Basic science and treatment options for articular cartilage injuries

Hydrogel-Enhanced Autologous Chondrocyte Implantation for Cartilage Regeneration-An Update on Preclinical Studies

Autologous chondrocyte implantation (ACI) and matrix-induced ACI (MACI) have demonstrated improved clinical outcomes and reduced revision rates for treating osteochondral and chondral defects. However, their ability to achieve lasting, fully functional repair remains limited. To overcome these challenges, scaffold-enhanced ACI, particularly utilizing hydrogel-based biomaterials, has emerged as an innovative strategy. These biomaterials are intended to mimic the biological composition, structural organization, and biomechanical properties of native articular cartilage. This review aims to provide comprehensive and up-to-date information on advancements in hydrogel-enhanced ACI from the past decade. We begin with a brief introduction to cartilage biology, mechanisms of cartilage injury, and the evolution of surgical techniques, particularly looking at ACI. Subsequently, we review the diversity of hydrogel scaffolds currently undergoing development and evaluation in preclinical studies for articular cartilage regeneration, emphasizing chondrocyte-laden hydrogels applicable to ACI. Finally, we address the key challenges impeding effective clinical translation, with particular attention to issues surrounding fixation and integration, aiming to inform and guide the future progression of tissue engineering strategies.

Editorial Commentary: Osteochondral Allograft of the Knee-Diffuse Edema at 6 Months on Magnetic Resonance Imaging Predicts Failure

Cartilage defects alter natural function of articular cartilage and can predispose patients to further cartilage wear and eventual osteoarthritis. These injuries present a challenging problem with a multitude of treatment options and lack of consensus on when to employ each. Options include conservative measures (limited weightbearing and immobilization), debridement, microfracture, autologous chondrocyte implantation, and osteochondral autograft and allograft. Indications may be based on defect size, joint alignment, age, activity level, body mass index, and sex. One option, osteochondral allograft (OCA) transplantation, is typically reserved for large and severe defects or revision. With regard to OCA prognosis, older patients, revision cases, patellar defects, and bipolar lesions confer elevated risk of failure, whereas traumatic or idiopathic cases, unipolar lesions, and short duration of symptoms have reported higher levels of satisfaction. Following surgery, the patient with persistent symptoms can present a conundrum. Recent research shows that in such cases, diffuse edema at 6 months on magnetic resonance imaging often predicts ultimate failure, in which case arthroplasty may be required.

In Situ Loading and Time-Resolved Synchrotron-Based Phase Contrast Tomography for the Mechanical Investigation of Connective Knee Tissues: A Proof-of-Concept Study

Articular cartilage and meniscus transfer and distribute mechanical loads in the knee joint. Degeneration of these connective tissues occurs during the progression of knee osteoarthritis, which affects their composition, microstructure, and mechanical properties. A deeper understanding of disease progression can be obtained by studying them simultaneously. Time-resolved synchrotron-based X-ray phase-contrast tomography (SR-PhC-µCT) allows to capture the tissue dynamics. This proof-of-concept study presents a rheometer setup for simultaneous in situ unconfined compression and SR-PhC-µCT of connective knee tissues. The microstructural response of bovine cartilage (n = 16) and meniscus (n = 4) samples under axial continuously increased strain, or two steps of 15% strain (stress-relaxation) is studied. The chondrocyte distribution in cartilage and the collagen fiber orientation in the meniscus are assessed. Variations in chondrocyte density reveal an increase in the top 40% of the sample during loading, compared to the lower half. Meniscus collagen fibers reorient perpendicular to the loading direction during compression and partially redisperse during relaxation. Radiation damage, image repeatability, and image quality assessments show little to no effects on the results. In conclusion, this approach is highly promising for future studies of human knee tissues to understand their microstructure, mechanical response, and progression in degenerative diseases.

Integrated gradient tissue-engineered osteochondral scaffolds: Challenges, current efforts and future perspectives

The osteochondral defect repair has been most extensively studied due to the rising demand for new therapies to diseases such as osteoarthritis. Tissue engineering has been proposed as a promising strategy to meet the demand of simultaneous regeneration of both cartilage and subchondral bone by constructing integrated gradient tissue-engineered osteochondral scaffold (IGTEOS). This review brought forward the main challenges of establishing a satisfactory IGTEOS from the perspectives of the complexity of physiology and microenvironment of osteochondral tissue, and the limitations of obtaining the desired and required scaffold. Then, we comprehensively discussed and summarized the current tissue-engineered efforts to resolve the above challenges, including architecture strategies, fabrication techniques and in vitro/in vivo evaluation methods of the IGTEOS. Especially, we highlighted the advantages and limitations of various fabrication techniques of IGTEOS, and common cases of IGTEOS application. Finally, based on the above challenges and current research progress, we analyzed in details the future perspectives of tissue-engineered osteochondral construct, so as to achieve the perfect reconstruction of the cartilaginous and osseous layers of osteochondral tissue simultaneously. This comprehensive and instructive review could provide deep insights into our current understanding of IGTEOS.

3D Bioprinting of Biomimetic Bilayered Scaffold Consisting of Decellularized Extracellular Matrix and Silk Fibroin for Osteochondral Repair

Recently, three-dimensional (3D) bioprinting technology is becoming an appealing approach for osteochondral repair. However, it is challenging to develop a bilayered scaffold with anisotropic structural properties to mimic a native osteochondral tissue. Herein, we developed a bioink consisting of decellularized extracellular matrix and silk fibroin to print the bilayered scaffold. The bilayered scaffold mimics the natural osteochondral tissue by controlling the composition, mechanical properties, and growth factor release in each layer of the scaffold. The in vitro results show that each layer of scaffolds had a suitable mechanical strength and degradation rate. Furthermore, the scaffolds encapsulating transforming growth factor-beta (TGF-β) and bone morphogenetic protein-2 (BMP-2) can act as a controlled release system and promote directed differentiation of bone marrow-derived mesenchymal stem cells. Furthermore, the in vivo experiments suggested that the scaffolds loaded with growth factors promoted osteochondral regeneration in the rabbit knee joint model. Consequently, the biomimetic bilayered scaffold loaded with TGF-β and BMP-2 would be a promising strategy for osteochondral repair.

