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Kunkle BF, Baxter NA, Caughman AM, Barcel JA, Scott DJ, Gross CE. Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis. Foot Ankle Spec 2023; 16:370-376. [PMID: 35583105 DOI: 10.1177/19386400221090358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT. METHODS A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups. RESULTS No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012). DISCUSSION Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Bryce F Kunkle
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Nicholas A Baxter
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander M Caughman
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - John A Barcel
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel J Scott
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
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Luo W, Wang Y, Han Q, Wang Z, Jiao J, Gong X, Liu Y, Zhang A, Zhang H, Chen H, Wang J, Wu M. Advanced strategies for constructing interfacial tissues of bone and tendon/ligament. J Tissue Eng 2022; 13:20417314221144714. [PMID: 36582940 PMCID: PMC9793068 DOI: 10.1177/20417314221144714] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/26/2022] [Indexed: 12/25/2022] Open
Abstract
Enthesis, the interfacial tissue between a tendon/ligament and bone, exhibits a complex histological transition from soft to hard tissue, which significantly complicates its repair and regeneration after injury. Because traditional surgical treatments for enthesis injury are not satisfactory, tissue engineering has emerged as a strategy for improving treatment success. Rapid advances in enthesis tissue engineering have led to the development of several strategies for promoting enthesis tissue regeneration, including biological scaffolds, cells, growth factors, and biophysical modulation. In this review, we discuss recent advances in enthesis tissue engineering, particularly the use of biological scaffolds, as well as perspectives on the future directions in enthesis tissue engineering.
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Affiliation(s)
- Wangwang Luo
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Yang Wang
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Qing Han
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Zhonghan Wang
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China,Orthopaedic Research Institute of Jilin
Province, Changchun, China
| | - Jianhang Jiao
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Xuqiang Gong
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Yang Liu
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Aobo Zhang
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Han Zhang
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Hao Chen
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Jincheng Wang
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China
| | - Minfei Wu
- Department of Orthopedics, The Second
Hospital of Jilin University, Changchun, China,Minfei Wu, Department of Orthopedics, The
Second Hospital of Jilin University, 218 Ziqiang Sreet, Changchun 130041, China.
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3
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Effect of Adipose-Derived Mesenchymal Stem Cells (ADMSCs) Application in Achilles-Tendon Injury in an Animal Model. Curr Issues Mol Biol 2022; 44:5827-5838. [PMID: 36547057 PMCID: PMC9776895 DOI: 10.3390/cimb44120396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Achilles-tendon rupture prevails as a common tendon pathology. Adipose-derived mesenchymal stem cells (ADMSCs) are multipotent stem cells derived from adipose tissue with attractive regeneration properties; thus, their application in tendinopathies could be beneficial. Methods: Male rabbit ADMSCs were obtained from the falciform ligament according to previously established methods. After tenotomy and suture of the Achilles tendon, 1 × 106 flow-cytometry-characterized male ADMSCs were injected in four female New Zealand white rabbits in the experimental group (ADMSC group), whereas four rabbits were left untreated (lesion group). Confirmation of ADMSC presence in the injured site after 12 weeks was performed with quantitative sex-determining region Y (SRY)-gene RT-PCR. At Week 12, histochemical analysis was performed to evaluate tissue regeneration along with quantitative RT-PCR of collagen I and collagen III mRNA. Results: Presence of male ADMSCs was confirmed at Week 12. No statistically significant differences were found in the histochemical analysis; however, statistically significant differences between ADMSC and lesion group expression of collagen I and collagen III were evidenced, with 36.6% and 24.1% GAPDH-normalized mean expression, respectively, for collagen I (p < 0.05) and 26.3% and 11.9% GAPDH-normalized mean expression, respectively, for collagen III (p < 0.05). The expression ratio between the ADMSC and lesion group was 1.5 and 2.2 for collagen I and collagen III, respectively. Conclusion: Our results make an important contribution to the understanding and effect of ADMSCs in Achilles-tendon rupture.
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Schulze-Tanzil GG, Delgado-Calcares M, Stange R, Wildemann B, Docheva D. Tendon healing: a concise review on cellular and molecular mechanisms with a particular focus on the Achilles tendon. Bone Joint Res 2022; 11:561-574. [PMID: 35920195 PMCID: PMC9396922 DOI: 10.1302/2046-3758.118.bjr-2021-0576.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Tendon is a bradytrophic and hypovascular tissue, hence, healing remains a major challenge. The molecular key events involved in successful repair have to be unravelled to develop novel strategies that reduce the risk of unfavourable outcomes such as non-healing, adhesion formation, and scarring. This review will consider the diverse pathophysiological features of tendon-derived cells that lead to failed healing, including misrouted differentiation (e.g. de- or transdifferentiation) and premature cell senescence, as well as the loss of functional progenitors. Many of these features can be attributed to disturbed cell-extracellular matrix (ECM) or unbalanced soluble mediators involving not only resident tendon cells, but also the cross-talk with immigrating immune cell populations. Unrestrained post-traumatic inflammation could hinder successful healing. Pro-angiogenic mediators trigger hypervascularization and lead to persistence of an immature repair tissue, which does not provide sufficient mechano-competence. Tendon repair tissue needs to achieve an ECM composition, structure, strength, and stiffness that resembles the undamaged highly hierarchically ordered tendon ECM. Adequate mechano-sensation and -transduction by tendon cells orchestrate ECM synthesis, stabilization by cross-linking, and remodelling as a prerequisite for the adaptation to the increased mechanical challenges during healing. Lastly, this review will discuss, from the cell biological point of view, possible optimization strategies for augmenting Achilles tendon (AT) healing outcomes, including adapted mechanostimulation and novel approaches by restraining neoangiogenesis, modifying stem cell niche parameters, tissue engineering, the modulation of the inflammatory cells, and the application of stimulatory factors.Cite this article: Bone Joint Res 2022;11(8):561-574.
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Affiliation(s)
| | - Manuel Delgado-Calcares
- Experimental Trauma Surgery, Department of Trauma Surgery, University Regensburg Medical Centre, Regensburg, Germany
| | - Richard Stange
- Department of Regenerative Musculoskeletal Medicine, Institute for Musculoskeletal Medicine (IMM), University Hospital Münster, Münster, Germany
| | - Britt Wildemann
- Department of Experimental Trauma Surgery, University Hospital Jena, Jena, Germany
| | - Denitsa Docheva
- Department of Musculoskeletal Tissue Regeneration, Orthopaedic Hospital König-Ludwig-Haus, University of Würzburg, Würzburg, Germany
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5
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Seow D, Yasui Y, Calder JDF, Kennedy JG, Pearce CJ. Treatment of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Complication Rates With Best- and Worst-Case Analyses for Rerupture Rates. Am J Sports Med 2021; 49:3728-3748. [PMID: 33783229 DOI: 10.1177/0363546521998284] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND An acute Achilles tendon rupture (AATR) is a common injury. The controversy that has surrounded the optimal treatment options for AATRs warrants an updated meta-analysis that is comprehensive, accounts for loss to follow-up, and utilizes the now greater number of available studies for data pooling. PURPOSE To meta-analyze the rates of all complications after the treatment of AATRs with a "best-case scenario" and "worst-case scenario" analysis for rerupture rates that assumes that all patients lost to follow-up did not or did experience a rerupture, respectively. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 1. METHODS Two authors performed a systematic review of the PubMed and Embase databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on February 17, 2020. The included studies were assessed in terms of the level of evidence, quality of evidence, and quality of the literature. A meta-analysis by fixed-effects models was performed if heterogeneity was low (I2 < 25%) and by random-effects models if heterogeneity was moderate to high (I2≥ 25%). RESULTS Surgical treatment was significantly favored over nonsurgical treatment for reruptures. Nonsurgical treatment was significantly favored over surgical treatment for complications other than reruptures, notably infections. Minimally invasive surgery was significantly favored over open repair for complications other than reruptures (no difference for reruptures), in particular for minor complications. CONCLUSION This meta-analysis demonstrated that surgical treatment was superior to nonsurgical treatment in terms of reruptures. However, the number needed to treat analysis produced nonmeaningful values for all treatment options, except for surgical versus nonsurgical treatment and minimally invasive surgery versus open repair. No single treatment option was revealed to be profoundly favorable with respect to every complication. The results of this meta-analysis can guide clinicians and patients in their treatment decisions that should be made jointly and on a case-by-case basis.
