Hierarchical ultrastructure: An overview of what is known about tendons and future perspective for tendon engineering

Liquid Crystalline Hydroxyapatite Nanorods Orchestrate Hierarchical Bone-Like Mineralization

Bone matrix exhibits exceptional mechanical properties due to its unique nanocomposite structure of type I collagen fibrils and hydroxyapatite (HAp) nanoparticles in hierarchical liquid crystalline (LC) order. However, the regeneration mechanism of this LC structure is elusive. This study investigates the role of the LC structure of HAp nanorods in guiding aligned mineralization and its underlying molecular mechanism. A unidirectionally oriented LC phase of HAp nanorods is developed through engineering-assisted self-assembling. This is used to study the growth direction of long-range aligned extracellular matrix (ECM) and calcium deposit formation during the osteogenic differentiation of human bone marrow-derived mesenchymal stem cells. It is found that 2 key regulatory genes, COL1A1 and COL4A6, lead to the formation of aligned ECM. Activation of the PI3K-Akt pathway enhances osteogenesis and promotes ordered calcium deposits. This study provides evidence for elucidating the mechanism of LC-induced ordered calcium deposition at hierarchical levels spanning from the molecular to macro-scale, as well as the switch from ordered to disordered mineralization. These findings illuminate bone regeneration, contribute to the development of biomimetic artificial bone with long-range ordered structures, and suggest a basis for therapeutic targeting of microstructure-affected bone disorders and the broader field of cell-ECM interactions.

Advances in the Development of Gradient Scaffolds Made of Nano-Micromaterials for Musculoskeletal Tissue Regeneration

The intricate hierarchical structure of musculoskeletal tissues, including bone and interface tissues, necessitates the use of complex scaffold designs and material structures to serve as tissue-engineered substitutes. This has led to growing interest in the development of gradient bone scaffolds with hierarchical structures mimicking the extracellular matrix of native tissues to achieve improved therapeutic outcomes. Building on the anatomical characteristics of bone and interfacial tissues, this review provides a summary of current strategies used to design and fabricate biomimetic gradient scaffolds for repairing musculoskeletal tissues, specifically focusing on methods used to construct compositional and structural gradients within the scaffolds. The latest applications of gradient scaffolds for the regeneration of bone, osteochondral, and tendon-to-bone interfaces are presented. Furthermore, the current progress of testing gradient scaffolds in physiologically relevant animal models of skeletal repair is discussed, as well as the challenges and prospects of moving these scaffolds into clinical application for treating musculoskeletal injuries.

Antifibrotic and Pro-regenerative Effects of SMAD3 siRNA and Collagen I mRNA-Loaded Lipid Nanoparticles in Human Tenocytes

Tendinopathy involves the inflammation and degeneration of the tendon due to repetitive strain injury. Current treatments primarily target inflammation resolution, yet they do not aim at tissue regeneration. In this study, a microfluidics approach is harnessed to develop a platform of lipid nanoparticles (LNPs) loaded simultaneously with SMAD3 siRNA and collagen I mRNA, aiming to explore its potential dual antifibrotic and regenerative effects in human tenocytes. The developed LNPs displayed size homogeneity and colloidal stability and exhibited high cytocompatibility in human tenocytes. Moreover, LNPs allowed for efficient uptake and transfection efficiency of the RNAs. In the in vitro efficacy studies, the gene expression and production of SMAD3 and collagen I were tested by real-time quantitative chain polymerase reaction and immuno- and intracellular staining, revealing collagen I production enhancement, SMAD3 inhibition, and modulation of other tendon repair factors by the LNPs. Overall, the potential of this platform of RNA-loaded LNPs to be used as a dual therapeutic approach to prevent fibrosis and promote tissue remodeling in late stages of tendon diseases was confirmed.

Effect of cilostazol on healing of achilles tendon ruptures: an experimental study on rats

PURPOSE

This study aimed to evaluate whether cilostazol (phosphodiesterase III inhibitor) could enhance the healing of Achilles tendon ruptures in rats.

