Peri-graft bone mass and connectivity as predictors for the strength of tendon-to-bone attachment after anterior cruciate ligament reconstruction

3D-printed porous titanium suture anchor: a rabbit lateral femoral condyle model

BACKGROUND

The inclusion of a connecting path in a porous implant can promote nutrient diffusion to cells and enhance bone ingrowth. Consequently, this study aimed to evaluate the biomechanical, radiographic, and histopathological performance of a novel 3D-printed porous suture anchor in a rabbit femur model.

METHODS

Three test groups were formed based on the type of suture anchor (SA): Commercial SA (CSA, Group A, n = 20), custom solid SA (CSSA, Group B, n = 20), and custom porous SA (CPSA, Group C, n = 20). The SAs were implanted in the lateral femoral condyle of the right leg in each rabbit. The rabbits (New Zealand white rabbits, male, mean body weight of 2.8 ± 0.5 kg, age 8 months) underwent identical treatment and were randomized into experimental and control groups via computer-generated randomization. Five rabbits (10 femoral condyles) were euthanized at 0, 4, 8, and 12 weeks post-implantation for micro-CT, histological analysis, and biomechanical testing.

RESULTS

At 12 weeks, the CPSA showed a higher BV/TV (median 0.7301, IQR 0.7276-0.7315) than the CSSA and CSA. The histological analysis showed mineralized osteocytes near the SA. At 4 weeks, new bone was observed around the CPSA and had penetrated its porous structure. By 12 weeks, there was no significant difference in ultimate failure load between the CSA and CPSA.

CONCLUSIONS

We demonstrated that the innovative 3D-printed porous suture anchor exhibited comparable pullout strength to conventional threaded suture anchors at the 12-week postoperative time-point period. Furthermore, our porous anchor design enhanced new bone formation and facilitated bone growth into the implant structure, resulting in improved biomechanical stability.

Mechanical properties, corrosion behavior, and in vitro and in vivo biocompatibility of hot-extruded Zn-5RE (RE = Y, Ho, and Er) alloys for biodegradable bone-fixation applications

Biodegradable Zn alloys have significant application potential for hard-tissue implantation devices owing to their suitable degradation behavior and favorable biocompatibility. Nonetheless, pure Zn and its alloys in the as-cast state are mechanically instable and low in strength, which restricts their clinical applicability. Here, we report the exceptional mechanical, corrosion, and biocompatibility properties of hot-extruded Zn-5RE (wt.%, RE = rare earth of Y; or Ho; or Er) alloys intended for use in biodegradable bone substitutes. The microstructural characteristics, mechanical behavior, corrosion resistance, cytocompatibility, osteogenic differentiation, and capacity of osteogenesis in vivo of the Zn-5RE alloys are comparatively investigated. The Zn-5Y alloy demonstrates the best tensile properties, encompassing a 138 MPa tensile yield strength, a 302 MPa ultimate tensile strength, and 63% elongation, while the Zn-5Ho alloy shows the highest compression yield strength of 260 MPa and Vickers hardness of 104 HV. The Zn-5Er alloy shows a 126 MPa tensile yield strength, a 279 MPa ultimate tensile strength, 52% elongation, a 196 MPa compression yield strength, and a 101 HV Vickers microhardness. Further, the Zn-5Er alloy has a 130 µm per year corrosion rate in electrochemical tests and a 26 µm per year degradation rate in immersion tests, which is the lowest among the tested alloys. It also has the best in vitro osteogenic differentiation ability and capacity for osteogenesis and osteointegration in vivo after implantation in rat femurs among the Zn-5RE alloys, indicating promising potential in load-bearing biodegradable internal bone-fixation applications. STATEMENT OF SIGNIFICANCE: This work reports the exceptional mechanical, corrosion, and biocompatibility properties of hot-extruded (HE) Zn-5 wt.%-rare earth (Zn-5RE) alloys using single yttrium (Y), holmium (Ho), and erbium (Er) alloying for biodegradable bone-implant applications. Our findings demonstrate that the HE Zn-5Er alloy showed σuts of 279 MPa, tensile yield strength of 126 MPa, elongation of 51.6%, compression yield strength of 196 MPa, and microhardness of 101.2 HV. Further, HE Zn-5Er showed the lowest electrochemical corrosion rate of 130 µm/y and lowest degradation rate of 26 µm/y, and the highest in vitro osteogenic differentiation ability, in vivo osteogenesis, and osteointegration ability after implantation in rat femurs among the Zn-5RE alloys, indicating promising potential in load-bearing biodegradable internal bone-fixation applications.

A biodegradable Zn-5Gd alloy with biomechanical compatibility, cytocompatibility, antibacterial ability, and in vitro and in vivo osteogenesis for orthopedic applications

Zinc (Zn) and some of its alloys are recognized as promising biodegradable implant materials due to their acceptable biocompatibility, facile processability, and moderate degradation rate. Nevertheless, the limited mechanical properties and stability of as-cast Zn alloys hinder their clinical application. In this work, hot-rolled (HR) and hot-extruded (HE) Zn-5 wt.% gadolinium (Zn-5Gd) samples were prepared by casting and respectively combining with hot rolling and hot extrusion for bone-implant applications. Their microstructure evolution, mechanical properties, corrosion behavior, cytotoxicity, antibacterial ability, and in vitro and in vivo osteogenesis were systematically evaluated. The HR and HE Zn-5Gd exhibited significantly improved mechanical properties compared with those of their pure Zn counterparts and the HR Zn-5Gd showed a unique combination of tensile properties with an ultimate tensile strength of ∼311.6 MPa, yield strength of ∼236.5 MPa, and elongation of ∼40.6%, all of which are greater than the mechanical properties required for bone-implant materials. The HR and HE Zn-5Gd showed higher corrosion resistance than their pure Zn counterpart in Hanks' solution and the HE Zn-5Gd had the lowest corrosion rate of 155 µm/y measured by electrochemical corrosion and degradation rate of 26.9 µm/y measured by immersion testing. The HR and HE Zn-5Gd showed high cytocompatibility toward MC3T3-E1 and MG-63 cells, high antibacterial effects against S. aureus, and better in vitro osteogenic activity than their pure Zn counterparts. Furthermore, the HE Zn-5Gd exhibited better in vivo biocompatibility, osteogenesis, and osteointegration ability than pure Zn and pure Ti. STATEMENT OF SIGNIFICANCE: This work reports the mechanical properties, corrosion behaviors, cytocompatibility, antibacterial ability, in vitro and in vivo osteogenesis of biodegradable Zn-Gd alloy for bone-implant applications. Our findings demonstrate that the hot-rolled (HR) Zn-5Gd showed a unique combination of tensile properties with an ultimate tensile strength of ∼311.6 MPa, yield strength of ∼236.5 MPa, and elongation of ∼40.6%. The HR and HE Zn-5Gd showed higher corrosion resistance than their pure Zn counterpart in Hanks' solution. The HR and HE Zn-5Gd showed high cytocompatibility toward MC3T3-E1 and MG-63 cells, good antibacterial effects against S. aureus, and better in vitro osteogenic activity. Furthermore, the HE Zn-5Gd exhibited better in vivo biocompatibility, osteogenesis, and osteointegration ability than pure Zn and pure Ti.

Inhibition of CX3CL1 by treadmill training prevents osteoclast-induced fibrocartilage complex resorption during TBI healing

Introduction

The healing of tendon-bone injuries is very difficult, often resulting in poor biomechanical performance and unsatisfactory functional recovery. The tendon-bone insertion has a complex four distinct layers structure, and previous studies have often focused on promoting the regeneration of the fibrocartilage layer, neglecting the role of its bone end repair in tendon-bone healing. This study focuses on the role of treadmill training in promoting bone regeneration at the tendon-bone insertion and its related mechanisms.

Methods

After establishing the tendon-bone insertion injury model, the effect of treadmill training on tendon-bone healing was verified by Micro CT and HE staining; then the effect of CX3CL1 on osteoclast differentiation was verified by TRAP staining and cell culture; and finally the functional recovery of the mice was verified by biomechanical testing and behavioral test.

Results

Treadmill training suppresses the secretion of CX3CL1 and inhibits the differentiation of local osteoclasts after tendon-bone injury, ultimately reducing osteolysis and promoting tendon bone healing.

Discussion

Our research has found the interaction between treadmill training and the CX3CL1-C3CR1 axis, providing a certain theoretical basis for rehabilitation training.

