Targeting the Hedgehog Signaling Pathway to Improve Tendon-to-Bone Integration

ABSTRACT Objective While the role of Hedgehog (Hh) signaling in promoting zonal fibrocartilage production during development is well-established, whether this pathway can be leveraged to improve tendon-to-bone repair in adults is unknown. Our objective was to genetically and pharmacologically stimulate the Hh pathway in cells that give rise to zonal fibrocartilaginous attachments to promote tendon-to-bone integration. Design Hh signaling was stimulated genetically, via constitutive Smo (SmoM2 construct) activation of activated bone marrow stromal cells, or pharmacologically, via systemic agonist delivery, to mice following anterior cruciate ligament reconstruction (ACLR). To assess tunnel integration, we measured mineralized fibrocartilage (MFC) formation in these mice 28 days post-surgery and performed tunnel pullout testing. Results Hh pathway-related genes increased in cells forming the zonal attachments in WT mice. Both genetic and pharmacologic stimulation of the Hh pathway increased MFC formation and integration strength 28 days post-surgery. We next conducted studies to define the role of Hh in specific stages of the tunnel integration process. We found Hh agonist treatment increased proliferation of the progenitor pool in the first week post-surgery. Additionally, genetic stimulation led to continued MFC production in later stages of the integration process. These results indicate that Hh signaling plays an important biphasic role in cell proliferation and differentiation towards fibrochondrocytes following ACLR. Conclusion This study reveals a biphasic role for Hh signaling during the tendon-to-bone integration process after ACLR. In addition, the Hh pathway is a promising therapeutic target to improve tendon-to-bone repair outcomes.