MATERIALS AND METHODS

The Achilles tendons of 24 healthy male adult rats were incised and repaired. The rats were randomly allocated to cilostazol and control groups. The cilostazol group received daily intragastric administration of 50 mg/kg cilostazol for 28 days, while the control group did not receive any medication. The rats were sacrificed on the 30th day, and the Achilles tendon was evaluated for biomechanical properties, histopathological characteristics, and immunohistochemical analysis.

RESULTS

All rats completed the experiment. The Movin sum score of the control group was significantly higher (p = 0.008) than that of the cilostazol group, with means of 11 ± 0.63 and 7.50 ± 1.15, respectively. Similarly, the mean Bonar score was significantly higher (p = 0.026) in the control group compared to the cilostazol group (8.33 ± 1.50 vs. 5.5 ± 0.54, respectively). Moreover, the Type I/Type III Collagen ratio was notably higher (p = 0.016) in the cilostazol group (52.2 ± 8.4) than in the control group (34.6 ± 10.2). The load to failure was substantially higher in the cilostazol group than in the control group (p = 0.034), suggesting that the tendons in the cilostazol group were stronger and exhibited greater resistance to failure.

CONCLUSIONS

The results of this study suggest that cilostazol treatment significantly improves the biomechanical and histopathological parameters of the healing Achilles tendon in rats. Cilostazol might be a valuable supplementary therapy in treating Achilles tendon ruptures in humans. Additional clinical studies are, however, required to verify these outcomes.

Immunomodulatory multicellular scaffolds for tendon-to-bone regeneration

Limited motor activity due to the loss of natural structure impedes recovery in patients suffering from tendon-to-bone injury. Conventional biomaterials focus on strengthening the regenerative ability of tendons/bones to restore natural structure. However, owing to ignoring the immune environment and lack of multi-tissue regenerative function, satisfactory outcomes remain elusive. Here, combined manganese silicate (MS) nanoparticles with tendon/bone-related cells, the immunomodulatory multicellular scaffolds were fabricated for integrated regeneration of tendon-to-bone. Notably, by integrating biomimetic cellular distribution and MS nanoparticles, the multicellular scaffolds exhibited diverse bioactivities. Moreover, MS nanoparticles enhanced the specific differentiation of multicellular scaffolds via regulating macrophages, which was mainly attributed to the secretion of PGE2 in macrophages induced by Mn ions. Furthermore, three animal results indicated that the scaffolds achieved immunomodulation, integrated regeneration, and function recovery at tendon-to-bone interfaces. Thus, the multicellular scaffolds based on inorganic biomaterials offer an innovative concept for immunomodulation and integrated regeneration of soft/hard tissue interfaces.

Cell Sheet Technology: An Emerging Approach for Tendon and Ligament Tissue Engineering

Tendon and ligament injuries account for a substantial proportion of disorders in the musculoskeletal system. While non-operative and operative treatment strategies have advanced, the restoration of native tendon and ligament structures after injury is still challenging due to its innate limited regenerative ability. Cell sheet technology is an innovative tool for tissue fabrication and cell transplantation in regenerative medicine. In this review, we first summarize different harvesting procedures and advantages of cell sheet technology, which preserves intact cell-to-cell connections and extracellular matrix. We then describe the recent progress of cell sheet technology from preclinical studies, focusing on the application of stem cell-derived sheets in treating tendon and ligament injuries, as well as highlighting its effects on mitigating inflammation and promoting tendon/graft-bone interface healing. Finally, we discuss several prerequisites for future clinical translation including the selection of appropriate cell source, optimization of preparation process, establishment of suitable animal model, and the fabrication of vascularized complex tissue. We believe this review could potentially provoke new ideas and drive the development of more functional biomimetic tissues using cell sheet technology to meet the needs of clinical patients.

