New technology for assessing microstructural components of tendons and ligaments

Comparison of the mechanical properties and mechanical damages to tendon tissue in three suspensory fixation techniques

Background

Anterior cruciate ligament (ACL) injury is the most common traumatic injury to the knee joint. Suspensory fixation has become popular in ACL reconstruction because of its high primary stability, less invasiveness, and surgical convenience. There are two common types of suspensory fixation devices: those with fixed-length and those with adjustable-length loops. Owing to structural differences and differences in initial tensioning techniques, it is expected that mechanical property and damage to the tendons will vary from device to device; however, no literature has examined this so far. The main purpose of this study was to evaluate the damage caused to the tendon by three different suspensory fixation devices. An effective mechanical test was carried out as a prerequisite.

Methods

First, the mechanical properties of simple loop device (SLD) as fixed-length loop device, first-generation, and second-generation adjustable devices (AD1 and AD2) as adjustable-length loop devices were tested (isolated device testing). Second, each device was tested using bovine extensor tendons (specimen testing). Cyclic testing included 2000 cycles; the devices were subsequently displaced until failure, and the ultimate tensile strength was determined using isolated device testing. Six samples of 3 devices were used in each testing experiment. After specimen testing, the surface structure of the tendon was evaluated quantitatively using optical coherence tomography (OCT) and our original histological scoring system.

Results

During isolated device testing, SLD demonstrated the least cyclic displacement, followed by AD1 and AD2. The highest ultimate tensile strength was observed in AD2, followed by SLD and AD1. In specimen testing, the least cyclic displacement was observed in SLD, followed by AD1 and AD2. Histologically, AD1 demonstrated a significantly lower score, with damaged surface morphology, than SLD and AD2. OCT values were significantly higher, with a more disturbing tendon surface structure, in AD1 than in SLD and AD2.

Conclusions

The first-generation adjustable loop device exhibited greatest graft tissue damage at the suspensory site in a clinically relevant setting. The thinner adjustable loop mechanism may have elevated graft damage by frictional stresses during loop adjustment or by repetitive tensioning stresses.

Non-destructive characterization of adult zebrafish models using Jones matrix optical coherence tomography

The zebrafish is a valuable vertebrate animal model in pre-clinical cancer research. A Jones matrix optical coherence tomography (JM-OCT) prototype operating at 1310 nm and an intensity-based spectral-domain OCT setup at 840 nm were utilized to investigate adult wildtype and a tumor-developing zebrafish model. Various anatomical features were characterized based on their inherent scattering and polarization signature. A motorized translation stage in combination with the JM-OCT prototype enabled large field-of-view imaging to investigate adult zebrafish in a non-destructive way. The diseased animals exhibited tumor-related abnormalities in the brain and near the eye region. The scatter intensity, the attenuation coefficients and local polarization parameters such as the birefringence and the degree of polarization uniformity were analyzed to quantify differences in tumor versus control regions. The proof-of-concept study in a limited number of animals revealed a significant decrease in birefringence in tumors found in the brain and near the eye compared to control regions. The presented work showed the potential of OCT and JM-OCT as non-destructive, high-resolution, and real-time imaging modalities for pre-clinical research based on zebrafish.

Stem Cell Therapy for Tendon Regeneration: Current Status and Future Directions

In adults the healing tendon generates fibrovascular scar tissue and recovers never histologically, mechanically, and functionally which leads to chronic and to degenerative diseases. In this review, the processes and mechanisms of tendon development and fetal regeneration in comparison to adult defect repair and degeneration are discussed in relation to regenerative therapeutic options. We focused on the application of stem cells, growth factors, transcription factors, and gene therapy in tendon injury therapies in order to intervene the scarring process and to induce functional regeneration of the lesioned tissue. Outlines for future therapeutic approaches for tendon injuries will be provided.

