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Lin S, Reisdorf R, Lu CK, Wang Z, An KN, Moran SL, Amadio PC, Zhao C. Cell-based tissue engineered flexor tendon allograft: A canine in vivo study. J Orthop Res 2024. [PMID: 38639414 DOI: 10.1002/jor.25854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/31/2024] [Accepted: 03/30/2024] [Indexed: 04/20/2024]
Abstract
This study aimed to compare the clinically established autologous extrasynovial tendon graft to a newly developed tissue-engineered allograft (Eng-allograft) in terms of functional outcomes following flexor tendon reconstruction in a canine model. The second and fifth flexor digitorum profundus (FDP) tendons from 16 dogs were transected and repaired in Zone II. After 6 weeks of cage activity, the repaired tendons were intentionally ruptured, creating a clinically relevant model for reconstruction. The re-ruptured FDP tendons were then reconstructed using either the clinically standard autologous extrasynovial tendon graft or the Eng-allograft, which had been revitalized with autologous bone marrow-derived mesenchymal stem cells (BMSCs) and synovialized using carbodiimide derivatized synovial fluid (cd-SYN). Following 12 weeks of postoperative rehabilitation, the functional outcomes of the surgical digits were evaluated. The Eng-allograft group exhibited improved digital function, including lower digit work of flexion and reduced adhesion status, while maintaining similar tendon gliding resistance compared to the autograft group. However, the failure load of both the distal and proximal host/graft conjunctions in the Eng-allograft group was significantly lower than that of the autograft group with higher graft rupture at the host-graft junction. In conclusion, the decellularized allogenic intrasynovial tendon, when revitalized BMSCs and synovialized with cd-SYN, demonstrates positive effects on digital function improvement and adhesion reduction. However, the healing at both proximal and distal graft/host junctions is far lower than the autograft. Further research is needed to enhance the healing capacity of allograft conjunctions, aiming to achieve a comparable level of healing seen with autografts.
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Affiliation(s)
- Subin Lin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ramona Reisdorf
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Chun Kuan Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zhanwen Wang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kai-Nan An
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Shi G, Koichi N, Wan R, Wang Y, Reisdorf R, Wilson A, Huang TC, Amadio PC, Meves A, Zhao C, Moran SL. Pentamidine-loaded gelatin decreases adhesion formation of flexor tendon. J Orthop Translat 2024; 45:75-87. [PMID: 38511123 PMCID: PMC10950576 DOI: 10.1016/j.jot.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 10/14/2023] [Accepted: 10/26/2023] [Indexed: 03/22/2024] Open
Abstract
Background Prevention of adhesion formation following flexor tendon repair is essential for restoration of normal finger function. Although many medications have been studied in the experimental setting to prevent adhesions, clinical application is limited due to the complexity of application and delivery in clinical translation. Methods In this study, optimal dosages of gelatin and pentamidine were validated by gelatin concentration test. Following cell viability, cell migration, live and dead cell, and cell adhesion assay of the Turkey tenocytes, a model of Turkey tendon repair was established to evaluate the effectiveness of the Pentamidine-Gelatin sheet. Results Pentamidine carried with gelatin, a Food and drug administration (FDA) approved material for drug delivery, showed good dynamic release, biocompatibility, and degradation. The optimal dose of pentamidine (25ug) was determined in the in vivo study using tenocyte viability, migration, and cell adhesion assays. Further biochemical analyses demonstrated that this positive effect may be due to pentamidine downregulating the Wnt signaling pathway without affecting collagen expression. Conclusions We tested a FDA-approved antibiotic, pentamidine, for reducing adhesion formation after flexor tendon repair in both in vitro and in vivo using a novel turkey animal model. Compared with the non-pentamidine treatment group, pentamidine treated turkeys had significantly reduced adhesions and improved digit function after six weeks of tendon healing. The translational potential of this article This study for the first time showed that a common clinical drug, pentamidine, has a potential for clinical application to reduce tendon adhesions and improve tendon gliding function without interfering with tendon healing.
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Affiliation(s)
- Guidong Shi
- Department of Orthopaedics, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nakagawa Koichi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rou Wan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Yicun Wang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ramona Reisdorf
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Abigayle Wilson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tony C.T. Huang
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Peter C. Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Steven L. Moran
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Reisdorf RL, Liu H, Bi C, Vrieze AM, Moran SL, Amadio PC, Zhao C. Carbodiimide-Derivatized Synovial Fluid for Tendon Graft Coating Improves Long-Term Functional Outcomes of Flexor Tendon Reconstruction. Plast Reconstr Surg 2023; 152:840e-849e. [PMID: 36912937 PMCID: PMC11095404 DOI: 10.1097/prs.0000000000010390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Flexor digitorum profundus (FDP) tendon injury is common in hand trauma, and flexor tendon reconstruction is one of the most challenging procedures in hand surgery because of severe adhesion that exceeds 25% and hinders hand function. The surface properties of a graft from extrasynovial tendons are inferior to those of the native intrasynovial FDP tendons, which has been reported as one of the major causations. Improved surface gliding ability of the extrasynovial graft is needed. Thus, this study used carbodiimide-derivatized synovial fluid and gelatin (cd-SF-gel) to modify the surface of the graft, thus improving functional outcomes using a dog in vivo model. METHODS Forty FDP tendons from the second and fifth digits of 20 adult women underwent reconstruction with a peroneus longus (PL) autograft after creation of a tendon repair failure model for 6 weeks. Graft tendons were either coated with cd-SF-gel ( n = 20) or not. Animals were euthanized 24 weeks after reconstruction, and digits were collected after the animals were euthanized for biomechanical and histologic analyses. RESULTS Adhesion score (cd-SF-gel, 3.15 ± 1.53; control, 5 ± 1.26; P < 0.00017), normalized work of flexion (cd-SF-gel, 0.47 ± 0.28 N-mm/degree; control, 1.4 ± 1.45 N-mm/degree; P < 0.014), and distal interphalangeal joint motion (cd-SF-gel, 17.63 ± 6.77 degrees; control, 7.07 ± 12.99 degrees; P < 0.0015) in treated grafts all showed significant differences compared with nontreated grafts. However, there was no significant difference in repair conjunction strength between the two groups. CONCLUSION Autograft tendon surface modification with cd-SF-gel improves tendon gliding ability, reduces adhesion formation, and enhances digit function without interfering with graft-host healing. CLINICAL RELEVANCE STATEMENT The authors demonstrate a clinically relevant and translational technology by using the patient's own synovial fluid to "synovialize" an autologous extrasynovial tendon graft to improve functional outcomes following flexor tendon reconstruction.
