Long-term Evaluation of Meniscal Tissue Formation in 3-dimensional-Printed Scaffolds With Sequential Release of Connective Tissue Growth Factor and TGF-β3 in an Ovine Model

Promotion of hMDSC differentiation by combined action of scaffold material and TGF-β superfamily growth factors

Objective

Herein we propose a combined action of collagen type I (CA) or synthetic collagen-like-peptide functionalized with the cell adhesive RGD motif (PEG-CLP-RGD) hydrogels and selected growth factors to promote chondrogenic differentiation of human muscle-derived stem cells (hMDSCs) under normal and reduced oxygen conditions.

Methods

hMDSCs were set for differentiation towards chondrogenic lineage using BMP-7 and TGF-β3. Cells were seeded onto hydrogels loaded with growth factors (75ng/scaffold) and cultured for 28 days under normal (21%) and severe hypoxic (1%) conditions. Chondrogenesis was evaluated by monitoring collagen type II and GAG deposition, and quantification of ACAN expression by RT-PCR.

Results

Sustained release of TGFβ3 from the hydrogels was observed, 8.7 ± 0.5% of the initially loaded amount diffused out after 24 h from both substrates. For the BMP-7 growth factor, 14.8 ± 0.3% and 18.2 ± 0.6% of the initially loaded amount diffused out after 24 h from CA and CLP-RGD, respectively. The key findings of this study are: i) the self-supporting hydrogels themselves can stimulate hMDSC chondrogenesis by inducing gene expression of cartilage-specific proteoglycan aggrecan and ECM production; ii) the effect of dual BMP-7 and TGF-β3 loading was more pronounced on CA hydrogel under normal oxygen conditions; iii) dual loading on PEG-CLP-RGD hydrogels did not have the synergistic effect, TGF-β3 was more effective under both oxygen conditions; iv) BMP-7 can improve chondrogenic effect of TGF-β3 on CA scaffolds, and hydrogels loaded with both growth factors can induce cartilage formation in hMDSC cultures.

Conclusion

Our results support the potential strategy of combining implantable hydrogels functionalized with differentiation factors toward improving cartilaginous repair.

Specific tissue engineering for temporomandibular joint disc perforation

BACKGROUND

The temporomandibular joint (TMJ) disc is a critical fibrocartilaginous structure with limited regenerative capacity in the oral system. Perforation of the TMJ disc can lead to osteoarthritis and ankylosis of the TMJ because of the lack of disc protection. Clinical treatments for TMJ disc perforation, such as discectomy, hyaluronic acid injection, endoscopic surgery and high position arthroplasty of TMJ, are questionable with regard to long-term outcomes, and only three fourths of TMJ disc perforations are repairable by surgery, even in the short-term. Tissue engineering offers the potential for cure of repairable TMJ disc perforations and regeneration of unrepairable ones.

OBJECTIVES

This review discusses the classification of TMJ disc perforation and defines typical TMJ disc perforation. Advancements in the engineering-based repair of TMJ disc perforation by stem cell therapy, construction of a disc-like scaffold and functionalization by offering bioactive stimuli are also summarized in the review, and the barriers developing engineering technologies need to overcome to be popularized are discussed.

Bioprinting of scaled-up meniscal grafts by spatially patterning phenotypically distinct meniscus progenitor cells within melt electrowritten scaffolds

