Regulation of alpha(v)beta3 and alpha5beta1 integrin receptors by basic fibroblast growth factor and platelet-derived growth factor-BB in intrasynovial flexor tendon cells

A Promising Candidate in Tendon Healing Events—PDGF-BB

Tendon injuries are one of the most common musculoskeletal disorders for which patients seek medical aid, reducing not only the quality of life of the patient but also imposing a significant economic burden on society. The administration of growth factors at the wound site is a feasible solution for enhancing tendon healing. Platelet-derived growth factor-BB (PDGF-BB) has a well-defined safety profile compared to other growth factors and has been approved by the Food and Drug Administration (FDA). The purpose of this review is to summarize the role of PDGF-BB in tendon healing through a comprehensive review of the published literature. Experimental studies suggest that PDGF-BB has a positive effect on tendon healing by enhancing inflammatory responses, speeding up angiogenesis, stimulating tendon cell proliferation, increasing collagen synthesis and increasing the biomechanics of the repaired tendon. PDGF-BB is regarded as a promising candidate in tendon healing. However, in order to realize its full potential, we still need to carefully consider and study key issues such as dose and application time in the future, so as to explore further applications of PDGF-BB in the tendon healing process.

Stem Cell Therapy for Tendon Regeneration: Current Status and Future Directions

In adults the healing tendon generates fibrovascular scar tissue and recovers never histologically, mechanically, and functionally which leads to chronic and to degenerative diseases. In this review, the processes and mechanisms of tendon development and fetal regeneration in comparison to adult defect repair and degeneration are discussed in relation to regenerative therapeutic options. We focused on the application of stem cells, growth factors, transcription factors, and gene therapy in tendon injury therapies in order to intervene the scarring process and to induce functional regeneration of the lesioned tissue. Outlines for future therapeutic approaches for tendon injuries will be provided.

Synergistic effect of co-immobilized FGF-2 and vitronectin-derived peptide on feeder-free expansion of induced pluripotent stem cells

Expansion of human induced pluripotent stem cells (h-iPSCs) on mouse derived feeder layers or murine cells secretions such as Matrigel hamper their clinical applications. Alternative methods have introduced novel substrates as stem cell niches or/and optimized combinations of humanized soluble factors as fully defined mediums. Accordingly vitronectin as a main part of ECM have been commercialized significantly as a stem cell niche-forming substrate. In this work, we used a functional peptide derived from vitronectin (VTN) and co-immobilized it with FGF-2 (as an indisputable ingredient of defined culture mediums) on chitosan film surface. After chemical and physical characterization of the pristine chitosan surface as well as ones modified by VTN or/and FGF-2, h-iPS cells were cultured on them at the xeno/feeder-free conditions. Our results demonstrated that co-immobilization of these two biomolecules has a synergistic effect on adhesion and clonal growth of h-iPS cells with maintained expression of pluripotency markers in a FGF-2 density-dependent manner. This is the first report of co-immobilization of an ECM derived molecule and a growth factor for stem cell culture.

Biologics for tendon repair

Tendon injuries are common and present a clinical challenge to orthopedic surgery mainly because these injuries often respond poorly to treatment and require prolonged rehabilitation. Therapeutic options used to repair ruptured tendons have consisted of suture, autografts, allografts, and synthetic prostheses. To date, none of these alternatives has provided a successful long-term solution, and often the restored tendons do not recover their complete strength and functionality. Unfortunately, our understanding of tendon biology lags far behind that of other musculoskeletal tissues, thus impeding the development of new treatment options for tendon conditions. Hence, in this review, after introducing the clinical significance of tendon diseases and the present understanding of tendon biology, we describe and critically assess the current strategies for enhancing tendon repair by biological means. These consist mainly of applying growth factors, stem cells, natural biomaterials and genes, alone or in combination, to the site of tendon damage. A deeper understanding of how tendon tissue and cells operate, combined with practical applications of modern molecular and cellular tools could provide the long awaited breakthrough in designing effective tendon-specific therapeutics and overall improvement of tendon disease management.

Treatment of tendinopathies with platelet-rich plasma

Pain and dysfunction related to tendinopathy are often refractory to traditional treatments and offer a unique challenge to physicians, because no gold standard treatment exists. Injectable biologics may represent a new modality in conjunction with a multifaceted treatment approach. Platelet-rich plasma (PRP) injections are not associated with the systemic or tendon degradation risks of corticosteroids or the inherent risks of surgery. Studies are promising but have not been replicated with high-powered evidence at the clinical level. Further evidence to expand understanding of the role of PRP in the treatment of tendinopathy is needed.

Performance of repetitive tasks induces decreased grip strength and increased fibrogenic proteins in skeletal muscle: role of force and inflammation

BACKGROUND

This study elucidates exposure-response relationships between performance of repetitive tasks, grip strength declines, and fibrogenic-related protein changes in muscles, and their link to inflammation. Specifically, we examined forearm flexor digitorum muscles for changes in connective tissue growth factor (CTGF; a matrix protein associated with fibrosis), collagen type I (Col1; a matrix component), and transforming growth factor beta 1 (TGFB1; an upstream modulator of CTGF and collagen), in rats performing one of two repetitive tasks, with or without anti-inflammatory drugs.