The influence of ruptured scar pattern of human anterior cruciate ligament remnant tissue on tendon-bone healing in vivo

The purpose of this study was to determine whether the transplantation of human cells from a non-reattached injured anterior cruciate ligament (ACL) remnant could enhance tendon-bone healing. Human ACL remnant tissue was classified into two groups based on the morphologic pattern as per Crain's classification: (1) non-reattachment group (Crain Ⅳ) and (2) reattachment group (Crain Ⅰ-Ⅲ). Seventy-five 10-week-old immunodeficient rats underwent ACL reconstruction followed by intracapsular administration of one of the following: (1) ACL-derived cells from the non-reattached remnant (non-reattachment group) (n = 5), (2) ACL-derived cells from the reattached tissue (reattachment group) (n = 5), or (3) phosphate-buffered saline (PBS) only (PBS group) (n = 5). Histological (Weeks 2, 4, and 8), immunohistochemical (Week 2), radiographic (Weeks 0, 2, 4, and 8), and biomechanical (Week 8) assessments were performed. Histological evaluation showed high and early healing, induction of endochondral ossification-like integration, and mature bone ingrowth at Week 4 in the non-reattachment group. Microcomputed tomography at Week 4 showed that the tibial bone tunnels in the non-reattachment group were significantly reduced compared to those in the reattachment and PBS groups. Moreover, biomechanical testing showed that ultimate load-to-failure in the non-reattachment group tended to be larger than that in the reattachment group, though not statistically significant. The enhanced healing potential in the non-reattachment group was explained by the increase in intrinsic angiogenesis/osteogenesis. In the subacute phase, the ACL-derived cells with the non-reattached morphologic pattern showed greater and earlier tendon bone healing compared with the cells obtained from the reattached morphologic pattern.

Doxycycline Promotes Graft Healing and Attenuates Posttraumatic Osteoarthritis After Anterior Cruciate Ligament Reconstruction in a Rat Model

BACKGROUND

Doxycycline (Doxy) has been shown to facilitate tendon healing by reducing on-site matrix metalloproteinase (MMP) activity, but its effect on graft healing after anterior cruciate ligament reconstruction (ACLR) has not been investigated, and the therapeutic effect of Doxy in preventing ACLR-induced posttraumatic osteoarthritis (PTOA) is unclear.

HYPOTHESIS

Doxy promotes graft healing and alleviates the progression of PTOA after ACLR.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sprague Dawley rats (n = 74; age, 12-13 weeks; male) that underwent ACLR were divided into untreated control and Doxy treatment (50 mg/kg/d orally until sacrifice) groups. At 2 and 6 weeks after surgery, graft healing was assessed by biomechanical testing, histology, immunohistochemical staining, and micro-computed tomography (μCT). The progression of PTOA was evaluated at 6 weeks by histology, the Mankin score, and immunofluorescence staining of the tibial plateau, and osteophyte formation was evaluated by μCT. Hindlimb weight distribution was evaluated at 6 weeks, and gait patterns were evaluated at 2 and 6 weeks. Intra-articular MMP activity was evaluated at 6 weeks in vivo using an MMP-activatable near-infrared fluorescent probe.

RESULTS

Graft healing was enhanced by Doxy treatment, and the ultimate failure load (P = .002) and stiffness of the graft (P = .007) were significantly higher in the Doxy group at week 2. Bone mineral density and bone volume/total volume for both the tibial and the femoral tunnels at week 6 in the Doxy group were significantly higher compared with in the control group (P < .05). The overall graft healing scores were significantly higher in the Doxy group. Doxy treatment enhanced graft integration, intratunnel graft integrity, and collagen birefringence; more collagen types 1 and 10 and less MMP-13 were found at the graft-bone interface. At week 6, the Doxy group had a lower modified Mankin score (P = .033) and showed fewer MMP 13-positive chondrocytes at the articular cartilage surface (P = .002), indicating moderate joint cartilage damage. μCT revealed less osteophyte formation, and gait analysis revealed more symmetric weightbearing and gait patterns, after Doxy treatment at week 6 (P < .05). In vivo imaging with the near-infrared fluorescent probe identified significantly lower intra-articular MMP activity in the Doxy group at week 6 (P = .016).

CONCLUSION

The oral administration of Doxy was able to synchronously promote graft healing and attenuate PTOA in an ACLR rat model.

CLINICAL RELEVANCE

Our results indicated that Doxy, a widely used drug, is potentially beneficial to patients after ACLR.

Biodegradable Zn-Dy binary alloys with high strength, ductility, cytocompatibility, and antibacterial ability for bone-implant applications

The unique combination of biodegradability, biocompatibility, and functionality of zinc (Zn)-based alloys makes them highly desirable for a wide range of medical applications. However, a long-standing problem associated with this family of biodegradable alloys in the as-cast state is their limited mechanical strength and slow degradation rate. Here we report the development of Zn-xDy (x = 1, 3, and 5 wt.%) alloys with high strength, ductility, cytocompatibility, antibacterial ability, and appropriate degradation rate for biodegradable bone-implant applications. Our results indicate that the mechanical properties of Zn-xDy alloys were effectively improved with increasing Dy addition and hot-rolling due to the second-phase strengthening. The hot-rolled (HR) Zn-3Dy alloy showed the best combined mechanical performance with an ultimate tensile strength of 270.5 MPa, a yield strength of 214.8 MPa, an elongation of 55.1%, and Brinell hardness of 75.9 HB. The corrosion and degradation rates of HR Zn-xDy alloys in Hanks' solution gradually increased with increasing Dy addition due to the intensification of galvanic corrosion. The HR Zn-3Dy alloy showed high antibacterial ability against S. aureus and cytocompatibility toward MC3T3-E1 cells among all the HR alloys. Overall, the HR Zn-3Dy alloy can be considered a promising biodegradable material for bone implants. STATEMENT OF SIGNIFICANCE: This work reports on Zn-xDy (x = 1, 3, and 5%) alloys fabricated by Dy alloying followed by hot-rolling for biodegradable bone-implant applications. Our findings demonstrate that the hot-rolled (HR) Zn-3Dy alloy showed the best combined mechanical performance with an ultimate tensile strength of 270.5 MPa, a yield strength of 214.8 MPa, an elongation of 55.1%, and Brinell hardness of 75.9 HB. The corrosion and degradation rates of HR Zn-xDy alloys in Hanks' solution gradually increased with increasing Dy addition due to the intensification of galvanic corrosion. Furthermore, the HR Zn-3Dy alloy showed greater antibacterial ability against S. aureus and the best cytocompatibility toward MC3T3-E1 cells among all the HR alloys.

Synergistic Effect of Reverse Drilling and Bone Dust on Femoral Tendon-Bone Healing After Anterior Cruciate Ligament Reconstruction in a Rabbit Model

BACKGROUND

Anterior cruciate ligament (ACL) injuries and bone tunnel enlargement (BTE) after ACL reconstruction (ACLR) remain frequent issues. Bone dust (BD) produced by tunnel preparation with osteogenic ability and reverse drilling (RD), an easy compaction technique, make it accessible to enhance tendon-bone healing in the clinic.

HYPOTHESIS

RD and BD synergistically promote tendon-bone healing by improving peritunnel bone and preventing BTE in femurs.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 96 New Zealand White rabbits underwent ACLR. The semitendinosus tendon was freed before medial parapatellar arthrotomy. After the native ACL was transected, bone tunnels were prepared through the footprint of the native ACL. All animals were randomly assigned to 1 of 4 groups according to different tunnel preparation methods: group 1 (irrigation after extraction drilling [ED]; control group), group 2 (irrigation after RD), group 3 (no irrigation after ED), and group 4 (no irrigation after RD). BD was harvested by irrigating tunnels and was characterized by morphology and size. The specimens underwent microarchitectural, histological, and biomechanical evaluations at 4, 8, and 12 weeks postoperatively.

RESULTS

Micro-computed tomography demonstrated more peritunnel bone and less BTE in the femurs of group 4 compared with the other groups. Histologically, BD possessed osteogenic activity in bone tunnels postoperatively. Meanwhile, group 4 regenerated a higher amount of the tendon-bone interface and more peritunnel bone than group 1. Biomechanically, group 4 showed higher failure loads and stiffness than group 1. However, peritunnel bone loss, active osteoclasts, and significant BTE were found in the femurs of group 1 and group 3 at 12 weeks postoperatively, while no strong correlation was found between BTE and inflammatory cytokines. Scanning electron microscopy and particle size analysis suggested that BD produced by ED and RD had no difference in size.

CONCLUSION

Tendon-bone healing was facilitated by the synergistic effect of RD and BD in femurs.

CLINICAL RELEVANCE

This study provides a more accessible and effective surgical strategy to promote tendon-bone healing after ACLR by increasing peritunnel bone and preventing BTE in femurs.

Exosomes secreted by hypoxia-stimulated bone-marrow mesenchymal stem cells promote grafted tendon-bone tunnel healing in rat anterior cruciate ligament reconstruction model

Background

After anterior cruciate ligament (ACL) reconstruction in clinic, firm and rapid integration of the grafted tendon into the bone tunnel remains a challenge. Exosomes from hypoxia-treated stem cells are beneficial for promoting angiogenesis and then coupling with osteogenesis. Therefore, exosomes from hypoxia-cultured bone-marrow mesenchymal stem cells (Hypo-Exos) may be a cell-free therapy for enhancing graft-bone incorporation after ACL reconstruction.

