Advanced glycation end-product cross-linking inhibits biomechanical plasticity and characteristic failure morphology of native tendon

Advanced glycation end products impair the repair of injured tendon: a study in rats

BACKGROUND

The AGEs levels in tissues of diabetics and elderly tend to be higher than in normal individuals. This study aims to determine the effects of AGEs on Achilles tendon repair.

MATERIALS AND METHODS

Thirty-six male eight-week-old Sprague Dawley rats were selected in this study. The rats were randomly divided into two experimental groups and a control group after the transection of the Achilles tendon. During the tendon repair, the experimental groups were injected around the Achilles tendon with 350mmol/L (low dose group) and 1000mmol/L (high dose group) D-ribose 0.2 ml respectively to increase the AGEs level, while in the control group were given the same amount of PBS. The injections were given twice a week for six weeks. Collagen-I, TNF-α, and IL-6 expression in the healed Achilles tendon was assessed. Additionally, macroscopic, pathological, and biomechanical evaluations of Achilles tendon repair were conducted.

RESULTS

The repaired Achilles tendons in the high dose group showed severe swelling and distinctive adhesions. The histological score went up with the increase of the AGEs in the Achilles tendon (p<0.001). TNF- α and IL-6 in the Achilles tendon increased (p<0.001, p<0.001), and the production of collagen-I decreased with the accumulation of AGEs in the repaired Achilles tendon (p<0.001). The tensile strength of Achilles tendon in the high dose group was impaired significantly.

CONCLUSION

In current study, the compromised tendon repair model induced by AGEs was successfully established in rat. The study demonstrated that AGEs significantly impair Achilles tendon repair.

Localization of advanced glycation end-products and their receptor in tendinopathic lesions

This study was designed to investigate the accumulation of advanced glycation end-products (AGEs) and the expression of the receptor of AGEs (RAGE) in tendinopathic tissues. In this study, tendinopathic posterior tibial tendons (PTT) were collected from patients (n=6). Redundant autografts of flexor digitorum longus tendon (FDL; n=3) were used for controls. The control and tendinopathic tendon tissues were used for extraction of proteins for western blot and sectioned for histology and immunohistochemistry. Tendinopathy of the PTT was confirmed histologically by the presentation of disorderly organized collagen fibers, high cellularity and increased vascularity. By immunohistochemistry, heterogeneous accumulation of AGEs was detected on the PTT sections and concentrated in areas, where collagen fibers were disorderly and tangled. In the PTT, roundish tenocytes were also AGEs-positive. In contrast, AGEs were diffuse, lightly stained in the FDL. A greater number of tenocytes within the tendinopathic lesions in the PTT were RAGE positive, compared to the tenocytes in the FDL. Western blot confirmed the expression of AGEs and RAGE in both tendinopathic PTT and control FDL but their band densities were not significantly different. The spatial relation of the accumulated AGEs and RAGE- positive tenocytes within the tendinopathic lesions indicates their involvement in the molecular pathology of tendinopathy.

Methylglyoxal alters collagen fibril nanostiffness and surface potential

Collagen fibrils are fundamental to the mechanical strength and function of biological tissues. However, they are susceptible to changes from non-enzymatic glycation, resulting in the formation of advanced glycation end-products (AGEs) that are not reversible. AGEs accumulate with aging and disease and can adversely impact tissue mechanics and cell-ECM interactions. AGE-crosslinks have been related, on the one hand, to dysregulation of collagen fibril stiffness and damage and, on the other hand, to altered collagen net surface charge as well as impaired cell recognition sites. While prior studies using Kelvin probe force microscopy (KPFM) have shown the effect glycation has on collagen fibril surface potential (i.e., net charge), the combined effect on individual and isolated collagen fibril mechanics, hydration, and surface potential has not been documented. Here, we explore how methylglyoxal (MGO) treatment affects the mechanics and surface potential of individual and isolated collagen fibrils by utilizing atomic force microscopy (AFM) nanoindentation and KPFM. Our results reveal that MGO treatment significantly increases nanostiffness, alters surface potential, and modifies hydration characteristics at the collagen fibril level. These findings underscore the critical impact of AGEs on collagen fibril physicochemical properties, offering insights into pathophysiological mechanical and biochemical alterations with implications for cell mechanotransduction during aging and in diabetes. STATEMENT OF SIGNIFICANCE: Collagen fibrils are susceptible to glycation, the irreversible reaction of amino acids with sugars. Glycation affects the mechanical properties and surface chemistry of collagen fibrils with adverse alterations in biological tissue mechanics and cell-ECM interactions. Current research on glycation, at the level of individual collagen fibrils, is sparse and has focused either on collagen fibril mechanics, with contradicting evidence, or surface potential. Here, we utilized a multimodal approach combining Kelvin probe force (KPFM) and atomic force microscopy (AFM) to examine how methylglyoxal glycation induces structural, mechanical, and surface potential changes on the same individual and isolated collagen fibrils. This approach helps inform structure-function relationships at the level of individual collagen fibrils.

