Fibrocartilage Regeneration Research Articles

Exercise Induced Endothelial Mesenchymal Transition (EndMT) Facilitates Meniscal Fibrocartilage Regeneration.

The meniscus is a semilunar wedge-shaped fibrocartilage tissue within the knee joint that is important for withstanding mechanical shock during joint motion. The intrinsic healing capacity of meniscus tissue is very limited, which makes meniscectomy the primary treatment method in the clinic. An effective translational strategy for regenerating the meniscus after total or subtotal meniscectomy, particularly for extensive meniscal lesions or degeneration, is yet to be developed. The present study demonstrates that the endothelial mesenchymal transition (EndMT) contributes to meniscal regeneration. The mechanical stimulus facilitated EndMT by activating TGF-β2 signaling. A handheld bioprinter system to intraoperatively fabricate a porous meniscus scaffold according to the resected meniscus tissue is developed; this can simplify the scaffold fabrication procedure and period. The transplantation of a porous meniscus scaffold combined with a postoperative regular exercise stimulus facilitated the regeneration of anisotropic meniscal fibrocartilaginous tissue and protected the joint cartilage from degeneration in an ovine subtotal meniscectomy model. Single-cell RNA sequencing and immunofluorescence co-staining analyses further confirmed the occurrence of EndMT during meniscal regeneration. EndMT-transformed cells gave rise to fibrochondrocytes, subsequently contributing to meniscal fibrocartilage regeneration. Thus, an efficient translational strategy to facilitate meniscal regeneration is developed.

Circadian Rhythm-Regulated ADSC-Derived sEVs and a Triphasic Microneedle Delivery System to Enhance Tendon-to-Bone Healing.

Modulating the inflammatory microenvironment to reconstruct the fibrocartilaginous layer while promoting tendon repair is crucial for enhancing tendon-to-bone healing in rotator cuff repair (RCR), a persistent challenge in orthopedics. Small extracellular vesicles (sEVs) hold significant potential to modulate inflammation, yet the efficient production of highly bioactive sEVs remains a substantial barrier to their clinical application. Moreover, achieving minimally invasive local delivery of sEVs to the tendon-to-bone interface presents significant technical difficulties. Herein, the circadian rhythm of adipose-derived stem cells is modulated to increase the yield and enhance the inflammatory regulatory capacity of sEVs. Circadian rhythm-regulated sEVs (CR-sEVs) enhance the cyclic adenosine monophosphate signaling pathway in macrophage (Mφ) via platelet factor 4 delivery, thereby inhibiting Mφ M1 polarization. Subsequently, a triphasic microneedle (MN) scaffold with a tip, stem, and base is designed for the local delivery of CR-sEVs (CR-sEVs/MN) at the tendon-to-bone junction, incorporating tendon-derived decellularized extracellular matrix in the base to facilitate tendon repair. CR-sEVs/MN mitigates inflammation, promotes fibrocartilage regeneration, and enhances tendon healing, thereby improving biomechanical strength and shoulder joint function in a rat RCR model. Combining CR-sEVs with this triphasic microneedle delivery system presents a promising strategy for enhancing tendon-to-bone healing in clinical settings.

M2 macrophage-derived exosomes promote tendon-to-bone healing by alleviating cellular senescence in aged rats

To explore the potential of M2 macrophage-derived exosomes (M2-Exos) in enhancing tendon-to-bone healing in aged rats by mitigating cellular senescence of bone marrow-derived stem cells (BMSCs). In vitro, effects of M2-Exos on alleviating cellular senescence and improving chondrogenic potential of senescent BMSCs were evaluated. Twenty-four young and forty-eight aged rats with chronic rotator cuff tear (RCT) were repaired and assigned into three groups: young group (young rats injected with fibrin at the enthesis), aged group (aged rats injected with fibrin at the enthesis), and aged + M2-Exos group (aged rats injected with fibrin containing M2-Exos at the enthesis). Six and twelve weeks after repair, enthesis regeneration was evaluated. Proteomic analysis was conducted to explore the mechanism through which M2-Exos mitigated cellular senescence. In senescent BMSCs treated with M2-Exos, there was a reduction in senescence biomarkers including senescence-associated β-galactosidase, p53, p21 and senescence associated secretory phenotype (P < .001). M2-Exos also enhanced chondrogenic potential of senescent BMSCs, reflected in higher Bern score (P < .001) and increased expression of Sox9 (P = .013), Col2a1 (P < .001), and Acan (P < .001). Histologically, aged rats treated with M2-Exos demonstrated significantly higher histological scores (P < .001 at both 6 and 12 weeks) and increased fibrocartilage regeneration at the enthesis. Biomechanically, these rats exhibited greater failure load, stiffness, and stress (all P < .001) at 12 weeks. Mechanistically, proteomic analysis suggested that M2-Exos might alleviate cellular senescence by potentially regulating DNA replication and repair. M2-Exos can significantly alleviate BMSC senescence and thereby enhance tendon-to-bone healing in an aged rat RCT model. This study suggests the potential utility of M2-Exos as a therapy for RCT in the older population.

