Advances and Prospects in Tissue-Engineered Meniscal Scaffolds for Meniscus Regeneration

Healthy but not osteoarthritic human meniscus-derived matrix scaffolds promote meniscus repair

Meniscus tissue is commonly injured due to sports-related injuries and age-related degeneration and approximately 50% of individuals with a meniscus tear will develop post-traumatic osteoarthritis (PTOA). Given that the meniscus has limited healing potential, new therapeutic strategies are required to enhance meniscus repair. Porcine meniscus-derived matrix (MDM) scaffolds improve meniscus integrative repair, but sources of human meniscus tissue have not been investigated. Therefore, the objectives of this study were to generate healthy and osteoarthritic (OA) MDM scaffolds and to compare meniscus cellular responses and integrative repair. Meniscus cells showed high viability on both healthy and OA scaffolds. While DNA content was higher in cell-seeded OA scaffolds than cell-seeded healthy scaffolds, CCK-8, and both sGAG and collagen content were similar between scaffold types. After 28 days in an ex vivo meniscus defect model, healthy and OA scaffolds had similar DNA, sGAG, and collagen content. However, the shear strength of repair was reduced in defects containing OA scaffolds compared to healthy scaffolds. In conclusion, healthy human allograft tissue is a useful source for generating MDM scaffolds that can support cellular growth, ECM production, and ex vivo integrative repair of the meniscus, highlighting the potential suitability for tissue engineering approaches to improve meniscus repair.

Current advances in engineering meniscal tissues: insights into 3D printing, injectable hydrogels and physical stimulation based strategies

The knee meniscus is the cushioning fibro-cartilage tissue present in between the femoral condyles and tibial plateau of the knee joint. It is largely avascular in nature and suffers from a wide range of tears and injuries caused by accidents, trauma, active lifestyle of the populace and old age of individuals. Healing of the meniscus is especially difficult due to its avascularity and hence requires invasive arthroscopic approaches such as surgical resection, suturing or implantation. Though various tissue engineering approaches are proposed for the treatment of meniscus tears, three-dimensional (3D) printing/bioprinting, injectable hydrogels and physical stimulation involving modalities are gaining forefront in the past decade. A plethora of new printing approaches such as direct light photopolymerization and volumetric printing, injectable biomaterials loaded with growth factors and physical stimulation such as low-intensity ultrasound approaches are being added to the treatment portfolio along with the contemporary tear mitigation measures. This review discusses on the necessary design considerations, approaches for 3D modeling and design practices for meniscal tear treatments within the scope of tissue engineering and regeneration. Also, the suitable materials, cell sources, growth factors, fixation and lubrication strategies, mechanical stimulation approaches, 3D printing strategies and injectable hydrogels for meniscal tear management have been elaborated. We have also summarized potential technologies and the potential framework that could be the herald of the future of meniscus tissue engineering and repair approaches.

[Mid-term effectiveness of arthroscopy and conservative treatment for symptomatic discoid lateral meniscus in middle-aged and elderly patients]

Objective

To compare the mid-term effectiveness of arthroscopy versus conservative treatment on symptomatic discoid lateral meniscus (SDLM) in middle-aged and elderly patients.

Methods

The clinical data of 118 middle-aged and elderly patients (154 knees) with SDLM who received arthroscopy or conservative treatment between June 2014 and May 2016 were retrospectively analyzed, including 76 patients (96 knees) in the arthroscopy group (group A) and 42 patients (58 knees) in the conservative treatment group (group B). There was no significant difference in age, gender, and body mass index between the two groups (P>0.05). Compared with group B, the symptoms duration in group A was longer, the incidences of discoid lateral meniscus injury and mechanical symptoms were higher, and the visual analogue scale (VAS) score and Lysholm score before treatment were worse, with significant differences (P<0.05). VAS score and Lysholm score before and after treatment were recorded and compared.

Results

The patients in both groups were followed up 60-74 months, with an average of 66.3 months. The follow-up time of group A and group B was (65.9±3.5) months and (67.0±4.0) months respectively, with no significant difference (t=-1.615, P=0.109). At last follow-up, in either group A or group B, the VAS score and Lysholm score significantly improved when compared with those before treatment (P<0.05). The differences of VAS score and Lysholm score in group A before and after treatment were significantly better than those in group B (P<0.05).

Conclusion

Arthroscopy and conservative treatment have a satisfactory mid-term effectiveness on SDLM in middle-aged and elderly patients. However, the improvement of symptoms and function of arthroscopy was significantly better than that of conservative treatment. For middle-aged and elderly SDLM patients with invalidated conventional treatment for 6 months, severe clinical symptoms, long duration of symptoms, and combined with mechanical symptoms, arthroscopy should be given priority even if they are complicated with early osteoarthritis.

