Tendon surface modification by chemically modified HA coating after flexor digitorum profundus tendon repair

Flexor Tendon Adhesion Formation: Current Concepts

Over the years, various physical and chemical/biological methods of inhibiting adhesion formation have been developed, focusing on how to suppress healing around the tendon and not inhibit healing within the tendon. Unfortunately, however, these methods are accompanied by drawbacks, both large and small, and no absolute antiadhesion method capable of maintaining tendon repair strength has yet been developed. Recent innovations in biomaterials science and tissue engineering have produced new antiadhesion technologies, such as barriers combined with cytokines and cells, which have improved outcomes in animal models, and which may find clinical relevance in the future.

Effects of lubricant and autologous bone marrow stromal cell augmentation on immobilized flexor tendon repairs

The purpose of the study was to test a novel treatment that carbodiimide-derivatized-hyaluronic acid-lubricin (cd-HA-lubricin) combined cell-based therapy in an immobilized flexor tendon repair in a canine model. Seventy-eight flexor tendons from 39 dogs were transected. One tendon was treated with cd-HA-lubricin plus an interpositional graft of 8 × 10(5) BMSCs and GDF-5. The other tendon was repaired without treatment. After 21 day of immobilization, 19 dogs were sacrificed; the remaining 20 dogs underwent a 21-day rehabilitation protocol before euthanasia. The work of flexion, tendon gliding resistance, and adhesion score in treated tendons were significantly less than the untreated tendons (p < 0.05). The failure strength of the untreated tendons was higher than the treated tendons at 21 and 42 days (p < 0.05). However, there is no significant difference in stiffness between two groups at day 42. Histologic analysis of treated tendons showed a smooth surface and viable transplanted cells 42 days after the repair, whereas untreated tendons showed severe adhesion formation around the repair site. The combination of lubricant and cell treatment resulted in significantly improved digit function, reduced adhesion formation. This novel treatment can address the unmet needs of patients who are unable to commence an early mobilization protocol after flexor tendon repair.

The use of hyaluronic acid after tendon surgery and in tendinopathies

Viscosupplementation with hyaluronic acid is safe and effective in the management of osteoarthritis, but its use in the treatment of tendon disorders has received less attention. The aim of this review is to summarize the current knowledge on this topic, evaluating experimental and clinical trials. A search of English-language articles was performed using the key search terms “hyaluronic acid” or “viscosupplementation” combined with “tendon,” “tendinopathy,“ “adhesions,“ or “gliding,“ independently. In quite all the experimental studies, performed after surgical procedures for tendon injuries or in the treatment of chronic tendinopathies, using different hyaluronic acid compounds, positive results (reduced formation of scars and granulation tissue after tendon repair, less adhesions and gliding resistance, and improved tissue healing) were observed. In a limited number of cases, hyaluronic acid has been employed in clinical practice. After flexor tendon surgery, a greater total active motion and fingers function, with an earlier return to work and daily activities, were observed. Similarly, in patients suffering from elbow, patellar, and shoulder tendons disorders, pain was reduced, and function improved. The positive effect of hyaluronic acid can be attributed to the anti-inflammatory activity, enhanced cell proliferation, and collagen deposition, besides the lubricating action on the sliding surface of the tendon.

A mouse model of flexor tendon repair

Mouse models offer invaluable cellular and molecular tools for the study of human pathologies including those associated with fibrotic and musculoskeletal diseases. In this methods manuscript, we describe a mouse model of repair and segmental reconstruction of flexor tendons, which in our laboratory has been an invaluable model to study tendon scarring and adhesions. Specifically, we describe in details all the surgical procedures involved, as well as the associated endpoint biomechanical assessments including a novel test of the flexion of the metatarsophalangeal joint as a measure of adhesions, and a standard protocol for biomechanical assessment of the tensile strength of the tendon and repair tissue.