Osteochondral Tissue Engineering: The Potential of Electrospinning and Additive Manufacturing

The socioeconomic impact of osteochondral (OC) damage has been increasing steadily over time in the global population, and the promise of tissue engineering in generating biomimetic tissues replicating the physiological OC environment and architecture has been falling short of its projected potential. The most recent advances in OC tissue engineering are summarised in this work, with a focus on electrospun and 3D printed biomaterials combined with stem cells and biochemical stimuli, to identify what is causing this pitfall between the bench and the patients' bedside. Even though significant progress has been achieved in electrospinning, 3D-(bio)printing, and induced pluripotent stem cell (iPSC) technologies, it is still challenging to artificially emulate the OC interface and achieve complete regeneration of bone and cartilage tissues. Their intricate architecture and the need for tight spatiotemporal control of cellular and biochemical cues hinder the attainment of long-term functional integration of tissue-engineered constructs. Moreover, this complexity and the high variability in experimental conditions used in different studies undermine the scalability and reproducibility of prospective regenerative medicine solutions. It is clear that further development of standardised, integrative, and economically viable methods regarding scaffold production, cell selection, and additional biochemical and biomechanical stimulation is likely to be the key to accelerate the clinical translation and fill the gap in OC treatment.

Cartilage Tissue Engineering by Extrusion Bioprinting: Process Analysis, Risk Evaluation, and Mitigation Strategies

Extrusion bioprinting is considered promising in cartilage tissue engineering since it allows the fabrication of complex, customized, and living constructs potentially suitable for clinical applications. However, clinical translation is often complicated by the variability and unknown/unsolved issues related to this technology. The aim of this study was to perform a risk analysis on a research process, consisting in the bioprinting of a stem cell-laden collagen bioink to fabricate constructs with cartilage-like properties. The method utilized was the Failure Mode and Effect Analysis/Failure Mode and Effect Criticality Analysis (FMEA/FMECA) which foresees a mapping of the process to proactively identify related risks and the mitigation actions. This proactive risk analysis allowed the identification of forty-seven possible failure modes, deriving from seventy-one potential causes. Twenty-four failure modes displayed a high-risk level according to the selected evaluation criteria and threshold (RPN > 100). The results highlighted that the main process risks are a relatively low fidelity of the fabricated structures, unsuitable parameters/material properties, the death of encapsulated cells due to the shear stress generated along the nozzle by mechanical extrusion, and possible biological contamination phenomena. The main mitigation actions involved personnel training and the implementation of dedicated procedures, system calibration, printing conditions check, and, most importantly, a thorough knowledge of selected biomaterial and cell properties that could be built either through the provided data/scientific literature or their preliminary assessment through dedicated experimental optimization phase. To conclude, highlighting issues in the early research phase and putting in place all the required actions to mitigate risks will make easier to develop a standardized process to be quickly translated to clinical use.

Glenohumeral Microfracturing of Contained Glenohumeral Defects: Mid- to Long-term Outcome

Purpose

To report mid- to long-term clinical and radiological outcomes after microfracturing for symptomatic chondral defects of the glenohumeral joint.

Methods

All patients who underwent glenohumeral arthroscopic microfracturing between 2002 and 2012 at a single center were considered for inclusion in this retrospective study. Clinical outcome was evaluated using the Constant Score, Oxford Shoulder Score, and Subjective Shoulder Value. Progression of joint space narrowing, sclerosis, marginal osteophytes, and presence of cysts over time were assessed using 4 different radiological grading systems.

Results

A total of 16 patients (n = 9 female, n = 7 male) with a mean age of 51.8 ± 12.6 years at the time of surgery and a mean follow-up of 122 ± 51.2 months (range, 61-204 months) were included in this retrospective study. Nine patients (56.3%) showed an isolated chondral defect, while 7 patients (43.8%) had concomitant pathologies. Constant Score (60.3 ± 12.7 vs. 85.9 ± 9.3; P < .001), Oxford Shoulder Score (29.0 ± 5.8 vs. 42.4 ± 4.5; P < .001), and Subjective Shoulder Value (23.9 ± 7.4 vs. 84.3 ± 10.9; P < .001) changed significantly from pre- to postoperative. The majority of patients (88%) were able to return to their preoperative level of activity. Three patients (19.8%) developed radiological signs of progressive glenohumeral degeneration during the study period. However, only 1 patient (6.25%) showed a progression of arthritic changes of more than 1 grade according to radiographic classifications. Two patients (12.5%) underwent revision surgery to a hemi shoulder arthroplasty during the study period at 12 and 36 months after the initial procedure.

Conclusions

Glenohumeral microfracturing is commonly performed together with other procedures, but seems to be a feasible treatment option for contained cartilage lesions in active patients reproducibly yielding good mid- to long-term outcome.

Level of Evidence

Level IV, therapeutic case series.

Materials and structures used in meniscus repair and regeneration: a review

Meniscus is a vital functional unit in knee joint. It acts as a lubricating structure, a nutrient transporting structure, as well as shock absorber during jumping, twisting and running and offers stability within the knee joint. It helps in load distribution, in bearing the tensile hoop stresses and balancing by providing a cushion effect between hard surfaces of two bones. Meniscus may be injured in sports, dancing, accident or any over stressed condition. Any meniscal lesion can lead to a gradual development of osteoarthritis or erosion of bone contact surface due to disturbed load and contact stress distribution caused by injury/pain. Once injured, the possibilities of self-repair are rare in avascular region of meniscus, due to lack of blood supply in avascular region. Meniscus has vascular and avascular regions in structure. Majority of the meniscus parts turn avascular with increase in age.

