Microfracture Lateral to the Greater Tuberosity of the Humerus Enhances Tendon-to-Bone Healing in a Rat Rotator Cuff Model.

BACKGROUND: Microfracture at the rotator cuff insertion is an established surgical marrow-stimulation technique for enhancing rotator cuff healing. However, the effect of lateralized or medialized microfracture on the insertion is unknown. PURPOSE: To compare the biomechanical and histologic effects of microfracture at 3 different regions for rotator cuff repair in a rat model. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 72 Sprague-Dawley rats with bilateral supraspinatus tendon insertion detachment were allocated into 4 groups with 4 different interventions: no microfracture at the humeral head as a control group (Con), traditional microfracture at the footprint area (MFA), and medialized microfracture to the footprint area (MMFA) on the articular surface of the humerus or lateralized microfracture to the footprint area at the greater tuberosity (LMFA). All underwent immediate repair. Tendon-to-bone healing was assessed by biomechanical and histologic tests 4 and 8 weeks postoperation. RESULTS: At 4 weeks, the LMFA group showed a significantly superior failure load compared with the other groups (all P < .05). The LMFA and MFA groups showed significantly superior stiffness compared with the Con and MMFA groups (all P < .01). At 8 weeks, superior failure load and stiffness were observed in the LMFA group compared with the control group (all P < .05). Histologic examination revealed that the LMFA group had superior collagen composition and tendon-to-bone maturation at the interface at 4 and 8 weeks compared with the Con group (all P < .05). CONCLUSION: Lateralized microfracture at the greater tuberosity improved the histologic quality of repair tissue and biomechanical strength at the tendon-to-bone insertion after rotator cuff repair in a rat model. CLINICAL RELEVANCE: Microfracture lateral to the footprint area might be a better way to enhance rotator cuff healing clinically.

Anatomical and Interpositional Bursa Preservation Showed Similar Improved Tendon to Bone Healing Compared With the Bursa Removal in a Rat Rotator Cuff Tear Model.

PURPOSE: To compare the effects of anatomical preservation (AP) and interpositional preservation (IP) of subacromial bursa tissue on tendon-to-bone healing in a rat model of rotator cuff tear. METHODS: In this study, 48 male Sprague-Dawley rats (average weight 283 g) underwent bilateral supraspinatus tendons severed by sharp incision and repaired immediately. The subacromial bursa tissues were completely removed in 16 rats, who served as the control (CON) group. The other 32 rats were randomly divided into 2 groups AP and IP between tendon and bone. Eight rats of each group were sacrificed for bilateral shoulders at 3 and 9 weeks after the operation, including 5 rats for biomechanical tests and 3 for histologic analysis. RESULTS: No significant differences in terms of biomechanical properties were observed among the groups 3 weeks after surgery. At 9 weeks, the maximum load and stiffness of the AP (32.95 ± 6.33 N, P = .029; 12.49 ± 3.17 N/mm, P < .001; respectively) and IP (33.58 ± 8.47 N, P = .015; 11.63 ± 2.84 N/mm, P = .010, respectively) groups were significantly superior to that of the CON group (26.59 ± 4.47 N; 8.42 ± 2.33 N/mm, respectively). More organized collagen and more mature tendon insertion were observed in AP and IP groups at the interface at 9 weeks, which means better tendon-to-bone healing compared with the CON group. CONCLUSIONS: The subacromial bursa plays a positive role in tendon-bone healing. Either anatomical preservation or interpositional preservation between tendon and bone can similarly facilitate the process of healing. CLINICAL RELEVANCE: Considering the additional surgical time and surgical manipulation, preserving the subacromial bursa at the anatomical position seems to be a better way to promote rotator cuff healing.

Reconstruction of paralyzed arm function in patients with hemiplegia through contralateral seventh cervical nerve cross transfer: a multicenter study and real-world practice guidance.

