. [PMID: 33667131 DOI: 10.1177/0363546521994511] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Poor healing of the tendon-bone interface after rotator cuff repair is one of the main causes of surgical failure. Previous studies demonstrated that demineralized cortical bone (DCB) could improve healing of the enthesis. PURPOSE To evaluate the outcomes of hierarchically demineralized cortical bone (hDCB) coated with stem cell-derived extracellular matrix (hDCB-ECM) in the repair of the rotator cuff in a rabbit model. STUDY DESIGN Controlled laboratory study. METHODS Tendon-derived stem cells (TDSCs) were isolated, cultured, and identified. Then, hDCB was prepared by the graded demineralization procedure. Finally, hDCB-ECM was fabricated via 2-week cell culture and decellularization, and the morphologic features and biochemical compositions of the hDCB-ECM were evaluated. A total of 24 rabbits (48 samples) were randomly divided into 4 groups: control, DCB, hDCB, and hDCB-ECM. All rabbits underwent bilateral detachment of the infraspinatus tendon, and the tendon-bone interface was repaired with or without scaffolds. After surgery, 8 rabbits were assessed by immunofluorescence staining at 2 weeks, and the others were assessed by micro-computed tomography (CT) examination, immunohistochemical staining, histological staining, and biomechanical testing at 12 weeks. RESULTS TDSCs were identified to have universal stem cell characteristics including cell markers, clonogenicity, and multilineage differentiation. The hDCB-ECM contained 3 components (bone, partial DCB, and DCB coated with ECM) with a gradient of calcium and phosphorus elements, and the ECM had stromal cell-derived factor 1, biglycan, and fibromodulin. Macroscopic observations demonstrated the absence of infection and rupture around the enthesis. The results of immunofluorescence staining showed that hDCB-ECM promoted stromal cell recruitment. Results of micro-CT analysis, immunohistochemical staining, and histological staining showed that hDCB-ECM enhanced bone and fibrocartilage formation at the tendon-bone interface. Biomechanical analysis showed that the hDCB-ECM group had higher ultimate tensile stress and Young modulus than the DCB group. CONCLUSION The administration of hDCB-ECM promoted healing of the tendon-bone interface. CLINICAL RELEVANCE hDCB-ECM could provide useful information for the design of scaffolds to repair the tendon-bone interface, and further studies are needed to determine its effectiveness.
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Affiliation(s)
- Shu-Kun He
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China.,Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, China
| | - Liang-Ju Ning
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Xuan Yao
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China.,Department of Clinical Hematology, Faculty of Laboratory Medicine, Army Medical University, Chongqing, China
| | - Ruo-Nan Hu
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Jing Cui
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Yi Zhang
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Wei Ding
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Jing-Cong Luo
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Ting-Wu Qin
- Laboratory of Stem Cell and Tissue Engineering, Orthopedic Research Institute, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
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17
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Yea JH, Kim I, Sym G, Park JK, Lee AY, Cho BC, Bae TS, Kim BJ, Jo CH. Regeneration of a full-thickness defect in rotator cuff tendon with umbilical cord-derived mesenchymal stem cells in a rat model. PLoS One 2020; 15:e0235239. [PMID: 33166292 PMCID: PMC7652329 DOI: 10.1371/journal.pone.0235239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
Although rotator cuff disease is a common cause of shoulder pain, there is still no treatment method that could halt or reveres its development and progression. The purpose of this study was to investigate the efficacy of umbilical cord-derived mesenchymal stem cells (UC MSCs) on the regeneration of a full-thickness rotator cuff defect (FTD) in a rat model. We injected either UC MSCs or saline to the FTD and investigated macroscopic, histological and biomechanical results and cell trafficking. Treatment with UC MSCs improved macroscopic appearance in terms of tendon thickness at two weeks, and inflammation, defect size, swelling/redness and connection surrounding tissue and slidability at four weeks compared to the saline group. Histologically, UC MSCs induced the tendon matrix formation recovering collagen organization, nuclear aspect ratio and orientation angle of fibroblast as well as suppressing cartilage-related glycosaminoglycan compared to saline group at four weeks. The UC MSCs group also improved ultimate failure load by 25.0% and 19.0% and ultimate stress by 27.3% and 26.8% at two and four weeks compared to saline group. UC MSCs labeled with PKH26 exhibited 5.3% survival at four weeks compared to three hours after injection. This study demonstrated that UC MSCs regenerated the FTD with tendon tissue similar properties to the normal tendon in terms of macroscopic, histological and biomechanical characteristics in a rat model.