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Affiliation(s)
- Dexter Seow
- National University Health System, Singapore
| | - Youichi Yasui
- Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan
| | - James D F Calder
- Fortius Clinic, London, UK.,Department of Bioengineering, Imperial College London, London, UK
| | - John G Kennedy
- NYU Langone Orthopedic Hospital, New York, New York, USA
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6
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Zhao J, Wang X, Han J, Yu Y, Chen F, Yao J. Boost Tendon/Ligament Repair With Biomimetic and Smart Cellular Constructs. Front Bioeng Biotechnol 2021; 9:726041. [PMID: 34532315 PMCID: PMC8438196 DOI: 10.3389/fbioe.2021.726041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/22/2021] [Indexed: 12/11/2022] Open
Abstract
Tendon and ligament are soft connective tissues that play essential roles in transmitting forces from muscle to bone or bone to bone. Despite significant progress made in the field of ligament and tendon regeneration over the past decades, many strategies struggle to recapitulate basic structure-function criteria of native ligament/tendon. The goal here is to provide a fundamental understanding of the structure and composition of ligament/tendon and highlight few key challenges in functional regeneration of these connective tissues. The remainder of the review will examine several biomaterials strategies including biomimetic scaffold with non-linear mechanical behavior, hydrogel patch with anisotropic adhesion and gene-activated scaffold for interactive healing of tendon/ligament. Finally, emerging technologies and research avenues are suggested that have the potential to enhance treatment outcomes of tendon/ligament injuries.
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Affiliation(s)
- Jianping Zhao
- Department of Orthopedics Trauma and Hand Surgery & Guangxi Key Laboratory of Regenerative Medicine, International Joint Laboratory on Regeneration of Bone and Soft Tissue, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.,Center for Materials Synthetic Biology, Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Xiang Wang
- Center for Materials Synthetic Biology, Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Jinyu Han
- Center for Materials Synthetic Biology, Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Yin Yu
- Center for Materials Synthetic Biology, Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Fei Chen
- Center for Materials Synthetic Biology, Institute of Synthetic Biology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Jun Yao
- Department of Orthopedics Trauma and Hand Surgery & Guangxi Key Laboratory of Regenerative Medicine, International Joint Laboratory on Regeneration of Bone and Soft Tissue, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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7
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Couppé C, Svensson RB, Skovlund SV, Jensen JK, Eriksen CS, Malmgaard-Clausen NM, Nybing JD, Kjaer M, Magnusson SP. Habitual side-specific loading leads to structural, mechanical and compositional changes in the patellar tendon of young and senior life-long male athletes. J Appl Physiol (1985) 2021; 131:1187-1199. [PMID: 34382838 DOI: 10.1152/japplphysiol.00202.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Effects of life-long physical activity on tendon function have been investigated in cross-sectional studies, but these are at risk of "survivorship" bias. Here, we investigate if life-long side-specific loading is associated with greater cross-sectional area (CSA), mechanical properties, cell density (DNA content) and collagen cross-link composition of the male human patellar tendon (PT), in vivo. Nine seniors and six young male life-long elite badminton players and fencers were included. CSA of the PT obtained by 3-tesla MRI, and ultrasonography-based bilateral PT mechanics were assessed. Collagen fibril characteristics, enzymatic cross-links, non-enzymatic glycation (autofluorescence), collagen and DNA content were measured biochemically in PT biopsies. The elite athletes had a ≥15% side-to-side difference in maximal knee extensor strength, reflecting chronic unilateral sport-specific loading patterns. The PT CSA was greater on the lead extremity compared with the non-lead extremity (17 %, p=0.0001). Furthermore, greater tendon stiffness (18 %, p=0.0404) together with lower tendon stress (22 %, p=0.0005) and tendon strain (18 %, p=0.0433) were observed on the lead extremity. No effects were demonstrated from side-to-side for glycation, enzymatic cross-link, collagen, and DNA content (50%, p=0.1160). Moreover, tendon fibril density was 87±28 fibrils/μm2 on the lead extremity and 68±26 fibrils/μm2 on the non-lead extremity (28%, p=0.0544). Tendon fibril diameter was 86±14 nm on the lead extremity and 94±14 nm on the non-lead extremity (-9%, p=0.1076). These novel data suggest that life-long side-specific loading in males yields greater patellar tendon size and stiffness possibly with concomitant greater fibril density but without changes of collagen cross-link composition.
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Affiliation(s)
- Christian Couppé
- Institute of Sports Medicine Copenhagen, Bispebjerg-Frederiksberg Hospitals, Denmark.,Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospitals, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Bispebjerg-Frederiksberg Hospitals, Denmark
| | - Sebastian V Skovlund
- Institute of Sports Medicine Copenhagen, Bispebjerg-Frederiksberg Hospitals, Denmark.,Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospitals, Denmark
| | | | | | | | - Janus Damm Nybing
- Department of Radiology, Bispebjerg-Frederiksberg Hospitals, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Bispebjerg-Frederiksberg Hospitals, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Bispebjerg-Frederiksberg Hospitals, Denmark.,Department of Physical and Occupational Therapy, Bispebjerg-Frederiksberg Hospitals, Denmark
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8
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Weinrich L, Paraskevaidis M, Schleip R, Agres AN, Tsitsilonis S. Does the Calcaneus Serve as Hypomochlion within the Lower Limb by a Myofascial Connection?-A Systematic Review. Life (Basel) 2021; 11:life11080745. [PMID: 34440492 PMCID: PMC8398293 DOI: 10.3390/life11080745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 11/29/2022] Open
Abstract
(1) Background: Clinical approaches have depicted interconnectivity between the Achilles tendon and the plantar fascia. This concept has been applied in rehabilitation, prevention, and in conservative management plans, yet potential anatomical and histological connection is not fully understood. (2) Objective: To explore the possible explanation that the calcaneus acts as a hypomochlion. (3) Methods: 2 databases (Pubmed and Livivo) were searched and studies, including those that examined the relationship of the calcaneus to the Achilles tendon and plantar fascia and its biomechanical role. The included studies highlighted either the anatomical, histological, or biomechanical aspect of the lower limb. (4) Results: Seventeen studies were included. Some studies depicted an anatomical connection that slowly declines with age. Others mention a histological similarity and continuity via the paratenon, while a few papers have brought forward mechanical reasoning. (5) Conclusion: The concept of the calcaneus acting as a fulcrum in the lower limb can partially be supported by anatomical, histological, and biomechanical concepts. Despite the plethora of research, a comprehensive understanding is yet to be investigated. Further research exploring the precise interaction is necessary.
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Affiliation(s)
- Luise Weinrich
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (L.W.); (M.P.)
| | - Melissa Paraskevaidis
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (L.W.); (M.P.)
| | - Robert Schleip
- Technische Universität München, 80333 München, Germany;
- Diploma University of Applied Sciences, 37242 Bad Sooden-Allendorf, Germany
| | - Alison N. Agres
- Julius Wolff Institute, Berlin Institute of Health and Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Serafeim Tsitsilonis
- Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (L.W.); (M.P.)
- Correspondence:
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Mahajan NP, Kondewar P, Kumar Gs P, Marfatia A. Surgical Management of Chronic Tendoachilles Tear in Elderly Patients - A Case Series. J Orthop Case Rep 2021; 11:57-62. [PMID: 34141672 PMCID: PMC8180331 DOI: 10.13107/jocr.2021.v11.i02.2026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Chronic tendoachilles (TA) tears are commonly missed injuries in elderly population with associated comorbidities and they usually occur as low-energy injuries. Appropriate surgical management helps in getting a better functional outcome in elderly patients. Case Series: We present a series of three cases of chronic TA tear in elderly patients managed surgically. Two patients had an insertional tear and they were managed with flexor hallucis longus (FHL) transfer and fixed with interference screw in the calcaneum. Another patient was managed with end-to-end suturing using fiber wire. All the patients are having good functional outcome without any wound complication or re rupture. Conclusion: Early diagnosis, meticulous repair, and handling of soft tissues and TA tear help in getting a better outcome in elderly patients. The final functional outcome depends on intraoperative stability of the repair, ankle physiotherapy, and wisely selection of the treatment method, which mainly depends on the location of the tear. Reconstruction with FHL tendon using interference screw in calcaneum helps to repair the insertional tears in elderly patients.
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Affiliation(s)
- Neetin P Mahajan
- Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India
| | - Pranay Kondewar
- Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India
| | - Prasanna Kumar Gs
- Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India
| | - Ankit Marfatia
- Department of Orthopaedics, Grant Government Medical College, Mumbai, Maharashtra, India
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11
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Siadat SM, Zamboulis DE, Thorpe CT, Ruberti JW, Connizzo BK. Tendon Extracellular Matrix Assembly, Maintenance and Dysregulation Throughout Life. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:45-103. [PMID: 34807415 DOI: 10.1007/978-3-030-80614-9_3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In his Lissner Award medal lecture in 2000, Stephen Cowin asked the question: "How is a tissue built?" It is not a new question, but it remains as relevant today as it did when it was asked 20 years ago. In fact, research on the organization and development of tissue structure has been a primary focus of tendon and ligament research for over two centuries. The tendon extracellular matrix (ECM) is critical to overall tissue function; it gives the tissue its unique mechanical properties, exhibiting complex non-linear responses, viscoelasticity and flow mechanisms, excellent energy storage and fatigue resistance. This matrix also creates a unique microenvironment for resident cells, allowing cells to maintain their phenotype and translate mechanical and chemical signals into biological responses. Importantly, this architecture is constantly remodeled by local cell populations in response to changing biochemical (systemic and local disease or injury) and mechanical (exercise, disuse, and overuse) stimuli. Here, we review the current understanding of matrix remodeling throughout life, focusing on formation and assembly during the postnatal period, maintenance and homeostasis during adulthood, and changes to homeostasis in natural aging. We also discuss advances in model systems and novel tools for studying collagen and non-collagenous matrix remodeling throughout life, and finally conclude by identifying key questions that have yet to be answered.