Purpose of this review is to highlight advances in meniscus repair with special focus on tissue engineering using textile/fiber based scaffolds, as well as the recent technical advances in scaffolds for meniscus recon- struction/ regeneration treatment.

The quest for mechanically and biologically functional soft biomaterials via soft network composites

Developing multifunctional soft biomaterials capable of addressing all the requirements of the complex tissue regeneration process is a multifaceted problem. In order to tackle the current challenges, recent research efforts are increasingly being directed towards biomimetic design concepts that can be translated into soft biomaterials via advanced manufacturing technologies. Among those, soft network composites consisting of a continuous hydrogel matrix and a reinforcing fibrous network closely resemble native soft biological materials in terms of design and composition as well as physicochemical properties. This article reviews soft network composite systems with a particular emphasis on the design, biomaterial and fabrication aspects within the context of soft tissue engineering and drug delivery applications.

Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions Revision 2018

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to meniscus and articular cartilage lesions. J Orthop Sports Phys Ther. 2018;48(2):A1-A50. doi:10.2519/jospt.2018.0301.

Cartilage and Muscle Cell Fate and Origins during Lizard Tail Regeneration

Introduction

Human cartilage is an avascular tissue with limited capacity for repair. By contrast, certain lizards are capable of musculoskeletal tissue regeneration following tail loss throughout all stages of their lives. This extraordinary ability is the result of a complex process in which a blastema forms and gives rise to the tissues of the regenerate. Blastemal cells have been shown to originate either from dedifferentiated tissues or from existing progenitor cells in various species, but their origin has not been determined in lizards. As reptiles, lizards are the closest relatives to mammals with enhanced regenerative potential, and the origin of blastemal cells has important implications for the regenerative process. Hence, the aim of this study is to determine the cellular origin of regenerated cartilage and muscle tissues in reptiles using the mourning gecko lizard as the regenerative model.

Methods

To trace the fate and differentiation potential of cartilage during tail regeneration, cartilage cells pre-labeled with the fluorescent tracer Dil were injected into lizard tails, and the contribution of cartilage cells to regenerated tail tissues was assessed by histologic examination at 7, 14, and 21 days post-tail amputation. The contribution of muscle cells to regenerated tail tissues was evaluated using muscle creatine kinase promoter-driven Cre recombinase in conjunction with the Cre-responsive green-to-red fluorescence shift construct CreStoplight. 21 days after amputation, tail tissues were analyzed by histology for red fluorescent protein (RFP)-positive cells.

Results

At 7 days post-amputation, Dil-labeled cartilage cells localized to the subapical space contributing to the blastema. At 14 and 21 days post-amputation, Dil-labeled cells remained in the subapical space and colocalized with Collagen type II (Col2) staining in the cartilage tube and myosin heavy chain (MHC) staining in regenerated muscle. Lineage tracing of myocytes showed colocalization of RFP with Col2 and MHC in differentiated tissues at 21 days post-amputation.

Conclusion

This study demonstrates that differentiated cartilage cells contribute to both regenerated muscle and cartilage tissues following tail loss, and in turn, differentiated muscle cells contribute to both tissue types as well. These findings suggest that dedifferentiation and/or transdifferentiation are at least partially responsible for the regenerative outcome in the mourning gecko.

In situ handheld three-dimensional bioprinting for cartilage regeneration

Articular cartilage injuries experienced at an early age can lead to the development of osteoarthritis later in life. In situ three-dimensional (3D) printing is an exciting and innovative biofabrication technology that enables the surgeon to deliver tissue-engineering techniques at the time and location of need. We have created a hand-held 3D printing device (biopen) that allows the simultaneous coaxial extrusion of bioscaffold and cultured cells directly into the cartilage defect in vivo in a single-session surgery. This pilot study assessed the ability of the biopen to repair a full-thickness chondral defect and the early outcomes in cartilage regeneration, and compared these results with other treatments in a large animal model. A standardized critical-sized full-thickness chondral defect was created in the weight-bearing surface of the lateral and medial condyles of both femurs of six sheep. Each defect was treated with one of the following treatments: (i) hand-held in situ 3D printed bioscaffold using the biopen (HH group), (ii) preconstructed bench-based printed bioscaffolds (BB group), (iii) microfractures (MF group) or (iv) untreated (control, C group). At 8 weeks after surgery, macroscopic, microscopic and biomechanical tests were performed. Surgical 3D bioprinting was performed in all animals without any intra- or postoperative complication. The HH biopen allowed early cartilage regeneration. The results of this study show that real-time, in vivo bioprinting with cells and scaffold is a feasible means of delivering a regenerative medicine strategy in a large animal model to regenerate articular cartilage.

Fabrication of injectable high strength hydrogel based on 4-arm star PEG for cartilage tissue engineering

Hydrogels prepared from poly(ethylene glycol) (PEG) are widely applied in tissue engineering, especially those derived from a combination of functional multi-arm star PEG and linear crosslinker, with an expectation to form a structurally ideal network. However, the poor mechanical strength still renders their further applications. Here we examined the relationship between the dynamics of the pre-gel solution and the mechanical property of the resultant hydrogel in a system consisting of 4-arm star PEG functionalized with vinyl sulfone and short dithiol crosslinker. A method to prepare mechanically strong hydrogel for cartilage tissue engineering is proposed. It is found that when gelation takes place at the overlap concentration, at which a slow relaxation mode just appears in dynamic light scattering (DLS), the resultant hydrogel has a local maximum compressive strength ∼20 MPa, while still keeps ultralow mass concentration and Young's modulus. Chondrocyte-laden hydrogel constructed under this condition was transplanted into the subcutaneous pocket and an osteochondral defect model in SCID mice. The in vivo results show that chondrocytes can proliferate and maintain their phenotypes in the hydrogel, with the production of abundant extracellular matrix (ECM) components, formation of typical chondrocyte lacunae structure and increase in Young's modulus over 12 weeks, as indicated by histological, immunohistochemistry, gene expression analyses and mechanical test. Moreover, newly formed hyaline cartilage was observed to be integrated with the host articular cartilage tissue in the defects injected with chondrocytes/hydrogel constructs. The results suggest that this hydrogel is a promising candidate scaffold for cartilage tissue engineering.