Meniscus injuries are a common problem in orthopedic medicine and are associated with a significantly increased risk of developing osteoarthritis. While developments have been made in the field of meniscus regeneration, the engineering of cell-laden constructs that mimic the complex structure, composition and biomechanics of the native tissue remains a significant challenge. This can be linked to the use of cells that are not phenotypically representative of the different zones of the meniscus, and an inability to direct the spatial organization of engineered meniscal tissues. In this study we investigated the potential of zone-specific meniscus progenitor cells (MPCs) to generate functional meniscal tissue following their deposition into melt electrowritten (MEW) scaffolds. We first confirmed that fibronectin selected MPCs from the inner and outer regions of the meniscus maintain their differentiation capacity with prolonged monolayer expansion, opening their use within advanced biofabrication strategies. By depositing MPCs within MEW scaffolds with elongated pore shapes, which functioned as physical boundaries to direct cell growth and extracellular matrix production, we were able to bioprint anisotropic fibrocartilaginous tissues with preferentially aligned collagen networks. Furthermore, by using MPCs isolated from the inner (iMPCs) and outer (oMPCs) zone of the meniscus, we were able to bioprint phenotypically distinct constructs mimicking aspects of the native tissue. An iterative MEW process was then implemented to print scaffolds with a similar wedged-shaped profile to that of the native meniscus, into which we deposited iMPCs and oMPCs in a spatially controlled manner. This process allowed us to engineer sulfated glycosaminoglycan and collagen rich constructs mimicking the geometry of the meniscus, with MPCs generating a more fibrocartilage-like tissue compared to the mesenchymal stromal/stem cells. Taken together, these results demonstrate how the convergence of emerging biofabrication platforms with tissue-specific progenitor cells can enable the engineering of complex tissues such as the meniscus.

Meniscal fibrocartilage regeneration inspired by meniscal maturational and regenerative process

Meniscus is a complex and crucial fibrocartilaginous tissue within the knee joint. Meniscal regeneration remains to be a scientific and translational challenge. We clarified that mesenchymal stem cells (MSCs) participated in meniscal maturation and regeneration using MSC-tracing transgenic mice model. Here, inspired by meniscal natural maturational and regenerative process, we developed an effective and translational strategy to facilitate meniscal regeneration by three-dimensionally printing biomimetic meniscal scaffold combining autologous synovium transplant, which contained abundant intrinsic MSCs. We verified that this facilitated anisotropic meniscus-like tissue regeneration and protected cartilage from degeneration in large animal model. Mechanistically, the biomechanics and matrix stiffness up-regulated Piezo1 expression, facilitating concerted activation of calcineurin and NFATc1, further activated YAP-pSmad2/3-SOX9 axis, and consequently facilitated fibrochondrogenesis of MSCs during meniscal regeneration. In addition, Piezo1 induced by biomechanics and matrix stiffness up-regulated collagen cross-link enzyme expression, which catalyzed collagen cross-link and thereby enhanced mechanical properties of regenerated tissue.

Novel Osteochondral Biotemplate Improves Long-term Cartilage Repair Compared With Microfracture in an Ovine Model

BACKGROUND

Current cartilage repair therapies do not re-create the complex mechanical interface between cartilage and bone, which is critical for long-term repair durability. New biomaterial designs that include hard tissue-soft tissue interface structures offer promise to improve clinical outcomes.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the efficacy and safety of a naturally derived osteochondral biotemplate with a novel contiguous hard tissue-soft tissue interface in an ovine model as a regenerative solution for articular cartilage defects. It was hypothesized that the osteochondral biotemplate would produce structurally superior repair tissue compared with microfracture over a 13-month period.

STUDY DESIGN

Controlled laboratory study.

METHODS

Osteochondral biotemplates were manufactured from porcine cancellous bone. Skeletally mature sheep (N = 30) were randomly allocated to 3 groups: early healing stage (euthanasia at 4 months), 6-month treatment, and 13-month treatment. In the early healing stage group, an 8 mm-diameter by 5 mm-deep osteochondral defect was created on the medial femoral condyle and treated at the time of iatrogenic injury with an osteochondral biotemplate. The contralateral limb received the same treatment 2 months later. In the 6- and 13-month treatment groups, 1 limb received the same osteochondral procedure as the early healing stage group. In the contralateral limb, an 8 mm-diameter, full-thickness cartilage defect (1-2 mm deep) was created and treated with microfracture. Cartilage repair and integration were quantitatively and qualitatively assessed with gross inspection, histological evaluation, and magnetic resonance imaging (MRI). Wilcoxon signed-rank and McNemar tests were used to compare the treatments.

RESULTS

At 6 and 13 months after treatment, the biotemplate was not present histologically. At 13 months, the biotemplate treatment demonstrated statistically higher histological scores than microfracture for integration with surrounding cartilage (biotemplate: 74 ± 31; microfracture: 28 ± 39; P = .03), type 2 collagen (biotemplate: 72 ± 33; microfracture: 40 ± 38; P = .02), total cartilage (biotemplate: 71 ± 9; microfracture: 59 ± 9; P = .01), and total integration (biotemplate: 85 ± 15; microfracture: 66 ± 20; P = .04). The osteochondral biotemplate treatment produced a notable transient nonneutrophilic inflammatory response that appeared to approach resolution at 13 months. MRI results were not statistically different between the 2 treatments.