Surface modification counteracts adverse effects associated with immobilization after flexor tendon repair

Although post-rehabilitation is routinely performed following flexor tendon repair, in some clinical scenarios post-rehabilitation must be delayed. We investigated modification of the tendon surface using carbodiimide derivatized hyaluronic acid and lubricin (cd-HA-Lub) to maintain gliding function following flexor tendon repair with postoperative immobilization in a in vivo canine model. Flexor digitorum profundus tendons from the 2nd and 5th digits of one forepaw of six dogs were transected and repaired. One tendon in each paw was treated with cd-HA-Lub; the other repaired tendon was not treated. Following tendon repair, a forearm cast was applied to fully immobilize the operated forelimb for 10 days, after which the animals were euthanized. Digit normalized work of flexion (nWOF) and tendon gliding resistance were assessed. The nWOF of the FDP tendons treated with cd-HA-Lub was significantly lower than the nWOF of the untreated tendons (p < 0.01). The gliding resistance of cd-HA-Lub treated tendons was also significantly lower than that of the untreated tendons (p < 0.05). Surface treatment with cd-HA-Lub following flexor tendon repair provides an opportunity to improve outcomes for patients in whom the post-operative therapy must be delayed after flexor tendon repair.

The bio-tribological properties of anti-adhesive agents commonly used during tendon repair

Frictional resistance to tendon gliding is minimized by surrounding loose areolar tissue. During periods of prolonged immobilization, for example, post-tendon-repair, adhesions can form between these two adjacent tissues, thereby limiting tendon function. Anti-adhesive agents can be applied during surgery to prevent adhesion formation, whilst reportedly providing some reduction in friction during in vitro tendon-bony pulley investigations. This bio-tribological study evaluates whether application of these agents can improve the lubrication between the tendon and surrounding tissue, thus potentially reducing the risk of re-rupturing the tendon at the repair site. The use of bovine synovial fluid (BSF) enabled an approximation of the in vivo lubrication regime, and subsequent comparison of the performance of three synthetic agents (50 mg/ml 5-fluorouracil; 5 mg/ml hyaluronic acid; ADCON-T/N). Coefficient of friction data was recorded and then compared with the Stribeck curve. BSF generated a fluid film that separated the two surfaces, giving rise to optimal lubrication conditions. This efficient regime was also generated following application of each anti-adhesion agent. The use of phosphate-buffered saline solution in generating only a boundary lubrication regime highlighted the effectiveness of the agents in reducing friction. Hyaluronic acid (5 mg/ml) was marginally deemed the most effective anti-adhesive agent at lubricating the tendon. Subsequently, it is concluded that the application of anti-adhesive agents post-surgery has secondary, tribological benefits that serve to reduce friction, and thus potentially the risk of failure, at the tendon repair site.

Compressive properties of cd-HA-gelatin modified intrasynovial tendon allograft in canine model in vivo

Although we sometimes use the intrasynovial tendon allograft as a donor, the gliding ability of allograft prepared by lyophilization is significantly decreased. The gliding ability of the grafted tendon after tendon reconstruction is very important because the high gliding resistance causes more adhesion and leads to poor clinical results. We recently revealed that tendon surface treatment with a carbodiimide derivatized HA (cd-HA)-gelatin mixture for intrasynovial tendon allograft significantly improved its gliding ability. The purpose of this study was to investigate whether this cd-HA-gelatin treatment affects the tendon mechanical property or not. A total of 40 flexor digitorum profundus (FDP) tendons from canines were evaluated for compressive property by using indentation test. Indentation stiffness was measured for normal tendon, rehydrated tendon after lyophilization, rehydrated tendon after lyophilization that was implanted 6 weeks in vivo, and cd-HA treated rehydrated tendon after lyophilization that was implanted 6 weeks in vivo. The results for all groups showed no significant difference in the tendon compressive properties. The findings of these results demonstrate that cd-HA treatment for intrasynovial tendon allograft is an excellent method to improve the tendon gliding ability after lyophilization without changing the compressive property of donor tendon.

Application of carbodiimide derivatized synovial fluid to enhance extrasynovial tendon gliding ability

PURPOSE

To investigate the effects of surface modification of extrasynovial tendon with a carbodiimide derivatized synovial fluid (SF) on the gliding ability of extrasynovial tendon for a possible tendon graft application.