Methods

Exosomes from normoxia-cultured bone-marrow mesenchymal stem cells (Norm-Exos) or Hypo-Exos were respectively cultured with human umbilical vein endothelial cells (HUVECs) for in-vitro evaluating their functions in HUVECs proliferation, migration, and tube formation. A total of 87 rats with single-bundle ACL reconstructions in the right knee were randomly allocated into 3 different treatments: phosphate-buffered saline (PBS) with the adhesive hydrogel injection as control (Ctrl), Norm-Exos with the adhesive hydrogel injection (Norm-Exos), and Hypo-Exos with the adhesive hydrogel injection (Hypo-Exos). At postoperative weeks 2, 4, or 8, the ACL graft-bone integrations were evaluated.

Results

Hypo-Exos was a better stimulator for in-vitro HUVECs proliferation, migration, and tube formation compared to PBS or Norm-Exos. Hypo-Exos within the adhesive hydrogel could be sustained-released at least 14 days around the peri-graft site. Radiologically, at week 4 or 8, femoral or tibial bone tunnel areas (BTA), as well as bone volume/total volume ratio (BV/TV) of the femoral or tibial peri-graft bone in the Hypo-Exos group, improved significantly better than these parameters of the Ctrl and Norm-Exos groups (P<0.05 for all). Histologically, the grafted tendon-bone interface in the Hypo-Exos group showed significantly higher histologic scores at week 4 or 8 as compared with the other groups (P<0.05 for all). Immunofluorescent staining verified that type H vessels were more abundant in the Hypo-Exos group when compared to the Ctrl or Norm-Exos group at week 2. Biomechanically, the Hypo-Exos group exhibited a significantly heightened failure load compared with the Ctrl and Norm-Exos groups (P<0.05 for all) at 8 weeks. Meanwhile, the stiffness in the Hypo-Exos group was the greatest among the three groups.

Conclusion

Peri-graft Hypo-Exos injection accelerates grafted tendon-bone tunnel integration after ACL reconstruction by improving peri-graft bone microarchitecture.

Local Administration of Metformin Improves Bone Microarchitecture and Biomechanical Properties During Ruptured Canine Achilles Tendon-Calcaneus Interface Healing

BACKGROUND

Tendon-bone interface (TBI) healing is a clinical dilemma that is closely relevant to new bone formation and remodeling at the repair site. Previous studies showed that metformin is an osteogenic inducer for stem cells in vitro and capable of stimulating bone regeneration in vivo.

HYPOTHESIS

Metformin would be effective for promoting TBI healing by enhancing new bone formation and remodeling.

STUDY DESIGN

Controlled laboratory study.

METHODS

Canine bone marrow stem cells (BMSCs) were cultured with various concentrations of metformin (0, 10, 50, 100, 200 μM). The effect of metformin on the osteogenic differentiation of canine BMSCs was evaluated via alizarin red staining and osteogenic gene expression. Eighteen mature beagles were included in a bilateral Achilles tendon-calcaneus (ATC) interface injury model. The right interface was reattached via surgical repair only, while the left was surgically reattached after implanting a fibrin glue containing metformin. At postoperative week 4 or 8, the healing quality of the wounded ATC interfaces was evaluated.

RESULTS

In vitro experiments determined that metformin was an osteogenic inducer for canine BMSCs. In vivo experiments showed that the metformin-treated ATC interfaces were repaired with significantly greater failure load and stiffness than was the no-metformin control site (P < .05 for all). Micro-computed tomography analysis showed that the metformin-treated specimens presented significantly higher bone volume/total volume and trabecular thickness than did the no-metformin control specimens (P < .05 for all), as confirmed via hematoxylin and eosin staining. Immunohistochemical staining showed that significantly more osteocalcin-positive cells were located at the newly formed bones treated with metformin than at the no-metformin control site at week 4 (P < .05). Masson trichrome staining showed that significantly more oriented collagen fibers anchored into the newly formed bone of the metformin-treated site than the no-metformin control site (P < .05).

CONCLUSION

Metformin induced the osteogenesis of canine BMSCs in vitro, and local administration of metformin provided an improvement of bone microarchitecture at the calcaneus as well as an increase in the tensile properties of the repaired ATC interfaces in canines.

CLINICAL RELEVANCE

Findings of the study indicate that local administration of metformin may be an effective strategy for TBI healing in clinic.

Autologous Dedifferentiated Osteogenic Bone Marrow Mesenchymal Stem Cells Promote Bone Formation in a Rabbit Model of Anterior Cruciate Ligament Reconstruction versus Bone Marrow Mesenchymal Stem Cells

PURPOSE

This study aimed to verify whether transplantation of dedifferentiated osteogenic bone marrow mesenchymal stem cells (De-BMSCs) at the tendon-bone interface could result in more bone formation than BMSC transplantation in anterior cruciate ligament (ACL) reconstruction.

METHODS

BMSCs from femur and tibia of New Zealand White rabbit were subjected to osteogenic induction and then cultured in osteogenic factor-free medium; the obtained cell population was termed De-BMSCs. Bilateral ACL reconstruction was performed in 48 adult rabbits. Three groups were established: control group with alginate gel injection, BMSCs group with the BMSCs injection, and De-BMSCs group with the De-BMSCs injection. At week 4 and 12 postoperatively, tendon-bone healing by histologic staining, micro-computed tomography examination, and biomechanical test were evaluated.

RESULTS

The expression of α1 chain of type I collagen, osteocalcin, and osteopontin at the tendon-bone interface in the De-BMSCs group was greater than in the control or BMSCs group. The bone volume/total volume by micro-computed tomography scan was significantly greater in the De-BMSCs group than that in the control group (P = .013) or BMSCs group (P = .045) at 4 weeks, and greater than that in the control group (P = .014) or BMSCs group (P = .017) at 12 weeks. The tunnel area was significantly smaller in the De-BMSCs group than in the control group (P = .013) or BMSCs group (P = .044) at 12 weeks. The failure load and stiffness in De-BMSCs group were both significantly enhanced at 4 and 12 weeks than control group or De-BMSCs group.

CONCLUSIONS

De-BMSCs transplantation can promote bone formation at the tendon-bone interface better than BMSCs transplantation in ACL reconstruction and increase the early biomechanical strength of the reconstructed ACL CLINICAL RELEVANCE: De-BMSCs transplantation is a potential choice for enhancing early bone formation in the tunnel in ACL reconstruction.

A biodegradable in situ Zn-Mg2Ge composite for bone-implant applications

Zinc (Zn)-based composites have received extensive attention as promising biodegradable materials due to their unique combination of moderate biodegradability, biocompatibility, and functionality. Nevertheless, the low mechanical strength of as-cast Zn-based composites impedes their practical clinical application. Here we reported the mechanical properties, corrosion behavior, wear properties, and cytotoxicity of in situ synthesized biodegradable Zn-xMg₂Ge (x = 1, 3, and 5 wt.%) composites for bone-implant applications. The mechanical properties of Zn-xMg₂Ge composites were effectively improved by alloying and hot-rolling due to particle reinforcement of the Mg₂Ge intermetallic phase and dynamic recrystallization. The hot-rolled (HR) Zn-3Mg₂Ge composite exhibited the best mechanical properties, including a yield strength of 162.3 MPa, an ultimate tensile strength of 264.3 MPa, an elongation of 10.9%, and a Brinell hardness of 83.9 HB. With an increase in Mg₂Ge content, the corrosion and degradation rates of the HR Zn-xMg₂Ge composites gradually increased, while their wear rate decreased and then increased in Hanks' solution. The diluted extract (12.5% concentration) of the HR Zn-3Mg₂Ge composite showed the highest cell viability compared to the other HR composites and their as-cast pure Zn counterparts. Overall, the HR Zn-3Mg₂Ge composite can be considered a promising biodegradable Zn-based composite for bone-implant applications. STATEMENT OF SIGNIFICANCE: This paper reports the mechanical properties, corrosion behavior, wear properties, and cytotoxicity of in situ synthesized biodegradable Zn-xMg₂Ge (x = 1, 3, and 5 wt.%) composites for bone-implant applications. Our findings demonstrated that the mechanical properties of Zn-xMg₂Ge composites were effectively improved by alloying and hot-rolling due to Mg₂Ge particle reinforcement and dynamic recrystallization. The hot-rolled Zn-3Mg₂Ge composite showed superior cytocompatibility, satisfying corrosion and degradation rates, and the best mechanical properties including a yield strength of 162.3 MPa, an ultimate tensile strength of 264.3 MPa, and an elongation of 10.9%.