CONCLUSION

Even with the inflammatory response, after 13 months, the osteochondral biotemplate outperformed microfracture in cartilage regeneration and demonstrated superiority in integration between the repair tissue and host tissue as well as integration between the newly formed cartilage and the underlying bone.

CLINICAL RELEVANCE

This work has demonstrated the clinical potential of a novel biomaterial template to regenerate the complex mechanical interface between cartilage and the subchondral bone.

3D printing of mechanically functional meniscal tissue equivalents using high concentration extracellular matrix inks

Decellularized extracellular matrix (dECM) has emerged as a promising biomaterial in the fields of tissue engineering and regenerative medicine due to its ability to provide specific biochemical and biophysical cues supportive of the regeneration of diverse tissue types. Such biomaterials have also been used to produce tissue-specific inks and bioinks for 3D printing applications. However, a major limitation associated with the use of such dECM materials is their poor mechanical properties, which limits their use in load-bearing applications such as meniscus regeneration. In this study, native porcine menisci were solubilized and decellularized using different methods to produce highly concentrated dECM inks of differing biochemical content and printability. All dECM inks displayed shear thinning and thixotropic properties, with increased viscosity and improved printability observed at higher pH levels, enabling the 3D printing of anatomically defined meniscal implants. With additional crosslinking of the dECM inks following thermal gelation at pH 11, it was possible to fabricate highly elastic meniscal tissue equivalents with compressive mechanical properties similar to the native tissue. These improved mechanical properties at higher pH correlated with the development of a denser network of smaller diameter collagen fibers. These constructs also displayed repeatable loading and unloading curves when subjected to long-term cyclic compression tests. Moreover, the printing of dECM inks at the appropriate pH promoted a preferential alignment of the collagen fibers. Altogether, these findings demonstrate the potential of 3D printing of highly concentrated meniscus dECM inks to produce mechanically functional and biocompatible implants for meniscal tissue regeneration. This approach could be applied to a wide variety of different biological tissues, enabling the 3D printing of tissue mimics with diverse applications from tissue engineering to surgical planning.

Quantum dots-labeled polymeric scaffolds for in vivo tracking of degradation and tissue formation

The inevitable gap between in vitro and in vivo degradation rate of biomaterials has been a challenging factor in the optimal designing of scaffold's degradation to be balanced with new tissue formation. To enable non-/minimum-invasive tracking of in vivo scaffold degradation, chemical modifications have been applied to label polymers with fluorescent dyes. However, the previous approaches may have limited expandability due to complicated synthesis processes. Here, we introduce a simple and efficient method to fluorescence labeling of polymeric scaffolds via blending with near-infrared (NIR) quantum dots (QDs), semiconductor nanocrystals with superior optical properties. QDs-labeled, 3D-printed PCL scaffolds showed promising efficiency and reliability in quantitative measurement of degradation using a custom-built fiber-optic imaging modality. Furthermore, QDs-PCL scaffolds showed neither cytotoxicity nor secondary labeling of adjacent cells. QDs-PCL scaffolds also supported the engineering of fibrous, cartilaginous, and osteogenic tissues from mesenchymal stem/progenitor cells (MSCs). In addition, QDs-PCL enabled a distinction between newly forming tissue and the remaining mass of scaffolds through multi-channel imaging. Thus, our findings suggest a simple and efficient QDs-labeling of PCL scaffolds and minimally invasive imaging modality that shows significant potential to enable in vivo tracking of scaffold degradation as well as new tissue formation.

Adipose-Derived Stem Cell Sheets Promote Meniscus Regeneration Regardless of Whether the Defect Involves the Inner Half or the Whole Width of the Anterior Half of the Medial Meniscus in a Rabbit Model

PURPOSE

To investigate the regenerative effect of adipose-derived stem cell (ADSC) sheets in two different rabbit models of meniscal defects.