Exosomes derived from bone marrow mesenchymal stem cell preconditioned by low-intensity pulsed ultrasound stimulation promote bone–tendon interface fibrocartilage regeneration and ameliorate rotator cuff fatty infiltration

BackgroundFibrovascular scar healing of bone-tendon interface (BTI) instead of functional fibrocartilage regeneration is the main concern associated with unsatisfactory prognosis in rotator cuff repair. Mesenchymal stem cells (MSCs) exosomes have been reported to be a new promising cell-free approach for rotator cuff healing. Whereas, controversies abound in whether exosomes of native MSCs alone can effectively induce chondrogenesis. PurposeTo explore the effect of exosomes derived from low-intensity pulsed ultrasound stimulation (LIPUS)-preconditioned bone marrow mesenchymal stem cells (LIPUS-BMSC-Exos) or un-preconditioned BMSCs (BMSC-Exos) on rotator cuff healing and the underlying mechanism. MethodsC57BL/6 mice underwent unilateral supraspinatus tendon detachment and repair were randomly assigned to saline, BMSCs-Exos or LIPUS-BMSC-Exos injection therapy. Histological, immunofluorescent and biomechanical tests were detected to investigate the effect of exosomes injection on BTI healing and muscle fatty infiltration of the repaired rotator cuff. In vitro, native BMSCs were incubated with BMSC-Exos or LIPUS-BMSC-Exos and then chondrogenic/adipogenic differentiation were observed. Further, quantitative real-time polymerase chain reaction (qRT-PCR) was performed to detect the chondrogenesis/adipogenesis-related miRNA profiles of LIPUS-BMSC-Exos and BMSC-Exos. The chondrogenic/adipogenic potential of the key miRNA was verified through function recover test with its mimic and inhibitor. ResultsThe results indicated that the biomechanical properties of the supraspinatus tendon-humeral junction were significantly improved in the LIPUS-BMSC-Exos group than that of the BMSCs-Exos group. The LIPUS-BMSC-Exos group also exhibited a higher histological score and more newly regenerated fibrocartilage at the repair site at postoperative 2 and 4 weeks and less fatty infiltration at 4 weeks than the BMSCs-Exos group. In vitro, co-culture of BMSCs with LIPUS-BMSC-Exos could significantly promote BMSCs chondrogenic differentiation and inhibit adipogenic differentiation. Subsequently, qRT-PCR revealed significantly higher enrichment of chondrogenic miRNAs and less enrichment of adipogenic miRNAs in LIPUS-BMSC-Exos compared with BMSC-Exos. Moreover, we demonstrated that this chondrogenesis-inducing potential was primarily attributed to miR-140, one of the most abundant miRNAs in LIPUS-BMSC-Exos. ConclusionLIPUS-preconditioned BMSC-Exos can effectively promote BTI fibrocartilage regeneration and ameliorate supraspinatus fatty infiltration by positive regulation of pro-chondrogenesis and anti-adipogenesis, which was primarily through delivering miR-140. The translational potential of this articleThese findings propose an innovative “LIPUS combined Exosomes strategy” for rotator cuff healing which combines both physiotherapeutic and biotherapeutic advantages. This strategy possesses a good translational potential as a local injection of LIPUS preconditioned BMSC-derived Exos during operation can be not only efficient for promoting fibrocartilage regeneration and ameliorating rotator cuff fatty infiltration, but also time-saving, simple and convenient for patients.

Enhanced fibrocartilage regeneration at the tendon-bone interface injury through extracellular matrix hydrogel laden with bFGF-overexpressing human urine-derived stem cells

