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Little D, Amadio PC, Awad HA, Cone SG, Dyment NA, Fisher MB, Huang AH, Koch DW, Kuntz AF, Madi R, McGilvray K, Schnabel LV, Shetye SS, Thomopoulos S, Zhao C, Soslowsky LJ. Preclinical tendon and ligament models: Beyond the 3Rs (replacement, reduction, and refinement) to 5W1H (why, who, what, where, when, how). J Orthop Res 2023; 41:2133-2162. [PMID: 37573480 PMCID: PMC10561191 DOI: 10.1002/jor.25678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/21/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023]
Abstract
Several tendon and ligament animal models were presented at the 2022 Orthopaedic Research Society Tendon Section Conference held at the University of Pennsylvania, May 5 to 7, 2022. A key objective of the breakout sessions at this meeting was to develop guidelines for the field, including for preclinical tendon and ligament animal models. This review summarizes the perspectives of experts for eight surgical small and large animal models of rotator cuff tear, flexor tendon transection, anterior cruciate ligament tear, and Achilles tendon injury using the framework: "Why, Who, What, Where, When, and How" (5W1H). A notable conclusion is that the perfect tendon model does not exist; there is no single gold standard animal model that represents the totality of tendon and ligament disease. Each model has advantages and disadvantages and should be carefully considered in light of the specific research question. There are also circumstances when an animal model is not the best approach. The wide variety of tendon and ligament pathologies necessitates choices between small and large animal models, different anatomic sites, and a range of factors associated with each model during the planning phase. Attendees agreed on some guiding principles including: providing clear justification for the model selected, providing animal model details at publication, encouraging sharing of protocols and expertise, improving training of research personnel, and considering greater collaboration with veterinarians. A clear path for translating from animal models to clinical practice was also considered as a critical next step for accelerating progress in the tendon and ligament field.
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Affiliation(s)
- Dianne Little
- Department of Basic Medical Sciences, The Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Peter C Amadio
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hani A Awad
- Department of Orthopaedics, Department of Biomedical Engineering, The Center for Musculoskeletal Research, University of Rochester, Rochester, New York, USA
| | - Stephanie G Cone
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware, USA
| | - Nathaniel A Dyment
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew B Fisher
- Joint Department of Biomedical Engineering, College of Engineering, North Carolina State University-University of North Carolina at Chapel Hill, Raleigh, North Carolina, USA
| | - Alice H Huang
- Department of Orthopedic Surgery, Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Drew W Koch
- Department of Clinical Sciences, College of Veterinary Medicine, and Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Andrew F Kuntz
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rashad Madi
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kirk McGilvray
- Department of Mechanical Engineering, School of Biomedical Engineering, Colorado State University, Fort Collins, Colorado, USA
| | - Lauren V Schnabel
- Department of Clinical Sciences, College of Veterinary Medicine, and Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
| | - Snehal S Shetye
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Chunfeng Zhao
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Louis J Soslowsky
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lin M, Li W, Ni X, Sui Y, Li H, Chen X, Lu Y, Jiang M, Wang C. Growth factors in the treatment of Achilles tendon injury. Front Bioeng Biotechnol 2023; 11:1250533. [PMID: 37781529 PMCID: PMC10539943 DOI: 10.3389/fbioe.2023.1250533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Abstract
Achilles tendon (AT) injury is one of the most common tendon injuries, especially in athletes, the elderly, and working-age people. In AT injury, the biomechanical properties of the tendon are severely affected, leading to abnormal function. In recent years, many efforts have been underway to develop effective treatments for AT injuries to enable patients to return to sports faster. For instance, several new techniques for tissue-engineered biological augmentation for tendon healing, growth factors (GFs), gene therapy, and mesenchymal stem cells were introduced. Increasing evidence has suggested that GFs can reduce inflammation, promote extracellular matrix production, and accelerate AT repair. In this review, we highlighted some recent investigations regarding the role of GFs, such as transforming GF-β(TGF-β), bone morphogenetic proteins (BMP), fibroblast GF (FGF), vascular endothelial GF (VEGF), platelet-derived GF (PDGF), and insulin-like GF (IGF), in tendon healing. In addition, we summarized the clinical trials and animal experiments on the efficacy of GFs in AT repair. We also highlighted the advantages and disadvantages of the different isoforms of TGF-β and BMPs, including GFs combined with stem cells, scaffolds, or other GFs. The strategies discussed in this review are currently in the early stages of development. It is noteworthy that although these emerging technologies may potentially develop into substantial clinical treatment options for AT injury, definitive conclusions on the use of these techniques for routine management of tendon ailments could not be drawn due to the lack of data.
