bFGF- and CaPP-Loaded Fibrin Clots Enhance the Bioactivity of the Tendon-Bone Interface to Augment Healing

Humidity-Responsive Amorphous Calcium-Magnesium Pyrophosphate/Cassava Starch Scaffold for Enhanced Neurovascular Bone Regeneration

Developing a neurovascular bone repair scaffold with an appropriate mechanical strength remains a challenge. Calcium phosphate (CaP) is similar to human bone, but its scaffolds are inherently brittle and inactive, which require recombination with active ions and polymers for bioactivity and suitable strength. This work discussed the synthesis of amorphous magnesium-calcium pyrophosphate (AMCP) and the subsequent development of a humidity-responsive AMCP/cassava starch (CS) scaffold. The scaffold demonstrated enhanced mechanical properties by strengthening the intermolecular hydrogen bonds and ionic bonds between AMCP and CS during the gelatinization and freeze-thawing processes. The release of active ions was rapid initially and stabilized into a long-term stable release after 3 days, which is well-matched with new bone growth. The release of pyrophosphate ions endowed the scaffold with antibacterial properties. At the cellular level, the released active ions simultaneously promoted the proliferation and mineralization of osteoblasts, the proliferation and migration of endothelial cells, and the proliferation of Schwann cells. At the animal level, the scaffold was demonstrated to promote vascular growth and peripheral nerve regeneration in a rat skull defect experiment, ultimately resulting in the significant and rapid repair of bone defects. The construction of the AMCP/CS scaffold offers practical suggestions and references for neurovascular bone repair.

Strategies to promote tendon-bone healing after anterior cruciate ligament reconstruction: Present and future

At present, anterior cruciate ligament (ACL) reconstruction still has a high failure rate. Tendon graft and bone tunnel surface angiogenesis and bony ingrowth are the main physiological processes of tendon-bone healing, and also the main reasons for the postoperative efficacy of ACL reconstruction. Poor tendon-bone healing has been also identified as one of the main causes of unsatisfactory treatment outcomes. The physiological process of tendon-bone healing is complicated because the tendon-bone junction requires the organic fusion of the tendon graft with the bone tissue. The failure of the operation is often caused by tendon dislocation or scar healing. Therefore, it is important to study the possible risk factors for tendon-bone healing and strategies to promote it. This review comprehensively analyzed the risk factors contributing to tendon-bone healing failure after ACL reconstruction. Additionally, we discuss the current strategies used to promote tendon-bone healing following ACL reconstruction.

Mesenchymal stem cells and macrophages and their interactions in tendon-bone healing

Tendon-bone insertion injuries (TBI), such as anterior cruciate ligament (ACL) and rotator cuff injuries, are common degenerative or traumatic pathologies with a negative impact on the patient's daily life, and they cause huge economic losses every year. The healing process after an injury is complex and is dependent on the surrounding environment. Macrophages accumulate during the entire process of tendon and bone healing and their phenotypes progressively transform as they regenerate. As the "sensor and switch of the immune system", mesenchymal stem cells (MSCs) respond to the inflammatory environment and exert immunomodulatory effects during the tendon-bone healing process. When exposed to appropriate stimuli, they can differentiate into different tissues, including chondrocytes, osteocytes, and epithelial cells, promoting reconstruction of the complex transitional structure of the enthesis. It is well known that MSCs and macrophages communicate with each other during tissue repair. In this review, we discuss the roles of macrophages and MSCs in TBI injury and healing. Reciprocal interactions between MSCs and macrophages and some biological processes utilizing their mutual relations in tendon-bone healing are also described. Additionally, we discuss the limitations in our understanding of tendon-bone healing and propose feasible ways to exploit MSC-macrophage interplay to develop an effective therapeutic strategy for TBI injuries.

The Translational potential of this article

This paper reviewed the important functions of macrophages and mesenchymal stem cells in tendon-bone healing and described the reciprocal interactions between them during the healing process. By managing macrophage phenotypes, mesenchymal stem cells and the interactions between them, some possible novel therapies for tendon-bone injury may be proposed to promote tendon-bone healing after restoration surgery.