Pioglitazone Antagonized the Effects of Advanced Glycation End Products on Achilles Tendon Healing and Improved the Recovery of Tendon Biomechanical Properties

Purpose

Advanced glycation end products (AGEs) often accumulate in the Achilles tendon during the course of diabetes. This study aims to determine the impact of AGEs on tendon repair and explore the role of pioglitazone in mitigating this impact.

Methods

Forty-eight male 8 week-old Sprague Dawley rats were selected in this study. After transection of Achilles tendon, the rats were randomly divided into four groups. The Achilles tendons of rats were injected with 1000 mmol/L D-ribose to elevate the content of AGEs within the tendons in two groups, the remaining two groups received injections of phosphate buffered saline (PBS) solution. Subsequently, the first two groups were respectively received oral administration of pioglitazone (20 mg/kg/day) and PBS. The remaining two groups were given the same treatment. The expression of the collagen-I, TNF-α, IL-6 of the repaired tendon were detected. The macroscopic, pathologic and biomechanical aspects of tendon healing were also evaluated.

Results

AGEs accumulation in tendon during the healing process increases the expression of inflammatory factors such as TNF-α and IL-6, leading to insufficient synthesis of collagen-I and delayed recovery of the tendon's tensile strength. Pioglitazone significantly attenuated the damage caused by AGEs to the tendon healing process, effectively improving the recovery of tendon tensile strength. Pioglitazone could not inhibit the generation of AGEs in the tissue and also had no impact on the normal healing process of the tendon.

Conclusions

Pioglitazone could prevent the deleterious impact of AGEs on the Achilles tendon healing and improve the biomechanical properties of the tendon.

Metabolic Syndrome and Tendon Disease: A Comprehensive Review

Metabolic syndrome (MS) is a multifaceted pathological condition characterized by the atypical accumulation of various metabolic components such as central obesity or excess weight, hyperlipidemia, low-density lipoprotein (LDL), hypertension, and insulin resistance. Recently, MS has been recognized as a notable contributor to heart and circulatory diseases. In addition, with increasing research, the impact of MS on tendon repair and disease has gradually emerged. Recent studies have investigated the relationship between tendon healing and diseases such as diabetes, dyslipidemia, obesity, and other metabolic disorders. However, diabetes mellitus (DM), hypercholesterolemia, obesity, and various metabolic disorders often coexist and together constitute MS. At present, insulin resistance is considered the major pathological mechanism underlying MS, central obesity is regarded as the predominant factor responsible for it, and dyslipidemia and other metabolic diseases are known as secondary contributors to MS. This review aims to evaluate the current literature regarding the impact of various pathological conditions in MS on tendon recovery and illness, and to present a comprehensive overview of the effects of MS on tendon recovery and diseases, along with the accompanying molecular mechanisms.

Review paper: The importance of consideration of collagen cross-links in computational models of collagen-based tissues

Collagen as the main protein in Extra Cellular Matrix (ECM) is the main load-bearing component of fibrous tissues. Nanostructure and architecture of collagen fibrils play an important role in mechanical behavior of these tissues. Extensive experimental and theoretical studies have so far been performed to capture these properties, but none of the current models realistically represent the complexity of network mechanics because still less is known about the collagen's inner structure and its effect on the mechanical properties of tissues. The goal of this review article is to emphasize the significance of cross-links in computational modeling of different collagen-based tissues, and to reveal the need for continuum models to consider cross-links properties to better reflect the mechanical behavior observed in experiments. In addition, this study outlines the limitations of current investigations and provides potential suggestions for the future work.

Gut Microbiome Dysbiosis as a Potential Risk Factor for Idiopathic Toe-Walking in Children: A Review

Idiopathic toe walking (ITW) occurs in about 5% of children. Orthopedic treatment of ITW is complicated by the lack of a known etiology. Only half of the conservative and surgical methods of treatment give a stable positive result of normalizing gait. Available data indicate that the disease is heterogeneous and multifactorial. Recently, some children with ITW have been found to have genetic variants of mutations that can lead to the development of toe walking. At the same time, some children show sensorimotor impairment, but these studies are very limited. Sensorimotor dysfunction could potentially arise from an imbalanced production of neurotransmitters that play a crucial role in motor control. Using the data obtained in the studies of several pathologies manifested by the association of sensory-motor dysfunction and intestinal dysbiosis, we attempt to substantiate the notion that malfunction of neurotransmitter production is caused by the imbalance of gut microbiota metabolites as a result of dysbiosis. This review delves into the exciting possibility of a connection between variations in the microbiome and ITW. The purpose of this review is to establish a strong theoretical foundation and highlight the benefits of further exploring the possible connection between alterations in the microbiome and TW for further studies of ITW etiology.

