Pleiotrophin-Neuregulin1 promote axon regeneration and sorting in conduit repair of critical nerve gap injuries

Significant challenges remain in the treatment of critical nerve gap injuries using artificial nerve conduits. We previously reported successful axon regeneration across a 40 mm nerve gap using a biosynthetic nerve implant (BNI) with multi-luminal synergistic growth factor release. However, axon sorting, remyelination, and functional recovery were limited. Neuregulin1 (NRG1) plays a significant role in regulating the proliferation and differentiation of Schwann cells (SCs) during development and after injury. We hypothesize that the release of NRG1 type III combined with pleiotrophin (PTN) in the BNI will enhance axon growth, remyelination, and function of regenerated nerves across a critical gap. A rabbit 40 mm peroneal gap injury model was used to investigate the therapeutic efficacy of BNIs containing either NRG1, PTN, or PTN+NRG1 growth factor release. We found that NRG1 treatment doubled the number of regenerated axons (1276±895) compared to empty controls (633±666) and PTN tripled this number (2270±989). NRG1 also significantly increased the number of SOX10⁺ Schwann cells in mid-conduit (20.42%±11.78%) and reduced the number of abnormal Remak axon bundles. The combination of PTN+NRG1 increased axon diameter (1.70±1.06) vs control (1.21±0.77) (p<0.01), with 15.35% of axons above 3 μm, comparable to autograft. However, the total number of remyelinated axons was not increased by the added NRG1 release, which correlated with absence of axonal NRG1 type III expression in the regenerated axons. Electrophysiological evaluation showed higher muscle force recruitment (23.8±16.0 mN vs 17.4±1.4 mN) and maximum evoked compound motor action potential (353 μV vs 37 μV) in PTN-NRG1 group versus control, which correlated with the improvement in the toe spread recovery observed in PTN-NRG1 treated animals (0.64±0.02) vs control (0.50±0.01). These results revealed the need of a combination of pro-regenerative and remyelinating growth factor combination therapy for the repair of critical nerve gaps.