3D-Printed Double-Helical Biodegradable Iron Suture Anchor: A Rabbit Rotator Cuff Tear Model

Suture anchors are extensively used in rotator cuff tear surgery. With the advancement of three-dimensional printing technology, biodegradable metal has been developed for orthopedic applications. This study adopted three-dimensional-printed biodegradable Fe suture anchors with double-helical threads and commercialized non-vented screw-type Ti suture anchors with a tapered tip in the experimental and control groups, respectively. The in vitro study showed that the Fe and Ti suture anchors exhibited a similar ultimate failure load in 20-pound-per-cubic-foot polyurethane foam blocks and rabbit bone. In static immersion tests, the corrosion rate of Fe suture anchors was 0.049 ± 0.002 mm/year. The in vivo study was performed on New Zealand white rabbits and SAs were employed to reattach the ruptured supraspinatus tendon. The in vivo ultimate failure load of the Fe suture anchors was superior to that of the Ti suture anchors at 6 weeks. Micro-computed tomography showed that the bone volume fraction and bone surface density in the Fe suture anchors group 2 and 6 weeks after surgery were superior, and the histology confirmed that the increased bone volume around the anchor was attributable to mineralized osteocytes. The three-dimensional-printed Fe suture anchors outperformed the currently used Ti suture anchors.

Analysis of hemodynamic changes after medial patellofemoral ligament reconstruction

The resumption of blood flow is an important factor in the remodeling process of the graft. The purpose of this study is to evaluate hemodynamic changes after medial patellofemoral ligament (MPFL) reconstruction using magnetic resonance angiography (MRA) as the evaluation of graft remodeling. Eleven knees that underwent anatomical MPFL reconstruction with the semitendinosus tendon were studied. We evaluated the blood flow around the bone tunnel wall in the arterial phase using MRA approximate 3 months and 1 year after surgery. Clinical and radiological evaluations were also analyzed. MRA showed an inflow vessel into the bone tunnel wall from the medial superior genicular artery on the femoral side, and from the articular branch of the descending genicular artery and the medial superior genicular artery on the patellar side. This contrast effect was decreased at 12 months after surgery in all cases. The clinical scores improved from baseline one year postoperatively. We revealed the blood flow to the bone tunnel wall after anatomical MPFL reconstruction is detected by MRA. The blood flow started within 2 or 3 months postoperatively and was sustained for 12 months. This study supported remodeling of the graft continues 3 months after surgery when the conformity of the patellofemoral joint stabilizes.

Nanog/NFATc1/Osterix signaling pathway-mediated promotion of bone formation at the tendon-bone interface after ACL reconstruction with De-BMSCs transplantation

Background

Bone formation plays an important role in early tendon–bone healing after anterior cruciate ligament reconstruction (ACLR). Dedifferentiated osteogenic bone marrow mesenchymal stem cells (De-BMSCs) have enhanced osteogenic potential. This study aimed to investigate the effect of De-BMSCs transplantation on the promotion of bone formation at the tendon–bone interface after ACLR and to further explore the molecular mechanism of the enhanced osteogenic potential of De-BMSCs.

Methods

BMSCs from the femurs and tibias of New Zealand white rabbits were subjected to osteogenic induction and then cultured in medium without osteogenic factors; the obtained cell population was termed De-BMSCs. De-BMSCs were induced to undergo osteo-, chondro- and adipo-differentiation in vitro to examine the characteristics of primitive stem cells. An ACLR model with a semitendinosus tendon was established in rabbits, and the animals were divided into a control group, BMSCs group, and De-BMSCs group. At 12 weeks after surgery, the rabbits in each group were sacrificed to evaluate tendon–bone healing by histologic staining, micro-computed tomography (micro-CT) examination, and biomechanical testing. During osteogenic differentiation of De-BMSCs, an siRNA targeting nuclear factor of activated T-cells 1 (NFATc1) was used to verify the molecular mechanism of the enhanced osteogenic potential of De-BMSCs.

Results

De-BMSCs exhibited some properties similar to BMSCs, including multiple differentiation potential and cell surface markers. Bone formation at the tendon–bone interface in the De-BMSCs group was significantly increased, and biomechanical strength was significantly improved. During the osteogenic differentiation of De-BMSCs, the expression of Nanog and NFATc1 was synergistically increased, which promoted the interaction of NFATc1 and Osterix, resulting in increased expression of osteoblast marker genes such as COL1A, OCN, and OPN.

Conclusions

De-BMSCs transplantation could promote bone formation at the tendon–bone interface after ACLR and improve the biomechanical strength of the reconstruction. The Nanog/NFATc1/Osterix signaling pathway mediated the enhanced osteogenic differentiation efficiency of De-BMSCs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02643-9.

Development of a high-strength Zn-Mn-Mg alloy for ligament reconstruction fixation

Although various biodegradable materials have been investigated for ligament reconstruction fixation in the past decades, only few of them possess a combination of high mechanical properties, appropriate degradation rate, good biocompatibility, and osteogenic effect, thus limiting their clinical applications. A high-strength Zn-0.8Mn-0.4Mg alloy (i.e., Zn08Mn04Mg) with yield strength of 317 MPa was developed to address this issue. The alloy showed good biocompatibility and promising osteogenic effect in vitro. The degradation effects of Zn08Mn04Mg interference screws on the interface between soft tissue and bone were investigated in anterior cruciate ligament (ACL) reconstruction in rabbits. Compared to Ti6Al4V, the Zn alloy screws significantly accelerated the formation of new bone and further induced partial tendon mineralization, which promoted tendon-bone integration. The newly developed screws are believed to facilitate early joint function recovery and rehabilitation training and also avoid screw breakage during insertion, thereby contributing to an extensive clinical prospect.

Revascularization to the bone tunnel wall after anterior cruciate ligament reconstruction may relate to the distance from the vessels

Purpose

We use magnetic resonance angiography to evaluate the difference of vascular ingrowth to the bone tunnel on the anterior and posterior walls quantitatively after anterior cruciate ligament reconstruction.

Materials and methods

One hundred patients underwent anterior cruciate ligament reconstruction with multi-stranded semitendinosus tendons. They were retrospectively divided into those who underwent magnetic resonance angiography 2, 3, 4 to 6, and ≥ 7 months after surgery. The mean signal-to-noise ratios of the bone tunnel walls in the femur and tibia from the digital data were measured and compared for the anterior and posterior walls.

Results

The signal-to-noise ratio of the posterior wall of the femoral bone tunnel was significantly higher than that of the anterior wall in each group. On the tibial side, the signal-to-noise ratio of the anterior wall was significantly higher than that of the posterior wall at ≥4 months after surgery.

Conclusions

This study showed that the blood flow after anterior cruciate ligament reconstruction to the femoral bone tunnel is maintained from the posterior wall, and is maintained to the tibial side from the anterior wall 4 months postoperatively. Revascularization to the bone tunnel wall after anterior cruciate ligament reconstruction may relate to the distance from the vessels.

[The killer turn in the posterior cruciate ligament reconstruction: mechanism and improvement]

OBJECTIVE

To summarize the research progress of killer turn in posterior cruciate ligament (PCL) reconstruction.

METHODS

The literature related to the killer turn in PCL reconstruction in recent years was searched and summarized.

RESULTS

The recent studies show that the killer turn is considered to be the most critical cause of graft relaxation after PCL reconstruction. In clinic, this effect can be reduced by changing the fixation mode of bone tunnel, changing the orientation of bone tunnel, squeezing screw fixation, retaining the remnant, and grinding the bone at the exit of bone tunnel. But there is still a lack of long-term follow-up.

CONCLUSION

There are still a lot of controversies on the improved strategies of the killer turn. More detailed basic researches focusing on biomechanics to further explore the mechanism of the reconstructed graft abrasion are needed.

Comparison of bone surface and trough fixation on bone-tendon healing in a rabbit patella-patellar tendon injury model

BACKGROUND

Many orthopedic surgical procedures involve reattachment between tendon and bone. Whether bone-tendon healing is better facilitated by tendon fixation on a bone surface or within a tunnel is unknown. The purpose of this study was to comparatively evaluate the effects of bone surface versus bone trough fixation on bone-tendon healing in a rabbit patella-patellar tendon (PPT) injury model.

METHODS

The rabbits underwent partial patellectomy with patellar-tendon fixation on the osteotomy surface (bone surface fixation, BSF group) (n = 28) or within a bone trough (bone trough fixation, BTF group) (n = 28). The PPT interface was evaluated by macroscopic observation, micro-computed tomography scanning, histological analysis, and biomechanical testing at postoperative week 8 or week 16.