The tendon-bone interface (TBI) is crucial in the transfer of mechanical loads; however, it is susceptible to injuries that frequently result in healing via fibrous scar tissue formation. Consequently, regeneration of the fibrocartilaginous zone has become a pivotal area subject. At present, the use of stem cells represents a notably promising approach for TBI treatment. Especially, human urine-derived stem cells (hUSCs) present a practical option for cell-based therapies. Nevertheless, the chondrogenic differentiation potential of hUSCs is limited. To address this, basic fibroblast growth factor (bFGF) was transinfected into hUSCs to bolster their differentiation capacity and facilitate the formation of fibrocartilage in the target area. Additionally, the local immune microenvironment dramatically influences TBI healing, with macrophages playing a vital role. Effective healing relies on the phenotype transition of macrophages, with an imbalance often leading to insufficient regeneration and scar tissue formation. Innovations in biomaterials have provided new avenues for TBI repair, such as the porcine small intestinal submucosa (SIS) hydrogel developed in our prior research. In addition to serving as a carrier for stem cell delivery, the hydrogel’s bioactive components support tissue repair and immune regulation. In the present study, SIS hydrogel loaded with hUSCs that overexpress bFGF was used for the treatment of TBI injury, which is expected to correct inflammatory response imbalances, and promote macrophage polarization towards healing phenotypes, creating a favorable immune microenvironment. The combined effects of bFGF and the optimized immune setting are anticipated to enhance hUSCs’ chondrogenic potential, aiding in the functional restoration of TBI injuries.

Comparison of 3 Different Surgical Techniques for Rotator Cuff Repair in a Rabbit Model: Direct Suture, Inlay Suture, and Polyether Ether Ketone (PEEK) Suture Anchor

Background: Rotator cuff tears have been repaired using the transosseous method for decades. The direct suture (DS) technique has been widely used for rotator cuff tears; however, the retear rate is relatively high. Suture anchors are now used frequently for rotator cuff repair (RCR) in accordance with recent developments in materials. However, polyether ether ketone (PEEK) may still cause complications such as the formation of cysts and osteophytes. Some studies have developed the inlay suture (IS) technique for RCR. Purpose/Hypothesis: To compare how 3 different surgical techniques—namely, the DS, IS, and PEEK suture anchor (PSA)—affect tendon-bone healing after RCR. We hypothesized that the IS technique would lead to better tendon-to-bone healing and that the repaired structure would be similar to the normal enthesis. Study Design: Controlled laboratory study. Methods: Acute infraspinatus tendon tears were created in 36 six-month-old male rabbits, which were divided into 3 groups based on the technique used for RCR: DS, IS, and PSA. Animals were euthanized at 6 and 12 weeks postoperatively and underwent a histological assessment and imaging. The expression of related proteins was demonstrated by immunohistochemistry and immunofluorescence staining. Mechanical properties were evaluated by biomechanical testing. Results: At 12 weeks, regeneration of the enthesis was observed in the 3 groups. However, the DS group showed a lower type I collagen content than the PSA and IS groups, which was similar to the results for scleraxis. The DS group displayed a significantly inferior type II collagen expression and proteoglycan deposition after safranin O/fast green and sirius red staining. With regard to runt-related transcription factor 2 and alkaline phosphatase, the IS group showed upregulated expression levels compared with the other 2 groups. Conclusion: Compared with the DS technique, the PSA and IS techniques contributed to the improved maturation of tendons and fibrocartilage regeneration, while the IS technique particularly promoted osteogenesis at the enthesis. Clinical Relevance: The IS and PSA techniques may be more beneficial for tendon-bone healing after RCR.

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.

Immunity-and-matrix-regulatory cells enhance cartilage regeneration for meniscus injuries: a phase I dose-escalation trial

Immunity-and-matrix-regulatory cells (IMRCs) derived from human embryonic stem cells have unique abilities in modulating immunity and regulating the extracellular matrix, which could be mass-produced with stable biological properties. Despite resemblance to mesenchymal stem cells (MSCs) in terms of self-renew and tri-lineage differentiation, the ability of IMRCs to repair the meniscus and the underlying mechanism remains undetermined. Here, we showed that IMRCs demonstrated stronger immunomodulatory and pro-regenerative potential than umbilical cord MSCs when stimulated by synovial fluid from patients with meniscus injury. Following injection into the knees of rabbits with meniscal injury, IMRCs enhanced endogenous fibrocartilage regeneration. In the dose-escalating phase I clinical trial (NCT03839238) with eighteen patients recruited, we found that intra-articular IMRCs injection in patients was safe over 12 months post-grafting. Furthermore, the effective results of magnetic resonance imaging (MRI) of meniscus repair and knee functional scores suggested that 5 × 107 cells are optimal for meniscus injury treatment. In summary, we present the first report of a phase I clinical trial using IMRCs to treat meniscus injury. Our results demonstrated that intra-articular injection of IMRCs is a safe and effective therapy by providing a permissive niche for cartilage regeneration.

Advances in 3D printing techniques for cartilage regeneration of temporomandibular joint disc and mandibular condyle.