Advanced glycation end-product accumulation differs by location and sex in aged osteoarthritic human menisci

OBJECTIVE

There is a clear link between increasing age and meniscus degeneration, leading to increased injury, osteoarthritis (OA) progression, and often total knee replacement. Advanced glycation end-products (AGEs) are non-enzymatic crosslinks and adducts that accumulate in collagen with age, altering tissue mechanics and cell function, ultimately leading to increased injury and inflammation. AGEs, both fluorescent and non-fluorescent, play a central role in age-related degradation of tissues throughout the body; however, little is known about their role in meniscus degeneration. The objective of this study was to characterize changes in aged OA menisci, specifically evaluating zonal AGE accumulation, to gain a better understanding of changes that may lead to age-related meniscal degeneration.

METHOD

Deidentified human menisci (N = 48, 52-84 years old) were obtained from subjects undergoing total knee replacement. Changes in extracellular matrix (ECM) were assessed by gross morphology, confocal analysis, and biochemical assays. Deoxyribonucleic acid (DNA), glycosaminoglycan (GAG), collagen, and AGE accumulation were compared with patient age, zonal region, and patient sex.

RESULTS

There were minimal changes in DNA, GAG, and collagen concentration with age or zone. However, collagen fraying and AGEs increased with age, with more AGEs accumulating in the meniscal horns compared to the central body and in male menisci compared to females.

CONCLUSIONS

Overall, this work provides greater insights into regional changes that occur in human menisci with age and OA. These results suggest AGEs may play a role in the degeneration of the meniscus, with AGEs being a possible target to reduce age-related tears, degeneration, and OA progression.

Effect of Diabetes on Tendon Structure and Function: Not Limited to Collagen Crosslinking

Diabetes mellitus (DM) is associated with musculoskeletal complications-including tendon dysfunction and injury. Patients with DM show altered foot and ankle mechanics that have been attributed to tendon dysfunction as well as impaired recovery post-tendon injury. Despite the problem of DM-related tendon complications, treatment guidelines specific to this population of individuals are lacking. DM impairs tendon structure, function, and healing capacity in tendons throughout the body, but the Achilles tendon is of particular concern and most studied in the diabetic foot. At macroscopic levels, asymptomatic, diabetic Achilles tendons may show morphological abnormalities such as thickening, collagen disorganization, and/or calcific changes at the tendon enthesis. At smaller length scales, DM affects collagen sliding and discrete plasticity due to glycation of collagen. However, how these alterations translate to mechanical deficits observed at larger length scales is an area of continued investigation. In addition to dysfunction of the extracellular matrix, tendon cells such as tenocytes and tendon stem/progenitor cells show significant abnormalities in proliferation, apoptosis, and remodeling capacity in the presence of hyperglycemia and advanced glycation end-products, thus contributing to the disruption of tendon homeostasis and healing. Improving our understanding of the effects of DM on tendons-from molecular pathways to patients-will progress toward targeted therapies in this group at high risk of foot and ankle morbidity.

Ribose Intake as Food Integrator: Is It a Really Convenient Practice?

Reports concerning the beneficial effects of D-ribose administration in cardiovascular and muscle stressful conditions has led to suggestions for the use of ribose as an energizing food supplement for healthy people. However, this practice still presents too many critical issues, suggesting that caution is needed. In fact, there are many possible negative effects of this sugar that we believe are underestimated, if not neglected, by the literature supporting the presentation of the product to the market. Here, the risks deriving from the use of free ribose as ATP source, forcing ribose-5-phosphate to enter into the pentose phosphate pathway, is emphasized. On the basis of the remarkable glycation capacity of ribose, the easily predictable cytotoxic effect of the molecule is also highlighted.

