Abstract
Tendon and ligament have specialized dynamic microenvironment characterized by a complex hierarchical extracellular matrix essential for tissue functionality, and responsible to be an instructive niche for resident cells. Among musculoskeletal diseases, tendon/ligament injuries often result in pain, substantial tissue morbidity, and disability, affecting athletes, active working people and elder population. This represents not only a major healthcare problem but it implies considerable social and economic hurdles. Current treatments are based on the replacement and/or augmentation of the damaged tissue with severe associated limitations. Thus, it is evident the clinical challenge and emergent need to recreate native tissue features and regenerate damaged tissues. In this context, the design and development of anisotropic bioengineered systems with potential to recapitulate the hierarchical architecture and organization of tendons and ligaments from nano to macro scale will be discussed in this chapter. Special attention will be given to the state-of-the-art fabrication techniques, namely spinning and electrochemical alignment techniques to address the demanding requirements for tendon substitutes, particularly concerning the importance of biomechanical and structural cues of these tissues. Moreover, the poor innate regeneration ability related to the low cellularity and vascularization of tendons and ligaments also anticipates the importance of cell based strategies, particularly on the stem cells role for the success of tissue engineered therapies. In summary, this chapter provides a general overview on tendon and ligaments physiology and current conventional treatments for injuries caused by trauma and/or disease. Moreover, this chapter presents tissue engineering approaches as an alternative to overcome the limitations of current therapies, focusing on the discussion about scaffolds design for tissue substitutes to meet the regenerative medicine challenges towards the functional restoration of damaged or degenerated tendon and ligament tissues.
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References
Frank CB (2004) Ligament structure, physiology and function. J Musculoskelet Neuronal Interact 4(2):199–201
Weintraub W (2003) The nature of tendons and ligaments. In Tendon and ligament healing: a new approach to sports and overuse injury. P. Publications, pp 5–24
Thorpe CT et al (2015) Chapter 1—Tendon physiology and mechanical behavior: structure–function relationships. In: Gomes ME, Reis RL, Rodrigues MT (eds) Tendon regeneration. Academic Press, Boston, pp 3–39
Woo SL-Y et al (2007) Chapter 9—Functional tissue engineering of ligament and tendon injuries. In: Mao JJ et al (eds) Transitional approaches in tissue engineering and regenerative medicine. Artech House Publishers, Norwood
Hsu S-L, Liang R, Woo SL (2010) Functional tissue engineering of ligament healing. BMC Sports Science, Medicine and Rehabilitation, pp 2–12
Costa-Almeida R et al (2015) Tendon stem cell niche. In: Turksen K (ed) Tissue engineering and stem cell niche. Springer, Berlin, pp 221–244
Wang JHC (2006) Mechanobiology of tendon. J Biomech 39(9):1563–1582
Andrades JA et al (2011) Chapter 5—Skeletal regeneration by mesenchymal stem cells: what else? In: Eberli D (ed) Regenerative medicine and tissue engineering—cells and biomaterials. InTech, Morn Hill
Ghosh KM, Deehan DJ (2010) Soft tissue knee injuries. Surg Oxf Int Ed 28(10):494–501
Cowin SC, Doty SB (2007) The constituents of tendons and ligaments. In: Cowin SC, Doty SB (eds) Tissue mechanics. Springer, New York, p 562
