Anatomical design and production of a novel three-dimensional co-culture system replicating the human flexor digitorum profundus enthesis.

The enthesis, the specialized junction between tendon and bone, is a common site of injury. Although notoriously difficult to repair, advances in interfacial tissue engineering techniques are being developed for restorative function. Most notably are 3D in vitro co-culture models, built to recreate the complex heterogeneity of the native enthesis. While cell and matrix properties are often considered, there has been little attention given to native enthesis anatomical morphometrics and replicating these to enhance clinical relevance. This study focuses on the flexor digitorum profundus (FDP) tendon enthesis and, by combining anatomical morphometrics with computer-aided design, demonstrates the design and construction of an accurate and scalable model of the FDP enthesis. Bespoke 3D-printed mould inserts were fabricated based on the size, shape and insertion angle of the FDP enthesis. Then, silicone culture moulds were created, enabling the production of bespoke anatomical culture zones for an in vitro FDP enthesis model. The validity of the model has been confirmed using brushite cement scaffolds seeded with osteoblasts (bone) and fibrin hydrogel scaffolds seeded with fibroblasts (tendon) in individual studies with cells from either human or rat origin. This novel approach allows a bespoke anatomical design for enthesis repair and should be applied to future studies in this area.

Repair of lateral temporo-sphenoidal encephalocoele via an endoscopic transorbital approach: ex vivo 3D printed simulation followed by in vivo deployment.

BACKGROUND: A temporo-sphenoidal encephalocoele occurs when temporal lobe herniates through a defect in the greater wing of the sphenoid bone into the sphenoid air sinus. The natural history is not well-understood, though presentation in adulthood with CSF rhinorrhoea and/or meningitis is typical. Lateral pneumatisation of the sphenoid sinus and elevated BMI may be contributory. AIMS: We explored the feasibility of a transorbital approach (TOA) for repair, using a combination of 3D modelling and simulation. We then successfully deployed this technique in vivo. METHODS: CT imaging for three patients who had previously undergone transcranial repair of lateral temporo-sphenoidal encephalocoele was used to generate data allowing 3D printed models of the skull base to be produced. The transorbital approach was simulated by performing a lateral orbitotomy followed by drilling of the sphenoid wing to expose the antero-basal middle fossa. 3D object scanning was used to create virtual models of the skull base post-surgery, from which surgical access was quantified in two ways: the area (mm2) of the middle fossa exposed by the TOA and the vertical attack angle. RESULTS: The mean surface area of the cranial access window achieved by simulated TOA was 325mm2. The mean vertical attack angle was 25°. One patient was subsequently treated successfully via TOA with no recurrence of their CSF leak, no orbital morbidity, excellent cosmesis, but resolving V2 numbness (follow-up 7 months). CONCLUSIONS: We have shown that the transorbital approach provides adequate surgical access. In our single case, surgical repair of a lateral temporo-sphenoidal encephalocoele via TOA was feasible, safe, and effective. This approach may offer some advantages compared with transcranial or endonasal approaches.

Engineering three-dimensional bone macro-tissues by guided fusion of cell spheroids.

Introduction: Bioassembly techniques for the application of scaffold-free tissue engineering approaches have evolved in recent years toward producing larger tissue equivalents that structurally and functionally mimic native tissues. This study aims to upscale a 3-dimensional bone in-vitro model through bioassembly of differentiated rat osteoblast (dROb) spheroids with the potential to develop and mature into a bone macrotissue. Methods: dROb spheroids in control and mineralization media at different seeding densities (1 × 104, 5 × 104, and 1 × 105 cells) were assessed for cell proliferation and viability by trypan blue staining, for necrotic core by hematoxylin and eosin staining, and for extracellular calcium by Alizarin red and Von Kossa staining. Then, a novel approach was developed to bioassemble dROb spheroids in pillar array supports using a customized bioassembly system. Pillar array supports were custom-designed and printed using Formlabs Clear Resin® by Formlabs Form2 printer. These supports were used as temporary frameworks for spheroid bioassembly until fusion occurred. Supports were then removed to allow scaffold-free growth and maturation of fused spheroids. Morphological and molecular analyses were performed to understand their structural and functional aspects. Results: Spheroids of all seeding densities proliferated till day 14, and mineralization began with the cessation of proliferation. Necrotic core size increased over time with increased spheroid size. After the bioassembly of spheroids, the morphological assessment revealed the fusion of spheroids over time into a single macrotissue of more than 2.5 mm in size with mineral formation. Molecular assessment at different time points revealed osteogenic maturation based on the presence of osteocalcin, downregulation of Runx2 (p < 0.001), and upregulated alkaline phosphatase (p < 0.01). Discussion: With the novel bioassembly approach used here, 3D bone macrotissues were successfully fabricated which mimicked physiological osteogenesis both morphologically and molecularly. This biofabrication approach has potential applications in bone tissue engineering, contributing to research related to osteoporosis and other recurrent bone ailments.