Optimizing artificial meniscus by mechanical stimulation of the chondrocyte-laden acellular meniscus using ad hoc bioreactor

Background

Tissue engineering focuses on reconstructing the damaged meniscus by mimicking the native meniscus. The application of mechanical loading on chondrocyte-laden decellularized whole meniscus is providing the natural microenvironment. The goal of this study was to evaluate the effects of dynamic compression and shear load on chondrocyte-laden decellularized meniscus.

Material and methods

The fresh samples of rabbit menisci were decellularized, and the DNA removal was confirmed by histological assessments and DNA quantification. The biocompatibility, degradation and hydration rate of decellularized menisci were evaluated. The decellularized meniscus was injected at a density of 1 × 10⁵ chondrocyte per scaffold and was subjected to 3 cycles of dynamic compression and shear stimuli (1 h of 5% strain, ± 25°shear at 1 Hz followed by 1 h rest) every other day for 2 weeks using an ad hoc bioreactor. Cytotoxicity, GAG content, ultrastructure, gene expression and mechanical properties were examined in dynamic and static condition and compared to decellularized and intact menisci.

Results

Mechanical stimulation supported cell viability and increased glycosaminoglycan (GAG) accumulation. The expression of collagen-I (COL-I, 10.7-folds), COL-II (6.4-folds), aggrecan (AGG, 3.2-folds), and matrix metalloproteinase (MMP3, 2.3-folds) was upregulated compared to the static conditions. Furthermore, more aligned fibers and enhanced tensile strength were observed in the meniscus treated in dynamic condition with no sign of mineralization.

Conclusion

Compress and shear stimulation mimics the loads on the joint during walking and be able to improve cell function and ultrastructure of engineered tissue to recreate a functional artificial meniscus.

Meniscus regeneration by 3D printing technologies: Current advances and future perspectives

Meniscal tears are a frequent orthopedic injury commonly managed by conservative strategies to avoid osteoarthritis development descending from altered biomechanics. Among cutting-edge approaches in tissue engineering, 3D printing technologies are extremely promising guaranteeing for complex biomimetic architectures mimicking native tissues. Considering the anisotropic characteristics of the menisci, and the ability of printing over structural control, it descends the intriguing potential of such vanguard techniques to meet individual joints’ requirements within personalized medicine. This literature review provides a state-of-the-art on 3D printing for meniscus reconstruction. Experiences in printing materials/technologies, scaffold types, augmentation strategies, cellular conditioning have been compared/discussed; outcomes of pre-clinical studies allowed for further considerations. To date, translation to clinic of 3D printed meniscal devices is still a challenge: meniscus reconstruction is once again clear expression of how the integration of different expertise (e.g., anatomy, engineering, biomaterials science, cell biology, and medicine) is required to successfully address native tissues complexities.

The arthroscopic minimally-invasive technique improves the clinical symptoms and facilitates the functional recovery of the lower limbs in knee joint bone trauma patients

OBJECTIVE

This study aims to demonstrate the effect of the arthroscopic minimally invasive technique on the clinical symptoms and lower limb functional recovery in knee joint bone trauma patients.

METHODS

From January 2015 to January 2020, 150 knee joint bone trauma patients were recruited as the study cohort and divided into two groups according to the different intervention method each patient underwent. The patients in the control group (the CG, n=68) were administered routine treatment, and the patients in the research group (the RG, n=82) were treated using the arthroscopic minimally invasive technique. The postoperative clinical operative indexes and the clinical effectiveness, as well as the intraoperative complications were observed in the two groups. The inflammatory factor levels before and after the surgeries were compared. The Visual Analogue Scale (VAS) was employed to evaluate the pain levels before and after the surgeries, the Hospital for Special Surgery Knee Scores (HSS) were used to assess the knee joint recoveries before and at six months after the operations, and the Fugl-Meyer Assessment Scale (FMAS) was used to determine the lower limb functional recovery before and at six months after the operations.

RESULTS

The RG had significantly shorter operation times, lower intraoperative blood losses, shorter average ambulation times, shorter hospital stays, shorter fracture healing times, and smaller incisions than the CG. Postoperatively, the IL-8 and TNF-α levels were significantly lower in the RG than in the CG. The RG exhibited observably lower VAS scores after the operations, as well as evidently higher HSS scores and FMAS scores at six months postoperatively than the CG. In comparison with the CG, the RG had a significantly higher total effective rate and a noticeably lower incidence of postoperative complications.

CONCLUSIONS

The arthroscopic minimally invasive technique is effective at treating patients with knee joint bone trauma, and it can promote the surgical recovery of patients and facilitate the functional recovery of the knee joint and the lower limbs.