Tissue engineering and the future of hip cartilage, labrum and ligamentum teres

As the field of hip arthroscopy continues to evolve, the biological understanding of orthopaedic tissues, namely articular cartilage, labral fibro-cartilage and the ligamentum teres continues to expand. Similarly, the need for biological solutions for the pre-arthritic and early arthritic hip continues to be a challenge for the sports medicine surgeon and hip arthroscopist. This article outlines existing biological and tissue-engineering technologies, some being used in clinical practice and other technologies being developed, and how these biological and tissue-engineering principals may one day influence the practice of hip arthroscopy. This review of hip literature is specific to emerging biological technologies for the treatment of chondral defects, labral tears and ligamentum teres deficiency. Of note, not all of the technologies described in this article have been approved by the United States Food and Drug Administration and some of the described uses of the approved technologies should be considered 'off-label' uses.

Cartilage tissue engineering: recent advances and perspectives from gene regulation/therapy

Diseases in articular cartilages affect millions of people. Despite the relatively simple biochemical and cellular composition of articular cartilages, the self-repair ability of cartilage is limited. Successful cartilage tissue engineering requires intricately coordinated interactions between matrerials, cells, biological factors, and phycial/mechanical factors, and still faces a multitude of challenges. This article presents an overview of the cartilage biology, current treatments, recent advances in the materials, biological factors, and cells used in cartilage tissue engineering/regeneration, with strong emphasis on the perspectives of gene regulation (e.g., microRNA) and gene therapy.

Developing functional musculoskeletal tissues through hypoxia and lysyl oxidase-induced collagen cross-linking

The inability to recapitulate native tissue biomechanics, especially tensile properties, hinders progress in regenerative medicine. To address this problem, strategies have focused on enhancing collagen production. However, manipulating collagen cross-links, ubiquitous throughout all tissues and conferring mechanical integrity, has been underinvestigated. A series of studies examined the effects of lysyl oxidase (LOX), the enzyme responsible for the formation of collagen cross-links. Hypoxia-induced endogenous LOX was applied in multiple musculoskeletal tissues (i.e., cartilage, meniscus, tendons, ligaments). Results of these studies showed that both native and engineered tissues are enhanced by invoking a mechanism of hypoxia-induced pyridinoline (PYR) cross-links via intermediaries like LOX. Hypoxia was shown to enhance PYR cross-linking 1.4- to 6.4-fold and, concomitantly, to increase the tensile properties of collagen-rich tissues 1.3- to 2.2-fold. Direct administration of exogenous LOX was applied in native cartilage and neocartilage generated using a scaffold-free, self-assembling process of primary chondrocytes. Exogenous LOX was found to enhance native tissue tensile properties 1.9-fold. LOX concentration- and time-dependent increases in PYR content (∼ 16-fold compared with controls) and tensile properties (approximately fivefold compared with controls) of neocartilage were also detected, resulting in properties on par with native tissue. Finally, in vivo subcutaneous implantation of LOX-treated neocartilage in nude mice promoted further maturation of the neotissue, enhancing tensile and PYR content approximately threefold and 14-fold, respectively, compared with in vitro controls. Collectively, these results provide the first report, to our knowledge, of endogenous (hypoxia-induced) and exogenous LOX applications for promoting collagen cross-linking and improving the tensile properties of a spectrum of native and engineered tissues both in vitro and in vivo.

Clinical rehabilitation guidelines for matrix-induced autologous chondrocyte implantation on the tibiofemoral joint

Autologous chondrocyte implantation (ACI) has become an established technique for the repair of full-thickness chondral defects in the knee. Matrix-induced ACI (MACI) is the third and current generation of this surgical technique, and, while postoperative rehabilitation following MACI aims to restore normal function in each patient as quickly as possible by facilitating a healing response without overloading the repair site, current published guidelines appear conservative, varied, potentially outdated, and often based on earlier ACI surgical techniques. This article reviews the existing evidence-based literature pertaining to cell loading and postoperative rehabilitation following generations of ACI. Based on this information, in combination with the technical benefits provided by third-generation MACI in comparison to its surgical predecessors, we present a rehabilitation protocol for patients undergoing MACI in the tibiofemoral joint that has now been implemented for several years by our institution in patients with MACI, with good clinical outcomes.

Is valgus unloader bracing effective in normally aligned individuals: implications for post-surgical protocols following cartilage restoration procedures

PURPOSE

Utilizing valgus unloader braces to reduce medial compartment loading in patients undergoing cartilage restoration procedures may be an alternative to non-weightbearing post-operative protocols in these patients. It was hypothesized that valgus unloader braces will reduce knee adduction moment during the stance phase in healthy subjects with normal knee alignment.

METHODS

Gait analysis was performed on twelve adult subjects with normal knee alignment and no history of knee pathology. Subjects were fitted with an off-the-shelf adjustable valgus unloader brace and tested under five conditions: one with no brace and four with increasing valgus force applied by the brace. Frontal and sagittal plane knee angles and external moments were calculated during stance via inverse dynamics. Analyses of variance were used to assess the effect of the brace conditions on frontal and sagittal plane joint angles and moments.

RESULTS

With increasing tension in the brace, peak frontal plane knee angle during stance shifted from 1.6° ± 4.2° varus without the brace to 4.1° ± 3.6° valgus with maximum brace tension (P = 0.02 compared with the no brace condition). Peak knee adduction moment and knee adduction impulse decreased with increasing brace tension (main effect of brace, P < 0.001). Gait velocity and sagittal plane knee biomechanics were minimally affected.

CONCLUSION

The use of these braces following a cartilage restoration procedure may provide adequate protection of the repair site without limiting the patient's mobility.