Anatomy and histomorphology of the flexor digitorum profundus enthesis: functional implications for tissue engineering and surgery.

BACKGROUND: The enthesis possesses morphological adaptations across the soft-hard tissue junction which are not fully restored during surgical avulsion repairs. This loss of anatomical structure, highly related to function, contributes to poor clinical outcomes. Investigating the native macro- and micro-structure of a specific enthesis can provide functional and biomechanical insights to develop specialised, novel tissue-engineered therapeutic options and potentially improve current surgical treatments for avulsion injuries. METHODS: This study examines the anatomy and histomorphology of the flexor digitorum profundus (FDP) enthesis in 96 fresh-frozen human cadaveric fingers, quantitatively and qualitatively analyzing the shape, size, angle of tendon fibres and histological architecture, and explores differences in sex, finger and distance along the enthesis using linear mixed effects models. RESULTS: Macroscopically, results showed a consistent trapezoidal insertion shape of 29.29 ± 2.35 mm2 mean surface area, but with significant morphometric size differences influenced primarily by the smaller dimensions of the little finger. Microscopically, a fibrocartilaginous enthesis was apparent with a 30.05 ± 0.72o mean angle of inserting tendon fibres, although regional variation in fibrocartilage and the angle change of tendon fibres before insertion existed. CONCLUSIONS: The implication of these findings on native and specific FDP enthesis function is discussed whilst providing recommendations for optimal FDP enthesis recreation for interfacial tissue engineers and hand surgeons. The study emphasizes the importance of region-specific knowledge whilst also describing methods applicable to assessing any soft tissue insertion.

Histomorphology of the Subregions of the Scapholunate Interosseous Ligament and Its Enthesis.

Background The scapholunate interosseous ligament (SLIL) has three subregions: dorsal, proximal, and volar. The SLIL enthesis has not previously been studied despite its important mechanical function in wrist joint biomechanics. Questions/Purposes This study aims to compare the histomorphological differences between the SLIL subregions, including at their entheses. Three questions are explored: Do the gross dimensions differ between SLIL subregions? Does the enthesis qualitatively, and its calcified fibrocartilage (CF) quantitatively, differ between (a) SLIL subregions and (b) scaphoid and lunate attachments? Methods Twelve fresh-frozen human cadaveric wrists were dissected and the gross dimensions of the SLIL subregions measured. Subregions were histologically processed for morphological and compositional analyses, including quantification of enthesis CF area. Results The dorsal subregion was the thickest. The dorsal and volar subregions had fibrocartilaginous entheses, while the proximal subregion was attached to articular cartilage. The dorsal subregion had significantly more CF than the volar subregion. There was no significant difference in the enthesis CF between scaphoid and lunate attachments in the three subregions. Conclusions There are significant morphological differences between the SLIL subregions. The dorsal subregion has the largest amount of CF, which is consistent with the greater biomechanical force subjected to this subregion. The similar histomorphology of the ligament at the scaphoid and lunate entheses suggests that similar biomechanical forces are applied to both attachments. Clinical Relevance The histomorphological results confirm that the dorsal subregion is the strongest of the three subregions. The results from the entheseal region may have important implications in the study of graft incorporation during SLIL reconstruction.

Investigating materials and orientation parameters for the creation of a 3D musculoskeletal interface co-culture model.

Musculoskeletal tissue interfaces are a common site of injury in the young, active populations. In particular, the interface between the musculoskeletal tissues of tendon and bone is often injured and to date, no single treatment has been able to restore the form and function of damaged tissue at the bone-tendon interface. Tissue engineering and regeneration hold great promise for the manufacture of bespoke in vitro models or implants to be used to advance repair and so this study investigated the material, orientation and culture choices for manufacturing a reproducible 3D model of a musculoskeletal interface between tendon and bone cell populations. Such models are essential for future studies focussing on the regeneration of musculoskeletal interfaces in vitro. Cell-encapsulated fibrin hydrogels, arranged in a horizontal orientation though a simple moulding procedure, were shown to best support cellular growth and migration of cells to form an in vitro tendon-bone interface. This study highlights the importance of acknowledging the material and technical challenges in establishing co-cultures and suggests a reproducible methodology to form 3D co-cultures between tendon and bone, or other musculoskeletal cell types, in vitro.