3D Bioprinted Implants for Cartilage Repair in Intervertebral Discs and Knee Menisci

Cartilage defects pose a significant clinical challenge as they can lead to joint pain, swelling and stiffness, which reduces mobility and function thereby significantly affecting the quality of life of patients. More than 250,000 cartilage repair surgeries are performed in the United States every year. The current gold standard is the treatment of focal cartilage defects and bone damage with nonflexible metal or plastic prosthetics. However, these prosthetics are often made from hard and stiff materials that limits mobility and flexibility, and results in leaching of metal particles into the body, degeneration of adjacent soft bone tissues and possible failure of the implant with time. As a result, the patients may require revision surgeries to replace the worn implants or adjacent vertebrae. More recently, autograft - and allograft-based repair strategies have been studied, however these too are limited by donor site morbidity and the limited availability of tissues for surgery. There has been increasing interest in the past two decades in the area of cartilage tissue engineering where methods like 3D bioprinting may be implemented to generate functional constructs using a combination of cells, growth factors (GF) and biocompatible materials. 3D bioprinting allows for the modulation of mechanical properties of the developed constructs to maintain the required flexibility following implantation while also providing the stiffness needed to support body weight. In this review, we will provide a comprehensive overview of current advances in 3D bioprinting for cartilage tissue engineering for knee menisci and intervertebral disc repair. We will also discuss promising medical-grade materials and techniques that can be used for printing, and the future outlook of this emerging field.

Fabrication of decellularized meniscus extracellular matrix according to inner cartilaginous, middle transitional, and outer fibrous zones result in zone-specific protein expression useful for precise replication of meniscus zones

Meniscus is a fibrocartilage composite tissue with three different microstructual zones, inner fibrocartilage, middle transitional, and outer fibrous zone. We hypothesized that decellularized meniscus extracellular matrix (DMECM) would have different characteristics according to zone of origin. We aimed to compare zone-specific DMECM in terms of biochemical characteristics and cellular interactions associated with tissue engineering. Micronized DMECM was fabricated from porcine meniscus divided into three microstructural zones. Characterization of DMECM was done by biochemical and proteomic analysis. Inner DMECM showed the highest glycosaminoglycan content, while middle DMECM showed the highest collagen content among groups. Proteomic analysis showed significant differences among DMECM groups. Inner DMECM showed better adhesion and migration potential to meniscus cells compared to other groups. DMECM resulted in expression of zone-specific differentiation markers when co-cultured with synovial mesenchymal stem cells (SMSCs). SMSCs combined with inner DMECM showed the highest glycosaminoglycan in vivo. Outer DMECM constructs, on the other hand, showed more fibrous tissue features, while middle DMECM constructs showed both inner and outer zone characteristics. In conclusion, DMECM showed different characteristics according to microstructural zones, and such material may be useful for zone-specific tissue engineering of meniscus.

Rehabilitation and Return to Play Following Meniscus Repair

Injuries to the meniscus, particularly tears, can have significant negative impacts on pain, function, and quality of life. Preservation of the meniscus is favorable, especially in the athletic and active populations. While first line treatment is often nonoperative in nature, recalcitrant, and more complex tears, typically require surgery. Meniscus repair rates have increased significantly during the last 2 decades as surgical techniques and postoperative outcomes have improved. Longer postoperative timeframes are to be expected when compared with menisectomy, however, accelerated programs have demonstrated favorable outcomes. Rehabilitation and return to play guidelines should reflect the intricacies of the tear type and repair procedure. Close communication with the surgeon is a vital component to optimize patient outcomes. Further, the patient's goals and expected level of return to function, or sport, must be taken into account for a rehabilitation program to be fully successful.

Clinical Outcomes of Meniscus Repair with or without Multiple Intra-Articular Injections of Platelet Rich Plasma after Surgery

Preservation of the meniscal volume is crucial in meniscus repair. The goal of this study was to evaluate the clinical outcome of repeated intra-articular platelet-rich plasma (PRP) injections after arthroscopic repair of a traumatic meniscal tear. We retrospectively reviewed 61 primary meniscal repairs in 61 patients (PRP group: 30; non-PRP: 31) from 2017 to 2018. Patients in the PRP group received repeated intra-articular PRP injections in week 2,4,6 after the primary meniscus repair. Subsequent meniscal repair treatment or meniscectomy, knee arthroplasty, and IKDC changes of less than 11.5 points were defined as healing failures. After following up for at least 24 months, the IKDC score was 75.1 ± 13.6, and the Lysholm score was 80.6 ± 14.9 in the PRP group and 72.6 ± 15.8 (IKDC) and 77.7 ± 17.2 (Lysholm) in the non-PRP group. Healing rates of the PRP and the non-PRP groups were 93.3% (Kaplan-Meier 91.6%) and 87.1% (Kaplan-Meier 84.7%), respectively (log rank test p = 0.874). Our study is the first to use multiple intra-articular PRP injections to facilitate meniscal healing after meniscal repair. Though selection bias may be present in this study, the PRP group had similar functional outcome and healing rate compared to non-PRP group.