Quantitative polarized light microscopy of human cochlear sections

Dysfunction of the inner ear is the most common cause of sensorineural hearing loss, which is the most common sensory deficit worldwide. Conventional imaging modalities are unable to depict the microanatomy of the human inner ear, hence the need to explore novel imaging modalities. We provide the first characterization of the polarization dependent optical properties of human cochlear sections using quantitative polarized light microscopy (qPLM). Eight pediatric cadaveric cochlear sections, aged 0 (term) to 24 months, were selected from the US National Temporal Bone Registry, imaged with qPLM and analyzed using Image J. Retardance of the bony otic capsule and basilar membrane were substantially higher than that of the stria vascularis, spiral ganglion neurons, organ of Corti and spiral ligament across the half turns of the spiraling cochlea. qPLM provides quantitative information about the human inner ear, and awaits future exploration in vivo.

The application of optical coherence tomography in musculoskeletal disease

Many musculoskeletal disorders (MDs) are associated with irreversible bone and cartilage damage; this is particularly true for osteoarthritis (OA). Therefore, a clinical need exists for modalities which can detect OA and other MDs at early stages. Optical coherence tomography (OCT) is an infrared-based imaging, currently FDA approved in cardiology and ophthalmology, which has a resolution greater than 10 microns and acquisition rate of 120 frames/second. It has shown feasibility for imaging early OA, identifying changes prior to cartilage thinning both in vitro and in vivo in patients and in OA animal models. In addition, OCT has shown an ability to identify early rheumatoid arthritis (RA) and guide tendon repair, but has the potential for an even greater impact. Clinical trials in OA are currently underway, as well as in several other MDs.

Towards improved collagen assessment: polarization-sensitive optical coherence tomography with tailored reference arm polarization

Single channel PS-OCT has advantages for assessing birefringent tissue components in various clinical scenarios, with implications for assessing pathology, ranging from osteoarthritis to myocardial infarction. While the technique has been successfully used both in vitro and in vivo, there have been limited attempts to optimize single channel PS-OCT with respect to performance, particularly paddle rotation. In this study, we developed and tested a new approach for the real-time assessment of birefringence through tailoring of reference arm polarization. Different polarization rotation patterns, as depicted on a Poincare sphere, were assessed with polarization filters and retarders. When further tested in tissue, PS-OCT assessments of bovine cartilage and tendon demonstrated that contrast was sensitive to the pattern selected, indicating that rotation pattern influenced birefringence assessment and providing insights into optimal patterns. We also discuss the difference between diagnostic accuracy and precision with respect to both the construction and application of PS-OCT embodiments.

Improving the efficiency of optical coherence tomography by using the non-ideal behaviour of a polarising beam splitter

We present a new way of improving the efficiency of optical coherence tomography by using the polarisation crosstalk of a polarising beam splitter to direct most of the available source optical power to the sample. The use of a quarter wave plate in both the reference and the sample arms allows most of the sample power to be directed to the detector while adjusting the reference arm to ensure noise optimised operation. As a result, the sensitivity of such a system can be improved by 6 dB, or alternatively the acquisition time can be improved by a factor of 4 for shot noise limited performance,compared to a traditional OCT configuration using a 50/50 beam splitter.

Applications of optical coherence tomography to cardiac and musculoskeletal diseases: bench to bedside?

Selected historical aspects of the transition of optical coherence tomography (OCT) research from the bench to bedside are focused on. The primary function of the National Institutes of Health (NIH) is to improve the diagnosis and treatment of human pathologies. Therefore, research funded by the NIH should have a direct envisioned pathway for transitioning bench work to the bedside. Ultimately, to be successful, this work must be accepted by physicians and by the general science community. This typically requires robustly validated hypothesis-driven research. Work that is not appropriately compared to the current gold standard or does not address a specific pathology is unlikely to achieve widespread acceptance. I outline OCT research in the musculoskeletal and cardiovascular systems, examining the rapid transition from bench to bedside and look at initial validated hypothesis-driven research data that suggested clinical utility, which drove technology development toward specific clinical scenarios. I also consider the time of initial funding compared to when it was applied in patients with clinical pathologies. Finally, ongoing bench work being performed in parallel with clinical studies is examined. The specific applications examined here are identifying unstable coronary plaque and the early detection of osteoarthritis, the former was brought to the bedside primarily through a commercial route while the latter through NIH-funded research.