Non-Invasive Cell Tracking with Brighter and Red-Transferred Luciferase for Potential Application in Stem Cell Therapy.

This study investigated the safety of a novel cell-labeling technology with mKATE and Renilla reniformis luciferase (mKATE-renLUC) and assessed the efficacy on tracking implanted human placental stromal cells (PSC) in an erectile dysfunction (ED) animal model. Human PSC were labeled with mKATE-renLUC using a lentivirus. Cell viability, apoptosis, proliferation, migration, surface marker expression and differentiation potential of the labeled PSC were evaluated and compared with non-labeled PSC. The paracrine profile of labeled cells was examined using an angiogenesis protein array. The brightness and duration of labeled cells with different densities were evaluated. An ED rat model was established and labeled PSC were injected into cavernosal tissue of the penis. The migration and distribution of transplanted PSC were monitored using an IVIS imaging system in real time. Implanted PSC were identified in isolated tissues via detection of mKATE fluorescence. The cell viability, morphology, proliferation, migration, surface marker expression and differentiation potential of mKATE-renLUC-labeled PSC were similar to those of non-labeled cells in vitro (no statistical difference p>0.05). Similar expressions of trophic factors were found between labeled and non-labeled PSC. The migration and distribution of PSC expressing renLUC were tracked in vivo using IVIS imaging system. mKATE-positive PSC were detected in penile, kidney, prostate and hepatic tissues using histological methods. This labeling technology provides a safe and effective cell-tracking approach with a brighter fluorophore and codon-optimized luciferase.

Nanoscale crystallinity modulates cell proliferation on plasma sprayed surfaces.

Calcium phosphate coatings have been applied to the surface of metallic prostheses to mediate hard and soft tissue attachment for more than 40years. Most coatings are formed of high purity hydroxyapatite, and coating methods are often designed to produce highly crystalline surfaces. It is likely however, that coatings of lower crystallinity can facilitate more rapid tissue attachment since the surface will exhibit a higher specific surface area and will be considerably more reactive than a comparable highly crystalline surface. Here we test this hypothesis by growing a population of MC3T3 osteoblast-like cells on the surface of two types of hip prosthesis with similar composition, but with differing crystallinity. The surfaces with lower crystallinity facilitated more rapid cell attachment and increased proliferation rate, despite having a less heterogeneous surface topography. This work highlights that the influence of the crystallinity of HA at the nano-scale is dominant over macro-scale topography for cell adhesion and growth. Furthermore, crystallinity could be easily adjusted by without compromising coating purity. These findings could facilitate designing novel coated calcium phosphate surfaces that more rapidly bond tissue following implantation.

Exploiting cell-mediated contraction and adhesion to structure tissues in vitro.

Progress in tissue engineering is now impacting beyond the field of regenerative medicine. Engineered tissues are now used as tools to evaluate the toxicity of compounds or even to enable the modelling of disease. While many of the materials that are used to facilitate tissue growth are designed to enable cell attachment, many researchers consider that the contraction and modification of these matrices by attached cells is not desirable and take measures to prevent this from occurring. Where substantial alignment of the molecules within tissues, however, is a feature of structure the process of contraction can be exploited to guide new matrix deposition. In this paper, we will demonstrate how we have used the cell contraction process to generate tissues with high levels of organization. The tissues that have been grown in the laboratory have been characterized using a suite of analytical techniques to demonstrate significant levels of matrix organization and mechanical behaviour analogous to natural tissues. This paper provides an overview of research that has been undertaken to determine how tissues have been grown in vitro with structuring from the molecular, right through to the macroscopic level.

Synthesis and in vitro degradation of a novel magnesium oxychloride cement.

Magnesium oxychloride cement (MOC) has been used in civil engineering as it exhibits a relatively high early strength and a low coefficient of thermal expansion. Its poor water resistance, although, has prevented its widespread use. Steady degradation when immersed in an aqueous environment, however, could be a beneficial property for a resorbable bone replacement. In this study, we have evaluated how different concentrations of phosphoric acid may be used to enhance water resistance providing some control over the rate of degradation. The phase compositions, microstructures, mechanical properties, and the degradation of MOC have been evaluated. As a preliminary assessment of biological suitability, the response of a population of bone marrow stromal cells to the surface was evaluated. X-ray diffraction data demonstrate that 5Mg(OH)2 ·MgCl2·8H2O (phase 5) was formed in all MOC samples. The MOC modified with H3PO4 exhibits good water resistance and can sustain strength in aqueous medium and by adjusting H3 PO4 concentration; degradation speed may be controlled. Cells cultured on the surface of the MOC attached and retained viability over the duration of the study.

