Surgical repair of rotator cuff tears have high failure rates (20–70%), often due to a lack of biological healing. Augmenting repairs with extracellular matrix-based scaffolds is a common option for surgeons, although to date, no commercially available product has proven to be effective. In this study, a novel collagen scaffold was assessed for its efficacy in augmenting rotator cuff repair. The collagen scaffold was assessed in vitro for cytocompatability and retention of tenocyte phenotype using alamarBLUE assays, confocal imaging and real-time PCR. Immunogenicity was assessed in vitro by the activation of pre-macrophage cells. In vivo, using a modified rat rotator cuff defect model, supraspinatus tendon repairs were carried out in 46 animals. Overlay augmentation with the collagen scaffold was compared to unaugmented repairs. At 6- and 12-weeks post-op the repairs were tested biomechanically to evaluate repair strength, and histologically for quality of healing. The collagen scaffold supported human tenocyte growth in vitro, with cells appearing morphologically tenocytic and expressing higher tendon gene markers compared to plastic controls. No immunogenic responses were provoked compared to suture material control. In vivo, augmentation with the scaffold improved the histological scores at 12 weeks (8.37/15 vs. 6.43/15, p=0.0317). However, no significant difference was detected on mechanical testing. While the collagen scaffold improved the quality of healing of the tendon, a meaningful increase in biomechanical strength was not achieved. This is likely due to its inability to affect the bone-tendon junction. Future materials/orthobiologics must target both the repaired tendon and the regenerating bone-tendon junction.

Summary

The presence or absence of crimp within the anterior cruciate ligament (ACL) sub-bundle anatomy was correlated with knee flexion angle changes and provided a measure of differential loading within its sub-bundle microstructure.

Summary

Macroscopic grading, histologic grading, morphometry, mineral analysis, and mechanical testing were performed to better understand the changes that occur in the cartilage, calcified cartilage, and subchondral bone in early osteoarthritis.

In the treatment of ligament injuries there has been much interest in the restoration of the actual ligament anatomy, and the extent to which the original enthesis may be re-established. This study therefore seeks to uncover new information on ligament microstructure and its insertion into bone.

Five bovine medial collateral ligaments (MCL) and five ovine anterior cruciate ligaments (ACL) were used in this study. All ligaments were harvested with the femoral and tibial bony insertions still intact. The bone ends were clamped and the MCL stretched to about 10% strain while the ACL underwent a 90° twist. The entire ligament-bone system, under load, was fixed in 10% formalin solution for 12 hours, following which it was partially decalcified to facilitate microsectioning. Thin 30 ìm-thick sections of the ligament-bone interface and ligament midsubstance were obtained. Differential Interference Contrast (DIC) optical microscopy was used to image the ligament and bone microarchitecture in the prescribed states of strain.

Fibre crimp patterns were examined for the prescribed loading condition and showed distinct sections of fibre recruitment. Transverse micro-imaging of the ligament showed a significant variation in the sub-bundle cross-sectional area, ranging from 100ìm to 800 ìm. Those bundles closer to the central long axis of the ligament were numerous and small, while moving towards the periphery, they were large and singular. Both classifications of entheses, direct and indirect, were observed in the MCL insertions into the femur and tibia respectively. Of interest was the indirect insertion where the macro-level view of the near parallel attachment of fibres to bone via the periosteum was revealed, at the microscale, to involve a gradually increasing orthogonal insertion of fibres. This unique transition occurred closer to the joint line. In the ACL the anterior-medial (AM) and posterior-lateral (PL) bundles were easily discernable. All insertions into bone for the ACL were of the direct type. Fibres were thus seen to transition through the four zones of gradual mineralization to bone. However the manner in which the AM and PL bundles insert into bone, and the lateral soft tissue transition between these two bundles, revealed a structural complexity that we believe is biomechanically significant.

This ‘mechano-structural’ investigation, using novel imaging techniques, has provided new insights into the microstructure of the ligament bone system. The images presented from this study are aimed to aid new approaches for reconstruction, and provide a blue-print for the design of ligament-bone systems via tissue engineering.

The spinal motion segment relies critically on there being a mechanically robust integration between the compliant disc tissues and the rigid vertebral bone. Achieving such integration represents a major structural challenge. This study explores in detail the microstructural mechanisms involved in both the nucleus-endplate and annulus-endplate regions.