Strategies for promoting tendon-bone healing: Current status and prospects

Tendon-bone insertion (TBI) injuries are common, primarily involving the rotator cuff (RC) and anterior cruciate ligament (ACL). At present, repair surgery and reconstructive surgery are the main treatments, and the main factor determining the curative effect of surgery is postoperative tendon-bone healing, which requires the stable combination of the transplanted tendon and the bone tunnel to ensure the stability of the joint. Fibrocartilage and bone formation are the main physiological processes in the bone marrow tract. Therefore, therapeutic measures conducive to these processes are likely to be applied clinically to promote tendon-bone healing. In recent years, biomaterials and compounds, stem cells, cell factors, platelet-rich plasma, exosomes, physical therapy, and other technologies have been widely used in the study of promoting tendon-bone healing. This review provides a comprehensive summary of strategies used to promote tendon-bone healing and analyses relevant preclinical and clinical studies. The potential application value of these strategies in promoting tendon-bone healing was also discussed.

Biological and Mechanical Factors and Epigenetic Regulation Involved in Tendon Healing

Tendons are an important part of the musculoskeletal system. Connecting muscles to bones, tendons convert force into movement. Tendon injury can be acute or chronic. Noticeably, tendon healing requires a long time span and includes inflammation, proliferation, and remodeling processes. The mismatch between endogenous and exogenous healing may lead to adhesion causing further negative effects. Management of tendon injuries and complications such as subsequent adhesion formation are still challenges for clinicians. Due to numerous factors, tendon healing is a complex process. This review introduces the role of various biological and mechanical factors and epigenetic regulation processes involved in tendon healing.

New frontiers of tendon augmentation technology in tissue engineering and regenerative medicine: a concise literature review

Tissue banking programs fail to meet the demand for human organs and tissues for transplantation into patients with congenital defects, injuries, chronic diseases, and end-stage organ failure. Tendons and ligaments are among the most frequently ruptured and/or worn-out body tissues owing to their frequent use, especially in athletes and the elderly population. Surgical repair has remained the mainstay management approach, regardless of scarring and adhesion formation during healing, which then compromises the gliding motion of the joint and reduces the quality of life for patients. Tissue engineering and regenerative medicine approaches, such as tendon augmentation, are promising as they may provide superior outcomes by inducing host-tissue ingrowth and tendon regeneration during degradation, thereby decreasing failure rates and morbidity. However, to date, tendon tissue engineering and regeneration research has been limited and lacks the much-needed human clinical evidence to translate most laboratory augmentation approaches to therapeutics. This narrative review summarizes the current treatment options for various tendon pathologies, future of tendon augmentation, cell therapy, gene therapy, 3D/4D bioprinting, scaffolding, and cell signals.

The effect of fibrin clot and C vitamin on the surgical treatment of Achilles tendon injury in the rat model✰

BACKGROUND

This study aimed to determine the histological, biochemical, and biomechanical efficacy of fibrin clot and vitamin C in the healing of Achilles tendon ruptures (ATR) in a rat model.

METHODS

52 adult Wistar-Albino rats (300-450 g) were used in the study. 12 rats were divided into four groups as Monitor (Group I), Control (Group II), Fibrin Clot (Group III), Fibrin Clot with vitamin C (Group IV). Four rats were used for fibrin clot preparation. Fibroblast Growth Factor (FGF) and Vascular Endothelial Growth Factor (VEGF) were measured on the 3rd, 7th, 14th, and 21st days. Four rats were sacrificed on the 21st day from each group for histological evaluation. The rest of the rats were sacrificed at 42nd day, half for biomechanical and a half for histological evaluation.

RESULTS

The 42nd-day HSS score of group IV was significantly lower than those of group I, group II and group III (p = 0.036, p = 0.019, and p = 0.036, respectively). Group IV showed a significantly higher Maximum force N value than those of group I, group II and group III (p = 0.034, p = 0.034 and, p = 0.025, respectively). The blood FGF and VEGF levels of group III and group IV on the 3rd, 7th, 14th, and 21st days were higher than those of group I and group II (p < 0.05).

CONCLUSION

Fibrin clot and vitamin C produced a stronger tendon structure in terms of biomechanics while providing histological and biochemically better quality tendon healing in the surgical treatment of ATR. This model can be used to accelerate high-quality tendon healing after ATR.

LEVEL OF EVIDENCE

Level II, experimental study.