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Affiliation(s)
| | - Danae E Zamboulis
- Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Chavaunne T Thorpe
- Comparative Biomedical Sciences, The Royal Veterinary College, University of London, London, UK
| | - Jeffrey W Ruberti
- Department of Bioengineering, Northeastern University, Boston, MA, USA
| | - Brianne K Connizzo
- Department of Biomedical Engineering, Boston University, Boston, MA, USA.
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12
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Longo UG, Berton A, Stelitano G, Madaudo C, Perna M, Ciuffreda M, Guarnieri A, Papalia R, Maffulli N, Denaro V. 2017 Marathon of Rome: Anthropometry and Sport Profile in 350 Runners and Association With Achilles and Patellar Tendinopathy. Clin J Sport Med 2021; 31:e15-e20. [PMID: 30365471 DOI: 10.1097/jsm.0000000000000695] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Achilles and patellar tendinopathy are common in runners. Despite the relevance of the problem, causative factors remain poorly understood. This cross-sectional study evaluated the association between Achilles and patellar tendinopathy and age, sex, weight, height, number of marathons, and impact profile in runners who participated in the 2017 Marathon of Rome. METHODS At the 2017 Marathon of Rome, 350 athletes (256 men and 94 women; mean age: 44.8 years, range 12-80 years) filled in the VISA-A and VISA-P questionnaires. A fully trained orthopedic surgeon made a diagnosis of Achilles and patellar tendinopathy according to clinical criteria. RESULTS Ninety-five participants were diagnosed with Achilles tendinopathy and 96 with patellar tendinopathy. There was evidence of a statistically significant positive association between age and Achilles and patellar tendinopathy, with no effect of sex, weight, and height on the presence of Achilles tendinopathy. There was no evidence of a statistically significant positive association between the number of marathons and impact profile and VISA-A score. There was a statistically significant association between VISA-P score and impact profile. Finally, there was evidence of a statistically significant positive association between VISA-A score and VISA-P score (P = 0.007). CONCLUSIONS In marathon runners, there was no evidence of a statistically significant association between sex, weight, height, number of marathons, and Achilles and patellar tendinopathy. However, age was associated with Achilles and patellar tendinopathy, and impact profile was associated with patellar tendinopathy.
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Affiliation(s)
- Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Alessandra Berton
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Giovanna Stelitano
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Cristina Madaudo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Massiliano Perna
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Andrea Guarnieri
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Rome, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy ; and
- Department of Musculoskeletal Disorders, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, United Kingdom
| | - Vincenzo Denaro
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy ; and
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13
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Shane AM, Reeves CL, Nguyen GB, Sebag JA. Revision Surgery for the Achilles Tendon. Clin Podiatr Med Surg 2020; 37:553-568. [PMID: 32471618 DOI: 10.1016/j.cpm.2020.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Treatment of Achilles tendon ruptures may be surgical or nonsurgical depending on health, history, age, acuity, and severity of the injury. With chronic or revisional injuries, the best method often requires an open repair with reconstructive soft tissue procedures. Revision surgery can be challenging because of the complexity involving tendinous deficits with nonviable and friable tissue. Surgical treatment is based on tendon approximation, size of the defect, tendon integrity, and functional demands. The goal is to restore anatomic and physiologic tension, provide adequate strength for proper ambulation, optimize functional return to activity, decrease pain, and decrease complications.
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Affiliation(s)
- Amber M Shane
- Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 250 North Alafaya Trail Suite 115, Orlando, FL 32828, USA.
| | - Christopher L Reeves
- Advent Health East Orlando Podiatric Surgery Residency, Orlando Foot and Ankle Clinic- Upperline Health, 250 North Alafaya Trail Suite 115, Orlando, FL 32828, USA
| | - Garrett B Nguyen
- Department of Podiatric Surgery, Advent Health East Orlando Podiatric Surgery Residency, 250 North Alafaya Trail Suite 1115, Orlando, FL 32828, USA
| | - Joshua A Sebag
- Department of Podiatric Surgery, Advent Health East Orlando Podiatric Surgery Residency, 250 North Alafaya Trail Suite 1115, Orlando, FL 32828, USA
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Tendon and ligament mechanical loading in the pathogenesis of inflammatory arthritis. Nat Rev Rheumatol 2020; 16:193-207. [PMID: 32080619 DOI: 10.1038/s41584-019-0364-x] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 12/18/2022]
Abstract
Mechanical loading is an important factor in musculoskeletal health and disease. Tendons and ligaments require physiological levels of mechanical loading to develop and maintain their tissue architecture, a process that is achieved at the cellular level through mechanotransduction-mediated fine tuning of the extracellular matrix by tendon and ligament stromal cells. Pathological levels of force represent a biological (mechanical) stress that elicits an immune system-mediated tissue repair pathway in tendons and ligaments. The biomechanics and mechanobiology of tendons and ligaments form the basis for understanding how such tissues sense and respond to mechanical force, and the anatomical extent of several mechanical stress-related disorders in tendons and ligaments overlaps with that of chronic inflammatory arthritis in joints. The role of mechanical stress in 'overuse' injuries, such as tendinopathy, has long been known, but mechanical stress is now also emerging as a possible trigger for some forms of chronic inflammatory arthritis, including spondyloarthritis and rheumatoid arthritis. Thus, seemingly diverse diseases of the musculoskeletal system might have similar mechanisms of immunopathogenesis owing to conserved responses to mechanical stress.
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Achilles Tendon Ruptures in Young Female Basketball Players: A Case Series. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:e016. [PMID: 31588421 PMCID: PMC6738549 DOI: 10.5435/jaaosglobal-d-19-00016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Achilles tendon ruptures are a common entity in middle-aged male athletes. There have been limited reports of these injuries in female athletes in general and no reports that we are aware of teenage female athletes with complete tears that required surgical intervention. We present a case series of three female basketball players treated at the same institution by the same surgeon under the age of 20 over a 9-month period with complete Achilles tendon ruptures that underwent surgery. Clinicians should be aware of this pathology when seeing female athletes with calf pain.
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Lorimer AV, Keogh JWL, Hume PA. Using stiffness to assess injury risk: comparison of methods for quantifying stiffness and their reliability in triathletes. PeerJ 2018; 6:e5845. [PMID: 30397548 PMCID: PMC6214235 DOI: 10.7717/peerj.5845] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 09/28/2018] [Indexed: 11/22/2022] Open
Abstract
Background A review of the literature has indicated that lower body stiffness, defined as the extent to which the lower extremity joints resists deformation upon contact with the ground, may be a useful measure for assessing Achilles injury risk in triathletes. The nature of overuse injuries suggests that a variety of different movement patterns could conceivably contribute to the final injury outcome, any number and combination of which might be observed in a single individual. Measurements which incorporate both kinetics and kinematics (such as stiffness) of a movement may be better able to shed light on individuals at risk of injury, with further analysis then providing the exact mechanism of injury for the individual. Stiffness can be measured as vertical, leg or joint stiffness to model how the individual interacts with the environment upon landing. However, several issues with stiffness assessments limit the effectiveness of these measures to monitor athletes’ performance and/or injury risk. This may reflect the variety of common biomechanical stiffness calculations (dynamic, time, true leg and joint) that have been used to examine these three stiffness levels (vertical, leg and joint) across a variety of human movements (i.e. running or hopping) as well as potential issues with the reliability of these measures, especially joint stiffness. Therefore, the aims of this study were to provide a comparison of the various methods for measuring stiffness during two forms of human bouncing locomotion (running and hopping) along with the measurement reliability to determine the best methods to assess links with injury risk in triathletes. Methods Vertical, leg and joint stiffness were estimated in 12 healthy male competitive triathletes on two occasions, 7 days apart, using both running at 5.0 ms−1 and hopping (2.2 Hz) tasks. Results Inter-day reliability was good for vertical (ICC = 0.85) and leg (ICC = 0.98) stiffness using the time method. Joint stiffness reliability was poor when assessed individually. Reliability was improved when taken as the sum of the hip, knee and ankle (ICC = 0.86). The knee and ankle combination provided the best correlation with leg stiffness during running (Pearson’s Correlation = 0.82). Discussion The dynamic and time methods of calculating leg stiffness had better reliability than the “true” method. The time and dynamic methods had the best correlation with the different combinations of joint stiffness, which suggests that they should be considered for biomechanical screening of triathletes. The knee and ankle combination had the best correlation with leg stiffness and is therefore proposed to provide the most information regarding lower limb mechanics during gait in triathletes.