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Affiliation(s)
- Meina Lin
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
| | - Wei Li
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
- Medical School, Shandong Modern University, Jinan, China
| | - Xiang Ni
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
| | - Yu Sui
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
| | - Huan Li
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
| | - Xinren Chen
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
| | - Yongping Lu
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
| | - Miao Jiang
- Liaoning Research Institute of Family Planning, China Medical University, Shenyang, China
| | - Chenchao Wang
- Department of Plastic Surgery, The First Hospital of China Medical University, Shenyang, China
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Increasing Vascular Response to Injury Improves Tendon Early Healing Outcome in Aged Rats. Ann Biomed Eng 2022; 50:587-600. [PMID: 35303172 PMCID: PMC9107615 DOI: 10.1007/s10439-022-02948-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/09/2022] [Indexed: 11/01/2022]
Abstract
Tendon injuries positively correlate with patient age, as aging has significant effects on tendon homeostatic maintenance and healing potential after injury. Vascularity is also influenced by age, with both clinical and animal studies demonstrating reduced blood flow in aged tissues. However, it is unknown how aging effects vascularity following tendon injury, and if this vascular response can be modulated through the delivery of angiogenic factors. Therefore, the objective of this study is to evaluate the vascular response following Achilles tendon injury in adult and aged rats, and to define the alterations to tendon healing in an aged model following injection of angiogenic factors. It was determined that aged rat Achilles tendons have a reduced angiogenesis following injury. Further, the delivery of vascular endothelial growth factor, VEGF, caused an increase in vascular response to tendon injury and improved mechanical outcome in this aged population. This work suggests that reduced angiogenic potential with aging may be contributing to impaired tendon healing response and that the delivery of angiogenic factors can rescue this impaired response. This study was also the first to relate changes in vascular response in an aged model using in vivo measures of blood perfusion to alterations in healing properties.
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Leahy T, Nuss C, Evans MK, Fung A, Shetye S, Soslowsky LJ. Achilles Tendon Ruptures in Middle-Aged Rats Heal Poorly Compared With Those in Young and Old Rats [Formula: see text]. Am J Sports Med 2022; 50:170-181. [PMID: 34851182 PMCID: PMC8819270 DOI: 10.1177/03635465211055476] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Achilles tendon ruptures are painful and debilitating injuries and are most common in middle-aged patients. There is a lack of understanding of the underlying causes for increased rupture rates in middle-aged patients and how healing outcomes after a rupture might be affected by patient age. Therefore, the objective of this study was to define age-specific Achilles tendon healing by assessing ankle functional outcomes and Achilles tendon mechanical and histological properties after a rupture using a rat model. HYPOTHESIS Rats representing the middle-aged patient population would demonstrate reduced healing capability after an Achilles tendon rupture, as demonstrated by a slower return to baseline ankle functional properties and inferior biomechanical and histological tendon properties. STUDY DESIGN Controlled laboratory study. METHODS Fischer 344 rats were categorized by age to represent young, middle-aged, and old patients, and Achilles tendon ruptures were induced in the right hindlimb. Animals were allowed to heal and were euthanized at 3 or 6 weeks after the injury. In vivo functional assays and ultrasound imaging were performed throughout the healing period, and ex vivo tendon mechanical and histological properties were assessed after euthanasia. RESULTS Rats representing middle-aged patients displayed reduced healing potential compared with the other age groups, as they demonstrated decreased recovery of in vivo functional and ultrasound assessment parameters and inferior mechanical and histological properties after an Achilles tendon rupture. CONCLUSION These findings may help explain the increased rupture rate observed clinically in middle-aged patients by suggesting that there may be altered tendon responses to daily trauma. CLINICAL RELEVANCE The results provide novel data on age-specific healing outcomes after an Achilles tendon rupture, which underscores the importance of considering a patient's age during treatment and expectations for outcomes.
