Genetic engineering of meniscal allografts

A Versatile Surgical Method for Studying Meniscus Implantation in a Rabbit Model

Meniscus injury is a health problem that greatly affects people's quality of life. In recent years, the number of diagnosed meniscus injury is increasing year by year. If not treated in time and correctly, it causes severe damages to the cartilage. Owing to the meniscus' limited healing ability, synthetic/tissue-engineered meniscus has emerged as a new treatment modality in recent years. Rabbit models, which have been proved to be a feasible animal model, have been extensively used to study meniscus implantation. However, there is not a unified and minimally invasive surgical method for meniscus implantation in rabbits, and the current surgical methods have unsolved problems, such as long incisions, patella valgus, and cutting of the medial collateral ligament. Therefore, the goal of this study is to provide a minimally invasive and versatile meniscus implantation method. Compared with the control group, our study showed less trauma to the animal model, and we believe that it has the application significance on tissue-engineered meniscus implantation. Impact statement Meniscal injury is a central area of sports medicine research because of the high and increasing global rate. With its profound potential implications for patients' functions and the subsequent development of arthritis, there is a great need for the synthetic/tissue-engineered menisci. Animal meniscus implantation models allow studying meniscus implantation with synthetic/tissue-engineered meniscus, and the rabbit model is a gold method for meniscus implantation in the laboratory. However, there has not yet been a minimally invasive and versatile surgical technique describing this surgery method. This article, therefore, provides a detailed description of the rabbit meniscus implantation method, including step-by-step surgical instructions and accompanying pictures.

Development of biological meniscus scaffold: Decellularization method and recellularization with meniscal cell population derived from mesenchymal stem cells

Tissue engineering approaches which include a combination of cells and scaffold materials provide an alternative treatment for meniscus regeneration. Decellularization and recellularization techniques are potential treatment options for transplantation. Maintenance of the ultrastructure composition of the extracellular matrix and repopulation with cells are important factors in constructing a biological scaffold and eliminating immunological reactions.The aim of the study is to develop a method to obtain biological functional meniscus scaffolds for meniscus regeneration. For this purpose, meniscus tissue was decellularized by our modified method, a combination of physical, chemical, and enzymatic methods and then recellularized with a meniscal cell population composed of fibroblasts, chondrocytes and fibrochondrocytes that obtained from mesenchymal stem cells. Decellularized and recellularized meniscus scaffolds were analysed biochemically, biomechanically and histologically. Our results revealed that cellular components of the meniscus were successfully removed by preserving collagen and GAG structures without any significant loss in biomechanical properties. Recellularization results showed that the meniscal cells were localized in the empty lacuna on the decellularized meniscus, and also well distributed and proliferated consistently during the cell culture period (p < 0.05). Furthermore, a high amount of DNA, collagen, and GAG contents (p < 0.05) were obtained with the meniscal cell population in recellularized meniscus tissue.The study demonstrates that our decellularization and recellularization methods were effective to develop a biological functional meniscus scaffold and can mimic the meniscus tissue with structural and biochemical features. We predict that the obtained biological meniscus scaffolds may provide avoidance of adverse immune reactions and an appropriate microenvironment for allogeneic or xenogeneic recipients in the transplantation process. Therefore, as a promising candidate, the obtained biological meniscus scaffolds might be verified with a transplantation experiment.

Nonviral ultrasound-mediated gene delivery in small and large animal models

Ultrasound-mediated gene delivery (sonoporation) is a minimally invasive, nonviral and clinically translatable method of gene therapy. This method offers a favorable safety profile over that of viral vectors and is less invasive as compared with other physical gene delivery approaches (e.g., electroporation). We have previously used sonoporation to overexpress transgenes in different skeletal tissues in order to induce tissue regeneration. Here, we provide a protocol that could easily be adapted to address various other targets of tissue regeneration or additional applications, such as cancer and neurodegenerative diseases. This protocol describes how to prepare, conduct and optimize ultrasound-mediated gene delivery in both a murine and a porcine animal model. The protocol includes the preparation of a microbubble-DNA mix and in vivo sonoporation under ultrasound imaging. Ultrasound-mediated gene delivery can be accomplished within 10 min. After DNA delivery, animals can be followed to monitor gene expression, protein secretion and other transgene-specific outcomes, including tissue regeneration. This procedure can be accomplished by a competent graduate student or technician with prior experience in ultrasound imaging or in performing in vivo procedures.