Theoretical and practical considerations on detection performance of time domain, Fourier domain, and swept source optical coherence tomography

Optical coherence tomography (OCT) based on spectral interferometry has recently been examined, with authors often suggesting superior performance compared with time domain approaches. The technologies have similar resolutions and the spectral techniques may currently claim faster acquisition rates. Contrary to many current opinions, their detection parameters may be inferior. The dynamic range and signal-to-noise ratio (SNR) correlate with image penetration, the contrast as a function of depth. This work examines the theoretical sensitivity, dynamic range, and SNR of the techniques, within the practical limits of optoelectronics, taking into account often ignored or misunderstood classical factors that affect performance, such as low frequency noise, analog to digital (AD) conversion losses, and methods for potentially improving sensitivity, including fast laser sweeping. The technologies are compared relative to these parameters. While Fourier domain OCT has some advantages such as signal integration, it appears unlikely that its disadvantages can ultimately be overcome for nontransparent tissue. Ultimately, time-domain (TD)-OCT appears to have the superior performance with respect to SNR and dynamic range. This may not be the case for transparent tissue of the eye. Certain positive aspects of swept source OCT leave the possibility open that its performance may approach that of (TD)-OCT in nontransparent tissue.

IR Laser and Heat-induced Changes in Annulus Fibrosus Collagen Structure

The purpose of this study was to characterize essential changes in the structure of annulus fibrosus (AF) after hydrothermal and infrared (IR) laser treatment and to correlate these results with alterations in tissue state. Polarization-sensitive optical coherence tomography imaging was used to measure collagen birefringence in AF. Differential scanning calorimetry was used as a complementary technique, providing detailed information on thermodynamic processes in the tissue. Birefringence, peak of the denaturation endotherm, and the enthalpy of denaturation (DeltaHm) were determined before and after hydrothermal heat treatment (85 degrees C for 15 min) and non-ablative Er:glass fiber laser exposures on AF in the whole disk (vertebrae-disk-vertebrae complex). Our data have demonstrated quantitative differences between results of laser and hydrothermal heating. Birefringence did not disappear and DeltaHm did not change after treatment in the water bath, but loss of birefringence and a decrease in the enthalpy did occur after laser exposure. These results could be explained by the photomechanical effect of laser irradiation. We suggest that thermo-mechanical stress played a dominant role in the disruption of the collagen network of AF under non-homogeneous laser heating.

Myocardial tissue characterization based on a polarization-sensitive optical coherence tomography system with an ultrashort pulsed laser

A polarization-sensitive optical coherence tomography (PSOCT) system using a femtosecond-laser as the broadband light source is implemented with the axial resolution of 5 microm in free space. Through the design of path-length difference between the two polarization inputs and the modulation of one of the polarization inputs, the PSOCT images of various input and output polarization combinations can be distinguished and simultaneously collected. The PSOCT system is then used for in vitro scanning of the myocardium tissues of normal and infarcted rat hearts. The destruction of the birefringence nature of the fiber muscle in the infarcted heart can be clearly observed.