Engineering multi-tissue units for regenerative Medicine: Bone-tendon-muscle units of the rotator cuff

Our body systems are comprised of numerous multi-tissue units. For the musculoskeletal system, one of the predominant functional units is comprised of bone, tendon/ligament, and muscle tissues working in tandem to facilitate locomotion. To successfully treat musculoskeletal injuries and diseases, critical consideration and thoughtful integration of clinical, biological, and engineering aspects are necessary to achieve translational bench-to-bedside research. In particular, identifying ideal biomaterial design specifications, understanding prior and recent tissue engineering advances, and judicious application of biomaterial and fabrication technologies will be crucial for addressing current clinical challenges in engineering multi-tissue units. Using rotator cuff tears as an example, insights relevant for engineering a bone-tendon-muscle multi-tissue unit are presented. This review highlights the tissue engineering strategies for musculoskeletal repair and regeneration with implications for other bone-tendon-muscle units, their derivatives, and analogous non-musculoskeletal tissue structures.

Effects of nanoparticle-mediated growth factor gene transfer to the injured microenvironment on the tendon-to-bone healing strength

The tendon-to-bone healing after trauma is usually slow and weak, and the repair site is easily disrupted during early mobilization exercise. bFGF and VEGFA gene therapy may hold promise in augmenting the tendon-to-bone healing process through enhancing cell proliferation and angiogenesis. This study is conducted to determine the effects of nanoparticle-mediated co-delivery of bFGF and VEGFA genes to the tendon-to-bone repair interface on the healing strength and biological responses in a chicken model. The PLGA nanoparticle/pEGFP-bFGF + pEGFP-VEGFA plasmid complexes were prepared and were characterized in vitro and in vivo. The nanoparticle/plasmid complexes can effectively transfer bFGF and VEGFA genes to the tendon-to-bone interface. Nanoparticle-mediated co-delivery of bFGF and VEGFA genes significantly improved the tendon-to-bone healing in terms of healing strengths and histology in a chicken flexor tendon repair model. Our results suggest a new biological approach to accelerate the tendon-to-bone healing.

FGF2: a key regulator augmenting tendon-to-bone healing and cartilage repair

Ligament/tendon and cartilage injuries are clinically common diseases that perplex most clinicians. Because of the lack of blood vessels and nerves, their self-repairing abilities are rather poor. Therefore, surgeries are necessary and also widely used to treat ligament/tendon or cartilage injuries. However, after surgery, there are still many problems that affect healing. In recent years, it has been found that exogenous FGF2 plays an important role in the repair of ligament/tendon and cartilage injuries and exerts a synergistic effect with endogenous FGF2. Therefore, FGF2 can be used as a new type of biomolecule to accelerate tendon-to-bone healing and cartilage repair after injury.

Osteoprotegerin/bone morphogenetic protein 2 combining with collagen sponges on tendon-bone healing in rabbits

INTRODUCTION

The aim was to investigate the effect of collagen sponges (CS) as a delivery device for osteoprotegerin (OPG)/bone morphogenetic protein 2 (BMP-2) and support matrix on the tendon-bone healing after anterior crusicate ligament (ACL) reconstruction in modeled rabbits.

MATERIALS AND METHODS

Sixty New Zealand white rabbits were randomly divided into four groups based on treatments they received at the tendon-bone interface after left knee ACL reconstruction: the control group, OPG/BMP-2, CS, and OPG/BMP-2/CS combination. At 4, 8 and 12 weeks post-surgery, five rabbits from each group were euthanized to examine the tendon-bone healing. Levels of OPG and BMP-2 in synovial fluid, the bone tunnel enlargement value, the histomorphological typing of tendon-bone interface, and the bone tunnel area of the tendon-bone interface were compared among different treatments.

RESULTS

The OPG/BMP-2/CS combination treatment group had the highest levels of OPG and BMP-2 in synovial fluid (both P < 0.05), the greatest number of Sharpey-like collagen fibers at all test points (P < 0.05), the most fibrocartilage enthesis on week 12, the greatest bone tunnel area (P < 0.05), and the greatest decrease in bone tunnel enlargement on week 12 (P < 0.05). Histomorphological typing of tendon-bone interface of all groups showed changes varying from tendon-bone separation to firm healing, and the change was most significant in the OPG/BMP-2/CS combination treatment group.

CONCLUSION

CS treatment alone serves as a fixing support, and CS combining with growth factors OPG/BMP-2 ensures slow and stable release of OPG/BMP-2, significantly improves the tendon-bone healing in the rabbit ACL model.

