Background: Although older adult patients have a higher retear rate after rotator cuff (RC) repair, the influence of aging on the healing process remains unclear. During mouse enthesis development, a multipotent progenitor co-expressing scleraxis (Scx) and SRY-box 9 (Sox9) contributes to enthesis formation. Scx+/Sox9+ cells may act as enthesis progenitors even during postnatal healing, and their number decreases with maturation. However, the pathophysiology of decreased RC healing ability due to aging remains unclear. We aimed to evaluate the effects of aging on tendon-to-bone healing after surgical RC repair in rats through biomechanical and histological analyses of Scx+ and Sox9+ progenitors in a ScxGFP transgenic rat model.
Methods: This was a controlled laboratory study. Adult Sprague-Dawley rats (n = 111) underwent unilateral surgery for supraspinatus tendon repair immediately after transection. The rats were divided into aged (95 weeks old) and control (12 weeks old) groups. The effects of aging were assessed using biomechanical tests at 6 weeks postoperatively and histologically at 2 and 6 weeks postoperatively. ScxGFP transgenic rats were used for the immunohistochemical assessment of Scx- and Sox9-expressing progenitors during the repair process. Sox9, Scx, and tenomodulin expression was assessed using real-time reverse transcription polymerase chain reaction.
Results: In the biomechanical test at 6 weeks postoperatively, the aged group had lower ultimate load to failure (Control: 20.4 ± 6.1 N, Aged: 14.9 ± 6.6 N, P = 0.007), stiffness (Control: 16.1 ± 6.2 N/mm, Aged: 12.6 ± 5.5 N/mm, P = 0.023), and ultimate stress to failure (Control: 6.0 ± 3.4 N/mm2, Aged: 3.4 ± 2.5 N/mm2, P < 0.001) than the control group. The total histological score of the aged group was lower than that of the control group at 6 weeks postoperatively (Control: 8.8 ± 0.8, Aged: 5.8 ± 0.4, P = 0.029). Immunohistochemistry tests showed that the percentages of Sox9+ (Control: 6.6 ± 1.1, Aged: 2.0 ± 1.0, P = 0.029) and Scx+/Sox9+ (Control: 3.6 ± 0.8, Aged: 1.1 ± 0.6, P = 0.029) cells at the reparative site were lower in the aged group than in the control group at 2 weeks postoperatively.
Conclusion: In a rat RC tendon-to-bone healing model, the decreased recruitment of Scx+/Sox9+ enthesis-related progenitor cells in the early phase may be associated with delayed reparative tissue remodeling in aging animals. These findings encourage the development of therapeutic strategies that biologically promote healing and reduce postoperative retears in older adult patients.
Keywords: Aging; enthesis progenitor; postoperative retear; rat model; rotator cuff repair; tendon-to-bone healing.
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