METHODOLOGY/RESULTS

To examine the roles of force versus repetition, rats performed either a high repetition negligible force food retrieval task (HRNF), or a high repetition high force handle-pulling task (HRHF), for up to 9 weeks, with results compared to trained only (TR-NF or TR-HF) and normal control rats. Grip strength declined with both tasks, with the greatest declines in 9-week HRHF rats. Quantitative PCR (qPCR) analyses of HRNF muscles showed increased expression of Col1 in weeks 3-9, and CTGF in weeks 6 and 9. Immunohistochemistry confirmed PCR results, and also showed greater increases of CTGF and collagen matrix in 9-week HRHF rats than 9-week HRNF rats. ELISA, and immunohistochemistry revealed greater increases of TGFB1 in TR-HF and 6-week HRHF, compared to 6-week HRNF rats. To examine the role of inflammation, results from 6-week HRHF rats were compared to rats receiving ibuprofen or anti-TNF-α treatment in HRHF weeks 4-6. Both treatments attenuated HRHF-induced increases in CTGF and fibrosis by 6 weeks of task performance. Ibuprofen attenuated TGFB1 increases and grip strength declines, matching our prior results with anti-TNFα.

CONCLUSIONS/SIGNIFICANCE

Performance of highly repetitive tasks was associated with force-dependent declines in grip strength and increased fibrogenic-related proteins in flexor digitorum muscles. These changes were attenuated, at least short-term, by anti-inflammatory treatments.

Regenerative tendon and ligament healing: opportunities with recombinant human platelet-derived growth factor BB-homodimer

Intrinsic tendon healing in response to injury is a reparative process that often results in formation of scar tissue with functional and mechanical properties inferior to those of the native tendon. Development of therapies that can promote regenerative, rather than reparative, healing hold the promise of improving patient recovery from tendon and ligament injuries by producing tissue that is morphologically and functionally equivalent to the native tissue. One therapeutic approach that has been a frequent topic of investigation in the preclinical literature is the use of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) to augment tendon and ligament repair. The chemotactic, mitogenic, and pro-angiogenic properties of rhPDGF-BB have been shown to result in recruitment and proliferation of tenogenic cells and a commensurate boost in extracellular matrix deposition and organization, improving the morphological and biomechanical properties of healing tendons and ligaments. The outcomes of the preclinical studies reviewed here strongly suggest that rhPDGF-BB will provide a new therapeutic opportunity to improve the treatment of injured tendons and ligaments.

Cytokines in rotator cuff degeneration and repair

The pathogenesis of rotator cuff degeneration remains poorly defined, and the incidence of degenerative tears is increasing in the aging population. Rates of recurrent tear and incomplete tendon-to-bone healing after repair remain significant for large and massive tears. Previous studies have documented a disorganized, fibrous junction at the tendon-to-bone interface after rotator cuff healing that does not recapitulate the organization of the native enthesis. Many biologic factors have been implicated in coordinating tendon-to-bone healing and maintenance of the enthesis after rotator cuff repair, including the expression and activation of transforming growth factor-β, basic fibroblast growth factor, platelet-derived growth factor-β, matrix metalloproteinases, and tissue inhibitors of metalloproteinases. Future techniques to treat tendinopathy and enhance tendon-to-bone healing will be driven by our understanding of the biology of this healing process after rotator cuff repair surgery. The use of cytokines to provide important signals for tissue formation and differentiation, the use of gene therapy techniques to provide sustained cytokine delivery, the use of stem cells, and the use of transcription factors to modulate endogenous gene expression represent some of these possibilities.

Biologic augmentation of rotator cuff repair

Rotator cuff repair is a common orthopedic procedure. Despite advances in surgical technique, the rotator cuff tendons often fail to heal after surgery. In recent years, a number of biologic strategies have been developed and tested to augment healing after rotator cuff repair. These strategies include allograft, extracellular matrices (ECMs), platelet rich plasma (PRP), growth factors, stem cells, and gene therapy. This chapter reviews the most current research on biologic augmentation of rotator cuff repair using these methods.

In vitro analysis of an rhGDF-5 suture coating process and the effects of rhGDF-5 on rat tendon fibroblasts

We describe a dipcoating method of coating 4-0 VICRYL sutures with recombinant human growth and differentiation factor-5 (rhGDF-5), and analyze the in vitro effects of rhGDF-5 on rat tendon fibroblasts (RTFs). Part I: Eight 4-0 VICRYL sutures were coated in a dipcoat solution using rhGDF-5 solutions at concentrations of 0, 40, 200, and 1000 μg/ml (n=32). ELISA was performed to determine the amount of rhGDF-5 that was transferred on the suture. Part II: Using a dipcoat solution of 200 μg/ml, four sutures were passed through rat tendon, and quantified ELISA was again performed. Cell proliferation, collagen synthesis, and RTF cell migration were also analyzed. The differences in the amount rhGDF-5 transferred on the suture between the different concentration groups were statistically significant. Furthermore, rhGDF-5-stimulated RTF cell migration, cell proliferation, and collagen synthesis at dipcoat concentrations of rhGDF-5 of at least 200 μg/ml.

Tissue engineered biological augmentation for tendon healing: a systematic review

INTRODUCTION

Tendon injuries give rise to significant morbidity. In the last few decades, several techniques have been increasingly used to optimize tendon healing.

SOURCES OF DATA

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each scaffold and the keywords 'tendon', 'rotator cuff', 'supraspinatus tendon', 'Achilles tendon', 'growth factors', 'cytokines', 'gene therapy', 'tissue engineering', 'mesenchymal' and 'stem cells' over the years 1966-2009. All articles relevant to the subject were retrieved, and their bibliographies were hand searched for further references in the context to tissue-engineered biological augmentation for tendon healing.

AREAS OF AGREEMENT

Several new techniques are available for tissue-engineered biological augmentation for tendon healing, growth factors, gene therapy and mesenchimal stem cells.

AREAS OF CONTROVERSY

Data are lacking to allow definitive conclusions on the use of these techniques for routine management of tendon ailments.