Temporomandibular joint (TMJ) osteoarthritis causes fibrocartilage damage to the TMJ disc and mandibular condyle, resulting in local pain and functional impairment that further reduces patients' quality of life. Tissue engineering offers a potential treatment for fibrocartilage regeneration of the TMJ disc and mandibular condyle. However, the heterogeneous structure of TMJ fibrocartilage tissue poses significant challenges for the fabrication of biomimetic scaffolds. Over the past two decades, some researchers have attempted to adopt three-dimensional (3D) printing techniques to fabricate biomimetic scaffolds for TMJ fibrocartilage regeneration, but publications on such attempts are limited and rarely report satisfactory results, indicating an urgent need for further development. This review outlines several popular 3D printing techniques and the significant elements of tissue-engineered scaffolds: seed cells, scaffold materials, and bioactive factors. Current research progress on 3D-printed scaffolds for fibrocartilage regeneration of the TMJ disc and mandibular condyle is reviewed. The current challenges in TMJ tissue engineering are mentioned along with some emerging tissue-engineering strategies, such as machine learning, stimuli-responsive delivery systems, and extracellular vesicles, which are considered as potential approaches to improve the performance of 3D-printed scaffolds for TMJ fibrocartilage regeneration. This review is expected to inspire the further development of 3D printing techniques for TMJ fibrocartilage regeneration.

High formability Mg-Zn-Gd wire facilitates ACL reconstruction via its swift degradation to accelerate intra-tunnel endochondral ossification

After reconstructing the anterior cruciate ligament (ACL), unsatisfactory bone tendon interface healing may often induce tunnel enlargement at the early healing stage. With good biological features and high formability, Magnesium-Zinc-Gadolinium (ZG21) wires are developed to bunch the tendon graft for matching the bone tunnel during transplantation. Microstructure, tensile strength, degradation, and cytotoxicity of ZG21 wire are evaluated. The rabbit model is used for assessing the biological effects of ZG21 wire by Micro-CT, histology, and mechanical test. The SEM/EDS, immunochemistry, and in vitro assessments are performed to investigate the underlying mechanism. Material tests demonstrate the high formability of ZG21 wire as surgical suture. Micro-CT shows ZG21 wire degradation accelerates tunnel bone formation, and histologically with earlier and more fibrocartilage regeneration at the healing interface. The mechanical test shows higher ultimate load in the ZG21 group. The SEM/EDS presents ZG21 wire degradation triggered calcium phosphate (Ca-P) deposition. IHC results demonstrate upregulation of Wnt3a, BMP2, and VEGF at the early phase and TGFβ3 and Type II collagen at the late phase of healing. In vitro tests also confirmed the Ca-P in the metal extract could elevate the expression of Wnt3a, β catenin, ocn and opn to stimulate osteogenesis. Ex vivo tests of clinical samples indicated suturing with ZG21 wire did not weaken the ultimate loading of human tendon tissue. In conclusion, the ZG21 wire is feasible for tendon graft bunching. Its degradation products accelerated intra-tunnel endochondral ossification at the early healing stage and therefore enhanced bone-tendon interface healing in ACL reconstruction.

Combination of autologous osteochondral and periosteum transplantation effectively promotes fibrocartilage regeneration at the tendon-bone junction of the rotator cuff in rabbits.

Rotator cuff tendon-bone healing often leads to scarring and low biomechanical strength, resulting in a tendency to re-tear. This study examined whether combining autologous osteochondral transplantation and periosteum transplantation increases fibrocartilage transition zone regeneration and improves biomechanical fixation. A total of 48 New Zealand white rabbits were divided into the periosteum, autologous osteochondral, combination of autologous osteochondral and periosteum, and control groups. The supraspinatus tendon was cut from the greater tuberosity and repaired by different transplants. A total of 12 rabbits were used for histological examination (haematoxylin and eosin staining, Masson's staining and Safranin-O staining) at 4, 8 and 12weeks after the repair, and 36 rabbits were used for biomechanical tests (maximal failure load and stiffness). At 4weeks following the operation, each group had a large tendon-bone gap with a small number of disordered collagen fibres. At 8weeks, the tendon-bone gap was smaller than that before the operation, and the tendon-bone gap in each experimental group was smaller with neater and denser collagen fibres and chondrocytes than in the control group, with the osteochondral combined periosteum group having the best results. At 12weeks, the typical tendon-bone transitional structure was observed in the osteochondral combined periosteum group, and more collagen fibres and chondrocytes were generated in each group. The osteochondral combined periosteum group had the largest staining area and the largest amount of cartilage. The maximum tensile strength and stiffness of each group increased over time. There was no significant difference in each group's maximum tensile strength and stiffness at 4weeks after the operation. However, the maximum tensile strength and stiffness of the osteochondral combined periosteum group at 8 and 12weeks after operation were significantly higher than those of other groups (P < 0.05). Histological and biomechanical results show that autologous osteochondral transplantation combined with periosteum transplantation can effectively promote the regeneration of fibrous cartilage in the tendon-bone junction of the rotator cuff. It is concluded that this technique is a new treatment method to promote tendon-bone healing in the rotator cuff.