METHODS

Forty-two rabbits were randomly divided into two groups: the whole (Group 1) or the inner half (Group 2) of anterior half of the medial meniscus was removed from both knees. The ADSC sheets were transplanted into one knee, whereas in the other knee the meniscal defect was left untreated (self-control). The histological score and expression of genes encoding collagen type I and II (COL1/2), SRY-box transcription factor 9 (SOX9), and aggrecan (ACAN) were compared between the ADSC sheet-treated and untreated menisci at 4 and 12 weeks. The ADSC sheet-treated menisci at 12 weeks were also analyzed immunohistochemically to assess the collagen component.

RESULTS

The histological score was significantly higher in the treated side than in the control side at 4 and 12 weeks in both groups (Group 1; P = .016 and .032; Group 2; P = .030 and .016, respectively). All genes evaluated showed significantly higher expression in the treated side than in the control side in both groups, except COL2 and SOX9 at 4 weeks and COL2 at 12 weeks in Group 1, and COL1 in Group 2 at 4 weeks. The ADSC sheet-treated meniscus in Group 1 contained mostly COL1, whereas the Group 2 had less COL1, but was rich in COL2.

CONCLUSIONS

ADSC sheets can promote meniscal regeneration regardless of whether the defect involves the inner half or whole width of the anterior half of the medial meniscus. However, the collagen component of the ADSC sheet-treated tissue differs depending on the defect site.

CLINICAL RELEVANCE

ADSCs may help meniscal regeneration due to meniscal defects after meniscectomy. This study suggests longer-term follow-up and mechanical analysis as next steps.

Biomaterials for meniscus and cartilage in knee surgery: state of the art

Meniscus and cartilage injuries of the knee joint lead to cartilage degeneration and osteoarthritis (OA). The research on biomaterials and artificial implants as substitutes in reconstruction and regeneration has become a main international focus in order to solve clinical problems such as irreparable meniscus injury, postmeniscectomy syndrome, osteochondral lesions and generalised chronic OA. In this review, we provide a summary of biomaterials currently used in clinical practice as well as state-of-the-art tissue engineering strategies and technologies that are developed for articular cartilage and meniscus repair and regeneration. The literature was reviewed over the last 5 years on clinically used meniscus and cartilage repair biomaterials, such as Collagen Meniscal Implant, Actifit, NUsurface, TruFit, Agili-C and MaioRegen. There are clinical advantages for these biomaterials and the application of these treatment options should be considered individually. Standardised evaluation protocols are needed for biological and mechanical assessment and comparison between different scaffolds, and long-term randomised independent clinical trials with large study numbers are needed to provide more insight into the use of these biomaterials. Surgeons should become familiar and stay up to date with evolving repair options to improve their armamentarium for meniscal and cartilage defects.

Oxo-M and 4-PPBP Delivery via Multi-Domain Peptide Hydrogel Toward Tendon Regeneration

We have recently identified novel small molecules, Oxo-M and 4-PPBP, which specifically stimulate endogenous tendon stem/progenitor cells (TSCs), leading to potential regenerative healing of fully transected tendons. Here, we investigated an injectable, multidomain peptide (MDP) hydrogel providing controlled delivery of the small molecules for regenerative tendon healing. We investigated the release kinetics of Oxo-M and 4-PPBP from MDP hydrogels and the effect of MDP-released small molecules on tenogenic differentiation of TSCs and in vivo tendon healing. In vitro, MDP showed a sustained release of Oxo-M and 4-PPBP and a slower degradation than fibrin. In addition, tenogenic gene expression was significantly increased in TSC with MDP-released Oxo-M and 4-PPBP as compared to the fibrin-released. Invivo, MDP releasing Oxo-M and 4-PPBP significantly improved tendon healing, likely associated with prolonged effects of Oxo-M and 4-PPBP on suppression of M1 macrophages and promotion of M2 macrophages. Comprehensive analyses including histomorphology, digital image processing, and modulus mapping with nanoindentation consistently suggested that Oxo-M and 4-PPBP delivered via MDP further improved tendon healing as compared to fibrin-based delivery. In conclusion, MDP delivered with Oxo-M and 4-PPBP may serve as an efficient regenerative therapeutic for in situ tendon regeneration and healing.