A microfluidics-derived growth factor gradient in a scaffold regulates stem cell activities for tendon-to-bone interface healing

Treatment of tendon-to-bone interface injury has long been challenging in sports medicine. The major obstacle lies with the complicated three-layer structure of the tissue that consists of a bone region with osteocytes, a tendon region with tenocytes and a transitional region with chondrocytes. Conventional tissue engineering approaches using simply biomaterial scaffolds, stem cells and combinations of them had limited abilities to reconstruct the gradient structure with normal biomechanical properties. We herein aim to construct a three-layer structure with bone marrow-derived stem cells and tendon stem cells cultured in a decellularized tendon scaffold, through application of a gradient of biological cues in the longitudinal direction of the scaffold that guides the stem cells to differentiate and remodel the extracellular matrix in response to different medium concentrations in different regions. A microfluidic chip, on which a tree-like flow pattern was implemented, was adopted to create the concentration gradient in a dichotomous manner. We screened for an optimized seeding ratio between the two stem cell types before incubation of the scaffold in the medium concentration gradient and surgical implantation. Histology and immunohistochemistry assessments, both qualitatively and semi-quantitatively, showed that the microfluidic system provided desired guidance to the seeded stem cells that the healing at 8-week post-implantation presented a similar structure to that of a normal tendon-to-bone interface, which was outstanding compared to treatments without gradient guidance, stem cells or scaffolds where chaotic and fibrotic structures were obtained. This strategy offers a potentially translational tissue engineering approach for better outcomes in tendon-to-bone healing.

Fibroblast growth factor 2-induced human amniotic mesenchymal stem cells combined with autologous platelet rich plasma augmented tendon-to-bone healing

Objective

The purpose of this study was to explore the effect of fibroblast growth factor 2 (FGF-2) on collagenous fibre formation and the osteogenic differentiation of human amniotic mesenchymal stem cells (hAMSCs) in vitro, as well as the effect of FGF-2–induced hAMSCs combined with autologous platelet-rich plasma (PRP) on tendon-to-bone healing in vivo.

Methods

In vitro, hAMSCs were induced by various concentrations of FGF-2 (0, 10, 20, and 40 ​ng/ml) for 14 days, and the outcomes of ligamentous differentiation and osteogenic differentiation were detected by quantitative real-time reverse transcription PCR, Western blot, immunofluorescence, and picrosirius red staining. In addition, a lentivirus carrying the FGF-2 gene was used to transfect hAMSCs, and transfection efficiency was detected by quantitative real time reverse transcription PCR (qRT-PCR) and Western blot. In vivo, the effect of hAMSCs transfected with the FGF-2 gene combined with autologous PRP on tendon-to-bone healing was detected via histological examination, as well as biomechanical analysis and radiographic analysis.

Results

In vitro, different concentrations of FGF-2 (10, 20, and 40 ​ng/ml) all promoted the ligamentous differentiation and osteogenic differentiation of hAMSCs, and the low concentration of FGF-2 (10 ​ng/ml) had a good effect on differentiation. In addition, the lentivirus carrying the FGF-2 gene was successfully transfected into hAMSCs with an optimal multiplicity of infection (MOI) (50), and autologous PRP was prepared successfully. In vivo, the hAMSCs transfected with the FGF-2 gene combined with autologous PRP had a better effect on tendon-to-bone healing than the other groups (p ​< ​0.05), as evidenced by histological examination, biomechanical analysis, and radiographic analysis.

Conclusion

hAMSCs transfected with the FGF-2 gene combined with autologous PRP could augment tendon-to-bone healing in a rabbit extra-articular model.

The translational potential of this article

hAMSCs transfected with the FGF-2 gene combined with autologous PRP may be a good clinical treatment for tendon-to-bone healing, especially for acute sports-related tendon–ligament injuries.

LncRNA TUG1 promoted osteogenic differentiation through promoting bFGF ubiquitination

LncRNA TUG1 has the potential to promote the osteogenic differentiation of several cells, but the role of lncRNA TUG1 in osteogenic differentiation of tendon stem/progenitor cells (TSPCs) is still unknown. This study aims to determine the role of lncRNA TUG1 in osteogenic differentiation of TSPCs. bFGF, RUNX2, and Osterix protein expressions were detected by western blot. LncRNA TUG1 and bFGF expression was detected by qRT-PCR. RNA immunoprecipitation (RIP) assay was used to confirm the interaction between TUG1 and bFGF2. Ubiquitination assay was used to determine the ubiquitination of bFGF protein. During osteogenic differentiation, the protein expression of bFGF was significantly downregulated in TSPCs, and the expression of TUG1 was significantly elevated in TSPCs. Interfering TUG1 or overexpressing bFGF suppressed osteogenic differentiation of TSPCs. In addition, lncRNA TUG1 interacted with bFGF, and lncRNA TUG1 promoted the ubiquitination of bFGF protein. We also determined that lncRNA TUG1 downregulated bFGF protein expression through promoting the ubiquitination of bFGF. LncRNA TUG1 promoted the osteogenic differentiation of TSPCs through promoting bFGF ubiquitination.