Causative or associative: A critical review of the role of advanced glycation end-products in bone fragility

The accumulation of advanced glycation end-products (AGEs) in the organic matrix of bone with aging and chronic disease such as diabetes is thought to increase fracture risk independently of bone mass. However, to date, there has not been a clinical trial to determine whether inhibiting the accumulation of AGEs is effective in preventing low-energy, fragility fractures. Moreover, unlike with cardiovascular or kidney disease, there are also no pre-clinical studies demonstrating that AGE inhibitors or breakers can prevent the age- or diabetes-related decrease in the ability of bone to resist fracture. In this review, we critically examine the case for a long-standing hypothesis that AGE accumulation in bone tissue degrades the toughening mechanisms by which bone resists fracture. Prior research into the role of AGEs in bone has primarily measured pentosidine, an AGE crosslink, or bulk fluorescence of hydrolysates of bone. While significant correlations exist between these measurements and mechanical properties of bone, multiple AGEs are both non-fluorescent and non-crosslinking. Since clinical studies are equivocal on whether circulating pentosidine is an indicator of elevated fracture risk, there needs to be a more complete understanding of the different types of AGEs including non-crosslinking adducts and multiple non-enzymatic crosslinks in bone extracellular matrix and their specific contributions to hindering fracture resistance (biophysical and biological). By doing so, effective strategies to target AGE accumulation in bone with minimal side effects could be investigated in pre-clinical and clinical studies that aim to prevent fragility fractures in conditions that bone mass is not the underlying culprit.

Data driven model of midportion achilles tendinopathy health created with factor analysis

Background

Achilles tendinopathy is a complex injury and the clinical presentation spans multiple different domains: physical and psychological symptoms, lower extremity function and tendon structure. A conceptual model of Achilles tendon health comprising these domains has been proposed in the literature. The aim of the study was to fit a model of Achilles tendinopathy using factor analysis and compare that to the conceptual model. An inclusive approach using a wide range of variables spanning multiple potential domains were included.

Methods

Participants (N = 99) with midportion Achilles tendinopathy were assessed with variables representing symptoms, physical function, tendon structure, metabolic syndrome, and psychologic symptoms. A Kaiser-Mayer-Olkin index was used to determine suitable variables for a subsequent exploratory factor analysis.

Results

A model emerged with an acceptable fit to the data (standardized root mean square of residuals = 0.078). Five uncorrelated factors emerged from the model and were labelled as biopsychosocial, lower extremity function, body size, load tolerance, and tendon structure. The total explained variance was 0.51 with the five factors explaining 0.14, 0.12, 0.10, 0.08, and 0.07 respectively. The results differed from the conceptual model as the factors of psychological variables and metabolic variables did not emerge from the analysis.

Conclusion

A data driven model of Achilles tendon health supports assessment of the clinical presentation over multiple domains. As the factors are uncorrelated, the results of assessment of, for example, tendon structure should not be expected to be associated with lower extremity function or biopsychosocial limitations. The results suggest that the Patient Reported Outcomes Measurement Information System, counter-movement jump height, body mass index, pain with hopping, and the tendon cross-sectional area can evaluate the five factors, respectively.

Trial registration

Registered on clinicaltrials.gov (Medicine NL of. ClinicalTrials.gov [Internet], 2018), ID number NCT03523325.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05702-1.

An inducible model for unraveling the effects of advanced glycation end-product accumulation in aging connective tissues

PURPOSE

In connective tissues there is a clear link between increasing age and degeneration. Advanced glycation end-products (AGEs) are believed to play a central role. AGEs are sugar-induced non-enzymatic crosslinks which accumulate in collagen with age and diabetes, altering tissue mechanics and cellular function. Despite ample correlative evidence linking collagen glycation to tissue degeneration, little is known how AGEs impact cell-matrix interactions, limiting therapeutic options. One reason for this limited understanding is that AGEs are typically induced using high concentrations of ribose which decrease cell viability, making it impossible to investigate cell-matrix interactions. The objective of this study was to develop a system to trigger AGE accumulation while maintaining cell viability.

MATERIALS AND METHODS

Using cell-seeded high density collagen gels, we investigated the effect of two systems for AGE induction, ribose at low concentrations (30, 100, and 200 mM) over 15 days of culture and riboflavin (0.25 and 0.75 mM) induced with blue light for 40 seconds (riboflavin-465 nm).

RESULTS

We found ribose and riboflavin-465 nm treatment produces fluorescent AGE quantities which match and/or exceed human fluorescent AGE levels for various tissues, ages, and diseases, without affecting cell viability or metabolism. Interestingly, a 40 second treatment of riboflavin-465 nm produced similar levels of fluorescent AGEs as 3 days of 100 mM ribose treatment.

CONCLUSIONS

Riboflavin-465 nm is a promising method to trigger AGEs on demand in vivo or in vitro without impacting cell viability and offers potential for unraveling the mechanism of AGEs in age and diabetes related tissue damage.

Prediction of Bilaterality in Patients With 1 Posterosuperior Rotator Cuff Tear

BACKGROUND

In patients with a known unilateral posterosuperior rotator cuff tear (PSRCT), the ability to predict a contralateral PSRCT may assist in earlier diagnosis and improved patient outcomes.