Engineering Anisotropic Meniscus: Zonal Functionality and Spatiotemporal Drug Delivery

Human meniscus is a fibrocartilaginous structure that is crucial for an adequate performance of the human knee joint. Degeneration of the meniscus is often followed by partial or total meniscectomy, which enhances the risk of developing knee osteoarthritis. The lack of a satisfactory treatment for this condition has triggered a major interest in drug delivery (DD) and tissue engineering (TE) strategies intended to restore a bioactive and fully functional meniscal tissue. The aim of this review is to critically discuss the most relevant studies on spatiotemporal DD and TE, aiming for a multizonal meniscal reconstruction. Indeed, the development of meniscal tissue implants should involve a provision for adequate active molecules and scaffold features that take into account the anisotropic ultrastructure of human meniscus. This zonal differentiation is reflected in the meniscus biochemical composition, collagen fiber arrangement, and cell distribution. In this sense, it is expected that a proper combination of advanced DD and zonal TE strategies will play a key role in the future trends in meniscus regeneration. Impact statement Meniscus degeneration is one of the main causes of knee pain, inflammation, and reduced mobility. Currently used suturing procedures and meniscectomy are far from being ideal solutions to the loss of meniscal function. Therefore, drug delivery (DD) and tissue engineering (TE) strategies are currently under investigation. DD systems aim at an in situ controlled release of growth factors, whereas TE strategies aim at mimicking the anisotropy of native meniscus. The goal of this review is to discuss these two main approaches, as well as synergies between them that are expected to lead to a real breakthrough in the field.

Meniscal Tears: Current Understanding, Diagnosis, and Management

From once being labelled as a functionless remain of leg muscle, extensive scientific investigations in recent decades have described the meniscus as one of the most crucial structures of the knee. The incidence of meniscal injuries is on the rise and can be attributed to the increased participation of youth in sporting activities. MRI continues to be the imaging modality of choice, and surgical management is the mainstay of treatment for meniscal tears. Arthroscopic partial meniscectomy (APM) is currently the most performed orthopedic procedure around the globe. However, recent studies have conclusively shown that outcomes after an APM are no better than the outcomes after a sham/placebo surgery. Meniscal repair is now being touted as a viable and effective alternative. Meniscal repair aims to achieve meniscal healing while completely avoiding the adverse effects of partial meniscectomy. Meniscal repairs have grown in popularity over the past three decades and have proved to be a much more efficient alternative to partial meniscectomy. It is now increasingly recommended to attempt meniscal repair in all repairable tears, especially in young and physically active patients. Partial Meniscal implants have also shown excellent outcomes in long-term studies, but its efficacy in acute settings still requires further research. Research performed on various techniques of meniscal regeneration looks promising, and regenerative medicine appears to be the way forward. This review aims to critically discuss the current understanding of the meniscus, its role in biomechanics of the knee joint, and the current methods used to diagnose and manage meniscal tears.

3D Direct Printing of Silicone Meniscus Implant Using a Novel Heat-Cured Extrusion-Based Printer

The first successful direct 3D printing, or additive manufacturing (AM), of heat-cured silicone meniscal implants, using biocompatible and bio-implantable silicone resins is reported. Silicone implants have conventionally been manufactured by indirect silicone casting and molding methods which are expensive and time-consuming. A novel custom-made heat-curing extrusion-based silicone 3D printer which is capable of directly 3D printing medical silicone implants is introduced. The rheological study of silicone resins and the optimization of critical process parameters are described in detail. The surface and cross-sectional morphologies of the printed silicone meniscus implant were also included. A time-lapsed simulation study of the heated silicone resin within the nozzle using computational fluid dynamics (CFD) was done and the results obtained closely resembled real time 3D printing. Solidworks one-convection model simulation, when compared to the on-off model, more closely correlated with the actual probed temperature. Finally, comparative mechanical study between 3D printed and heat-molded meniscus is conducted. The novel 3D printing process opens up the opportunities for rapid 3D printing of various customizable medical silicone implants and devices for patients and fills the current gap in the additive manufacturing industry.

Biological and Mechanical Predictors of Meniscus Function: Basic Science to Clinical Translation

Progressive knee joint degeneration occurs following removal of a torn meniscus. However, there is significant variability in the rate of development of post-meniscectomy osteoarthritis (OA). While there is no current consensus on the risk factors for development of knee OA in patients with meniscus tears, it is likely that both biological and biomechanical factors play critical roles. In this perspective paper, we review the mechanical and the biological predictors of the response of the knee to partial meniscectomy. We review the role of patient-based studies, in vivo animal models, cadaveric models, bioreactor systems, and statistically augmented computational models for the study of meniscus function and post-meniscectomy OA, providing insight into the important interplay between biomechanical and biologic factors. We then discuss the clinical translation of these concepts for "biologic augmentation" of meniscus healing and meniscus replacement. Ultimately, collaborative studies between engineers, biologists, and clinicians is the optimal way to improve our understanding of meniscus pathology and response to injury and/or disease, and to facilitate effective translation of laboratory findings to improved treatments for our patients. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:937-945, 2020.