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Affiliation(s)
- Ji-Hye Yea
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - InJa Kim
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Gayoung Sym
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Kyung Park
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Ah-Young Lee
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Chan Cho
- Department of Biomedical Engineering, Collage of Science and Engineering, Jungwon University, Goesan-gun, Chungcheongbuk-do, Korea
| | - Tae Soo Bae
- Department of Biomedical Engineering, Collage of Science and Engineering, Jungwon University, Goesan-gun, Chungcheongbuk-do, Korea
| | - Byoung Jae Kim
- Department of Obstetrics & Gynecology, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Chris Hyunchul Jo
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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18
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Hypoxia-Induced Mesenchymal Stem Cells Exhibit Stronger Tenogenic Differentiation Capacities and Promote Patellar Tendon Repair in Rabbits. Stem Cells Int 2020; 2020:8822609. [PMID: 33133195 PMCID: PMC7591963 DOI: 10.1155/2020/8822609] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 12/13/2022] Open
Abstract
Tendon injury is a common but tough medical problem. Unsatisfactory clinical results have been reported in tendon repair using mesenchymal stem cell (MSC) therapy, creating a need for a better strategy to induce MSCs to tenogenic differentiation. This study was designed to examine the effect of hypoxia on the tenogenic differentiation of different MSCs and their tenogenic differentiation capacities under hypoxia condition in vitro and to investigate the in vivo inductility of hypoxia in tenogenesis. Adipose tissue-derived MSCs (AMSCs) and bone marrow-derived MSCs (BMSCs) were isolated and characterized. The expression of hypoxia-induced factor-1 alpha (Hif-1α) was examined to confirm the establishment of hypoxia condition. qRT-PCR, western blot, and immunofluorescence staining were used to evaluate the expression of tendon-associated marker Col-1a1, Col-3a1, Dcn, and Tnmd in AMSCs and BMSCs under hypoxia condition, compared with Tgf-β1 induction. In vivo, a patellar tendon injury model was established. Normoxic and hypoxic BMSCs were cultured and implanted. Histological, biomechanical, and transmission electron microscopy analyses were performed to assess the improved healing effect of hypoxic BMSCs on tendon injury. Our in vitro results showed that hypoxia remarkably increased the expression of Hif-1α and that hypoxia not only promoted a significant increase in tenogenic markers in both AMSCs and BMSCs compared with the normoxia group but also showed higher inductility compared with Tgf-β1. In addition, hypoxic BMSCs exhibited higher potential of tenogenic differentiation than hypoxic AMSCs. Our in vivo results demonstrated that hypoxic BMSCs possessed better histological and biomechanical properties than normoxic BMSCs, as evidenced by histological scores, patellar tendon biomechanical parameters, and the range and average of collagen fibril diameters. These findings suggested that hypoxia may be a practical and reliable strategy to induce tenogenic differentiation of BMSCs for tendon repair and could enhance the effectiveness of MSCs therapy in treating tendon injury.
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Yea JH, Park JK, Kim IJ, Sym G, Bae TS, Jo CH. Regeneration of a full-thickness defect of rotator cuff tendon with freshly thawed umbilical cord-derived mesenchymal stem cells in a rat model. Stem Cell Res Ther 2020; 11:387. [PMID: 32894193 PMCID: PMC7487485 DOI: 10.1186/s13287-020-01906-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/05/2020] [Accepted: 08/26/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND It is difficult to immediately use mesenchymal stem cells (MSCs) for the patient with rotator cuff disease because isolation and culture time are required. Thus, the MSCs would be prepared in advanced in cryopreserved condition for an "off-the-shelf" usage in clinic. This study investigated the efficacy of freshly thawed MSCs on the regeneration of a full-thickness tendon defect (FTD) of rotator cuff tendon in a rat model. METHODS We evaluated morphology, viability, and proliferation of cultured umbilical cord-derived MSCs (C-UC MSCs) and freshly thawed umbilical cord-derived MSCs (T-UC MSCs) at passage 10 in vitro. In animal experiments, we created a FTD in the supraspinatus of rats and injected the injured tendon with saline, cryopreserved agent (CPA; control), C-UC MSCs, and T-UC MSCs, respectively. Two and 4 weeks later, macroscopic, histological, biomechanical, and cell trafficking were evaluated. T test and ANOVA were used with SPSS. Differences with p < .05 were considered statistically significant. RESULTS T-UC MSCs had fibroblast-like morphology and showed greater than 97% viability and stable proliferation comparable to the C-UC MSCs at passage 10. In animal experiments, compared with the control group, the macroscopic appearance of the T-UC MSCs was more recovered at 2 and 4 weeks such as inflammation, defect size, neighboring tendon, swelling/redness, the connecting surrounding tissue and slidability. Histologically, the nuclear aspect ratio, orientation angle of fibroblasts, collagen organization, and fiber coherence were improved by 33.33%, 42.75%, 1.86-fold, and 1.99-fold at 4 weeks, and GAG-rich area decreased by 88.13% and 94.70% at 2 and 4 weeks respectively. Further, the T-UC MSCs showed enhanced ultimate failure load by 1.55- and 1.25-fold compared with the control group at both 2 and 4 weeks. All the improved values of T-UC MSCs were comparable to those of C-UC MSCs. Moreover, T-UC MSCs remained 8.77% at 4 weeks after injury, and there was no significant difference between C-UC MSCs and T-UC MSCs. CONCLUSIONS The morphology, viability, and proliferation of T-UC MSCs were comparable to those of C-UC MSCs. Treatment with T-UC MSCs could induce tendon regeneration of FTD at the macroscopic, histological, and biomechanical levels comparable to treatment with C-UC MSCs.
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Affiliation(s)
- Ji-Hye Yea
- Department of Translational Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Jin-Kyung Park
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - In Ja Kim
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Gayoung Sym
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Tae-Soo Bae
- Department of Biomedical Engineering, Collage of Science and Engineering, Jungwon University, 85, Munmu-ro, Goesan-eup, Goesan-gun, Chungcheongbuk-do, 367-805, Korea
| | - Chris Hyunchul Jo
- Department of Translational Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea.
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Ficklscherer A, Zhang AZ, Beer T, Gülecyüz MF, Klar RM, Safi E, Woiczinski M, Jansson V, Müller PE. The effect of autologous Achilles bursal tissue implants in tendon-to-bone healing of rotator cuff tears in rats. J Shoulder Elbow Surg 2020; 29:1892-1900. [PMID: 32299772 DOI: 10.1016/j.jse.2020.01.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/22/2019] [Accepted: 01/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to investigate the influence of autologous bursal tissue derived from the Achilles bursa on tendon-to-bone healing after rotator cuff tear repair in a rat model. METHODS A total of 136 Sprague-Dawley rats were randomly assigned to either an untreated or a bursal tissue application group or biomechanical testing and histologic testing after rotator cuff repair. After separating the supraspinatus tendon close to the greater tuberosity, the tendon was reattached either unaltered or with a bursal tissue interposition sewn onto the interface. Immunohistologic analysis was performed 1 and 7 weeks after supraspinatus tendon reinsertion. Biomechanical testing of the tendon occurred 6 and 7 weeks after reinsertion. RESULTS Immunohistologic results demonstrated a significantly higher percentage of Type II collagen (P = .04) after 1 and 7 weeks in the tendon-to-bone interface using autologous bursal tissue in comparison to control specimens. The bursa group showed a significantly higher collagen I to III quotient (P = .03) at 1 week after surgery in comparison to the 7-week postsurgery bursa groups and controls. Biomechanical assessment showed that overall tendon stiffness (P = .002) and the tendon viscoelasticity in the bursa group (P = .003) was significantly improved after 6 and 7 weeks. There was no significant difference (P = .55) in force to failure between the bursa group and the control group after 6 and 7 weeks. CONCLUSION Autologous bursal tissue derived from the Achilles bursa and implanted to the tendon-to-bone interface after rotator cuff repair facilitates a faster healing response to re-establish the biologic and biomechanical integrity of the rotator cuff in rats.