GROWING POINTS

The emerging field of tissue engineering holds the promise to use new techniques for tendon augmentation and repair. Preliminary studies support the idea that these techniques can provide an alternative for tendon augmentation with great therapeutic potential.

AREAS TIMELY FOR DEVELOPING RESEARCH

The optimization strategies discussed in this article are currently at an early stage of development. Although these emerging technologies may develop into substantial clinical treatment options, their full impact needs to be critically evaluated in a scientific fashion.

Tendon healing

An understanding of the processes of tendon healing and tendon-to-bone healing is important for the intraoperative and postoperative management of patients with tendon ruptures or of patients requiring tendon transfers in foot and ankle surgery. Knowledge of the normal process allows clinicians to develop strategies when normal healing fails. This article reviews the important work behind the identification of the normal phases and control of tendon healing. It outlines the failed response in tendinopathy and describes tendon-to-bone healing in view of its importance in foot and ankle surgery.

Tissue engineering and rotator cuff tendon healing

Rotator cuff tears are common soft-tissue injuries that often require surgical treatment. Initial efforts to better tendon healing centered on improving the strength of the repair. More recent studies have focused on biologic enhancement of the healing process. Tissue engineering is a multidisciplinary field that involves the application of scientific principles toward creating living tissue to replace, repair, or augment diseased tissue. Gene therapy involves the transfer of a certain gene into a cell so that the cell translates the gene into a specific protein. The advantage of using a gene-therapy, tissue-engineered approach to effect healing rests in the ability of the physician to select growth factors with documented roles in the tendon-healing cascade. Ideally, an improvement to the current repair technique would yield improved tendon healing leading to improved clinical results.

Phenotypic Drift in Human Tenocyte Culture

Tendon ruptures are increasingly common, repair can be difficult, and healing is poorly understood. Tissue engineering approaches often require expansion of cell numbers to populate a construct, and maintenance of cell phenotype is essential for tissue regeneration. Here, we characterize the phenotype of human Achilles tenocytes and assess how this is affected by passaging. Tenocytes, isolated from tendon samples from 6 patients receiving surgery for rupture of the Achilles tendon, were passaged 8 times. Proliferation rates and cell morphology were recorded at passages 1, 4, and 8. Total collagen, the ratio of collagen types I and III, and decorin were used as indicators of matrix formation, and expression of the integrin beta1 subunit as a marker of cell-matrix interactions. With increasing passage number, cells became more rounded, were more widely spaced at confluence, and confluent cell density declined from 18,700/cm2 to 16,100/cm2 ( p = 0.009). No change to total cell layer collagen was observed but the ratio of type III to type I collagen increased from 0.60 at passage 1 to 0.89 at passage 8 ( p < 0.001). Decorin expression significantly decreased with passage number, from 22.9 +/- 3.1 ng/ng of DNA at passage 1, to 9.1 +/- 1.8 ng/ng of DNA at passage 8 ( p < 0.001). Integrin expression did not change. We conclude that the phenotype of tenocytes in culture rapidly drifts with progressive passage.

Effect of suture repair on expression of beta1 integrin subunit in wounded rat patellar tendon

Integrins play key roles in wound healing by mediating cell adhesion events. The purpose of this study was to determine how to change the expression level of the beta1 integrin subunit (integrin beta1) in the restoration of a tendon and to investigate the influence of suture on its expression. The lateral half of the patellar tendon in rats was transected. Half the rats were sutured immediately and the other half were left as they were. The rats were killed at 4, 7, 10, 14, 28, and 56 days postsurgery. Integrin beta1 expression in each harvested tendon was analyzed using immunohistochemistry and real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR). Integrin beta1 was immunolocalized in fibroblasts adjacent to the wound and within the repair site itself. Although immunoreactivity for integrin beta1 in the unsutured group decreased on the tenth day, that in the sutured group continued to increase. In real-time quantitative RT-PCR, integrin beta1 mRNA expression level increased in both groups, but that in the unsutured group was higher than that in the sutured group. Our study indicates that suture influences the expression and mRNA level of integrin beta1, which is associated with tendon healing.

Flexor tendon biology

Significant advances in the understanding of intrasynovial flexor tendon repair and rehabilitation have been made since the early 1970s. The concept of adhesion-free, or primary tendon healing--that tendons could heal intrinsically without the ingrowth of fibrous adhesions from the surrounding sheath has been validated both experimentally and clinically in studies over the past 25 years. Recent attempts to understand and improve the results of intrasynovial flexor tendon repair have focused upon restoration of the gliding surface, augmentation of early post-operative repair site biomechanical strength and on the elucidation of the molecular biology of early post-operative tendon healing. The goals of the surgical treatment of patients with intrasynovial flexor tendon lacerations remain unchanged: to achieve a primary tendon repair of sufficient tensile strength to allow application of a post-operative mobilization rehabilitation protocol. This program should inhibit the formation of intrasynovial adhesions and restore the gliding surface, while facilitating the healing of the repair site.

Tenomodulin is necessary for tenocyte proliferation and tendon maturation

Tenomodulin (Tnmd) is a member of a new family of type II transmembrane glycoproteins. It is predominantly expressed in tendons, ligaments, and eyes, whereas the only other family member, chondromodulin I (ChM-I), is highly expressed in cartilage and at lower levels in the eye and thymus. The C-terminal extracellular domains of both proteins were shown to modulate endothelial-cell proliferation and tube formation in vitro and in vivo. We analyzed Tnmd function in vivo and provide evidence that Tnmd is processed in vivo and that the proteolytically cleaved C-terminal domain can be found in tendon extracts. Loss of Tnmd expression in gene targeted mice abated tenocyte proliferation and led to a reduced tenocyte density. The deposited amounts of extracellular matrix proteins, including collagen types I, II, III, and VI and decorin, lumican, aggrecan, and matrilin-2, were not affected, but the calibers of collagen fibrils varied significantly and exhibited increased maximal diameters. Tnmd-deficient mice did not have changes in tendon vessel density, and mice lacking both Tnmd and ChM-I had normal retinal vascularization and neovascularization after oxygen-induced retinopathy. These results suggest that Tnmd is a regulator of tenocyte proliferation and is involved in collagen fibril maturation but do not confirm an in vivo involvement of Tnmd in angiogenesis.