PCL-MECM-Based Hydrogel Hybrid Scaffolds and Meniscal Fibrochondrocytes Promote Whole Meniscus Regeneration in a Rabbit Meniscectomy Model

Regeneration of an injured meniscus continues to be a scientific challenge due to its poor self-healing potential. Tissue engineering provides an avenue for regenerating a severely damaged meniscus. In this study, we first investigated the superiority of five concentrations (0%, 0.5%, 1%, 2%, and 4%) of meniscus extracellular matrix (MECM)-based hydrogel in promoting cell proliferation and the matrix-forming phenotype of meniscal fibrochondrocytes (MFCs). We found that the 2% group strongly enhanced chondrogenic marker mRNA expression and cell proliferation compared to the other groups. Moreover, the 2% group showed the highest glycosaminoglycan (GAG) and collagen production by day 14. We then constructed a hybrid scaffold by 3D printing a wedge-shaped poly(ε-caprolactone) (PCL) scaffold as a backbone, followed by injection with the optimized MECM-based hydrogel (2%), which served as a cell delivery system. The hybrid scaffold (PCL-hydrogel) clearly yielded favorable biomechanical properties close to those of the native meniscus. Finally, PCL scaffold, PCL-hydrogel, and MFCs-loaded hybrid scaffold (PCL-hydrogel-MFCs) were implanted into the knee joints of New Zealand rabbits that underwent total medial meniscectomy. Six months postimplantation we found that the PCL-hydrogel-MFCs group exhibited markedly better gross appearance and cartilage protection than the PCL scaffold and PCL-hydrogel groups. Moreover, the regenerated menisci in the PCL-hydrogel-MFCs group had similar histological structures, biochemical contents, and biomechanical properties as the native menisci in the sham operation group. In conclusion, PCL-MECM-based hydrogel hybrid scaffold seeded with MFCs can successfully promote whole meniscus regeneration, and cell-loaded PCL-MECM-based hydrogel hybrid scaffold may be a promising strategy for meniscus regeneration in the future.

Development of decellularized meniscus extracellular matrix and gelatin/chitosan scaffolds for meniscus tissue engineering

BACKGROUND

Meniscus tissue engineering has provided a great potential treatment for meniscal injuries. However, few scaffolds in meniscus tissue engineering have matched the mechanical properties of native meniscus.

OBJECTIVE

In this study, we developed a composite scaffold using decellularized meniscus extracellular matrix (DMECM) and gelatin/chitosan (G/C) to explore a preferable ratio to enhance the elastic modulus and cytotoxicity properties of scaffolds.

METHODS

The microstructure, porosity, cytotoxicity, and strength of the composite scaffolds were evaluated. The micro-architectures of the samples were evaluated using scanning electron microscope (SEM). Fourier Transform Infrared analysis (FTIR) was used to confirm the chemical structure with different type composite scaffolds. The compressive elastic modulus of all the scaffolds were measured by the universal tensile testing machine DNS300. Calcein-AM (fluorescent green) and propidium iodide (fluorescent red) were used to stain live cells and dead cells. Morphology and spatial distribution of cells within scaffolds were observed by confocal laser scanning microscopy FV 1000.

RESULTS

SEM showed that the composite scaffolds had suitable porous structure. CCK-8 and live/dead staining demonstrated that the composite scaffolds had no cytotoxicity and could promote bone marrow mesenchymal stem cells (BMSCs) proliferation. The FTIR results demonstrated the successful mixing of these two elements, and the addition of DMECM improved the elastic modulus and cytotoxicity of G/C composite scaffolds.

CONCLUSIONS

This study developed a composite scaffold using DMECM and G/C, and demonstrated that it might be suitable for meniscal tissue engineering application.