RESULTS

Macroscopically, no signs of infection or osteoarthritis were observed, and the regenerated tissue bridging the residual patella and patellar tendon showed no obvious difference between the two groups. There were significantly higher bone mineral density ​and trabecular thickness ​in BSF group compared with BTF group at week 8 (p ​< ​0.05 for both). However, the bone volume fraction (BVF), bone mineral density and trabecular thickness in BSF group were significantly lower than those in BTF group (p ​< ​0.05 for all) at week 16. Histological analysis demonstrated that new bone was formed at the proximal patella and reattached to the residual patellar tendon through a regenerated fibrocartilage-like tissue in both groups. There was more formation and better remodelling of fibrocartilage-like tissue in BTF group than BSF group at week 8 and week 16 (p ​< ​0.05 for both). Biomechanical testing revealed that there was higher failure load and stiffness at the PPT interface in BTF group than BSF group at week 16 (p ​< ​0.05 for both).

CONCLUSIONS

These results suggested that raptured tendon fixation in a bone trough resulted in superior bone-tendon healing in comparison with tendon fixation on bone surface in a rabbit PPT injury model.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Although the structural and functional difference of knee joint between human and rabbit limit the results to be directly used in clinical, our research does offer a valuable reference for the improvement of reattachment between bone and tendon.

Anterior Cruciate Ligament Reconstruction in a Rabbit Model Using a Decellularized Allogenic Semitendinous Tendon Combined with Autologous Bone Marrow-Derived Mesenchymal Stem Cells

As a regular adoptable material for anterior cruciate ligament (ACL) reconstruction, free tendon allograft exhibits unsatisfactory outcomes, such as retarded ligamentization and tendon–bone integration. The application of bone marrow‐derived mesenchymal stem cells (BMSCs), as well as a decellularized free tendon allograft developed by our group, was proven to be effective in improving ACL reconstruction results. This study aimed to investigate the efficacy and feasibility of decellularized allogenic semitendinous tendon (ST) combined with autologous BMSCs used as a substitute to free tendon allograft in a rabbit model. This study finally shows that the decellularized allogenic ST combined with autologous BMSCs could significantly improve ACL reconstruction results compared with allograft. stem cells translational medicine2019;8:971&982

Effect of Low-Intensity Pulsed Ultrasound After Autologous Adipose-Derived Stromal Cell Transplantation for Bone-Tendon Healing in a Rabbit Model

BACKGROUND

Low-intensity pulsed ultrasound (LIPUS), as a safe biophysiotherapy, can enhance bone-tendon (B-T) healing in vivo and induce osteogenic or chondrogenic differentiation of mesenchymal stromal cells in vitro. This study aimed to determine whether LIPUS can improve the efficacy of transplanted mesenchymal stromal cells on B-T healing.

HYPOTHESIS

LIPUS can induce lineage-specific differentiation of transplanted adipose-derived stromal cells (ASCs) at the B-T healing site, thus resulting in superior healing quality when compared with LIPUS or ASCs alone.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 112 mature rabbits with partial patellectomy in the hindlimb were randomly assigned into mock sonication without ASCs (control), ultrasonication without ASCs (LIPUS), mock sonication with ASCs (ASCs), and ultrasonication with ASCs (LIPUS + ASCs). The treatment time of the mock sonication or ultrasonication was 20 minutes per day. Autologous ASCs were transplanted to the healing site by fibrin glue during the operation, and LIPUS was delivered daily starting at postoperative day 3 until euthanasia. The patella-patellar tendon junctions were postoperatively harvested at 8 and 16 weeks for radiological, histological, and mechanical evaluations. Additionally, 9 animals were used for ASC tracking with mCherry protein.

RESULTS

Radiologically, there was more new bone formation and remodeling in the LIPUS + ASCs group as compared with the other groups. Synchrotron radiation micro-computed tomography showed that the LIPUS + ASCs group significantly increased bone volume fraction, trabecular thickness, and trabecular number at the healing site as compared with the other groups at postoperative 8 weeks ( P < .05 for all). Histologically, immunohistochemical staining confirmed that the transplanted mCherry-ASCs can differentiate into osteoblasts and fibrochondrocytic-like cells. Meanwhile, as compared with the other groups, the LIPUS + ASCs group showed more formation and maturity of the fibrocartilage layer and new bone at postoperative weeks 8 and 16 ( P < .05 for all). Biomechanically, the LIPUS + ASCs group showed significantly higher failure load and stiffness versus the other groups at postoperative weeks 8 and 16 ( P < .05 for all).

CONCLUSION

Autologous ASC transplantation stimulated with LIPUS can result in superior B-T healing quality when compared with LIPUS or ASCs alone.

CLINICAL RELEVANCE

This study demonstrates the effectiveness of using ASC transplantation stimulated with LIPUS for B-T healing and provides a foundation for future clinical studies.

Evaluation of the theoretical optimal angle of the tibial tunnel in transtibial anatomic posterior cruciate ligament reconstruction by computed tomography

Background

“Killer turn” effect is a critical explanation for the recurrent posterior laxity following transtibial posterior cruciate ligament (PCL) reconstruction, which affected by the angle of the tibial tunnel. Meanwhile, excessive tunnel angle would have an adverse impact on the healing of tendon to bone. The purpose was to evaluate the theoretical optimal angle of the tibial tunnel in transtibial anatomic PCL reconstruction.

Methods

The measurements were performed on CT sagittal plane, including the thickness of cancellous bone (L1), the theoretical optimal angle of the tibial tunnel (TOA, which was measured between tibial plateau and the extension cord connecting the center of PCL insertion site with a point 5 mm superior from marrow cavity vertex), L2 - the distance from anterior tunnel aperture to anterior end of tibial plateau, L3 - the distance from anterior tunnel aperture to tibial tuberosity (lowest edge of patellar ligament attachment).

Results

The value of TOA and L3 were 35.4 ± 7.9 ° and 26.8 ± 11.4 mm, respectively. L1 and L2 were higher in males than females (L1, P = 0.002; L2, P = 0.046). Regarding age, L1, TOA, L2 and L3 were higher in the 46–60 years group than 31–45 years group (P = 0.02, P = 0.001, P = 0.038, P = 0.032, respectively). With regard to height, L1 was lower in group I - < 1.66 m than group II - 1.66 to 1.75 m and group III - > 1.75 m (I v II, P = 0.015, I v III, P = 0.026). L2 was also lower in group I than group II and group III (I v II, P = 0.026, I v III, P = 0.006). TOA and L3 showed no significant differences among sex and height groups (P > 0.05).

Conclusions

TOA (35.4 ° ± 7.9 °) and L3 (26.8 ± 11.4 mm) could be used as a reference for ideal tibial tunnel placement in transtibial anatomic PCL reconstruction, so as to prevent recurrent PCL laxity and ensure good graft healing. However, further clinical validation is needed.

Magnesium (Mg) based interference screws developed for promoting tendon graft incorporation in bone tunnel in rabbits

How to enhance tendon graft incorporation into bone tunnels for achieving satisfactory healing outcomes in patients with anterior cruciate ligament reconstruction (ACLR) is one of the most challenging clinical problems in orthopaedic sports medicine. Several studies have recently reported the beneficial effects of Mg implants in bone fracture healing, indicating the use potential of Mg devices in promoting the tendon graft osteointegration. Here, we developed an innovative Mg-based interference screws for fixation of the tendon graft in rabbits underwent ACLR and investigated the biological role of Mg-based implants in the graft healing. The titanium (Ti) interference screw was used as the control. We demonstrated that Mg interference screw significantly accelerated the incorporation of the tendon graft into bone tunnels via multiscale analytical methods including scanning electronic microscopy/energy dispersive spectrometer (SEM/EDS), micro-hardness, micro-Fourier transform infrared spectroscopy (μFTIR), and histology. Our in vivo study showed that Mg implants enhanced the recruitment of bone marrow stromal stem cells (BMSCs) towards peri-implant bone tissue, which may be ascribed to the upregulation of local TGF-β1 and PDGF-BB. Besides, the in vitro study revealed that higher Mg ions was beneficial to the improvement of capability in cell adhesion and osteogenic differentiation of BMSCs. Thus, the enhancement in cell migration, cell adhesion and osteogenic differentiation of BMSCs may contribute to an improved tendon graft osteointegration in the Mg group. Our findings in this work may further facilitate clinical applications of Mg-based interference screws for enhancing tendon graft-bone junction healing in patients indicated for ACLR.

STATEMENT OF SIGNIFICANCE

How to promote tendon-bone junction healing is one of the major challenging issues for satisfactory clinical outcomes in patients after ACL reconstruction. The improvement of bony ingrowth into the tendon graft-bone interface can enhance the tendon graft osteointegration. In this study, we applied Mg based interference screws to fix the tendon graft in rabbits and found the use of Mg screws could accelerate and significantly increase mineralized matrix formation at the tendon-bone interface in animals when compared to those with Ti screws. We elucidated the mechanism behind the favorable effects of Mg screws on the graft healing in both in vitro and in vivo studies from multiscale technologies. The optimized interface structure and function in Mg group may be ascribed to the improved cell migration capability, enhanced cell adhesion strength and promoted osteogenic differentiation ability of BMSCs under the stimuli of Mg ions degraded from implanted Mg screws. Our findings may help us broaden our thinking in the application potential of Mg interference screws in future clinical trials.