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Affiliation(s)
- Ramona L. Reisdorf
- Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Haoyu Liu
- Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Chun Bi
- Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Alyssa M. Vrieze
- Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Steven L. Moran
- Division of Plastic and Reconstruction Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Peter C. Amadio
- Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905 USA
| | - Chunfeng Zhao
- Division of Orthopedic Research, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905 USA
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Yaşar B. Encircling tendon repair site with collagen sheet in flexor zone 2: retrospective study. J Orthop Surg Res 2023; 18:793. [PMID: 37875954 PMCID: PMC10594895 DOI: 10.1186/s13018-023-04294-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Peritendinous adhesion is the most common complication of tendon repairs in the hand and often requires surgical intervention, resulting in increased labor loss and increased treatment costs. Many agents used to reduce tendon adhesion in animal models, however these agents have not entered clinical use. This study is the first-ever clinical study that evaluates encircling tendon repair site with collagen sheet as an anti-adhesion barrier. METHODS Between December 2014 and January 2020, 156 patients included in this study, with clean cut isolated flexor digitorum profundus (FDP) tendon injury in flexor tendon zone 2. All tendons repaired with modified double Kessler technique. In 76 patients, tendon repair site encircled with collagen sheet. 80 patients were randomly selected from our clinical records and functional results are compared with Strickland's total active motion grading system. RESULTS The mean total range of motion was 79% in the control group and 81% in the collagen sheet group, and there was no statistically significant difference between the two groups (Z: - 1.393, p = 0.164). In the control group, very good and good repair according to Strikland classification was 65/80 (81%). In the collagen sheet group, it was 62/76 (82%), respectively. There was statistically significant difference between 5 FDP TAM measurements between collagen sheet and control group (t(35) = 0.29, p = 0.016, p < 0.05). The mean TAM of the 5 FDP tendons in the collagen sheet group: 83.8 (SD: 8.2) in the and 76.1 (SD: 9.5) in the control group. CONCLUSIONS For the first time in the literature, functional results of Zone 2 flexor tendon repair using collagen sheets in patients with clean cut tendon injuries reported. However, there were no statistical difference about total active motion between control and collagen sheet group, 5th FDS tendon repairs encircled with collagen sheets had better outcomes. Prospective studies in patient groups with high adhesion risk are recommended.
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Affiliation(s)
- Burak Yaşar
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences Turkey, Ankara Bilkent City Hospital, Ankara, Turkey.
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Abstract
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.
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Affiliation(s)
- Tomoyuki Kuroiwa
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, USA.
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Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery. Plast Reconstr Surg Glob Open 2022; 10:e4558. [PMID: 36225846 PMCID: PMC9542854 DOI: 10.1097/gox.0000000000004558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
Abstract
The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program.
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Korcari A, Buckley MR, Loiselle AE. Characterization of scar tissue biomechanics during adult murine flexor tendon healing. J Mech Behav Biomed Mater 2022; 130:105192. [PMID: 35339739 PMCID: PMC11103245 DOI: 10.1016/j.jmbbm.2022.105192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 12/14/2022]
Abstract
Tendon injuries are very common and result in significant impairments in mobility and quality of life. During healing, tendons produce a scar at the injury site, characterized by abundant and disorganized extracellular matrix and by permanent deficits in mechanical integrity compared to healthy tendon. Although a significant amount of work has been done to understand the healing process of tendons and to develop potential therapeutics for tendon regeneration, there is still a significant gap in terms of assessing the direct effects of therapeutics on the functional and material quality specifically of the scar tissue, and thus, on the overall tendon healing process. In this study, we focused on characterizing the mechanical properties of only the scar tissue in flexor digitorum longus (FDL) tendons during the proliferative and early remodeling healing phases and comparing these properties with the mechanical properties of the composite healing tissue. Our method was sensitive enough to identify significant differences in structural and material properties between the scar and tendon-scar composite tissues. To account for possible inaccuracies due to the small aspect ratio of scar tissue, we also applied inverse finite element analysis (iFEA) to compute mechanical properties based on simulated tests with accurate specimen geometries and boundary conditions. We found that the scar tissue linear tangent moduli calculated from iFEA were not significantly different from those calculated experimentally at all healing timepoints, validating our experimental findings, and suggesting the assumptions in our experimental calculations were accurate. Taken together, this study first demonstrates that due to the presence of uninjured stubs, testing composite healing tendons without isolating the scar tissue overestimates the material properties of the scar itself. Second, our scar isolation method promises to enable more direct assessment of how different treatment regimens (e.g., cellular ablation, biomechanical and/or biochemical stimuli, tissue engineered scaffolds) affect scar tissue function and material quality in multiple different types of tendons.
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Affiliation(s)
- Antonion Korcari
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, 14642, USA; Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
| | - Mark R Buckley
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, 14642, USA; Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA.
| | - Alayna E Loiselle
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, 14642, USA; Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA.
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Corduneanu‑Luca A, Pasca S, Tamas C, Moraru D, Ciuntu B, Stanescu C, Hreniuc‑Jemnoschi I, Tecuceanu A, Stamate T. Improving flexor tendon gliding by using the combination of carboxymethylcellulose‑polyethylene oxide on murine model. Exp Ther Med 2021; 23:105. [PMID: 34976147 PMCID: PMC8674966 DOI: 10.3892/etm.2021.11028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/14/2021] [Indexed: 11/08/2022] Open
Abstract
The current approach to flexor tendon injuries is complex and is no longer limited to suturing techniques. Strategies for improving hand function currently include rehabilitation protocols, appropriate suturing materials and techniques, changing the gliding surface by using lubricants and providing growth factors. One product, originally used in spinal surgery, has been shown to be effective in preventing postoperative adhesions. It is a combination of carboxymethylcellulose and polyethylene oxide-Dynavisc® (FzioMed, Inc.). The aim of the present study was to test the effect of Dynavisc® on acute injuries of the intrasynovial flexor tendons in the prevention of postoperative adhesions and the improvement of functional results. The study was performed on 20 Wistar rats distributed in two groups. The control group, represented by 10 rats, in which after the reconstruction of the flexor tendon, the peritendinous area was injected with saline solution and the study group, in which the peritendinous area was injected with a single administration of the lubricating gel, Dynavisc® (carboxymethylcellulose and polyethylene oxide). At 4 and 12 weeks, the rats were sacrificed and tissue biopsy consisted of tendon fragments and adjacent tissue. The evaluation of the results was performed by measuring the adhesion score and observing histological parameters. The presence of important adhesions was found in the control group compared with the group treated with Dynavisc®, where a supple and smooth tendon, with significantly fewer adhesions were found. The differences between the two groups were significant, thus indicating the efficiency of the lubricant in preventing adhesions. This study supported the important role of Dynavisc® in the regeneration of the tendon and the peritendinous structures, by limiting aberrant fibrous proliferation in the regeneration process and helping to build a peritendinous space.