Biochemical Stimulus-Based Strategies for Meniscus Tissue Engineering and Regeneration

Meniscus injuries are very common and still pose a challenge for the orthopedic surgeon. Meniscus injuries in the inner two-thirds of the meniscus remain incurable. Tissue-engineered meniscus strategies seem to offer a new approach for treating meniscus injuries with a combination of seed cells, scaffolds, and biochemical or biomechanical stimulation. Cell- or scaffold-based strategies play a pivotal role in meniscus regeneration. Similarly, biochemical and biomechanical stimulation are also important. Seed cells and scaffolds can be used to construct a tissue-engineered tissue; however, stimulation to enhance tissue maturation and remodeling is still needed. Such stimulation can be biomechanical or biochemical, but this review focuses only on biochemical stimulation. Growth factors (GFs) are one of the most important forms of biochemical stimulation. Frequently used GFs always play a critical role in normal limb development and growth. Further understanding of the functional mechanism of GFs will help scientists to design the best therapy strategies. In this review, we summarize some of the most important GFs in tissue-engineered menisci, as well as other types of biological stimulation.

Advances in combining gene therapy with cell and tissue engineering-based approaches to enhance healing of the meniscus

Meniscal lesions are common problems in orthopaedic surgery and sports medicine, and injury or loss of the meniscus accelerates the onset of knee osteoarthritis (OA). Despite a variety of therapeutic options in the clinics, there is a critical need for improved treatments to enhance meniscal repair. In this regard, combining gene-, cell-, and tissue engineering-based approaches is an attractive strategy to generate novel, effective therapies to treat meniscal lesions. In the present work, we provide an overview of the tools currently available to improve meniscal repair and discuss the progress and remaining challenges for potential future translation in patients.

Overexpression of TGF-β via rAAV-Mediated Gene Transfer Promotes the Healing of Human Meniscal Lesions Ex Vivo on Explanted Menisci

BACKGROUND

Direct application of therapeutic gene vectors derived from the adeno-associated virus (AAV) might be beneficial to improve the healing of meniscal tears.

PURPOSE

To test the ability of recombinant AAV (rAAV) to overexpress the potent transforming growth factor-β (TGF-β) in primary cultures of human meniscal fibrochondrocytes, in human meniscal explants, and in experimental human meniscal lesions as a new tool to enhance meniscal repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

The effects of the candidate treatment on the proliferative and metabolic activities of meniscal cells were monitored in vitro for up to 21 days and in situ in intact and injured human menisci for up to 15 days using biochemical, immunohistochemical, histological, and histomorphometric analyses.

RESULTS

Efficient production of TGF-β via rAAV was achieved in vitro and in situ, both in the intact and injured meniscus. Application of the rAAV TGF-β vector stimulated the levels of cell proliferation and matrix synthesis (type I collagen) compared with control gene transfer in all systems tested, especially in situ in regions of poor healing capacity and in sites of meniscal injury. No adverse effects of the candidate treatment were observed at the level of osseous differentiation, as tested by immunodetection of type X collagen. Most remarkably, a significant reduction of the amplitude of meniscal tears was noted after TGF-β treatment, an effect that was associated with increased expression levels of the α-smooth muscle actin contractile marker.

CONCLUSION

Overexpression of TGF-β via rAAV gene transfer is capable of modulating the reparative activities of human meniscal cells, allowing for the healing of meniscal lesions by convenient injection in sites of injury.

CLINICAL RELEVANCE

Direct gene-based approaches using rAAV have strong potential to develop new therapeutic options that aim at treating human meniscal defects.

Meniscal allograft transplantation. Part 1: systematic review of graft biology, graft shrinkage, graft extrusion, graft sizing, and graft fixation

PURPOSE

To provide a systematic review of the literature regarding five topics in meniscal allograft transplantation: graft biology, shrinkage, extrusion, sizing, and fixation.