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Affiliation(s)
- Andreas Ficklscherer
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Anja Z Zhang
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany.
| | - Thomas Beer
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Mehmet F Gülecyüz
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Roland M Klar
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Elem Safi
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Matthias Woiczinski
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Volkmar Jansson
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
| | - Peter E Müller
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University Hospital of Munich, Munich, Germany
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Dunham C, Havlioglu N, Chamberlain A, Lake S, Meyer G. Adipose stem cells exhibit mechanical memory and reduce fibrotic contracture in a rat elbow injury model. FASEB J 2020; 34:12976-12990. [PMID: 33411380 PMCID: PMC8745456 DOI: 10.1096/fj.202001274r] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/14/2020] [Accepted: 07/22/2020] [Indexed: 02/06/2023]
Abstract
Fibrosis is driven by a misdirected cell response causing the overproduction of extracellular matrix and tissue dysfunction. Numerous pharmacological strategies have attempted to prevent fibrosis but have attained limited efficacy with some detrimental side effects. While stem cell treatments have provided more encouraging results, they have exhibited high variability and have not always improved tissue function. To enhance stem cell efficacy, we evaluated whether mechanical memory could direct cell response. We hypothesized that mechanically pre-conditioning on a soft matrix (soft priming) will delay adipose-derived stem cell (ASC) transition to a pro-fibrotic phenotype, expanding their regenerative potential, and improving healing in a complex tissue environment. Primary ASCs isolated from rat and human subcutaneous fat exhibited mechanical memory, demonstrated by a delayed cell response to stiffness following two weeks of soft priming including decreased cell area, actin coherency, and extracellular matrix production compared to cells on stiff substrates. Soft primed ASCs injected into our rat model of post-traumatic elbow contracture decreased histological evidence of anterior capsule fibrosis and increased elbow range-of-motion when evaluated by joint mechanics. These findings suggest that exploiting mechanical memory by strategically controlling the culture environment during cell expansion may improve the efficacy of stem cell-based therapies targeting fibrosis.
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Affiliation(s)
- Chelsey Dunham
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Necat Havlioglu
- Department of Pathology, John Cochran VA Medical Center, St. Louis, MO, USA
| | - Aaron Chamberlain
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Spencer Lake
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
- Department of Mechanical Engineering & Materials Science, Washington University in St. Louis, MO, USA
- Center of Regenerative Medicine, Washington University in St. Louis, St. Louis, MO
| | - Gretchen Meyer
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
- Center of Regenerative Medicine, Washington University in St. Louis, St. Louis, MO
- Program in Physical Therapy, Washington University in St. Louis, St. Louis, MO
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Liu R, Zhang S, Chen X. Injectable hydrogels for tendon and ligament tissue engineering. J Tissue Eng Regen Med 2020; 14:1333-1348. [PMID: 32495524 DOI: 10.1002/term.3078] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/06/2020] [Accepted: 05/17/2020] [Indexed: 01/14/2023]
Abstract
The problem of tendon and ligament (T/L) regeneration in musculoskeletal diseases has long constituted a major challenge. In situ injection of formable biodegradable hydrogels, however, has been demonstrated to treat T/L injury and reduce patient suffering in a minimally invasive manner. An injectable hydrogel is more suitable than other biological materials due to the special physiological structure of T/L. Most other materials utilized to repair T/L are cell-based, growth factor-based materials, with few material properties. In addition, the mechanical property of the gel cannot reach the normal T/L level. This review summarizes advances in natural and synthetic polymeric injectable hydrogels for tissue engineering in T/L and presents prospects for injectable and biodegradable hydrogels for its treatment. In future T/L applications, it is necessary develop an injectable hydrogel with mechanics, tissue damage-specific binding, and disease response. Simultaneously, the advantages of various biological materials must be combined in order to achieve personalized precision therapy.
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Affiliation(s)
- Richun Liu
- Guangxi Collaborative Innovation Center for Biomedicine, Guangxi Medical University, Nanning, Guangxi, China
| | - Shichen Zhang
- Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Chen
- Guangxi Collaborative Innovation Center for Biomedicine, Guangxi Medical University, Nanning, Guangxi, China.,Dr. Li Dak Sum & Yip Yio Chin Center for Stem Cell and Regenerative Medicine, School of Medicine, Zhejiang University, Hangzhou, China
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Mao X, Li X, Hu W, Hao S, Yuan Y, Guan L, Guo B. Downregulated brain and muscle aryl hydrocarbon receptor nuclear translocator-like protein-1 inhibits osteogenesis of BMSCs through p53 in type 2 diabetes mellitus. Biol Open 2020; 9:bio051482. [PMID: 32554484 PMCID: PMC7358138 DOI: 10.1242/bio.051482] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/27/2020] [Indexed: 12/05/2022] Open
Abstract
The bone marrow mesenchymal stem cells (BMSCs)-mediated abnormal bone metabolism can delay and impair the bone remodeling process in type 2 diabetes mellitus (T2DM). Our previous study demonstrated that the downregulation of brain and muscle aryl hydrocarbon receptor nuclear translocator-like protein 1 (BMAL1), a circadian clock protein, inhibited the Wnt/β-catenin pathway via enhanced GSK-3β in diabetic BMSCs. In this article, we confirmed that the downregulated BMAL1 in T2DM played an inhibitory role in osteogenic differentiation of BMSCs. Upregulation of BMAL1 in the diabetic BMSCs significantly recovered the expression pattern of osteogenic marker genes and alkaline phosphatase (Alp) activity. We also observed an activation of the p53 signaling pathways, exhibited by increased p53 and p21 in diabetic BMSCs. Downregulation of p53 resulting from overexpression of BMAL1 was detected, and when we applied p53 gene silencing (shRNA) and the p53 inhibitor, pifithrin-α (PFT-α), the impaired osteogenic differentiation ability of diabetic BMSCs was greatly restored. However, there was no change in the level of expression of BMAL1. Taken together, our results first revealed that BMAL1 regulated osteogenesis of BMSCs through p53 in T2DM, providing a novel direction for further exploration of the mechanism underlying osteoporosis in diabetes.
