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Korpershoek JV, Rikkers M, Vonk LA. Isolation of Chondrons from Hyaline Cartilage. Methods Mol Biol 2023; 2598:21-27. [PMID: 36355282 DOI: 10.1007/978-1-0716-2839-3_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
In native healthy hyaline cartilage, the chondrocytes are surrounded by a pericellular matrix that has a distinct composition and function compared to the hyaline cartilage extracellular matrix. The chondrocyte together with its pericellular matrix is called a chondron. The type VI collagen, which is the main component of the pericellular matrix, is resistant to enzymatic digestion by pure collagenase and dispase that do digest the extracellular matrix. Therefore, this combination of enzymes can be used to enzymatically isolate chondrons from hyaline cartilage. Chondrons have a high potential for cartilage tissue engineering. This chapter describes in detail how chondrons can be isolated from hyaline cartilage for further use.
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Affiliation(s)
- Jasmijn V Korpershoek
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Margot Rikkers
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lucienne A Vonk
- Department of Orthopaedics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- CO.DON AG, Teltow, Germany.
- Xintela AB, Lund, Sweden.
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Ossendorff R, Walter SG, Schildberg FA, Spang J, Obudzinski S, Preiss S, Schneider S, Salzmann GM. Biologic principles of minced cartilage implantation: a narrative review. Arch Orthop Trauma Surg 2022. [PMID: 36385655 DOI: 10.1007/s00402-022-04692-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/01/2022] [Indexed: 11/18/2022]
Abstract
Cartilage tissue has a very limited ability to regenerate. Symptomatic cartilage lesions are currently treated by various cartilage repair techniques. Multiple treatment techniques have been proposed in the last 30 years. Nevertheless, no single technique is accepted as a gold standard. Minced cartilage implantation is a newer technique that has garnered increasing attention. This procedure is attractive because it is autologous, can be performed in a single surgery, and is therefore given it is cost-effective. This narrative review provides an overview of the biological potential of current cartilage regenerative repair techniques with a focus on the translational evidence of minced cartilage implantation.
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Jacer S, Shafaei H, Soleimani Rad J. An Investigation on the Regenerative Effects of Intra Articular Injection of Co-Cultured Adipose Derived Stem Cells with Chondron for Treatment of Induced Osteoarthritis. Adv Pharm Bull 2018; 8:297-306. [PMID: 30023332 PMCID: PMC6046423 DOI: 10.15171/apb.2018.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/28/2018] [Accepted: 04/29/2018] [Indexed: 12/12/2022] Open
Abstract
Purpose: Adipose tissue derived stem cells (ASCs) and chondrocytes are best cells for articular cartilage regeneration. Chondrocyte with peri-cellular matrix (PCM) is called chondron provides ideal microenviroment than chondrocytes. We aimed to evaluate the regenerative effects of intra-articular injection of ASCs co-cultures with chondron in induced osteoarthritis (OA). Methods: ASC, from the peri-renal fat of male rat and chondron from primary newborn rat hyaline cartilage were isolated. ASCs were cultured for at least three passages in vitro. Six weeks after OA induction, rats were randomly distributed in five groups of control, osteoarthritic, ASC, chondron and co-cultured. ASCs (107), chondrons (107) and combination of chondrons and ASCs (107) were injected into intra-articular space of the rat knee. The effect of treatments was evaluated by macroscopic and microscopic examinations. The expression levels of collagen type ΙΙ was studied by immunohistochemistry. Results: Macroscopic appearance of the co-cultured group, showed much enhanced articular cartilage regeneration compared to ASC and chondron groups. H&E showed evidence of repair site of articular surface without erosion and fibrillation versus OA group which showed thin layer of hyaline cartilage over tidemark and spontaneous fibrocartilage formation. Metachromatic regions stained with toluidine blue were larger in treatment groups versus OA group. Strong intensity of type ΙΙ collagen staining was observed in co-culture group compared to other groups. Conclusion: Co-culture of chondrons and ASCs increased articular hyaline cartilage formation and provides a useful tool to improve limitations of each of applied cells in this model.