PURPOSE

To determine factors associated with bilateral PSRCT and their most predictive combinations using a nonhospitalized general population.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This study involved 736 individuals (n = 1472 shoulders) drawn from a rural cohort. PSRCT was diagnosed using magnetic resonance imaging. Symptoms of the contralateral shoulder were not considered. The demographic, physical, social, metabolic, and imaging factors, as well as comorbidities, were evaluated using logistic regression analysis. Cutoff values for the significantly associated variables obtained from multivariable logistic regression analysis were calculated using the receiver operating characteristic (ROC) curve. The areas under the ROC curve (AUCs) of the combinations of significantly associated variables were compared using the DeLong method to determine the combination most predictive of bilateral PSRCT. The likelihood ratio and the posttest probability for each of the combinations were assessed.

RESULTS

Age ≥61 years, manual labor, critical shoulder angle (CSA) ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome were significantly associated with bilateral PSRCT in multivariable analysis (P < .001). The 1-by-1 combination of any 4 of the 6 associated factors significantly increased the AUC of any smaller combinations of those 6 factors (P < .001). The AUCs of the 4-somes were all similar (P ≥ .383) and were not significantly increased by further addition of identified associated factors (P ≥ .422). Any combination of 4 of the 6 associated factors was highly predictive of bilateral PSRCT, each having a minimum AUC of 0.70, a likelihood ratio of >10, and a minimum posttest probability of 80%.

CONCLUSION

Unilateral PSRCT, accompanied by any 4 of the variables of age ≥61 years, manual labor, CSA ≥35°, retraction degree of Patte ≥ grade 2, biceps tendon injury, and metabolic syndrome, is highly predictive of PSRCT in the other shoulder.

Regulators of collagen crosslinking in developing and adult tendons

Tendons are collagen-rich musculoskeletal tissues that possess the mechanical strength needed to transfer forces between muscles and bones. The mechanical development and function of tendons are impacted by collagen crosslinks. However, there is a limited understanding of how collagen crosslinking is regulated in tendon during development and aging. Therefore, the objective of the present review was to highlight potential regulators of enzymatic and non-enzymatic collagen crosslinking and how they impact tendon function. The main collagen crosslinking enzymes include lysyl oxidase (LOX) and the lysyl oxidase-like isoforms (LOXL), whereas non-enzymatic crosslinking is mainly mediated by the formation of advanced glycation end products (AGEs). Regulators of the LOX and LOXL enzymes may include mechanical stimuli, mechanotransducive cell signaling pathways, sex hormones, transforming growth factor (TGF)β family, hypoxia, and interactions with intracellular or extracellular proteins. AGE accumulation in tendon is due to diabetic conditions and aging, and can be mediated by diet and mechanical stimuli. The formation of these enzymatic and non-enzymatic collagen crosslinks plays a major role in tendon biomechanics and in the mechanisms of force transfer. A more complete understanding of how enzymatic and non-enzymatic collagen crosslinking is regulated in tendon will better inform tissue engineering and regenerative therapies aimed at restoring the mechanical function of damaged tendons.

Targeting extracellular matrix glycation to attenuate fibroblast activation

The extracellular matrix (ECM) of the tumor microenvironment undergoes constant remodeling that alters its biochemical and mechano-physical properties. Non-enzymatic glycation can induce the formation of advanced glycation end-products (AGEs), which may cause abnormal ECM turnover with excessively cross-linked collagen fibers. However, the subsequent effects of AGE-mediated matrix remodeling on the characteristics of stromal cells in tumor microenvironments remain unclear. Here, we demonstrate that AGEs accumulated in the ECM alter the fibroblast phenotype within a three-dimensional collagen matrix. Both the AGE interaction with its receptor (RAGE) and integrin-mediated mechanotransduction signaling were up-regulated in glycated collagen matrix, leading to fibroblast activation to acquire a cancer-associated fibroblast (CAF)-like phenotype. These effects were blocked with neutralizing antibodies against RAGE or the inhibition of focal adhesion (FA) signaling. An AGE cross-link breaker, phenyl-4,5-dimethylthiazolium bromide (ALT 711), also reduced the transformation of fibroblasts into the CAF-like phenotype because of its dual inhibitory role in the AGE-modified matrix. Apart from targeting the AGE-RAGE interaction directly, the decreased matrix stiffness attenuated fibroblast activation by inhibiting the downstream cellular response to matrix stiffness. Our results suggest that indirect/direct targeting of accumulated AGEs in the ECM has potential for targeting the tumor stroma to improve cancer therapy. STATEMENT OF SIGNIFICANCE: Advanced glycated end-products (AGEs)-modified extracellular matrix (ECM) is closely associated with pathological states and is recognized as a critical factor that precedes tumorigenesis. While increased matrix stiffness is known to induce fibroblast activation, less is known about how both biochemical and mechano-physical changes in AGE-mediated matrix-remodeling cooperate to produce a myofibroblastic cancer-associated fibroblast (CAF)-like phenotype. For the first time, we found that both the AGE interaction with its receptor (RAGE) and integrin-mediated mechanotransduction were up-regulated in glycated collagen matrix, leading to fibroblast activation. We further demonstrated that an AGE cross-link breaker, ALT-711, reduced the CAF-like transformation because of its dual inhibitory role in the AGE-modified matrix. Our findings offer promising extracellular-reversion strategies targeting the non-enzymatic ECM glycation, to regulate fibroblast activation.