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.

Post-Traumatic Osteoarthritis Assessment in Emerging and Advanced Pre-Clinical Meniscus Repair Strategies: A Review

Surgical repair of meniscus injury is intended to help alleviate pain, prevent further exacerbation of the injury, restore normal knee function, and inhibit the accelerated development of post-traumatic osteoarthritis (PTOA). Meniscus injuries that are treated poorly or left untreated are reported to significantly increase the risk of PTOA in patients. Current surgical approaches for the treatment of meniscus injuries do not eliminate the risk of accelerated PTOA development. Through recent efforts by scientists to develop innovative and more effective meniscus repair strategies, the use of biologics, allografts, and scaffolds have come into the forefront in pre-clinical investigations. However, gauging the extent to which these (and other) approaches inhibit the development of PTOA in the knee joint is often overlooked, yet an important consideration for determining the overall efficacy of potential treatments. In this review, we catalog recent advancements in pre-clinical therapies for meniscus injuries and discuss the assessment methodologies that are used for gauging the success of these treatments based on their effect on PTOA severity. Methodologies include histopathological evaluation of cartilage, radiographic evaluation of the knee, analysis of knee function, and quantification of OA predictive biomarkers. Lastly, we analyze the prevalence of these methodologies using a systemic PubMed® search for original scientific journal articles published in the last 3-years. We indexed 37 meniscus repair/replacement studies conducted in live animal models. Overall, our findings show that approximately 75% of these studies have performed at least one assessment for PTOA following meniscus injury repair. Out of this, 84% studies have reported an improvement in PTOA resulting from treatment.

Advances in the Mechanisms Affecting Meniscal Avascular Zone Repair and Therapies

Injuries to menisci are the most common disease among knee joint-related morbidities and cover a widespread population ranging from children and the general population to the old and athletes. Repair of the injuries in the meniscal avascular zone remains a significant challenge due to the limited intrinsic healing capacity compared to the peripheral vascularized zone. The current surgical strategies for avascular zone injuries remain insufficient to prevent the development of cartilage degeneration and the ultimate emergence of osteoarthritis (OA). Due to the drawbacks of current surgical methods, the research interest has been transferred toward facilitating meniscal avascular zone repair, where it is expected to maintain meniscal tissue integrity, prevent secondary cartilage degeneration and improve knee joint function, which is consistent with the current prevailing management idea to maintain the integrity of meniscal tissue whenever possible. Biological augmentations have emerged as an alternative to current surgical methods for meniscal avascular zone repair. However, understanding the specific biological mechanisms that affect meniscal avascular zone repair is critical for the development of novel and comprehensive biological augmentations. For this reason, this review firstly summarized the current surgical techniques, including meniscectomies and meniscal substitution. We then discuss the state-of-the-art biological mechanisms, including vascularization, inflammation, extracellular matrix degradation and cellular component that were associated with meniscal avascular zone healing and the advances in therapeutic strategies. Finally, perspectives for the future biological augmentations for meniscal avascular zone injuries will be given.

Biosynthetic scaffolds for partial meniscal loss: A systematic review from animal models to clinical practice

Acute or degenerative meniscus tears are the most common knee lesions. Meniscectomy provides symptomatic relief and functional recovery only in the short- to mid-term follow-up but significantly increases the risk of osteoarthritis. For this reason, preserving the meniscus is key, although it remains a challenge. Allograft transplants present many disadvantages, so during the last 20 years preclinical and clinical research focused on developing and investigating meniscal scaffolds. The aim of this systematic review was to collect and evaluate all the available evidence on biosynthetic scaffolds for meniscus regeneration both in vivo and in clinical studies. Three databases were searched: 46 in vivo preclinical studies and 30 clinical ones were found. Sixteen natural, 15 synthetic, and 15 hybrid scaffolds were studied in vivo. Among them, only 2 were translated into clinic: the Collagen Meniscus Implant, used in 11 studies, and the polyurethane-based scaffold Actifit®, applied in 19 studies. Although positive outcomes were described in the short- to mid-term, the number of concurrent procedures and the lack of randomized trials are the major limitations of the available clinical literature. Few in vivo studies also combined the use of cells or growth factors, but these augmentation strategies have not been applied in the clinical practice yet. Current solutions offer a significant but incomplete clinical improvement, and the regeneration potential is still unsatisfactory. Building upon the overall positive results of these "old" technologies to address partial meniscal loss, further innovation is urgently needed in this field to provide patients better joint sparing treatment options.