Novel therapy using a fish scale collagen scaffold for rotator cuff healing in rat models.

Large and massive rotator cuff tears are challenging for surgeons because of postoperative complications such as repaired site retears. Recently, collagen extracted from fish scales has gained more attention because fish byproducts are considered a safer collagen source than other animal-derived scaffolds. This study aimed to evaluate the biological efficacy of tilapia scale-derived collagen scaffolds for rotator cuff repair in rat models. The infraspinatus tendon was resected from the greater tuberosity of Sprague-Dawley rats. In the control group, the tendon edge was sutured directly to the humeral head. In the augmentation group, the repaired site was augmented with a tilapia scale-derived collagen scaffold. Histologic examinations were performed at 2 and 4weeks postoperatively via safranin O and immunofluorescence staining (isolectin B4 and type II collagen) in the bone-tendon junction. For mechanical analysis, the ultimate failure load of the tendon-humeral head complex was evaluated at 6weeks postoperatively. During safranin O staining, the repaired enthesis demonstrated greater proteoglycan staining in the augmentation group than in the control group at 4weeks postoperatively. Compared to controls, the augmentation group had significantly higher vascular staining with isolectin B4 at 2 and 4weeks postoperatively, type II collagen expression at 4weeks postoperatively, and ultimate failure load at 6weeks postoperatively. Augmentation therapy using tilapia scale-derived type I collagen scaffolds promoted angiogenesis and fibrocartilage regeneration at the enthesis and provided higher mechanical strength than controls.

Intermittent fasting promotes repair of rotator cuff injury in the early postoperative period by regulating the gut microbiota.

BackgroundThe repair of rotator cuff injury is affected by lifestyle and metabolic factors. Intermittent fasting (IF) can promote repair of damaged tissue by regulating intestinal flora, which provides an idea of therapy for rotator cuff injury. The aim of this study was to investigate the effects of fasting on rotator cuff repair after injury, and the role of intestinal flora or a single strain in this process.MethodsMice underwent rotator cuff injury were treated with intermittent fasting or fed ad libitum. Fasting began one month before surgery and continued until euthanasia. Fresh feces were collected at 2 weeks before surgery, on the day of surgery, and 2, 4, 8 weeks postoperatively for 16S rRNA microbiome sequencing. Supraspinatus tendon-humerus ​(SSTH) complex was collected at 2, 4 and 8 weeks after surgery. Live parabacteroides distasonis (Parabacteroides distasonis) was used for repair of rotator cuff injury, with equal amount of pasteurized P. distasonis (KPD) or sterile anaerobic phosphate buffer saline (PBS) as control. Biomechanical, radiological, histological analysis were used to assess the effect of rotator cuff repair.ResultsBiomechanical, radiological and histological analysis indicated that intermittent fasting significantly promoted the repair of rotator cuff injury in the early postoperative period (P ＜ 0.05), but significantly inhibited the repair of rotator cuff injury at 4 weeks postoperatively (P ＜ 0.05). 16S rRNA Microbiome sequencing result showed that P. distasonis was the species with the most obvious changes in intestinal flora of mice after fasting. The results of tensile test, X-ray analysis and histological analysis indicated that the live P. distasonis (LPD) significantly impaired the biomechanical properties, bone regeneration and fibrocartilage regeneration of enthesis postoperatively (P ＜ 0.05).ConclusionIntermittent fasting promoted repair of rotator cuff injury in the early postoperative period by regulating the gut microbiota, in which P. distasonis played an important role.The translational potential of this articleIntermittent fasting (IF) may be a beneficial lifestyle for the repair of rotator cuff injury in the early postoperative period in clinical, and the influence of a certain strain on the repair of rotator cuff injury may also provide an idea for the treatment of rotator cuff injury in the future.

Chondrogenic differentiation of mouse CD105+ stem/progenitor cells on amino-group-functionalized biosilica-hydrogel scaffolds