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Affiliation(s)
| | - Sorin Pasca
- Department of Veterinary Pathology, Faculty of Veterinary Medicine, ‘Ion Ionescu de la Brad’ University of Agricultural Sciences and Veterinary Medicine, 700490 Iasi, Romania
| | - Camelia Tamas
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Dan Moraru
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Bogdan Ciuntu
- Department of General Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Cristina Stanescu
- Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University, 800216 Galati, Romania
| | - Irina Hreniuc‑Jemnoschi
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Angela Tecuceanu
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Teodor Stamate
- Department of Plastic Surgery, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
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Gao Z, Hassouneh L, Yang X, Pang J, Thornton PD, Tronci G. Hydrogen phosphate-mediated acellular biomineralisation within a dual crosslinked hyaluronic acid hydrogel. Eur Polym J 2021. [DOI: 10.1016/j.eurpolymj.2020.110187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lu CC, Zhang T, Amadio PC, An KN, Moran SL, Gingery A, Zhao C. Lateral slit delivery of bone marrow stromal cells enhances regeneration in the decellularized allograft flexor tendon. J Orthop Translat 2019; 19:58-67. [PMID: 31844614 PMCID: PMC6896678 DOI: 10.1016/j.jot.2019.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/09/2019] [Accepted: 05/14/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/OBJECTIVE Stem cell-based therapy has been applied to accelerate the revitalization of allograft tendon into a viable and functional tendon. Although many authors have proposed different methods to help the seeded stem cell distribution in the decellularized allograft, limited success has been achieved as tendon is a high dense connective tissue. We hypothesized that bone marrow stromal cells (BMSCs), seeded through the lateral slit, can regenerate the decellularized tendon (DCT) graft. The cell proliferation, cell viability, and tendon-specific gene expression are increased with the seeded cell density. METHODS Eighty-seven flexor digitorum profundus tendons were equally and randomly divided into 6 treatment groups that were seeded with low-density (2 × 107 cells/mL) and high-density (5 × 107 cells/mL) BMSCs through lateral slits cultured for 2 and 4 weeks, DCT without cells, and fresh live tendons. Tendons were evaluated for cell distribution, cell proliferation, cell viability, gene expression of Collagen I and Collagen III, tenogenic markers, and MMPs. RESULTS Histologic evaluation revealed BMSCs distributed from the lateral slit to the whole DCT. BMSCs were proliferated and kept viable in lateral slit decellularized tendon (LSDCT) in both seeded cell density groups after 2 and 4 weeks of culture. However, no significant differences in the cell proliferation between both cell density groups at 2 and 4 weeks of culture were observed. The lowest cell viability was found in the high-density group after 4 weeks of culture. BMSCs in LSDCT showed a significant tendency of higher gene expression of Collagen I, Collagen III, tenascin C, MMP2, MMP9, and MMP13 compared to normal tendons in both cell density groups at 2 and 4 weeks of culture. CONCLUSION BMSCs proliferated and remained viable after 2 and 4 weeks of culture with distribution throughout the lateral slits. Lateral slit preparation allows for the effective delivery and maintenance of mesenchymal cells with proliferation and generating a tenogenic behaviour of DCT in both the low and high cell densities in an in vitro model. THE TRANSLATION POTENTIAL OF THIS ARTICLE Revitalizing the implanted decellularized allograft is important for clinical application. In this study, we demonstrated that the DCT, with lateral slits, could harbour the seeded stem cell and stimulate proliferation with collagen synthesis. This evidence was presented for clinical application of the lateral slit technique, in DCT grafts, which would repopulate the seeded BMSCs during tendon and ligament reconstruction.
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Affiliation(s)
- Cheng-Chang Lu
- Biomechanics & Tendon and Soft Tissue Biology Laboratories, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
- Kaohsiung Medical University Hospital, Orthopaedic Department, Kaohsiung, Taiwan
- Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tao Zhang
- Biomechanics & Tendon and Soft Tissue Biology Laboratories, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | - Peter C. Amadio
- Biomechanics & Tendon and Soft Tissue Biology Laboratories, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | - Kai-Nan An
- Biomechanics & Tendon and Soft Tissue Biology Laboratories, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | - Steven L. Moran
- Biomechanics & Tendon and Soft Tissue Biology Laboratories, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | - Anne Gingery
- Biomechanics & Tendon and Soft Tissue Biology Laboratories, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
| | - Chunfeng Zhao
- Biomechanics & Tendon and Soft Tissue Biology Laboratories, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, USA
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Liu Q, Zhu Y, Qi J, Amadio PC, Moran SL, Gingery A, Zhao C. Isolation and characterization of turkey bone marrow-derived mesenchymal stem cells. J Orthop Res 2019; 37:1419-1428. [PMID: 30548886 DOI: 10.1002/jor.24203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/06/2018] [Indexed: 02/04/2023]
Abstract
Flexor tendon injury is often associated with suboptimal outcomes and results in substantial digit dysfunction. Stem cells have been isolated from several experimental animals for the growing interest and needs of utilizing cell-based therapies. Recently, turkey has been developed as a new large animal model for flexor tendon research. In the present study, we reported the isolation and characterization of bone marrow-derived mesenchymal stem cells (BMSCs) from 8- to 12-month-old heritage-breed turkeys. The isolated cells demonstrated fibroblast-like morphology, clonogenic capacity, and high proliferation rate. These cells were positive for surface antigens CD90, CD105, and CD44, but were negative for CD45. The multipotency of turkey BMSCs was determined by differentiating cells into osteogenic, adipogenic, chondrogenic, and tenogenic lineages. There was upregulated gene expression of tenogenic markers, including mohawk, tenomodulin, and EGR1 as well as increased collagen synthesis in BMP12 induced cells. The successful isolation and verification of bone marrow-derived MSCs from turkey would provide opportunities of studying cell-based therapies and developing new treatments for tendon injuries using this novel preclinical large animal model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1419-1428, 2019.
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Affiliation(s)
- Qian Liu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, P. R. China
| | - Yaxi Zhu
- Department of Molecular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jun Qi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anne Gingery
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Liu Q, Yu Y, Reisdorf RL, Qi J, Lu CK, Berglund LJ, Amadio PC, Moran SL, Steinmann SP, An KN, Gingery A, Zhao C. Engineered tendon-fibrocartilage-bone composite and bone marrow-derived mesenchymal stem cell sheet augmentation promotes rotator cuff healing in a non-weight-bearing canine model. Biomaterials 2018; 192:189-198. [PMID: 30453215 DOI: 10.1016/j.biomaterials.2018.10.037] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/26/2018] [Accepted: 10/26/2018] [Indexed: 12/18/2022]
Abstract
Reducing rotator cuff failure after repair remains a challenge due to suboptimal tendon-to-bone healing. In this study we report a novel biomaterial with engineered tendon-fibrocartilage-bone composite (TFBC) and bone marrow-derived mesenchymal stem cell sheet (BMSCS); this construct was tested for augmentation of rotator cuff repair using a canine non-weight-bearing (NWB) model. A total of 42 mixed-breed dogs were randomly allocated to 3 groups (n = 14 each). Unilateral infraspinatus tendon underwent suture repair only (control); augmentation with engineered TFBC alone (TFBC), or augmentation with engineered TFBC and BMSCS (TFBC + BMSCS). Histomorphometric analysis and biomechanical testing were performed at 6 weeks after surgery. The TFBC + BMSCS augmented repairs demonstrated superior histological scores, greater new fibrocartilage formation and collagen fiber organization at the tendon-bone interface compared with the controls. The ultimate failure load and ultimate stress were 286.80 ± 45.02 N and 4.50 ± 1.11 MPa for TFBC + BMSCS group, 163.20 ± 61.21 N and 2.60 ± 0.97 MPa for control group (TFBC + BMSCS vs control, P = 1.12E-04 and 0.003, respectively), 206.10 ± 60.99 N and 3.20 ± 1.31 MPa for TFBC group (TFBC + BMSCS vs TFBC, P = 0.009 and 0.045, respectively). In conclusion, application of an engineered TFBC and BMSCS can enhance rotator cuff healing in terms of anatomic structure, collagen organization and biomechanical strength in a canine NWB model. Combined TFBC and BMSCS augmentation is a promising strategy for rotator cuff tears and has a high potential impact on clinical practice.