Biocompatibility of hydrogel derived from equine tendon extracellular matrix in horses subcutaneous tissue

Tendinopathies account for a substantial proportion of musculoskeletal injuries. To improve treatment outcomes for partial and total tendon ruptures, new therapies are under investigation. These include the application of mesenchymal stem cells (MSCs) and biocompatible scaffolds derived from the Extracellular Matrix (ECM). Synthetic polymer hydrogels have not demonstrated results as promising as those achieved with ECM hydrogels sourced from the original tissue. This study aimed to evaluate the biocompatibility of a hydrogel formulated from equine tendon ECM. Six horses were administered three subcutaneous doses of the hydrogel, with a saline solution serving as a control. Biopsies were conducted on days 7, 14, and 56 post-application to gauge the hydrogel's impact. Throughout the experiment, the horse's physical condition remained stable. Thermographic analyses revealed a temperature increase in the treated groups compared to the control group within the initial 12 h. The von Frey test, used to measure the mechanical nociceptive threshold, also showed significant differences between the treated group and the control group at 6 h, 21 days, and 28 days. Histopathological analyses identified an inflammatory response on day 7, which was absent on days 14 and 56. Transmission electron microscopy indicated a decrease in inflammatory cellularity, while immunohistochemistry staining suggested an increased presence of inflammatory factors on day 14. In summary, the hydrogel is easily injectable, triggers a temporary local inflammatory response, and integrates into the adjacent tissue from day 14 onwards.

An Atelocollagen Injection Enhances the Healing of Nonoperatively Treated Achilles Tendon Tears: An Experimental Study in Rats

Background

There is growing interest in nonoperative treatment for the management of Achilles tendon ruptures (ATRs). However, nonoperative treatment is limited by the risk of tendon reruptures and low satisfaction rates. Recently, atelocollagen injections have been reported to have beneficial effects on tendon healing.

Purpose

To evaluate the beneficial effects of injected atelocollagen on Achilles tendon healing and investigate the mechanism of atelocollagen on tendon healing.

Study Design

Controlled laboratory study.

Methods

Percutaneous tenotomy of the right Achilles tendon in 66 rats was performed. The animals were equally divided into the noninjection group (NG) and the collagen injection group (CG). At 1, 3, and 6 weeks, the Achilles functional index, cross-sectional area, load to failure, stiffness, stress, and the modified Bonar score were assessed. Transmission electron microscopy, western blotting, and immunohistochemistry were also performed.

Results

The Achilles functional index (-6.8 vs -43.0, respectively; P = .040), load to failure (42.1 vs 27.0 N, respectively; P = .049), and stiffness (18.8 vs 10.3 N/mm, respectively; P = .049) were higher in the CG than those in the NG at 3 weeks. There were no significant differences in histological scores between the 2 groups. Transmission electron microscopy analysis showed that the mean diameter of collagen fibrils in the CG was greater than that in the NG at 3 weeks (117.2 vs 72.6 nm, respectively; P < .001) and 6 weeks (202.1 vs 144.0 nm, respectively; P < .001). Western blot analysis showed that the expression of collagen type I in the CG was higher than that in the NG at 1 week (P = .005) and 6 weeks (P = .001).

Conclusion

An atelocollagen injection had beneficial effects on the healing of nonoperatively treated Achilles tendon injuries. The Achilles tendon of CG rats exhibited better functional, biomechanical, and morphological outcomes compared with NG rats. The molecular data indicated that the mechanism of atelocollagen injections may be associated with an increased amount of collagen type I.

Clinical Relevance

An atelocollagen injection might be a good adjuvant option for the nonoperative treatment of ATRs.