Influence of the Injury-to-Surgery Interval on the Healing Potential of Human Anterior Cruciate Ligament-Derived Cells

BACKGROUND

Vascular CD34+ cells in anterior cruciate ligament (ACL) tissue have the potential for high proliferation and multilineage differentiation that can accelerate tendon-bone healing. While patient characteristics, such as age, can affect tendon-bone healing, the influence of elapsed time after injury on the healing process is unclear.

HYPOTHESIS

Cells obtained during the early phase after injury will exhibit a greater tendon-bone healing potential compared with chronic phase counterparts when applied to an immunodeficient rat model of ACL reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Adult human ACL-ruptured tissue was harvested from patients undergoing arthroscopic primary ACL reconstruction and classified into 2 groups based on the time elapsed between injury and surgery: (1) early group (≤3 months from injury) and (2) chronic group (>3 months from injury). In addition, 76 ten-week-old female immunodeficient rats underwent ACL reconstruction, followed by intracapsular administration of one of the following: (1) ACL-derived cells from the early group (n = 5), (2) ACL-derived cells from the chronic group (n = 5), or (3) phosphate-buffered saline (PBS) only (n = 5). During the 8 weeks after surgery, histological (weeks 2, 4, 8), immunohistochemical (week 2), radiographic (weeks 0, 2, 4, 8), and biomechanical (week 8) analyses were performed to evaluate tendon-bone healing.

RESULTS

In the early group, the histological evaluation showed early healing, induction of endochondral ossification-like integration, and mature bone ingrowth. Micro-computed tomography showed that the tibial bone tunnels at week 4 and week 8 were significantly reduced in the early group compared with those in the chronic group and PBS group ( P < .05). Moreover, biomechanical tensile strength was significantly greater in the early group than in the other groups ( P < .05). An accelerated healing potential in the early group was further demonstrated by the enhancement of intrinsic angiogenesis/osteogenesis and human-derived vasculogenesis/osteogenesis.

CONCLUSION

Compared with human ACL-derived cells obtained during the chronic phase, cells obtained during the early phase after injury have a greater tendon-bone healing potential when used in an immunodeficient rat model of ACL reconstruction.

CLINICAL RELEVANCE

During ACL reconstruction surgery, transplanting ACL remnant tissue in the early phase after injury could accelerate and enhance tendon-bone healing.

The Effect of Graft Pretensioning on Bone Tunnel Diameter and Bone Formation After Anterior Cruciate Ligament Reconstruction in a Rat Model: Evaluation With Micro-Computed Tomography

BACKGROUND

Moderate graft pretensioning in anterior cruciate ligament (ACL) reconstruction is paramount to restore knee stability and normalize knee kinematics. However, little is known about the effect of graft pretensioning on graft-to-bone healing after ACL reconstruction.

HYPOTHESIS

Moderate graft pretensioning will improve bone formation within the bone tunnel after ACL reconstruction, resulting in superior load to failure.

STUDY DESIGN

Controlled laboratory study.

METHODS

67 male Sprague-Dawley rats underwent unilateral ACL reconstruction with a flexor digitorum longus tendon autograft. The graft was subjected to pretensioning forces of 0 N, 5 N, or 10 N. Custom-made external fixators were used for knee immobilization postoperatively. Rats were euthanized for biomechanical load-to-failure testing (n = 45) and micro-computed tomography (μCT) examination (n = 22) at 3 and 6 weeks after surgery. Three regions of each femoral and tibial bone tunnel (aperture, middle, and tunnel exit) were chosen for measurement of tunnel diameter and new bone formation.

RESULTS

Biomechanical tests revealed significantly higher load-to-failure in the 5-N graft pretensioned group compared with the 0- and 10-N groups at 3 weeks (8.58 ± 2.67 N vs 3.96 ± 1.83 N and 4.46 ± 2.62 N, respectively) and 6 weeks (16.56 ± 3.50 N vs 10.82 ± 1.97 N and 7.35 ± 2.85 N, respectively) after surgery ( P < .05). The mean bone tunnel diameters at each of the 3 regions were significantly smaller in the 5-N group, at both the femoral and tibial tunnel sites, than in the 0- and 10-N groups ( P < .05). At 3 and 6 weeks postoperatively, the bone mineral density, bone volume fraction, and connectivity density around the aperture and middle regions of the tibial bone tunnels were all significantly higher in the 5-N group compared with the 0- and 10-N groups ( P < .05). In the aperture and middle regions of the femoral bone tunnels, pretensioning at either 5 or 10 N resulted in increased bone formation compared with the nonpretensioned group at 3 weeks postoperatively. No differences were found in bone formation between any of the 3 femoral tunnel regions at 6 weeks.

CONCLUSION

Graft pretensioning can stimulate new bone formation and improve tendon-to-bone tunnel healing after ACL reconstruction.

CLINICAL RELEVANCE

Optimal graft pretensioning force in ACL reconstruction can improve bone tunnel healing. Further study is necessary to understand the mechanisms underlying the effect of graft pretensioning on healing at the bone-tunnel interface.

Biodegradable Magnesium Screws Accelerate Fibrous Tissue Mineralization at the Tendon-Bone Insertion in Anterior Cruciate Ligament Reconstruction Model of Rabbit

The incorporation of tendon graft into bone tunnel is one of the most challenging clinical issues in anterior cruciate ligament (ACL) reconstruction. As a biodegradable metal, Mg has appropriate mechanical strength and osteoinductive effects, thus may be a promising alternative to commercialized products used for graft fixation. Therefore, it was hypothesized that Mg based interference screws would promote tendon graft-bone junction healing when compared to Ti screws. Herein, we compared the effects of Mg and Ti screws on tendon graft healing in rabbits with ACL reconstruction via histological, HR-pQCT and mechanical analysis. The histological results indicated that Mg screws significantly improved the graft healing quality via promoting mineralization at the tendon graft enthesis. Besides, Mg screws significantly promoted bone formation in the peri-screw region at the early healing stage. Importantly, Mg screws exhibited excellent corrosion resistance and the degradation of Mg screws did not induce bone tunnel widening. In tensile testing, there were no significant differences in the load to failure, stress, stiffness and absorption energy between Mg and Ti groups due to the failure mode at the midsubstance. Our findings demonstrate that Mg screws can promote tendon graft healing after ACL reconstruction, implying a potential alternative to Ti screws for clinical applications.

Measurement of regional trabecular bone attenuation of the knee following anterior cruciate ligament rupture

INTRODUCTION

The purpose of this study was to determine regional trabecular bone attenuation changes of the knee using computed tomography after anterior cruciate ligament rupture.

MATERIALS AND METHODS

Thirty one patients'-computed tomography images of the injured knees were used to measure trabecular bone attenuation in seven predetermined regions.

RESULTS

Trabecular bone attenuation at four of seven regions (anteromedial area of the proximal tibia, anterolateral area of the proximal tibia, posteromedial area of the proximal tibia, and posterocentral area of the proximal tibia) was negatively correlated with the duration after injury. Independent negative correlation between the duration after injury and the density in anteromedial area of the proximal tibia was detected.

CONCLUSIONS

After anterior cruciate ligament injury, trabecular bone attenuation of the knee decreases by time in certain regions of proximal tibia. Anteromedial region is the most significantly effected of all, which it is the anterior cruciate ligament fixation area.

Magnesium inference screw supports early graft incorporation with inhibition of graft degradation in anterior cruciate ligament reconstruction

Patients after anterior cruciate ligament (ACL) reconstruction surgery commonly encounters graft failure in the initial phase of rehabilitation. The inhibition of graft degradation is crucial for the successful reconstruction of the ACL. Here, we used biodegradable high-purity magnesium (HP Mg) screws in the rabbit model of ACL reconstruction with titanium (Ti) screws as a control and analyzed the graft degradation and screw corrosion using direct pull-out tests, microCT scanning, and histological and immunohistochemical staining. The most noteworthy finding was that tendon graft fixed by HP Mg screws exhibited biomechanical properties substantially superior to that by Ti screws and the relative area of collagen fiber at the tendon-bone interface was much larger in the Mg group, when severe graft degradation was identified in the histological analysis at 3 weeks. Semi-quantitative immunohistochemical results further elucidated that the MMP-13 expression significantly decreased surrounding HP Mg screws with relatively higher Collagen II expression. And HP Mg screws exhibited uniform corrosion behavior without displacement or loosening in the femoral tunnel. Therefore, our results demonstrated that Mg screw inhibited graft degradation and improved biomechanical properties of tendon graft during the early phase of graft healing and highlighted its potential in ACL reconstruction.

