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Zhao C, Ozasa Y, Shimura H, Reisdorf RL, Thoreson AR, Jay G, Moran SL, An KN, Amadio PC. Effects of lubricant and autologous bone marrow stromal cell augmentation on immobilized flexor tendon repairs. J Orthop Res 2016; 34:154-60. [PMID: 26177854 PMCID: PMC5166703 DOI: 10.1002/jor.22980] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 07/08/2015] [Indexed: 02/04/2023]
Abstract
The purpose of the study was to test a novel treatment that carbodiimide-derivatized-hyaluronic acid-lubricin (cd-HA-lubricin) combined cell-based therapy in an immobilized flexor tendon repair in a canine model. Seventy-eight flexor tendons from 39 dogs were transected. One tendon was treated with cd-HA-lubricin plus an interpositional graft of 8 × 10(5) BMSCs and GDF-5. The other tendon was repaired without treatment. After 21 day of immobilization, 19 dogs were sacrificed; the remaining 20 dogs underwent a 21-day rehabilitation protocol before euthanasia. The work of flexion, tendon gliding resistance, and adhesion score in treated tendons were significantly less than the untreated tendons (p < 0.05). The failure strength of the untreated tendons was higher than the treated tendons at 21 and 42 days (p < 0.05). However, there is no significant difference in stiffness between two groups at day 42. Histologic analysis of treated tendons showed a smooth surface and viable transplanted cells 42 days after the repair, whereas untreated tendons showed severe adhesion formation around the repair site. The combination of lubricant and cell treatment resulted in significantly improved digit function, reduced adhesion formation. This novel treatment can address the unmet needs of patients who are unable to commence an early mobilization protocol after flexor tendon repair.
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Affiliation(s)
- Chunfeng Zhao
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
| | - Yasuhiro Ozasa
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
| | - Haruhiko Shimura
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
| | - Ramona L. Reisdorf
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
| | - Andrew R. Thoreson
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
| | - Gregory Jay
- Department of Emergency Medicine, Brown University, Providence, Rhode Island
| | - Steven L. Moran
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
| | - Kai-Nan An
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
| | - Peter C. Amadio
- Division of Orthopedic Research Mayo Clinic, Biomechanics Laboratory and the Tendon & Soft Tissue Biology Laboratory, Rochester, Minnesota
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Ciclamini D, Panero B, Titolo P, Tos P, Battiston B. Particularities of hand and wrist complex injuries in polytrauma management. Injury 2014; 45:448-51. [PMID: 24119831 DOI: 10.1016/j.injury.2013.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2013] [Indexed: 02/02/2023]
Abstract
Hand and wrist lesions are relatively common in polytraumatised patients. These subjects sustain a wide range of potential life-threatening conditions and hand and wrist injuries incurred are often not diagnosed or are insufficiently treated. Closed lesions are the most frequently missed diagnosis, but even severe open lesions may be incorrectly treated. Most of these hand and wrist injuries can have a strong negative impact on long-term quality of life, particularly when treatment of these injuries is poor or delayed. Orthopaedic and hand surgeons should be vigilant in their assessment and treatment of patients with multiple injuries and a global approach, based on the advanced trauma life support (ATLS)-protocol, must be applied. The very common association of head, chest, abdomen, bone and soft-tissue lesions in the polytraumatised patient requires a multidisciplinary team approach from the beginning. The energy of trauma in these patients often causes complex injuries to the wrist and hand; these require correct treatment in terms of both timing and techniques. It is not possible to create a practical, useful guideline with a "one lesion-one solution" approach, because every case is different; therefore, this paper describes a spectrum of indications and techniques that may be useful in managing hand and wrist injuries, particularly in polytraumatised patients.
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Affiliation(s)
- Davide Ciclamini
- U.O.C Muscoloskeletal Traumatology, U.O.D. Microsurgery, C.T.O. Hospital, Torino, Italy.
| | - Bernardino Panero
- U.O.C Muscoloskeletal Traumatology, U.O.D. Microsurgery, C.T.O. Hospital, Torino, Italy
| | - Paolo Titolo
- U.O.C Muscoloskeletal Traumatology, U.O.D. Microsurgery, C.T.O. Hospital, Torino, Italy
| | - Pierluigi Tos
- U.O.C Muscoloskeletal Traumatology, U.O.D. Microsurgery, C.T.O. Hospital, Torino, Italy
| | - Bruno Battiston
- U.O.C Muscoloskeletal Traumatology, U.O.D. Microsurgery, C.T.O. Hospital, Torino, Italy
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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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Schöffl V, Küpper T. Feet injuries in rock climbers. World J Orthop 2013; 4:218-28. [PMID: 24147257 PMCID: PMC3801241 DOI: 10.5312/wjo.v4.i4.218] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 07/17/2013] [Accepted: 07/23/2013] [Indexed: 02/06/2023] Open
Abstract
While injuries of the upper extremity are widely discussed in rock climbers, reports about the lower extremity are rare. Nevertheless almost 50 percent of acute injuries involve the leg and feet. Acute injuries are either caused by ground falls or rock hit trauma during a fall. Most frequently strains, contusions and fractures of the calcaneus and talus. More rare injuries, as e.g., osteochondral lesions of the talus demand a highly specialized care and case presentations with combined iliac crest graft and matrix associated autologous chondrocyte transplantation are given in this review. The chronic use of tight climbing shoes leads to overstrain injuries also. As the tight fit of the shoes changes the biomechanics of the foot an increased stress load is applied to the fore-foot. Thus chronic conditions as subungual hematoma, callosity and pain resolve. Also a high incidence of hallux valgus and hallux rigidus is described.