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Affiliation(s)
- Sorayya Jacer
- Department of Anatomical Science, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hajar Shafaei
- Department of Anatomical Science, Tabriz University of Medical Sciences, Tabriz, Iran.,Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jafar Soleimani Rad
- Department of Anatomical Science, Tabriz University of Medical Sciences, Tabriz, Iran.,Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Guilak F, Nims RJ, Dicks A, Wu CL, Meulenbelt I. Osteoarthritis as a disease of the cartilage pericellular matrix. Matrix Biol 2018; 71-72:40-50. [PMID: 29800616 DOI: 10.1016/j.matbio.2018.05.008] [Citation(s) in RCA: 242] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 01/16/2023]
Abstract
Osteoarthritis is a painful joint disease characterized by progressive degeneration of the articular cartilage as well as associated changes to the subchondral bone, synovium, and surrounding joint tissues. While the effects of osteoarthritis on the cartilage extracellular matrix (ECM) have been well recognized, it is now becoming apparent that in many cases, the onset of the disease may be initially reflected in the matrix region immediately surrounding the chondrocytes, termed the pericellular matrix (PCM). Growing evidence suggests that the PCM - which along with the enclosed chondrocytes are termed the "chondron" - acts as a critical transducer or "filter" of biochemical and biomechanical signals for the chondrocyte, serving to help regulate the homeostatic balance of chondrocyte metabolic activity in response to environmental signals. Indeed, it appears that alterations in PCM properties and cell-matrix interactions, secondary to genetic, epigenetic, metabolic, or biomechanical stimuli, could in fact serve as initiating or progressive factors for osteoarthritis. Here, we discuss recent advances in the understanding of the role of the PCM, with an emphasis on the reciprocity of changes that occur in this matrix region with disease, as well as how alterations in PCM properties could serve as a driver of ECM-based diseases such as osteoarthritis. Further study of the structure, function, and composition of the PCM in normal and diseased conditions may provide new insights into the understanding of the pathogenesis of osteoarthritis, and presumably new therapeutic approaches for this disease.
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Affiliation(s)
- Farshid Guilak
- Department of Orthopaedic Surgery, Washington University, Saint Louis, MO 63110, United States; Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, United States; Department of Biomedical Engineering, Washington University, Saint Louis, MO 63110, United States.
| | - Robert J Nims
- Department of Orthopaedic Surgery, Washington University, Saint Louis, MO 63110, United States; Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, United States
| | - Amanda Dicks
- Department of Orthopaedic Surgery, Washington University, Saint Louis, MO 63110, United States; Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, United States; Department of Biomedical Engineering, Washington University, Saint Louis, MO 63110, United States
| | - Chia-Lung Wu
- Department of Orthopaedic Surgery, Washington University, Saint Louis, MO 63110, United States; Shriners Hospitals for Children - St. Louis, St. Louis, MO 63110, United States
| | - Ingrid Meulenbelt
- Department of Molecular Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Owida HA, De Las Heras Ruiz T, Dhillon A, Yang Y, Kuiper NJ. Co-culture of chondrons and mesenchymal stromal cells reduces the loss of collagen VI and improves extracellular matrix production. Histochem Cell Biol 2017; 148:625-638. [PMID: 28821957 DOI: 10.1007/s00418-017-1602-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 12/01/2022]
Abstract
Adult articular chondrocytes are surrounded by a pericellular matrix (PCM) to form a chondron. The PCM is rich in hyaluronan, proteoglycans, and collagen II, and it is the exclusive location of collagen VI in articular cartilage. Collagen VI anchors the chondrocyte to the PCM. It has been suggested that co-culture of chondrons with mesenchymal stromal cells (MSCs) might enhance extracellular matrix (ECM) production. This co-culture study investigates whether MSCs help to preserve the PCM and increase ECM production. Primary bovine chondrons or chondrocytes or rat MSCs were cultured alone to establish a baseline level for ECM production. A xenogeneic co-culture monolayer model using rat MSCs (20, 50, and 80%) was established. PCM maintenance and ECM production were assessed by biochemical assays, immunofluorescence, and histological staining. Co-culture of MSCs with chondrons enhanced ECM matrix production, as compared to chondrocyte or chondron only cultures. The ratio 50:50 co-culture of MSCs and chondrons resulted in the highest increase in GAG production (18.5 ± 0.54 pg/cell at day 1 and 11 ± 0.38 pg/cell at day 7 in 50:50 co-culture versus 16.8 ± 0.61 pg/cell at day 1 and 10 ± 0.45 pg/cell at day 7 in chondron monoculture). The co-culture of MSCs with chondrons appeared to decelerate the loss of the PCM as determined by collagen VI expression, whilst the expression of high-temperature requirement serine protease A1 (HtrA1) demonstrated an inverse relationship to that of the collagen VI. Together, this implies that MSCs directly or indirectly inhibited HtrA1 activity and the co-culture of MSCs with chondrons enhanced ECM synthesis and the preservation of the PCM.