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Affiliation(s)
- Xiaofei Mao
- Department of Stomatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiaoguang Li
- Department of Stomatology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - Wei Hu
- Department of Stomatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Siwei Hao
- Department of Stomatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Yifang Yuan
- Department of Stomatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Lian Guan
- Department of Stomatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Bin Guo
- Department of Stomatology, Chinese PLA General Hospital, Beijing 100853, China
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Leong NL, Kator JL, Clemens TL, James A, Enamoto-Iwamoto M, Jiang J. Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration. J Orthop Res 2020; 38:7-12. [PMID: 31529731 PMCID: PMC7307866 DOI: 10.1002/jor.24475] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 09/10/2019] [Indexed: 02/04/2023]
Abstract
Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7-12, 2020.
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Affiliation(s)
- Natalie L Leong
- Department of Orthopaedic Surgery, University of Maryland, 10 N. Greene St., Baltimore, Maryland, 21201
- Department of Surgery, Baltimore VA Medical Center, Baltimore, Maryland
| | - Jamie L Kator
- Department of Orthopaedic Surgery, University of Maryland, 10 N. Greene St., Baltimore, Maryland, 21201
| | - Thomas L Clemens
- Department of Orthopaedic Surgery, University of Maryland, 10 N. Greene St., Baltimore, Maryland, 21201
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Aaron James
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Motomi Enamoto-Iwamoto
- Department of Orthopaedic Surgery, University of Maryland, 10 N. Greene St., Baltimore, Maryland, 21201
| | - Jie Jiang
- Department of Orthopaedic Surgery, University of Maryland, 10 N. Greene St., Baltimore, Maryland, 21201
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Tarafder S, Brito JA, Minhas S, Effiong L, Thomopoulos S, Lee CH. In situ tissue engineering of the tendon-to-bone interface by endogenous stem/progenitor cells. Biofabrication 2019; 12:015008. [PMID: 31561236 PMCID: PMC6904927 DOI: 10.1088/1758-5090/ab48ca] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The long-term success of surgical repair of rotator cuff tears is largely dependent on restoration of a functional tendon-to-bone interface. We implemented micro-precise spatiotemporal delivery of growth factors in three-dimensional printed scaffolds for integrative regeneration of a fibrocartilaginous tendon-to-bone interface. Sustained and spatially controlled release of tenogenic, chondrogenic and osteogenic growth factors was achieved using microsphere-based delivery carriers embedded in thin membrane-like scaffolds. In vitro, the scaffolds embedded with spatiotemporal delivery of growth factors successfully guided regional differentiation of mesenchymal progenitor cells, forming multiphase tissues with tendon-like, cartilage-like and bone-like regions. In vivo, when implanted at the interface between the supraspinatus tendon and the humeral head in a rat rotator cuff repair model, these scaffolds promoted recruitment of endogenous tendon progenitor cells followed by integrative healing of tendon and bone via re-formation of strong fibrocartilaginous interfaces. Our findings demonstrate the potential of in situ tissue engineering of tendon-to-bone interfaces by endogenous progenitor cells. The in situ tissue engineering approach shows translational potential for improving outcomes after rotator cuff repair.
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Affiliation(s)
- Solaiman Tarafder
- Regenerative Engineering Laboratory, Columbia University Medical Center, 630 W. 168th Street, VC12-230, NY 10032, New York
| | - John A Brito
- Regenerative Engineering Laboratory, Columbia University Medical Center, 630 W. 168th Street, VC12-230, NY 10032, New York
| | - Sumeet Minhas
- Regenerative Engineering Laboratory, Columbia University Medical Center, 630 W. 168th Street, VC12-230, NY 10032, New York
| | - Linda Effiong
- Department of Orthopedic Surgery, Columbia University Medical Center, 650 W. 168th Street, BB14-1408, NY 10032, New York
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Columbia University Medical Center, 650 W. 168th Street, BB14-1408, NY 10032, New York
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace, NY 10027, New York
| | - Chang H Lee
- Regenerative Engineering Laboratory, Columbia University Medical Center, 630 W. 168th Street, VC12-230, NY 10032, New York
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Morikawa D, Johnson JD, Kia C, McCarthy MBR, Macken C, Bellas N, Baldino JB, Cote MP, Mazzocca AD. Examining the Potency of Subacromial Bursal Cells as a Potential Augmentation for Rotator Cuff Healing: An In Vitro Study. Arthroscopy 2019; 35:2978-2988. [PMID: 31629585 DOI: 10.1016/j.arthro.2019.05.024] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/09/2019] [Accepted: 05/12/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE To compare the potency of mesenchymal stem cells between the cells derived from the subacromial bursa to concentrated bone marrow aspirate (cBMA) taken from patients undergoing rotator cuff (RC) repair. METHODS Subacromial bursa and cBMA were harvested arthroscopically from 13 patients (age 57.4 ± 5.2 years, mean ± standard deviation) undergoing arthroscopic primary RC repair. Bone marrow was aspirated from the proximal humerus and concentrated using an automated system (Angel System; Arthrex). Subacromial bursa was collected from 2 sites (over the RC tendon and muscle) and digested with collagenase to isolate a single cellular fraction. Proliferation, number of colony-forming units, differentiation potential, and gene expression were compared among the cells derived from each specimen. RESULTS The cells derived from subacromial bursa showed significantly higher proliferation compared with the cells derived from cBMA after 5, 7, and 10 days (P = .018). Regarding colony-forming units, the subacromial bursa had significantly more colonies than cBMA (P = .002). Subacromial bursal cells over the RC tendon produced significantly more colonies than cells over both the RC muscle and cBMA (P = .033 and P = .028, respectively). Moreover, when compared with cBMA, cells derived from subacromial bursa showed significantly higher differentiation ability and higher gene expression indicative of chondrogenesis, osteogenesis, and adipogenesis. CONCLUSION The subacromial bursa is an easily accessible tissue that can be obtained during RC repair, with significant pluripotent stem cell potency for tendon healing. Compared with cBMA taken from the proximal humerus, bursal cells showed significantly increased differentiation ability and gene expression over time. CLINICAL RELEVANCE Failed RC repairs have been partly attributed to a poor healing environment. Biologic augmentation of the repair site may help increase healing potential and incorporation of the cuff at the tendon-bone interface.
