Deterioration of mechanical properties of the autograft in controlled stress-shielded augmentation procedures. An experimental study with rabbit patellar tendon

Suture Augmentation Does Not Change Biomechanical Properties and Histological Remodeling of Tendon Graft in Anterior Cruciate Ligament Reconstruction: A Study in a Porcine Model

PURPOSE

To evaluate the initial safety of the combined use of ultra-high molecular weight polyethylene (UHMWPE) sutures for suture augmentation (SA) in a porcine ACL reconstruction model and examine whether the procedure can affect the anterior knee laxity and structural properties of the tendon graft itself, influence histological remodeling, and cause a foreign body-induced inflammation.

METHODS

Ten pigs were divided into SA and non-SA Groups to undergo ACL reconstruction using an autologous semitendinosus tendon with and without SA, respectively. At 12 weeks postoperatively, the tibial fixation of the grafted tendon and SA was removed, and the anterior knee laxity and structural characteristics of the grafted tendon were evaluated for mechanical testing. Histological evaluation, including the ligament tissue maturation index (LTMI) score and the presence or absence of foreign-body reaction, was evaluated.

RESULTS

There was no significant difference in anterior laxity between the two groups (SA Group, 1.19 ± 0.78 mm; non-SA Group, 1.08 ± 0.42 mm; P = 1). There were no significant differences in maximum load failure, yield strength, stiffness, elongation at failure, and the LTMI score between the two groups (P = 0.31, 1, 1, 1, and 0.24, respectively). All grafted tendons showed no foreign-body reactions.

CONCLUSION

Suture augmentation did not have significant effect on the anterior knee laxity and the structural properties of the grafted tendon, interfere with histological remodeling, or cause foreign body-induced reactions.

CLINICAL RELEVANCE

The results of our study may lay the foundation for further clinical studies to verify the usefulness of ACL reconstruction with SA.

Influence of mechanical unloading on histological changes of the patellar tendon insertion in rabbits

BACKGROUND

The purpose of this study was to clarify the influence of mechanical unloading on histological changes of the patellar tendon (PT) insertion in rabbits.

MATERIALS AND METHODS

The PT was completely released from stress by drawing the patella toward the tibial tubercle with a stainless steel wire installed between the patella and tibial tubercle (mechanical unloading group, n=28). The animals of the sham group underwent the same surgical procedure; however, the wire was not tightened (n=28). The average thickness of the Safranin O-stained glycosaminoglycan (GAG) area, chondrocyte apoptosis rate and chondrocyte proliferation rate of the cartilage layer at the insertion were measured at one, two, four, and six weeks.

RESULTS

The chondrocyte apoptosis rate in the mechanical unloading group was significantly higher than that in the sham group at one and four weeks (p<0.05). The chondrocyte proliferation rate in the mechanical unloading group was significantly lower than that in the sham group at four and six weeks (p<0.05). The average thickness of the GAG-stained area in the mechanical unloading group was significantly lower than that in the sham group at six weeks (p<0.05).

CONCLUSION

Mechanical unloading significantly affected the increase in the chondrocyte apoptosis rate, decrease in the chondrocyte proliferation rate, and decrease in the GAG layer thickness at the PT insertion for up to six weeks in rabbits.

CLINICAL RELEVANCE

We suggest that more than 6 weeks of mechanical unloading should be avoided to prevent degeneration at the PT insertion.

Rotator cuff regeneration using a bioabsorbable material with bone marrow-derived mesenchymal stem cells in a rabbit model

BACKGROUND

Rotator cuff regeneration using tissue engineering techniques is a challenging treatment in elderly patients with irreparable rotator cuff tears.

HYPOTHESIS

A polyglycolic acid sheet scaffold with seeded mesenchymal stem cells (MSCs) may enhance the expression of type I collagen products and increase the mechanical strength of the regenerated tendon in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

A surgically created defect of infraspinatus tendons of rabbits was reconstructed with 2 different materials, a polyglycolic acid (PGA) sheet alone (PGA group) (n = 34) and a PGA sheet seeded with autologously cultured MSCs (MSC group) (n = 34). The authors created a tendon defect model without embedding any graft as the control model (control group) (n = 34). The rabbits were sacrificed at 4, 8, and 16 weeks after the operation and then were histologically evaluated. The rabbits were also biomechanically evaluated by measuring the ultimate failure loads and Young's modulus at 4 and 16 weeks following implantation.

RESULTS

In the MSC group, the fibrocartilage layers and Sharpey fibers were found regularly in the insertion site at 8 weeks compared with the PGA group. In control group, thin membranes with many fibroblasts arranged in an irregular pattern linked the end of the torn cuff to the bone without any Sharpey fibers and type I collagen. A large volume of type I collagen was found in comparison with type III collagen at 16 weeks in the MSC group, whereas type III collagen was more prevalent than type I in the PGA group. The tendon maturing score in the MSC group had higher values than the PGA and control groups at 8 and 16 weeks (mean values were 21.0 ± 0.89, 24.0 ± 2.53 in the MSC group; 16.7 ± 2.25, 21.3 ± 2.42 in the PGA group; and 10.2 ± 0.98, 12.2 ± 1.72 in the control group, respectively) (P < .05). The results of the mechanical analysis revealed that the regenerated tendons in the MSC group had better tensile strength than in the PGA and control groups at 16 weeks (mean values were 3.04 ± 0.54 in the MSC group, 2.38 ± 0.63 in the PGA group, and 1.58 ± 0.13 in the control group) (P < .05).

CONCLUSION

Bone marrow-derived MSCs were able to regenerate tendon-bone insertions and the tendon belly, including the production of type I collagen, and increased the mechanical strength of the regenerated rotator cuff tendon.

CLINICAL RELEVANCE

Rotator cuff regeneration using MSCs is a promising treatment for massive rotator cuff defects.

Mechanical assessment of two different methods of tripling hamstring tendons when using suspensory fixation

PURPOSE

To investigate two different methods of suture fixation and tendon behaviour when using an Endobutton and a tripled tendon.