METHODS

A systematic literature search was conducted using the PubMed (MEDLINE), ScienceDirect, and EBSCO-CINAHL databases. Articles were classified only in one topic, but information contained could be reported into other topics. Information was classified according to type of study (animal, in vitro human, and in vivo human) and level of evidence (for in vivo human studies).

RESULTS

Sixty-two studies were finally included: 30 biology, 3 graft shrinkage, 11 graft extrusion, 17 graft size, and 6 graft fixation (some studies were categorized in more than one topic). These studies corresponded to 22 animal studies, 22 in vitro human studies, and 23 in vivo human studies (7 level II, 10 level III, and 6 level IV).

CONCLUSIONS

The principal conclusions were as follows: (a) Donor cells decrease after MAT and grafts are repopulated with host cells form synovium; (b) graft preservation alters collagen network (deep freezing) and causes cell apoptosis with loss of viable cells (cryopreservation); (c) graft shrinkage occurs mainly in lyophilized and gamma-irradiated grafts (less with cryopreservation); (d) graft extrusion is common but has no clinical/functional implications; (e) overall, MRI is not superior to plain radiograph for graft sizing; (f) graft width size matching is more important than length size matching; (g) height appears to be the most important factor influencing meniscal size; (h) bone fixation better restores contact mechanics than suture fixation, but there are no differences for pullout strength or functional results; and (i) suture fixation has more risk of graft extrusion compared to bone fixation.

LEVEL OF EVIDENCE

Systematic review of level II-IV studies, Level IV.

Gene Therapy for Cartilage Repair

The concept of using gene transfer strategies for cartilage repair originates from the idea of transferring genes encoding therapeutic factors into the repair tissue, resulting in a temporarily and spatially defined delivery of therapeutic molecules to sites of cartilage damage. This review focuses on the potential benefits of using gene therapy approaches for the repair of articular cartilage and meniscal fibrocartilage, including articular cartilage defects resulting from acute trauma, osteochondritis dissecans, osteonecrosis, and osteoarthritis. Possible applications for meniscal repair comprise meniscal lesions, meniscal sutures, and meniscal transplantation. Recent studies in both small and large animal models have demonstrated the applicability of gene-based approaches for cartilage repair. Chondrogenic pathways were stimulated in the repair tissue and in osteoarthritic cartilage using genes for polypeptide growth factors and transcription factors. Although encouraging data have been generated, a successful translation of gene therapy for cartilage repair will require an ongoing combined effort of orthopedic surgeons and of basic scientists.

Importance of independent measurement of width and length of lateral meniscus during preoperative sizing for meniscal allograft transplantation

BACKGROUND

Successful meniscus transplantation depends on an accurate sizing of the meniscal allograft. Although accurate sizing of the meniscal allograft is crucial during meniscus transplantation, the accuracy of meniscal measurement methods is still in debate.

PURPOSE

This study was undertaken to evaluate the relationship between the width and length of the lateral meniscus. These anatomic dimensions were also evaluated in the context of the patient's height, weight, gender, and body mass index (BMI).

STUDY DESIGN

Descriptive laboratory study.

METHODS

Ninety-one samples of fresh lateral meniscus were obtained during total knee arthroplasty. The samples were obtained carefully without injuring the meniscus itself and the bony attachment sites. For each lateral meniscus, the anatomic dimensions (width [LMW] and length [LML]) were recorded. The height, weight, gender, and BMI of the patients were also recorded. The Pearson correlation and multivariate and linear regression analysis were applied for each variable. The accuracy was defined as those measures that fell within 10% of the original size. A P value ≤ .05 was considered significant.

RESULTS

The mean LMW was 30.7 mm (standard deviation [SD] = 3.5) and 27.0 mm (SD = 2.6) for men and women, respectively. The mean LML was 33.7 mm (SD = 4.3) and 30.8 mm (SD = 2.6) for men and women, respectively. Thirty-nine samples (42.5%) showed LMW measurements within a 10% difference of LML, whereas 50 samples (55%) showed an LMW greater than a 10% difference of LML. Although there were correlations between LML with LMW in men and correlations between weight and LMW with LML in women, the accuracy for the derived linear regression formulas was 3%, 9%, and 12%, respectively.