Sharma P, Maffulli N (2006) Biology of tendon injury: healing, modeling and remodeling. J Musculoskelet Neuronal Interact 6(2):181–190
Riggin CN, Morris TR, Soslowsky LJ (2015) Chapter 5—Tendinopathy II: etiology, pathology, and healing of tendon injury and disease. In: Gomes ME, Reis RL, Rodrigues MT (eds) Tendon regeneration. Academic Press, Boston, pp 149–183
Ackermann PW (2015) Chapter 4—Tendinopathy I: understanding epidemiology, pathology, healing, and treatment. In: Gomes ME, Reis RL, Rodrigues MT (eds) Tendon regeneration. Academic Press, Boston, pp 113–147
Rodrigues MT, Reis RL, Gomes ME (2013) Engineering tendon and ligament tissues: present developments towards successful clinical products. J Tissue Eng Regen Med 7(9):673–686
Siegel L, Vandenakker-Albanese C, Siegel D (2012) Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Clin J Sport Med 22(4):349–355
Kiapour AM, Murray MM (2014) Basic science of anterior cruciate ligament injury and repair. Bone Joint Res 3(2):20–31
Mascarenhas R et al (2012) Bone-patellar tendon-bone autograft versus hamstring autograft anterior cruciate ligament reconstruction in the young athlete: a retrospective matched analysis with 2–10 year follow-up. Knee Surg Sports Traumatol Arthrosc 20:1520–1527
Øiestad BE, Holm I, Engebretsen L, Aune AK, Gunderson R, Risberg MA (2013) The prevalence of patellofemoral osteoarthritis 12 years after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 21(4):942–949
Liu Z-T et al (2010) Four-strand hamstring tendon autograft versus LARS artificial ligament for anterior cruciate ligament reconstruction. Int Orthop 34(1):45–49
Batty LM et al (2015) Synthetic devices for reconstructive surgery of the cruciate ligaments: a systematic review. Arthroscopy 31(5):957–968
Tiefenboeck TM et al (2015) Clinical and functional outcome after anterior cruciate ligament reconstruction using the LARS™ system at a minimum follow-up of 10 years. Knee 22(6):565–568
Chen J et al (2009) Scaffolds for tendon and ligament repair: review of the efficacy of commercial products. Expert Rev Med Devices 6(1):61–73
Yannas IV (2001) Tissue and organ regeneration in adults. Springer, New York
Czaplewski SK et al (2014) Tenogenic differentiation of human induced pluripotent stem cell-derived mesenchymal stem cells dictated by properties of braided submicron fibrous scaffolds. Biomaterials 35(25):6907–6917
Steinert AF et al (2011) Mesenchymal stem cell characteristics of human anterior cruciate ligament outgrowth cells. Tissue Eng Part A 17(9–10):1375–1388
Bi Y et al (2007) Identification of tendon stem/progenitor cells and the role of the extracellular matrix in their niche. Nat Med 13(10):1219–1227
Chen X et al (2009) Stepwise differentiation of human embryonic stem cells promotes tendon regeneration by secreting fetal tendon matrix and differentiation factors. Stem Cells 27(6):1276–1287
Xu W et al (2013) Human iPSC-derived neural crest stem cells promote tendon repair in a rat patellar tendon window defect model. Tissue Eng Part A 19(21–22):2439–2451
Otabe K et al (2015) The transcription factor Mohawk controls tenogenic differentiation of bone marrow mesenchymal stem cells in vitro and in vivo. J Orthop Res 33(1):1–8
Tan S-L et al (2015) Identification of pathways mediating growth differentiation factor5-induced tenogenic differentiation in human bone marrow stromal cells. PLoS ONE 10(11):e0140869
Urdzikova LM, Sedlacek R, Suchy T, Amemori T, Ruzicka J, Lesny P, Havlas V, Jendelova P (2014) Human multipotent mesenchymal stem cells improve healing after collagenase tendon injury in the rat. Biomed Eng Online 13(42). doi:10.1186/1475-925X-13-42, http://biomedical-engineering-online.biomedcentral.com/articles/10.1186/1475-925X-13-42