METHODS

Thirty bovine tendons and foam blocks were randomly allocated to three groups: group 1: The tendon was doubled through 40-mm Endobutton; group 2: Tripled tendon--whip-stitched with No. 2 Ultrabraid, passed through an Endobutton and third limb secured to the loop via seven knots; and group 3: Tripled tendon--whip-stitched with No. 2 Fibreloop and fixed as group 2. A tunnel matching the graft diameter was drilled through the block. The graft was passed through the tunnel and fixed with an interference screw. The constructs were cycled at 1 Hz from 10 to 50 N for 10 cycles followed by 50-250 N at 1 Hz for 500 cycles. Load-to-failure test was then carried out at a rate of 20 mm/min. A custom digital image capture technique was used to measure and calculate displacement, strain and stress. Statistical analysis was carried out using Kruskal-Wallis test and paired t test.

RESULTS

There was no statistical significant difference between ultimate tensile strength (UTS) (P = 0.35) and yield load (0.41) between the 3 groups. The mean displacement of the third tendon limb in group 2 was 4.8 mm and in group 3, 1.5 mm. Displacement was not statistically significant (P = 0.07). The mean stress in the third limb versus the doubled portion of tendon in group 2 was 0.4 ± 0.02 versus 4.8 ± 0.52 MPa and in group 3, 0.5 ± 0.03 versus 5.2 ± 0.52 MPa.

CONCLUSIONS

In this biomechanical study, there was no mechanical difference in the overall properties between a doubled and tripled tendon graft. Significant cyclic elongation occurred in the third limb of the tripled tendon in comparison with the doubled portioned. Further work is needed to determine whether these mechanical findings translate to clinical practice. Caution should be used when tripling hamstring grafts. In particular, tripling small grafts provides no biomechanical advantage immediately and possibly long term, thus potentially increasing the risk of failure.

Effect of cyclic three-dimensional strain on cell proliferation and collagen synthesis of fibroblast-seeded chitosan-hyaluronan hybrid polymer fiber

BACKGROUND

Tissue engineering techniques using biodegradable three-dimensional (3D) scaffolds with cultured cells offer more potential alternatives for the treatment of severe ligament and tendon injuries. In tissue engineering, one of the crucial roles of 3D scaffolds is to provide a temporary template with the biomechanical characteristics of the native extracellular matrix (ECM) until the regenerated tissue matures. The purpose of the present study was to assess the effect of various cyclic mechanical stresses on cell proliferation and ECM production in a 3D scaffold made from chitosan and hyaluronan for ligament and tendon tissue engineering.

METHODS

Three-dimensional scaffolds seeded with rabbit patella tendon fibroblasts were attached to a bioreactor under various conditions: static group, no strain; stretch group, tensile strain; rotational group, rotational strain; combined group, rotational and tensile strain. In the Static group, 3 weeks of stationary culture was performed. In the remaining three groups, a loading regimen of 0.5 Hz for 18 h and then 6 h rest was carried out for 2 weeks after 1 week of static culture. The DNA content was determined to quantify cell proliferation. Real-time reverse transcription polymerase chain reaction analysis was performed to assess the mRNA levels of the ECM products.

RESULTS

DNA content of the combined group was significantly higher than that of the static and stretch groups, and that of the rotational group was significant higher than that of the static and stretch groups at 21 days after cultivation. The mRNA level of types I and III collagen and fibromodulin in the combined group was significantly higher than that in the other three groups. The amount of collagen synthesis in the combined group was higher than that in the static group, but the difference was not significant.

CONCLUSIONS

Multidimensional cyclic mechanical strain to mimic the physiological condition in vivo has the potential to improve or accelerate tissue regeneration in ligament and tendon tissue engineering using 3D scaffolds in vitro.

Effect of selective estrogen receptor modulator/raloxifene analogue on proliferation and collagen metabolism of tendon fibroblast

The selective estrogen receptor modulator raloxifene is therapeutically beneficial for postmenopausal connective tissue degradation, such as osteoporosis, vascular sclerosis, and dermal degradation; however, the effects of raloxifene on postmenopausal tendon metabolism have not been clarified. In this study, we investigated the effects of raloxifene analogue (LY117018) on cell proliferation and collagen metabolism using cultured rat Achilles tendon fibroblasts. 17beta-Estradiol (E(2); 10(-11)-10(-9) M) and LY117018 (10(-9)-10(-7) M) had no significant effects on tendon fibroblast proliferation, based on a BrdU (5-bromo-2'-deoxyuridine) incorporation assay (24 hr) and a WST-8 colorimetric assay (2 or 6 days). Neither E(2) nor LY117018 significantly altered the expression of type I collagen, which is a main component of the tendon extracellular matrix (ECM), whereas both E(2) and LY117018 significantly increased the expression of matrix metalloproteinase (MMP)-13, which is responsible for tendon collagen degradation in rat. Also, both E(2) and LY117018 increased the expression of type III collagen and elastin, which are minor components of tendon ECM, but are considered to govern the elastic properties of tendons. These changes in collagen and MMP induced by either E(2) or LY117018 were attenuated by the estrogen receptor alpha blocker ICI 182,780. The results of this study suggest that postmenopausal estrogen deficiency might downregulate tendon collagen turnover and decrease tendon elasticity. Further, raloxifene treatment might restore these changes to premenopausal levels.

Tendon-bone insertion repair and regeneration using polyglycolic acid sheet in the rabbit rotator cuff injury model

BACKGROUND

The quality of tendons has considerable limitations regarding torn rotator cuff tendons. Tissue-engineering techniques using a biodegradable scaffold offer potential alternatives for recreating a valid tendon-to-bone interface.

HYPOTHESIS

A polyglycolic acid (PGA) sheet could facilitate the regeneration of the rotator cuff tendon insertion in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

An implant consisting of a PGA sheet, a rapidly absorbable material, was used to replace a completely resected infra-spinatus tendon insertion in 33 adult Japanese white rabbits. The contralateral infraspinatus tendon was replaced by poly-L-lactate-epsilon-caprolactone (PLC), a slowly absorbable material, by the same methods based on the results of the pilot study. Histological comparisons were made at 4, 8, and 16 weeks, and mechanical evaluations were performed at 4 and 16 weeks in both groups. Unrepaired defects were created in a control group.