In SituMonitoring of Tendon Structural Changes by Elastic Scattering Spectroscopy: Correlation with Changes in Collagen Fibril Diameter and Crimp

The aim of this study was to monitor structural changes in loaded rabbit digital flexor tendons in situ and ex situ via elastic scattering spectroscopy (ESS). The optical setup consisted of a xenon white light source (lambda = 320-860 nm), connected to a fiber optic probe (with a source-detector separation of approximately 350 microm) and a spectrometer, controlled by a personal computer (PC). Cadaveric rabbit tendons were studied in situ under 3 tensional regimens: unloaded (no extrinsic tension applied), stretched, and 1-kg loaded and compared with excised tendons (i.e., no tension). Four times more light was detected in in situ unloaded tendons perpendicular to the tendon long axis than parallel to it. Backscatter anisotropy was expressed as the anisotropy factor (AF600nm: ratio of greatest to least backscatter intensity, measured with orthogonal probe positions). Differences in backscatter anisotropy between tendons from different digits were not significant. AF600nm had the smallest value (2.72 +/- 0.38) for the least aligned tendon preparations (excised tendons), and increased to 7.17 +/- 0.54 (1-kg loaded) as in situ loads were applied. Electron microscopy revealed that the distribution of collagen fibril diameters changed as loads were applied, with the diameter of larger fibrils decreasing approximately 33% for 1-kg loaded compared with excised tendons. Polarized light microscopy showed a characteristic crimp pattern in excised tendons, but this was hardly detectable in unloaded tendons and not detectable in tendons fixed in situ under a 1-kg load. We propose that the increase in optical anisotropy is a function of collagen fibril straightening and reducing fibril diameter as the tendon undergoes progressive loading. These findings are important for monitoring structure in vivo and in bioreactors for tissue engineers.

Characterizing of tissue microstructure with single-detector polarization-sensitive optical coherence tomography

Assessing tissue birefringence with imaging modality polarization-sensitive optical coherence tomography (PS-OCT) could improve the characterization of in vivo tissue pathology. Among the birefringent components, collagen may provide invaluable clinical information because of its alteration in disorders ranging from myocardial infarction to arthritis. But the features required of clinical imaging modality in these areas usually include the ability to assess the parameter of interest rapidly and without extensive data analysis, the characteristics that single-detector PS-OCT demonstrates. But beyond detecting organized collagen, which has been previously demonstrated and confirmed with the appropriate histological techniques, additional information can potentially be gained with PS-OCT, including collagen type, form versus intrinsic birefringence, the collagen angle, and the presence of multiple birefringence materials. In part I, we apply the simple but powerful fast-Fourier transform (FFT) to both PS-OCT mathematical modeling and in vitro bovine meniscus for improved PS-OCT data analysis. The FFT analysis yields, in a rapid, straightforward, and easily interpreted manner, information on the presence of multiple birefringent materials, distinguishing the true anatomical structure from patterns in image resulting from alterations in the polarization state and identifying the tissue/phantom optical axes. Therefore the use of the FFT analysis of PS-OCT data provides information on tissue composition beyond identifying the presence of organized collagen in real time and directly from the image without extensive mathematical manipulation or data analysis. In part II, Helistat phantoms (collagen type I) are analyzed with the ultimate goal of improved tissue characterization. This study, along with the data in part I, advance the insights gained from PS-OCT images beyond simply determining the presence or absence of birefringence.

Assessment of coronary plaque collagen with polarization sensitive optical coherence tomography (PS-OCT)

INTRODUCTION

Current evidence indicates that most plaques classified as vulnerable or ruptured plaque do not lead to unstable angina or myocardial infarction. Improved methods are needed to risk stratify plaques to identify those which lead to most acute coronary syndromes. Collagen depletion in the intima overlying lipid collections appears to be a critical component of unstable plaques. In this study, we use polarization sensitive optical coherence tomography (PS-OCT) for the assessment of coronary plaque collagen. Collagen is birefringent, meaning that different polarization states travel through it at different velocities.