Combined decellularisation and dehydration improves the mechanical properties of tissue-engineered sinews.

Novel sources of replacement sinews are needed to repair damaged tissue after injury. The current methods of repair ultilise autografts, allografts or xenografts, although each method has distinct disadvantages that limit their success. Decellularisation of harvested tissues has been previously investigated for sinew repair with the long-term aim of repopulating the structure with autologous cells. Although this procedure shows promise, the demand for donor scaffolds will always outweigh supply. Here, we report the fabrication of fibrin-based tissue-engineered sinews, which can be decellularised, dehydrated and stored. The sinews may then be rehydrated and repopulated with an autologous cell population. In addition to enabling production of patient-specific implants, interestingly, the process of combined decellularisation, dehydration and rehydration enhanced the mechanical properties of the sinew. The treated sinews exhibited a 2.6-fold increase in maximum load and 8-fold increase in ultimate tensile strength when compared with the control group (p < 0.05 in both cases).

Imaging the hard/soft tissue interface.

Interfaces between different tissues play an essential role in the biomechanics of native tissues and their recapitulation is now recognized as critical to function. As a consequence, imaging the hard/soft tissue interface has become increasingly important in the area of tissue engineering. Particularly as several biotechnology based products have made it onto the market or are close to human trials and an understanding of their function and development is essential. A range of imaging modalities have been developed that allow a wealth of information on the morphological and physical properties of samples to be obtained non-destructively in vivo or via destructive means. This review summarizes the use of a selection of imaging modalities on interfaces to date considering the strengths and weaknesses of each. We will also consider techniques which have not yet been utilized to their full potential or are likely to play a role in future work in the area.

A novel method for monitoring mineralisation in hydrogels at the engineered hard-soft tissue interface.

The capacity to study the deposition of mineral within a hydrogel structure is of significant interest to a range of therapies that seek to replace the hard tissues and the hard-soft tissue interface. Here, a method is presented that utilises Confocal Raman microscopy as a tool for monitoring mineralisation within hydrogels. Synthetic hard-soft material interfaces were fabricated by apposing brushite (a sparingly soluble calcium phosphate) and biopolymer gel monoliths. The resulting structures were matured over a period of 28 days in phosphate buffered saline. Confocal Raman microscopy of the interfacial region showed the appearance of calcium phosphate salt deposits away from the original interface within the biopolymeric structures. Furthermore, the appearance of octacalcium phosphate and carbonated hydroxyapatite was observed in the region of the brushite cement opposing the biopolymer gel. This study describes not only a method for analysing these composite structures, but also suggests a method for recapitulating the graduated tissue structures that are often found in vivo.

Monitoring sinew contraction during formation of tissue-engineered fibrin-based ligament constructs.

The ability to study the gross morphological changes occurring during tissue formation is vital to producing tissue-engineered structures of clinically relevant dimensions in vitro. Here, we have used nondestructive methods of digital imaging and optical coherence tomography to monitor the early-stage formation and subsequent maturation of fibrin-based tissue-engineered ligament constructs. In addition, the effect of supplementation with essential promoters of collagen synthesis, ascorbic acid (AA) and proline (P), has been assessed. Contraction of the cell-seeded fibrin gel occurs unevenly within the first 5 days of culture around two fixed anchor points before forming a longitudinal ligament-like construct. AA+P supplementation accelerates gel contraction in the maturation phase of development, producing ligament-like constructs with a higher collagen content and distinct morphology to that of unsupplemented constructs. These studies highlight the importance of being able to control the methods of tissue formation and maturation in vitro to enable the production of tissue-engineered constructs with suitable replacement tissue characteristics for repair of clinical soft-tissue injuries.

Optimizing an intermittent stretch paradigm using ERK1/2 phosphorylation results in increased collagen synthesis in engineered ligaments.