Evaluating the role of type 2 diabetes mellitus in rotator cuff tendinopathy: Development and analysis of a novel rat model

OBJECTIVE

To establish and validate an intact rotator cuff rat model for exploring the pathophysiological effects of type 2 diabetes on the rotator cuff tendon in vivo.

METHODS

A total of 45 adult male rats were randomly divided into a control group (n = 9) and type 2 diabetes group (n=36). The rats were sacrificed at 2 weeks (T2DM-2w group, n=9), 4 weeks (T2DM-4w group, n=9), 8 weeks (T2DM-8w group, n=9), and 12 weeks (T2DM-12w group, n=9) after successful modeling of type 2 diabetes. Bilateral shoulder samples were collected for gross observation and measurement, protein expression(enzyme-linked immunosorbent assay,ELISA), histological evaluation, biomechanical testing, and gene expression (real-time quantitative polymerase chain reaction, qRT-PCR).

RESULTS

Protein expression showed that the expression of IL-6 and Advanced glycation end products (AGEs)in serum increased in type 2 diabetic group compared with the non-diabetic group. Histologically, collagen fibers in rotator cuff tendons of type 2 diabetic rats were disorganized, ruptured, and with scar hyperplasia, neovascularization, and extracellular matrix disturbances, while Bonar score showed significant and continuously aggravated tendinopathy over 12 weeks. The biomechanical evaluation showed that the ultimate load of rotator cuff tendons in type 2 diabetic rats gradually decreased, and the ultimate load was negatively correlated with AGEs content. Gene expression analysis showed increased expression of genes associated with matrix remodeling (COL-1A1), tendon development (TNC), and fatty infiltration (FABP4) in tendon specimens from the type 2 diabetic group.

CONCLUSION

Persistent type 2 diabetes is associated with the rupture of collagen fiber structure, disturbance in the extracellular matrix, and biomechanical decline of the rotator cuff tendon. The establishment of this new rat model of rotator cuff tendinopathy provides a valuable research basis for studying the cellular and molecular mechanisms of diabetes-induced rotator cuff tendinopathy.

Human Achilles tendon mechanical behavior is more strongly related to collagen disorganization than advanced glycation end-products content

Diabetes is associated with impaired tendon homeostasis and subsequent tendon dysfunction, but the mechanisms underlying these associations is unclear. Advanced glycation end-products (AGEs) accumulate with diabetes and have been suggested to alter tendon function. In vivo imaging in humans has suggested collagen disorganization is more frequent in individuals with diabetes, which could also impair tendon mechanical function. The purpose of this study was to examine relationships between tendon tensile mechanics in human Achilles tendon with accumulation of advanced glycation end-products and collagen disorganization. Achilles tendon specimens (n = 16) were collected from individuals undergoing lower extremity amputation or from autopsy. Tendons were tensile tested with simultaneous quantitative polarized light imaging to assess collagen organization, after which AGEs content was assessed using a fluorescence assay. Moderate to strong relationships were observed between measures of collagen organization and tendon tensile mechanics (range of correlation coefficients: 0.570-0.727), whereas no statistically significant relationships were observed between AGEs content and mechanical parameters (range of correlation coefficients: 0.020-0.210). Results suggest that the relationship between AGEs content and tendon tensile mechanics may be masked by multifactorial collagen disorganization at larger length scales (i.e., the fascicle level).