BACKGROUND: A previous randomized controlled trial showed contralateral seventh cervical nerve (CC7) cross transfer to be safe and effective in restoring the arm function of spastic arm paralysis patients in a specified population. Guidance on indications, safety and expected long-term improvements of the surgery are needed for clinical practice. METHODS: This is a retrospective, multicenter, propensity score-matched cohort study. All patients registered between 2013 and 2019 with unilateral spastic arm paralysis over 1 year who were registered at one of five centers in China and South Korea were included. Patients received CC7 cross transfer or rehabilitation treatment in each center. Primary outcome was the change in the upper-extremity Fugl-Meyer (UEFM) score from baseline to 2-year follow-up; larger increase indicated better functional improvements. FINDINGS: The analysis included 425 eligible patients. After propensity score matching, 336 patients who were 1:1 matched into surgery and rehabilitation groups. Compared to previous trial, patient population was expanded on age (< 12 and > 45 years old), duration of disease (< 5 years) and severity of paralysis (severe disabled patients with UEFM < 20 points). In matched patients, the overall increases of UEFM score from preoperative evaluation to 2-year follow-up were 15.14 in the surgery group and 2.35 in the rehabilitation group (difference, 12.79; 95% CI: 12.02-13.56, p < 0.001). This increase was 16.58 at 3-year and 18.42 at 5-year follow-up compared with the surgery group baseline. Subgroup analysis revealed substantial increase on UEFM score in each subgroup of age, duration of disease, severity of paralysis and cause of injury. No severe complication or disabling sequela were reported in the surgery group. INTERPRETATION: This study showed that CC7 cross transfer can provide effective, safe and stable functional improvements in long-term follow-up, and provided evidences for expanding the indications of the surgery to a wider population of patients with hemiplegia.

Differential Gene Expression in Primary Cultured Sensory and Motor Nerve Fibroblasts.

Fibroblasts (Fbs) effectively promote Schwann cells (SCs) migration, proliferation, and neurite regeneration. Whether Fbs express different motor and sensory phenotypes that regulate the cell behavior and peripheral nerve function has not been elucidated. The present study utilized the whole rat genome microarray analysis and identified a total of 121 differentially expressed genes between the primary cultured motor and sensory Fbs. The genes with high expression in sensory Fbs were related to proliferation, migration, chemotaxis, motility activation, protein maturation, defense response, immune system, taxis, and regionalization, while those with high expression in motor Fbs were related to neuron differentiation, segmentation, and pattern specification. Thus, the significant difference in the expression of some key genes was found to be associated with cell migration and proliferation, which was further validated by quantitative real-time PCR (qPCR). The cell proliferation or migration analysis revealed a higher rate of cell migration and proliferation of sensory Fbs than motor Fbs. Moreover, the downregulated expression of chemokine (C-X-C motif) ligand 10 (CXCL10) and chemokine (C-X-C motif) ligand 3 (CXCL3) suppressed the proliferation rate of sensory Fbs, while it enhanced that of the motor Fbs. However, the migration rate of both Fbs was suppressed by the downregulated expression of CXCL10 or CXCL3. Furthermore, a higher proportion of motor or sensory SCs migrated toward their respective (motor or sensory) Fbs; however, few motor or sensory SCs co-cultured with the other type of Fbs (sensory or motor, respectively), migrated toward the Fbs. The current findings indicated that Fbs expressed the distinct motor and sensory phenotypes involved in different patterns of gene expression, biological processes, and effects on SCs. Thus, this study would provide insights into the biological differences between motor and sensory Fbs, including the role in peripheral nerve regeneration.

Derivation of Schwann cell precursors from neural crest cells resident in bone marrow for cell therapy to improve peripheral nerve regeneration.