Dynamic mechanical input is believed to play a critical role in the development of functional musculoskeletal tissues. To study this phenomenon, cyclic uniaxial mechanical stretch was applied to engineered ligaments using a custom-built bioreactor and the effects of different stretch frequency, amplitude, and duration were determined. Stretch acutely increased the phosphorylation of p38 (3.5±0.74-fold), S6K1 (3.9±0.19-fold), and ERK1/2 (2.45±0.32-fold). The phosphorylation of ERK1/2 was dependent on time, rather than on frequency or amplitude, within these constructs. ERK1/2 phosphorylation was similar following stretch at frequencies from 0.1 to 1 Hz and amplitudes from 2.5% to 15%, whereas phosphorylation reached maximal levels at 10 min of stretch and returned toward basal within 60 min of stretch. Following a single 10-min bout of cyclic stretch, the cells remained refractory to a second stretch for up to 6 h. Using the phosphorylation of ERK1/2 as a guide, the optimum stretch paradigm was hypothesized to be 10 min of stretch at 2.5% of resting length repeated every 6 h. Consistent with this hypothesis, 7 days of stretch using this optimized intermittent stretch program increased the collagen content of the grafts more than a continuous stretch program (CTL=3.1%±0.44%; CONT=4.8%±0.30%; and INT=5.9%±0.56%). These results suggest that short infrequent bouts of loading are optimal for improving engineered tendon and ligament physiology.

Degradation of polysaccharide hydrogels seeded with bone marrow stromal cells.

In order to produce hydrogel cell culture substrates that are fit for the purpose, it is important that the mechanical properties are well understood not only at the point of cell seeding but throughout the culture period. In this study the change in the mechanical properties of three biopolymer hydrogels alginate, low methoxy pectin and gellan gum have been assessed in cell culture conditions. Samples of the gels were prepared encapsulating rat bone marrow stromal cells which were then cultured in osteogenic media. Acellular samples were also prepared and incubated in standard cell culture media. The rheological properties of the gels were measured over a culture period of 28 days and it was found that the gels degraded at very different rates. The degradation occurred most rapidly in the order alginate > Low methoxy pectin > gellan gum. The ability of each hydrogel to support differentiation of bone marrow stromal cells to osteoblasts was also verified by evidence of mineral deposits in all three of the materials. These results highlight that the mechanical properties of biopolymer hydrogels can vary greatly during in vitro culture, and provide the potential of selecting hydrogel cell culture substrates with mechanical properties that are tissue specific.

Engineering an in vitro model of a functional ligament from bone to bone.

For musculoskeletal tissues that transmit loads during movement, the interfaces between tissues are essential to minimizing injury. Therefore, the reproduction of functional interfaces within engineered musculoskeletal tissues is critical to the successful transfer of the technology to the clinic. The goal of this work was to rapidly engineer ligament equivalents in vitro that contained both the soft tissue sinew and a hard tissue bone mimetic. This goal was achieved using cast brushite (CaHPO(4)·2H(2)O) anchors to mimic bone and a fibrin gel embedded with fibroblasts to create the sinew. The constructs formed within 7 days. Fourteen days after seeding, the interface between the brushite and sinew could withstand a stress of 9.51 ± 1.7 kPa before failure and the sinew reached a Young's modulus value of 0.16 ± 0.03 MPa. Treatment with ascorbic acid and proline increased the collagen content of the sinew (from 1.34% ± 0.2% to 8.34% ± 0.37%), strength of the interface (29.24 ± 6 kPa), and modulus of the sinew (2.69 ± 0.25 MPa). Adding transforming growth factor-ß resulted in a further increase in collagen (11.25% ± 0.39%), interface strength (42 ± 8 kPa), and sinew modulus (5.46 ± 0.68 MPa). Both scanning electron and Raman microscopy suggested that the interface between the brushite and sinew mimics the in vivo tidemark at the enthesis. This work describes a major step toward the development of tissue-engineered ligaments for the repair of ligament ruptures in humans.

Factors affecting the longevity and strength in an in vitro model of the bone-ligament interface.

The interfaces between musculoskeletal tissues with contrasting moduli are morphologically and biochemically adapted to allow the transmission of force with minimal injury. Current methods of tissue engineering ligaments and tendons do not include the interface and this may limit the future clinical success of engineered musculoskeletal tissues. This study aimed to use solid brushite cement anchors to engineer intact ligaments from bone-to-bone, creating a functional musculoskeletal interface in vitro. We show here that modifying anchor shape and cement composition can alter both the longevity and the strength of an in vitro model of the bone-ligament interface: with values reaching 23 days and 21.6 kPa, respectively. These results validate the use of brushite bone cement to engineer the bone-ligament interface in vitro and raise the potential for future use in ligament replacement surgery.