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Affiliation(s)
- Anna V Lorimer
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand
| | - Justin W L Keogh
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand.,Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Patria A Hume
- Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand
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Prosenz J, Rath C, Hadrovic-Avdic M, Hirtler L. The Twist of the Achilles Tendon - Associations of Torsions in the Lower Extremity. Clin Anat 2018; 31:1085-1091. [PMID: 30098267 DOI: 10.1002/ca.23247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/01/2018] [Indexed: 11/09/2022]
Abstract
Achilles tendinopathy and rupture of the Achilles tendon (AT) are frequent pathologies. Even though they may be associated with the twisted morphology of the AT, quantitative data on the extent of the twist of the entire AT are not available. The aim of this study was to investigate the torsion of the AT based on its individual parts and to evaluate a possible correlation with the torsion of the long bones of the lower extremity. Forty embalmed lower extremities were included in this study. The lateral deviation of the AT and its torsional angle as well as the angles of the individual parts in trans-section were measured. Thereafter, the torsions of femur and tibia were evaluated. Measuring the lateral deviation of the fibers resulted in an average torsion of the AT of 34.59° (SD 16.8°). The angles of the different parts of the AT in trans-section resulted in a median AT torsion of 15.73°, showing various patterns of rotations of the individual muscles. A statistically significant correlation between the torsions of the lower extremity and the AT (P =0.0242, r = 0.40) as well as a correlation between the femoral torsion and the AT torsion (P = 0.0127, r = 0.44) were found. This study adds to the morphological understanding of the torsion of the AT and its correlation with the torsions of the long bones of the lower extremity. Especially, the torsion of the femur seems to be connected to the torsion of the tendon. Clin. Anat. 31:1085-1091, 2018. © 2018 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.
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Affiliation(s)
- Julian Prosenz
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Claus Rath
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Merisa Hadrovic-Avdic
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
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18
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Connizzo BK, Grodzinsky AJ. Multiscale Poroviscoelastic Compressive Properties of Mouse Supraspinatus Tendons Are Altered in Young and Aged Mice. J Biomech Eng 2018; 140:2666618. [PMID: 29238818 PMCID: PMC5816244 DOI: 10.1115/1.4038745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/04/2017] [Indexed: 02/02/2023]
Abstract
Rotator cuff disorders are one of the most common causes of shoulder pain and disability in the aging population but, unfortunately, the etiology is still unknown. One factor thought to contribute to the progression of disease is the external compression of the rotator cuff tendons, which can be significantly increased by age-related changes such as muscle weakness and poor posture. The objective of this study was to investigate the baseline compressive response of tendon and determine how this response is altered during maturation and aging. We did this by characterizing the compressive mechanical, viscoelastic, and poroelastic properties of young, mature, and aged mouse supraspinatus tendons using macroscale indentation testing and nanoscale high-frequency AFM-based rheology testing. Using these multiscale techniques, we found that aged tendons were stiffer than their mature counterparts and that both young and aged tendons exhibited increased hydraulic permeability and energy dissipation. We hypothesize that regional and age-related variations in collagen morphology and organization are likely responsible for changes in the multiscale compressive response as these structural parameters may affect fluid flow. Importantly, these results suggest a role for age-related changes in the progression of tendon degeneration, and we hypothesize that decreased ability to resist compressive loading via fluid pressurization may result in damage to the extracellular matrix (ECM) and ultimately tendon degeneration. These studies provide insight into the regional multiscale compressive response of tendons and indicate that altered compressive properties in aging tendons may be a major contributor to overall tendon degeneration.
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Affiliation(s)
- Brianne K. Connizzo
- Department of Biological Engineering,
Massachusetts Institute of Technology,
Cambridge, MA 02139
| | - Alan J. Grodzinsky
- Department of Biological Engineering,Massachusetts Institute of Technology,
Cambridge, MA 02139;
Center for Biomedical Engineering,Massachusetts Institute of Technology,
Cambridge, MA 02139;
Department of Electrical Engineeringand Computer Science,
Massachusetts Institute of Technology,
Cambridge, MA 02139;
Department of Mechanical Engineering,Massachusetts Institute of Technology,
Cambridge, MA 02139
e-mail:
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19
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Abstract
Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal tenotomies, minimally invasive tendon scraping, open débridement and tubularization, and tendon augmentation with flexor hallucis longus.
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Affiliation(s)
- Avreeta Singh
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Arash Calafi
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Chris Diefenbach
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Chris Kreulen
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Eric Giza
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA.
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20
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Abstract
Achilles tendon injuries can be serious injuries requiring either operative or nonoperative management. For appropriate surgical candidates, operative intervention may provide lower rerupture rates and adequate end-to-end tendon healing. Our preference is an open Achilles tendon repair, specifically a limited open technique using the PARS device (Arthrex, Naples, FL). Postoperatively, we use functional rehabilitation and early range of motion. Although the current literature remains controversial regarding operative versus nonoperative management, the authors have obtained satisfactory results in appropriately chosen surgical candidates.
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Affiliation(s)
- Robert D Santrock
- Department of Orthopaedics, Robert C. Byrd Health Sciences Center, West Virginia University, PO Box 9196 - South, Morgantown, WV 26506, USA.
| | - Andrew J Friedmann
- Department of Orthopaedics, Robert C. Byrd Health Sciences Center, West Virginia University, PO Box 9196 - South, Morgantown, WV 26506, USA
| | - Andrew E Hanselman
- Department of Orthopaedics, Robert C. Byrd Health Sciences Center, West Virginia University, PO Box 9196 - South, Morgantown, WV 26506, USA
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21
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Kauwe M. Acute Achilles Tendon Rupture: Clinical Evaluation, Conservative Management, and Early Active Rehabilitation. Clin Podiatr Med Surg 2017; 34:229-243. [PMID: 28257676 DOI: 10.1016/j.cpm.2016.10.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The Achilles tendon (AT) is the strongest, largest, and most commonly ruptured tendon in the human body. Physical examination provides high sensitivity and specificity. Imaging studies are not recommended unless there are equivocal findings in the physical examination. Recent studies have shown that the risk of re-rupture is negated with implementation of functional rehabilitation protocols. Heterogeneity in study design makes conclusions on the specifics of functional rehabilitation protocols difficult; however, it is clear that early weight bearing and early controlled mobilization lead to better patient outcome and satisfaction in both surgically and conservatively treated populations.
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Affiliation(s)
- Merrell Kauwe
- Foot and Ankle Department, UnityPoint Trinity Regional Medical Center, 804 Kenyon Road, Suite 310, Fort Dodge, IA 50501, USA.
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22
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Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6492597. [PMID: 27885357 PMCID: PMC5112330 DOI: 10.1155/2016/6492597] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/20/2016] [Indexed: 12/30/2022]
Abstract
Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options.
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23
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The influence of ultrasound measurement techniques on the age-related differences in Achilles tendon size. Exp Gerontol 2016; 76:68-71. [DOI: 10.1016/j.exger.2016.01.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/07/2015] [Accepted: 01/27/2016] [Indexed: 11/20/2022]
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24
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Lomas A, Ryan C, Sorushanova A, Shologu N, Sideri A, Tsioli V, Fthenakis G, Tzora A, Skoufos I, Quinlan L, O'Laighin G, Mullen A, Kelly J, Kearns S, Biggs M, Pandit A, Zeugolis D. The past, present and future in scaffold-based tendon treatments. Adv Drug Deliv Rev 2015; 84:257-77. [PMID: 25499820 DOI: 10.1016/j.addr.2014.11.022] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/08/2014] [Accepted: 11/12/2014] [Indexed: 02/07/2023]
Abstract
Tendon injuries represent a significant clinical burden on healthcare systems worldwide. As the human population ages and the life expectancy increases, tendon injuries will become more prevalent, especially among young individuals with long life ahead of them. Advancements in engineering, chemistry and biology have made available an array of three-dimensional scaffold-based intervention strategies, natural or synthetic in origin. Further, functionalisation strategies, based on biophysical, biochemical and biological cues, offer control over cellular functions; localisation and sustained release of therapeutics/biologics; and the ability to positively interact with the host to promote repair and regeneration. Herein, we critically discuss current therapies and emerging technologies that aim to transform tendon treatments in the years to come.