α5β1 integrin induces the expression of noncartilaginous procollagen gene expression in articular chondrocytes cultured in monolayers

Introduction

Articular chondrocytes undergo an obvious phenotypic change when cultured in monolayers. During this change, or dedifferentiation, the expression of type I and type III procollagen is induced where normal chondrocytes express little type I and type III procollagen. In this study, we attempted to determine the mechanism(s) for the induction of such procollagen expression in dedifferentiating chondrocytes.

Methods

All experiments were performed using primary-cultured human articular chondrocytes under approval of institutional review boards. Integrin(s) responsible for the induction of type I and type III procollagen expression were specified by RNAi experiments. The signal pathway(s) involved in the induction were determined by specific inhibitors and RNAi experiments. Adenovirus-mediated experiments were performed to identify a small GTPase regulating the activity of integrins in dedifferentiating chondrocytes. The effect of inhibition of integrins on dedifferentiation was investigated by experiments using echistatin, a potent disintegrin. The effect of echistatin was investigated first with monolayer-cultured chondrocytes, and then with pellet-cultured chondrocytes.

Results

In dedifferentiating chondrocytes, α5β1 integrin was found to be involved in the induction of type I and type III procollagen expression. The induction was known to be mediated by v-akt murine thymoma viral oncogene homolog (AKT) signaling. Among the three AKT isoforms, AKT1 seemed to be most involved in the signaling. Elated RAS viral (r-ras) oncogene homolog (RRAS) was considered to regulate the progression of dedifferentiation by modulating the affinity and avidity of α5β1 integrin to ligands. Echistatin inhibited dedifferentiation of monolayer-cultured chondrocytes. Furthermore, the matrix formed by pellet-cultured chondrocytes more closely resembled that of normal cartilage compared with the controls.

Conclusions

The result of this study has shown, for the first time, that α5β1 integrin may be responsible for the induction of non-cartilaginous collagen expression in chondrocytes undergoing dedifferentiation. Again, this study has shown that the inhibition of ligand ligation to integrins may be an effective strategy to inhibit phenotypic change of cultured chondrocytes, and to improve the quality of matrix synthesized by primary cultured chondrocytes.

Regenerating cartilages by engineered ASCs: prolonged TGF-β3/BMP-6 expression improved articular cartilage formation and restored zonal structure

Adipose-derived stem cells (ASCs) hold promise for cartilage regeneration but their chondrogenesis potential is inferior. Here, we used a baculovirus (BV) system that exploited FLPo/Frt-mediated transgene recombination and episomal minicircle formation to genetically engineer rabbit ASCs (rASCs). The BV system conferred prolonged and robust TGF-β3/BMP-6 expression in rASCs cultured in porous scaffolds, which critically augmented rASCs chondrogenesis and suppressed osteogenesis/hypertrophy, leading to the formation of cartilaginous constructs with improved maturity and mechanical properties in 2-week culture. Twelve weeks after implantation into full-thickness articular cartilage defects in rabbits, these engineered constructs regenerated neocartilages that resembled native hyaline cartilages in cell morphology, matrix composition and mechanical properties. The neocartilages also displayed cartilage-specific zonal structures without signs of hypertrophy and degeneration, and eventually integrated with host cartilages. In contrast, rASCs that transiently expressed TGF-β3/BMP-6 underwent osteogenesis/hypertrophy and resulted in the formation of inferior cartilaginous constructs, which after implantation regenerated fibrocartilages. These data underscored the crucial role of TGF-β3/BMP-6 expression level and duration in rASCs in the cell differentiation, constructs properties and in vivo repair. The BV-engineered rASCs that persistently express TGF-β3/BMP-6 improved the chondrogenesis, in vitro cartilaginous constructs production and in vivo hyaline cartilage regeneration, thus representing a remarkable advance in cartilage engineering.

In vitro generation of whole osteochondral constructs using rabbit bone marrow stromal cells, employing a two-chambered co-culture well design

The regeneration of whole osteochondral constructs with a physiological structure has been a significant issue, both clinically and academically. In this study, we present a method using rabbit bone marrow stromal cells (BMSCs) cultured on a silk-RADA peptide scaffold in a specially designed two-chambered co-culture well for the generation of multilayered osteochondral constructs in vitro. This specially designed two-chambered well can simultaneously provide osteogenic and chondrogenic stimulation to cells located in different regions of the scaffold. We demonstrated that this co-culture approach could successfully provide specific chemical stimulation to BMSCs located on different layers within a single scaffold, resulting in the formation of multilayered osteochondral constructs containing cartilage-like and subchondral bone-like tissue, as well as the intermediate osteochondral interface. The cells in the intermediate region were found to be hypertrophic chondrocytes, embedded in a calcified extracellular matrix containing glycosaminoglycans and collagen types I, II and X. In conclusion, this study provides a single-step approach that highlights the feasibility of rabbit BMSCs as a single-cell source for multilayered osteochondral construct generation in vitro.

In vitro generation of a multilayered osteochondral construct with an osteochondral interface using rabbit bone marrow stromal cells and a silk peptide-based scaffold

Tissue engineering of a biological osteochondral multilayered construct with a cartilage-interface subchondral bone layer is a key challenge. This study presented a rabbit bone marrow stromal cell (BMSC)/silk fibroin scaffold-based co-culture approach to generate tissue-engineered osteochondral grafts with an interface. BMSC-seeded scaffolds were first cultured separately in osteogenic and chondrogenic stimulation media. The two differentiated pieces were then combined using an RADA self-assembling peptide and subsequently co-cultured. Gene expression, histological and biochemical analyses were used to evaluate the multilayered structure of the osteochondral graft. A complete osteochondral construct with a cartilage-subchondral bone interface was regenerated and BMSCs were used as the only cell source for the osteochondral construct and interface regeneration. Furthermore, in the intermediate region of co-cultured samples, hypertrophic chondrogenic gene markers type X collagen and MMP-13 were found on both chondrogenic and osteogenic section edges after co-culture. However, significant differences gene expression profile were found in distinct zones of the construct during co-culture and the section in the intermediate region had significantly higher hypertrophic chondrocyte gene expression. Biochemical analyses and histology results further supported this observation. This study showed that specific stimulation from osteogenic and chondrogenic BMSCs affected each other in this co-culture system and induced the formation of an osteochondral interface. Moreover, this system provided a possible approach for generating multilayered osteochondral constructs.