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Affiliation(s)
- Qian Liu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Orthopaedics, The Second Xiangya Hospital, Central South University, Changsha, PR China
| | - Yinxian Yu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Jun Qi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chun-Kuan Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kai-Nan An
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anne Gingery
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Two stage reconstruction of flexor tendon injuries in zone II after missed injury or failed repair. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Wei Z, Reisdorf RL, Thoreson AR, Jay GD, Moran SL, An KN, Amadio PC, Zhao C. Comparison of Autograft and Allograft with Surface Modification for Flexor Tendon Reconstruction: A Canine in Vivo Model. J Bone Joint Surg Am 2018; 100:e42. [PMID: 29613931 PMCID: PMC6372221 DOI: 10.2106/jbjs.17.00925] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Flexor tendon injury is common, and tendon reconstruction is indicated clinically if the primary repair fails or cannot be performed immediately after tendon injury. The purpose of the current study was to compare clinically standard extrasynovial autologous graft (EAG) tendon and intrasynovial allogeneic graft (IAG) that had both undergone biolubricant surface modification in a canine in vivo model. METHODS Twenty-four flexor digitorum profundus (FDP) tendons from the second and fifth digits of 12 dogs were used for this study. In the first phase, a model of failed FDP tendon repair was created. After 6 weeks, the ruptured FDP tendons with a scarred digit were reconstructed with the use of either EAG or IAG tendons treated with carbodiimide-derivatized hyaluronic acid and lubricin. At 12 weeks after tendon reconstruction, the digits were harvested for functional, biomechanical, and histologic evaluations. RESULTS The tendon failure model was a clinically relevant and reproducible model for tendon reconstruction. The IAG group demonstrated improved digit function with decreased adhesion formation, lower digit work of flexion, and improved graft gliding ability compared with the EAG group. However, the IAG group had decreased healing at the distal tendon-bone junction. Our histologic findings verified the biomechanical evaluations and, further, showed that cellular repopulation of allograft at 12 weeks after reconstruction is still challenging. CONCLUSIONS FDP tendon reconstruction using IAG with surface modification has some beneficial effects for reducing adhesions but demonstrated inferior healing at the distal tendon-bone junction compared with EAG. These mixed results indicate that vitalization and turnover acceleration are crucial to reducing failure of reconstruction with allograft. CLINICAL RELEVANCE Flexor tendon reconstruction is a common surgical procedure. However, postoperative adhesion formation may lead to unsatisfactory clinical outcomes. In this study, we developed a potential flexor tendon allograft using chemical and tissue-engineering approaches. This technology could improve function following tendon reconstruction.
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Affiliation(s)
- Zhuang Wei
- Orthopedic Biomechanics Laboratory, Division of Orthopedics Research, Mayo Clinic, Rochester, Minnesota
| | - Ramona L. Reisdorf
- Orthopedic Biomechanics Laboratory, Division of Orthopedics Research, Mayo Clinic, Rochester, Minnesota
| | - Andrew R. Thoreson
- Orthopedic Biomechanics Laboratory, Division of Orthopedics Research, Mayo Clinic, Rochester, Minnesota
| | | | - Steven L. Moran
- Orthopedic Biomechanics Laboratory, Division of Orthopedics Research, Mayo Clinic, Rochester, Minnesota
| | - Kai-Nan An
- Orthopedic Biomechanics Laboratory, Division of Orthopedics Research, Mayo Clinic, Rochester, Minnesota
| | - Peter C. Amadio
- Orthopedic Biomechanics Laboratory, Division of Orthopedics Research, Mayo Clinic, Rochester, Minnesota
| | - Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Division of Orthopedics Research, Mayo Clinic, Rochester, Minnesota,E-mail address for C. Zhao:
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Zhang T, Lu CC, Reisdorf RL, Thoreson AR, Gingery A, Moran SL, Amadio PC, Zhao C. Revitalized and synovialized allograft for intrasynovial flexor tendon reconstruction in an in vivo canine model. J Orthop Res 2018; 36:2218-2227. [PMID: 29575268 DOI: 10.1002/jor.23889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/02/2018] [Indexed: 02/04/2023]
Abstract
This study was to test our hypothesis that flexor tendon reconstruction with an allograft revitalized with bone marrow stromal cells (BMSCs) and synovialized with carbodiimide derivatized autologous synovial fluid (cd-SYN) would result in better digit functional restoration than the conventional allograft tendon. A total of 32 flexor digital profundus tendons from the second and fifth digit of 16 dogs were created a repair failure model first. Then, failed-repaired tendons were reconstructed with either a revitalized-synovialized allograft tendon or a clinical standard autograft tendon (control group). The allograft tendon was seeded with autologous BMSCs in multiple slits and the graft surface was coated with cd-SYN. A 6 weeks after tendon reconstruction, the digits were harvested and evaluated for digit function, adhesion status, tendon gliding resistance, attachment strength, cell viability, and histologic factors. The allograft group had significantly improved digit function compared with the control group through decreased work of flexion, increased digit range of motion under 2-Newton force, and less adhesion score (p < .05). However, the distal attachment-site strength and stiffness in the allograft tendon were significantly weaker than the autografts (p < .05). No significant difference was found for gliding resistance. Histologically, allograft tendons coated with allograft had smoother surfaces and showed tendon-to-bone and tendon-to-tendon incorporation. Viable BMSCs were found in the tendon slits 6 weeks after the graft. In conclusion, cellular lubricant-based modification of allograft tendons improved digit function and reduced the adhesions compared with autograft for flexor tendon reconstruction. However, improvement of graft-to-host tendon healing is still challenging. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Tao Zhang
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
- Joint Surgery and Sports Medicine, Jinan Central Hospital, 250013, Shandong, China
| | - Cheng-Chang Lu
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
| | - Ramona L Reisdorf
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
| | - Andrew R Thoreson
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
| | - Anne Gingery
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
| | - Steven L Moran
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
| | - Peter C Amadio
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
| | - Chunfeng Zhao
- Orthopedic Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 55905, Rochester, Minnesota
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17
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Kadar A, Thoreson AR, Reisdorf RL, Amadio PC, Moran SL, Zhao C. Turkey model for flexor tendon research: in vitro comparison of human, canine, turkey, and chicken tendons. J Surg Res 2017; 216:46-55. [PMID: 28807213 DOI: 10.1016/j.jss.2017.03.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 02/23/2017] [Accepted: 03/24/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Flexor tendon injuries are one of the most common hand injuries and remain clinically challenging for functional restoration. Canine and chicken have been the most commonly used animal models for flexor tendon-related research but possess several disadvantages. The purpose of this study was to explore a potential turkey model for flexor tendon research. METHODS The third digit from human cadaveric hands, canine forepaws, turkey foot, and chicken foot were used for this study. Six digits in each of four species were studied in detail, comparing anatomy of the flexor apparatus, joint range of motioņ tendon excursion, tendon cross-sectional area, work of flexion, gliding resistance at the level of the A2 pulley, modulus of elasticity, suture retention strength, and histology across species. RESULTS Anatomically, the third digit in the four species displayed structural similarities; however, the tendon cross-sectional area of the turkey and human were similar and larger than canine and chicken. Furthermore, the turkey digit resembles the human's finger with the lack of webbing between digits, similar vascularization, tendon excursion, work of flexion, gliding resistance, mechanical properties, and suture holding strength. More importantly, human and turkey tendons were most similar in histological appearance. CONCLUSIONS Turkey flexor tendons have many properties that are comparable to human flexor tendons which would provide a clinically relevant, economical, nonhuman companion large animal model for flexor tendon research.
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Affiliation(s)
- Assaf Kadar
- Department of Orthopedic Surgery, Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota; Division of Orthopaedic Surgery, Department of Orthopedic Surgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew R Thoreson
- Department of Orthopedic Surgery, Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Ramona L Reisdorf
- Department of Orthopedic Surgery, Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Peter C Amadio
- Department of Orthopedic Surgery, Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Steven L Moran
- Department of Orthopedic Surgery, Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, Minnesota.