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25
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de Almeida MDS, de Freitas KM, Oliveira LP, Vieira CP, Guerra FDR, Dolder MAH, Pimentel ER. Acupuncture Increases the Diameter and Reorganisation of Collagen Fibrils during Rat Tendon Healing. Acupunct Med 2015; 33:51-7. [DOI: 10.1136/acupmed-2014-010548] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Our previous study showed that electroacupuncture (EA) increases the concentration and reorganisation of collagen in a rat model of tendon healing. However, the ultrastructure of collagen fibrils after acupuncture is unknown. Objectives To assess the effect of acupuncture protocols on the ultrastructure of collagen fibrils during tendon healing. Methods Sixty-four rats were divided into the following groups: non-tenotomised (normal group), tenotomised (teno group), tenotomised and subjected to manual acupuncture at ST36 (ST36 group), BL57 (BL57 group) and ST36+BL57 (SB group) and EA at ST36+BL57 (EA group). The mass-average diameter (MAD) and the reorganisation of collagen fibril diameters were determined during the three phases of tendon healing (at 7, 14 and 21 days). Results The MAD increased during the three phases of healing in the SB group. In the EA group, MAD increased initially but was reduced at day 21. The reorganisation of collagen fibrils was improved in the EA and SB groups at days 14 and 21, respectively. EA at day 21 appeared to reduce the reorganisation. Conclusions These results indicate that the use of EA up to day 14 and manual acupuncture at ST36+BL57 up to day 21 improve the ultrastructure of collagen fibrils, indicating strengthening of the tendon structure. These data suggest a potential role for acupuncture in rehabilitation protocols.
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Affiliation(s)
- Marcos dos Santos de Almeida
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas—UNICAMP, Campinas, São Paulo, Brazil
| | - Karine Moura de Freitas
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas—UNICAMP, Campinas, São Paulo, Brazil
| | - Letícia Prado Oliveira
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas—UNICAMP, Campinas, São Paulo, Brazil
| | - Cristiano Pedrozo Vieira
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas—UNICAMP, Campinas, São Paulo, Brazil
| | - Flávia Da Ré Guerra
- Department of Anatomy, Biomedical Science Institute, Federal University of Alfenas, UNIFAL-MG, Alfenas, Minas Gerais, Brazil
| | - Mary Anne Heidi Dolder
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas—UNICAMP, Campinas, São Paulo, Brazil
| | - Edson Rosa Pimentel
- Department of Structural and Functional Biology, Institute of Biology, State University of Campinas—UNICAMP, Campinas, São Paulo, Brazil
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Dakin SG, Dudhia J, Smith RKW. Resolving an inflammatory concept: the importance of inflammation and resolution in tendinopathy. Vet Immunol Immunopathol 2014; 158:121-7. [PMID: 24556326 PMCID: PMC3991845 DOI: 10.1016/j.vetimm.2014.01.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/19/2013] [Accepted: 01/06/2014] [Indexed: 01/01/2023]
Abstract
Injuries to the superficial digital flexor tendon (SDFT) are an important cause of morbidity and mortality in equine athletes, but the healing response is poorly understood. One important drive for the healing of connective tissues is the inflammatory cascade, but the role of inflammation in tendinopathy has been contentious in the literature. This article reviews the processes involved in the healing of tendon injuries in natural disease and experimental models. The importance of inflammatory processes known to be active in tendon disease is discussed with particular focus on recent findings related specifically to the horse. Whilst inflammation is necessary for debridement after injury, persistent inflammation is thought to drive fibrosis, a perceived adverse consequence of tendon healing. Therefore the ability to resolve inflammation by the resident cell populations in tendons at an appropriate time would be crucial for successful outcome. This review summarises new evidence for the importance of resolution of inflammation after tendon injury. Given that many anti-inflammatory drugs suppress both inflammatory and resolving components of the inflammatory response, prolonged use of these drugs may be contraindicated as a therapeutic approach. We propose that these findings have profound implications not only for current treatment strategies but also for the possibility of developing novel therapeutic approaches involving modulation of the inflammatory process.
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Affiliation(s)
- Stephanie G Dakin
- Royal Veterinary College, Department of Clinical Sciences and Services, North Mymms, Hatfield, Hertfordshire AL9 7TA, United Kingdom.
| | - Jayesh Dudhia
- Royal Veterinary College, Department of Clinical Sciences and Services, North Mymms, Hatfield, Hertfordshire AL9 7TA, United Kingdom
| | - Roger K W Smith
- Royal Veterinary College, Department of Clinical Sciences and Services, North Mymms, Hatfield, Hertfordshire AL9 7TA, United Kingdom
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27
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Dakin SG, Smith RKW, Heinegård D, Önnerfjord P, Khabut A, Dudhia J. Proteomic analysis of tendon extracellular matrix reveals disease stage-specific fragmentation and differential cleavage of COMP (cartilage oligomeric matrix protein). J Biol Chem 2014; 289:4919-27. [PMID: 24398684 PMCID: PMC3931053 DOI: 10.1074/jbc.m113.511972] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
During inflammatory processes the extracellular matrix (ECM) is extensively remodeled, and many of the constituent components are released as proteolytically cleaved fragments. These degradative processes are better documented for inflammatory joint diseases than tendinopathy even though the pathogenesis has many similarities. The aims of this study were to investigate the proteomic composition of injured tendons during early and late disease stages to identify disease-specific cleavage patterns of the ECM protein cartilage oligomeric matrix protein (COMP). In addition to characterizing fragments released in naturally occurring disease, we hypothesized that stimulation of tendon explants with proinflammatory mediators in vitro would induce fragments of COMP analogous to natural disease. Therefore, normal tendon explants were stimulated with IL-1β and prostaglandin E2, and their effects on the release of COMP and its cleavage patterns were characterized. Analyses of injured tendons identified an altered proteomic composition of the ECM at all stages post injury, showing protein fragments that were specific to disease stage. IL-1β enhanced the proteolytic cleavage and release of COMP from tendon explants, whereas PGE2 had no catabolic effect. Of the cleavage fragments identified in early stage tendon disease, two fragments were generated by an IL-1-mediated mechanism. These fragments provide a platform for the development of neo-epitope assays specific to injury stage for tendon disease.
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Affiliation(s)
- Stephanie Georgina Dakin
- From the Department of Clinical Sciences and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, United Kingdom and
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Couppé C, Svensson RB, Grosset JF, Kovanen V, Nielsen RH, Olsen MR, Larsen JO, Praet SFE, Skovgaard D, Hansen M, Aagaard P, Kjaer M, Magnusson SP. Life-long endurance running is associated with reduced glycation and mechanical stress in connective tissue. AGE (DORDRECHT, NETHERLANDS) 2014; 36:9665. [PMID: 24997017 PMCID: PMC4150896 DOI: 10.1007/s11357-014-9665-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 06/18/2014] [Indexed: 05/07/2023]
Abstract
Life-long regular endurance exercise is known to counteract the deterioration of cardiovascular and metabolic function and overall mortality. Yet it remains unknown if life-long regular endurance exercise can influence the connective tissue accumulation of advanced glycation endproducts (AGEs) that is associated with aging and lifestyle-related diseases. We therefore examined two groups of healthy elderly men: 15 master athletes (64 ± 4 years) who had been engaged in life-long endurance running and 12 old untrained (66 ± 4 years) together with two groups of healthy young men; ten young athletes matched for running distance (26 ± 4 years), and 12 young untrained (24 ± 3 years). AGE cross-links (pentosidine) of the patellar tendon were measured biochemically, and in the skin, it was assessed by a fluorometric method. In addition, we determined mechanical properties and microstructure of the patellar tendon. Life-long regular endurance runners (master athletes) had a 21 % lower AGE cross-link density compared to old untrained. Furthermore, both master athletes and young athletes displayed a thicker patellar tendon. These cross-sectional data suggest that life-long regular endurance running can partly counteract the aging process in connective tissue by reducing age-related accumulation of AGEs. This may not only benefit skin and tendon but also other long-lived protein tissues in the body. Furthermore, it appears that endurance running yields tendon tissue hypertrophy that may serve to lower the stress on the tendon and thereby reduce the risk of injury.