METHODS

We used 63 peroneus longus tendons from canine hind legs. We immediately assessed 3 tendons morphologically using a scanning electron microscope (SEM); these served as the normal tendon group. The other 60 tendons were randomly assigned to each of 6 experimental groups treated with (1) control (saline); (2) 1% 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDC) plus 1% N-hydroxysuccinimide (NHS) (cd only); (3) 1% EDC/NHS plus 10% gelatin (cd-G); (4) SF plus 1% EDC/NHS plus 10% gelatin (cd-SF-G); (5) SF only; or (6) SF plus 1% EDC/NHS (cd-SF). We measured the gliding resistance for 1,000 cycles of simulated flexion-extension motion. We also observed the tendon surface smoothness by SEM.

RESULTS

Compared with the first cycle in each group, the gliding resistance after 1,000 cycles of tendon motion was significantly increased in the control, cd only, cd-gelatin, SF only, and cd-SF groups (p<.05). In contrast, we found no significant difference in gliding resistance between the first cycle and 1,000 cycles for the cd-SF-G-treated group. In addition, the gliding resistance in the cd-SF, cd-G, and cd-SF-G groups was significantly lower than the control group after 1,000 cycles of tendon motion (p<.05) and the gliding resistance of the cd-SF-G group was significantly lower than both the cd-G and cd-SF groups (p<.05). On SEM, the surface treated with cd-SF-G was smooth after 1,000 cycles, whereas the other surfaces were rough.

CONCLUSIONS

Surface modification of extrasynovial tendon with cd-SF-G improves tendon gliding ability. This treatment may be useful clinically in improving the outcomes of tendon autografts.

The quadriga effect revisited: designing a "safety incision" to prevent tendon repair rupture and gap formation in a canine model in vitro

Loss of experimental animals due to tendon repair failure results in the need for additional animals to complete the study. We designed a relief proximal to the flexor digitorum profundus (FDP) tendon repair site to serve as a "safety incision" to prevent repair site ruptures and maximize safety incision-to-suture strength. The FDP tendons were dissected in 24 canine forepaws. The 2nd and 5th tendons were lacerated at the proximal interphalangeal joint level and sutured using a modified Kessler technique and peripheral running suture. Tendon width was measured where the FDP tendon separates into each individual digit and a safety incision, equal to the 2nd and 5th tendon widths, was performed 3, 4, or 5 mm (Groups 1, 2, and 3) proximal to the separation. The tendons were pulled at a rate of 1 mm/s until either the "safety incision" ruptured or the repair failed. There was no gap formation at the repair site in Groups 1 and 2. However, all Group 3 tendons failed by repair site rupture with the safety incision intact. An adequate safety incision to protect repair gap and rupture and maintain tendon tension for the FDP animal model should be about 4 mm from where the FDP tendon separates.

Effects of a lubricin-containing compound on the results of flexor tendon repair in a canine model in vivo

BACKGROUND

Tendon surface modification with a synthetic biopolymer, carbodiimide-derivatized hyaluronic acid and gelatin with the addition of lubricin (CHL), has been shown to reduce gliding resistance after tendon repair in an in vitro model. The purpose of the study was to investigate whether CHL would reduce adhesion formation and improve digital function after flexor tendon repair in a canine model in vivo.

METHODS

Sixty dogs were randomly assigned to either a biopolymer-treated group (n = 30) or an untreated control group (n = 30). The second and fifth flexor digitorum profundus tendons from each dog were lacerated fully at the zone-II area and then repaired. Passive synergistic motion therapy was started on the fifth postoperative day and continued until the dogs were killed on day 10, day 21, or day 42. The repaired tendons were evaluated for adhesions, normalized work of flexion, gliding resistance, repair strength, stiffness, and histological characteristics.

RESULTS

The normalized work of flexion of the repaired tendons treated with CHL was significantly lower than that of the non-CHL-treated repaired tendons at all time points (p < 0.05), and the prevalence of severe adhesions was also significantly decreased in the CHL-treated tendons at day 42 (p < 0.05). However, the repair failure strength and stiffness of the CHL-treated group were also significantly reduced compared with those of the control group at days 21 and 42 (p < 0.05) and the rate of tendon rupture was significantly higher in the treated group than in the control group at day 42 (p < 0.05).

