Oxidative stress inhibits tendon-to-bone healing after rotator cuff repair. Regulation of oxidative stress has the potential to accelerate this healing, but its mechanism remains unclear.
Purpose:
To investigate the effects of reducing oxidative stress by applying antioxidants, such as N-acetylcysteine (NAC) and vitamin C (VC), on rotator cuff repair in a rat rotator cuff repair model.
Study design:
Controlled laboratory study.
Methods:
A total of 48 Sprague Dawley rats underwent bilateral surgery to repair the infraspinatus tendon to its insertion site 1 week after detachment. Rats were assigned to either the NAC group, the VC group, or a control group. Histological evaluation was performed via hematoxylin-eosin or toluidine blue staining, and oxidative stress was assessed via dihydroethidium intensity and protein carbonyl concentration at 3 and 6 weeks. Superoxide dismutase 1 (SOD1), SOD2, SOD3, peroxiredoxin 5, collagen type I (COL1), COL3, matrix metalloproteinase 1 (MMP-1), MMP-3, and MMP-13 expression and SOD activity were determined at 3 and 6 weeks. Biomechanical tests were performed at 6 and 12 weeks.
Results:
Histological evaluation showed that the number of chondrocytes in the NAC group at 6 weeks and in the VC group at 3 and 6 weeks, the area of fibrocartilage at 6 weeks in the VC group, and collagen fibers at 6 weeks in the NAC and VC groups were significantly increased compared with those in the control group. Dihydroethidium intensity at 3 and 6 weeks and protein carbonyls at 6 weeks in the NAC and VC groups were significantly decreased. SOD1 expression and SOD activity at 3 weeks in the VC group and peroxiredoxin 5 expression at 6 weeks in the NAC group were significantly upregulated compared with that in the control group. COL3 expression was significantly upregulated at 6 weeks in the VC group, and MMP-13 expression was significantly decreased at 6 weeks in the NAC and VC groups. The biomechanical strength showed no significant difference.
Conclusion:
Antioxidant treatment, via NAC or VC administration, reduced oxidative stress in the rotator cuff repair site and accelerated healing.
Clinical Relevance:
These findings provide essential indications to develop clinical strategies for improved healing after rotator cuff surgical repair in patients.
Amrouche-MekkiouiIDjerdjouriB. N-acetylcysteine improves redox status, mitochondrial dysfunction, mucin-depleted crypts and epithelial hyperplasia in dextran sulfate sodium-induced oxidative colitis in mice. Eur J Pharmacol. 2012;691(1-3):209-217.
2.
BadrGHozzeinWNBadrBM, et al. Bee venom accelerates wound healing in diabetic mice by suppressing activating transcription factor-3 (ATF-3) and inducible nitric oxide synthase (iNOS)-mediated oxidative stress and recruiting bone marrow-derived endothelial progenitor cells. J Cell Physiol. 2016;231(10):2159-2171.
3.
BoileauPBrassartNWatkinsonDJ, et al. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?J Bone Joint Surg Am. 2005;87(6):1229-1240.
4.
BuchmannSWalzLSandmannGH, et al. Rotator cuff changes in a full thickness tear rat model: verification of the optimal time interval until reconstruction for comparison to the healing process of chronic lesions in humans. Arch Orthop Trauma Surg. 2011;131(3):429–435.
5.
BussHChanTPSluisKBDomiganNMWinterbournCC. Protein carbonyl measurement by a sensitive ELISA method. Free Radic Biol Med. 1997;23(3):361-366.
6.
ChaudhurySXiaZThakkarDHakimiOCarrAJ. Gene expression profiles of changes underlying different-sized human rotator cuff tendon tears. J Shoulder Elbow Surg. 2016;25(10):1561-1570.
7.
CohenDBKawamuraSEhteshamiJRRodeoSA. Indomethacin and celecoxib impair rotator cuff tendon-to-bone healing. Am J Sports Med. 2006;34(3):362-369.
8.
De SimoniSLinardDHermansEKnoopsBGoemaereJ. Mitochondrial peroxiredoxin-5 as potential modulator of mitochondria-ER crosstalk in MPP+-induced cell death. J Neurochem. 2013;125(3):473-485.
9.
DeepmalaSlattery JKumarN, et al. Clinical trials of N-acetylcysteine in psychiatry and neurology: a systematic review. Neurosci Biobehav Rev. 2015;55:294-321.
10.
DoddSDeanOCopolovDLMalhiGSBerkM. N-acetylcysteine for antioxidant therapy: pharmacology and clinical utility. Expert Opin Biol Ther. 2008;8(12):1955-1962.
11.
DuchmanKRGoetzJEUribeBU, et al. Delayed administration of recombinant human parathyroid hormone improves early biomechanical strength in a rat rotator cuff repair model. J Shoulder Elbow Surg. 2016;25(8):1280-1287.
12.
FindikRBIlkayaFGuresciS, et al. Effect of vitamin C on collagen structure of cardinal and uterosacral ligaments during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2016;201:31-35.