Mesenchymal stem/progenitor cells (MSPCs) are critical for tissue regeneration. Moreover, the CD105 antigen identifies early MSPCs with increased chondrogenic differentiation ability. We hypothesized that amine-(NH2)-functionalized biosilica incorporating hydrogel scaffolds, seeded with mCoSPCs105+ would contribute to creating tissue-engineered scaffolds, capable of de novo cartilage synthesis. Scaffolds were characterized by water uptake, lysozyme degradation, axial compression, scanning electron microscopy, and energy-dispersive X-ray spectroscopy. Differentiation stimulus of scaffold functionalization was evaluated using Alcian blue staining. Cartilage-forming abilities of mCoSPCs105+ were evaluated using Quantitative reverse transcription polymerase chain reaction (qRT-PCR) and immunohistochemistry. Biosilica particle incorporation into scaffolds resulted in increased water uptake capacity and compression force withstanding abilities. Amine-(NH2)-group functionalization of biosilica led to significantly increased stem cell differentiation potential, by Alcian blue staining, in the first 3 weeks. Scaffold attachment and viable cell proliferation were observed for 6 weeks under chondrogenic differentiation. Downregulation of Runx2, an increase of Col10a1, Ihh, and maintenance of Sox9, was seen under these culture conditions. mCoSPCs105+ gene expression pattern was defined by the significant upregulation of Col1a1, Col2a1, Prg4, and Agc-1 over 6 weeks of incubation compared to the unsorted control. Immunostaining of cell-seeded scaffolds revealed significantly higher secretion of proteins relevant to cartilage extracellular matrix. The preselecting of CD105+ phenotype in MSPCs may enhance tissue regeneration of fibrocartilage and biosilica nanoparticles may be a beneficial additive in tissue engineering of scaffolds.

Biomechanical and Histological Results of Dual-Suspensory Reconstruction Using Banded Tendon Graft to Bridge Massive Rotator Cuff Tears in a Chronic Rabbit Model

Background: Bridging rotator cuff tendon defects with a patch is a reasonable treatment for massive rotator cuff tears (MRCTs). However, the poor outcomes associated with routine patch repair have prompted exploration into superior bridging techniques and graft structures. Purpose: To detect whether dual-suspensory reconstruction using a banded graft would be superior to routine bridging using a patch graft to treat MRCTs and to detect the comparative effectiveness of patellar tendon (PT) and fascia lata (FL) grafts in dual-suspensory reconstruction. Study Design: Controlled laboratory study. Methods: Unilateral chronic MRCTs were created in 72 mature male New Zealand White rabbits, which were randomly divided into 3 groups: (1) patch bridging repair using rectangular FL autograft (PR-FL), (2) dual-suspensory bridging reconstruction using banded FL autograft (DSR-FL), and (3) dual-suspensory bridging reconstruction using banded PT autograft (DSR-PT). In each group, the mean failure load and stiffness of the cuff-graft-humerus (C-G-H) complexes of 6-week and 12-week specimens were recorded, with the failure modes and sites noted. Moreover, cuff-to-graft and graft-to-bone interface healing and graft substance remodeling of the complexes were histologically evaluated (via hematoxylin and eosin, Picrosirius red, Masson trichrome, and Safranin O/fast green staining) at 6 and 12 weeks to assess integrations between the bridging constructs and the native bone or rotator cuff tendons. Results: The DSR-PT group had the greatest mean failure loads and stiffness of the C-G-H complexes at 6 and 12 weeks (41.81 ± 7.00 N, 10.34 ± 2.68 N/mm; 87.62 ± 9.20 N, 17.98 ± 1.57 N/mm, respectively), followed by the DSR-FL group (32.04 ± 5.49 N, 8.20 ± 2.27 N/mm; 75.30 ± 7.31 N, 14.39 ± 3.29 N/mm, respectively). In the DSR-PT and DSR-FL groups, fewer specimens failed at the graft-to-bone junction and more failed at the cuff-to-graft junction, but both groups had higher median failure loads at 6 and 12 weeks (DSR-PT: cuff-to-graft junction, 37.80 and 83.76 N; graft-to-bone junction, 45.46 and 95.86 N) (DSR-FL: cuff-to-graft junction, 28.52 and 67.68 N; graft-to-bone junction, 37.92 and 82.18 N) compared with PR-FL (cuff-to-graft junction, 27.17 and 60.04 N; graft-to-bone junction, 30.12 and 55.95 N). At 12 weeks, the DSR-FL group had higher median failure loads at graft substance (72.26 N) than the PR-FL group (61.27 N). Moreover, the PR-FL group showed more inflammatory responses at the 2 healing interfaces and the graft substance in the 6-week specimens and subsequently displayed poorer interface healing (assessed via collagen organization, collagen maturity, and fibrocartilage regeneration) and graft substance remodeling (assessed via collagen organization and maturity) in 12-week specimens compared with the DSR-PT and DSR-FL groups. Superior interface healing and substance remodeling processes were observed in the DSR-PT group compared with the DSR-FL group. Conclusion: When compared with routine patch repair, the dual-suspensory reconstructions optimized biomechanical properties and improved interface healing and graft substance remodeling for bridging MRCTs. Furthermore, the dual-suspensory technique using the PT graft presented superior histological and biomechanical characteristics than that using FL. Clinical Relevance: The dual-suspensory reconstruction technique using banded tendon grafts may enhance bridging constructs for MRCTs in humans, warranting further investigations of clinical outcomes.