RESULTS

In the control group, the rotator cuff defects were covered with thin fibrous membranes with many fibroblasts arranged in an irregular pattern. In the PLC group, some chondrocytes were seen in the tendon insertion; however, these were not arranged along the long axis for a 16-week period. In the PGA group, a well-arranged fibrocartilage layer could be found in the regenerated tendon insertions; however, these tendon insertions were mainly regenerated by type III collagen. In mechanical examinations, the PGA group had significantly higher values in the maximum failure load, tensile strength, and Young's modulus for the 4-week and 16-week periods. These 3 categories statistically improved from 4 to 16 weeks postoperatively in both groups except for the Young's modulus in the PGA group (E = 5.66 at 4 weeks to 5.53 at 16 weeks).

CONCLUSION

The PGA sheet scaffold material allows for tendon insertion regeneration with a fibrocartilage layer but displays mechanical properties inferior to those of the normal tendon in an animal model.

CLINICAL RELEVANCE

The PGA sheet represent a possible alternative scaffold material for tendon regeneration in rotator cuff repair.

Isolated fibrillar damage in tendons stimulates local collagenase mRNA expression and protein synthesis

The etiology of repetitive stress injuries in tendons has not been clearly identified. While minor trauma has been implicated as an inciting factor, the precise magnitude and structural level of tissue injury that initiates this degenerative cascade has not been determined. The purpose of this study was to determine if isolated tendon fibril damage could initiate an upregulation of interstitial collagenase (MMP13) mRNA and protein in tendon cells associated with the injured fibril(s). Rat tail tendon fascicles were subjected to in vitro tensile loading until isolated fibrillar damage was documented. Once fibrillar damage occurred, the tendons were immediately unloaded to 100g and maintained at that displacement for 24h under tissue culture conditions. In addition, non-injured tendon fascicles were maintained under unloaded (stress-deprived) conditions in culture for 24h to act as positive controls. In situ hybridization or immunohistochemistry was then performed to localize collagenase mRNA expression or protein synthesis, respectively. Fibrillar damage occurred at a similar stress (41.13+/-5.94MPa) and strain (13.24+/-1.94%) in the experimental tendons. In situ hybridization and immunohistochemistry demonstrated an upregulation of interstitial collagenase mRNA and protein, respectively, in only those cells associated with the damaged fibril(s). In the control (stress-deprived) specimens, collagenase mRNA expression and protein synthesis were observed throughout the fascicle. The results suggest that isolated fibrillar damage and the resultant upregulation of collagenase mRNA and protein in this damaged area occurs through a mechanobiological understimulation of tendon cells. This collagenase production may weaken the tendon and put more of the extracellular matrix at risk for further damage during subsequent loading.

Effects of administration of transforming growth factor (TGF)-beta1 and anti-TGF-beta1 antibody on the mechanical properties of the stress-shielded patellar tendon

Previous studies have shown that, in the stress-shielded patellar tendon, the mechanical properties of the tendon were dramatically reduced and TGF-beta was over-expressed in tendon fibroblasts. In the present study, therefore, we tested two supportive hypotheses using 40 rabbits: One was that an application of TGF-beta1 might significantly increase the tensile strength and the tangent modulus of the stress-shielded patellar tendon. The other one was that an administration of anti-TGF-beta1 antibody might significantly reduce the mechanical properties of the stress-shielded patellar tendon. In the results, an application of 4-ng TGF-beta1 significantly increased the tangent modulus of the stress-shielded patellar tendon at 3 weeks (p = 0.019), compared with the sham treatment. Concerning the tensile strength, the 4-ng TGF-beta1 application increased the average value, but a statistical significance was not reached. An application of 50-microg anti-TGF-beta1 antibody significantly reduced the tangent modulus and the tensile strength of the stress-shielded patellar tendon at 3 weeks (p = 0.0068 and p = 0.0355), compared with the sham treatment. Because the stress-shielding treatment used in this study dramatically reduces the tangent modulus and the tensile strength of the patellar tendon, the present study suggested that an administration of TGF-beta1 weakly but significantly inhibited the reduction of the mechanical properties of the stress-shielded patellar tendon, and that inactivation of TGF-beta1 with its antibody significantly enhanced the reduction of the mechanical properties that occurs in the stress-shielded patellar tendon. These results suggested that TGF-beta1 plays an important role in remodeling of the stress-shielded patellar tendon.

Rotator cuff regeneration using chitin fabric as an acellular matrix

Twenty-one rabbits were used to investigate the feasibility of using nonwoven chitin fabric as an acellular matrix for rotator cuff regeneration. Infraspinatus tendons were cut bilaterally to create 10 x 10-mm defects. The defect in the right shoulder was covered with chitin fabric. The contralateral defect was left free as a control. The specimens were evaluated histologically and immunohistochemically at 2, 4, 8, and 12 weeks and biomechanically at 12 weeks after surgery. The acellular matrix increased cell numbers and improved collagen fiber alignment. The regenerated tissues were composed of type III collagen. The structural properties of the grafted shoulder were significantly greater than those of the control. This study revealed that using chitin fabric as an acellular matrix has advantages in enhancing both biologic and mechanical regeneration of rotator cuff tendons.

Application of tissue engineering techniques for rotator cuff regeneration using a chitosan-based hyaluronan hybrid fiber scaffold

BACKGROUND

The current surgical procedures for irreparable rotator cuff tears have considerable limitations. Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing these conditions.

HYPOTHESIS

A chitosan-based hyaluronan hybrid scaffold could enhance type I collagen products with seeded fibroblasts and thereby increase the mechanical strength of regenerated tendon in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

The scaffolds were created from chitosan-based hyaluronan hybrid polymer fibers. Forty-eight rabbit infraspinatus tendons and their humeral insertions were removed to create defects. Each defect was covered with a fibroblast-seeded scaffold (n = 16) or a non-fibroblast-seeded scaffold (n = 16). In the other 16 shoulders, the rotator cuff defect was left free as the control. At 4 and 12 weeks after surgery, the engineered tendons were assessed by histological, immunohistochemical (n = 2), and biomechanical (n = 6) analyses.

RESULTS

Type I collagen was only seen in the fibroblast-seeded scaffold and increased in the regenerated tissue. The tensile strength and tangent modulus in the fibroblast-seeded scaffold were significantly improved from 4 to 12 weeks postoperatively. The fibroblast-seeded scaffold had a significantly greater tangent modulus than did the non-fibroblast-seeded scaffold and the control at 12 weeks.