13.
FinkelTHolbrookNJ. Oxidants, oxidative stress and the biology of ageing. Nature. 2000;408(1):239-247.
14.
GarrettIRBoyceBFOreffoRO, et al. Oxygen-derived free radicals stimulate osteoclastic bone resorption in rodent bone in vitro and in vivo. J Clin Invest. 1990;85(3):632-639.
15.
GimbelJAVan KleunenJPMehtaS, et al. Supraspinatus tendon organizational and mechanical properties in a chronic rotator cuff tear animal model. J Biomech. 2004;37(5):739-749.
16.
HalliwellB. Free radicals, antioxidants, and human disease— curiosity, cause, or consequence?Lancet. 1994;344(1):721-724.
17.
HaradaYMifuneYInuiA, et al. Rotator cuff repair using cell sheets derived from human rotator cuff in a rat model. J Orthop Res. 2017;35(2):289-296.
18.
IchimTEMinevBBraciakT, et al. Intravenous ascorbic acid to prevent and treat cancer-associated sepsis?J Transl Med. 2011;9:25.
19.
IdeJTokunagaT. Rotator cuff tendon-to-bone healing at 12 months after patch grafting of acellular dermal matrix in an animal model. J Orthop Sci. 2018;23(2):207-212.
20.
ItoigawaYSuzukiOSanoH, et al. The role of an octacalcium phosphate in the re-formation of infraspinatus tendon insertion. J Shoulder Elbow Surg. 2015;24(7):e175-e184.
21.
ItoigawaYYoshidaKNojiriH, et al. Association of recurrent tear after arthroscopic rotator cuff repair and superoxide-induced oxidative stress. Am J Sports Med. 2021;49(8):2048-2055.
22.
KanekoYTanigawaNSatoY, et al. Oral administration of N-acetyl cysteine prevents osteoarthritis development and progression in a rat model. Sci Rep. 2019;9(1):18741.
23.
KimRJHahYSGwarkJYParkHB. N-acetylcysteine reduces glutamate-induced cytotoxicity to fibroblasts of rat supraspinatus tendons. Connect Tissue Res. 2019;60(5):431-443.
24.
KinoshitaHOritaSInageK, et al. Skeletal muscle cell oxidative stress as a possible therapeutic target in a denervation-induced experimental sarcopenic model. Spine (Phila Pa 1976). 2019;44(8):e446-e455.
25.
KoikeYTrudelGUhthoffH. Formation of a new enthesis after attachment of the supraspinatus tendon: a quantitative histologic study in rabbits. J Orthop Res. 2005;23(6):1433-1440.
26.
LeeYWFuSCYeungMY, et al. Effects of redox modulation on cell proliferation, viability, and migration in cultured rat and human tendon progenitor cells. Oxid Med Cell Longev. 2017;2017:8785042.
27.
LiKDengGDengY, et al. High cholesterol inhibits tendon-related gene expressions in tendon-derived stem cells through reactive oxygen species-activated nuclear factor-kappaB signaling. J Cell Physiol. 2019;234(10):18017-18028.
28.
LiuYDaiCGaoRLiJ. Ascorbic acid protects against colistin sulfate-induced neurotoxicity in PC12 cells. Toxicol Mech Methods. 2013;23(8):584-590.
29.
Lopez-OtinCBlascoMAPartridgeLSerranoMKroemerG. The hallmarks of aging. Cell. 2013;153(6):1194-1217.
30.
MagginiSBeveridgeSSuterM. A combination of high-dose vitamin C plus zinc for the common cold. J Int Med Res. 2012; 40(1):28-42.
31.
MiaoLSt ClairDK. Regulation of superoxide dismutase genes: implications in disease. Free Radic Biol Med. 2009;47(4):344-356.
32.
MorikawaDItoigawaYNojiriH, et al. Contribution of oxidative stress to the degeneration of rotator cuff entheses. J Shoulder Elbow Surg. 2014;23(5):628-635.
33.
MorikawaDNojiriHItoigawaY, et al. Antioxidant treatment with vitamin C attenuated rotator cuff degeneration caused by oxidative stress in Sod1-deficient mice. JSES Open Access. 2018;2(1):91-96.
34.
MullerSADurselenLHeisterbachPEvansCMajewskiM. Effect of a simple collagen type I sponge for Achilles tendon repair in a rat model. Am J Sports Med. 2016;44(8):1998-2004.
35.
NakashimaDFujitaNHataJ, et al. Quantitative analysis of intervertebral disc degeneration using Q-space imaging in a rat model. J Orthop Res. 2020;38(10):2220-2229.
36.
NhoSJYadavHShindleMKMacgillivrayJD. Rotator cuff degeneration: etiology and pathogenesis. Am J Sports Med. 2008;36(5):987-993.
37.
NijmehJMoldobaevaAWagnerEM. Role of ROS in ischemia-induced lung angiogenesis. Am J Physiol Lung Cell Mol Physiol. 2010;299(4):L535-L541.
38.