Gonçalves AI et al (2014) Understanding the role of growth factors in modulating stem cell tenogenesis. PLoS ONE 8(12):e83734
de Mattos Carvalho A et al (2011) Use of adipose tissue-derived mesenchymal stem cells for experimental tendinitis therapy in equines. J Equine Vet Sci 31(1):26–34
Molloy T, Wang Y, Murrell GAC (2003) The roles of growth factors in tendon and ligament healing. Sports Med 33(5):381–394
Temenoff JS, Mikos AG (2000) Review: tissue engineering for regeneration of articular cartilage. Biomaterials 21(5):431–440
Rizzello G et al (2012) Growth factors and stem cells for the management of anterior cruciate ligament tears. Open Orthop J 6:525–530
Klein MB et al (2002) Flexor tendon healing in vitro: effects of TGF-β on tendon cell collagen production. J Hand Surg 27(4):615–620
Chan BP et al (2000) Effects of basic fibroblast growth factor (bFGF) on early stages of tendon healing: a rat patellar tendon model. Acta Orthop Scand 71(5):513–518
Sahoo S, Toh SL, Goh JCH (2010) A bFGF-releasing silk/PLGA-based biohybrid scaffold for ligament/tendon tissue engineering using mesenchymal progenitor cells. Biomaterials 31(11):2990–2998
Murray MM et al (2007) Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold. J Orthop Res 25(8):1007–1017
Murray M et al (2006) Use of a collagen-platelet rich plasma scaffold to stimulate healing of a central defect in the canine ACL. J Orthop Res 24(4):820–830
Ricchetti ET et al (2012) Scaffold devices for rotator cuff repair. J Shoulder Elbow Surg 21(2):251–265
Dunn MG et al (1995) Development of fibroblast-seeded ligament analogs for ACL reconstruction. J Biomed Mater Res 29(11):1363–1371
Bellincampi LD et al (1998) Viability of fibroblast-seeded ligament analogs after autogenous implantation. J Orthop Res 16(4):414–420
Weadock K et al (1995) Physical crosslinking of collagen fibers: comparison of ultraviolet irradiation and dehydrothermal treatment. J Biomed Mater Res 29(11):1373–1379
Gurkan UA et al (2010) Comparison of morphology, orientation, and migration of tendon derived fibroblasts and bone marrow stromal cells on electrochemically aligned collagen constructs. J Biomed Mater Res, Part A 94A(4):1070–1079
Altman GH et al (2003) Silk-based biomaterials. Biomaterials 24(3):401–416
Vepari C, Kaplan DL (2007) Silk as a biomaterial. Prog Polym Sci 32(8–9):991–1007
Chen JL et al (2010) Efficacy of hESC-MSCs in knitted silk-collagen scaffold for tendon tissue engineering and their roles. Biomaterials 31(36):9438–9451
Chen X et al (2014) Scleraxis-overexpressed human embryonic stem cell-derived mesenchymal stem cells for tendon tissue engineering with knitted silk-collagen scaffold. Tissue Eng Part A 20(11–12):1583–1592
Chen J et al (2003) Human bone marrow stromal cell and ligament fibroblast responses on RGD-modified silk fibers. J Biomed Mater Res, Part A 67(2):559–570
Majima T et al (2007) Chitosan-based hyaluronan hybrid polymer fibre scaffold for ligament and tendon tissue engineering. Proc Inst Mech Eng Part H 221(5):537–546
Moffat KL et al (2009) Novel nanofiber-based scaffold for rotator cuff repair and augmentation. Tissue Eng Part A 15(1):115–126
Fan H et al (2009) Anterior cruciate ligament regeneration using mesenchymal stem cells and silk scaffold in large animal model. Biomaterials 30(28):4967–4977
Laitinen O et al (1992) Mechanical properties of biodegradable ligament augmentation device of poly(l-lactide) in vitro and in vivo. Biomaterials 13(14):1012–1016
Cooper JA et al (2007) Biomimetic tissue-engineered anterior cruciate ligament replacement. Proc Natl Acad Sci USA 104(9):3049–3054