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Edsfeldt S, Holm B, Mahlapuu M, Reno C, Hart DA, Wiig M. PXL01 in sodium hyaluronate results in increased PRG4 expression: a potential mechanism for anti-adhesion. Ups J Med Sci 2017; 122:28-34. [PMID: 27658527 PMCID: PMC5361429 DOI: 10.1080/03009734.2016.1230157] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To investigate the anti-adhesive mechanisms of PXL01 in sodium hyaluronate (HA) by using the rabbit lactoferrin peptide, rabPXL01 in HA, in a rabbit model of healing tendons and tendon sheaths. The mechanism of action for PXL01 in HA is interesting since a recent clinical study of the human lactoferrin peptide PXL01 in HA administered around repaired tendons in the hand showed improved digit mobility. MATERIALS AND METHODS On days 1, 3, and 6 after tendon injury and surgical repair, reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR) was used to assess mRNA expression levels for genes encoding the mucinous glycoprotein PRG4 (also called lubricin) and a subset of matrix proteins, cytokines, and growth factors involved in flexor tendon repair. RabPXL01 in HA was administered locally around the repaired tendons, and mRNA expression was compared with untreated repaired tendons and tendon sheaths. RESULTS We observed, at all time points, increased expression of PRG4 mRNA in tendons treated with rabPXL01 in HA, but not in tendon sheaths. In addition, treatment with rabPXL01 in HA led to repression of the mRNA levels for the pro-inflammatory mediators interleukin (IL)-1β, IL-6, and IL-8 in tendon sheaths. CONCLUSIONS RabPXL01 in HA increased lubricin mRNA production while diminishing mRNA levels of inflammatory mediators, which in turn reduced the gliding resistance and inhibited the adhesion formation after flexor tendon repair.
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Affiliation(s)
- Sara Edsfeldt
- Department of Surgical Sciences, Hand Surgery, Uppsala University, Uppsala, Sweden
- Department of Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Björn Holm
- Department of Surgical Sciences, Hand Surgery, Uppsala University, Uppsala, Sweden
- Department of Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
| | | | - Carol Reno
- Department of Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - David A. Hart
- Department of Surgery, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
| | - Monica Wiig
- Department of Surgical Sciences, Hand Surgery, Uppsala University, Uppsala, Sweden
- Department of Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- CONTACT Monica Wiig, MD, PhD , Department of Surgical Sciences, Hand Surgery, Uppsala University, PO Box 256, SE-751 05 Uppsala, Sweden
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Flexor Tendon Sheath Engineering Using Decellularized Porcine Pericardium. Plast Reconstr Surg 2016; 138:630e-641e. [DOI: 10.1097/prs.0000000000002459] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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20
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Meier Bürgisser G, Calcagni M, Bachmann E, Fessel G, Snedeker JG, Giovanoli P, Buschmann J. Rabbit Achilles tendon full transection model - wound healing, adhesion formation and biomechanics at 3, 6 and 12 weeks post-surgery. Biol Open 2016; 5:1324-33. [PMID: 27635037 PMCID: PMC5051656 DOI: 10.1242/bio.020644] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
After tendon rupture repair, two main problems may occur: re-rupture and adhesion formation. Suitable non-murine animal models are needed to study the healing tendon in terms of biomechanical properties and extent of adhesion formation. In this study 24 New Zealand White rabbits received a full transection of the Achilles tendon 2 cm above the calcaneus, sutured with a 4-strand Becker suture. Post-surgical analysis was performed at 3, 6 and 12 weeks. In the 6-week group, animals received a cast either in a 180 deg stretched position during 6 weeks (adhesion provoking immobilization), or were re-casted with a 150 deg position after 3 weeks (adhesion inhibiting immobilization), while in the other groups (3 and 12 weeks) a 180 deg position cast was applied for 3 weeks. Adhesion extent was analyzed by histology and ultrasound. Histopathological scoring was performed according to a method by Stoll et al. (2011), and the main biomechanical properties were assessed. Histopathological scores increased as a function of time, but did not reach values of healthy tendons after 12 weeks (only around 15 out of 20 points). Adhesion provoking immobilization led to an adhesion extent of 82.7±9.7%, while adhesion inhibiting immobilization led to 31.9±9.8% after 6 weeks. Biomechanical properties increased over time, however, they did not reach full strength nor elastic modulus at 12 weeks post-operation. Furthermore, the rabbit Achilles tendon model can be modulated in terms of adhesion formation to the surrounding tissue. It clearly shows the different healing stages in terms of histopathology and offers a suitable model regarding biomechanics because it exhibits similar biomechanics as the human flexor tendons of the hand. Summary: The rabbit Achilles tendon full transection model can be used to study adhesion extent in a controlled way. It also mimics the biomechanics of human hand flexor tendons.
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Affiliation(s)
- Gabriella Meier Bürgisser
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
| | - Maurizio Calcagni
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
| | - Elias Bachmann
- Uniklinik Balgrist, Department of Orthopedics, Forchstrasse 340, Zurich 8008, Switzerland
| | - Gion Fessel
- Uniklinik Balgrist, Department of Orthopedics, Forchstrasse 340, Zurich 8008, Switzerland
| | - Jess G Snedeker
- Uniklinik Balgrist, Department of Orthopedics, Forchstrasse 340, Zurich 8008, Switzerland Laboratory for Orthopaedic Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ), Rämistrasse 101, Zurich CH-8092, Switzerland
| | - Pietro Giovanoli
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
| | - Johanna Buschmann
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Sternwartstrasse 14, Zurich 8091, Switzerland
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Recombinant human lubricin for prevention of postoperative intra-abdominal adhesions in a rat model. J Surg Res 2016; 208:20-25. [PMID: 27993210 DOI: 10.1016/j.jss.2016.08.092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/10/2016] [Accepted: 08/26/2016] [Indexed: 12/08/2022]
Abstract
BACKGROUND Postoperative intra-abdominal adhesions are a major cause of morbidity and mortality and contribute to a heavy burden on health care resources. At present, numerous introduced adhesion prevention products have demonstrated some benefit but none are consistently effective. The aim of this study was to examine the effectiveness of recombinant human lubricin in preventing intra-abdominal adhesion formation. MATERIALS AND METHODS A total of 62 male Wistar Albino rats were randomly assigned to the study. Six rats were used to the initial pilot study and 56 rats were randomized into four groups: (1) control cecal abrasion; (2) treatment cecal abrasion with 0.5 mg/mL lubricin solution; (3) control cecal enterotomy and primary closure; and (4) treatment cecal enterotomy and primary closure with 0.5 mg/mL lubricin solution. Rats were sacrificed at 3 d and 21 d postoperatively for the pilot and main studies, respectively. Macroscopic and microscopic adhesion severity was graded by blinded investigators. RESULTS For the pilot study, all six rats successfully reached the end point indicating safety of the lubricin gel. In the main randomized study, adhesions in the treated cecal abrasion group were significantly reduced both macroscopically (P = 0.001) and microscopically (fibrosis P = 0.009, inflammation P < 0.0001), when compared with the control group. In the cecal enterotomy group, adhesions were reduced for the treatment group in macroscopic (P = 0.011) and microscopic grading (fibrosis P = 0.500, inflammation P = 0.206) compared with the control group. CONCLUSIONS Recombinant human lubricin significantly reduced both macroscopic and microscopic intra-abdominal adhesions in the cecal abrasion group. The cecal enterotomy group showed modest macroscopic adhesion reduction. Future study using higher concentration of lubricin solution are needed to investigate its toxicity and more profound antiadhesion properties in significant operations.