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Affiliation(s)
- Christian Couppé
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Bldg. 8, Bispebjerg Bakke 23, DK-2400, Copenhagen, NV, Denmark,
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Hébert-Losier K, Schneiders AG, García JA, Sullivan SJ, Simoneau GG. Influence of knee flexion angle and age on triceps surae muscle fatigue during heel raises. J Strength Cond Res 2013; 26:3134-47. [PMID: 22158096 DOI: 10.1519/jsc.0b013e318243ff0e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The triceps surae (TS) muscle-tendon unit is 1 of the most commonly injured in elite and recreational athletes, with a high prevalence in middle-aged adults. The performance of maximal numbers of unilateral heel raises is used to assess, train, and rehabilitate TS endurance and conventionally prescribed in 0° knee flexion (KF) for the gastrocnemius and 45° for the soleus (SOL). However, the extent of muscle selectivity conferred through the change in the knee angle is lacking for heel raises performed to volitional fatigue. This study investigated the influence of knee angle on TS muscle fatigue during heel raises and determined whether fatigue differed between middle-aged and younger-aged adults. Forty-eight healthy individuals aged 18-25 and 35-45 years performed maximal numbers of unilateral heel raises in 0° and 45° KF. Median frequencies and linear regression slopes were calculated from the SOL, gastrocnemius medialis (GM), and gastrocnemius lateralis (GL) surface electromyographic signals. Stepwise mixed-effect regressions were used for analysis. The subjects completed an average of 45 and 48 heel raises in 0° and 45° KF, respectively. The results indicated that the 3 muscles fatigued during testing as all median frequencies decreased, and regression slopes were negative. Consistent with muscle physiology and fiber typing, fatigue was greater in the GM and GL than in the SOL (p < 0.001). However, knee angle did not influence TS muscle fatigue parameters (p = 0.814), with similar SOL, GM, and GL fatigue in 0° and 45° KF. These findings are in contrast with the traditionally described clinical use of heel raises in select knee angles for the gastrocnemius and the SOL. Furthermore, no difference in TS fatigue between the 2 age groups was able to be determined, despite the reported higher prevalence of injury in middle-aged individuals.
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Affiliation(s)
- Kim Hébert-Losier
- Center for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Dakin SG, Dudhia J, Smith RKW. Science in brief: Resolving tendon inflammation. A new perspective. Equine Vet J 2013; 45:398-400. [DOI: 10.1111/evj.12030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- S. G. Dakin
- Department of Veterinary Clinical Sciences; Royal Veterinary College; UK
| | - J. Dudhia
- Department of Veterinary Clinical Sciences; Royal Veterinary College; UK
| | - R. K. W. Smith
- Department of Veterinary Clinical Sciences; Royal Veterinary College; UK
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Lavagnino M, Gardner K, Arnoczky SP. Age-related changes in the cellular, mechanical, and contractile properties of rat tail tendons. Connect Tissue Res 2012. [PMID: 23186207 DOI: 10.3109/03008207.2012.744973] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Tendon laxity following injury, cyclic creep, or repair has been shown to alter the normal homeostasis of tendon cells, which can lead to degenerative changes in the extracellular matrix. While tendon cells have been shown to have an inherent contractile mechanism that gives them some ability to retighten lax tendons and reestablish a homeostatic cellular environment, the effect of age on this process is unknown. To determine the effect of aging on cell number, cell shape, and tensile modulus on tendons as well as the rate of cell-mediated contraction of lax tendons, tail tendon fascicles from 1-, 3-, and 12-month-old rats were analyzed. Aging results in a decrease (p < 0.001) in cell number per mm(2): 1 m (981 ± 119), 3 m (570 ± 108), and 12 m (453 ± 23), a more flattened (p < 0.001) cell nuclei shape and a higher (p < 0.001) tensile modulus (MPa) of the tendons: 1 m (291 ± 2), 3 m (527 ± 38), and 12 m (640 ± 102). Both the extent and rate of contraction over 7 days decreased with age (p = 0.007). This decrease in contraction rate with age correlates to the observed changes seen in aging tendons [increased modulus (r(2) = 0.95), decreased cell number (r(2) = 0.89)]. The ability of tendons to regain normal tension following injury or exercise-induced laxity is a key factor in the recovery of tendon function. The decreased contraction rate as a function of age observed in the current study may limit the ability of tendon cells to retighten lax tendons in older individuals. This, in turn, may place these structures at further risk for injury or altered function.
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Affiliation(s)
- Michael Lavagnino
- Laboratory for Comparative Orthopaedic Research, College of Veterinary Medicine, Michigan State University, East Lansing, MI 48824, USA
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Dakin SG, Dudhia J, Werling NJ, Werling D, Abayasekara DRE, Smith RKW. Inflamm-aging and arachadonic acid metabolite differences with stage of tendon disease. PLoS One 2012; 7:e48978. [PMID: 23155437 PMCID: PMC3498370 DOI: 10.1371/journal.pone.0048978] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 10/01/2012] [Indexed: 01/01/2023] Open
Abstract
The contribution of inflammation to the pathogenesis of tendinopathy and high prevalence of re-injury is not well established, although recent evidence suggests involvement of prostaglandins. We investigated the roles of prostaglandins and inflammation-resolving mediators in naturally occurring equine tendon injury with disease stage and age. Levels of prostaglandins E2 (PGE2), F2α (PGF2α), lipoxin A4 (LXA4) and its receptor FPR2/ALX were analysed in extracts of normal, sub-acute and chronic injured tendons. To assess whether potential changes were associated with altered PGE2 metabolism, microsomal prostaglandin E synthase-1 (mPGES-1), prostaglandin dehydrogenase (PGDH), COX-2 and EP4 receptor expression were investigated. The ability of tendons to resolve inflammation was determined by assessing FPR2/ALX expression in natural injury and IL-1β stimulated tendon explants. Alterations in the profile of lipid mediators during sub-acute injury included low PGE2 and elevated LXA4 levels compared to normal and chronic injuries. In contrast, PGF2α levels remained unchanged and were three-fold lower than PGE2. The synthetic capacity of PGE2 as measured by the ratio of mPGES-1:PGDH was elevated in sub-acute injury, suggesting aberrations in tendon prostaglandin metabolism, whilst COX-2 and EP4 receptor were unchanged. Paradoxically low tendon PGE2 levels in early injury may be attributed to increased local clearance via PGDH or the class switching of lipid mediators from the prostaglandin to the lipoxin axis. PGE2 is therefore implicated in the development of tendon inflammation and its ensuing resolution. Whilst there was no relationship between age and tendon LXA4 levels, there was an age-associated decline in FPR2/ALX receptor expression with concurrent increased PGE2 levels in injury. Furthermore, uninjured tendon explants from younger (<10 years) but not older horses (≥10 years) treated with IL-1β responded by increasing FPR2/ALX suggesting aged individuals exhibit a reduced capacity to resolve inflammation via FPR2/ALX, which may present a potential mechanism for development of chronic tendinopathy and re-injury.
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Affiliation(s)
- Stephanie Georgina Dakin
- Department of Veterinary Clinical Sciences, Royal Veterinary College, University of London, Hatfield, United Kingdom.
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Maffulli N, Del Buono A, Spiezia F, Longo UG, Denaro V. Light microscopic histology of quadriceps tendon ruptures. INTERNATIONAL ORTHOPAEDICS 2012; 36:2367-71. [PMID: 22878910 PMCID: PMC3479299 DOI: 10.1007/s00264-012-1637-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 07/25/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess histological changes and possible differences in the quadriceps of patients undergoing open repair of the tendon after spontaneous rupture, and subjects with no history of tendon pathology. MATERIALS Biopsies were harvested from the quadriceps tendon of 46 patients (34 men, 12 women) who had reported unilateral atraumatic quadriceps tendon rupture and had undergone surgical repair of the tendon. Samples were also harvested from both the tendons in 11 (N = 11 × 2) patients, nine males and two females, dying from cardiovascular disorders. For each tendon, three slides were randomly selected and examined under light microscopy, and assessed using a semiquantitative grading scale (range 0-21) which considers fibre structure, fibre arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen stainability, and hyalinisation. RESULTS The pathological sum-score averaged 19.2 ± 3.7 in ruptured tendons and 5.6 ± 2.0 in controls, and all variables considered were significantly different between the two groups, showing an association between tendon abnormalities and rupture (0.05 < P < 0.001). CONCLUSION This study confirms that the presence of histological degenerative changes in torn quadriceps tendons increases the risk of rupture.
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England, UK.
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Chang HN, Pang JHS, Chen CPC, Ko PC, Lin MS, Tsai WC, Yang YM. The effect of aging on migration, proliferation, and collagen expression of tenocytes in response to ciprofloxacin. J Orthop Res 2012; 30:764-8. [PMID: 22021103 DOI: 10.1002/jor.21576] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 10/06/2011] [Indexed: 02/04/2023]
Abstract
Quinolone-induced tendinopathy or tendon rupture tends to be age-related. However, the synergistic effects of quinolone and aging on tenocytes remained to be explored. Tenocytes intrinsic to rat Achilles tendon from two age groups (young: 2 months; and near senescent (old): 24 months) were treated with ciprofloxacin. Tenocyte migration and proliferation were assessed by transwell filter migration assay and MTT (3-[4,5-Dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay, respectively. Messenger RNA and protein expressions of types I and III collagen were determined by reverse transcription-polymerase chain reaction (RT/PCR) and Western blot analysis, respectively. Transwell filter migration assay revealed that ciprofloxacin inhibited tenocytes migration, which became more significant in old tenocytes (p < 0.05). The results of MTT assay revealed that tenocytes proliferation decreased after ciprofloxacin treatment (p < 0.05), which also became more significant in old tenocytes. The results of RT-PCR and Western blot analysis revealed that mRNA and protein expressions of type I collagen remained unchanged in either young or old tenocytes with ciprofloxacin treatment, whereas the expressions of type III collagen were down-regulated by ciprofloxacin, which was more significant in old tenocytes. In conclusion, aging potentiated the ciprofloxacin-mediated inhibition of migration, proliferation, and expression of type III collagen of tenocytes.