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Affiliation(s)
- Daichi Morikawa
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.; Department of Orthopaedic Surgery, Juntendo University, Tokyo, Japan.
| | - Jeremiah D Johnson
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Cameron Kia
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Mary Beth R McCarthy
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Craig Macken
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Nicholas Bellas
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Joshua B Baldino
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A
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No healing improvement after rotator cuff reconstruction augmented with an autologous periosteal flap. Knee Surg Sports Traumatol Arthrosc 2019; 27:3212-3221. [PMID: 30989274 DOI: 10.1007/s00167-019-05384-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up. METHODS Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant-Murley Score (CS), ultrasonography examination and 3T MR imaging were performed. RESULTS Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4-13.0). Questions answered with "yes" in SST improved from baseline 5.0 (range 1.0-8.0) to short 10.5 (range 8.0-12.0) and final follow-up 12.0 (range 7.0-12.0). CS improved from 53.5 (range 25.0-66.0) to 80.8 (range 75.9-89.3) and finally to 79.8 points (range 42.3-95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05). CONCLUSION No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore. LEVEL OF EVIDENCE IV.
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Kaizawa Y, Franklin A, Leyden J, Behn AW, Tulu US, Sotelo Leon D, Wang Z, Abrams GD, Chang J, Fox PM. Augmentation of chronic rotator cuff healing using adipose-derived stem cell-seeded human tendon-derived hydrogel. J Orthop Res 2019; 37:877-886. [PMID: 30747435 DOI: 10.1002/jor.24250] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 01/24/2019] [Indexed: 02/04/2023]
Abstract
Rotator cuff (RTC) repair outcomes are unsatisfactory due to the poor healing capacity of the tendon bone interface (TBI). In our preceding study, tendon hydrogel (tHG), which is a type I collagen rich gel derived from human tendons, improved biomechanical properties of the TBI in a rat chronic RTC injury model. Here we investigated whether adipose-derived stem cell (ASC)-seeded tHG injection at the repair site would further improve RTC healing. Rats underwent bilateral supraspinatus tendon detachment. Eight weeks later injured supraspinatus tendons were repaired with one of four treatments. In the control group, standard transosseous suture repair was performed. In the ASC, tHG, tHGASC groups, ASC in media, tHG, and ASC-seeded tHG were injected at repair site after transosseous suture repair, respectively. Eight weeks after repair, the TBI was evaluated biomechanically, histologically, and via micro CT. Implanted ASCs were detected in ASC and tHGASC groups 7 weeks after implantation. ACS implantation improved bone morphometry at the supraspinatus insertion on the humerus. Injection of tHG improved biomechanical properties of the repaired TBI. RTC healing in tHGASC group was significantly better than control but statistically equivalent to the tHG group based on biomechanical properties, fibrocartilage area at the TBI, and bone morphometry at the supraspinatus insertion. In a rat RTC chronic injury model, no biomechanical advantage was gained with ASC augmentation of tHG. Clinical Significance: Tendon hydrogel augmentation with adipose derived stem cells does not significantly improve TBI healing over tHG alone in a chronic rotator cuff injury model. © 2019 Orthopaedic Research Society. This article has been contributed to by US Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Yukitoshi Kaizawa
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, California, 94304
| | - Austin Franklin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, California, 94304
| | - Jacinta Leyden
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, California, 94304
| | - Anthony W Behn
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, California, 94305
| | - Ustun S Tulu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304
| | - Daniel Sotelo Leon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, California, 94304
| | - Zhen Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, California, 94304
| | - Geoffrey D Abrams
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Palo Alto, California, 94305
| | - James Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, California, 94304
| | - Paige M Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, California, 94304.,Division of Plastic and Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, California, 94304
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29
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Liu F, Meng Q, Yin H, Yan Z. Stem Cells in Rotator Cuff Injuries and Reconstructions: A Systematic Review and Meta-Analysis. Curr Stem Cell Res Ther 2019; 14:683-697. [PMID: 31244430 DOI: 10.2174/1574888x14666190617143952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Multiple studies have focused on stem cell-based treatments for rotator cuff disorders; however, the outcomes are not consistent. OBJECTIVES This systematic review and meta-analysis were performed to evaluate the effects of stem cells on rotator cuff healing. METHODS A detailed search of relevant studies was conducted in three databases including Pubmed/ Medline, Cochrane library, and Embase databases, using the following keywords: "rotator cuff" or "Tissue Engineering" AND "stem cell" from inception to January 01, 2019. The standard mean difference (SMD) and 95% confidence interval (CI) for each individual study were extracted from the original studies or calculated based on relevant data and pooled to obtain integrated estimates using random effects modeling. RESULTS A total of 22 studies were identified. The results demonstrated that the ultimate strain in the stem cell group was significantly higher than that in the control group at 4 and 8 weeks. Muscle weight in the stem cell group was higher than the control group at 8 weeks, while no significant differences were detected at 16 weeks. The stem cell group had lower visual analog scale scores (VAS) at 1, 3, and 6 months, and higher American shoulder and elbow surgeons score (ASES) at 3 months. In addition, the walking distance, time, and speed in the stem cell group were significantly superior to those in the control group. CONCLUSIONS This meta-analysis confirms that stem cells improved the rehabilitation of rotator cuff disorders. However, larger-scale studies are needed to further support these findings.