Mechanical properties of human patellar tendon collagen fibrils. An exploratory study of aging and sex

Tendons are connective tissues that transmit mechanical forces from muscle to bone and consist mainly of nano-scale fibrils of type I collagen. Aging has been associated with reduced mechanical function of tendons at the whole-tendon level and also with increased glycation of tendon collagen fibrils. Yet, the mechanical effects of aging at the fibril level remain unknown. In vitro glycation has previously been reported to substantially increase fibril strength and stiffness in young rats, suggesting a potentially large effect of aging through the glycation mechanism. We therefore expected that aging would have a similar major impact on fibril mechanical properties. In addition, differences in fibril mechanical properties between men and women have never been studied. This study investigated human patellar tendon biopsies from young (26 ± 4 years) and elderly (66 ± 1 years), men and women by measuring the mechanical properties of individual collagen fibrils using a custom nano-mechanical device. There were no major mechanical differences with either age or sex, but there were modestly greater failure stress (22%) and tensile modulus at both low and high strain (16% and 26% respectively) in the elderly group. No significant differences in mechanical properties were observed between men and women. The slightly greater strength and stiffness in the elderly group are in contrasts to the age-related deficits observed for whole-tendons in vivo, although the study was not designed to investigate these minor differences.

Advanced glycation end productions and tendon stem/progenitor cells in pathogenesis of diabetic tendinopathy

Tendinopathy is a challenging complication observed in patients with diabetes mellitus. Tendinopathy usually leads to chronic pain, limited joint motion, and even ruptured tendons. Imaging and histological analyses have revealed pathological changes in various tendons of patients with diabetes, including disorganized arrangement of collagen fibers, microtears, calcium nodules, and advanced glycation end product (AGE) deposition. Tendon-derived stem/ progenitor cells (TSPCs) were found to maintain hemostasis and to participate in the reversal of tendinopathy. We also discovered the aberrant osteochondrogenesis of TSPCs in vitro. However, the relationship between AGEs and TSPCs in diabetic tendinopathy and the underlying mechanism remain unclear. In this review, we summarize the current findings in this field and hypothesize that AGEs could alter the properties of tendons in patients with diabetes by regulating the proliferation and differentiation of TSPCs in vivo.

High glucose represses the proliferation of tendon fibroblasts by inhibiting autophagy activation in tendon injury

Diabetic foot ulcer (DFU) is a kind of common and disabling complication of Diabetes Mellitus (DM). Emerging studies have demonstrated that tendon fibroblasts play a crucial role in remodeling phase of wound healing. However, little is known about the mechanism underlying high glucose (HG)-induced decrease in tendon fibroblasts viability. In the present study, the rat models of DFU were established, and collagen deposition, autophagy activation and cell apoptosis in tendon tissues were assessed using Hematoxylin–Eosin (HE) staining, immunohistochemistry (IHC), and TdT-mediated dUTP Nick-End Labeling (TUNEL) assay, respectively. Tendon fibroblasts were isolated from Achilles tendon of the both limbs, and the effect of HG on autophagy activation in tendon fibroblasts was assessed using Western blot analysis, Cell Counting Kit-8 (CCK-8) assay, and flow cytometry. We found that cell apoptosis was increased significantly and autophagy activation was decreased in foot tendon tissues of DFU rats compared with normal tissues. The role of HG in regulating tendon fibroblasts viability was then investigated in vitro, and data showed that HG repressed cell viability and increased cell apoptosis. Furthermore, HG treatment reduced LC3-II expression and increased p62 expression, indicating that HG repressed autophagy activation of tendon fibroblasts. The autophagy activator rapamycin reversed the effect. More importantly, rapamycin alleviated the suppressive role of HG in tendon fibroblasts viability. Taken together, our data demonstrate that HG represses tendon fibroblasts proliferation by inhibiting autophagy activation in tendon injury.

Decellularized pericardium tissues at increasing glucose, galactose and ribose concentrations and at different time points studied using scanning X-ray microscopy

Diseases like widespread diabetes or rare galactosemia may lead to high sugar concentrations in the human body, thereby promoting the formation of glycoconjugates. Glycation of collagen, i.e. the formation of glucose bridges, is nonenzymatic and therefore cannot be prevented in any other way than keeping the sugar level low. It relates to secondary diseases, abundantly occurring in aging populations and diabetics. However, little is known about the effects of glycation of collagen on the molecular level. We studied in vitro the effect of glycation, with d-glucose and d-galactose as well as d-ribose, on the structure of type 1 collagen by preparing decellularized matrices of bovine pericardia soaked in different sugar solutions, at increasing concentrations (0, 2.5, 5, 10, 20 and 40 mg ml-1), and incubated at 37°C for 3, 14, 30 and 90 days. The tissue samples were analyzed with small- and wide-angle X-ray scattering in scanning mode. We found that glucose and galactose produce similar changes in collagen, i.e. they mainly affect the lateral packing between macromolecules. However, ribose is much faster in glycation, provoking a larger effect on the lateral packing, but also seems to cause qualitatively different effects on the collagen structure.