CONCLUSION

This scaffold material enhanced the production of type I collagen and led to improved mechanical strength in the regenerated tissues of the rotator cuff in vivo.

CLINICAL RELEVANCE

Rotator cuff regeneration is feasible using this tissue engineering technique.

Collagen fibril diameter distribution does not reflect changes in the mechanical properties of in vitro stress-deprived tendons

The purpose of this study was to determine if an association exists between the tensile properties and the collagen fibril diameter distribution in in vitro stress-deprived rat tail tendons. Rat tail tendons were paired into two groups of 21 day stress-deprived and 0 time controls and compared using transmission electron microscopy (n = 6) to measure collagen fibril diameter distribution and density, and mechanical testing (n =6) to determine ultimate stress and tensile modulus. There was a statistically significant decrease in both ultimate tensile strength (control: 17.95+/-3.99 MPa, stress-deprived: 6.79+/-3.91 MPa) and tensile modulus (control: 312.8+/-89.5 MPa, stress-deprived: 176.0+/-52.7 MPa) in the in vitro stress-deprived tendons compared to controls. However, there was no significant difference between control and stress-deprived tendons in the number of fibrils per tendon counted, mean fibril diameter, mean fibril density, or fibril size distribution. The results of this study demonstrate that the decrease in mechanical properties observed in in vitro stress-deprived rat tail tendons is not correlated with the collagen fibril diameter distribution and, therefore, the collagen fibril diameter distribution does not, by itself, dictate the decrease in mechanical properties observed in in vitro stress-deprived rat tail tendons.

The effect of growth factors on biomechanical properties of the bone-patellar tendon-bone graft after anterior cruciate ligament reconstruction: a canine model study

BACKGROUND

No studies have dealt with the effect of growth factors on the free tendon autograft in anterior cruciate ligament reconstruction.

HYPOTHESIS

Application of exogenous transforming growth factor-beta and epidermal growth factor may affect the structural properties and histology of the bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty dogs underwent anterior cruciate ligament reconstruction with the autogenous bone-patellar tendon-bone graft in bilateral knees. In 10 animals, 12 ng transforming growth factor-beta and 300 ng epidermal growth factor mixed with fibrin sealant of 0.6 mL were applied to the left knee. In the remaining 10 dogs, fibrin sealant alone was applied to the left knee. No additional treatments were applied to the right knee.

RESULTS

The growth factor application increased the stiffness and maximum failure load of the femur-graft-tibia complex at 12 weeks (P =.016 and P =.012, respectively); the sham treatment did not significantly affect them. Histologically, most of the cells in the grafts treated with growth factors had spindle-shaped nuclei; cells in the other grafts had round-shaped nuclei.

CONCLUSIONS

Application of transforming growth factor-beta and epidermal growth factor improves the structural properties of the autograft after anterior cruciate ligament reconstruction in the canine model.

CLINICAL RELEVANCE

Application of growth factors is a possible strategy to prevent graft deterioration in anterior cruciate ligament reconstruction.

Ex vivo static tensile loading inhibits MMP-1 expression in rat tail tendon cells through a cytoskeletally based mechanotransduction mechanism

To determine the effect of various degrees of ex vivo static tensile loading on the expression of collagenase (MMP-1) in tendon cells, rat tail tendons were statically loaded in tension at 0.16, 0.77, 1.38 or 2.6 MPa for 24 h. Northern blot analysis was used to assay for mRNA expression of MMP-1 in freshly harvested, 24 h load deprived, and 24 h statically loaded tendons. Western blot analysis was used to assay for pro-MMP-1 and MMP-1 protein expression in fresh and 24 h load deprived tendons. Freshly harvested rat tail tendons demonstrated no evidence of MMP-1 mRNA expression and no evidence of the pro-MMP-1 or MMP-1 protein. Ex vivo load deprivation for 24 h resulted in a marked increase in the mRNA expression of MMP-1 which coincided with a marked increase of both pro-MMP-1 and MMP-1 protein expression. When tendons were subjected to ex vivo static tensile loading during the 24 h culture period, a significant inhibition of this upregulation of MMP-1 mRNA expression was found with increasing load (p<0.05). A strong (r2=0.78) and significant (p<0.001) inverse correlation existed between the level of static tensile load and the expression of MMP-1. Disruption of the actin cytoskeleton with cytochalasin D abolished the inhibitory effect of ex vivo static tensile loading on MMP-1 expression. The results of this study suggest that up-regulation of MMP-1 expression in tendon cells ex vivo can be inhibited by static tensile loading, presumably through a cytoskeletally based mechanotransduction pathway.

Stress shielding of patellar tendon: effect on small-diameter collagen fibrils in a rabbit model

The purpose of this study was to assess the effects of stress shielding on the microstructure and ultrastructure of the patellar tendon using 40 mature female Japanese white rabbits. The patellar tendon was completely released from stress by drawing the patella toward the tibial tubercle with a stainless steel wire installed between them. Microstructurally, stress shielding for 3 and 6 weeks increased the number of cells approximately fivefold, to that of the control tendon. Collagen bundles were less well oriented in the stress-shielded tendon than in the control. Ultrastructurally, small collagen fibrils with a diameter of less than 90 nm increased in the stress-shielded tendon. The median collagen fibril diameter in 6-week stress-shielded tendon was significantly smaller ( P << 0.05) than in the control tendon (58.8% of control). The ratio of the total area of collagen fibrils to the whole visualized area in the stress-shielded patellar tendon was significantly smaller at 3 and 6 weeks than that in the control. This study demonstrated that complete stress shielding significantly affects the microstructure and ultrastructure of the patellar tendon

Biomechanical comparisons of three posterior cruciate ligament reconstruction procedures with load-controlled and displacement-controlled cyclic tests

BACKGROUND

Biomechanical behaviors of posterior cruciate ligament reconstructions under cyclic loading have not been sufficiently clarified.

HYPOTHESIS

Biomechanical behaviors of the reconstruction that involves use of flexor tendons and an Endobutton are significantly different under cyclic loading from behaviors of the two standard reconstructions in which bone-patellar tendon-bone graft is used.

STUDY DESIGN

Controlled laboratory study.