CONCLUSION

The length cannot be predicted accurately from the width of the lateral meniscus. The height, weight, gender, and BMI failed to estimate the dimensions of the lateral meniscus. Therefore, it is essential to measure the width and length separately and match it with the allograft with other size measuring methods.

CLINICAL RELEVANCE

This study emphasizes the importance of measuring the width and length of the lateral meniscus independently during preoperative sizing for a meniscal allograft transplantation procedure. The height, weight, gender, and body mass index may not be reliable parameters for estimating the size of the meniscus.

Generation and characterization of a human acellular meniscus scaffold for tissue engineering

Meniscus tears are frequent indications for arthroscopic evaluation which can result in partial or total meniscectomy. Allografts or synthetic meniscus scaffolds have been used with varying success to prevent early degenerative joint disease in these cases. Problems related to reduced initial and long-term stability, as well as immunological reactions prevent widespread clinical use so far. Therefore, the aim of this study was to develop a new construct for tissue engineering of the human meniscus based on an acellular meniscus allograft. Human menisci (n = 16) were collected and acellularized using the detergent sodium dodecyl sulfate as the main ingredient or left untreated as control group. These acellularized menisci were characterized biomechanically using a repetitive ball indentation test (Stiffness N/mm, residual force N, relative compression force N) and by histological (hematoxylin-eosin, phase-contrast) as well as immunohistochemical (collagen I, II, VI) investigation. The processed menisci histologically appeared cell-free and had biomechanical properties similar to the intact meniscus samples (p > 0.05). The collagen fiber arrangement was not altered, according to phase-contrast microscopy and immunohistochemical labeling. The removal of the immunogenic cell components combined with the preservation of the mechanically relevant parts of the extracellular matrix could make these scaffolds ideal implants for future tissue engineering of the meniscus.

Bone morphogenetic proteins in soft-tissue reconstruction

Different options are reviewed in the field of musculoskeletal tissue reconstruction, from the addition of biological actors (cells, growth factors, biological or artificial scaffolds) to the application of gene therapy or tissue engineering. Growth factors can enable innovative solutions to treat such disease if we can extrapolate to soft tissue the promising results obtained in bone reconstruction with bone morphogenetic proteins. However, as in bone reconstruction, soft-tissue regeneration will depend on the drug delivery carrier, the scaffold for the newly formed tissue, the dose of growth factor and the animal model, which must all be explored before extrapolation to clinical problems.

rAAV-mediated overexpression of FGF-2 promotes cell proliferation, survival, and alpha-SMA expression in human meniscal lesions

Meniscal tears are a common problem in sports medicine. Direct application of therapeutic vectors derived from the adeno-associated virus might be beneficial to enhance meniscal repair. We tested the hypothesis that overexpression of fibroblast growth factor 2 (FGF-2) through recombinant adeno-associated virus (rAAV) vectors leads to detectable metabolic changes in human meniscal fibrochondrocytes and in human meniscal defects. rAAV-mediated gene transfer was investigated for its ability to promote FGF-2 secretion in human meniscal fibrochondrocytes in vitro, in intact human meniscal explants in situ, and in experimentally created human meniscal lesions. Effects of the treatment on cell proliferation and survival, extracellular matrix synthesis, and expression of the alpha-smooth muscle actin (alpha-SMA) contractile marker were monitored using biochemical, immunohistochemical, histological, and histomorphometric analyses. Efficient production of FGF-2 through rAAV could be achieved in vitro and in situ, both in the intact and injured meniscus. Application of the candidate FGF-2 vector allowed for enhanced cell proliferation and survival compared with control transduction, in particular in areas with poor healing capacity and in sites of injury, consistent with the mitogenic activities of the growth factor. Remarkably, a significant reduction of the amplitude of meniscal tears was noted after FGF-2 treatment, with increased levels of alpha-SMA expression. In contrast, there was no significant stimulation of synthesis of the major extracellular matrix components when the candidate vector was applied and instead, a decrease in the matrix/DNA contents was reported, in good agreement with the properties of FGF-2. Such a direct gene-based approach may have value in options aiming at treating human meniscal defects.