High-purity magnesium interference screws promote fibrocartilaginous entheses regeneration in the anterior cruciate ligament reconstruction rabbit model via accumulation of BMP-2 and VEGF

Interference screw in the fixation of autologous tendon graft to the bone tunnel is widely accepted for the reconstruction of anterior cruciate ligament (ACL), but the regeneration of fibrocartilaginous entheses could hardly be achieved with the traditional interference screw. In the present work, biodegradable high-purity magnesium (HP Mg) showed good cytocompatibility and promoted the expression of bone morphogenetic protein-2 (BMP-2) and vascular endothelial growth factor (VEGF), fibrocartilage markers (Aggrecan, COL2A1 and SOX-9), and glycosaminoglycan (GAG) production in vitro. The HP Mg screw was applied to fix the semitendinosus autograft to the femoral tunnel in a rabbit model of ACL reconstruction with titanium (Ti) screw as the control. The femur-tendon graft-tibia complex was retrieved at 3, 6, 9 and 12 weeks. Gross observation and range of motion (ROM) of the animal model reached normal levels at 12 weeks. No sign of host reaction was found in the X-ray scanning. The HP Mg group was comparable to the Ti group with respect to biomechanical properties of the reconstructed ACL, and the ultimate load to failure and stiffness increased 12 weeks after surgery. In the histological analysis, the HP Mg group formed distinct fibrocartilage transition zones at the tendon-bone interface 12 weeks after surgery, whereas a disorganized fibrocartilage layer was found in the Ti group. In the immunohistochemical analysis, highly positive staining of BMP-2, VEGF and the specific receptor for BMP-2 (BMPR1A) was shown at the tendon-bone interface of the HP Mg group compared with the Ti group. Furthermore, the HP Mg group had significantly higher expression of BMP-2 and VEGF than the Ti group in the early phase of tendon-bone healing, followed by enhanced expression of fibrocartilage markers and GAG production. Therefore we proposed that the stimulation of BMP-2 and VEGF by Mg ions was responsible for the fibrochondrogenesis of Mg materials. HP Mg was promising as a biodegradable interference screw with the potential to promote fibrocartilaginous entheses regeneration in ACL reconstruction.

Age-dependent healing potential of anterior cruciate ligament remnant-derived cells

BACKGROUND

The anterior cruciate ligament (ACL) does not heal spontaneously after injury, and ACL patients of different ages respond differently to treatment. Although ACL-derived CD34-positive cells contribute to bone-tendon healing after ACL reconstruction, the relationship between the healing potential of ACL-derived cells and a patient's age is unknown.

HYPOTHESIS

ACL-derived cells from young patients will have a greater effect on the maturation of bone-tendon integration in an immunodeficient rat model of ACL reconstruction compared with cells derived from older patients.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixty 10-week-old female immunodeficient rats underwent ACL reconstruction (using the autologous flexor digitorum longus tendon as a graft) followed by intracapsular administration of ACL-derived cells from patients aged 10 to 19 years (younger group) or patients aged 30 to 39 years (older group), or they were given phosphate-buffered saline (PBS; PBS group). Histologic, radiographic, and biomechanical examinations were performed 2 to 8 weeks after surgery. In addition, intrinsic and human cell-derived angiogenesis and osteogenesis were examined by immunohistochemistry.

RESULTS

In the younger group, histologic assessment demonstrated early bone-tendon healing, which induced endochondral ossification-like integration. Micro-computed tomography showed a statistically significant reduction in the area of tibial bone tunnel in the younger group (week 4, 20.0% ± 11.2% reduction; week 8, 25.7% ± 5.6% reduction) compared with the older group (week 4, 1.8% ± 3.0% reduction; week 8, 4.0% ± 5.9% reduction) and the PBS group (week 4, -0.5% ± 3.2% reduction; week 8, 3.3% ± 5.2% reduction) (week 4, P < .05; week 8, P < .01). Failure loads during tensile testing demonstrated a significantly higher ultimate load to failure in the younger group (17.52 ± 4.01 N) compared with the older (8.05 ± 2.91 N) and PBS (7.01 ± 3.16 N) groups (P < .05), and isolectin B4 and rat osteocalcin immunostaining indicated enhanced intrinsic angiogenesis and osteogenesis in the younger group. There was no statistically significant difference in the results of radiographic and biomechanical examinations between the older and PBS groups. Double immunohistochemistry for human-specific endothelial cell and osteoblast markers demonstrated a greater ability of differentiation into endothelial cells and osteoblasts in the younger group.

CONCLUSION

ACL-derived cells from younger patients enhanced early bone-tendon healing in an immunodeficient rat model of ACL reconstruction.

CLINICAL RELEVANCE

Surgeons should consider a patient's age when performing ACL reconstruction with remnant preservation or ruptured tissue incorporation, as this can predict healing ability.

Effect of zinc ions on improving implant fixation in osteoporotic bone

The application of titanium (Ti) and its alloys in tooth restoration and joint replacement for aged patients with unfavorable conditions is gaining popularity. Therefore, strategies aiming at improving the fixation of Ti-based implants are worth investigating. This study was designed to observe whether modification of Ti implants by zinc (Zn) could enhance the fixation capability in osteoporotic bone. Two kinds of implants, hydroxyapatite (HA) coated Ti and Zn-incorporated HA (ZnHA) coated Ti, were inserted into the femoral metaphysis longitudinally in ovariectomized (OVX) rats. Specimens were harvested and subjected to double fluorescence labeling examination at week 6 after surgery. At week 12, samples were evaluated with histomorphometry, micro-CT (μCT) analysis and biomechanical test. Compared to the HA coated implants, ZnHA coating improved mineral apposition rate (MAR) of peri-implant bone, which was revealed by double fluorescence labeling; bone area ratio (BA) and bone-to-implant contact (BIC) were also higher for the latter group by histomorphometry. μCT images suggested that more bone mass was formed around the ZnHA coated implants as compared to the HA coated implants. Biomechanical push-out test showed that the ZnHA coated implants demonstrated higher strength of osseointegration than the HA group. The current study suggested that Zn ions could enhance bone formation and improve implant fixation in OVX rats.

Effect of graft tensioning on mechanical restoration in a rat model of anterior cruciate ligament reconstruction using free tendon graft

PURPOSE

Initial graft tensioning is important in anterior cruciate ligament reconstruction (ACLR), but its effect on graft healing is still not clear. Since all previous animal studies on graft tensioning used bone-patellar tendon-bone, this study aimed to investigate the effect of initial graft tensioning on ACLR using tendon graft.

METHODS

Fifty-five Sprague-Dawley rats underwent ACLR using flexor digitorum longus tendon graft. A constant force of 2 or 4 N was applied during graft fixation. At 0, 2, and 6 weeks, knee samples were harvested (n = 6) for static knee laxity test and graft pull-out test. Histological examination was performed at 2 and 6 weeks post-injury (n = 4).

RESULTS

At time zero, knee laxity was restored by ACLR with 2 or 4 N tensioning as compared to ACL-deficient group (p < 0.001), and the 4 N group exhibited a better restoration as compared to 2 N group (p = 0.031). At week 2 post-operation, the 4 N group still exhibited a better restoration in knee laxity (p = 0.001) and knee stiffness (p = 0.002) than the 2 N group; the graft pull-out force (p = 0.032) and stiffness (p = 0.010) were also higher. At week 6 post-operation, there was no significant difference between the 2 and 4 N group in knee laxity and graft pull-out strength. Histological examination showed that the beneficial effect of higher initial graft tension may be contributed by maintenance of graft integrity at mid-substance and reduction in adverse peri-graft bone changes in the femoral tunnel region.

CONCLUSIONS

A higher initial graft tension favours the restoration of knee laxity and promotes graft healing in ACLR using free tendon graft in the rat model.

ACL graft healing and biologics

Operative reconstruction of a torn anterior cruciate ligament (ACL) has become the most broadly accepted treatment. An important, but underreported, outcome of ACL reconstruction is graft failure, which poses a challenge for the orthopedic surgeon. An understanding of the tendon-bone healing and the intra-articular ligamentization process is crucial for orthopedic surgeons to make appropriate graft choices and to be able to initiate optimal rehabilitation protocols after surgical ACL reconstruction. This article focuses on the current understanding of the tendon-to-bone healing process for both autografts and allografts and discusses strategies to biologically augment healing.

Chronological changes in the collagen-type composition at tendon-bone interface in rabbits

Objectives

The purpose of this study was to evaluate chronological changes in the collagen-type composition at tendon–bone interface during tendon–bone healing and to clarify the continuity between Sharpey-like fibres and inner fibres of the tendon.