Tissue engineering and cartilage

Human articular cartilage is an avascular structure, which, when injured, poses significant hurdles to repair strategies. Not only does the defect need to be repopulated with cells, but preferentially with hyaline-like cartilage.SUCCESSFUL TISSUE ENGINEERING RELIES ON FOUR SPECIFIC CRITERIA: cells, growth factors, scaffolds, and the mechanical environment. The cell population utilized may originate from cartilage itself (chondrocytes) or from growth factors that direct the development of mesenchymal stem cells toward a chondrogenic phenotype. These stem cells may originate from various mesenchymal tissues including bone marrow, synovium, adipose tissue, skeletal muscle, and periosteum. Another unique population of multipotent cells arises from Wharton's jelly in human umbilical cords. A number of growth factors have been associated with chondrogenic differentiation of stem cells and the maintenance of the chondrogenic phenotype by chondrocytes in vitro, including TGFbeta; BMP-2, 4 and 7; IGF-1; and GDF-5.Scaffolds chosen for effective tissue engineering with respect to cartilage repair can be protein based (collagen, fibrin, and gelatin), carbohydrate based (hyaluronan, agarose, alginate, PLLA/PGA, and chitosan), or formed by hydrogels. Mechanical compression, fluid-induced shear stress, and hydrostatic pressure are aspects of mechanical loading found in within the human knee joint, both during gait and at rest. Utilizing these factors may assist in stimulating the development of more robust cells for implantation.Effective tissue engineering has the potential to improve the quality of life of millions of patients and delay future medical costs related to joint arthroplasty and associated procedures.

Surgical treatment options for osteochondritis dissecans of the knee

Osteochondritis dissecans of the knee is identified with increasing frequency in the young adult patient. Left untreated, osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. Treatment of osteochondritis dissecans may include nonoperative or operative intervention. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Reestablishing the joint surface, maximizing the osteochondral biologic environment, achieving rigid fixation, and ensuring early motion are paramount to fragment preservation. In cases where the fragment is not amenable to preservation, the treatment may include complex reconstruction procedures, such as marrow stimulation, osteochondral autograft, fresh osteochondral allograft, and autologous chondrocyte implantation. Treatment goals include pain relief, restoration of function, and the prevention of secondary osteoarthritis.

Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression

The management of patients after anterior cruciate ligament reconstruction should be evidence based. Since our original published guidelines in 1996, successful outcomes have been consistently achieved with the rehabilitation principles of early weight bearing, using a combination of weight-bearing and non-weight-bearing exercise focused on quadriceps and lower extremity strength, and meeting specific objective requirements for return to activity. As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure that the most up-to-date evidence is guiding rehabilitative care. Emerging evidence on rehabilitative interventions and advancements in concomitant surgeries, including those addressing chondral and meniscal injuries, continues to grow and greatly affect the rehabilitative care of patients with anterior cruciate ligament reconstruction. The aim of this article is to update previously published rehabilitation guidelines, using the most recent research to reflect the most current evidence for management of patients after anterior cruciate ligament reconstruction. The focus will be on current concepts in rehabilitation interventions and modifications needed for concomitant surgery and pathology.

LEVEL OF EVIDENCE

Therapy, level 5.

Catabolic factors and osteoarthritis-conditioned medium inhibit chondrogenesis of human mesenchymal stem cells

Articular cartilage has a very limited intrinsic repair capacity leading to progressive joint damage. Therapies involving tissue engineering depend on chondrogenic differentiation of progenitor cells. This chondrogenic differentiation will have to survive in a diseased joint. We postulate that catabolic factors in this environment inhibit chondrogenesis of progenitor cells. We investigated the effect of a catabolic environment on chondrogenesis in pellet cultures of human mesenchymal stem cells (hMSCs). We exposed chondrogenically differentiated hMSC pellets, to interleukin (IL)-1α, tumor necrosis factor (TNF)-α or conditioned medium derived from osteoarthritic synovium (CM-OAS). IL-1α and TNF-α in CM-OAS were blocked with IL-1Ra or Enbrel, respectively. Chondrogenesis was determined by chondrogenic markers collagen type II, aggrecan, and the hypertrophy marker collagen type X on mRNA. Proteoglycan deposition was analyzed by safranin o staining on histology. IL-1α and TNF-α dose-dependently inhibited chondrogenesis when added at onset or during progression of differentiation, IL-1α being more potent than TNF-α. CM-OAS inhibited chondrogenesis on mRNA and protein level but varied in extent between patients. Inhibition of IL-1α partially overcame the inhibitory effect of the CM-OAS on chondrogenesis whereas the TNF-α contribution was negligible. We show that hMSC chondrogenesis is blocked by either IL-1α or TNF-α alone, but that there are additional factors present in CM-OAS that contribute to inhibition of chondrogenesis, demonstrating that catabolic factors present in OA joints inhibit chondrogenesis, thereby impairing successful tissue engineering.