Meniscal allograft size can be predicted by height, weight, and gender

PURPOSE

Our purpose was to determine if height, weight, and gender can be used to accurately predict proper meniscal allograft dimensions.

METHODS

Data were obtained from the Joint Restoration Foundation (AlloSource, Centennial, CO) regarding meniscal size and patient characteristics from meniscal donors. Donor height, weight, sex, age, and anatomic meniscal dimensions were recorded for 930 donor menisci in 664 patients. Multivariate regressions were completed using gender, height, and weight as independent variables and lateral meniscus length, lateral meniscus width, medial meniscus length, and medial meniscus width as dependent variables. The regression formulas were then reapplied to the data in order to produce estimated meniscus dimensions based on donor height, weight, and gender. A 90:10 split of the data was used to validate the regression models. Predicted meniscal size was then compared to actual meniscal size and the results compared to current measurement techniques.

RESULTS

Regression formulas showed the ability to predict meniscal size based on gender, height, and weight with standard deviations (SDs) equal to or less than current radiographic techniques (SD, 6.4% to 8.2%). Average differences between predicted size and actual size ranged from 5.2% to 6.5% for length and 5.2% to 6.0% for width. Patient height was found to be a much more powerful predictor of meniscal size than patient weight. Data from the 90:10 split of data validated the model on an independent sample. These validated outputs were then compared to contemporary techniques and found to have lower SDs and average error rates in the majority of cases.

CONCLUSIONS

We have proposed a validated regression model that uses height, weight, and gender variables to accurately predict required allograft meniscal size. We compared it against previously published data for radiographic and magnetic resonance imaging sizing techniques and found it to produce results that were, overall, slightly more accurate.

CLINICAL RELEVANCE

This model provides a novel method for sizing meniscal allografts.

In vitro analysis of an allogenic scaffold for tissue-engineered meniscus replacement

Scaffolds play a key role in the field of tissue engineering. Particularly for meniscus replacement, optimal scaffold properties are critical. The aim of our study was to develop a novel scaffold for replacement of meniscal tissue by means of tissue engineering. Emphasis was put on biomechanical properties comparable to native meniscus, nonimmunogenecity, and the possibility of seeding cells into and cultivating them within the scaffold (nontoxicity). For this purpose, native ovine menisci were treated in vitro in a self-developed enzymatic process. Complete cell removal was achieved and shown both histologically and electron microscopically (n = 15). Immunohistochemical reaction (MHC 1/MHC 2) was positive for native ovine meniscus and negative for the scaffold. Compared to native meniscus (25.8 N/mm) stiffness of the scaffold was significantly increased (30.2 N/mm, p < 0.05, n = 10). We determined the compression (%) of the native meniscus and the scaffold under a load of 7 N. The compression was 23% for native meniscus and 29% for the scaffold (p < 0.05, n = 10). Residual force of the scaffold was significantly lower (5.2 N vs. 4.9 N, p < 0.05, n = 10). Autologous fibrochondrocytes were needle injected and successfully cultivated within the scaffolds over a period of 4 weeks (n = 10). To our knowledge, this study is the first to remove cells and immunogenetic proteins (MHC 1/MHC 2) completely out of native meniscus and preserve important biomechanical properties. Also, injected cells could be successfully cultivated within the scaffold. Further in vitro and in vivo animal studies are necessary to establish optimal cell sources, sterilization, and seeding techniques. Cell differentiation, matrix production, in vivo remodeling of the construct, and possible immunological reactions after implantation are subject of further studies.