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Affiliation(s)
- Fanxiao Liu
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong University, No.324, Road Jing Wu Wei Qi, Jinan 250021, Shandong, China
| | - Qingqi Meng
- Department of Orthopaedics, Guangzhou Red Cross Hospital, Jinan University, Tongfu road 396, Haizhu district, Guangzhou, China
| | - Heyong Yin
- Department of Trauma Surgery, University of Regensburg, Am biopark 9, 93049 Regensburg, Germany
| | - Zexing Yan
- Department of Trauma Surgery, University of Regensburg, Am biopark 9, 93049 Regensburg, Germany
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30
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Liu Q, Yu Y, Reisdorf RL, Qi J, Lu CK, Berglund LJ, Amadio PC, Moran SL, Steinmann SP, An KN, Gingery A, Zhao C. Engineered tendon-fibrocartilage-bone composite and bone marrow-derived mesenchymal stem cell sheet augmentation promotes rotator cuff healing in a non-weight-bearing canine model. Biomaterials 2018; 192:189-198. [PMID: 30453215 DOI: 10.1016/j.biomaterials.2018.10.037] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/26/2018] [Accepted: 10/26/2018] [Indexed: 12/18/2022]
Abstract
Reducing rotator cuff failure after repair remains a challenge due to suboptimal tendon-to-bone healing. In this study we report a novel biomaterial with engineered tendon-fibrocartilage-bone composite (TFBC) and bone marrow-derived mesenchymal stem cell sheet (BMSCS); this construct was tested for augmentation of rotator cuff repair using a canine non-weight-bearing (NWB) model. A total of 42 mixed-breed dogs were randomly allocated to 3 groups (n = 14 each). Unilateral infraspinatus tendon underwent suture repair only (control); augmentation with engineered TFBC alone (TFBC), or augmentation with engineered TFBC and BMSCS (TFBC + BMSCS). Histomorphometric analysis and biomechanical testing were performed at 6 weeks after surgery. The TFBC + BMSCS augmented repairs demonstrated superior histological scores, greater new fibrocartilage formation and collagen fiber organization at the tendon-bone interface compared with the controls. The ultimate failure load and ultimate stress were 286.80 ± 45.02 N and 4.50 ± 1.11 MPa for TFBC + BMSCS group, 163.20 ± 61.21 N and 2.60 ± 0.97 MPa for control group (TFBC + BMSCS vs control, P = 1.12E-04 and 0.003, respectively), 206.10 ± 60.99 N and 3.20 ± 1.31 MPa for TFBC group (TFBC + BMSCS vs TFBC, P = 0.009 and 0.045, respectively). In conclusion, application of an engineered TFBC and BMSCS can enhance rotator cuff healing in terms of anatomic structure, collagen organization and biomechanical strength in a canine NWB model. Combined TFBC and BMSCS augmentation is a promising strategy for rotator cuff tears and has a high potential impact on clinical practice.
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Affiliation(s)
- Qian Liu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, PR China
| | - Yinxian Yu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Jun Qi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chun-Kuan Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kai-Nan An
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anne Gingery
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Lemmon EA, Locke RC, Szostek AK, Ganji E, Killian ML. Partial-width injuries of the rat rotator cuff heal with fibrosis. Connect Tissue Res 2018; 59:437-446. [PMID: 29874950 PMCID: PMC6324170 DOI: 10.1080/03008207.2018.1485666] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/31/2018] [Accepted: 05/31/2018] [Indexed: 02/03/2023]
Abstract
PURPOSE Identify the healing outcomes following a partial-width, full-thickness injury to the rotator cuff tendon-bone attachment and establish if the adult attachment can regenerate the morphology of the healthy attachment. HYPOTHESIS We hypothesized that a partial-width injury to the attachment would heal via fibrosis and bone remodeling, resulting in increased cellularity and extra-cellular matrix deposition, reduced bone volume (BV), osteoclast presence, and decreased collagen organization compared to shams. MATERIALS AND METHODS A partial-width injury was made using a biopsy punch at the center one-third of the rat infraspinatus attachment. Contralateral limbs underwent a sham operation. Rats were sacrificed at 3 and 8 weeks after injury for analyses. Analyses performed at each time point included cellularity (Hematoxylin & Eosin), ECM deposition (Masson's Trichrome), BV (micro-computed tomography; microCT), osteoclast activity (Tartrate Resistant Acid Phosphatase; TRAP), and collagen fibril organization (Picrosirius Red). Injured and sham shoulders were compared at both 3 and 8 weeks using paired, two-way ANOVAs with repeated measures (Sidak's correction for multiple comparisons). RESULTS Cellularity and ECM deposition increased at both 3 and 8 weeks compared to sham contralateral attachments. BV decreased and osteoclast presence increased at both 3 and 8 weeks compared to sham contralateral limbs. Collagen fibril organization was reduced at 3 weeks after injury compared to 3-week sham attachments. CONCLUSIONS These findings suggest that a partial-width injury to the rotator cuff attachment does not fully regenerate the native structure of the healthy attachment. The injury model healed via scar-like fibrosis and did not propagate into a full-width tear after 8 weeks of healing.