The recent advances in scaffolds for integrated periodontal regeneration

The periodontium is an integrated, functional unit of multiple tissues surrounding and supporting the tooth, including but not limited to cementum (CM), periodontal ligament (PDL) and alveolar bone (AB). Periodontal tissues can be destructed by chronic periodontal disease, which can lead to tooth loss. In support of the treatment for periodontally diseased tooth, various biomaterials have been applied starting as a contact inhibition membrane in the guided tissue regeneration (GTR) that is the current gold standard in dental clinic. Recently, various biomaterials have been prepared in a form of tissue engineering scaffold to facilitate the regeneration of damaged periodontal tissues. From a physical substrate to support healing of a single type of periodontal tissue to multi-phase/bioactive scaffold system to guide an integrated regeneration of periodontium, technologies for scaffold fabrication have emerged in last years. This review covers the recent advancements in development of scaffolds designed for periodontal tissue regeneration and their efficacy tested in vitro and in vivo. Pros and Cons of different biomaterials and design parameters implemented for periodontal tissue regeneration are also discussed, including future perspectives.

A review of strategies for development of tissue engineered meniscal implants

The meniscus is a key stabilizing tissue of the knee that facilitates proper tracking and movement of the knee joint and absorbs stresses related to physical activity. This review article describes the biology, structure, and functions of the human knee meniscus, common tears and repair approaches, and current research and development approaches using modern methods to fabricate a scaffold or tissue engineered meniscal replacement. Meniscal tears are quite common, often resulting from sports or physical training, though injury can result without specific contact during normal physical activity such as bending or squatting. Meniscal injuries often require surgical intervention to repair, restore basic functionality and relieve pain, and severe damage may warrant reconstruction using allograft transplants or commercial implant devices. Ongoing research is attempting to develop alternative scaffold and tissue engineered devices using modern fabrication techniques including three-dimensional (3D) printing which can fabricate a patient-specific meniscus replacement. An ideal meniscal substitute should have mechanical properties that are close to that of natural human meniscus, and also be easily adapted for surgical procedures and fixation. A better understanding of the organization and structure of the meniscus as well as its potential points of failure will lead to improved design approaches to generate a suitable and functional replacement.

Injectable Fibrin/Polyethylene Oxide Semi-IPN Hydrogel for a Segmental Meniscal Defect Regeneration

BACKGROUND

Meniscal deficiency from meniscectomy is a common situation in clinical practices. Regeneration of the deficient meniscal portion, however, is still not feasible.

PURPOSE

To develop an injectable hydrogel system consisting of fibrin (Fb) and polyethylene oxide (PEO) and to estimate its clinical potential for treating a segmental defect of the meniscus in a rabbit meniscal defect model.

STUDY DESIGN

Controlled laboratory study.

METHODS

The Fb/PEO hydrogel was fabricated by extruding 100 mg·mL^-1 of fibrinogen solution and 2,500 U·mL^-1 of thrombin solution containing 100 mg·mL^-1 of PEO through a dual-syringe system. The hydrogels were characterized by rheological analysis and biodegradation tests. The meniscal defects of New Zealand White male rabbits were generated by removing 60% of the medial meniscus from the anterior side. The removed portion included the central portion. The Fb/PEO hydrogel was injected into the meniscal defect of the experimental knee through the joint space between the femoral condyle and tibial plateau at the anterior knee without a skin incision. The entire medial menisci from both knees of each rabbit were collected and photographed before placement in formalin for histological processing. Hematoxylin and eosin, safranin O, and immunohistochemical staining for type II collagen was performed. The biomechanical property of the regenerated meniscus was evaluated using a universal tensile machine.