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Affiliation(s)
- Hsiang-Ning Chang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Taiwan
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Abstract
Achilles tendon ruptures are best managed acutely. Neglected Achilles tendon ruptures are debilitating injuries and the increased complexity of the situation must be appreciated. Surgical management is recommended, and only in the poorest surgical candidate is conservative treatment entertained. Numerous treatment algorithms and surgical techniques have been described. A V-Y advancement flap and flexor halluces longus tendon transfer have been found to be reliable and achieve good clinical outcomes for defects ranging from 2 cm to 8 cm. This article focuses on the treatment options for the neglected Achilles tendon rupture.
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Dakin SG, Werling D, Hibbert A, Abayasekara DRE, Young NJ, Smith RKW, Dudhia J. Macrophage sub-populations and the lipoxin A4 receptor implicate active inflammation during equine tendon repair. PLoS One 2012; 7:e32333. [PMID: 22384219 PMCID: PMC3284560 DOI: 10.1371/journal.pone.0032333] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 01/25/2012] [Indexed: 01/15/2023] Open
Abstract
Macrophages (Mϕ) orchestrate inflammatory and reparatory processes in injured connective tissues but their role during different phases of tendon healing is not known. We investigated the contribution of different Mϕ subsets in an equine model of naturally occurring tendon injury. Post mortem tissues were harvested from normal (uninjured), sub-acute (3–6 weeks post injury) and chronically injured (>3 months post injury) superficial digital flexor tendons. To determine if inflammation was present in injured tendons, Mϕ sub-populations were quantified based on surface antigen expression of CD172a (pan Mϕ), CD14highCD206low (pro-inflammatory M1Mϕ), and CD206high (anti-inflammatory M2Mϕ) to assess potential polarised phenotypes. In addition, the Lipoxin A4 receptor (FPR2/ALX) was used as marker for resolving inflammation. Normal tendons were negative for both Mϕ and FPR2/ALX. In contrast, M1Mϕ predominated in sub-acute injury, whereas a potential phenotype-switch to M2Mϕ polarity was seen in chronic injury. Furthermore, FPR2/ALX expression by tenocytes was significantly upregulated in sub-acute but not chronic injury. Expression of the FPR2/ALX ligand Annexin A1 was also significantly increased in sub-acute and chronic injuries in contrast to low level expression in normal tendons. The combination of reduced FPR2/ALX expression and persistence of the M2Mϕ phenotype in chronic injury suggests a potential mechanism for incomplete resolution of inflammation after tendon injury. To investigate the effect of pro-inflammatory mediators on lipoxin A4 (LXA4) production and FPR2/ALX expression in vitro, normal tendon explants were stimulated with interleukin-1 beta and prostaglandin E2. Stimulation with either mediator induced LXA4 release and maximal upregulation of FPR2/ALX expression after 72 hours. Taken together, our data suggests that although tenocytes are capable of mounting a protective mechanism to counteract inflammatory stimuli, this appears to be of insufficient duration and magnitude in natural tendon injury, which may potentiate chronic inflammation and fibrotic repair, as indicated by the presence of M2Mϕ.
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Affiliation(s)
- Stephanie Georgina Dakin
- Department of Veterinary Clinical Sciences, Royal Veterinary College, University of London, Hatfield, United Kingdom.
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Barboni B, Curini V, Russo V, Mauro A, Di Giacinto O, Marchisio M, Alfonsi M, Mattioli M. Indirect co-culture with tendons or tenocytes can program amniotic epithelial cells towards stepwise tenogenic differentiation. PLoS One 2012; 7:e30974. [PMID: 22348033 PMCID: PMC3277591 DOI: 10.1371/journal.pone.0030974] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 12/29/2011] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Amniotic epithelial cells (AEC) have potential applications in cell-based therapy. Thus far their ability to differentiate into tenocytes has not been investigated although a cell source providing a large supply of tenocytes remains a priority target of regenerative medicine in order to respond to the poor self-repair capability of adult tendons. Starting from this premise, the present research has been designed firstly to verify whether the co-culture with adult primary tenocytes could be exploited in order to induce tenogenic differentiation in AEC, as previously demonstrated in mesenchymal stem cells. Since the co-culture systems inducing cell differentiation takes advantage of specific soluble paracrine factors released by tenocytes, the research has been then addressed to study whether the co-culture could be improved by making use of the different cell populations present within tendon explants or of the high regenerative properties of fetal derived cell/tissue. METHODOLOGY/PRINCIPAL FINDINGS Freshly isolated AEC, obtained from ovine fetuses at mid-gestation, were co-incubated with explanted tendons or primary tenocytes obtained from fetal or adult calcaneal tendons. The morphological and functional analysis indicated that AEC possessed tenogenic differentiation potential. However, only AEC exposed to fetal-derived cell/tissues developed in vitro tendon-like three dimensional structures with an expression profile of matrix (COL1 and THSB4) and mesenchymal/tendon related genes (TNM, OCN and SCXB) similar to that recorded in native ovine tendons. The tendon-like structures displayed high levels of organization as documented by the cell morphology, the newly deposited matrix enriched in COL1 and widespread expression of gap junction proteins (Connexin 32 and 43). CONCLUSIONS/SIGNIFICANCE The co-culture system improves its efficiency in promoting AEC differentiation by exploiting the inductive tenogenic soluble factors released by fetal tendon cells or explants. The co-cultural system can be proposed as a low cost and easy technique to engineer tendon for biological study and cell therapy approach.
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Affiliation(s)
- Barbara Barboni
- Department of Comparative Biomedical Science, University of Teramo, Teramo, Italy
- StemTeCh Group, Chieti, Italy
| | - Valentina Curini
- Department of Comparative Biomedical Science, University of Teramo, Teramo, Italy
- StemTeCh Group, Chieti, Italy
- * E-mail:
| | - Valentina Russo
- Department of Comparative Biomedical Science, University of Teramo, Teramo, Italy
- StemTeCh Group, Chieti, Italy
| | - Annunziata Mauro
- Department of Comparative Biomedical Science, University of Teramo, Teramo, Italy
- StemTeCh Group, Chieti, Italy
| | - Oriana Di Giacinto
- Department of Comparative Biomedical Science, University of Teramo, Teramo, Italy
| | - Marco Marchisio
- Department of Biomorphology, University of Chieti, Chieti, Italy
- StemTeCh Group, Chieti, Italy
| | - Melissa Alfonsi
- Department of Biomedical Sciences, University of Chieti, Chieti, Italy
- StemTeCh Group, Chieti, Italy
| | - Mauro Mattioli
- Department of Comparative Biomedical Science, University of Teramo, Teramo, Italy
- StemTeCh Group, Chieti, Italy
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Tsai WC, Chang HN, Yu TY, Chien CH, Fu LF, Liang FC, Pang JHS. Decreased proliferation of aging tenocytes is associated with down-regulation of cellular senescence-inhibited gene and up-regulation of p27. J Orthop Res 2011; 29:1598-603. [PMID: 21452304 DOI: 10.1002/jor.21418] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/28/2011] [Indexed: 02/04/2023]
Abstract
Symptomatic tendinopathy tends to be age-related. However, the molecular mechanisms of ageing and its effects on tenocyte proliferation and cell cycle progression are unknown. We examined tenocytes from Achilles tendons in rats from three age groups (young, 2 months; middle-aged, 12 months, and near senescence, 24 months). Tenocyte proliferation was assessed by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay and flow cytometry. Senescence-associated β-galactosidase (SA β-gal) staining was performed in all groups of tenocytes. mRNA and protein expression of cellular senescence-inhibited gene (CSIG) and p27 was measured by reverse transcription-polymerase chain reaction (RT-PCR) and Western blot, respectively. The results of MTT assay revealed that tenocyte proliferation decreased with age (p < 0.05). Cell cycle progression was arrested at G0/G1 phase in senescent tenocytes. More senescent tenocytes expressed SA β-gal than young tenocytes did. By RT-PCR and Western blot analysis, the gene and protein expression of CSIG was found to be down-regulated, whereas that of p27 was up-regulated with age. In conclusion, the proliferation of tenocytes declines with age and is associated with the down-regulation of CSIG and up-regulation of p27.