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Affiliation(s)
- Elisabeth A Lemmon
- a Department of Animal and Food Sciences and Biomedical Engineering , University of Delaware , Newark , DE , USA
| | - Ryan C Locke
- b Department of Biomedical Engineering , University of Delaware , Newark , DE , USA
| | - Adrianna K Szostek
- a Department of Animal and Food Sciences and Biomedical Engineering , University of Delaware , Newark , DE , USA
| | - Elahe Ganji
- c Department of Mechanical Engineering and Biomedical Engineering , University of Delaware , Newark , DE , USA
| | - Megan L Killian
- b Department of Biomedical Engineering , University of Delaware , Newark , DE , USA
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Bianco ST, Moser HL, Galatz LM, Huang AH. Biologics and stem cell-based therapies for rotator cuff repair. Ann N Y Acad Sci 2018; 1442:35-47. [PMID: 30008172 DOI: 10.1111/nyas.13918] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/01/2018] [Accepted: 06/11/2018] [Indexed: 12/20/2022]
Abstract
The rotator cuff is composed of several distinct muscles and tendons that function in concert to coordinate shoulder motion. Injuries to these tendons frequently result in permanent dysfunction and persistent pain. Despite considerable advances in operation techniques, surgical repair alone still does not fully restore rotator cuff function. This review focuses on recent research in the use of biologics and stem cell-based therapies to augment repair, highlighting promising avenues for future work and remaining challenges. While a number of animal models are used for rotator cuff studies, the anatomy of the rotator cuff varies dramatically between species. Since the rodent rotator cuff shares the most anatomical features with the human, this review will focus primarily on rodent models to enable consistent interpretation of outcome measures.
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Affiliation(s)
- Spencer T Bianco
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Helen L Moser
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York.,Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Leesa M Galatz
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alice H Huang
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York
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33
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Narayanan G, Nair LS, Laurencin CT. Regenerative Engineering of the Rotator Cuff of the Shoulder. ACS Biomater Sci Eng 2018; 4:751-786. [PMID: 33418763 DOI: 10.1021/acsbiomaterials.7b00631] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rotator cuff tears often heal poorly, leading to re-tears after repair. This is in part attributed to the low proliferative ability of the resident cells (tendon fibroblasts and tendon-stem cells) upon injury to the rotator cuff tissue and the low vascularity of the tendon insertion. In addition, surgical outcomes of current techniques used in clinical settings are often suboptimal, leading to the formation of neo-tissue with poor biomechanics and structural characteristics, which results in re-tears. This has prompted interest in a new approach, which we term as "Regenerative Engineering", for regenerating rotator cuff tendons. In the Regenerative Engineering paradigm, roles played by stem cells, scaffolds, growth factors/small molecules, the use of local physical forces, and morphogenesis interplayed with clinical surgery techniques may synchronously act, leading to synergistic effects and resulting in successful tissue regeneration. In this regard, various cell sources such as tendon fibroblasts and adult tissue-derived stem cells have been isolated, characterized, and investigated for regenerating rotator cuff tendons. Likewise, numerous scaffolds with varying architecture, geometry, and mechanical characteristics of biologic and synthetic origin have been developed. Furthermore, these scaffolds have been also fabricated with biochemical cues (growth factors and small molecules), facilitating tissue regeneration. In this Review, various strategies to regenerate rotator cuff tendons using stem cells, advanced materials, and factors in the setting of physical forces under the Regenerative Engineering paradigm are described.
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Affiliation(s)
- Ganesh Narayanan
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut 06030, United States
| | - Lakshmi S Nair
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut 06269, United States.,Department of Materials Science and Engineering, University of Connecticut, Storrs, Connecticut 06269, United States
| | - Cato T Laurencin
- Institute for Regenerative Engineering, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Department of Reconstructive Sciences, University of Connecticut Health Center, Farmington, Connecticut 06030, United States.,Department of Chemical and Biomolecular Engineering, University of Connecticut, Storrs, Connecticut 06269, United States.,Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut 06269, United States.,Department of Materials Science and Engineering, University of Connecticut, Storrs, Connecticut 06269, United States.,Connecticut Institute for Clinical and Translational Science, University of Connecticut Health Center, Farmington, Connecticut 06030, United States
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Lebaschi A, Nakagawa Y, Wada S, Cong GT, Rodeo SA. Tissue-specific endothelial cells: a promising approach for augmentation of soft tissue repair in orthopedics. Ann N Y Acad Sci 2018; 1410:44-56. [PMID: 29265420 DOI: 10.1111/nyas.13575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 11/12/2017] [Accepted: 11/13/2017] [Indexed: 12/13/2022]
Abstract
Biologics are playing an increasingly significant role in the practice of modern medicine and surgery in general and orthopedics in particular. Cell-based approaches are among the most important and widely used modalities in orthopedic biologics, with mesenchymal stem cells and other multi/pluripotent cells undergoing evaluation in numerous preclinical and clinical studies. On the other hand, fully differentiated endothelial cells (ECs) have been found to perform critical roles in homeostasis of visceral tissues through production of an adaptive panel of so-called "angiocrine factors." This newly discovered function of ECs renders them excellent candidates for novel approaches in cell-based biologics. Here, we present a review of the role of ECs and angiocrine factors in some visceral tissues, followed by an overview of current cell-based approaches and a discussion of the potential applications of ECs in soft tissue repair.