Genetically enhanced engineering of meniscus tissue using ex vivo delivery of transforming growth factor-beta 1 complementary deoxyribonucleic acid

To investigate the use of a scaffold seeded with genetically modified meniscal cells or mesenchymal stem cells (MSCs) for the healing of meniscal lesions, primary meniscus cells and bone marrow-derived MSCs were isolated from bovine calves and transduced with first-generation adenoviral vectors encoding green fluorescent protein, luciferase, or transforming growth factor (TGF)-beta1 complementary deoxyribonucleic acid (cDNA). The genetically modified cells were seeded in type I collagen-glycosaminoglycan (GAG) matrices and transplanted into tears of the avascular zone of bovine menisci. After 3 weeks of in vitro culture, constructs and repair tissues were analyzed histologically, biochemically, and using reverse transcriptase polymerase chain reaction. Recombinant adenovirus readily transduced meniscal cells and MSCs, and transgene expression remained high after the cells were incorporated into collagen-GAG matrices. Transfer of TGF-beta1 cDNA increased cellularitiy and the synthesis of GAG/DNA [microg/microg]. It also led to stronger staining for proteoglycans and type II collagen and enhanced expression of meniscal genes. Transplantation of the TGF-beta1 transduced constructs into meniscal lesions of the avascular zone resulted in filling of the lesions with repair tissue after 3 weeks of in vitro culture. These results indicate that TGF-beta1 cDNA delivery may affect cell-based meniscus repair approaches in vivo.

Second generation of meniscus transplantation: in-vivo study with tissue engineered meniscus replacement

INTRODUCTION

The options available after meniscus loss offer only limited chances for a long-term success. In the following experimental study, we investigated the effect of meniscus tissue engineering on properties of the collagen meniscus implant (CMI).

METHODS

Autologous fibrochondrocytes, obtained per biopsy from adult Merino sheep (n=25), were released from the matrix, cultured in-vitro and seeded into CMI scaffolds (n=10, group 1). Following a 3-week in-vitro culture, the tissue engineered menisci were used for autologous transplantation. Macroscopical and histological evaluation were performed in comparison with non-seeded CMI controls (n=10, group 2) and with meniscus-resected controls (n=5, group 3) after 3 weeks (each 1 animal group 1 and 2) and 3 months.

RESULTS

The lameness score did not show any difference between the groups. Meniscus tissue was found in seven knee joints (group 1), in five knee joints (group 2) and in two knee joints (group 3). The size of the transplants reduced from 25.9+/-4.5 to 20.1+/-10.8 mm (group 1) and from 25.9+/-1.5 to 14.4+/-12.5 mm (group 2). Histologically, enhanced vascularisation, accelerated scaffold re-modelling, higher content of extra-cellular matrix and lower cell number were noted in the pre-seeded menisci in comparison with non-seeded controls. Dense high-cellular fibrous scar tissue was found in two of five cases in the resection control group.

CONCLUSION

Tissue engineering of meniscus with autologous fibrochondrocytes demonstrates a macroscopic and histological improvement of the transplants. However, further development of the methods, especially of the scaffold and of the cell-seeding procedure must prove the feasibility of this procedure for human applications.

Menisci are efficiently transduced by recombinant adeno-associated virus vectors in vitro and in vivo

BACKGROUND

Meniscal tears remain an unsolved problem in sports medicine. Gene transfer is a potential approach to enhancing meniscal repair. Recombinant adeno-associated virus is a method of gene transfer that has advantages over previously used approaches to this problem.

HYPOTHESIS

Direct gene transfer to meniscal cells can be accomplished using recombinant adeno-associated virus in vitro and in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

Recombinant adeno-associated viruses containing the reporter gene lacZ were tested for their ability to achieve gene transfer into lapine and human meniscal cells in vitro and into lapine meniscal defects in vivo. Results were assessed by detecting beta-galactosidase, the enzyme encoded by the lacZ gene.

RESULTS

Maximal efficiency of gene transfer was 81.6% +/- 6.6% for lapine and 87.2% +/- 14.8% for human meniscal cells in vitro. Expression of the transferred gene continued for the 28-day duration of the study. When the recombinant adeno-associated virus vector was injected into meniscal tears in a lapine meniscal tear model, transgene expression continued in meniscal cells adjacent to the tear for at least 20 days in vivo.

CONCLUSIONS

The data suggest that recombinant adeno-associated virus vectors can directly and efficiently transfer and stably express foreign genes in isolated lapine and human meniscal cells in vitro and in lapine meniscal defects in vivo.