Meniscus-Derived Matrix Scaffolds Promote the Integrative Repair of Meniscal Defects

Meniscal tears have a poor healing capacity, and damage to the meniscus is associated with significant pain, disability, and progressive degenerative changes in the knee joint that lead to osteoarthritis. Therefore, strategies to promote meniscus repair and improve meniscus function are needed. The objective of this study was to generate porcine meniscus-derived matrix (MDM) scaffolds and test their effectiveness in promoting meniscus repair via migration of endogenous meniscus cells from the surrounding meniscus or exogenously seeded human bone marrow-derived mesenchymal stem cells (MSCs). Both endogenous meniscal cells and MSCs infiltrated the MDM scaffolds. In the absence of exogenous cells, the 8% MDM scaffolds promoted the integrative repair of an in vitro meniscal defect. Dehydrothermal crosslinking and concentration of the MDM influenced the biochemical content and shear strength of repair, demonstrating that the MDM can be tailored to promote tissue repair. These findings indicate that native meniscus cells can enhance meniscus healing if a scaffold is provided that promotes cellular infiltration and tissue growth. The high affinity of cells for the MDM and the ability to remodel the scaffold reveals the potential of MDM to integrate with native meniscal tissue to promote long-term repair without necessarily requiring exogenous cells.

The Meniscus in Normal and Osteoarthritic Tissues: Facing the Structure Property Challenges and Current Treatment Trends

The treatment of meniscus injuries has recently been facing a paradigm shift toward the field of tissue engineering, with the aim of regenerating damaged and diseased menisci as opposed to current treatment techniques. This review focuses on the structure and mechanics associated with the meniscus. The meniscus is defined in terms of its biological structure and composition. Biomechanics of the meniscus are discussed in detail, as an understanding of the mechanics is fundamental for the development of new meniscal treatment strategies. Key meniscal characteristics such as biological function, damage (tears), and disease are critically analyzed. The latest technologies behind meniscal repair and regeneration are assessed.

Are the Biological and Biomechanical Properties of Meniscal Scaffolds Reflected in Clinical Practice? A Systematic Review of the Literature

The aim of this PRISMA review was to assess whether the CMI and Actifit scaffolds, when used in clinical practice, improve clinical outcomes and demonstrate the ideal biological and biomechanical properties of scaffolds: being chondroprotective, porous, resorbable, able to mature and promote regeneration of tissue. This was done by only including studies that assessed clinical outcome and used a scale to assess both integrity of the scaffold and its effects on articular cartilage via MRI. A search was performed on PubMed, EMBASE, Scopus and clinicaltrials.gov. 2457 articles were screened, from which eight studies were selected: four used Actifit, three used CMI and one compared the two. All studies reported significant improvement in at least one clinical outcome compared to baseline. Some studies suggested that the scaffolds appeared to show porosity, mature, resorb and/or have possible chondroprotective effects, as assessed by MRI. The evidence for clinical translation is limited by differences in study methodology and small sample sizes, but is promising in terms of improving clinical outcomes in the short to mid-term. Higher level evidence, with MRI and histological evaluation of the scaffold and articular cartilage, is now needed to further determine whether these scaffolds exhibit these useful properties.

A collagen-coated sponge silk scaffold for functional meniscus regeneration

Tissue engineering is a promising solution for meniscal regeneration after meniscectomy. However, in situ reconstruction still poses a formidable challenge due to multifunctional roles of the meniscus in the knee. In this study, we fabricate a silk sponge from 9% (w/v) silk fibroin solution through freeze drying and then coat its internal space and external surface with collagen sponge. Subsequently, various characteristics of the silk-collagen scaffold are evaluated, and cytocompatibility of the construct is assessed in vitro and subcutaneously. The efficacy of this composite scaffold for meniscal regeneration is evaluated through meniscus reconstruction in a rabbit meniscectomy model. It is found that the internally coated collagen sponge enhances the cytocompatibility of the silk sponge, and the external layer of collagen sponge significantly improves the initial frictional property. Additionally, the silk-collagen composite group shows more tissue ingrowth and less cartilage wear than the pure silk sponge group at 3 months postimplantation in situ. These findings thus demonstrate that the composite scaffold had less damage to the joint surface than the silk alone through promoting functional meniscal regeneration after meniscectomy, which indicates its clinical potential in meniscus reconstruction.

Biomechanical Stimulus Based Strategies for Meniscus Tissue Engineering and Regeneration

Meniscus injuries are very common in the knee joint. Treating a damaged meniscus continues to be a scientific challenge in sport medicine because of its poor self-healing potential and few clinical therapeutic options. Tissue engineering strategies are very promising solutions for repairing and regenerating a damaged meniscus. Meniscus is exposed to a complex biomechanical microenvironment, and it plays a crucial role in meniscal development, growth, and repairing. Over the past decades, increasing attention has been focused on the use of biomechanical stimulus to enhance biomechanical properties of the engineered meniscus. Further understanding the influence of mechanical stimulation on cell proliferation and differentiation, metabolism, relevant gene expression, and pro/anti-inflammatory responses may be beneficial to enhance meniscal repair and regeneration. On the one hand, this review describes some basic information about meniscus; on the other hand, we sum up the various biomechanical stimulus based strategies applied in meniscus tissue engineering and how these factors affect meniscal regeneration. We hope this review will provide researchers with inspiration on tissue engineering strategies for meniscus regeneration in the future.