CONCLUSIONS

Treatment with the lubricin-containing gel CHL appears to be an effective means of decreasing postoperative flexor tendon adhesions, but it is also associated with some impairment of tendon healing. Future studies will be necessary to determine if the positive effects of CHL on adhesion formation can be maintained while reducing its adverse effect on the structural integrity of the repaired tendon.

Carbodiimide-derivatized hyaluronic acid surface modification of lyophilized flexor tendon: a biomechanical study in a canine in vitro model

BACKGROUND

Intrasynovial grafts are the ideal solution to replace defects in intrasynovial flexor tendons, but autologous graft sources are rarely available. The purpose of the present study was to test the hypotheses that an intrasynovial tendon prepared with repetitive freeze-thaw cycles and lyophilization (as a means of reducing immunogenicity) has increased frictional force (gliding resistance) in comparison with fresh intrasynovial tendons and that a lyophilized intrasynovial flexor tendon that is modified with carbodiimide-derivatized hyaluronic acid and gelatin has decreased frictional force in comparison with untreated lyophilized tendons.

METHODS

Thirty-six flexor digitorum profundus tendons from the second and fifth digits of canine hind paws were randomly assigned to three groups. Twelve tendons were immediately assessed both mechanically and morphologically and served as the normal tendon group. The other twenty-four tendons were prepared with repetitive freeze-thaw cycles and lyophilization and were randomly assigned to two groups, including one group in which the tendons were treated with carbodiimide-derivatized hyaluronic acid and gelatin and one group in which the tendons were not treated. The frictional force was measured during 1000 cycles of simulated flexion-extension motion in all tendons, and the mean frictional forces were compared. The tendons were then observed with use of transmitted light microscopy for residual hyaluronic acid on the tendon surface, and the smoothness of the surface was evaluated with use of scanning electron microscopy.

RESULTS

The frictional force after lyophilization was significantly increased by 104.9% after the first cycle and by 99.5% after 1000 cycles in comparison with the normal tendon (p < 0.05). The frictional force of the lyophilized tendons after treatment with carbodiimide-derivatized hyaluronic acid and gelatin was not significantly different from that of normal tendons. The untreated lyophilized tendon surfaces were observed on scanning electron microscopy to be rough in appearance, whereas the normal surface and the surface treated with carbodiimide-derivatized hyaluronic acid and gelatin were smooth, with residual hyaluronic acid present on the gliding surface.

CONCLUSIONS

Lyophilization alters tendon surface morphology and increases tendon frictional force. Surface modification with carbodiimide-derivatized hyaluronic acid and gelatin can mitigate this adverse effect.

CLINICAL RELEVANCE

Tendon surface modification with carbodiimide-derivatized hyaluronic acid and gelatin can improve the gliding ability of lyophilized flexor tendons and therefore may improve the utility of lyophilized tendon allografts as a tendon graft substitute.

Lubricin surface modification improves tendon gliding after tendon repair in a canine model in vitro

This study investigated the effects of lubricin on the gliding of repaired flexor digitorum profundus (FDP) tendons in vitro. Canine FDP tendons were completely lacerated, repaired with a modified Pennington technique, and treated with one of the following solutions: saline, carbodiimide derivatized gelatin/hyaluronic acid (cd-HA-gelatin), carbodiimide derivatized gelatin to which lubricin was added in a second step (cd-gelatin + lubricin), or carbodiimide derivatized gelatin/HA + lubricin (cd-HA-gelatin + lubricin). After treatment, gliding resistance was measured up to 1,000 cycles of simulated flexion/extension motion. The increase in average and peak gliding resistance in cd-HA-gelatin, cd-gelatin + lubricin, and cd-HA-gelatin + lubricin tendons was less than the control tendons after 1,000 cycles (p < 0.05). The increase in average gliding resistance of cd-HA-gelatin + lubricin treated tendons was also less than that of the cd-HA-gelatin treated tendons (p < 0.05). The surfaces of the repaired tendons and associated pulleys were assessed qualitatively with scanning electron microscopy and appeared smooth after 1,000 cycles of tendon motion for the cd-HA-gelatin, cd-gelatin + lubricin, and cd-HA-gelatin + lubricin treated tendons, while that of the saline control appeared roughened. These results suggest that tendon surface modification can improve tendon gliding ability, with a trend suggesting that lubricin fixed on the repaired tendon may provide additional improvement over that provided by HA and gelatin alone.