FGF-2-Induced Human Amniotic Mesenchymal Stem Cells Seeded on a Human Acellular Amniotic Membrane Scaffold Accelerated Tendon-to-Bone Healing in a Rabbit Extra-Articular Model

Background

FGF-2 (basic fibroblast growth factor) has a positive effect on the proliferation and differentiation of many kinds of MSCs. Therefore, it represents an ideal molecule to facilitate tendon-to-bone healing. Nonetheless, no studies have investigated the application of FGF-2-induced human amniotic mesenchymal stem cells (hAMSCs) to accelerate tendon-to-bone healing in vivo.

Objective

The purpose of this study was to explore the effect of FGF-2 on chondrogenic differentiation of hAMSCs in vitro and the effect of FGF-2-induced hAMSCs combined with a human acellular amniotic membrane (HAAM) scaffold on tendon-to-bone healing in vivo.

Methods

In vitro, hAMSCs were transfected with a lentivirus carrying the FGF-2 gene, and the potential for chondrogenic differentiation of hAMSCs induced by the FGF-2 gene was assessed using immunofluorescence and toluidine blue (TB) staining. HAAM scaffold was prepared, and hematoxylin and eosin (HE) staining and scanning electron microscopy (SEM) were used to observe the microstructure of the HAAM scaffold. hAMSCs transfected with and without FGF-2 were seeded on the HAAM scaffold at a density of 3 × 10⁵ cells/well. Immunofluorescence staining of vimentin and phalloidin staining were used to confirm cell adherence and growth on the HAAM scaffold. In vivo, the rabbit extra-articular tendon-to-bone healing model was created using the right hind limb of 40 New Zealand White rabbits. Grafts mimicking tendon-to-bone interface (TBI) injury were created and subjected to treatment with the HAAM scaffold loaded with FGF-2-induced hAMSCs, HAAM scaffold loaded with hAMSCs only, HAAM scaffold, and no special treatment. Macroscopic observation, imageological analysis, histological assessment, and biomechanical analysis were conducted to evaluate tendon-to-bone healing after 3 months.

Results

In vitro, cartilage-specific marker staining was positive for the FGF-2 overexpression group. The HAAM scaffold displayed a netted structure and mass extracellular matrix structure. hAMSCs or hAMSCs transfected with FGF-2 survived on the HAAM scaffold and grew well. In vivo, the group treated with HAAM scaffold loaded with FGF-2-induced hAMSCs had the narrowest bone tunnel after three months as compared with other groups. In addition, macroscopic and histological scores were higher for this group than for the other groups, along with the best mechanical strength.

Conclusion

hAMSCs transfected with FGF-2 combined with the HAAM scaffold could accelerate tendon-to-bone healing in a rabbit extra-articular model.

Autologous Freeze-Dried, Platelet-Rich Plasma Carrying Icariin Enhances Bone-Tendon Healing in a Rabbit Model

BACKGROUND

Tendon-bone interface (TBI) injuries are common in sports activities. Owing to the limited regenerative ability of the TBI, its functional healing remains a difficulty in clinical practice. Icariin (ICA) provides strong stimulation for osteogenesis. Platelet-rich plasma (PRP) can be used as a carrier for bioactive molecules, although its ability to provide sustained release for such molecules needs improvement.

HYPOTHESIS

Freeze-dried PRP (FD-PRP) as a carrier for ICA can provide sustained release of ICA into the tendon-bone (T-B) healing site, thus accelerating T-B healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 84 New Zealand rabbits with partial patellectomy in the hindlimb were randomly allocated into 3 different treatments: ICA incorporated with FD-PRP (ICA/FD-PRP), FD-PRP alone (FD-PRP), or saline control (CTL). The rabbit patella-patellar tendon (PP) interfaces were postoperatively harvested at postoperative week 8 or 16 for gross, radiological, histological, and mechanical evaluations.