H-loop Knotless Double-Row Repair Versus Knotted Suture Bridge for Rotator Cuff Tears: A Biomechanical and Histological Study in an Animal Model

Background: Knotted suture bridge repair (KSBR) has been widely proven to be an effective method for rotator cuff repairs. However, the occurrence of type 2 failure after suture bridge repair remains a frequent problem because of the stress concentration and disturbance of tendon perfusion in the medial row. The authors have developed the H-loop knotless double–row repair (HLDR) to counteract these problems. Purpose: To compare the biomechanical and histological outcomes of HLDR and KSBR for rotator cuff tear in the rabbit model. Study Design: Controlled laboratory study. Methods: Acute bilateral supraspinatus tears were created on the shoulders of 46 New Zealand White rabbits. HLDR and KSBR were randomly performed on the left side or right side. Thirteen animals each were sacrificed at 2, 4, and 8 weeks after surgery (n = 39), with 6 rabbits used for histological evaluation and the other 7 rabbits for biomechanical testing. The remaining 7 animals from the original 46 were only used for initial biomechanical evaluation at week 0. Results: Macroscopically, all repaired tendons were connected to their footprint on the greater tuberosity without postoperative complications at 8 weeks after surgery. The HLDR group had significantly better histological bone–to–tendon integration compared with the KSBR group in terms of fibrocartilage regeneration, collagen composition, and fiber organization. The biomechanical outcomes in the HLDR group were demonstrated to be better than those of the KSBR group at time 0 and 8 weeks after surgery. Conclusion: Both repair techniques were effective for rotator cuff tears in a rabbit rotator cuff tear model; however, HLDR demonstrated more advantages in improving biomechanical properties and histological tendon–to–bone healing compared with KSBR. Clinical Relevance: This animal study suggested that HLDR might be an alternative choice for rotator cuff tears in humans to increase tendon–to–bone healing and reduce the rate of failure to heal.

L’implantation de fragments méniscaux autologues enveloppés par du fascia induit la régénération du fibrocartilage en cas de pertes de substance méniscales sévères chez le mouton : étude histologique et biomécanique

IntroductionCurrently, various studies have been reported to regenerate the meniscus tissue in a large defect after partial meniscectomy using biological or synthetic scaffolds with or without fibrochondrocytes. However, the clinical utility of those treatments has not been established as of yet. HypothesisPurposes of this study were to develop a sheep model to evaluate feasibility of this new surgical strategy to treat the irreparable meniscus injury, and to test the hypothesis that implantation of autogenous meniscal fragments wrapped with a fascia sheath may significantly induce fibrocartilage regeneration in a large meniscal defect in the sheep model. Methods and methodsTwenty Suffolk sheep were used. In each animal, an anterior 10-mm width of the right medial meniscus was resected. Then, the animals were divided into the following 2 groups. In Group I, the defect was enveloped with a fascia from the left thigh. In Group II, the resected meniscus fragmented into small pieces was grafted into the defect. Then the defect was enveloped with a fascia. In each group, 5 of 10 sheep were used for histological and biomechanical evaluations, respectively, at 12 weeks after surgery. ResultsIn Group I, the defect was incompletely filled with thin fibrous tissues, while fibrocartilage tissues rarely regenerated in the tissue. In Group II, all defects were completely filled with thick fibrocartilage tissues, which were richly stained with the safranin O staining. Both the gross and histological observation score of Group II was significantly (p=0.0005, p=0.0005) greater than that of Group I. Concerning the cross-sectional area of the regenerated tissue, Group II was significantly (p=0.0002) greater than Group I. In the biomechanical evaluation, the maximal load and the linear stiffness of the meniscus-tibia complex were significantly (p=0.0015, p=0.0283) greater in Group II than in Group I. DiscussionsImplantation of autogenous meniscal fragments wrapped with a fascia sheath significantly induces fibrocartilage regeneration into a large meniscal defect in the sheep model. Level of evidencenot applicable; Controlled Laboratory Study, Experimental in vivo study.