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Zhao C, Sun YL, Jay GD, Moran SL, An KN, Amadio PC. Surface modification counteracts adverse effects associated with immobilization after flexor tendon repair. J Orthop Res 2012; 30:1940-4. [PMID: 22714687 PMCID: PMC3449004 DOI: 10.1002/jor.22177] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/01/2012] [Indexed: 02/04/2023]
Abstract
Although post-rehabilitation is routinely performed following flexor tendon repair, in some clinical scenarios post-rehabilitation must be delayed. We investigated modification of the tendon surface using carbodiimide derivatized hyaluronic acid and lubricin (cd-HA-Lub) to maintain gliding function following flexor tendon repair with postoperative immobilization in a in vivo canine model. Flexor digitorum profundus tendons from the 2nd and 5th digits of one forepaw of six dogs were transected and repaired. One tendon in each paw was treated with cd-HA-Lub; the other repaired tendon was not treated. Following tendon repair, a forearm cast was applied to fully immobilize the operated forelimb for 10 days, after which the animals were euthanized. Digit normalized work of flexion (nWOF) and tendon gliding resistance were assessed. The nWOF of the FDP tendons treated with cd-HA-Lub was significantly lower than the nWOF of the untreated tendons (p < 0.01). The gliding resistance of cd-HA-Lub treated tendons was also significantly lower than that of the untreated tendons (p < 0.05). Surface treatment with cd-HA-Lub following flexor tendon repair provides an opportunity to improve outcomes for patients in whom the post-operative therapy must be delayed after flexor tendon repair.
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Affiliation(s)
- Chunfeng Zhao
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Yu-Long Sun
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Gregory D. Jay
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI
| | - Steven L. Moran
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Kai-Nan An
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Peter C. Amadio
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Schöffl V, Heid A, Küpper T. Tendon injuries of the hand. World J Orthop 2012; 3:62-9. [PMID: 22720265 PMCID: PMC3377907 DOI: 10.5312/wjo.v3.i6.62] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 05/11/2012] [Accepted: 06/05/2012] [Indexed: 02/06/2023] Open
Abstract
Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an “intrinsic” tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing.
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Schöffl V, Winkelmann HP. [Traumatic and degenerative tendon lesions of the hand]. DER ORTHOPADE 2011; 39:1108-16. [PMID: 21052633 DOI: 10.1007/s00132-010-1688-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Tendon lesions are the second most common injury in the hand and therefore an important factor in orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons; nevertheless, also less frequent injuries such as damage to the functional system of tendon sheath and pulley or dull avulsions need to be considered. Besides the clinical examination, ultrasound and MRI have proven to be important diagnostic tools. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger "intrinsic" tendon healing to guarantee a good outcome.
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Affiliation(s)
- V Schöffl
- Sektionen Sportorthopädie - Sporttraumatologie - Sportmedizin und Chirurgie der oberen Extremität, Klinik für Orthopädie und Unfallchirurgie, Klinikum Bamberg, Bugerstraße 80, 96049 Bamberg.
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Zhao C, Sun YL, Ikeda J, Kirk RL, Thoreson AR, Moran SL, An KN, Amadio PC. Improvement of flexor tendon reconstruction with carbodiimide-derivatized hyaluronic acid and gelatin-modified intrasynovial allografts: study of a primary repair failure model. J Bone Joint Surg Am 2010; 92:2817-28. [PMID: 21123612 PMCID: PMC7002081 DOI: 10.2106/jbjs.i.01148] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tendon grafts play an important role in flexor tendon reconstruction. This study was an investigation of the effects of surface modification of allograft intrasynovial tendons with carbodiimide-derivatized hyaluronic acid and gelatin in an in vivo canine model. To mimic the actual clinical situation, a novel and clinically relevant model of a failed primary flexor tendon repair was used to evaluate the flexor tendon grafts. METHODS Twenty-eight flexor digitorum profundus tendons from the second and fifth digits of fourteen dogs were lacerated and repaired in zone II in a first-surgery phase. The dogs were allowed free active motion postoperatively. In a second phase, six weeks later, the tendons were reconstructed with use of a flexor digitorum profundus allograft. In each dog, one graft was treated with carbodiimide-derivatized hyaluronic acid and gelatin (the CHG group) and the other was treated with saline solution, as a control. The dogs were restricted from free active motion, but daily therapy was performed beginning on postoperative day 5 and continued until six weeks after the operation, when the animals were killed. The outcomes were evaluated on the basis of digit work of flexion, gliding resistance, healing at the distal attachment, graft cell viability, histological findings, and findings on scanning electron microscopy. RESULTS In the first phase, all twenty-eight repaired tendons ruptured, with scar and adhesion formation in the repair site. Six weeks after allograft reconstruction, the mean work of flexion was 0.37 and 0.94 N-mm/degree in the CHG group and the saline-solution control group, respectively; these values were significantly different (p < 0.05). The gliding resistance in the CHG group was also significantly less than that in the saline-solution control group (0.18 versus 0.28 N) (p < 0.05), but no difference between groups was observed with regard to the distal tendon-bone pullout strength. Histological analysis showed that tenocytes in the host tendon proliferated and migrated toward the acellular allograft. CONCLUSIONS This primary repair failure model was reproducible and reliable, with a uniform failure pattern, and provides an appropriate and clinically relevant animal model with which to study flexor tendon reconstruction. The surface modification of allografts with carbodiimide-derivatized hyaluronic acid and gelatin improved digital function and tendon gliding ability.
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Affiliation(s)
- Chunfeng Zhao
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Yu-Long Sun
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Jun Ikeda
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Ramona L. Kirk
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Andrew R. Thoreson
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Steven L. Moran
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Kai-Nan An
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
| | - Peter C. Amadio
- Biomechanics Laboratory, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for C. Zhao:
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