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Affiliation(s)
- Amir Lebaschi
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Yusuke Nakagawa
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Susumu Wada
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Guang-Ting Cong
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York
| | - Scott A Rodeo
- Orthopedic Soft Tissue Research Program, Hospital for Special Surgery, New York, New York.,Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York
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35
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Yan Z, Yin H, Nerlich M, Pfeifer CG, Docheva D. Boosting tendon repair: interplay of cells, growth factors and scaffold-free and gel-based carriers. J Exp Orthop 2018; 5:1. [PMID: 29330711 PMCID: PMC5768579 DOI: 10.1186/s40634-017-0117-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/20/2017] [Indexed: 12/21/2022] Open
Abstract
Background Tendons are dense connective tissues and critical components for the integrity and function of the musculoskeletal system. Tendons connect bone to muscle and transmit forces on which locomotion entirely depends. Due to trauma, overuse and age-related degeneration, many people suffer from acute or chronic tendon injuries. Owing to their hypovascularity and hypocellularity, tendinopathies remain a substantial challenge for both clinicians and researchers. Surgical treatment includes suture or transplantation of autograft, allograft or xenograft, and these serve as the most common technique for rescuing tendon injuries. However, the therapeutic efficacies are limited by drawbacks including inevitable donor site morbidity, poor graft integration, adhesion formations and high rates of recurrent tearing. This review summarizes the literature of the past 10 y concerning scaffold-free and gel-based approaches for treating tendon injuries, with emphasis on specific advantages of such modes of application, as well as the obtained results regarding in vitro and in vivo tenogenesis. Results The search was focused on publications released after 2006 and 83 articles have been analysed. The main results are summarizing and discussing the clear advantages of scaffold-free and hydrogels carriers that can be functionalized with cells alone or in combination with growth factors. Conclusion The improved understanding of tissue resident adult stem cells has made a significant progress in recent years as well as strategies to steer their fate toward tendon lineage, with the help of growth factors, have been identified. The field of tendon tissue engineering is exploring diverse models spanning from hard scaffolds to gel-based and scaffold-free approaches seeking easier cell delivery and integration in the site of injury. Still, the field needs to consider a multifactorial approach that is based on the combination and fine-tuning of chemical and biomechanical stimuli. Taken together, tendon tissue engineering has now excellent foundations and enters the period of precision and translation to models with clinical relevance on which better treatment options of tendon injuries can be shaped up.
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Affiliation(s)
- Zexing Yan
- Laboratory of Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Heyong Yin
- Laboratory of Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Michael Nerlich
- Laboratory of Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Christian G Pfeifer
- Laboratory of Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Denitsa Docheva
- Laboratory of Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany. .,Director of Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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Carballo CB, Lebaschi A, Rodeo SA. Cell-based approaches for augmentation of tendon repair. TECHNIQUES IN SHOULDER & ELBOW SURGERY 2017; 18:e6-e14. [PMID: 29276433 PMCID: PMC5737795 DOI: 10.1097/bte.0000000000000132] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cell-based approaches are among the principal interventions in orthobiologics to improve tendon and ligament healing and to combat degenerative processes. The number of options available for investigation are expanding rapidly and investigators have an increasing number of cell types to choose from for research purposes. However, in part due to the current regulatory environment, the list of available cells at clinicians' disposal for therapeutic purposes is still rather limited. In this review, we present an overview of the main cellular categories in current use. Notable recent developments in cell-based approaches include the introduction of diverse sources of mesenchymal stem cells, pluripotent cells of extra-embryonic origin, and the emerging popularity of fully differentiated cells such as tenocytes and endothelial cells. Delivery strategies are discussed and a succinct discussion of the current regulatory environment in the United States is presented.
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Affiliation(s)
- Camila B Carballo
- Laboratory for Joint Tissue Repair and Regeneration, Orthopedic Soft Tissue Research Program, Hospital for Special Surgery
| | - Amir Lebaschi
- Laboratory for Joint Tissue Repair and Regeneration, Orthopedic Soft Tissue Research Program, Hospital for Special Surgery
| | - Scott A Rodeo
- Laboratory for Joint Tissue Repair and Regeneration, Orthopedic Soft Tissue Research Program, Hospital for Special Surgery
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Zong JC, Mosca MJ, Degen RM, Lebaschi A, Carballo C, Carbone A, Cong GT, Ying L, Deng XH, Rodeo SA. Involvement of Indian hedgehog signaling in mesenchymal stem cell-augmented rotator cuff tendon repair in an athymic rat model. J Shoulder Elbow Surg 2017; 26:580-588. [PMID: 27887870 DOI: 10.1016/j.jse.2016.09.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/21/2016] [Accepted: 09/29/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Bone marrow aspirate has been used in recent years to augment tendon-to-bone healing, including in rotator cuff repair. However, the healing mechanism in cell-based therapy has not been elucidated in detail. METHODS Sixteen athymic nude rats were randomly allocated to 2 groups: experimental (human mesenchymal stem cells in fibrin glue carrier) and control (fibrin glue only). Animals were sacrificed at 2 and 4 weeks. Immunohistochemical staining was performed to evaluate Indian hedgehog (Ihh) signaling and SOX9 signaling in the healing enthesis. Macrophages were identified using CD68 and CD163 staining, and proliferating cells were identified using proliferating cell nuclear antigen staining. RESULTS More organized and stronger staining for collagen II and a higher abundance of SOX9+ cells were observed at the enthesis in the experimental group at 2 weeks. There was significantly higher Gli1 and Patched1 expression in the experimental group at the enthesis at 2 weeks and higher numbers of Ihh+ cells in the enthesis of the experimental group vs control at both 2 weeks and 4 weeks postoperatively. There were more CD68+ cells localized to the tendon midsubstance at 2 weeks compared with 4 weeks, and there was a higher level of CD163 staining in the tendon midsubstance in the experimental group than in the control group at 4 weeks. CONCLUSION Stem cell application had a positive effect on fibrocartilage formation at the healing rotator cuff repair site. Both SOX9 and Ihh signaling appear to play an important role in the healing process.
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Affiliation(s)
- Jian-Chun Zong
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | | | - Ryan M Degen
- The Hospital for Special Surgery, New York, NY, USA
| | | | | | | | | | - Liang Ying
- The Hospital for Special Surgery, New York, NY, USA
| | | | - Scott A Rodeo
- The Hospital for Special Surgery, New York, NY, USA.
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