Cbl-mediated ubiquitination of alpha5 integrin subunit mediates fibronectin-dependent osteoblast detachment and apoptosis induced by FGFR2 activation

Fibroblast growth factor receptor signaling is an important mechanism regulating osteoblast function. To gain an insight into the regulatory role of FGF receptor-2 (FGFR2) signaling in osteoblasts, we investigated integrin-mediated attachment and cell survival in human calvarial osteoblasts expressing activated FGFR2. FGFR2 activation reduced osteoblast attachment on fibronectin. This was associated with reduced expression of the alpha5 integrin subunit normally expressed in human calvarial osteoblasts in vivo. Treatment with lactacystin, a potent inhibitor of proteasome, restored alpha5 integrin levels in FGFR2 mutant osteoblasts. Immunoprecipitation analysis showed that alpha5 integrin interacts with both the E3 ubiquitin ligase Cbl and ubiquitin. Immunocytochemistry revealed that alpha5 integrin colocalizes with FGFR2 and Cbl at the leading edge in membrane ruffle regions. Transfection with the 70Z-Cbl mutant lacking the RING domain required for Cbl-ubiquitin interaction, or with the G306E Cbl mutant that abolishes the binding ability of Cbl phosphotyrosine-binding domain restored alpha5 integrin levels. This suggests that Cbl-mediated ubiquitination plays an essential role in alpha5 integrin proteasome degradation induced by FGFR2 activation. Reduced alpha5 integrin expression was associated with an increased Bax/Bcl-2 ratio and increased caspase-9 and -3 activities in FGFR2 mutant osteoblasts. Forced expression of alpha5 integrin rescued cell attachment and corrected both the Bax/Bcl-2 ratio and caspase-3 and caspase-9 activities in FGFR2 mutant osteoblasts. We show that Cbl recruitment induced by FGFR2 activation triggers alpha5 integrin degradation by the proteasome, which results in reduced osteoblast attachment on fibronectin and caspase-dependent apoptosis. This identifies a functional role of the alpha5 integrin subunit in the induction of apoptosis triggered by FGFR2 activation in osteoblasts, and reveals that a Cbl-dependent mechanism is involved in the coordinated regulation of cell apoptosis induced by alpha5 integrin degradation.

Tendon healing in vitro: genetic modification of tenocytes with exogenous PDGF gene and promotion of collagen gene expression

PURPOSE

Promotion of collagen production can increase tendon healing strength and reduce repair ruptures. Transfer of an exogenous growth factor gene to tenocytes of intrasynovial tendons may enhance the capacity of cells to produce collagen. We transferred the platelet-derived growth factor B (PDGF-B) gene to tenocytes and investigated its effects on the expression of the PDGF gene and the type I collagen gene in an in vitro tenocyte culture model.

METHODS

Tenocytes obtained from explant cultures of rat intrasynovial tendons were treated for 12 hours with the plasmid containing the PDGF complementary deoxyribonucleic acid (cDNA) with liposome and were then cultured for 6 additional days. The control tenocytes did not receive the exogenous gene and liposome. Efficiency of the gene transfer was evaluated by using reverse transcription polymerase chain reactions (RT-PCR) to detect the presence of the transferred gene in the tenocytes. Enhancement of the expression of the target gene was assessed by RT-PCR with primers effective to amplify both internal and transferred genes. Expression of the type I collagen gene was determined by quantitative analysis of the products of RT-PCR.

RESULTS

Levels of expression of the type I collagen gene by tenocytes were increased significantly by transfer of the exogenous PDGF gene to the tenocytes. Efficiency of the gene transfer was confirmed by the presence of exogenous PDGF cDNA in the tenocytes receiving the transferred gene. Expression of the PDGF gene increased significantly in the cells treated with exogenous PDGF cDNA.

CONCLUSIONS

Exogenous PDGF genes can be transferred effectively into intrasynovial tenocytes and the transfer increases significantly the expression of genes for PDGF and type I collagen. Transfer of the PDGF gene may offer a novel way of effectively promoting healing of intrasynovial flexor tendons. The findings warrant future in vivo study to test the effectiveness of gene therapy to promote flexor tendon healing.

Clinical implications of growth factors in flexor tendon wound healing

Recent research has focused on the role of growth factors in flexor tendon wound healing. These basic science reports have described the identification and quantification of various growth factors in in vitro and in vivo models. Although these reports have begun to piece together the cascade of events involved in flexor tendon wound healing, the clinical relevance for the practicing hand surgeon is unclear. Growth factors are cell-secreted proteins that regulate cellular functions. These growth factors are involved in cell differentiation and growth, including the normal processes of development and tissue repair. Several growth factors recently have been identified as playing roles in tendon healing including vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and transforming growth factor beta (TGF-beta). In addition, the transcription factor NF-kappaB has been implicated in the signaling pathways of these growth factors. The purpose of this article is to describe what is known about the molecular basis of flexor tendon wound healing, to review the most commonly studied growth factors, and to summarize likely clinical applications of these growth factors to flexor tendon repair.

Promoting the proliferative and synthetic activity of knee meniscal fibrochondrocytes using basic fibroblast growth factor in vitro

BACKGROUND

Meniscal tears situated within the inner avascular region do not heal despite suturing. New approaches need to be developed to augment surgical repair.