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Liu DH, Tsai MW, Lin SH, Chou CL, Chiu JW, Chiang CC, Kao CL. Ultrasound-Guided Hyaluronic Acid Injections for Trigger Finger: A Double-Blinded, Randomized Controlled Trial. Arch Phys Med Rehabil 2015; 96:2120-7. [PMID: 26340807 DOI: 10.1016/j.apmr.2015.08.421] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/04/2015] [Accepted: 08/18/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate the effects of ultrasound-guided injections of hyaluronic acid (HA) versus steroid for trigger fingers in adults. DESIGN Prospective, double-blinded, randomized controlled study. SETTING Tertiary care center. PARTICIPANTS Subjects with a diagnosis of trigger finger (N=36; 39 affected digits) received treatment and were evaluated. INTERVENTIONS Subjects were randomly assigned to HA and steroid injection groups. Both study medications were injected separately via ultrasound guidance with 1 injection. MAIN OUTCOME MEASURES The classification of trigger grading, pain, functional disability, and patient satisfaction were evaluated before the injection and 3 weeks and 3 months after the injection. RESULTS At 3 months, 12 patients (66.7%) in the HA group and 17 patients (89.5%) in the steroid group exhibited no triggering of the affected fingers (P=.124). The treatment results at 3 weeks and 3 months showed similar changes in the Quinnell scale (P=.057 and .931, respectively). A statistically significant interaction effect between group and time was found for visual analog scale (VAS) and Michigan Hand Outcome Questionnaire (MHQ) evaluation (P<.05). The steroid group had a lower VAS at 3 months after injection (steroid 0.5±1.1 vs HA 2.7±2.4; P<.001). The HA group demonstrated continuing significant improvement in MHQ at 3 months (change from 3wk: steroid -2.6±14.1 vs HA 19.1±37.0; P=.023; d=.78). CONCLUSIONS Ultrasound-guided injection of HA demonstrated promising results for the treatment of trigger fingers. The optimal frequency, dosage, and molecular weight of HA injections for trigger fingers deserve further investigation for future clinical applications.
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Affiliation(s)
- Ding-Hao Liu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Mei-Wun Tsai
- Institute of Physical Therapy and Assistive Technology, School of Biomedical Science and Engineering, National Yang-Ming University, Taipei, Taiwan
| | - Shan-Hui Lin
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan
| | - Chen-Liang Chou
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jan-Wei Chiu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan
| | - Chao-Ching Chiang
- Division of Orthopaedic Trauma, Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chung-Lan Kao
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan; Institute of Physical Therapy and Assistive Technology, School of Biomedical Science and Engineering, National Yang-Ming University, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Ji X, Bao N, An KN, Amadio PC, Steinmann SP, Zhao C. A Canine Non-Weight-Bearing Model with Radial Neurectomy for Rotator Cuff Repair. PLoS One 2015; 10:e0130576. [PMID: 26107616 PMCID: PMC4479444 DOI: 10.1371/journal.pone.0130576] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 05/21/2015] [Indexed: 11/19/2022] Open
Abstract
Background The major concern of using a large animal model to study rotator cuff repair is the high rate of repair retears. The purpose of this study was to test a non-weight-bearing (NWB) canine model for rotator cuff repair research. Methods First, in the in vitro study, 18 shoulders were randomized to 3 groups. 1) Full-width transections repaired with modified Mason-Allen sutures using 3-0 polyglactin suture, 2) Group 1 repaired using number 2 (#2) polyester braid and long-chain polyethylene suture, and 3) Partial-width transections leaving the superior 2 mm infraspinatus tendon intact without repair. In the in vivo study of 6 dogs, the infraspinatus tendon was partially transected as the same as the in vitro group 3. A radial neurectomy was performed to prevent weight bearing. The operated limb was slung in a custom-made jacket for 6 weeks. Results In the in vitro study, mean ultimate tensile load and stiffness in Group 2 were significantly higher than Group 1 and 3 (p<0.05). In the in vivo study, gross inspection and histology showed that the preserved superior 2-mm portion of the infraspinatus tendon remained intact with normal structure. Conclusions Based on the biomechanical and histological findings, this canine NWB model may be an appropriate and useful model for studies of rotator cuff repair.
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Affiliation(s)
- Xiaoxi Ji
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, 55905, United States of America
- Trauma Center, Shanghai First People’s Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China
| | - Nirong Bao
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, 55905, United States of America
| | - Kai-Nan An
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, 55905, United States of America
| | - Peter C. Amadio
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, 55905, United States of America
| | - Scott P. Steinmann
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, 55905, United States of America
| | - Chunfeng Zhao
- Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, Rochester, MN, 55905, United States of America
- * E-mail:
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24
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Ji X, Reisdorf RL, Thoreson AR, Berglund LR, Moran SL, Jay GD, An KN, Amadio PC, Zhao C. Surface Modification with Chemically Modified Synovial Fluid for Flexor Tendon Reconstruction in a Canine Model in Vivo. J Bone Joint Surg Am 2015; 97:972-8. [PMID: 26085530 PMCID: PMC4469787 DOI: 10.2106/jbjs.n.01100] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Functional restoration is the major concern after flexor tendon reconstruction in the hand. The purpose of the present study was to investigate the effects of modifying the surface of extrasynovial tendon autografts with carbodiimide-derivatized synovial fluid with gelatin (cd-SF-G) on functional outcomes of flexor tendon reconstruction using a canine model. METHODS The second and fifth flexor digitorum profundus tendons from eleven dogs were transected and repaired in zone II. The dogs then had six weeks of free activity leading to tendon rupture and scar formation (the repair-failure phase). In the reconstruction phase, two autologous peroneus longus tendons from each dog were harvested; one tendon was coated with cd-SF-G and the other, with saline solution, as a control. A non-weight-bearing rehabilitation protocol was followed for six weeks after reconstruction. The digits were then harvested and evaluations of function, adhesion status, gliding resistance, attachment strength, cell viability, and histology were performed. RESULTS The tendons coated with cd-SF-G demonstrated significantly lower values (mean and standard deviation) compared with the saline-solution group for work of flexion (0.63 ± 0.24 versus 1.34 ± 0.42 N-mm/deg), adhesion score (3.5 ± 1.6 versus 6.1 ± 1.3), proximal adhesion breaking force (8.6 ± 3.2 versus 20.2 ± 10.2 N), and gliding resistance (0.26 ± 0.08 versus 0.46 ± 0.22 N) (p < 0.05). There was no significant difference between the cd-SF-G and saline-solution groups (p > 0.05) in distal attachment-site strength (56.9 ± 28.4 versus 77.2 ± 36.2 N), stiffness (19 ± 7.5 versus 24.5 ± 14.5 N/mm), and compressive modulus from indentation testing (4.37 ± 1.26 versus 3.98 ± 1.24 N/mm). Histological analysis showed that tendons coated with cd-SF-G had smoother surfaces and demonstrated tendon-to-bone and tendon-to-tendon incorporation. No significant difference in viable cell count between the two groups was observed on tendon culture. CONCLUSIONS Modification of the flexor tendon surface with cd-SF-G significantly improved digital function and reduced adhesion formation without affecting graft healing and stiffness. CLINICAL RELEVANCE This study used native synovial fluid as a basic lubricating reagent to treat a tendon graft in vivo, a novel avenue for improving clinical outcomes of flexor tendon reconstruction. This methodology may also apply to other surgical procedures where postoperative adhesions impair function.