Methods

Male white rabbits were used to create an extra-articular bone–tendon graft model by grafting the extensor digitorum longus into a bone tunnel. Three rabbits were killed at two, four, eight, 12 and 26 weeks post-operatively. Elastica van Gieson staining was used to colour 5 µm coronal sections, which were examined under optical and polarised light microscopy. Immunostaining for type I, II and III collagen was also performed.

Results

Sharpey-like fibres comprised of type III collagen in the early phase were gradually replaced by type I collagen from 12 weeks onwards, until continuity between the Sharpey-like fibres and inner fibres of the tendon was achieved by 26 weeks.

Conclusions

Even in rabbits, which heal faster than humans, an observation period of at least 12 to 26 weeks is required, because the collagen-type composition of the Sharpey-like fibre bone–tendon connection may have insufficient pullout strength during this period. These results suggest that caution is necessary when permitting post-operative activity in humans who have undergone intra-bone tunnel grafts.

Therapeutic potential of anterior cruciate ligament-derived stem cells for anterior cruciate ligament reconstruction

We recently reported that the ruptured regions of the human anterior cruciate ligament (ACL) contained vascular-derived stem cells, which showed the potential for high expansion and multilineage differentiation. In this study, we performed experiments to test the hypothesis that ACL-derived CD34(+) cells could contribute to tendon-bone healing. ACL-derived cells were isolated from the rupture site of human ACL by fluorescence-activated cell sorting. Following ACL reconstruction, immunodeficient rats received intracapsular administration of either ACL-derived CD34(+) cells, nonsorted (NS) cells, CD34(+) cells, or phosphate-buffered saline (PBS). We also performed in vitro cell proliferation assays and enzyme-linked immunosorbent assays for vascular endothelial growth factor (VEGF) secretion. We confirmed the recruitment of the transplanted cells into the perigraft site after intracapuslar injection by immunohistochemical staining at week 1. Histological evaluation showed a greater area of collagen fiber formation and more collagen type II expression in the CD34(+) group than the other groups at the week 2 time point. Immunostaining with isolectin B4 and rat osteocalcin demonstrated enhanced angiogenesis and osteogenesis in the CD34(+) group at week 2. Moreover, double immunohistochemical staining for human-specific endothelial cell (EC) and osteoblast (OB) markers at week 2 demonstrated a greater ability of differentiation into ECs and OBs in the CD34(+) group. Microcomputerized tomography showed the greatest healing of perigraft bone at week 4 in the CD34(+) cell group, and the failure load of tensile test at week 8 demonstrated the greatest biomechanical strength in the CD34(+) group. Furthermore, the in vitro studies indicated that the CD34(+) group was superior to the other groups in their cell proliferation and VEGF secretion capacities. We demonstrated that ACL-derived CD34(+) cells contributed to the tendon-bone healing after ACL reconstruction via the enhancement of angiogenesis and osteogenesis, which also contributed to an increase in biomechanical strength.

Effect of varying the length of soft-tissue grafts in the tibial tunnel in a canine anterior cruciate ligament reconstruction model

PURPOSE

To investigate the effect of graft length within the bone tunnel on tendon-bone healing at an early stage after anterior cruciate ligament (ACL) reconstruction using Achilles tendon autograft in a canine model.

METHODS

We divided 40 adult dogs into 4 groups (n = 10 per group). Each dog underwent ACL reconstruction with Achilles tendon autograft in both knees. In groups I, II, III, and IV, the graft length within the tibia tunnel was 5 mm, 10 mm, 15 mm, and 20 mm, respectively. Five dogs in each group were killed 6 and 12 weeks postoperatively, with 3 knees used for histologic observation and 7 knees for mechanical testing.

RESULTS

Six weeks after surgery, the histologic scores in group I were lower than those in the other groups (P < .01) and those in group II were lower than those in group III and group IV (P < .01). However, there was no difference between group III and group IV (P > .05). At 12 weeks, there were no significant differences in histologic scores between groups (P > .05). The biomechanical test at 6 weeks showed that the mean graft pullout strength improved from group I to group IV. Except between groups III and IV (P = .142), there was a significant difference in the pullout strength among other groups. At week 12, the failure points were in the midsubstance of most specimens and more tibial-side graft pullout was found in group I than in the other groups (P < .001).

CONCLUSIONS

The histologic maturity and biomechanical strength of the tendon-bone junction after ACL reconstruction in dogs will be delayed at an early stage if the graft length in the bone tunnel is less than 15 mm.

CLINICAL RELEVANCE

There is a minimal acceptable amount of intratunnel tendon graft to allow satisfactory early tendon-bone healing, and attempts to save tendon graft length that lower the amount of intratunnel graft below a minimum of 15 mm should be avoided.

Micro-CT-based bone ceramic scaffolding and its performance after seeding with mesenchymal stem cells for repair of load-bearing bone defect in canine femoral head

Osteonecrosis of the femoral head is a debilitating and painful orthopedic condition characterized by joint collapse. Salvage of the femoral head is highly desirable to preserve the contour and mechanical properties and prevent joint collapse. This study aimed to develop a new tissue-engineering approach for treatment of large bone defect in femoral head, that is, after osteonecrosis. The biphasic calcium phosphate (BCP) ceramic scaffolds were fabricated by a 3D gel-lamination technique based on micro-computed tomography (micro-CT) images of the cancellous bone microarchitecture of femoral heads. After seeding with autologous bone marrow-derived mesenchymal stem cells (BMSCs) in vitro, the cell-scaffold composite was implanted into a bone defect surgically induced in canine femoral head via trapdoor procedure, which was a common procedure for treatment of osteonecrosis. A total of 24 adult dogs were randomly divided into three groups (n = 8 each) for implantation of the BCP scaffold with or without with BMSCs, and also the autologous bone chips for comparisons. All animals were sacrificed at 30 weeks postoperatively and processed for radiological and histological evaluations. The contour of the femoral head was well preserved with implantation of BCP scaffolds with or without BMSCs, whereas joint collapse was found after treatment with autologous bone chips. The osteointegration and new bone formation was significantly greater with BCP scaffold implantation with than without BMSC seeding and showed greater strength and compressive modulus in the repair site. Micro-CT-based bone ceramic scaffolds seeding with BMSC might be a promising way to repair bone defects in the femoral head.

Biology and augmentation of tendon-bone insertion repair

Surgical reattachment of tendon and bone such as in rotator cuff repair, patellar-patella tendon repair and anterior cruciate ligament (ACL) reconstruction often fails due to the failure of regeneration of the specialized tissue ("enthesis") which connects tendon to bone. Tendon-to-bone healing taking place between inhomogenous tissues is a slow process compared to healing within homogenous tissue, such as tendon to tendon or bone to bone healing. Therefore special attention must be paid to augment tendon to bone insertion (TBI) healing. Apart from surgical fixation, biological and biophysical interventions have been studied aiming at regeneration of TBI healing complex, especially the regeneration of interpositioned fibrocartilage and new bone at the healing junction. This paper described the biology and the factors influencing TBI healing using patella-patellar tendon (PPT) healing and tendon graft to bone tunnel healing in ACL reconstruction as examples. Recent development in the improvement of TBI healing and directions for future studies were also reviewed and discussed.

Grafted tendon healing in tibial tunnel is inferior to healing in femoral tunnel after anterior cruciate ligament reconstruction: a histomorphometric study in rabbits

PURPOSE

This study aimed to test whether graft healing in the tibial tunnel was inferior to that in the femoral tunnel after anterior cruciate ligament (ACL) reconstruction in rabbits.

METHODS

Surgical reconstruction by use of the digital extensor tendon in the bone tunnel was performed in 18 rabbits. The rabbits were killed at weeks 2, 6, and 12 postoperatively, with 6 at each time point, for histologic examination.

RESULTS

The transiently formed cartilaginous interface was gradually mineralized during re-establishment of direct tendon-to-bone integration, which was observed significantly less in the tibial tunnel than in the femoral tunnel (P < .05). The cell density of the graft was significantly lower in the tibial tunnel than that in the femoral tunnel at weeks 2 and 6 postoperatively (P < .05 for both). An increase in the immature type III collagen content was accompanied by a decrease in graft collagen fiber organization, with healing over time in both the femoral and tibial tunnels. The collagen fiber organization of the graft was significantly poorer in the tibial tunnel than that in the femoral tunnel at week 12 after surgery (P < .05).

CONCLUSIONS

Grafted tendon healing in the tibial tunnel was inferior to that in the femoral tunnel at the tendon-to-bone interface and with regard to the grafted tendon within the bone tunnel after ACL reconstruction in rabbits.

CLINICAL RELEVANCE

Future biopsy study is desirable to test whether this observation was valid clinically, which might provide a scientific basis for therapeutic targets to improve the outcome of ACL surgery.