Freeman JW, Woods MD, Laurencin CT (2007) Tissue engineering of the anterior cruciate ligament using a braid-twist scaffold design. J Biomech 40(9):2029–2036
Petrigliano FA et al (2007) The effects of local bFGF release and uniaxial strain on cellular adaptation and gene expression in a 3D environment: implications for ligament tissue engineering. Tissue Eng 13(11):2721–2731
Leong NL et al (2015) Evaluation of polycaprolactone Scaffold with basic fibroblast growth factor and fibroblasts in an athymic rat model for anterior cruciate ligament reconstruction. Tissue Eng Part A 21(11–12):1859–1868
Xu Y et al (2013) Fabrication of electrospun poly(l-lactide-co-ε-caprolactone)/collagen nanoyarn network as a novel, three-dimensional, macroporous, aligned scaffold for tendon tissue engineering. Tissue Eng Part C Methods 19(12):925–936
Xu Y et al (2014) The effect of mechanical stimulation on the maturation of TDSCs-poly(l-lactide-co-e-caprolactone)/collagen scaffold constructs for tendon tissue engineering. Biomaterials 35(9):2760–2772
Leung M et al (2013) Tenogenic differentiation of human bone marrow stem cells via a combinatory effect of aligned chitosan-poly-caprolactone nanofibers and TGF-[small beta]3. J Mater Chem B 1(47):6516–6524
Domingues RMA et al (2016) Enhancing the biomechanical performance of anisotropic nanofibrous scaffolds in tendon tissue engineering: reinforcement with cellulose nanocrystals. Adv Healthc Mater. doi:10.1002/adhm.201501048
Wang L et al (2015) Nanofiber yarn/hydrogel core-shell scaffolds mimicking native skeletal muscle tissue for guiding 3D myoblast alignment, elongation, and differentiation. ACS Nano 9(9):9167–9179
Shuakat MN, Lin T (2014) Recent developments in electrospinning of nanofiber yarns. J Nanosci Nanotechnol 14(2):1389–1408
Zhang C et al (2015) Well-aligned chitosan-based ultrafine fibers committed teno-lineage differentiation of human induced pluripotent stem cells for Achilles tendon regeneration. Biomaterials 53:716–730
Younesi M et al (2014) Tenogenic induction of human MSCs by anisotropically aligned collagen biotextiles. Adv Funct Mater 24(36):5762–5770
Domingues RMA, Gomes ME, Reis RL (2014) The potential of cellulose nanocrystals in tissue engineering strategies. Biomacromolecules 15(7):2327–2346
Nivison-Smith L, Weiss AS (2012) Alignment of human vascular smooth muscle cells on parallel electrospun synthetic elastin fibers. J Biomed Mater Res, Part A 100A(1):155–161
Spanoudes K et al (2014) The biophysical, biochemical, and biological toolbox for tenogenic phenotype maintenance in vitro. Trends Biotechnol 32(9):474–482
Yin Z et al (2010) The regulation of tendon stem cell differentiation by the alignment of nanofibers. Biomaterials 31(8):2163–2175
Zhou C et al (2013) Electrospun bio-nanocomposite scaffolds for bone tissue engineering by cellulose nanocrystals reinforcing maleic anhydride grafted PLA. ACS Appl Mater Interfaces 5(9):3847–3854
Abbah SA, Spanoudes K, O’Brien T, Pandit A, Zeugolis DI (2014) Assessment of stem cell carriers for tendon tissue engineering in pre-clinical models. Stem Cell Res Ther 5(38). doi:10.1186/scrt426, http://stemcellres.biomedcentral.com/articles/10.1186/scrt426
Barber JG et al (2011) Braided nanofibrous scaffold for tendon and ligament tissue engineering. Tissue Eng Part A 19(11–12):1265–1274
Liu W et al (2015) Generation of electrospun nanofibers with controllable degrees of crimping through a simple, plasticizer-based treatment. Adv Mater 27(16):2583–2588
Surrao DC et al (2012) A crimp-like microarchitecture improves tissue production in fibrous ligament scaffolds in response to mechanical stimuli. Acta Biomater 8(10):3704–3713