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Affiliation(s)
- H A Owida
- Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, ST4 7QB, UK
| | - T De Las Heras Ruiz
- Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, ST4 7QB, UK
| | - A Dhillon
- Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, ST4 7QB, UK
| | - Y Yang
- Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, ST4 7QB, UK.
| | - N J Kuiper
- Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, ST4 7QB, UK
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Shafaei H, Bagernezhad H, Bagernajad H. Importance of Floating Chondrons in Cartilage Tissue Engineering. World J Plast Surg 2017; 6:62-67. [PMID: 28289615 PMCID: PMC5339611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Dedifferentiation of chondrocytes remains a major problem for cartilage tissue engineering. Chondrocytes loss differentiated phenotype in in vitro culture that is undesired for repair strategies. The chondrocyte is surrounded by a pericellular matrix (PCM), together forming the chondron. PCM has a positive effect on the maintenance of chondrocyte phenotype during culture in comparison to uncovered chondrocyte. Studies suggest that the PCM influence on functional properties of the chondrocytes. However there is no study to show gene expression phenotype differences between round chondron and fibroblastic chondrocytes. We aimed to investigate the effect of pericellular matrix in maintaining of chondrogenic gene expression to solve dedifferentiation problem of chondrocyte. METHODS In this study enzymatically isolated chondrons were cultured for 7 days. Morphology of chondrons were assessed by microscopic examination. Chondrogenic gene expression of Sox9, aggrecan (AGG), cartilage oligomeric matrix protein (COMP), Link protein and chondro-osteogenic gene expression (Runx2, Col1, Col 10 and MMP13) of attached and float chondrons were assessed by real time RT PCR. RESULTS Microscopic observation showed that round shape of chondron observed at day 7 in floating chondrocytes. Gene expression results showed that attached chondrons significantly dedifferentiated by low gene expression of Sox9 and COMP and high MMP13 versus floating cells. CONCLUSION Our results showed that PCM of chondrocyte could restore differentiated state of chondrocytes at day 7. Using unattached form of chondron in cartilage tissue PCM in maintenance of chondrogenic gene expression engineering could be a novel method to solve dedifferentiation problem of chondrocyte.