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Affiliation(s)
- Xiaoxi Ji
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Ramona L. Reisdorf
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Andrew R. Thoreson
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Lawrence R. Berglund
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Steven L. Moran
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Gregory D. Jay
- Department of Emergency Medicine, Brown University, 593 Eddy Street, Claverick 100, Providence, RI 02903
| | - Kai-Nan An
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Peter C. Amadio
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Chunfeng Zhao
- Departments of Orthopedic Surgery (X.J., R.L.R., A.R.T., L.R.B., K-N.A., P.C.A., and C.Z.) and Plastic Surgery (S.L.M.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
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Thomopoulos S, Parks WC, Rifkin DB, Derwin KA. Mechanisms of tendon injury and repair. J Orthop Res 2015; 33:832-9. [PMID: 25641114 PMCID: PMC4418182 DOI: 10.1002/jor.22806] [Citation(s) in RCA: 319] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/13/2014] [Indexed: 02/04/2023]
Abstract
Tendon disorders are common and lead to significant disability, pain, healthcare cost, and lost productivity. A wide range of injury mechanisms exist leading to tendinopathy or tendon rupture. Tears can occur in healthy tendons that are acutely overloaded (e.g., during a high speed or high impact event) or lacerated (e.g., a knife injury). Tendinitis or tendinosis can occur in tendons exposed to overuse conditions (e.g., an elite swimmer's training regimen) or intrinsic tissue degeneration (e.g., age-related degeneration). The healing potential of a torn or pathologic tendon varies depending on anatomic location (e.g., Achilles vs. rotator cuff) and local environment (e.g., intrasynovial vs. extrasynovial). Although healing occurs to varying degrees, in general healing of repaired tendons follows the typical wound healing course, including an early inflammatory phase, followed by proliferative and remodeling phases. Numerous treatment approaches have been attempted to improve tendon healing, including growth factor- and cell-based therapies and rehabilitation protocols. This review will describe the current state of knowledge of injury and repair of the three most common tendinopathies--flexor tendon lacerations, Achilles tendon rupture, and rotator cuff disorders--with a particular focus on the use of animal models for understanding tendon healing.
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Affiliation(s)
- Stavros Thomopoulos
- Washington University, Department of Orthopedic Surgery, Saint Louis, MO,Corresponding Authors: Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, . Kathleen A. Derwin, Ph.D., Cleveland Clinic Lerner Research Institute, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, Ohio 44195, Phone: 216-445-5982,
| | - William C. Parks
- Cedars Sinai Medical Center, Department of Medicine, Los Angeles, CA
| | | | - Kathleen A. Derwin
- Cleveland Clinic Lerner Research Institute, Cleveland, OH,Corresponding Authors: Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, . Kathleen A. Derwin, Ph.D., Cleveland Clinic Lerner Research Institute, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, Ohio 44195, Phone: 216-445-5982,
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Ryan CNM, Sorushanova A, Lomas AJ, Mullen AM, Pandit A, Zeugolis DI. Glycosaminoglycans in Tendon Physiology, Pathophysiology, and Therapy. Bioconjug Chem 2015; 26:1237-51. [DOI: 10.1021/acs.bioconjchem.5b00091] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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What is the best candidate allograft for ACL reconstruction? An in vitro mechanical and histologic study in a canine model. J Biomech 2015; 48:1811-6. [PMID: 25981102 DOI: 10.1016/j.jbiomech.2015.04.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/24/2015] [Accepted: 04/27/2015] [Indexed: 11/21/2022]
Abstract
The knee joint is generally characterized by very low friction and high wear resistance. Several previous studies have compared ACL with the commonly used allografts from tensile properties perspective. No study has reported about the graft tendons from a frictional perspective, which is an important parameter for ACL functional performance. Twenty hind legs were used to harvest FDP tendon, ACL, ACH, and patellar tendon. Samples were evaluated with surface friction testing, indentation testing for tendon compressive moduli, lubricin immunohistochemistry, and histologic analysis. Frictional force of FDP tendon and ACL was significantly less than that of patellar tendon and ACH at first and fifth cycles. At the tenth cycle, the FDP tendon, ACL, and ACH showed significantly less frictional force than patellar tendon; after 100 cycles, the FDP tendon and ACL showed significantly less frictional force than patellar tendon. The compressive moduli of the FDP tendon, ACL, and ACH were significantly greater than that of patellar tendon. Histologic results showed that FDP tendon and ACL had a smooth surface with a thin layer of epitenon cells; patellar tendon and ACH had a rough surface and a layer of paratenon. Lubricin was found on the surface and extracellular matrix of FDP tendon and ACL. There was only limited lubricin expression on the surface and extracellular matrix of the ACH and patellar tendon. The FDP tendon has friction force and lubricin expression similar to those of native ACL. However, patellar tendon and ACH show higher friction force and less lubricin expression than ACL.
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Wu J, Thoreson AR, Reisdorf RL, An KN, Moran SL, Amadio PC, Zhao C. Biomechanical evaluation of flexor tendon graft with different repair techniques and graft surface modification. J Orthop Res 2015; 33:731-7. [PMID: 25665071 PMCID: PMC5175471 DOI: 10.1002/jor.22844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 01/27/2015] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to investigate the biomechanical properties of modified repair techniques for flexor tendon reconstruction and the effects of surface modification using carbodiimide-derivatized synovial fluid plus gelatin (cd-SF-G), compared to the traditional repair techniques. The second and fifth digits from 16 canine forepaws were randomly divided into 4 groups: (1) traditional graft repairs (TGR group) including distal Bunnell repair and proximal Pulvertaft weave repair; (2) modified graft repairs (MGR group) including distal graft bony attachment repair and proximal step-cut repair; (3) group TGR coated with cd-SF-G (TGR-C group); and (4) group MGR coated with cd-SF-G (MGR-C group). Digit normalized work of flexion (nWOF), ultimate failure strength, and stiffness were measured. The nWOF in MGR group was significantly less than TGR group (p < 0.05). The nWOF in groups treated with cd-SF-G was significantly less than their untreated counterparts (p < 0.05). Ultimate load to failure of the MGR-C group was significantly greater than the TGR-C group (p < 0.05), but no significant difference in stiffness was found between these two groups. The modified techniques cannot only improve tendon gliding abilities but can also improve breaking strength. Additionally, surface modification with cd-SF-G significantly decreased the work of flexion.