RESULTS

Our results showed that FD-PRP can act as a carrier for sustained release of ICA into the T-B healing site. Macroscopically, no signs of infection or osteoarthritis were shown in the regenerated PP interfaces, and the area of cartilaginous metaplasia in the FD-PRP and ICA/FD-PRP groups at postoperative week 16 was significantly larger than that of the CTL group (P < .05 for all). Radiologically, micro-computed tomography showed that new bone which formed at the healing site in the ICA/FD-PRP group was significantly increased, remodeled, and mineralized in comparison with the CTL group (P < .05 for all). Histologically, the ICA/FD-PRP group exhibited a significant native PP interface, as shown by the enlargement and remodeling of new bone, well-organized collagen fibers, and robust production of proteoglycans in the regenerated fibrocartilage. The mechanical strength of the regenerated PP interface was significantly improved in the ICA/FD-PRP group. Significantly higher failure load and stiffness were shown in the ICA/FD-PRP group compared with the CTL and FD-PRP groups, respectively (P < .05 for all).

CONCLUSION

FD-PRP is a suitable sustained-release carrier for ICA, and ICA/FD-PRP can provide sustained release of ICA into the T-B healing site, thus effectively accelerating T-B healing.

CLINICAL RELEVANCE

Findings of this study demonstrate the feasibility of using FD-PRP as a carrier for ICA to improve T-B healing and provide a foundation for future clinical application.

Effect of Autologous Platelet-Rich Plasma and Gelatin Sponge for Tendon-to-Bone Healing After Rabbit Anterior Cruciate Ligament Reconstruction

PURPOSE

To investigate platelet-rich plasma (PRP) combined with gelatin sponge (GS) to improve tendon-bone interface healing and structure formation.

METHODS

Characterization of the GS scaffold was performed with a scanning electron microscope, and the release curve after loading with PRP was evaluated. A real-time reverse transcription quantitative polymerase chain reaction assay was performed to test the levels of tendon-to-bone healing-related gene expression. Finally, 18 New Zealand white rabbits were randomly divided into 3 groups and underwent semitendinosus autograft anterior cruciate ligament reconstruction: autograft group without PRP, PRP group, and PRP-GS group. All rabbits were killed 8 weeks after the operation. Magnetic resonance imaging scans, biomechanical testing, and histologic evaluation were performed.

RESULTS

An enzyme-linked immunosorbent assay and cell counting kit-8 assay showed that the GS could control the release of PRP and prolong its bioactivity time, as well as promote bone marrow mesenchymal stem cell proliferation. In the PRP-GS group, the levels of related genes were upregulated compared with the PRP group (P < .05). Lower signal in the magnetic resonance images indicated fibrocartilage formation in the 2 groups with PRP. In addition, histologic staining showed that the tendon-bone connection had a greater fibrocartilaginous transition region in the PRP-GS group, and the histologic scores were higher (vs the PRP group, P = .039). The maximum failure load and stiffness were higher in the PRP-GS group than in the other 2 groups.

CONCLUSIONS

GS loading with PRP could prolong the bioactivity time of PRP and promote bone marrow mesenchymal stem cell proliferation and osteogenic gene expression in vitro. It also promoted the early healing process at the tendon-bone junction in a rabbit anterior cruciate ligament reconstruction model.

CLINICAL RELEVANCE

GS is a natural material and offers satisfactory biocompatibility. Using GS as a scaffold to control the release of bioactive factors in bone tunnels may be useful, but additional studies in human subjects will be necessary to evaluate its clinical prospects.

Growth factor delivery strategies for rotator cuff repair and regeneration

The high incidence of degenerative tears and prevalence of retears (20-95%) after surgical repair makes rotator cuff injuries a significant health problem. This high retear rate is attributed to the failure of the repaired tissue to regenerate the native tendon-to-bone insertion (enthesis). Biological augmentation of surgical repair such as autografts, allografts, and xenografts are confounded by donor site morbidity, immunogenicity, and disease transmission, respectively. In contrast, these risks may be alleviated via growth factor therapy, which can actively influence the healing environment to promote functional repair. Several challenges have to be overcome before growth factor delivery can translate into clinical practice such as the selection of optimal growth factor(s) or combination, identification of the most efficient stage and duration of delivery, and the design considerations for the delivery device. Emerging insight into the injury-repair microenvironment and our understanding of growth factor mechanisms in healing are informing the design of advanced delivery scaffolds to effectively treat rotator cuff tears. Here, we review potential growth factor candidates, design parameters and material selection for growth factor delivery, innovative and dynamic delivery scaffolds, and novel therapeutic targets from tendon and developmental biology for the structural and functional healing of rotator cuff repair.