[Study on the preparation of polycaprolactone/type collagen tissue engineered meniscus scaffold by three-dimensional printing and its physiochemical properties]

Objective

To manufacture a polycaprolactone (PCL)/type Ⅰ collagen (COL Ⅰ) tissue engineered meniscus scaffold (hereinafter referred to as PCL/COL Ⅰ meniscus scaffold) by three-dimensional (3D) printing with low temperature deposition technique and to study its physicochemical properties.

Methods

First, the 15% PCL/4% COLⅠ composite solution and 15% PCL simple solution were prepared. Then, 15% PCL/4% COL Ⅰmeniscus scaffold and 15% PCL meniscal scaffold were prepared by using 3D printing with low temperature deposition techniques. The morphology and microstructure of the scaffolds were observed by gross observation and scanning electron microscope. The compression modulus and tensile modulus of the scaffolds were measured by biomechanical test. The components of the scaffolds were analyzed by Fourier transform infrared spectroscopy (FTIR). The contact angle of the scaffold surface was measured. The meniscus cells of rabbits were cultured with the two scaffold extracts and scaffolds, respectively. After cultured, the cell proliferations were detected by cell counting kit 8 (CCK-8), and the normal cultured cells were used as controls. Cell adhesion and growth of scaffold-cell complex were observed by scanning electron microscope.

Results

According to the gross and scanning electron microscope observations, two scaffolds had orientated 3D microstructures and pores, but the surface of the PCL/COLⅠ meniscus scaffold was rougher than the PCL meniscus scaffold. Biomechanical analysis showed that the tensile modulus and compression modulus of the PCL/COL Ⅰ meniscus scaffold were not significantly different from those of the PCL meniscus scaffold ( P>0.05). FTIR analysis results showed that COL Ⅰ and PCL were successful mixed in PCL/ COL Ⅰ meniscus scaffolds. The contact angle of PCL/COLⅠ meniscus scaffold [(83.19±7.49)°] was significantly lower than that of PCL meniscus scaffold [(111.13±5.70)°] ( t=6.638, P=0.000). The results of the CCK-8 assay indicated that with time, the number of cells cultured in two scaffold extracts showed an increasing trend, and there was no significant difference when compared with the control group ( P>0.05). Scanning electron microscope observation showed that the cells attached on the PCL/ COL Ⅰ meniscus scaffold more than that on the PCL scaffold.

Conclusion

PCL/COLⅠmeniscus scaffolds are prepared by 3D printing with low temperature deposition technique, which has excellent physicochemical properties without cytotoxicity. PCL/COLⅠmeniscus scaffold is expected to be used as the material for meniscus tissue engineering.

Should the meniscal height be considered for preoperative sizing in meniscal transplantation?

PURPOSE AND HYPOTHESIS

In preoperative sizing for meniscal transplantation, most authors take into consideration the length and width of the original meniscus, but not its height. This study aimed at evaluating (1) whether the meniscal height is associated with the meniscal length and width, (2) whether the heights of the meniscal segments are associated with the individual's anthropometric data, (3) whether the heights of the meniscal segments are associated with each other in the same meniscus, and (4) the degree of symmetry of the meniscal dimensions between the right and left knees.

METHODS

In this cross-sectional, observational study, two independent radiologists measured the meniscal length, width and height in knee magnetic resonance imaging scans obtained from 25 patients with patello-femoral pain syndrome. Reproducibility of measurements was calculated with intraclass correlation coefficients. Associations between the anthropometric data and the meniscal measurements, the meniscal length and width versus height, and the heights of the meniscal segments in the same meniscus were examined with Pearson's correlation.

RESULTS

Inter-observer reliability was excellent (>0.8) for length and height and good (0.6-0.8) for width measurements. There was also excellent agreement (>0.8) for the length and width of the menisci in the right and left knees. The heights of the horns of the lateral meniscus showed good agreement (0.6-0.8), while the heights of the other meniscal segments had excellent agreement between the sides (>0.8). There were significant associations with generally low (r < 0.5) correlation between the heights of the meniscal segments and the lengths and widths of the menisci, between the meniscal height and anthropometric data, and between the heights of the meniscal segments in the same meniscus. Correlations between anthropometric data and meniscal length and width were generally high (r > 0.7).

CONCLUSIONS

There was excellent agreement between the meniscal dimensions of the right and left knees, and a weak association between the meniscal height with the meniscal width and length, between the height of the menisci with anthropometric data and between the heights of the segments in the same meniscus. The height of the meniscal segments may be a new variable in preoperative meniscal measurement.

A Novel Approach for Meniscal Regeneration Using Kartogenin-Treated Autologous Tendon Graft

BACKGROUND

The meniscus is one of the most commonly injured parts of the body, and meniscal healing is difficult.