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Affiliation(s)
- Hajar Shafaei
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran;
| | - Hajar Bagernezhad
- Radiology Department, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Bagernajad
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran;
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Nikpou P, Nejad DM, Shafaei H, Roshangar L, Samadi N, Navali AM, Sadegpour AR, Shanehbandi D, Rad JS. Study of chondrogenic potential of stem cells in co-culture with chondrons. Iran J Basic Med Sci 2016; 19:638-45. [PMID: 27482345 PMCID: PMC4951603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Three-dimensional biomimetic scaffolds have widespread applications in biomedical tissue engineering due to similarity of their nanofibrous architecture to native extracellular matrix. Co-culture system has stimulatory effect on chondrogenesis of adult mesenchymal stem cells. This work presents a co-culture strategy using human articular chondrons and adipose-derived stem cells (ASCs) from infrapatellar fat pad (IPFP) for cartilage tissue production. MATERIALS AND METHODS Isolated stem cells were characterized by flowcytometry. Electrospun and polycaprolactone (PCL) scaffolds (900 nm fiber diameter) was obtained from Bon Yakhteh (Tehran-Iran) and human infrapatellar fat pad-derived stem cells (IPFP-ASCs) were seeded on them. IPFP-ASCs on scaffolds were co-cultured with articular chondrons using transwell. After 21 day, chondrogenic differentiation of stem cell was evaluated by determining the genes expression of collagen2, aggrecan and Indian hedgehog using real-time RT-PCR. RESULTS Genes expression of collagen2, aggrecan by IPFP-ASCs did not alter significantly in comparison with control group. Howevers, expression of Indian hedgehog decreased significantly compared to control group (P< 0.05). CONCLUSION These findings indicate that chondrons obtained from osteoarthritic articular cartilage did not stimulate chondrogenic differentiation of IPFP-ASCs in co-culture.
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Affiliation(s)
- Parisa Nikpou
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Hajar Shafaei
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Roshangar
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nasser Samadi
- Department of Biochemistry and Laboratory Sciences, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Ali Reza Sadegpour
- Department of Orthopedy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Dariush Shanehbandi
- Department of Immunolog, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jafar Soleimani Rad
- Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran,Umblical Cord Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran,Corresponding author: Jafar Soleimani Rad. Gholgasht Ave, Tabriz University of Medical Sciences, Faculty of Medicine, Tabriz, Iran. Tel: +98-41-33342086; Fax: +98-41-33342086;
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Abstract
Chondrocytes in articular cartilage are surrounded by a narrow pericellular matrix (PCM) that is both biochemically and biomechanically distinct from the extracellular matrix (ECM) of the tissue. While the PCM was first observed nearly a century ago, its role is still under investigation. In support of early hypotheses regarding its function, increasing evidence indicates that the PCM serves as a transducer of biochemical and biomechanical signals to the chondrocyte. Work over the past two decades has established that the PCM in adult tissue is defined biochemically by several molecular components, including type VI collagen and perlecan. On the other hand, the biomechanical properties of this structure have only recently been measured. Techniques such as micropipette aspiration, in situ imaging, computational modeling, and atomic force microscopy have determined that the PCM exhibits distinct mechanical properties as compared to the ECM, and that these properties are influenced by specific PCM components as well as disease state. Importantly, the unique relationships among the mechanical properties of the chondrocyte, PCM, and ECM in different zones of cartilage suggest that this region significantly influences the stress-strain environment of the chondrocyte. In this review, we discuss recent advances in the measurement of PCM mechanical properties and structure that further increase our understanding of PCM function. Taken together, these studies suggest that the PCM plays a critical role in controlling the mechanical environment and mechanobiology of cells in cartilage and other cartilaginous tissues, such as the meniscus or intervertebral disc.
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Affiliation(s)
- Rebecca E Wilusz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA; Department of Biomedical Engineering, Duke University Medical Center, Durham, NC, USA; Department of Cell Biology, Duke University Medical Center, Durham, NC, USA
| | - Johannah Sanchez-Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA; Department of Biomedical Engineering, Duke University Medical Center, Durham, NC, USA; Department of Cell Biology, Duke University Medical Center, Durham, NC, USA
| | - Farshid Guilak
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA; Department of Biomedical Engineering, Duke University Medical Center, Durham, NC, USA; Department of Cell Biology, Duke University Medical Center, Durham, NC, USA.