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Affiliation(s)
- Thomas Leahy
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Courtney Nuss
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Kate Evans
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Fung
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Snehal Shetye
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - Louis J. Soslowsky
- McKay Orthopaedic Laboratory, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
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Liu X, Zhu B, Li Y, Liu X, Guo S, Wang C, Li S, Wang D. The Role of Vascular Endothelial Growth Factor in Tendon Healing. Front Physiol 2021; 12:766080. [PMID: 34777022 PMCID: PMC8579915 DOI: 10.3389/fphys.2021.766080] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Angiogenesis is crucial to facilitate tendon healing, such as delivering oxygen and nutrients, removing waste products, and controlling immune responses. Vascular endothelial growth factor (VEGF) is one of the most vital angiogenic factors that regulate blood vessel formation in tendon healing. Recently, biological therapies, including the application of exogenous VEGF, have been attracting increasing attention. However, at present, the effect of the application of exogenous VEGF in tendon healing is controversial, as the role of endogenous VEGF in tendons has also not been fully elucidated. This article will summarize the role of both endogenous and exogenous VEGF in tendon healing and discuss possible reasons for the controversy. The present review shows that tendon repair is facilitated only by proper angiogenesis and VEGF at the early stage, whereas the persistent high VEGF expression and prolonged presence of blood vessels may impair tendon repair at a later stage.
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Affiliation(s)
- Xueli Liu
- Institute of Physical Education, Southwest Medical University, Luzhou, China.,Department of Rehabilitation, Sichuan Vocational College of Health and Rehabilitation, Zigong, China
| | - Bin Zhu
- Institute of Physical Education, Southwest Medical University, Luzhou, China
| | - Yujie Li
- Institute of Physical Education, Southwest Medical University, Luzhou, China
| | - Xinyue Liu
- Institute of Physical Education, Southwest Medical University, Luzhou, China
| | - Sheng Guo
- Spinal Surgery Department, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Chenglong Wang
- Spinal Surgery Department, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Sen Li
- Spinal Surgery Department, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Dingxuan Wang
- Institute of Physical Education, Southwest Medical University, Luzhou, China
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Williamson PM, Freedman BR, Kwok N, Beeram I, Pennings J, Johnson J, Hamparian D, Cohen E, Galloway JL, Ramappa AJ, DeAngelis JP, Nazarian A. Tendinopathy and tendon material response to load: What we can learn from small animal studies. Acta Biomater 2021; 134:43-56. [PMID: 34325074 DOI: 10.1016/j.actbio.2021.07.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 12/20/2022]
Abstract
Tendinopathy is a debilitating disease that causes as much as 30% of all musculoskeletal consultations. Existing treatments for tendinopathy have variable efficacy, possibly due to incomplete characterization of the underlying pathophysiology. Mechanical load can have both beneficial and detrimental effects on tendon, as the overall tendon response depends on the degree, frequency, timing, and magnitude of the load. The clinical continuum model of tendinopathy offers insight into the late stages of tendinopathy, but it does not capture the subclinical tendinopathic changes that begin before pain or loss of function. Small animal models that use high tendon loading to mimic human tendinopathy may be able to fill this knowledge gap. The goal of this review is to summarize the insights from in-vivo animal studies of mechanically-induced tendinopathy and higher loading regimens into the mechanical, microstructural, and biological features that help characterize the continuum between normal tendon and tendinopathy. STATEMENT OF SIGNIFICANCE: This review summarizes the insights gained from in-vivo animal studies of mechanically-induced tendinopathy by evaluating the effect high loading regimens have on the mechanical, structural, and biological features of tendinopathy. A better understanding of the interplay between these realms could lead to improved patient management, especially in the presence of painful tendon.