Equine tendon mechanical behaviour: Prospects for repair and regeneration applications

Tendons are dense connective tissues that play an important role in the biomechanical function of the musculoskeletal system. The mechanical forces have been implicated in every aspect of tendon biology. Tendon injuries are frequently occurring and their response to treatments is often unsatisfactory. A better understanding of tendon biomechanics and mechanobiology can help develop treatment options to improve clinical outcomes. Recently, tendon tissue engineering has gained more attention as an alternative treatment due to its potential to overcome the limitations of current treatments. This review first provides a summary of tendon mechanical properties, focusing on recent findings of tendon mechanobiological responses. In the next step, we highlight the biomechanical parameters of equine energy-storing and positional tendons. The final section is devoted to how mechanical loading contributes to tenogenic differentiation using bioreactor systems. This study may help develop novel strategies for tendon injury prevention or accelerate and improve tendon healing.

Three-Dimensional Cell Culture System for Tendon Tissue Engineering

Tendon, connective tissue between bone and muscle has unique component of the musculoskeletal system. It plays important role for transporting mechanical stress from muscle to bone and enabling locomotive motion of the body. There are some restoration capacities in the tendon tissue, but the injured tendons are not completely regenerated after acute and chronic tendon injury. At this point, the treatment options for tendon injuries are limited and not that successful. Therefore, biomedical engineering approaches are emerged to cope with this issue. Among them, three-dimensional cell culture platforms provided similarity to in vivo conditions and suggested opportunities for new therapeutic approaches for treatment of tendon injuries. In this review, we focus on the characteristics of tendon tissue and tendon pathologies which can be targets for tendon tissue engineering strategies. Then proof-of-concept and pre-clinical studies leveraging advanced 3-dimensional cell culture platforms for tendon tissue regeneration have been discussed.

Instantaneous self-healing and strongly adhesive self-adaptive hyaluronic acid-based hydrogel for controlled drug release to promote tendon wound healing

The treatment of tendon injuries is an important healthcare challenge. Irregular wounds, hypocellularity, and prolonged inflammation impede the rate of healing for tendon injuries. To address these problems, a high-tenacity shape-adaptive, mussel-like hydrogel (PH/GMs@bFGF&PDA) was designed and constructed with polyvinyl alcohol (PVA) and hyaluronic acid grafted with phenylboronic acid (BA-HA) by encapsulating polydopamine and gelatin microspheres containing basic fibroblast growth factor (GMs@bFGF). The shape-adaptive PH/GMs@bFGF&PDA hydrogel can quickly adapt to irregular tendon wounds, and the strong adhesion (101.46 ± 10.88 kPa) can keep the hydrogel adhered to the wound at all times. In addition, the high tenacity and self-healing properties allow the hydrogel to move with the tendon without fracture. Additionally, even if fractured, it can quickly self-heal and continue to adhere to the tendon wound, while slowly releasing basic fibroblast growth factor during the inflammatory phase of the tendon repair process, promoting cell proliferation, migration and shortening the inflammatory phase. In acute tendon injury and chronic tendon injury models, PH/GMs@bFGF&PDA significantly alleviated inflammation and promoted collagen I secretion, enhancing wound healing through the synergistic effects of its shape-adaptive and high-adhesion properties.

Recent advances in tendon tissue engineering strategy

Tendon injuries often result in significant pain and disability and impose severe clinical and financial burdens on our society. Despite considerable achievements in the field of regenerative medicine in the past several decades, effective treatments remain a challenge due to the limited natural healing capacity of tendons caused by poor cell density and vascularization. The development of tissue engineering has provided more promising results in regenerating tendon-like tissues with compositional, structural and functional characteristics comparable to those of native tendon tissues. Tissue engineering is the discipline of regenerative medicine that aims to restore the physiological functions of tissues by using a combination of cells and materials, as well as suitable biochemical and physicochemical factors. In this review, following a discussion of tendon structure, injury and healing, we aim to elucidate the current strategies (biomaterials, scaffold fabrication techniques, cells, biological adjuncts, mechanical loading and bioreactors, and the role of macrophage polarization in tendon regeneration), challenges and future directions in the field of tendon tissue engineering.