HYPOTHESIS

Kartogenin (KGN) induces tendon stem cells (TSCs) to differentiate into cartilage cells in vitro and form meniscus-like tissue in vivo. A damaged meniscus can be replaced with a KGN-treated autologous tendon graft.

STUDY DESIGN

Controlled laboratory study.

METHODS

In the in vitro experiments, TSCs were isolated from rabbit patellar tendons and cultured with various concentrations of KGN, from 0 to 1000 µM. The effect of KGN on the chondrogenesis of TSCs in vitro was investigated by histochemical staining and quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). The in vivo experiments were carried out on 6 New Zealand White rabbits by removing a meniscus from the rabbit knee and implanting an autologous tendon graft treated with KGN or saline. The meniscus formation in vivo was examined by histological analysis and immune staining.

RESULTS

The proliferation of TSCs was promoted by KGN in a concentration-dependent manner. Both histochemical staining and qRT-PCR showed that the chondrogenic differentiation of TSCs was increased with KGN concentration. After 3 months of implantation, the tendon graft treated with KGN formed a meniscus-like tissue with a white and glistening appearance, while the saline-treated tendon graft retained tendon-like tissue and appeared yellowish and unhealthy. Histochemical staining showed that after 3 months of implantation, the KGN-treated tendon graft had a structure similar to that of normal meniscus. Many cartilage-like cells and fibrocartilage-like tissues were found in the KGN-treated tendon graft. However, no cartilage-like cells were found in the saline-treated tendon graft after 3 months of implantation. Furthermore, the KGN-treated tendon graft was positively stained by both anti-collagen type I and type II antibodies, but the saline-treated tendon graft was not stained by collagen type II.

CONCLUSION

The findings indicated that KGN can induce the differentiation of TSCs into cartilage-like cells in vitro and in vivo. The results suggest that KGN-treated tendon graft may be a good substitute for meniscal repair and regeneration.

CLINICAL RELEVANCE

This study revealed the direct effects of KGN on the chondrogenic differentiation of TSCs in vitro and in vivo. A KGN-treated autologous tendon graft induced formation of a meniscus-like tissue in vivo. This study provides a new cartilage regenerating technology for the treatment of damaged meniscus.

Advances and Prospects in Stem Cells for Cartilage Regeneration

The histological features of cartilage call attention to the fact that cartilage has a little capacity to repair itself owing to the lack of a blood supply, nerves, or lymphangion. Stem cells have emerged as a promising option in the field of cartilage tissue engineering and regenerative medicine and could lead to cartilage repair. Much research has examined cartilage regeneration utilizing stem cells. However, both the potential and the limitations of this procedure remain controversial. This review presents a summary of emerging trends with regard to using stem cells in cartilage tissue engineering and regenerative medicine. In particular, it focuses on the characterization of cartilage stem cells, the chondrogenic differentiation of stem cells, and the various strategies and approaches involving stem cells that have been used in cartilage repair and clinical studies. Based on the research into chondrocyte and stem cell technologies, this review discusses the damage and repair of cartilage and the clinical application of stem cells, with a view to increasing our systematic understanding of the application of stem cells in cartilage regeneration; additionally, several advanced strategies for cartilage repair are discussed.

Relevance of meniscal cell regional phenotype to tissue engineering

PURPOSE

Meniscus contains heterogeneous populations of cells that have not been fully characterized. Cell phenotype is often lost during culture; however, culture expansion is typically required for tissue engineering. We examined and compared cell-surface molecule expression levels on human meniscus cells from the vascular and avascular regions and articular chondrocytes while documenting changes during culture-induced dedifferentiation.

MATERIALS AND METHODS

Expressions of 16 different surface molecules were examined by flow cytometry after monolayer culture for 24 h, 1 week, and 2 weeks. Menisci were also immunostained to document the spatial distributions of selected surface molecules.

RESULTS

Meniscus cells and chondrocytes exhibited several similarities in surface molecule profiles with dynamic changes during culture. A greater percentage of meniscal cells were positive for CD14, CD26, CD49c, and CD49f compared to articular chondrocytes. Initially, more meniscal cells from the vascular region were positive for CD90 compared to cells from the avascular region or chondrocytes. Cells from the vascular region also expressed higher levels of CD166 and CD271 compared to cells from the avascular region. CD90, CD166, and CD271-positive cells were predominately perivascular in location. However, CD166-positive cells were also located in the superficial layer and in the adjacent synovial and adipose tissue.

CONCLUSIONS

These surface marker profiles provide a target phenotype for differentiation of progenitors in tissue engineering. The spatial location of progenitor cells in meniscus is consistent with higher regenerative capacity of the vascular region, while the surface progenitor subpopulations have potential to be utilized in tears created in the avascular region.