HYPOTHESIS

To demonstrate that basic fibroblast growth factor, used as a single agent or in combination with serum, stimulates the activity of fibrochondrocytes by enhancing proliferation and extracellular matrix synthesis in all meniscal zones, including the inner (avascular) zone of the meniscus.

STUDY DESIGN

Controlled laboratory study.

METHODS

Monolayer cell cultures were prepared from the inner, middle, and outer zones of the lateral meniscus. Various concentrations of basic fibroblast growth factor were used in the presence or absence of 10% fetal calf serum. The authors measured the uptake of radiolabeled thymidine to assess cell proliferation and radioactive sulfur and proline to assess extracellular matrix formation.

RESULTS

Overall, basic fibroblast growth factor-stimulated cells from all meniscal zones to proliferate and to form new extra-cellular matrix (P <.05). The basic fibroblast growth factor (in the absence of serum) increased DNA formation and protein synthesis by cells from the inner meniscal zone by 7- and 15-fold, respectively (P <.001).

CONCLUSIONS

These results indicate that meniscal cells and, more important, cells from the avascular zone are capable of responding favorably to the addition of basic fibroblast growth factor by expressing their intrinsic potential to proliferate and generate new extracellular matrix.

CLINICAL RELEVANCE

The results suggest that it may be possible to augment surgical repair of the meniscus in the future.

Role of extracellular matrix in adaptation of tendon and skeletal muscle to mechanical loading

The extracellular matrix (ECM), and especially the connective tissue with its collagen, links tissues of the body together and plays an important role in the force transmission and tissue structure maintenance especially in tendons, ligaments, bone, and muscle. The ECM turnover is influenced by physical activity, and both collagen synthesis and degrading metalloprotease enzymes increase with mechanical loading. Both transcription and posttranslational modifications, as well as local and systemic release of growth factors, are enhanced following exercise. For tendons, metabolic activity, circulatory responses, and collagen turnover are demonstrated to be more pronounced in humans than hitherto thought. Conversely, inactivity markedly decreases collagen turnover in both tendon and muscle. Chronic loading in the form of physical training leads both to increased collagen turnover as well as, dependent on the type of collagen in question, some degree of net collagen synthesis. These changes will modify the mechanical properties and the viscoelastic characteristics of the tissue, decrease its stress, and likely make it more load resistant. Cross-linking in connective tissue involves an intimate, enzymatical interplay between collagen synthesis and ECM proteoglycan components during growth and maturation and influences the collagen-derived functional properties of the tissue. With aging, glycation contributes to additional cross-linking which modifies tissue stiffness. Physiological signaling pathways from mechanical loading to changes in ECM most likely involve feedback signaling that results in rapid alterations in the mechanical properties of the ECM. In developing skeletal muscle, an important interplay between muscle cells and the ECM is present, and some evidence from adult human muscle suggests common signaling pathways to stimulate contractile and ECM components. Unaccostumed overloading responses suggest an important role of ECM in the adaptation of myofibrillar structures in adult muscle. Development of overuse injury in tendons involve morphological and biochemical changes including altered collagen typing and fibril size, hypervascularization zones, accumulation of nociceptive substances, and impaired collagen degradation activity. Counteracting these phenomena requires adjusted loading rather than absence of loading in the form of immobilization. Full understanding of these physiological processes will provide the physiological basis for understanding of tissue overloading and injury seen in both tendons and muscle with repetitive work and leisure time physical activity.

Platelet-derived growth factor gene delivery stimulates ex vivo gingival repair

Destruction of tooth support due to the chronic inflammatory disease periodontitis is a major cause of tooth loss. There are limitations with available treatment options to tissue engineer soft tissue periodontal defects. The exogenous application of growth factors (GFs) such as platelet-derived growth factor (PDGF) has shown promise to enhance oral and periodontal tissue regeneration. However, the topical administration of GFs has not led to clinically significant improvements in tissue regeneration because of problems in maintaining therapeutic protein levels at the defect site. The utilization of PDGF gene transfer may circumvent many of the limitations with protein delivery to soft tissue wounds. The objective of this study was to test the effect of PDGF-A and PDGF-B gene transfer to human gingival fibroblasts (HGFs) on ex vivo repair in three-dimensional collagen lattices. HGFs were transduced with adenovirus encoding PDGF-A and PDGF-B genes. Defect fill of bilayer collagen gels was measured by image analysis of cell repopulation into the gingival defects. The modulation of gene expression at the defect site and periphery was measured by RT-PCR during a 10-day time course after gene delivery. The results demonstrated that PDGF-B gene transfer stimulated potent (>4-fold) increases in cell repopulation and defect fill above that of PDGF-A and corresponding controls. PDGF-A and PDGF-B gene expression was maintained for at least 10 days. PDGF gene transfer upregulated the expression of phosphatidylinosital 3-kinase and integrin alpha5 subunit at 5 days after adenovirus transduction. These results suggest that PDGF gene transfer has potential for periodontal soft tissue-engineering applications.

cDNA-arrays and real-time quantitative PCR techniques in the investigation of chronic Achilles tendinosis