Study of the Cytotoxicity of a Composite of Carboxymethylcellulose (CMC) and a BioCeramic (Biphasic Calcium Phosphate-BCP) Injection for Use in Articular Cartilage Repair

The failure of organs and tissues caused by trauma and other injuries is one of the most costly of human health problems. It is estimated that 1.6 million people experience work limitations caused by osteoarthritis and related disorders, representing 8.3% of all main conditions. Joint injuries frequently lead to progressive joint degeneration and post-traumatic osteoarthritis. Articular cartilage has only a limited capacity for self-healing, mainly due to the fact that it is avascular; and once seriously damaged, articular cartilage lesions will not regenerate. There is strong evidence that cartilage lesions may lead to osteoarthritis when left untreated. Numerous animal experiments and clinical studies have shown that early biological reconstruction of circumscribed cartilage defects in the knee is superior to conservative or delayed surgical treatment. Tissue engineering has shown promising therapeutic strategies for repair or regeneration of damaged tissues. Currently, ceramic based and polymeric scaffolds have been developed to bring about the restoration of tissue functions. The bioceramics associated with water-soluble polymers have been developed as substitutes for various orthopedic applications. The objectives of this work are the processing and characterization of a composite of carboxymethylcellulose (CMC) and biphasic calcium phosphate (Biphasic Calcium Phosphate - BCP) in the form of a hydrogel, and a study of its cytotoxicity (in vitro), aimed at its application as an injectable biomaterial in order to repair the extracellular matrix of articular cartilage. The CMC and BCP were characterized by Fourier Transform Infrared Spectrometry (FTIR) and X-Ray Diffraction (XRD), X-ray fluorescence (XRF), respectively, and scanning electron microscopy (SEM) of powders and the composite. To evaluate the biological effect of the composite hydrogel, tests of cytotoxicity (MTT) and rheological tests under real conditions of use were performed. The composite of carboxymethylcellulose (CMC) and bioceramics (biphasic calcium phosphate-BCP) in the form of hydrogel showed an adequate injectability in the conditions studied, and a non-toxic response, presenting potential for use as fillers or to stimulate the healing of cartilage defects in the extracellular matrix of articular cartilage.

The effect of storage medium tonicity on osteochondral autograft plug diameter

PURPOSE

The purpose of this study was to investigate the effect of differing storage medium on osteochondral plug diameter.

METHODS

Four storage conditions were evaluated: air, hypotonic solution (sterile water), isotonic saline solution (0.9% sodium chloride), and hypertonic saline solution (3.0% sodium chloride). Four osteochondral plugs were acquired (4.5-mm harvesting system) from each of 10 fresh calf femurs and randomized to 1 of 4 storage media (N = 40). Micro-computed tomography was used to evaluate the precise diameter of each plug. After a time 0 scan, each plug was placed in a designated storage medium and rescanned at 3 time points over approximately 1 hour. A region of interest was identified from approximately 1 to 6 mm proximal to the tidemark. Custom software automatically calculated the diameter of each plug.

RESULTS

The time 0 plug diameter (mean ± 95% confidence interval) for all specimens was 4.66 ± 0.01 mm. There were no significant differences between any of the groups at the baseline scan. There were also no significant differences between the time 0 and subsequent scans of the unsubmerged specimens. However, all of the liquid solutions (hypertonic, isotonic, and hypotonic) resulted in a significant increase in diameter from their baseline scans (P < .05), indicating that a cause may be increased extracellular matrix fluid pressure.

CONCLUSIONS

Placing an osteochondral plug in a liquid solution increased the diameter of the subchondral bone. Size increase from the storage medium appeared to level off within 14 minutes after placement in solution.

CLINICAL RELEVANCE

Increases in diameter of the plug may alter the ease of insertion of the graft, possibly increasing contact pressure on cartilage during plug implantation.

Total knee arthroplasty in motivated patients with knee osteoarthritis and athletic activity approach type goals: a conceptual decision-making model

Knee osteoarthritis is one of the most common disabling medical conditions. With longer life expectancy the number of total knee arthroplasty (TKA) procedures being performed worldwide is projected to increase dramatically. Patient education, physical activity, bodyweight levels, expectations and goals regarding the ability to continue athletic activity participation are also increasing. For the subset of motivated patients with knee osteoarthritis who have athletic activity approach type goals, early TKA may not be the best knee osteoarthritis treatment option to improve satisfaction, quality of life and outcomes. The purpose of this clinical commentary is to present a conceptual decision-making model designed to improve the knee osteoarthritis treatment intervention outcome for motivated patients with athletic activity approach type goals. The model focuses on improving knee surgeon, patient and rehabilitation clinician dialogue by rank ordering routine activities of daily living and quality of life evoking athletic activities based on knee symptom exacerbation or re-injury risk. This process should help establish realistic patient expectations and goals for a given knee osteoarthritis treatment intervention that will more likely improve self-efficacy, functional independence, satisfaction and outcomes while decreasing the failure risk associated with early TKA.

Tailoring the mechanical properties of 3D-designed poly(glycerol sebacate) scaffolds for cartilage applications

Matching tissue engineering scaffold modulus to that of native tissue is highly desirable. Effective scaffold modulus can be altered through changes in base material modulus and/or scaffold pore architecture. Because the latter may be restricted by tissue in-growth requirements, it is advantageous to be able to alter the base material modulus of a chosen scaffold material. Here, we show that the bulk modulus of poly(glycerol sebacate) (PGS) can be changed by varying molar ratios during prepolymer synthesis and by varying curing time. We go on to show that PGS can be used to create 3D designed scaffolds via solid freeform fabrication methods with modulus values that fall within the ranges of native articular cartilage equilibrium modulus. Furthermore, using base material modulus inputs, homogenization finite element analysis can effectively predict the tangent modulus of PGS scaffold designs, which provides a significant advantage for designing new cartilage regeneration scaffolds. Lastly, we demonstrate that this relatively new biomedical material supports cartilaginous matrix production by chondrocytes in vitro. (c) 2010 Wiley Periodicals, Inc. J Biomed Mater Res, 2010.