METHODS

In a porcine model, the tendon/Endobutton reconstruction, the tendon-bone/interference screw reconstruction, and the tendon-bone/tibial-inlay reconstruction were biomechanically compared by using two cyclic tests. In each group of 15 specimens, 5 knees underwent tensile testing without cyclic loading, and the remaining 10 underwent the same tensile test after 5000 cycles of load-controlled or displacement-controlled loading.

RESULTS

At the 5000th cycle, the peak displacement or the peak load was affected by each type of cyclic loading to a significantly greater degree in the knees with the tendon/Endobutton procedure than in the knees reconstructed with the other two procedures.

CONCLUSIONS

Plastic deformation occurred more easily during cyclic loading in the knees with the tendon/Endobutton reconstruction than in the knees with the tendon-bone reconstructions.

CLINICAL RELEVANCE

When the tendon/Endobutton reconstruction is used, a longer period of postoperative immobilization is necessary.

Timing of administration of transforming growth factor-beta and epidermal growth factor influences the effect on material properties of the in situ frozen-thawed anterior cruciate ligament

One of the future goals in ligament reconstruction is to prevent graft deterioration after transplantation. The aim of this study is to clarify whether an administration of TGF-beta1 and EGF significantly affect biomechanical properties of the in situ frozen-thawed anterior cruciate ligament (ACL), an ACL autograft model, and to elucidate whether the timing of this administration may influence its effect. Rabbits were randomly divided into 4 groups after the freeze-thaw treatment with liquid nitrogen was applied to the right knee. In 2 groups, 4-ng TGF-beta1 and 100-ng EGF mixed with 0.2-ml fibrin sealant were applied around the ACL at 3 and 6 weeks after the treatment, respectively. In the remaining two groups, only 0.2-ml fibrin sealant was applied around the ACL at 3 and 6 weeks, respectively. In each group, all animals were sacrificed at 12 weeks after the freeze-thaw treatment. These growth factors applied at 3 weeks significantly inhibited not only the increase of water content and the cross-sectional area of the ACL but also reduction of the tensile strength and the tangent modulus of the ACL (p<0.0001), which were induced by the freeze-thaw treatment. However, the application at 6 weeks did not significantly affect the changes of these parameters after the treatment. This study demonstrated that the timing of administration of TGF-beta and EGF after the freeze-thaw treatment significantly influences its effect on the biomechanical properties of the frozen-thawed ACL.

Effects of stress deprivation on mechanical properties of the in situ frozen-thawed semitendinosus tendon in rabbits

OBJECTIVE

To clarify the effect of complete stress deprivation on the mechanical properties of the in situ frozen-thawed semitendinosus tendon, an idealized autograft model.

DESIGN

Ninety-six rabbits were divided into three groups. In the frozen group (n=36), we applied the freeze-thaw treatment to the semitendinosus tendon to necrotize fibroblasts in the tendon. In the frozen and stress-shielded group (n=30), after we applied the same freeze-thaw treatment to the tendon, we completely released the tendon from stress. In the sham group (n=30), a sham operation was applied. In each group, 6 rabbits were sacrificed at 0 (only in the frozen group), 1, 2, 3, 6 and 12 weeks after surgery.

BACKGROUND

Previous studies have not clarified remodeling of the semitendinosus autograft in ligament reconstruction or its idealized model.

METHODS

The tendon was frozen with liquid nitrogen. The tendon was released from stress with the originally developed technique using a polyester tape. In each period, 5 out of the 6 rabbits were evaluated with tensile testing, and the remaining rabbit was histologically observed.

RESULTS

Complete stress shielding significantly increased the cross-sectional area of the frozen-thawed tendon at 1 and 2 weeks, while it significantly inhibited the increase of the area due to the freeze-thaw treatment at 3 and 6 weeks. Complete stress shielding significantly reduced material properties of the frozen-thawed tendon after 2 weeks.

CONCLUSIONS

The frozen-thawed semitendinosus tendon has unique remodeling characteristics under a stress-shielded condition, which were not the same as those of the frozen-thawed patellar tendon.

RELEVANCE

Remodeling of the semitendinosus tendon autograft under stress-shielded conditions may be different from that of the patellar tendon autograft.

Tendon healing in a bone tunnel. Part I: Biomechanical results after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep

PURPOSE

Interference fit fixation of soft-tissue grafts has recently raised strong interest because it allows for anatomic graft fixation that may increase knee stability and graft isometry. Although clinical data show promising results, no data exist on how tendon healing progresses using this fixation. The purpose of the present study was to investigate anterior cruciate ligament (ACL) reconstruction biomechanically using direct tendon-to-bone interference fit fixation with biodegradable interference screws in a sheep model.

TYPE OF STUDY

Animal study.

METHODS

Thirty-five mature sheep underwent ACL reconstruction with an autologous Achilles tendon split graft. Grafts were directly fixed with poly-(D,L-lactide) interference screws. Animals were euthanized after 6, 9, 12, 24, and 52 weeks and standard biomechanical evaluations were performed.

RESULTS

All grafts at time zero failed by pullout from the bone tunnel, whereas grafts at 6 and 9 weeks failed intraligamentously at the screw insertion site. At 24 and 52 weeks, grafts failed by osteocartilaginous avulsion. At 24 weeks, interference screws were macroscopically degraded. At 6 and 9 weeks tensile stress was only 6.8% and 9.6%, respectively, of the graft tissue at time zero. At 52 weeks, tensile stress of the reconstruction equaled 63.8% and 47.3% of the Achilles tendon graft at time zero and the native ACL, respectively. A complete restitution of anterior-posterior drawer displacement was found at 52 weeks compared with the time-zero reconstruction.

CONCLUSIONS

It was found that over the whole healing period the graft fixation proved not to be the weak link of the reconstruction and that direct interference fit fixation withstands loads without motion restriction in the present animal model. The weak link during the early healing stage was the graft at its tunnel entrance site, leading to a critical decrease in mechanical properties. This finding indicates that interference fit fixation of a soft-tissue graft may additionally alter the mechanical properties of the graft in the early remodeling stage because of a possible tissue compromise at the screw insertion site. Although mechanical properties of the graft tissue had not returned to normal at 1 year compared with those at time zero, knee stability had returned to normal at that time. There was no graft pullout after 24 weeks, indicating that screw degradation does not compromise graft fixation.