Vertebra-nucleus-vertebra samples were obtained from mature ovine lumbar motion segments and subjected to a novel ring-severing technique designed to eliminate the strain-limiting influence of any remaining annular elements. These samples were loaded in tension and then chemically fixed in order to preserve the stretched fibre arrangement, and then decalcified. Annulus-vertebra samples were similarly treated but without any loading prior to fixation. Differential interference contrast optical microscopy was then used to image at high resolution cryosectioned slices of the still integrated disc-vertebral endplate regions while maintained in their fully hydrated state.

Structural continuity across the nucleus-endplate junction was sufficient for the samples to support, on average, 20 N before tensile failure occurred. Microscopic examination revealed fibres inserting into the endplates and extending continuously from vertebra to vertebra in the central nuclear region. While the fibres in the nucleus possess a significant level of structural integration with the endplates their role is not primarily a tensile one: rather, in combination with their convoluted geometry, they confer on the nucleus a form of ‘tethered’ mobility. This permits a high degree of shape change in the nucleus during normal disc function in which hydrostatic loading plays an essential role. The annular fibre bundles on entering the endplate are shown to subdivide into sub-bundles to form a 3-D multi-leaf morphology with each leaf separated by cartilaginous endplate matrix. This branched morphology increases the interface area between bundle and matrix in proportion to the number of sub-bundles formed.

Our study challenges previously published views on nucleus-endplate relationships. We also show that the robust integration of the annular fibres in the endplate is achieved via a branched morphology exploiting a mechanism of shear-stress transfer, with the anchorage strength optimised over a relatively short endplate insertion depth.

In this microanatomical and biomechanical study we investigated OA lesion sites and the adjacent intact tissue in an attempt to uncover clues of a pre-OA tissue state and its progression to OA.

Bovine patellae (n=30) showing various degrees of degeneration, where lesions were located in the distal-lateral quarter, were used for the microanatomical study. Cartilage-on-bone samples were cut to include one with the lesion site and the other with the adjacent intact site. These blocks were formalin fixed. For the mechanical testing tissue samples (n=20) ranging from intact to mildly through to severely degenerate were statically compressed (7MPa) to near-equilibrium using a cylindrical indenter, and then formalin-fixed to capture this deformed state. Following mild decalcification of both sets of tissues, full-depth cartilage-bone cryo-sections incorporating the intact-lesion transition and the deformation profile were obtained and studied in their fully hydrated state using differential interference contrast optical microscopy (DIC).

There were three mechanically-significant microstructural features of the cartilage-bone system that varied with tissue degeneration:

the integrity of the strain limiting surface layer,

Importantly, our mechanical analysis showed how disruption of the cartilage continuum by surface disruption and matrix fibrillar de-structuring, had wider mechanical consequences at the biologically-active osteochondral junction of the adjacent healthy cartilage. The structural changes in the osteochondral junction beneath the still-intact articular cartilage adjacent to the lesion site included the ‘sprouting’ of bone spicules or cones that were morphologically similar to those associated with primary bone formation.

The microanatomical and micromechanical data suggests that there is a mechanobiological link between the altered microstructural response of degenerate cartilage to load and the way in which structural changes develop in the normal adjacent tissue. We propose that while the progression of OA involves first the processes of new bone formation in tissue adjacent to lesion sites, its initiation is due to a disrupted cartilage matrix that alters a regional mechanical environment that includes adjacent healthy tissue.

The natural history of spontaneous osteonecrosis of the medial tibial plateau remains controversial and incomplete. We have studied 21 patients (aged between 53 and 77 years) with clinical and scintigraphic features of spontaneous osteonecrosis of the medial tibial plateau who were observed prospectively for at least three years (37 months to 8.5 years). The mean duration of follow-up was 5.6 years.

The mean duration of symptoms at presentation was 4.7 weeks (3 days to 12 weeks). Radiographs of the affected knee at the first visit were normal in 15 patients and mildly arthritic in six. The characteristic radiographic lesion of osteonecrosis was noted at presentation in five of the mildly arthritic knees and during the evolution of the disease in eight of the radiographically normal knees. During the follow-up, subchondral sclerosis of the affected medial tibial plateau was noted in 16 knees.

There are three distinct patterns of outcome: 1) acute extensive collapse of the medial tibial plateau in two knees within three months of onset; 2) rapid progression to varying degrees of osteoarthritis in 12 knees, in eight within a year, in all within two years and deterioration of the pre-existing osteoarthritis in three; and 3) complete resolution in four knees, two of which were normal at presentation and two mildly osteoarthritic.

The two patients with acute extensive collapse and three who had rapid progression to severe osteoarthritis required total knee arthroplasty.

We conclude that osteonecrosis of the medial tibial plateau progresses in most cases to significant degenerative disease of the knee.