Knee pain and mobility impairments: meniscal and articular cartilage lesions

The Orthopaedic Section of the American Physical Therapy Association presents this fifth set of clinical practice guidelines on knee pain and mobility impairments, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

Cartilage tissue engineering on fibrous chitosan scaffolds produced by a replica molding technique

The biocompatibility of chitosan and its similarity with glycosaminoglycans make it attractive as a scaffold for cartilage engineering. Fibrous scaffolds may simulate cartilage extracellular matrix structure and promote chondrocyte functions. Our objectives were to produce chitosan fibers of different size and evaluate their potential for chondrogenesis. A novel replica molding technique was developed to produce chitosan nonwoven scaffolds made of fiber measuring 4, 13, or 22 mum in width. A polyglycolic acid mesh (PGA) served as a reference group. Controls were analyzed 48 h after seeding porcine chondrocytes via scanning electron microscopy (SEM), DNA, and glycosaminoglycan (GAG) quantifications. Constructs were cultured for 21 days prior to confocal microscopy, SEM, histology, and quantitative analysis (weight, water, DNA, GAG and collagen II). Chondrocytes maintained their phenotypic appearance and a viability above 85% on the chitosan scaffolds. Chondrocytes attach preferentially to PGA, resulting in a greater cellularity of these constructs. However, based on the GAG/DNA and Collagen II/DNA ratios, matrix production per chondrocyte was improved in chitosan constructs, especially on smaller fibers. The differences between PGA and chitosan are more likely to result from the chemical composition rather than their structural characteristics. Although chitosan appears to promote matrix formation, further studies should be aimed at improving its cell adhesion properties.

Rehabilitation following a minimally invasive procedure for the repair of a combined anterior cruciate and posterior cruciate ligament partial rupture in a 15-year-old athlete

STUDY DESIGN

Case report.

BACKGROUND

The healing response procedure is a minimally invasive arthroscopic surgical technique used to stimulate healing in the treatment of partial cruciate ligament tears. The purpose of this report is to provide information on the surgical procedure, the postoperative rehabilitation, and the overall functional results in a patient who underwent such a procedure.

CASE DESCRIPTION

A 15-year-old male, who sustained a partial tear of both the anterior cruciate and posterior cruciate ligament while playing football, underwent arthroscopic surgical management utilizing a healing response technique. Precautions concerning range of motion and resisted activities were followed postoperatively to protect the healing cruciate ligaments. The postoperative protocol consisted of 3 phases, culminating in return-to-sport training. Treatment incorporated cardiovascular, proprioceptive, strength, power, plyometric, and sport-specific activities. Treatment was progressed based on specific criteria emphasizing proper movement patterns and eccentric control during functional activities.

OUTCOMES

The patient attended 31 physical therapy sessions over 17 weeks. Strength improved from 3/5 to 5/5, knee range of motion returned to normal, Lower Extremity Functional Scale scores improved from 21/80 to 80/80, and successful outcomes on functional return-to-sport testing allowed the patient to return to competitive athletics.

DISCUSSION

Primary repair of cruciate ligament tears has yielded poor results, and partial cruciate ligament tears may not require complete surgical reconstruction. The healing response technique offers a possible solution for the treatment of partial cruciate ligament tears. A criterion-based postoperative protocol was derived based on current evidence regarding rehabilitation following cruciate ligament reconstruction and evidence regarding lower extremity rehabilitation principles and injury prevention.

LEVEL OF EVIDENCE

Therapy, level 4.

Drilling and microfracture lead to different bone structure and necrosis during bone-marrow stimulation for cartilage repair

Bone marrow stimulation is performed using several surgical techniques that have not been systematically compared or optimized for a desired cartilage repair outcome. In this study, we investigated acute osteochondral characteristics following microfracture and comparing to drilling in a mature rabbit model of cartilage repair. Microfracture holes were made to a depth of 2 mm and drill holes to either 2 mm or 6 mm under cooled irrigation. Animals were sacrificed 1 day postoperatively and subchondral bone assessed by histology and micro-CT. We confirmed one hypothesis that microfracture produces fractured and compacted bone around holes, essentially sealing them off from viable bone marrow and potentially impeding repair. In contrast, drilling cleanly removed bone from the holes to provide access channels to marrow stroma. Our second hypothesis that drilling would cause greater osteocyte death than microfracture due to heat necrosis was not substantiated, because more empty osteocyte lacunae were associated with microfracture than drilling, probably due to shearing and crushing of adjacent bone. Drilling deeper to 6 mm versus 2 mm penetrated the epiphyseal scar in this model and led to greater subchondral hematoma. Our study revealed distinct differences between microfracture and drilling for acute subchondral bone structure and osteocyte necrosis. Additional ongoing studies suggest these differences significantly affect long-term cartilage repair outcome.

Osteochondral allografts: state of the art

The use of osteochondral allografts to treat focal osteochondral lesions continues to gain popularity, supported by long-term results. Clinicians must be knowledgeable concerning the possible risks of disease transmission, graft rejection, infection, and graft failure to advise the patient and obtain an informed consent. With advancing scientific and clinical research, future operative indications will likely continue to expand. A significant amount of literature regarding storage methods has recently been published; it is hoped that continued research will lead to techniques for prolonged graft storage to prevent availability concerns.

Emerging technologies and fourth generation issues in cartilage repair

The goals of successful cartilage repair include reducing pain, improving symptoms, and long-term function; preventing early osteoarthritis and subsequent total knee replacements; and rebuilding hyaline cartilage instead of fibrous tissue. Current methods such as microfracture, osteoarticular autograft transfer system, mosaicplasty, and autologous chondrocyte implantation are somewhat successful in regenerating cartilage; however, they also have significant limitations. The future of fourth generation cartilage repair focuses on gene therapy, the use of stem cells (bone marrow, adipose, or muscle derived), and tissue engineering. Emerging techniques include creating elastin-like polymers derived from native elastin sequences to serve as biocompatible scaffolds; using hydrogels to obtain a homogeneous distribution of cells within a 3-dimensional matrix; and using nonviral gene delivery via nucleofection to allow mesenchymal stem cells the ability to express osteogenic growth factors. Although many of the techniques mentioned have yet to be used in a cartilage regeneration model, we have tried to anticipate how methods used in other specialties may facilitate improved cartilage repair.