METHODS AND RESULTS

Changes in PS-OCT images are a measure of tissue birefringence. Twenty-two coronary artery segments were imaged with PS-OCT and analyzed by picrosirius staining (a measure of collagen intensity and fiber size) and trichrome blue. The regression plot between PS-OCT changes and measured collagen yielded a correlation coefficient value of 0.475 (p<0.002). The predictive value of a PS-OCT measurement of negligible birefringence (less than 33% change) for minimal collagen was 93% while the predictive value of high birefringence (greater than 66% change) for high collagen concentrations was 89%. The effect of fiber type (chemical composition) was minimal relative to the effect due to fiber concentration.

CONCLUSION

The capability of PS-OCT to assess plaque collagen content, in addition to its ability to generate high resolution structural assessments, make it a potentially powerful technology for identifying high risk plaques.

Dermal connective tissue development in mice: an essential role for tenascin-X

Deficiency of the extracellular matrix protein tenascin-X (TNX) causes a recessive form of Ehlers-Danlos syndrome (EDS) characterized by hyperextensible skin and hypermobile joints. It is not known whether the observed alterations of dermal collagen fibrils and elastic fibers in these patients are caused by disturbed assembly and deposition or by altered stability and turnover. We used biophysical measurements and immunofluorescence to study connective tissue properties in TNX knockout and wild-type mice. We found that TNX knockout mice, even at a young age, have greatly disturbed biomechanical properties of the skin. No joint abnormalities were noted at any age. The spatio-temporal expression of TNX during normal mouse skin development, during embryonic days 13-19 (E13-E19), was distinct from tropoelastin and the dermal fibrillar collagens type I, III, and V. Our data show that TNX is not involved in the earliest phase (E10-E14) of the deposition of collagen fibrils and elastic fibers during fetal development. From E15 to E19, TNX starts partially to colocalize with the dermal collagens and elastin, and in adult mice, TNX is present in the entire dermis. In adult TNX knockout mice, we observed an apparent increase of elastin. We conclude that TNX knockout mice only partially recapitulate the phenotype of TNX-deficient EDS patients, and that TNX could potentially be involved in maturation and/or maintenance of the dermal collagen and elastin network.

Variables affecting polarization-sensitive optical coherence tomography imaging examined through the modeling of birefringent phantoms

Characteristics of tissue birefringence provide valuable diagnostic information when optical coherence tomography (OCT) imaging is performed. We mathematically model single-detector polarization-sensitive (PS) OCT (PS-OCT) for imaging an alternating layered phantom with birefringence. The theoretical analysis and the simulated data all reveal complexities associated with PS-OCT imaging. Various tissue parameters affect the retrieved PS-OCT signal and hence the image features. A better understanding of the mechanisms that control PS-OCT imaging would be useful for interpretation of tissue images and ultimately useful to provide more diagnostic information.

High-resolution optical coherence tomographic imaging of osteoarthritic cartilage during open knee surgery

This study demonstrates the first real-time imaging in vivo of human cartilage in normal and osteoarthritic knee joints at a resolution of micrometers, using optical coherence tomography (OCT). This recently developed high-resolution imaging technology is analogous to B-mode ultrasound except that it uses infrared light rather than sound. Real-time imaging with 11-microm resolution at four frames per second was performed on six patients using a portable OCT system with a handheld imaging probe during open knee surgery. Tissue registration was achieved by marking sites before imaging, and then histologic processing was performed. Structural changes including cartilage thinning, fissures, and fibrillations were observed at a resolution substantially higher than is achieved with any current clinical imaging technology. The structural features detected with OCT were evident in the corresponding histology. In addition to changes in architectural morphology, changes in the birefringent or the polarization properties of the articular cartilage were observed with OCT, suggesting collagen disorganization, an early indicator of osteoarthritis. Furthermore, this study supports the hypothesis that polarization-sensitive OCT may allow osteoarthritis to be diagnosed before cartilage thinning. This study illustrates that OCT, which can eventually be developed for use in offices or through an arthroscope, has considerable potential for assessing early osteoarthritic cartilage and monitoring therapeutic effects for cartilage repair with resolution in real time on a scale of micrometers.