Biomechanical properties and vascularity of an anterior cruciate ligament graft can be predicted by contrast-enhanced magnetic resonance imaging. A two-year study in sheep

Magnetic resonance imaging has been used to determine graft integrity and study the remodeling process of anterior cruciate ligament grafts morphologically in humans. The goal of the present study was to compare graft signal intensity and morphologic characteristics on magnetic resonance imaging with biomechanical and histologic parameters in a long-term animal model. Thirty sheep underwent anterior cruciate ligament reconstruction with an autologous Achilles tendon split graft and were sacrificed after 6, 12, 24, 52, or 104 weeks. Before sacrifice, all animals underwent plain and contrast-enhanced (gadolinium-diethylenetriamine pentacetic acid) magnetic resonance imaging (1.5 T, proton density weighted, 2-mm sections) of their operated knees. The signal/noise quotient was calculated and data were correlated to the maximum load to failure, tensile strength, and stiffness of the grafts. The vascularity of the grafts was determined immunohistochemically by staining for endothelial cells (factor VIII). We found that high signal intensity on magnetic resonance imaging reflects a decrease of mechanical properties of the graft during early remodeling. Correlation analyses revealed significant negative linear correlations between the signal/noise quotient and the load to failure, stiffness, and tensile strength. In general, correlations for contrast-enhanced measurements of signal intensity were stronger than those for plain magnetic resonance imaging. Immunohistochemistry confirmed that contrast medium enhancement reflects the vascular status of the graft tissue during remodeling. We conclude that quantitatively determined magnetic resonance imaging signal intensity may be a useful tool for following the graft remodeling process in a noninvasive manner.

A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model

We evaluated knee function, tensile properties, and histologic appearance of a healing intraarticular bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction in a goat model. The patellar tendon graft was fixed such that both bone-to-bone (femoral tunnel) and bone-to-tendon (tibial tunnel) healing could be studied. The total anteroposterior translation significantly increased from 3 to 6 weeks, ranging from increases of 28.8% to 46.7%. In situ forces in the replacement graft decreased as much as 22.2% at 6 weeks. Conversely, tensile properties of the femur-anterior cruciate ligament graft-tibia complex did not change significantly from 3 to 6 weeks. However, the mode of failure changed from the graft pulling out of the tibial tunnel at 3 weeks to a mix of midsubstance failures (N = 2) and pullouts (N = 5) at 6 weeks. Histologic evaluations revealed progressive and complete incorporation of the bone block in the femoral tunnel, but only partial incorporation of the tendinous part of the graft in the tibial tunnel. The differences demonstrated at 3 and 6 weeks may be a result of the remodeling process of the midsubstance of the graft as the interfaces within the osseous tunnels mature.

In-vitro cyclic tensile loading of an immobilized and mobilized ligament autograft selectively inhibits mRNA levels for collagenase (MMP-1)

To test the hypothesis that loading conditions can be used to "engineer" ligament autograft behaviors, the effect of cyclic tension on the mRNA levels of matrix molecules and collagenase in in-vivo immobilized and mobilized 6-week rabbit medial collateral ligament (MCL) autografts was examined using an in-vitro system. Femur-[autograft MCL]-tibia complexes were subjected to a tensile stress of 4 MPa at 0.5 Hz for 1 min, followed by 14 min of rest. This 15-min testing cycle was repeated for 4 h. Semi-quantitative reverse transcrip-tase polymerase chain reaction (RT-PCR) was performed on RNA from mechanically treated MCL autografts, using rabbit-specific primer sets for types I and III collagen, biglycan, decorin, fibromodulin, lumican, versican, matrix metalloproteinase-1 (MMP-1, collagenase-1), MMP-13 (collagenase-3), and a housekeeping gene, glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Interestingly, 4 h of culture of normal control MCLs led to increased mRNA levels for MMP-1 (P < 0.05), but there were no significant changes in MMP-13 mRNA levels. Total RNA levels in that normal MCL tissue were, however, decreased after culture (P < 0.05). In-vitro tensile loading of in-vivo mobilized autografts resulted in a significant increase in total RNA (185% of in-vitro non-loaded autografts). On the other hand, in-vitro tensile loading of in-vivo immobilized autografts resulted in no significant changes in total RNA levels compared with levels in non-loaded control grafts. MMP-1 mRNA levels in both the in-vivo mobilized (47% of non-loaded autograft) and in-vivo immobilized (38% of non-loaded autograft) MCL autografts were significantly lower than those in non-loaded control tissue following in-vitro tensile loading, but there were no significant changes in the mRNA levels for the seven other matrix molecules assessed. These results show that it is possible to selectively inhibit MMP-1 mRNA levels in autograft ligaments by supplying mechanical stimuli in vitro. The results also demonstrate that in-vivo immobilization leads to a decrease in the effects of subsequent in-vitro mechanical loading in such autografts with respect to total RNA levels. Collectively, these results demonstrate that both in-vivo and in-vitro loading have implications in the engineering of an ideal ligament graft.

Extrinsic cell infiltration and revascularization accelerate mechanical deterioration of the patellar tendon after fibroblast necrosis

This study was performed to determine the contribution of extrinsic cell infiltration and revascularization into the patellar tendon in alteration of the mechanical properties of the patellar tendon after intrinsic fibroblast necrosis using 77 rabbits. In Group I, after the patellar tendon underwent the in situ freeze-thaw treatment, a wrapping treatment was performed to inhibit any extrinsic cell infiltration into the tendon. In Group II, the patellar tendon underwent the freeze-thaw treatment without any of the wrapping treatment. In Group III, the patellar tendon underwent the same wrapping treatment but without any freeze-thaw treatment. The cell culture study demonstrated that the in situ freeze-thaw treatment killed from 97 to 100 percent of the cells in the patellar tendon. Histologically, no cells were found in the midsubstance of the patellar tendon in Group I at 1, 3, and 6 weeks. In Group II, a number of cells and some vessels were found scattered in the tendon at 3 and 6 weeks. Mechanically, the elastic modulus and the tensile strength of the patellar tendon of Group II were significantly lower than those of Groups I and III at 3 and 6 weeks. These facts suggest that extrinsic cell infiltration and revascularization from the surrounding tissues accelerate the deterioration of the mechanical properties of the patellar tendon matrix after intrinsic fibroblast necrosis.