Implantation of autogenous meniscal fragments wrapped with a fascia sheath induces fibrocartilage regeneration in a large meniscal defect in sheep: A histological and biomechanical study

IntroductionCurrently, various studies have been reported to regenerate the meniscus tissue in a large defect after partial meniscectomy using biological or synthetic scaffolds with or without fibrochondrocytes. However, the clinical utility of those treatments has not been established as of yet. HypothesisPurposes of this study were to develop a sheep model to evaluate feasibility of this new surgical strategy to treat the irreparable meniscus injury, and to test the hypothesis that implantation of autogenous meniscal fragments wrapped with a fascia sheath may significantly induce fibrocartilage regeneration in a large meniscal defect in the sheep model. Methods and methodsTwenty Suffolk sheep were used. In each animal, an anterior 10-mm width of the right medial meniscus was resected. Then, the animals were divided into the following 2 groups. In Group I, the defect was enveloped with a fascia from the left thigh. In Group II, the resected meniscus fragmented into small pieces was grafted into the defect. Then the defect was enveloped with a fascia. In each group, 5 of 10 sheep were used for histological and biomechanical evaluations, respectively, at 12 weeks after surgery. ResultsIn Group I, the defect was incompletely filled with thin fibrous tissues, while fibrocartilage tissues rarely regenerated in the tissue. In Group II, all defects were completely filled with thick fibrocartilage tissues, which were richly stained with the safranin O staining. Both the gross and histological observation score of Group II was significantly (p=0.0005, p=0.0005) greater than that of Group I. Concerning the cross-sectional area of the regenerated tissue, Group II was significantly (p=0.0002) greater than Group I. In the biomechanical evaluation, the maximal load and the linear stiffness of the meniscus-tibia complex were significantly (p=0.0015, p=0.0283) greater in Group II than in Group I. DiscussionImplantation of autogenous meniscal fragments wrapped with a fascia sheath significantly induces fibrocartilage regeneration into a large meniscal defect in the sheep model. Level of evidenceNot applicable; Controlled Laboratory Study, Experimental in vivo study.

The role of tendon derived stem/progenitor cells and extracellular matrix components in the bone tendon junction repair.

Fibrocartilage enthesis is the junction between bone and tendon with a typical characteristics of fibrocartilage transition zones. The regeneration of this transition zone is the bottleneck for functional restoration of bone tendon junction (BTJ). Biomimetic approaches, especially decellularized extracellular matrix (ECM) materials, are strategies which aim to mimic the components of tissues to the utmost extent, and are becoming popular in BTJ healing because of their ability not only to provide scaffolds to allow cells to attach and migrate, but also to provide a microenvironment to guide stem/progenitor cells lineage-specific differentiation. However, the cellular and molecular mechanisms of those approaches, especially the ECM proteins, remain unclear. For BTJ reconstruction, fibrocartilage regeneration is the key for good integrity of bone and tendon as well as its mechanical recovery, so the components which can guide stem cells to a chondrogenic commitment in biomimetic approaches might well be the key for fibrocartilage regeneration and eventually for the better BTJ healing. In this review, we firstly discuss the importance of cartilage-like formation in the healing process of BTJ. Next, we explore the possibility of tendon-derived stem/progenitor cells as cell sources for BTJ regeneration due to their multi-differentiation potential. Finally, we summarize the role of extracellular matrix components of BTJ in guiding stem cell fate to a chondrogenic commitment, so as to provide cues for understanding the mechanisms of lineage-specific potential of biomimetic approaches as well as to inspire researchers to incorporate unique ECM components that facilitate BTJ repair into design.

A reinforced nanofibrous patch with biomimetic mechanical properties and chondroinductive effect for rotator cuff tissue engineering

Patch augmented surgery has been a feasible technique for rotator cuff repair. An ideal rotator cuff tissue engineering patch should have proper mechanical properties to match the native tendons and sufficient biological effect to promote tendon-bone healing. In this study, kartogenin (KGN)-grafted poly (ether-ester-urethane)urea/gelatin composite nanofibrous patches (PEEUU-GEL-KGN) were fabricated via electrospinning process followed by crosslinking of GEL and covalent grafting of KGN. The optimized PEEUU-GEL-KGN nanofibrous patches exhibited biomimetic mechanical properties, including sufficient tensile strength, non-linear stress-strain profiles, and remarkable elasticity and cyclical properties. In vitro investigations revealed that the patches possessed outstanding biocompatibility and performed a sustained release of KGN for a long time. Modification with GEL and KGN significantly improved hydrophilicity of the patches, promoted the adhesion, spreading, and proliferation of mesenchymal stem cells and upregulated the expression of cartilage-related genes. In vivo studies demonstrated that the implanted PEEUU-GEL-KGN patches effectively improved the tissue cellularity and collagen alignment, accelerated the fibrocartilage regeneration, augmented the biomechanical strength of the repaired enthesis, and reinforced the fixing of the tendon to the bone. Overall, the PEEUU-GEL-KGN patches enhanced tendon-bone healing and resisted rotator cuff re-tear. Therefore, the PEEUU-GEL-KGN patch is a highly promising candidate for rotator cuff tissue engineering.