CLINICAL RELEVANCE

This direct gene transfer approach may form a basis for improved treatments of meniscal tears.

Tissue engineering of the meniscus

Meniscus lesions are among the most frequent injuries in orthopaedic practice and they will inevitably lead to degeneration of the knee articular cartilage. The fibro-cartilage-like tissue of the meniscus is notorious for its limited regenerative capacity. Tissue engineering could offer new treatment modalities for repair of meniscus tears and eventually will enable the replacement of a whole meniscus by a tissue-engineered construct. Many questions remain to be answered before the final goal, a tissue-engineered meniscus is available for clinical implementation. These questions are related to the selection of an optimal cell type, the source of the cells, the need to use growth factor(s) and the type of scaffold that can be used for stimulation of differentiation of cells into tissues with optimal phenotypes. Particularly in a loaded, highly complex environment of the knee, optimal mechanical properties of such a scaffold seem to be of utmost importance. With respect to cells, autologous meniscus cells seems the optimal cell source for tissue engineering of meniscus tissue, but their availability is limited. Therefore research should be stimulated to investigate the suitability of other cell sources for the creation of meniscus tissue. Bone marrow stroma cells could be useful since it is well known that they can differentiate into bone and cartilage cells. With respect to growth factors, TGF-beta could be a suitable growth factor to stimulate cells into a fibroblastic phenotype but the problems of TGF-beta introduced into a joint environment should then be solved. Polyurethane scaffolds with optimal mechanical properties and with optimal interconnective macro-porosity have been shown to facilitate ingrowth and differentiation of tissue into fibro-cartilage. However, even these materials cannot prevent cartilage degeneration in animal models. Surface modification and/or seeding of cells into the scaffolds before implantation may offer a solution for this problem in the future.This review focuses on a number of specific questions; what is the status of the development of procedures for lesion healing and how far are we from replacing the entire meniscus by a (tissue-engineered) prosthesis. Subquestions related to the type of scaffold used are: is the degree of tissue ingrowth and differentiation related to the initial mechanical properties and if so, what is the influence of those properties on the subsequent remodelling of the tissue into fibro-cartilage; what is the ideal pore geometry and what is the optimal degradation period to allow biological remodelling of the tissue in the scaffold. Finally, we will finish with our latest results of the effect of tear reconstruction and the insertion of prostheses on articular cartilage degradation.

The current state of meniscal allograft transplantation and replacement

This review details current efforts to transplant or to replace a meniscus. Different substitutes for meniscal transplantation or replacement have been used with varying experimental and clinical success. Meniscal transplantation emerges as a useful option for selected patients with a stable knee and appropriate alignment. Some long-term studies of meniscal transplantation prove that cartilage protection is possible. Clear convincing evidence that meniscal transplantation or replacement restores the normal function of the knee joint has not been shown. In keeping with the multiple functions and anatomy of the meniscus experience of meniscal transplantation has shown that many aspects have to be considered to achieve successful results. This offers many possibilities for further scientific investigations.

Gene therapy and tissue engineering for sports medicine

Sports injuries usually involve tissues that display a limited capacity for healing. The treatment of sports injuries has improved over the past 10 to 20 years through sophisticated rehabilitation programs, novel operative techniques, and advances in the field of biomechanical research. Despite this considerable progress, no optimal solution has been found for treatment of various sports-related injuries, including muscle injuries, ligament and tendon ruptures, central meniscal tears, cartilage lesions, and delayed bone fracture healing. New biological approaches focus on the treatment of these injuries with growth factors to stimulate and hasten the healing process. Gene therapy using the transfer of defined genes encoding therapeutic proteins represents a promising way to efficiently deliver suitable growth factors into the injured tissue. Tissue engineering, which may eventually be combined with gene therapy, may potentially result in the creation of tissues or scaffolds for regeneration of tissue defects following trauma. In this article we will discuss why gene therapy and tissue engineering are becoming increasingly important in modern orthopaedic sports medicine practice. We then will review recent research achievements in the area of gene therapy and tissue engineering for sports-related injuries, and highlight the potential clinical applications of this technology in the treatment of patients with musculoskeletal problems following sports-related injuries.