Micropattern Silk Fibroin Film Facilitates Tendon Repair In Vivo and Promotes Tenogenic Differentiation of Tendon Stem/Progenitor Cells through the α2β1/FAK/PI3K/AKT Signaling Pathway In Vitro

Background

Tendon injuries are common clinical disorders. Due to the limited regeneration ability of tendons, tissue engineering technology is often used as an adjuvant treatment. This study explored the molecular pathways underlying micropattern SF film-regulated TSPC propensity and their repairing effects to highlight the application value of micropattern SF films.

Methods

First, we characterized the physical properties of the micropattern SF films and explored their repairing effects on the injured tendons in vivo. Then, we seeded TSPCs on SF films in vitro and determined the micropattern SF film-induced gene expression and activation of signaling pathways in TSPCs through high-throughput RNA sequencing and proteomics assays.

Results

The results of in vivo studies suggested that micropattern SF films can promote remodeling of the injured tendon. In addition, immunohistochemistry (IHC) results showed that tendon marker genes were significantly increased in the micropattern SF film repair group. Transcriptomic and proteomic analyses demonstrated that micropattern SF film-induced genes and proteins in TSPCs were mainly enriched in the focal adhesion kinase (FAK)/actin and phosphoinositide 3-kinase (PI3K)/AKT pathways. Western blot analysis showed that the expression of integrins α2β1, tenascin-C (TNC), and tenomodulin (TNMD) and the phosphorylation of AKT were significantly increased in the micropattern SF film group, which could be abrogated by applying PI3K/AKT inhibitors.

Conclusion

Micropattern SF films modified by water annealing can promote remodeling of the injured tendon in vivo and regulate the tendon differentiation of TSPCs through the α2β1/FAK/PI3K/AKT signaling pathway in vitro. Therefore, they have great medical value in tendon repair.

Risk factors associated with tendon adhesions after hand tendon repair

Background

Tendon adhesions after hand tendon repair are one of the most difficult complications of hand surgery and can cause severe disability. This study aimed to assess the risk factors associated with tendon adhesions after hand tendon repair to provide a theoretical foundation for the early prevention of tendon adhesions in patients with tendon injuries. Moreover, this study intends to increase doctors' awareness of the issue and serves as a reference for developing new prevention and treatment strategies.

Methods

We retrospectively analyzed 1,031 hand trauma cases that underwent repair after finger tendon injury in our department between June 2009 and June 2019. Tendon adhesions, tendon injury zones, and other relevant information were collected, summarized, and analyzed. The significance of data was determined using a t-test or Pearson's chi-square test, and odds ratios (OR) were calculated using logistic regression tests to describe factors associated with post-tendon repair adhesions.

Results

A total of 1,031 patients were enrolled in this study. There were 817 males and 214 females with an average age of 34.98 (2-82) years. The injured side included 530 left and 501 right hands. Postoperative finger tendon adhesions occurred in 118 cases (11.45%), including 98 males and 20 females, 57 left and 61 right hands. The risk factors for the total sample in the descending order were degloving injury, no functional exercise, zone II flexor tendon injury, time from injury to surgery >12 h, combined vascular injury, and multiple tendon injuries. The flexor tendon sample shared the same risk factors as the total sample. Risk factors for the extensor tendon sample were degloving injury, no functional exercise.

Conclusions

Clinicians should pay close attention to patients with tendon trauma in hand having the following risk factors: degloving injury, zone II flexor tendon injury, lack of functional exercise, time from injury to surgery >12 h, combined vascular injury, and multiple tendon injuries. Due to the high risk of post-repair adhesions in patients with the conditions mentioned above, individualized treatment measures should be designed for the risk factors, and postoperative functional exercise of the hand is required.