RESULTS

The Fb/PEO hydrogel was fabricated by an in situ gelation process, and the hydrogel displayed a semi-interpenetrating polymer network structure. We demonstrated that the mechanical properties of Fb-based hydrogels increased in a PEO-dependent manner. Furthermore, the addition of PEO delayed the biodegradation of the hydrogel. Our in vivo data demonstrated that, as compared with Fb hydrogel, Fb/PEO hydrogel injection into the meniscectomy model showed improved tissue regeneration. The regenerated meniscal tissue by Fb/PEO hydrogel showed enhanced tissue quality, which was supported by the histological and biomechanical properties.

CONCLUSION

The Fb/PEO hydrogel had an effective tissue-regenerative ability through injection into the in vivo rabbit meniscal defect model.

CLINICAL RELEVANCE

This injectable hydrogel system can promote meniscal repair and be readily utilized in clinical application.

An interleukin-4-loaded bi-layer 3D printed scaffold promotes osteochondral regeneration

Multilayer scaffolds fabricated by 3D printing or other techniques have been used to repair osteochondral defects. However, it remains a challenge to regenerate the articular cartilage and subchondral bone simultaneously with higher performance. In the present study, we enhanced the repair efficiency of osteochondral defects by developing a bi-layer scaffold: an interleukin-4 (IL-4)-loaded radially oriented gelatin methacrylate (GelMA) scaffold printed with digital light processing (DLP) in the upper layer and a porous polycaprolactone and hydroxyapatite (PCL-HA) scaffold printed with fused deposition modeling (FDM) in the lower layer. An in vitro test showed that both layers supported cell adhesion and proliferation, as the lower layer promoted osteogenic differentiation and the upper layer with IL-4 relieved the negative effects of inflammation on murine chondrocytes, which were induced by interleukin-1β (IL-1β) and M1 macrophages. In a rabbit osteochondral defect repair model, the IL-4-loaded bi-layer scaffold group obtained the highest histological score (24 ± 2) compared to the nontreated (11 ± 1) and pure bi-layer scaffold (16 ± 1) groups after 16 weeks of implantation, which showed that the IL-4-loaded bi-layer scaffold promoted regeneration of both cartilage and subchondral bone with increased formation of neocartilage and neobone tissues. Thus, the IL-4-loaded bi-layer scaffold is an attractive candidate for repair and regeneration of osteochondral defects.

Advanced Polymer-Based Drug Delivery Strategies for Meniscal Regeneration

The meniscus plays a critical role in maintaining knee joint homeostasis. Injuries to the meniscus, especially considering the limited self-healing capacity of the avascular region, continue to be a challenge and are often treated by (partial) meniscectomy, which has been identified to cause osteoarthritis. Currently, meniscus tissue engineering focuses on providing extracellular matrix (ECM)-mimicking scaffolds to direct the inherent meniscal regeneration process, and it has been found that various stimuli are essential. Numerous bioactive factors present benefits in regulating cell fate, tissue development, and healing, but lack an optimal delivery system. More recently, bioengineers have developed various polymer-based drug delivery systems (PDDSs), which are beneficial in terms of the favorable properties of polymers as well as novel delivery strategies. Engineered PDDSs aim to provide not only an ECM-mimicking microenvironment but also the controlled release of bioactive factors with release profiles tailored according to the biological concerns and properties of the factors. In this review, both different polymers and bioactive factors involved in meniscal regeneration are discussed, as well as potential candidate systems, with examples of recent progress. This article aims to summarize drug delivery strategies in meniscal regeneration, with a focus on novel delivery strategies rather than on specific delivery carriers. The current challenges and future prospects for the structural and functional regeneration of the meniscus are also discussed. Impact statement Meniscal injury remains a clinical Gordian knot owing to the limited healing potential of the region, restricted surgical approaches, and risk of inducing osteoarthritis. Existing tissue engineering scaffolds that provide mechanical support and a favorable microenvironment also lack biological cues. Advanced polymer-based delivery strategies consisting of polymers incorporating bioactive factors have emerged as a promising direction. This article primarily reviews the types and applications of biopolymers and bioactive factors in meniscal regeneration. Importantly, various carrier systems and drug delivery strategies are discussed with the hope of inspiring further advancements in this field.