The aetiology and pathogenesis of chronic painful Achilles tendinosis are unknown. This investigation aimed to use cDNA arrays and real-time quantitative polymerase chain reaction (real-time PCR) technique to study tendinosis and control tissue samples. Five patients (females mean age 57.1+/-4.3 (years+/-SD)) with chronic painful Achilles tendinosis were included. From all patients, one biopsy was taken from the area with tendinosis and one from a clinically normal area (control) of the tendon. The tissue samples were immediately immersed in RNAlater and frozen at -80 degrees C until RNA extraction. Portions of pooled RNA from control and tendinosis sites, respectively, were transcribed to cDNA, radioactively labelled (32P), hybridized to cDNA expression arrays, and exposed to phosphoimager screens over night. Expressions of specific genes, shown to be regulated in the cDNA array analysis, were analyzed in the individual samples using real-time PCR. cDNA arrays showed that gene expressions for matrix-metalloproteinase-2 (MMP-2), fibronectin subunit B (FNRB), vascular endothelial growth factor (VEGF), and mitogen-activated protein kinase p38 (MAPKp38) were up-regulated, while matrix-metalloproteinase-3 (MMP-3) and decorin were down-regulated, in tendinosis tissue compared with control tissue. Using real-time PCR, 4/5 and 3/5 patients showed up-regulation of MMP-2 and FNRB mRNA, respectively. For decorin, VEGF, and MAPKp38, real-time PCR revealed a great variability among patients. Interestingly, the mRNAs for several cytokines and cytokine receptors were not regulated, indicating the absence of an inflammatory process in chronic painful Achilles tendinosis. In conclusion, cDNA-arrays and real-time PCR can be used to study differences in gene expression levels between tendinosis and control tendon tissue.

Tendon healing in vitro: promotion of collagen gene expression by bFGF with NF-kappaB gene activation

PURPOSE

Matrix synthesis of intrasynovial tendon cells and activation of nuclear transcription factors are pivotal to promotion of flexor tendon healing. We investigated the effects of basic fibroblast growth factor (bFGF) on synthesis of type I collagen and activation of nuclear transcription factor kappaB (NF-kappaB) in an in vitro culture model of intrasynovial tenocytes.

METHOD

Tenocytes obtained from explant culture of rabbit intrasynovial tendon segments were treated with bFGF at concentrations of 0, 2, and 10 ng/mL. Expression of type I collagen and NF-kappaB genes was determined by quantitative analysis of products of reverse-transcription polymerase chain reactions. Proliferation of the cells was assessed by incorporation of bromodeoxyuridine into the DNA of the cells.

RESULTS

Expression levels of type I collagen and NF-kappaB genes of tenocytes were increased significantly by bFGF. Cell proliferation as indicated by DNA labeling was promoted significantly by bFGF. Expression of the NF-kappaB gene increased proportionately to the amounts of bFGF stimulating the cells and was correlated with increases in proliferation rate of tenocytes.

CONCLUSIONS

Results of this study show that expression of type I collagen and NF-kappaB genes is promoted manifestly by bFGF. The effects were proportionate to in vitro proliferation rates of tenocytes. The study indicated that matrix synthesis of flexor tendons can be promoted by bFGF and that NF-kappaB may play a pivotal role in initiating proliferation and type I collagen synthesis of tenocytes.

Growth factors in the treatment of diabetic foot ulcers

BACKGROUND

Chronic foot ulceration is a major source of morbidity in diabetic patients. Despite traditional comprehensive wound management, including vascular reconstruction, there remains a cohort of patients with non-responding wounds, often resulting in amputation. These wounds may benefit from molecular manipulation of growth factors to enhance the microcirculation.

METHODS

A review of the current literature was performed using Pubmed, with secondary references obtained from key articles.

RESULTS AND CONCLUSION

There has been a generally disappointing clinical outcome from growth factor trials, although topical platelet-derived growth factor has shown significant benefit and should be considered in non-healing, well perfused ulcers after failure of conventional wound care. The modulatory role of the extracellular matrix in the cellular response to growth factors and data from regenerative-type fetal wound healing are further areas of interest. The chemical induction of microvessel formation may become a future therapeutic option.

Biomimetic approaches to tendon repair

The linear organization of collagen fibers in tendons results in optimal stiffness and strength at low strains under tensile load. However, this organization makes repairing ruptured or lacerated tendons extremely difficult. Current suturing techniques to join split ends of tendons, while providing sufficient mechanical strength to prevent gapping, are inadequate to carry normal loads. Immobilization protocols necessary to restore tendon congruity result in scar formation at the repair site and peripheral adhesions that limit excursion. These problems are reviewed to emphasize the need for novel approaches to tendon repair, one of which is the development of biomimetic tendons. The objective of the empirical work described here was to produce biologically-based, biocompatible tendon replacements with appropriate mechanical properties to enable immediate mobilization following surgical repair. Nor-dihydroguaiaretic acid (NDGA), a di-catechol from creosote bush, caused a dose dependent increase in the material properties of reconstituted collagen fibers, achieving a 100-fold increase in strength and stiffness over untreated fibers. The maximum tensile strength of the optimized NDGA treated fibers averaged 90 MPa; the elastic modulus of these fibers averaged 580 MPa. These properties were independent of strain rates ranging from 0.60 to 600 mm/min. Fatigue tests established that neither strength nor stiffness were affected after 80 k cycles at 5% strain. Treated fibers were not cytotoxic to tendon fibroblasts. Fibroblasts attached and proliferated on NDGA treated collagen normally. NDGA-fibers did not elicit a foreign body response nor did they stimulate an immune reaction during six weeks in vivo. The fibers survived 6 weeks with little evidence of fragmentation or degradation. The polymerization scheme described here produces a fiber-reinforced NDGA-polymer with mechanical properties approaching an elastic solid. The strength, stiffness and fatigue properties of the NDGA-treated fibers are comparable to those of tendon. These fibers are biocompatible with tendon fibroblasts and elicit little rejection or antigenic response in vivo. These results indicate that NDGA polymerization may provide a viable approach for producing collagenous materials that can be used to bridge gaps in ruptured or lacerated tendons. The tendon-like properties of the NDGA-fiber would allow early mobilization after surgical repair. We predict that timely loading of parted tendons joined by this novel biomaterial will enhance mechanically driven production of neo-tendon by the colonizing fibroblasts and result in superior repair and rapid return to normal properties.