We have previously successfully enriched post-migratory neural crest cells (NCCs) from postnatal rat bone marrow (BM). These BM-NCCs possess glial and neuronal differentiating potential. Based on the neural crest origin of Schwann cells (SCs), in this study, we aimed at using a straightforward protocol to derive Schwann cell precursors (SCPs) from BM-NCCs. Several clonal subpopulations were isolated from BM-NCCs, displaying long-term proliferative capacity and maintaining the NCC identity. The BM-NCC clones could be induced to differentiate into SCs. In particular, clone N1 gave rise to a large and pure population of SCs. Clone N1-derived SCs demonstrated the myelinating capacity in their co-culture with primary dorsal root ganglion (DRG) neurons. The decreased expression of NCC-markers and increased expression of SC-markers were related to the differentiation state of clone N1-derived SCs. To investigate the repair-promoting effects of clone N1 on injured peripheral neurons in vitro and in vivo, on one hand, the oxygen glucose deprivation-injured DRG neurons were treated with clone N1-conditioned medium, improving the cell survival and axon growth of neurons; on the other hand, clone N1 or clone N1-derived SCs were respectively implanted to the crush sciatic nerve of rats, and clone N1 yielded the better outcome of nerve regeneration and function restoration than clone N1-derived SCs. Taken together, all the results collectively showed that clone N1 could be identified as SCPs, which might hold promise for cell therapy to improve peripheral nerve regeneration.

Expression changes of nerve cell adhesion molecules L1 and semaphorin 3A after peripheral nerve injury.

The expression of nerve cell adhesion molecule L1 in the neuronal growth cone of the central nervous system is strongly associated with the direction of growth of the axon, but its role in the regeneration of the peripheral nerve is still unknown. This study explored the problem in a femoral nerve section model in rats. L1 and semaphorin 3A mRNA and protein expressions were measured over the 4-week recovery period. Quantitative polymerase chain reaction showed that nerve cell adhesion molecule L1 expression was higher in the sensory nerves than in motor nerves at 2 weeks after injury, but vice versa for the expression of semaphorin 3A. Western blot assay results demonstrated that nerve cell adhesion molecule L1 expression was higher in motor nerves than in the sensory nerves at the proximal end after injury, but its expression was greater in the sensory nerves at 2 weeks. Semaphorin 3A expression was higher in the motor nerves than in the sensory nerves at 3 days and 1 week after injury. Nerve cell adhesion molecule L1 and semaphorin 3A expressions at the distal end were higher in the motor nerves than in the sensory nerves at 3 days, 1 and 2 weeks. Immunohistochemical staining results showed that nerve cell adhesion molecule L1 expression at the proximal end was greater in the sensory nerves than in the motor nerves; semaphorin 3A expression was higher in the motor nerves than in the sensory nerves at 2 weeks after injury. Taken together, these results indicated that nerve cell adhesion molecules L1 and semaphorin 3A exhibited different expression patterns at the proximal and distal ends of sensory and motor nerves, and play a coordinating role in neural chemotaxis regeneration.

MicroRNA-351 inhibits denervation-induced muscle atrophy by targeting TRAF6.

MicroRNAs (miRs) have been observed to be involved in the modulation of various physiopathological processes. However, the impacts of miRNAs on muscle atrophy have not been fully investigated. In the present study, the results demonstrated that miR-351 was differentially expressed in the tibialis anterior (TA) muscle at various times following sciatic nerve transection, and the time-dependent expression profile of miR-351 was inversely correlated with that of tumor necrosis factor receptor-associated factor 6 (TRAF6) at the mRNA and protein levels. The dual luciferase reporter assay indicated that miR-351 was able to significantly downregulate the expression levels of TRAF6 by directly targeting the 3'-untranslated region of TRAF6. Overexpression of miR-351 inhibited a significant decrease in the wet weight ratio or cross-sectional area of the TA muscle following sciatic nerve transection. Western blot analysis indicated that the protein expression levels of TRAF6, muscle ring-finger protein 1 (MuRF1) and muscle atrophy F-box (MAFBx) in denervated TA muscles were suppressed by overexpression of miR-351. These results demonstrate that miR-351 inhibits denervation-induced atrophy of TA muscles following sciatic nerve transection at least partially through negative regulation of TRAF6 as well as MuRF1 and MAFBx, the two downstream signaling molecules of TRAF6.