Meniscal tissue repair with nanofibers: future perspectives

The knee menisci are critical to the long-term health of the knee joint. Because of the high incidence of injury and degeneration, replacing damaged or lost meniscal tissue is extremely clinically relevant. The multiscale architecture of the meniscus results in unique biomechanical properties. Nanofibrous scaffolds are extremely attractive to replicate the biochemical composition and ultrastructural features in engineered meniscus tissue. We review recent advances in electrospinning to generate nanofibrous scaffolds and the current state-of-the-art of electrospun materials for meniscal regeneration. We discuss the importance of cellular function for meniscal tissue engineering and the application of cells derived from multiple sources. We compare experimental models necessary for proof of concept and to support translation. Finally, we discuss future directions and potential for technological innovations.

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 substitution, a developing and long-awaited demand

The menisci represent indispensable intraarticular components of a well-functioning knee joint. Sports activities, traumatic incidents, or simply degenerative conditions can cause meniscal injuries, which often require surgical intervention. Efforts in biomechanical and clinical research have led to the recommendation of a meniscus-preserving rather than a meniscus-resecting treatment approach. Nevertheless, partial or even total meniscal resection is sometimes inevitable. In such circumstances, techniques of meniscal substitution are required. Autologous, allogenic, and artificial meniscal substitutes are available which have evolved in recent years. Basic anatomical and biomechanical knowledge, clinical application, radiological and clinical outcomes as well as future perspectives of meniscal substitutes are presented in this article. A comprehensive knowledge of the different approaches to meniscal substitution is required in order to integrate these evolving techniques in daily clinical practice to prevent the devastating effects of lost meniscal tissue.

Deletion of p21 expression accelerates cartilage tissue repair via chondrocyte proliferation

Articular cartilage tissue has a poor healing potential, and when subjected to traumatic damage this tissue undergoes cartilage degeneration and osteoarthritis. The association between the regulation of cell cycle checkpoints and tissue regeneration has been previously investigated, and p21 was initially identified as a potent inhibitor of cell cycle progression. However, the effects of p21 defects on damaged tissue remain controversial. Therefore, the aim of the present study was to evaluate the effects of p21 deficiency on cartilage repair. A mouse model of articular cartilage repair was generated by inducing a patellar groove scratch in 8‑week‑old p21‑knockout (KO) mice and C57Bl/6 wild‑type (WT) mice. Mice were sacrificed at 4 and 8 weeks post‑surgery. The present study also investigated the effect of p21 deficiency on cartilage differentiation in ATDC5 cells in vitro. Safranin O staining results indicated that cartilage repair initially occurred in p21 KO mice. In addition, immunohistochemical analysis demonstrated that p21 KO upregulated proliferating cell nuclear antigen and increased cell proliferation. However, type II collagen and Sox9 expression levels remained unchanged in p21 KO and WT mice. Moreover, it was identified that p21 downregulation did not affect Sox9 and type II collagen expression levels in vitro. Furthermore, p21 deficiency promoted healing of articular cartilage damage, which was associated with cell proliferation in vivo, and increased chondrocyte proliferation but not differentiation in vitro. Therefore, the present results suggested that p21 does not affect Sox9 or type II collagen expression levels during cartilage differentiation in the repair of cartilage defects.

The Meniscus Tear: A Review of Stem Cell Therapies

Meniscal injuries have posed a challenging problem for many years, especially considering that historically the meniscus was considered to be a structure with no important role in the knee joint. This led to earlier treatments aiming at the removal of the entire structure in a procedure known as a meniscectomy. However, with the current understanding of the function and roles of the meniscus, meniscectomy has been identified to accelerate joint degradation significantly and is no longer a preferred treatment option in meniscal tears. Current therapies are now focused to regenerate, repair, or replace the injured meniscus to restore its native function. Repairs have improved in technique and materials over time, with various implant devices being utilized and developed. More recently, strategies have applied stem cells, tissue engineering, and their combination to potentiate healing to achieve superior quality repair tissue and retard the joint degeneration associated with an injured or inadequately functioning meniscus. Accordingly, the purpose of this current review is to summarize the current available pre-clinical and clinical literature using stem cells and tissue engineering for meniscal repair and regeneration.