Effect of curing time and concentration for a chemical treatment that improves surface gliding for extrasynovial tendon grafts in vitro

The purpose of this study was to evaluate whether treatment time and concentration of these reagents have an effect on the resulting gliding resistance. Forty peroneus longus (PL) tendons were used, from 20 adult mongrel dogs, along with the A2 pulley obtained from the ipsilateral hind paw. After the baseline gliding resistance was measured, the PL tendons were treated with one of three concentrations of hyaluronic acid (HA) and 1-ethyl-3-[3-dimethylaminopropyl] carbodiimide hydrochloride (EDC) or N-hydroxysuccinimide (NHS) mixed with 10% gelatin for various times (5, 30, and 60 min). Tendon friction was measured over 1000 cycles of simulated flexion/extension motion. Gliding resistance of the untreated PL tendons had no significant difference among the groups. After surface treatment with low concentration of HA and EDC/NHS for 5-min cure, the gliding resistance was similar to that of the untreated PL tendon and significantly higher than its 30- and 60-min treatment. For the rest of high concentration of HA and EDC/NHS groups, the gliding resistance was lower than that of untreated PL tendon. However, there was no significant difference among the timing points. It is possible to optimize the effect of surface treatment on friction and durability by regulating cure time and concentration of reagents in a canine extrasynovial tendon in vitro.

Surface treatment of flexor tendon autografts with carbodiimide-derivatized hyaluronic Acid. An in vivo canine model

BACKGROUND

Clinical and experimental studies have demonstrated that restrictive adhesions and poor digital motion are common complications after extrasynovial tendon grafting in an intrasynovial environment. The purpose of this study was to test the hypothesis that surface modification of an extrasynovial tendon with use of a carbodiimide-derivatized hyaluronic acid-gelatin polymer (cd-HA) improves gliding ability and digital function after tendon grafting in a canine model in vivo.

METHODS

The peroneus longus tendons from both hindpaws of twenty-four dogs were harvested and transplanted to replace the flexor digitorum profundus tendons in the second and fifth digits of one forepaw. Prior to grafting, one of the peroneus longus tendons was coated with cd-HA, which consists of 1% hyaluronic acid, 10% gelatin, 0.25% 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDC), and 0.25% N-hydroxysuccinimide (NHS), while the other was immersed in saline solution only. Eight dogs were killed at one, three, and six weeks. Digital normalized work of flexion, tendon gliding resistance, and hyaluronic acid quantification (with the hyaluronic acid-binding-protein staining technique) were the outcome measures.

RESULTS

The normalized work of flexion of the tendons treated with cd-HA was significantly lower than that of the saline-solution-treated controls at each time-point (p < 0.05). The gliding resistance of the cd-HA group was significantly lower than that of the saline-solution group at three and six weeks (p < 0.05). The ratio between the intensity of staining of the cd-HA-treated tendons with that of the saline-solution-treated controls was significantly greater at time-0 than at three or six weeks (p < 0.05), but there was no significant difference between time-0 and one-week values.

CONCLUSIONS

Treating the surface of an extrasynovial tendon autograft with a carbodiimide-derivatized hyaluronic acid-gelatin polymer decreases digital work of flexion and tendon gliding resistance in this flexor tendon graft model in vivo.

CLINICAL RELEVANCE

cd-HA gelatin may provide surgeons with a new and useful method to improve the quality of tendon graft surgery.

Updates in flexor tendon repair at zone ii

This article reviews the history and current management concepts of flexor tendon lacerations. Classic and contemporary repair techniques are discussed. The most popular rehabilitation protocols are also reviewed.