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Wilusz RE, Zauscher S, Guilak F. Micromechanical mapping of early osteoarthritic changes in the pericellular matrix of human articular cartilage. Osteoarthritis Cartilage 2013; 21:1895-903. [PMID: 24025318 PMCID: PMC3856176 DOI: 10.1016/j.joca.2013.08.026] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 08/26/2013] [Accepted: 08/29/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Osteoarthritis (OA) is a degenerative joint disease characterized by the progressive loss of articular cartilage. While macroscale degradation of the cartilage extracellular matrix (ECM) has been extensively studied, microscale changes in the chondrocyte pericellular matrix (PCM) and immediate microenvironment with OA are not fully understood. The objective of this study was to quantify osteoarthritic changes in the micromechanical properties of the ECM and PCM of human articular cartilage in situ using atomic force microscopy (AFM). METHOD AFM elastic mapping was performed on cryosections of human cartilage harvested from both condyles of macroscopically normal and osteoarthritic knee joints. This method was used to test the hypotheses that both ECM and PCM regions exhibit a loss of mechanical properties with OA and that the size of the PCM is enlarged in OA cartilage as compared to normal tissue. RESULTS Significant decreases were observed in both ECM and PCM moduli of 45% and 30%, respectively, on the medial condyle of OA knee joints as compared to cartilage from macroscopically normal joints. Enlargement of the PCM, as measured biomechanically, was also observed in medial condyle OA cartilage, reflecting the underlying distribution of type VI collagen in the region. No significant differences were observed in elastic moduli or their spatial distribution on the lateral condyle between normal and OA joints. CONCLUSION Our findings provide new evidence of significant site-specific degenerative changes in the chondrocyte micromechanical environment with OA.
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Affiliation(s)
- Rebecca E. Wilusz
- Department of Orthopaedic Surgery, Duke University Medical Center
- Department of Biomedical Engineering, Duke University
| | - Stefan Zauscher
- Department of Mechanical Engineering and Materials Science, Duke University
| | - Farshid Guilak
- Department of Orthopaedic Surgery, Duke University Medical Center
- Department of Biomedical Engineering, Duke University
- Department of Mechanical Engineering and Materials Science, Duke University
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Wilusz RE, Guilak F. High resistance of the mechanical properties of the chondrocyte pericellular matrix to proteoglycan digestion by chondroitinase, aggrecanase, or hyaluronidase. J Mech Behav Biomed Mater 2013; 38:183-97. [PMID: 24156881 DOI: 10.1016/j.jmbbm.2013.09.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 09/09/2013] [Accepted: 09/20/2013] [Indexed: 11/18/2022]
Abstract
In articular cartilage, the extracellular matrix (ECM) and chondrocyte-associated pericellular matrix (PCM) are characterized by a high concentration of proteoglycans (PGs) and their associated glycosaminoglycans (GAGs). These molecules serve important biochemical, structural, and biomechanical roles in the tissue and differences in their regional distributions suggest that different GAG/PG species contribute to the specific biomechanical properties of the ECM and PCM. The objective of this study was to investigate region-specific contributions of aggrecan, chondroitin and dermatan sulfate, and hyaluronan to the micromechanical properties of articular cartilage PCM and ECM in situ. Cryosections of porcine cartilage underwent digestion with ADAMTS-4, chondroitinase ABC, bacterial hyaluronidase or human leukocyte elastase. Guided by immunofluorescence for type VI collagen, AFM stiffness mapping was used to evaluate the elastic properties of matched PCM and ECM regions in paired control and digested cartilage sections. These methods were used to test the hypotheses that specific enzymatic digestion of GAGs or PGs would reduce both PCM and ECM elastic moduli. Elastase, which digests a number of PGs, some types of collagen, and non-collagenous proteins, was used as a positive control. ECM elastic moduli were significantly reduced by all enzyme treatments. However, PCM micromechanical properties were unaffected by enzymatic digestion of aggrecan, chondroitin/dermatan sulfate, and hyaluronan but were significantly reduced by 24% following elastase digestion. Our results provide new evidence for high resistance of PCM micromechanical properties to PG digestion and suggest a potential role for elastase in the degradation of the ECM and PCM.
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Affiliation(s)
- Rebecca E Wilusz
- Department of Orthopaedic Surgery, Duke University Medical Center, USA; Department of Biomedical Engineering, Duke University, USA
| | - Farshid Guilak
- Department of Orthopaedic Surgery, Duke University Medical Center, USA; Department of Biomedical Engineering, Duke University, USA.
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