Tissue-engineered repair of osteochondral defects: effects of the age of donor cells and host tissue

Transplantation of a tissue-engineered construct containing cells of a chondrocytic phenotype into an osteochondral defect provides a biological solution to this type of injury. Among the factors that affect cell proliferation and phenotypic expression, age is one that has not been well characterized. In this study adult and aged male donor cells, derived from perichondrium, were cultured and adsorbed into a polylactic acid (PLA) scaffold and transplanted into osteochondral defects created in adult (8- to 10-month-old) and aged (4- to 5-year-old) female rabbits. Three groups were investigated: (1) adult cells transplanted into aged defects, (2) aged cells transplanted into aged defects, and (3) aged cells transplanted into adult defects. In vitro characterization of adult and aged cells and in vivo assessment of osteochondral repair tissue at 12 weeks posttransplantation were carried out. The in vitro studies demonstrated that the proliferation rate of aged cells was less than that of mature cells during the earliest stage of culture. Also, the chondrocytic phenotype was reduced in aged cells compared with mature cells. The in vivo results showed that donor (SRY-positive) cell survival differed among the three groups: survival of adult cells into aged defect > survival of aged cells into aged defect > survival of aged cells into adult defect. The biological acceptability of the repair, defined as smooth firm cartilaginous tissue filling the defect, was < 25% of the operated specimens in each of the three groups. This repair tissue contained only 20-25% of the amounts of type II collagen and glycosaminoglycans found in normal articular cartilage. These data suggest that the outcome of tissue-engineered repair of osteochondral defects is affected by both the age of donor cells and the age of the host.

ACL transection influences mRNA levels for collagen type I and TNF-alpha in MCL scar

To assess the mRNA expression of extracellular matrix genes which might correlate with or contribute to mechanically weaker medial collateral ligament (MCL) scars in the ACL-deficient rabbit knee joint compared to those in anterior cruciate ligament (ACL) intact knee joints, a bilateral MCL injury was induced in 10 skeletally mature female NZW rabbits. As part of the same surgical procedure, the ACL was transected in one of the knees while the contralateral knee had a sham procedure. The side having the combined MCL and ACL injury was randomly assigned. After six weeks, the rabbits were euthanized. Histological assessments were performed on samples of the MCL scars from each operated knee (n = 3 animals) and mRNA levels for collagen type I, III, V, decorin, biglycan, lumican, fibromodulin, TGF-beta, IL-1, TNF-alpha, MMP-1, MMP-13, and a housekeeping gene (GAPDH) were assessed using semiquantitative RT-PCR on RNA isolated from the MCL scar tissue of the remaining animals (n = 7 animals). Levels of mRNA for each gene were normalized using the corresponding GAPDH value. Results showed that the total RNA yield (per mg wet weight) in the MCL scar of the ACL-deficient knee was significantly greater than that in the MCL scar from the ACL-intact knee. Collagen type I mRNA levels were significantly lower and mRNA levels for TNF-alpha were significantly greater in the scars of ACL-deficient knees compared to scars from ACL-intact joints. There were no significant differences between ACL-deficient and ACL-intact knees with respect to MCL scar mRNA levels for the remaining genes assessed. Histologically, the "flaw" area, which has been shown to correlate with mechanical properties in previous studies, was significantly greater in MCL scars from ACL-deficient knees than in the ACL-intact MCL scars. The mean number of cells/mm2 in MCL scars from ACL-deficient knees was significantly greater than in MCL scars from ACL-intact knees. The present study suggests that MCL scar cell metabolism is differentially influenced by the combined injury environment.

The vasculature and its role in the damaged and healing tendon

Tendon pathology has many manifestations, from spontaneous rupture to chronic tendinitis or tendinosis; the etiology and pathology of each are very different, and poorly understood. Tendon is a comparatively poorly vascularised tissue that relies heavily upon synovial fluid diffusion to provide nutrition. During tendon injury, as with damage to any tissue, there is a requirement for cell infiltration from the blood system to provide the necessary reparative factors for tissue healing. We describe in this review the response of the vasculature to tendon damage in a number of forms, and how and when the revascularisation or neovascularisation process occurs. We also include a section on the revascularisation of tendon during its use as a tendon graft in both ligament reconstruction and tendon-tendon grafting.

The ontogeny of scarless healing II: EGF and PDGF-B gene expression in fetal rat skin and fibroblasts as a function of gestational age

Twenty years ago, surgeons noted the ability of early-gestation fetal skin to heal in a scarless manner. Since that time, numerous investigators have attempted to elucidate the mechanisms behind this phenomenon. As a result of this effort, it is now well established that many animals undergo a transition late in development from scarless cutaneous healing to a scar-forming, adultlike phenotype. The authors have been interested in the role played by cytokines known to be involved in the adult wound-healing process and how they relate to scarless repair. They therefore asked the following question: Are genes for epidermal growth factor (EGF) and platelet-derived growth factor-B (PDGF-B) expressed differentially as a function of gestational age in fetal rat skin and dermal fibroblasts? To answer this question, skin from fetal Sprague-Dawley rats (N = 56) at time points that represented both the scarless and scar-forming periods of rat gestation was harvested. In addition, fibroblasts derived from fetal rat skin were cultured in vitro at similar times. These cells were expanded in culture and, when confluent, total ribonucleic acid from both fibroblasts and whole skin was extracted and subjected to Northern blot analysis with probes for EGF and PDGF-B. Results demonstrated that neither EGF nor PDGF-B gene expression changed markedly as a function of gestational age in fetal fibroblasts alone. In whole skin, however, both EGF and PDGF-B demonstrated a marked decrease in gene expression with increasing gestational age. Furthermore, the most striking decrease in gene expression for both cytokines came between 16 and 18 days of gestation-the transition point between scarless and scar-forming repair in the fetal rat. These data suggest that EGF and PDGF may play a role in the mechanism of scarless cutaneous repair. Moreover, it appears that fetal fibroblasts are not the cell type responsible for this differential gene expression. These results raise questions about the unique cytokine milieu likely to be present during the time of scarless healing and the cells that ultimately guide the mechanisms leading to skin regeneration.