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Riggin CN, Rodriguez AB, Weiss SN, Raja HA, Chen M, Schultz SM, Sehgal CM, Soslowsky LJ. Modulation of vascular response after injury in the rat Achilles tendon alters healing capacity. J Orthop Res 2021; 39:2000-2016. [PMID: 32936495 PMCID: PMC7960560 DOI: 10.1002/jor.24861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 09/02/2020] [Accepted: 09/14/2020] [Indexed: 02/04/2023]
Abstract
Tendons are relatively hypovascular but become hypervascular during both injury and degeneration. This is due to the angiogenic response, or the formation of new blood vessels, to tissue injury. The objective of this study was to evaluate the effect of vascular modulation in the rat Achilles tendons during healing. Fischer rats received a bilateral Achilles incisional injury followed by local injections of vascular endothelial growth factor (VEGF), anti-VEGF antibody (B20.4-1-1), or saline either early or late during the healing process. Vascular modulation and healing were evaluated using multiple in vivo ultrasound imaging modalities, in vivo functional assessment, and ex vivo measures of tendon compositional and mechanical properties. The late delivery of anti-VEGF antibody, B20, caused a temporary reduction in healing capacity during a time point where vascularity was also decreased, and then an improvement during a later time point where vascularity was increased relative to control. However, VEGF delivery had a minimal impact on healing and vascular changes in both early and late delivery times. This study was the first to evaluate vascular changes using both in vivo imaging methods and ex vivo histological methods, as well as functional and mechanical outcomes associated with these vascular changes. Clinical significance: this study demonstrates that the alteration of vascular response through the delivery of angiogenic growth factors has the ability to alter tendon healing properties.
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Affiliation(s)
- Corinne N Riggin
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, 307A Stemmler Hall, 36 Street & Hamilton Walk, Philadelphia, PA 19104
| | - Ashley B Rodriguez
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, 307A Stemmler Hall, 36 Street & Hamilton Walk, Philadelphia, PA 19104
| | - Stephanie N Weiss
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, 307A Stemmler Hall, 36 Street & Hamilton Walk, Philadelphia, PA 19104
| | - Harina A Raja
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, 307A Stemmler Hall, 36 Street & Hamilton Walk, Philadelphia, PA 19104
| | - Mengcun Chen
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, 307A Stemmler Hall, 36 Street & Hamilton Walk, Philadelphia, PA 19104
| | - Susan M Schultz
- Department of Radiology, University of Pennsylvania, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104
| | - Chandra M Sehgal
- Department of Radiology, University of Pennsylvania, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104
| | - Louis J Soslowsky
- McKay Orthopaedic Research Laboratory, University of Pennsylvania, 307A Stemmler Hall, 36 Street & Hamilton Walk, Philadelphia, PA 19104,Corresponding Author: Louis J Soslowsky, McKay Orthopaedic Research Laboratory, University of Pennsylvania, 307A Stemmler Hall, 36 Street & Hamilton Walk, Philadelphia, PA 19104, , Phone: 215-898-8653, Fax: 215-573-2133
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Kim SE, Kim JG, Park K. Biomaterials for the Treatment of Tendon Injury. Tissue Eng Regen Med 2019; 16:467-477. [PMID: 31624702 DOI: 10.1007/s13770-019-00217-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 12/26/2022] Open
Abstract
Background Most tendon injuries are occurring from a gradual wearing and tearing of the tendon tissues from overuse. Such injuries are usually seen in sports, exercising, or daily activities that involve a high mechanical load and weight bearing. However, owing to the lack of both cellularity and blood vessels in tendons, the process of tendon repair is slow and inefficient. Although various conservative (non-surgical) and surgical management options are conducted by the clinicians, a gold standard of these approaches does not exist. In this regard, the treatment of tendon injuries is challenging. Method Here, we describe the recent advances of biomaterial-based approaches for the treatment of injured tendons. Results Regenerative medicine is an emerging multidisciplinary research that specializes in the repair of damaged tendon tissues through the delivery of regenerative factors by biomaterials. Conclusion Although current biomaterial-based treatment strategies have shown their potential for tendon healing, future research and clinical applications should focused on finding the optimum combinations of regenerative factors with ideal biomaterials for the repair of tendons.
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Affiliation(s)
- Sung Eun Kim
- 1Department of Orthopedic Surgery and Rare Diseases Institute, Korea University Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul, 08308 Republic of Korea
| | - Jae Gyoon Kim
- Department of Orthopedic Surgery, College of Medicine, Korea University Ansan Hospital, Korea University, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do 15355 Republic of Korea
| | - Kyeongsoon Park
- 3Department of Systems Biotechnology, College of Biotechnology and Natural Resources, Chung-Ang University, 4726 Seodong-daero, Daedeok-myeon, Anseong-si, Gyeonggi-do 17546 Republic of Korea
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