OmeroğluSPekerTTurkozkanNOmeroğluH. High-dose vitamin C supplementation accelerates the Achilles tendon healing in healthy rats. Arch Orthop Trauma Surg. 2009;129(2):281-286.
39.
OztermeliAKaracaSYucelI, et al. The effect of erythropoietin on rat rotator cuff repair model: an experimental study. J Orthop Surg (Hong Kong). 2019;27(2):2309499019856389.
40.
ParasassiTBrunelliRCostaG, et al. Thiol redox transitions in cell signaling: a lesson from N-acetylcysteine. ScientificWorldJournal. 2010;10:1192-1202.
41.
RobertsonCMChenCTShindleMK, et al. Failed healing of rotator cuff repair correlates with altered collagenase and gelatinase in supraspinatus and subscapularis tendons. Am J Sports Med. 2012;40(9):1993-2001.
42.
SchroderEPontingCP. Evidence that peroxiredoxins are novel members of the thioredoxin fold superfamily. Protein Sci. 1998;7(1):2465-2468.
43.
ShibuyaSOzawaYTodaT, et al. Collagen peptide and vitamin C additively attenuate age-related skin atrophy in Sod1-deficient mice. Biosci Biotechnol Biochem. 2014;78(7):1212-1220.
44.
SiesH. Oxidative stress: oxidants and antioxidants. Exp Physiol. 1997;82(2):291-295.
45.
SimoninMAGegout-PottiePMinnA, et al. Pefloxacin-induced Achilles tendon toxicity in rodents: biochemical changes in proteoglycan synthesis and oxidative damage to collagen. Antimicrob Agents Chemother. 2000;44(4):867-872.
46.
SullivanPGKrishnamurthySPatelSPPandyaJDRabchevskyAG. Temporal characterization of mitochondrial bioenergetics after spinal cord injury. J Neurotrauma. 2007;24(6):991-999.
47.
TobwalaSZhangXZhengY, et al. Disruption of the integrity and function of brain microvascular endothelial cells in culture by exposure to diesel engine exhaust particles. Toxicol Lett. 2013;220(1):1-7.
48.
TraberMGStevensJF. Vitamins C and E: beneficial effects from a mechanistic perspective. Free Radic Biol Med. 2011;51(5):1000-1013.
49.
UeharaHItoigawaYWadaT, et al. Relationship of superoxide dismutase to rotator cuff injury/tear in a rat model. J Orthop Res. 2022;40(5):1006-1015.
50.
WeiASCallaciJJJuknelisD, et al. The effect of corticosteroid on collagen expression in injured rotator cuff tendon. J Bone Joint Surg Am. 2006;88(6):1331-1338.
51.
WeischerCHKrisingerJKarzelK. Effects of mellitic acid (MA) and sodium fluoride (NaF) on the histological appearance of murine fetal tibiae cultured in vitro. Histol Histopathol. 1986;1(3):303-308.
52.
WhittakerPCanhamPB. Demonstration of quantitative fabric analysis of tendon collagen using two-dimensional polarized light microscopy. Matrix. 1991;11(1):56-62.
53.
WilliamsIFMcCullaghKGSilverIA. The distribution of types I and III collagen and fibronectin in the healing equine tendon. Connect Tissue Res. 1984;12(3-4):211-227.
54.
WoodZASchroderERobin HarrisJPooleLB. Structure, mechanism and regulation of peroxiredoxins. Trends Biochem Sci. 2003;28(1):32-40.
55.
YamakuraFKawasakiH. Post-translational modifications of superoxide dismutase. Biochim Biophys Acta. 2010;1804(1):318-325.
56.
YokoyaSMochizukiYNatsuK, et al. Rotator cuff regeneration using a bioabsorbable material with bone marrow–derived mesenchymal stem cells in a rabbit model. Am J Sports Med. 2012;40(6):1259-1268.
57.
YonemitsuRTokunagaTShukunamiC, et al. Fibroblast growth factor 2 enhances tendon-to-bone healing in a rat rotator cuff repair of chronic tears. Am J Sports Med. 2019;47(7):1701-1712.
58.
YoshidaKItoigawaYWadaT, et al. Association of superoxide-induced oxidative stress with rotator cuff tears in human patients. J Orthop Res. 2019;38(1):212-218.
59.
YuanJMurrellGATrickettA, et al. Overexpression of antioxidant enzyme peroxiredoxin 5 protects human tendon cells against apoptosis and loss of cellular function during oxidative stress. Biochim Biophys Acta. 2004;1693(1):37-45.
60.
YuanJMurrellGACTrickettAWangMX. Involvement of cytochrome c release and caspase-3 activation in the oxidative stress-induced apoptosis in human tendon fibroblasts. Biochim Biophys Acta. 2003;1641(1):35-41.
61.
ZielonkaJKalyanaramanB. Hydroethidine- and MitoSOX-derived red fluorescence is not a reliable indicator of intracellular superoxide formation: another inconvenient truth. Free Radic Biol Med. 2010;48(8):983-1001.