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Affiliation(s)
- Jingheng Wu
- Biomechanics & Tendon and Soft Tissue Biology Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905,Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Andrew R. Thoreson
- Biomechanics & Tendon and Soft Tissue Biology Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905
| | - Ramona L. Reisdorf
- Biomechanics & Tendon and Soft Tissue Biology Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905
| | - Kai-Nan An
- Biomechanics & Tendon and Soft Tissue Biology Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905
| | - Steven L. Moran
- Biomechanics & Tendon and Soft Tissue Biology Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905
| | - Peter C. Amadio
- Biomechanics & Tendon and Soft Tissue Biology Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905
| | - Chunfeng Zhao
- Biomechanics & Tendon and Soft Tissue Biology Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905
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Wiig ME, Dahlin LB, Fridén J, Hagberg L, Larsen SE, Wiklund K, Mahlapuu M. PXL01 in sodium hyaluronate for improvement of hand recovery after flexor tendon repair surgery: randomized controlled trial. PLoS One 2014; 9:e110735. [PMID: 25340801 PMCID: PMC4207831 DOI: 10.1371/journal.pone.0110735] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 09/15/2014] [Indexed: 01/20/2023] Open
Abstract
Background Postoperative adhesions constitute a substantial clinical problem in hand surgery. Fexor tendon injury and repair result in adhesion formation around the tendon, which restricts the gliding function of the tendon, leading to decreased digit mobility and impaired hand recovery. This study evaluated the efficacy and safety of the peptide PXL01 in preventing adhesions, and correspondingly improving hand function, in flexor tendon repair surgery. Methods This prospective, randomised, double-blind trial included 138 patients admitted for flexor tendon repair surgery. PXL01 in carrier sodium hyaluronate or placebo was administered around the repaired tendon. Efficacy was assessed by total active motion of the injured finger, tip-to-crease distance, sensory function, tenolysis rate and grip strength, and safety parameters were followed, for 12 months post-surgery. Results The most pronounced difference between the treatment groups was observed at 6 months post-surgery. At this timepoint, the total active motion of the distal finger joint was improved in the PXL01 group (60 vs. 41 degrees for PXL01 vs. placebo group, p = 0.016 in PPAS). The proportion of patients with excellent/good digit mobility was higher in the PXL01 group (61% vs. 38%, p = 0.0499 in PPAS). Consistently, the PXL01 group presented improved tip-to-crease distance (5.0 vs. 15.5 mm for PXL01 vs. placebo group, p = 0.048 in PPAS). Sensory evaluation showed that more patients in the PXL01 group felt the thinnest monofilaments (FAS: 74% vs. 35%, p = 0.021; PPAS: 76% vs. 35%, p = 0.016). At 12 months post-surgery, more patients in the placebo group were considered to benefit from tenolysis (30% vs. 12%, p = 0.086 in PPAS). The treatment was safe, well tolerated, and did not increase the rate of tendon rupture. Conclusions Treatment with PXL01 in sodium hyaluronate improves hand recovery after flexor tendon repair surgery. Further clinical trials are warranted to determine the most efficient dose and health economic benefits. Trial Registration ClinicalTrials.gov NCT01022242; EU Clinical Trials 2009-012703-25.
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Affiliation(s)
- Monica E. Wiig
- Department of Surgical Science, Hand Surgery, Uppsala University, Uppsala, Sweden
- Uppsala University Hospital, Uppsala, Sweden
- * E-mail:
| | - Lars B. Dahlin
- Department of Clinical Sciences Malmö - Hand Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Jan Fridén
- Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Lars Hagberg
- Department of Hand Surgery, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Sören E. Larsen
- Department for Orthopaedics, Unit for Hand Surgery, Odense University Hospital, Odense, Denmark
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Describe and apply the current evidence-based treatment of acute flexor tendon injuries. (2) Compare and contrast the current postoperative therapy regimens following repair of flexor tendons. (3) Apply an evidence-based decision-making process for suture techniques of flexor tendon injuries. SUMMARY Flexor tendon repair remains a challenge for hand surgeons to reliably obtain excellent results. Surgical decisions should rely on the surgeon's experience, outcome studies, and direct evidence. This review is a compilation of the evidence from the literature on optimizing outcomes for flexor tendon repair.
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Meier Bürgisser G, Buschmann J. History and performance of implant materials applied as peritendinous antiadhesives. J Biomed Mater Res B Appl Biomater 2014; 103:212-28. [PMID: 24810922 DOI: 10.1002/jbm.b.33182] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/18/2014] [Accepted: 04/05/2014] [Indexed: 01/14/2023]
Abstract
Peritendinous fibrotic adhesions after tendon surgery are still a problem up-to-date. Approaches to overcome or at least minimize adhesion formation include implantation of barrier materials, application of lubricants or combinations of materials and functionalized drugs that are controllably released and support the healing tendon to glide and achieve the full range of motion after regeneration. Although a huge amount of different materials have been experimentally tested, the optimal strategy with respect to material and method has not yet been determined. In this review, we present a historical overview of physical barriers as well as liquid agents that have been used in order to prevent peritendinous adhesion formation. The materials are divided according to their first publication into two time frames; before and after 1980. There is no claim to include all materials tested neither will the "best" material be chosen; however, we present several materials that were experimentally tested in different animal trials as well as in clinical trials in contrast to other materials that were only tested once and disappeared from the assortment of anti-adhesives; which as such is a valuable information about its applicability for this purpose.
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Affiliation(s)
- Gabriella Meier Bürgisser
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Sternwartstrasse 14, 8091, Zurich, Switzerland
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Fox PM, Farnebo S, Lindsey D, Chang J, Schmitt T, Chang J. Decellularized human tendon-bone grafts for composite flexor tendon reconstruction: a cadaveric model of initial mechanical properties. J Hand Surg Am 2013; 38:2323-8. [PMID: 24055133 DOI: 10.1016/j.jhsa.2013.08.092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE After complex hand trauma, restoration of tendon strength is challenging. Tendon insertion tears typically heal as fibrous scars after surgical reconstruction and create a weak point at the tendon-bone interface. In addition, major tendon loss may overwhelm the amount of available autograft for reconstruction. An off-the-shelf product may help address these challenges. We hypothesized that decellularized human flexor digitorum profundus and distal phalanx tendon-bone composite grafts were a feasible option for flexor tendon reconstruction after complex hand trauma. By replacing the entire injured composite segment, the need for tendon repair within the tendon sheath, reconstruction of the tendon-bone interface, and use of limited autograft could be eliminated. METHODS Paired human cadaver forearms were dissected to obtain the flexor digitorum profundus tendon with an attached block of distal phalanx. Tendon-bone grafts were pair-matched and divided into 2 groups: decellularized grafts (n = 12) and untreated (control) grafts (n = 11). Grafts in the decellularized group were subjected to physiochemical decellularization. Pair-matched tendon-bone grafts (decellularized and untreated) were placed back into the flexor tendon sheath and secured distally using a tie-over button and proximally by weaving the graft into the flexor digitorum superficialis tendon in the distal forearm. The ultimate load, location of failure, and excursion were determined. RESULTS Decellularized tendon-bone composite grafts demonstrated no significant difference in ultimate failure load or stiffness compared with untreated grafts. Both groups eventually failed in varied locations along the repair. The most common site of failure in both groups was the tie-over button. The decellularized group failed at the tendon-bone insertion in 3 specimens (25%) compared with none in the untreated group. Both groups demonstrated an average tendon excursion of approximately 82 mm before failure. CONCLUSIONS Decellularization of human flexor tendon-distal phalanx tendon-bone constructs did not compromise initial strength despite chemical and mechanical decellularization in a cadaveric model. At the time of repair, decellularized flexor tendon-bone grafts can exceed the strength and excursion needed for hand therapy immediately after reconstruction. CLINICAL RELEVANCE These tendon-bone grafts may become an option for complex hand reconstruction at or near tendon-bone insertions and throughout the tendon sheath. Further work is required to assess the role of reseeding in an in vivo model.
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Affiliation(s)
- Paige M Fox
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center; and Section of Plastic Surgery, VA Palo Alto Health Care System, Stanford, CA
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