TRAF6 inhibition rescues dexamethasone-induced muscle atrophy.

Tumor necrosis factor receptor-associated factor 6 (TRAF6), a unique E3 ubiquitin ligase and adaptor protein, is involved in activation of various signaling cascades. Recent studies identify TRAF6 as one of the novel regulators of skeletal muscle atrophy. The role of TRAF6 in glucocorticoid-induced muscle atrophy, however, remains to be elucidated. In this study, we show that TRAF6 and its downstream signaling molecules, muscle atrophy F-box (MAFBx) and muscle ring finger 1 (MuRF1), were all upregulated in dexamethasone-induced atrophy of mouse C2C12 myotubes or mouse tibialis anterior (TA) muscle. To further investigate the role of TRAF6 in dexamethasone-induced muscle atrophy, TRAF6-siRNA was used to transfect cultured C2C12 myotubes or was injected into the TA muscle of mice respectively, and we note that TRAF6 knockdown attenuated dexamethasone-induced muscle atrophy in vitro and in vivo, and concomitantly decreased the expression of MuRF1 and MAFBx. Our findings suggest that a decreased expression of TRAF6 could rescue dexamethasone-induced skeletal muscle atrophy through, at least in part, regulation of the expression of MAFBx and MuRF1.

Long-term outcome of the repair of 50 mm long median nerve defects in rhesus monkeys with marrow mesenchymal stem cells-containing, chitosan-based tissue engineered nerve grafts.

Despite great progress in the fields of tissue engineering and stem cell therapy, the translational and preclinical studies are required to accelerate the clinical application of tissue engineered nerve grafts, as an alternative to autologous nerve grafts, for peripheral nerve repair. Rhesus monkeys (non-human primates) are more clinically relevant and more suitable for scaling up to humans as compared to other mammalians. Based on this premise, and considering a striking similarity in the anatomy and function between human and monkey hands, here we used chitosan/PLGA-based, autologous marrow mesenchymal stem cells (MSCs)-containing tissue engineered nerve grafts (TENGs) for bridging a 50-mm long median nerve defect in rhesus monkeys. At 12 months after grafting, locomotive activity observation, electrophysiological assessments, and FG retrograde tracing tests indicated that the recovery of nerve function by TENGs was more efficient than that by chitosan/PLGA scaffolds alone; histological and morphometric analyses of regenerated nerves further confirmed that the morphological reconstruction by TENGs was close to that by autografts and superior to that by chitosan/PLGA scaffolds alone. In addition, blood test and histopathological examination demonstrated that TENGs featured by addition of autologous MSCs could be safely used in the primate body. These findings suggest the efficacy of our developed TENGs for peripheral nerve regeneration and their promising perspective for clinical applications.

Chitooligosaccharides promote peripheral nerve regeneration in a rabbit common peroneal nerve crush injury model.

Chitooligosaccharides (COSs) are the biodegradation products of chitosan that have been demonstrated with neuroaffinity and/or neuroprotective actions. In this study, we investigated the possible benefits of treatment with COSs on nerve regeneration after crush injuries to peripheral nerves. The rabbits with the crushed common peroneal nerve were treated by daily intravenous injection of 1.5 or 3 mg/kg body weight of COSs or identical volume of saline (as the control) for a 6-week period. At the end of COSs treatment, electrophysiological assessments, Meyer's trichrome and Masson trichrome staining, and transmission electron microscopy were used to evaluate the regeneration of injured common peroneal nerve and atrophy of the tibialis posterior muscle. The results showed that the compound muscle action potentials, the number of regenerated myelinated nerve fibers, the thickness of regenerated myelin sheaths, and the cross-sectional area of tibialis posterior muscle fibers were significantly improved in the nerves that received COSs treatment and the results with COSs treatment displayed a dose-dependent pattern. This study demonstrated that COSs accelerated peripheral nerve regeneration after crush injury to rabbit common peroneal nerves. The COSs could probably become a potential neuroprotective agent for improvement of peripheral nerve regeneration after the injury and deserve for further studies.