Investigation of the relationship between tensile viscoelasticity and unloaded ultrasound shear wave measurements in ex vivo tendon

Mechanical properties of biological tissues are of key importance for proper function and in situ methods for mechanical characterization are sought after in the context of both medical diagnosis as well as understanding of pathophysiological processes. Shear wave elastography (SWE) and accompanying physical modelling methods provide valid estimates of stiffness in quasi-linear viscoelastic, isotropic tissue but suffer from limitations in assessing non-linear viscoelastic or anisotropic material, such as tendon. Indeed, mathematical modelling predicts the longitudinal shear wave velocity to be unaffected by the tensile but rather the shear viscoelasticity. Here, we employ a heuristic experimental testing approach to the problem to assess the most important potential confounders, namely tendon mass density and diameter, and to investigate associations between tendon tensile viscoelasticity with shear wave descriptors. Small oscillatory testing of animal flexor tendons at two baseline stress levels over a large frequency range comprehensively characterized tensile viscoelastic behavior. A broad set of shear wave descriptors was retrieved on the unloaded tendon based on high frame-rate plane wave ultrasound after applying an acoustic deformation impulse. Tensile modulus and strain energy dissipation increased logarithmically and linearly, respectively, with the frequency of the applied strain. Shear wave descriptors were mostly unaffected by tendon diameter but were highly sensitive to tendon mass density. Shear wave group and phase velocity showed no association with tensile elasticity or strain rate-stiffening but did show an association with tensile strain energy dissipation. The longitudinal shear wave velocity may not characterize tensile elasticity but rather tensile viscous properties of transversely isotropic collagenous tissues.

Advanced Nanofiber-Based Scaffolds for Achilles Tendon Regenerative Engineering

The Achilles tendon (AT) is responsible for running, jumping, and standing. The AT injuries are very common in the population. In the adult population (21–60 years), the incidence of AT injuries is approximately 2.35 per 1,000 people. It negatively impacts people’s quality of life and increases the medical burden. Due to its low cellularity and vascular deficiency, AT has a poor healing ability. Therefore, AT injury healing has attracted a lot of attention from researchers. Current AT injury treatment options cannot effectively restore the mechanical structure and function of AT, which promotes the development of AT regenerative tissue engineering. Various nanofiber-based scaffolds are currently being explored due to their structural similarity to natural tendon and their ability to promote tissue regeneration. This review discusses current methods of AT regeneration, recent advances in the fabrication and enhancement of nanofiber-based scaffolds, and the development and use of multiscale nanofiber-based scaffolds for AT regeneration.

Sehnenpathologien im Bereich des Fußes – Inflammation versus Degeneration: wo liegen die Unterschiede?

Die Ursachen für Tendopathien bzw. Tenosynovialitiden sind mannigfaltig. Stoffwechsel und Genaktivität der Bindegewebszellen im Sehnengewebe reagieren sehr empfindlich auf mechanische Beanspruchung und aber auch entzündliche Reize im Hinblick auf die Integrität der extrazellulären Matrix. Hierin unterscheiden sich entzündliche und degenerative Sehnenerkrankungen nicht. Die verbesserten medikamentösen Möglichkeiten einer nachhaltigen Entzündungskontrolle erlaubt es dem Rheumaorthopäden auch häufiger sich an den fusschirurgischen Prinzipien eines Gelenkerhaltes orientieren zu können. Weiterhin erfordert jedoch die mit chronisch degenerativen Prozeßen nicht vergleichbare Entzündungsintensität einen ausreichenden Erfahrungsschatz im peri- und intraoperativen Umganges mit den RA, SpA und PsA Patienten.

Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice

Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.

Is the human sclera a tendon-like tissue? A structural and functional comparison

Collagen rich connective tissues fulfill a variety of important functions throughout the human body, most of which having to resist mechanical challenges. This review aims to compare structural and functional aspects of tendons and sclera, two tissues with distinct location and function, but with striking similarities regarding their cellular content, their extracellular matrix and their low degree of vascularization. The description of these similarities meant to provide potential novel insight for both the fields of orthopedic research and ophthalmology.