Effects of growth on the response of the rabbit patellar tendon to stress shielding: a biomechanical study

OBJECTIVE

To know the effect of stress deprivation on the dimensions and mechanical properties of the patellar tendon during growth.

DESIGN

The dimensions and tensile properties of stress-shielded patellar tendons were studied in growing rabbits and compared to those in mature animals.

BACKGROUND

Although the effects of stress deprivation on the remodeling of ligaments and tendons have been studied in various animal models, the effect of growth on the remodeling has not been studied well.

METHOD

A stress shielding technique was applied to 1-, 2-, and 3-month-old Japanese white rabbits to completely remove stress in the patellar tendons for 4, 7, and 14 days. Changes in the dimensions and mechanical properties as well as fibroblast density of the tendon were determined.

RESULTS

The tensile strength and tangent modulus of the patellar tendons were markedly decreased by stress shielding, while the cross-sectional area was significantly increased, with the largest changes in 1-month-old rabbits. Fibroblast density also increased; however, the degree of increase was highest in 3-month-old rabbits.

CONCLUSION

The changes in the dimensions and mechanical properties of the patellar tendons induced by stress shielding were greater in younger animals.

RELEVANCE

The biomechanical response of tendons and ligaments to stress deprivation induced by, for example, limb immobilization is greater and occurs earlier in younger subjects, which is important for the surgical treatment and rehabilitation protocol of joint diseases in young subjects.

Mechanical properties of collagen fascicles from in situ frozen and stress-shielded rabbit patellar tendons

OBJECTIVE

To know the effects of stress shielding on the biomechanical properties of collagen fascicles obtained from in situ frozen patellar tendons (an autograft model).

DESIGN

Collagen fascicles of approximately 300 microm in diameter were obtained from in situ frozen rabbit patellar tendons and also from in situ frozen and stress-shielded ones, and their mechanical properties and fibroblast density were determined.

BACKGROUND

Stress shielding changes the mechanical properties of in situ frozen patellar tendons in which there exist no fibroblasts. The mechanisms of this phenomenon have not been studied well.

METHOD

Patellar tendons of both in situ frozen group and in situ frozen and stress-shielded group were frozen in situ by liquid nitrogen to kill fibroblasts. Then, in the in situ frozen and stress-shielded group, no tension was applied to the tendons for 2, 3, and 6 weeks, while normal tension was applied to the tendons of the in situ frozen group. Tensile properties of the collagen fascicles obtained from these tendons were determined using a microtensile tester, and were compared to the collagen fascicles from non-frozen, stress-shielded patellar tendons.

RESULTS

Tangent modulus and tensile strength of collagen fascicles from the in situ frozen and stress-shielded group progressively decreased with the time of stress shielding; however, these decreases were much smaller than those of the fascicles obtained from non-frozen, stress-shielded tendons. Although there were few fibroblasts in the patellar tendon of the in situ frozen and stress-shielded group at 2 weeks, the modulus and strength of the fascicles from the posterior portion were significantly lower than those in the in situ frozen group. In addition, the reduction of strength caused by stress shielding was much smaller in collagen fascicles than in bulk patellar tendons.

CONCLUSION

The mechanical properties of collagen fascicles in in situ frozen tendons (an autograft model) are affected by stress shielding even under acellular condition. RelevanceThe in situ frozen, stress-shielded patellar tendon is a model of augmented autografts which are clinically used for the reconstruction of injured anterior cruciate ligaments. The sub-macroscopic studies of the tendon are useful to understand the mechanisms of the reduction of graft strength and its gradual recovery observed after reconstruction.

The effect of nonphysiologically high initial tension on the mechanical properties of in situ frozen anterior cruciate ligament in a canine model

An experimental study was performed in 32 adult beagle dogs to clarify the effect of nonphysiologically high initial tension on the mechanical and histologic properties of in situ frozen anterior cruciate ligaments. Both anterior cruciate ligaments in each dog underwent the in situ freeze-thaw treatment. The tibial insertion of the ligament was then made free from the tibia along with a cylindrical bone block. In the right knee, an initial tension of 20 N was applied on the anterior cruciate ligament by translocating the bone block in the distal direction. In the left knee, this bone block was anatomically reduced. Each bone block was firmly fixed with an interference screw. Ten animals were sacrificed at 6 weeks and 10 at 12 weeks. The tensile strength and the tangent modulus in the highly tensioned knee were significantly less than those in the physiologically tensioned knee at 12 weeks. Histologically, cell nuclei appeared to be spindle-shaped in the physiologically tensioned knee, while oval nuclei and focal degenerative changes with a number of vacuoles were occasionally found in the matrix in the highly tensioned knee. This study demonstrated that a nonphysiologically high tension significantly deteriorates the mechanical properties of the in situ frozen anterior cruciate ligament compared with physiologic tension.

Effects of in situ freezing and stress-shielding on the ultrastructure of rabbit patellar tendons

The effects of in situ freezing and the combination of in situ freezing and stress-shielding on the microstructure and ultrastructure of the patellar tendon were studied with use of 20 mature rabbits. The patellar tendon was frozen in situ with liquid nitrogen to kill fibroblasts and then was completely released from stress by chronically pulling a stainless-steel wire installed between the patella and the tibial tubercle. Microstructurally, the freezing treatment induced separation of collagen fiber bundles and fibroblast necrosis at 3 weeks, although the separation disappeared at 6 weeks. Ultrastructurally, small collagen fibrils with a diameter of less than 90 nm were predominant; at 6 weeks, the area occupied by collagen fibrils had decreased. In the frozen-shielded tendon, numerous large spaces were observed in the matrix at 3 weeks. This treatment increased the number of fibrils with a diameter greater than 360 nm and decreased the number of collagen fibrils per unit of area and the area occupied by collagen fibrils at 3 weeks. This study demonstrated that in situ freezing and the combination of in situ freezing and stress-shielding leads to a smaller volume of collagen fibrils per unit of cross section of the patellar tendon by mechanisms that remain to be defined.