Chen F, Hayami JWS, Amsden BG (2014) Electrospun poly(l-lactide-co-acryloyl carbonate) fiber scaffolds with a mechanically stable crimp structure for ligament tissue engineering. Biomacromolecules 15(5):1593–1601
Lomas AJ et al (2015) The past, present and future in scaffold-based tendon treatments. Adv Drug Deliv Rev 85:257–277
LaCroix AS et al (2013) Relationship between tendon stiffness and failure: a metaanalysis. J Appl Physiol 115(1):43–51
Domingues RMA et al (2015) Chapter 10—Fabrication of hierarchical and biomimetic fibrous structures to support the regeneration of tendon tissues. In: Gomes ME, Reis RL, Rodrigues MT (eds) Tendon regeneration. Academic Press, Boston, pp 259–280
Pauly HM et al (2016) Mechanical properties and cellular response of novel electrospun nanofibers for ligament tissue engineering: effects of orientation and geometry. J Mech Behav Biomed Mater 61:258–270
Bosworth LA et al (2013) Investigation of 2D and 3D electrospun scaffolds intended for tendon repair. J Mater Sci - Mater Med 24(6):1605–1614
Mouthuy P-A et al (2015) Fabrication of continuous electrospun filaments with potential for use as medical fibres. Biofabrication 7(2):025006
Yang G et al (2016) Multilayered polycaprolactone/gelatin fiber-hydrogel composite for tendon tissue engineering. Acta Biomater 35:68–76
Aibibu D et al (2016) Textile cell-free scaffolds for in situ tissue engineering applications. J Mater Sci - Mater Med 27:63
Cheng X et al (2008) An electrochemical fabrication process for the assembly of anisotropically oriented collagen bundles. Biomaterials 29(22):3278–3288
Uquillas JA, Kishore V, Akkus A (2011) Effects of phosphate-buffered saline concentration and incubation time on the mechanical and structural properties of electrochemically aligned collagen threads. Biomed Mater 6(3):035008
Uquillas JA, Kishore V, Akkus O (2012) Genipin crosslinking elevates the strength of electrochemically aligned collagen to the level of tendons. J Mech Behav Biomed Mater 15:176–189
Kishore V et al (2011) Incorporation of a decorin biomimetic enhances the mechanical properties of electrochemically aligned collagen threads. Acta Biomater 7(6):2428–2436
Kishore V et al (2012) Tenogenic differentiation of human MSCs induced by the topography of electrochemically aligned collagen threads. Biomaterials 33(7):2137–2144
Kishore V et al (2012) In vivo response to electrochemically aligned collagen bioscaffolds. J Biomed Mater Res B Appl Biomater 100B(2):400–408
Islam A et al (2015) Biomechanical evaluation of a novel suturing scheme for grafting load-bearing collagen scaffolds for rotator cuff repair. Clin Biomech 30(7):669–675
Cheng CW, Solorio LD, Alsberg E (2014) Decellularized tissue and cell-derived extracellular matrices as scaffolds for orthopaedic tissue engineering. Biotechnol Adv 32(2):462–484
Acknowledgments
The authors wish to acknowledge the financial support of the Portuguese Foundation for Science and Technology for the post-doctoral grant (SFRH/BPD/111729/2015) and for the projects Recognize (UTAP-ICDT/CTM-BIO/0023/2014) and POCI-01-0145-FEDER-007038.
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Santos, M.L., Rodrigues, M.T., Domingues, R.M.A., Reis, R.L., Gomes, M.E. (2017). Biomaterials as Tendon and Ligament Substitutes: Current Developments. In: Oliveira, J., Reis, R. (eds) Regenerative Strategies for the Treatment of Knee Joint Disabilities. Studies in Mechanobiology, Tissue Engineering and Biomaterials, vol 21. Springer, Cham. https://doi.org/10.1007/978-3-319-44785-8_17
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