Metabolic Regulation of Tendon Inflammation and Healing Following Injury

PURPOSE OF REVIEW

This review seeks to provide an overview of the role of inflammation and metabolism in tendon cell function, tendinopathy, and tendon healing. We have summarized the state of knowledge in both tendon and enthesis.

RECENT FINDINGS

Recent advances in the field include a substantial improvement in our understanding of tendon cell biology, including the heterogeneity of the tenocyte environment during homeostasis, the diversity of the cellular milieu during in vivo tendon healing, and the effects of inflammation and altered metabolism on tendon cell function in vitro. In addition, the mechanisms by which altered systemic metabolism, such as diabetes, disrupts tendon homeostasis continue to be better understood. A central conclusion of this review is the critical need to better define fundamental cellular and signaling mechanisms of inflammation and metabolism during tendon homeostasis, tendinopathy, and tendon healing in order to identify therapies to enhance or maintain tendon function.

Accumulation of collagen molecular unfolding is the mechanism of cyclic fatigue damage and failure in collagenous tissues

Overuse injuries to dense collagenous tissues are common, but their etiology is poorly understood. The predominant hypothesis that micro-damage accumulation exceeds the rate of biological repair is missing a mechanistic explanation. Here, we used collagen hybridizing peptides to measure collagen molecular damage during tendon cyclic fatigue loading and computational simulations to identify potential explanations for our findings. Our results revealed that triple-helical collagen denaturation accumulates with increasing cycles of fatigue loading, and damage is correlated with creep strain independent of the cyclic strain rate. Finite-element simulations demonstrated that biphasic fluid flow is a possible fascicle-level mechanism to explain the rate dependence of the number of cycles and time to failure. Molecular dynamics simulations demonstrated that triple-helical unfolding is rate dependent, revealing rate-dependent mechanisms at multiple length scales in the tissue. The accumulation of collagen molecular denaturation during cyclic loading provides a long-sought "micro-damage" mechanism for the development of overuse injuries.

Effect of testing temperature on the nanostructural response of tendon to tensile mechanical overload

Despite many in vitro mechanical experiments of tendon being conducted at room temperature, few assessments have been made to determine how the structural response of tendon to mechanical overload may vary with ambient temperature. We explored whether damage to the collagen nanostructure of tendon resulting from tensile rupture varies with temperature. Use of bovine tail tendons in combination with NaBH₄ crosslink stabilization treatment allowed us to probe the mechanisms underlying the observed changes. Untreated tendons and NaBH₄-stabilized tendons were pulled to rupture at temperatures of 24, 37, and 55 °C. Of nine mechanical parameters measured from the resulting stress-strain curves, only yield stress differed between the tendons tested at 37 and 24 °C. When tested at 55 °C, untreated tendons showed large reductions in ultimate strength and toughness, while NaBH₄-stabilized tendons showed smaller reductions. Differential scanning calorimetry was used to assess damage to the collagen fibril nanostructure of tendons resulting from rupture, with samples from the ruptured tendons compared to samples from the same tendons removed prior to loading. While there was indication that overload-induced molecular packing disruption to collagen fibrils may be heightened at 37 °C, statistical increases in damage compared to that occurring at 24 °C were only seen when testing was conducted at 55 °C. The results show that the temperature sensitivity of tendon to ramp loading depends on crosslinking within the tissue. In poorly crosslinked tissues, collagen may be more susceptible to mechanical damage when tested at physiologic temperature compared to room temperature. For tendons with a high density of thermally stable crosslinks, such as the human Achilles or patellar tendons, testing at room temperature should produce comparable results to testing at physiologic temperature.

Diabetes and Collagen: Interrelations

This review summarizes information on interrelations between diabetes development and collagen metabolism and structure. The growing global problem of diabetes requires the search for new strategies of its complications correction. Among them collagen structure violations and/or its impaired metabolism most often lead to profound disability. Even after several decades of intense studies, pathophysiological mechanisms underlying collagen changes in diabetes mellitus are still not well clear. The main complication is that not only diabetes cause changes in collagen metabolism and structure. Collagens via some mechanisms also may regulate glucose homeostasis, both directly and indirectly. The author also presented the results of own studies on bone and skin type I collagen amino acid composition changes with diabetes. Deepening our understanding of collagen metabolism and diabetes interrelations allows us to optimize approaches to overcome the collagen-mediated consequences of this disease. Recently, it has been clearly demonstrated that use of only antidiabetic agents cannot fully correct such violations. Preparations on the base of flavonoids, collagens and amino acids could be considered as perspective directions in this area of drug development.