Effects of initial graft tension on clinical outcome after anterior cruciate ligament reconstruction. Autogenous doubled hamstring tendons connected in series with polyester tapes

We conducted a prospective, randomized, short-term study to clarify the effects of initial graft tension on clinical outcome after arthroscopically assisted anterior cruciate ligament reconstruction with autogenous doubled semitendinosus and gracilis tendons connected in series with polyester tapes. Seventy Japanese patients with chronic, "isolated" anterior cruciate ligament tears were entered in the study. The patients were randomly divided into three groups based on initial graft tension: Group 1 (20 N), Group 2 (40 N), or Group 3 (80 N). No statistical differences were noted among the three groups with regard to their background factors. The patients were observed for 2 years or more after surgery. Postoperatively, the average side-to-side difference in anterior laxity was 2.2 +/- 2.4 mm in Group 1, 1.4 +/- 1.8 mm in Group 2, and 0.6 +/- 1.7 mm in Group 3. Analysis of variance testing showed that the postoperative laxity in Group 3 was significantly less than that in Group 1. Spearman's rank-order correlation analysis also demonstrated significant correlation between the magnitude of initial graft tension and the magnitude of the postoperative laxity. This study demonstrates that relatively high initial tension (up to 80 N) reduces the postoperative anterior laxity of the knee joint after anterior cruciate ligament reconstruction using the doubled autogenous hamstring tendons connected in series with polyester tapes.

Biomechanical studies of the remodeling of knee joint tendons and ligaments

Living tissues and organs are dynamic and change their mechanical properties and structure in response to stress alteration as a phenomenon of functional adaptation and optimal operation. This phenomenon is called 'Tissue Remodeling', and Wolff's law on bone remodeling is widely known. Several recent studies have shown that fibrous connective tissues such as tendons and ligaments also have the ability of remodeling. However, relatively little is known about the stress and motion effects on tissue homeostasis in biological soft tissues. This article primarily deals with changes of the biomechanical properties of knee joint tendons and ligaments through a wide variety of treatment modalities, including stress deprivation, recovery after stress deprivation, and stress enhancement. The experimental results indicate that tendons and ligaments have an ability to adapt in response to the change of stress if the extent of stress alteration is within allowable ranges.

Effects of restressing on the mechanical properties of stress-shielded patellar tendons in rabbits

We studied the effects of restressing on the mechanical properties and morphology of stress-shielded rabbit patellar tendons. After completely unloading the patellar tendon for 1 to 3 weeks, tension was again applied to the tendon for subsequent 3 to 12 weeks. Although the stress shielding markedly decreased the tangent modulus and tensile strength of the tendon, restressing significantly increased them. However, the mechanical properties of the tendon were not completely recovered even after a prolonged period of restressing. The microstructure of the tendon was also restored by restressing, although the recovery was incomplete. These results indicate that the mechanical properties and morphology of tendinous tissue change in response to mechanical demands.

Biomechanical effects of stress shielding of the rabbit patellar tendon depend on the degree of stress reduction

A rabbit model was used to discover whether the effects of stress shielding on the mechanical properties of the patellar tendon depend on the degree of stress reduction. Ninety mature female Japanese White rabbits were divided into three groups: completely stress-shielded partially stress-shielded and sham-operation and contralateral controls. In the experimental groups, tension applied to the patellar tendon was 0%, approximately 30%, and 100% of the normal tension, respectively, with a polyester artificial ligament. Tensile tests were carried out on patella-patellar tendon-tibia complexes harvested 1, 2, 3, 6, or 12 weeks after surgery. The tensile strength decreased in comparison with the sham-operation group to 50.2, 13.5, 9.7, and 20.7% in the completely stress-shielded group and to 75.2, 57.6, 59.6, 57.3, and 72.9% in the partially stress-shielded group. The tensile strength in the completely stress-shielded group was significantly less than that in the partially stress-shielded group at 1, 2, 3, and 6 weeks. The cross-sectional area of the patellar tendon significantly increased to 132, 206, 237, and 136% in the completely stress-shielded group and to 136, 170, 175, 155, and 127% in the partially stress-shielded group compared with the sham-operation group. The cross-sectional area of the completely stress-shielded tendon was significantly larger than that of the partially stress-shielded tendon at 1, 2, and 3 weeks. This study demonstrated that effects of stress shielding on the mechanical properties of the patellar tendon were dependent on the degree of stress shielding.

Effect of stress deprivation and cyclic tensile loading on the material and morphologic properties of canine flexor digitorum profundus tendon: an in vitro study

The effect of stress deprivation and cyclic tensile loading on the mechanical and histologic properties of the canine flexor digitorum profundus tendon was examined using an in vitro system. Stress deprivation resulted in a progressive and statistically significant decrease in the tensile modulus over an 8-week period. Histologically, stress-deprived tendons demonstrated quantitative changes in the morphology and number of cells and in the alignment of collagen. The change in tensile properties was not associated with an alteration in the water content of the tissue, but the change appeared to be dependent on the presence of a viable cell population. Dead (acellular) tendons did not undergo any alteration in tensile modulus in this in vitro system. In vitro cyclic tensile loading of tendons over a 4-week time period resulted in a significant increase in the tensile modulus (93% of the control) compared with that of the stress-deprived tendons (68% of the control). This loading regimen also maintained the normal histologic pattern of the tendons. The results of this study are similar to those previously reported for in vivo studies and suggest that this in vitro model may represent a valid system with which to test the effects of various stress conditions on the tensile properties of tissues.

Graft site morbidity with autogenous semitendinosus and gracilis tendons

To distinguish between morbidity caused by harvesting semitendinosus and gracilis tendons and morbidity associated with anterior cruciate ligament reconstruction surgery, we performed a prospective randomized study using 65 patients who underwent anterior cruciate ligament reconstruction using these tendons. The patients underwent either contralateral (N = 34) or ipsilateral (N = 31) graft harvest. For the nonoperated knees in the ipsilateral harvest group, isometric and isokinetic strength of the quadriceps and hamstring muscles increased to approximately 120% of the preoperative value at 12 months after surgery. Compared with these knees, the tendon harvest did not affect quadriceps muscle strength at all. However, harvest did decrease hamstring muscles strength for 9 months after surgery. The graft harvest in the knees with anterior cruciate ligament reconstruction also did not significantly affect quadriceps muscle strength, but it did significantly decrease hamstring muscles strength only at 1 month. Activity-related soreness at the donor site was rarely restricting and resolved by 3 months. This study demonstrated that the semitendinosus and gracilis tendon graft is a reasonable choice to minimize the donor site morbidity in ligament reconstruction using autografts.