The effect of variations in applied rehabilitation force on collagen concentration and maturation at the intrasynovial flexor tendon repair site

The biochemical means by which accelerated rehabilitation alters intrasynovial flexor tendon repair site collagen synthesis and extracellular matrix maturation are not fully understood. We hypothesized that an increased level of applied rehabilitative force in a clinically relevant animal model would hasten the maturation of the repair site extracellular matrix as demonstrated by total collagen and collagen cross-link assessment. Twenty-eight flexor digitorum profundus tendons from 14 adult dogs were transected and repaired. The animals received either low- or high-force rehabilitation and were killed 10, 21, and 42 days after surgery. A 10-mm segment of tendon surrounding the repair site was obtained. Biochemical analysis showed that total collagen concentration was significantly reduced at each time point, that the reducible cross-link ratio of dihydroxylysinonorleucine to hydroxylysinonorleucine was significantly increased at each time point, and that the nonreducible pyridinoline cross-link content was significantly decreased at 10 days in both rehabilitative groups. Total collagen content did not vary to a statistically significant degree with either time or as a function of rehabilitation type. Based on these findings several clinically relevant observations can be made. Increasing collagen concentration and repair site maturation do not explain the previously demonstrated increased tensile properties of tendon that occur between 3 and 6 weeks after repair. Higher force rehabilitation does not alter the biochemical composition of the healing tendon through 6 weeks. Coupled with other recent data these findings suggest that high-force rehabilitation does not stimulate accelerated healing after intrasynovial flexor tendon repair.

Differential expression of integrin alpha v and beta 3 in serosal tissue of human intraperitoneal organs and adhesion

OBJECTIVE

To assess the expression of integrin alpha v and beta 3 in the serosal tissue of intraperitoneal organs and adhesions in persons with and without adhesions.

DESIGN

Prospective study.

SETTING

Academic research centers.

PATIENT(S)

Fifty-seven patients undergoing abdominal or pelvic surgery.

MAIN OUTCOME MEASURE(S)

Integrin alpha v and beta 3 messenger RNA (mRNA) expression was evaluated by quantitative reverse transcription polymerase chain reaction.

RESULT(S)

The serosal tissue of the parietal peritoneum, uterus, fallopian tubes, ovary, and the large and small bowel, as well as peritoneal adhesions, skin, fascia, subcutaneous tissue, and omentum, expresses integrin alpha v and beta 3 mRNA. The level of alpha v and beta 3 mRNA expression varied among these tissues; expression of the former substance was highest in uterine serosa and lowest in the skin and small bowel, and expression of the latter substance was highest in the fallopian tubes and skin and lowest in the uterine serosa. Parietal peritoneum and adhesions express equal levels of integrin alpha v; however, integrin beta 3 expression was >100-fold lower in adhesions than in peritoneum. The level of integrin beta 3 expression in omentum, small and large bowels, and subcutaneous tissue was 100-fold to 10,000-fold lower than in other tissues.

CONCLUSION(S)

Serosal tissue of peritoneal organs and adhesions express variable levels of integrin alpha v and beta 3 mRNA. On the basis of such variation and the knowledge that tissue injury alters local integrin expression, integrins may play a key role in adhesion development, particularly in tissue with higher integrin expression.

A novel function for the tumor suppressor p16(INK4a): induction of anoikis via upregulation of the alpha(5)beta(1) fibronectin receptor

The tumor suppressor gene p16(INK4a) inhibits the kinase activity of the cyclin-dependent kinase 4-6/cyclin D complexes and subsequent phosphorylation of critical substrates necessary for transit through the G1 phase of the cell cycle. Recent studies suggested that control of the G1/S boundary might not be the sole biological function of p16(INK4a). We hypothesized that p16(INK4a) might influence hitherto unknown critical features of a malignant epithelial phenotype, such as anchorage dependence. Here we provide evidence that stable transfection of p16(INK4a) restitutes apoptosis induction upon loss of anchorage (anoikis) in a variety of human cancer cells. Anoikis in p16(INK4a)-transfected cells was evidenced by DNA fragmentation and poly(ADP-ribose) polymerase cleavage upon cultivation on polyhydroxyethylmethacrylate-coated dishes and was associated with suppression of anchorage-independent growth as well as complete loss of tumorigenicity. p16(INK4a)-mediated anoikis was due to selective transcriptional upregulation of the alpha(5) integrin chain of the alpha(5)beta(1) fibronectin receptor as detected by FACS((R)) analysis, immunoprecipitation, Northern blotting, and nuclear run-on assays. Addition of soluble fibronectin and inhibitory alpha(5) antibodies to nonadherent cells completely abolished p16(INK4a)-mediated anoikis, whereas laminin was ineffective. Furthermore, antisense-induced downregulation of the alpha(5) integrin chain in p16(INK4a)-transfected cells restored resistance to anoikis. These data suggest a novel functional interference between a cell cycle-regulating tumor suppressor gene and membrane-bound integrins, thus regulating a hallmark feature of an epithelial transformed phenotype: susceptibility to anoikis.