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Affiliation(s)
- Wen-Chung Tsai
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, Taiwan
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Doughty MJ. Options for determination of 2-D distribution of collagen fibrils in transmission electron micrographs-Application to the mammalian corneal stroma. Microsc Res Tech 2011; 74:184-95. [DOI: 10.1002/jemt.20890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
The Achilles tendon is the most injured tendon of athletes in the lower extremities and is the most common tendon to rupture spontaneously. Operative repair provides earlier return to sporting activities and lesser rate of rerupture. The general goal is to attempt anastomosis of the acute ruptured ends; however, delayed ruptures may require more extensive procedures. New surgical approaches, including percutaneous and mini-open techniques, are being introduced to potentially diminish perioperative complications. Advent of early protective range of motion and rehabilitation has shown a potential for earlier return to sporting activities for Achilles ruptures.
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Biancalana A, Veloso LA, Gomes L. Obesity affects collagen fibril diameter and mechanical properties of tendons in Zucker rats. Connect Tissue Res 2010; 51:171-8. [PMID: 20073987 DOI: 10.3109/03008200903191312] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Obesity is currently considered to be a world epidemic and one of the major public health problems in many countries, whose incidence is increasing at alarming rates. Genetically obese Zucker rats are used as a model of obesity and were employed in the present study. Tendons transmit contractile force from muscles to bone, thus permitting articular movement. The objective of our study was to analyze the ultrastructural, biochemical, and biomechanical alterations that occur in the deep digital flexor tendon of obese Zucker rats compared to lean animals. Ultrastructural analysis showed differences in collagen fibril diameter distribution and mass-average diameter between obese and lean animals. Regarding mechanical parameters, there was a significant difference in maximum displacement and strain. Hydroxyproline content was higher in obese animals. In view of the excess weight and peculiar conditions to which the tendon of obese animals is submitted, we concluded that obesity provokes alterations in the composition and organization of tendon extracellular matrix components. These alterations might be related to organizational and structural modifications in the collagen bundles, influencing the mechanical properties of the tendon and the progression to a pathological state.
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Affiliation(s)
- Adriano Biancalana
- Department of Anatomy, Cell Biology, Physiology and Biophysics, Institute of Biology, State University of Campinas, Campinas, Brazil
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Karkhanis S, Mumtaz H, Kurdy N. Functional management of Achilles tendon rupture: A viable option for non-operative management. Foot Ankle Surg 2010; 16:81-6. [PMID: 20483140 DOI: 10.1016/j.fas.2009.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 05/23/2009] [Accepted: 05/30/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND Functional management of the ruptured Achilles tendon can be effective using orthoses like the removable walker boot (Foam Walker Boot, Air Cast UK Limited, Lincolnshire, United Kingdom). We conducted this study to look at the outcome of our protocol using this orthosis. MATERIALS AND METHODS We retrospectively reviewed 107 non-operatively managed Achilles tendon ruptures over the last 5 years. Case notes were analyzed for demographics and immediate outcomes. Long term outcomes were assessed by a postal questionnaire using the Achilles Tendon Total Rupture Score (ATRS). RESULTS Of the 107 tendons (male:female=71:36, mean age=50 years), 105 tendons (98%) healed with an average discharge time of 22 weeks. Six patients reported major complications and 6 reported minor complications. We received 56 questionnaires with a mean ATRS score of 21. Seventy-seven percent returned to pre-injury level of activity. CONCLUSION Functional management of Achilles tendon rupture, under appropriate supervision, provides a viable option for non-operative management.
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Affiliation(s)
- S Karkhanis
- Department of Trauma & Orthopaedics, University Hospital of South Manchester NHS Trust, Wythenshawe Hospital, Manchester M23 9LT, United Kingdom.
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Doral MN, Alam M, Bozkurt M, Turhan E, Atay OA, Dönmez G, Maffulli N. Functional anatomy of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc 2010; 18:638-43. [PMID: 20182867 DOI: 10.1007/s00167-010-1083-7] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 02/02/2010] [Indexed: 12/19/2022]
Abstract
The Achilles tendon is the strongest and thickest tendon in the human body. It is also the commonest tendon to rupture. It begins near the middle of the calf and is the conjoint tendon of the gastrocnemius and soleus muscles. The relative contribution of the two muscles to the tendon varies. Spiralisation of the fibres of the tendon produces an area of concentrated stress and confers a mechanical advantage. The calcaneal insertion is specialised and designed to aid the dissipation of stress from the tendon to the calcaneum. The insertion is crescent shaped and has significant medial and lateral projections. The blood supply of the tendon is from the musculotendinous junction, vessels in surrounding connective tissue and the osteotendinous junction. The vascular territories can be classified simply in three, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. This leaves a relatively hypovascular area in the mid-portion of the tendon where most problems occur. The Achilles tendon derives its innervation from the sural nerve with a smaller supply from the tibial nerve. Tenocytes produce type I collagen and form 90% of the cellular component of the normal tendon. Evidence suggests ruptured or pathological tendon produce more type III collagen, which may affect the tensile strength of the tendon. Direct measurements of forces reveal loading in the Achilles tendon as high as 9 KN during running, which is up to 12.5 times body weight.
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Affiliation(s)
- Mahmut Nedim Doral
- Faculty of Medicine, Department of Orthopedics and Traumatology, Hacettepe University, Ankara, Turkey
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Abstract
The characteristic cells in tendons and ligaments are called tenocytes, which are responsible for the formation and turnover of the extracellular matrix. They react to external stimuli and facilitate the functional adaptation of the proteoglycan and collagen network to mechanical requirements. Via numerous cellular processes they form a complex communicating network which demonstrates coordinated directional reactions. As is common to all tissues in the human body, tendons are subject to age changes which influence the tenocytes, but additionally the structural organization and hence the function of the extracellular matrix. The function and organization of tendons are also affected by mechanical forces, as well as by various cytokines produced in the tissue and by the application of anti-inflammatory medication.
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Maffulli N, Longo UG, Ronga M, Khanna A, Denaro V. Favorable outcome of percutaneous repair of achilles tendon ruptures in the elderly. Clin Orthop Relat Res 2010; 468:1039-46. [PMID: 19543777 PMCID: PMC2835610 DOI: 10.1007/s11999-009-0944-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 06/05/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Percutaneous repair of Achilles tendon (AT) ruptures reportedly reduces the risk of rerupture compared to nonoperative treatment and reduces the risk of wound infection compared to open surgery. We retrospectively reviewed the postoperative Achilles tendon total rupture score (ATRS), and the maximum calf circumference in 35 patients over 65 years of age who sustained an acute tear of the AT and underwent percutaneous repair of the AT. There were 26 men and nine women with a mean age at operation of 73.4 +/- 8.7 years (range, 65-86 years). Of the 35 recruited patients, we report on 27 patients for whom we have a full data set. The minimum followup was 49 months (mean, 88 months; range, 49-110 months). The ATRS had a postoperative average rating of 69.4 +/- 14 (range, 56-93). All patients were able to bear weight fully on the affected limb by the eighth postoperative week. The data suggest that percutaneous repair of the AT is a suitable option for patients older than 65, producing similar outcomes when compared to percutaneous repair in younger patients of previous reports. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, University Hospital of North Staffordshire, Keele University School of Medicine, Stoke on Trent, UK ,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG England
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
| | - Mario Ronga
- Department of Orthopaedics and Traumatology, University of Insubria Ospedale di Circolo, Varese, Italy
| | - Anil Khanna
- Department of Trauma and Orthopaedic Surgery, University Hospital of North Staffordshire, Keele University School of Medicine, Stoke on Trent, UK
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Rome, Italy
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Tohno Y, Suwanahoy P, Tohno S, Sinthubua A, Azuma C, Nishiwaki F, Moriwake Y, Kumai T, Minami T, Laowatthanaphong S, Mahakkanukrauh P, Oishi T, Hayashi M. Age-related changes of elements in the tendons of the peroneus longus muscles in Thai, Japanese, and monkeys. Biol Trace Elem Res 2010; 133:291-303. [PMID: 19618135 DOI: 10.1007/s12011-009-8442-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 06/23/2009] [Indexed: 10/20/2022]
Abstract
To elucidate compositional changes of the tendon of the peroneus longus muscle with aging, the authors investigated age-related changes of elements in the insertion of tendons of the peroneus longus muscle (peroneus longus tendons) in Thai, Japanese, and monkeys and the relationships among element contents by direct chemical analysis. After ordinary dissections at Chiang Mai University and Nara Medical University were finished, the peroneus longus tendons were resected from the subjects. The peroneus longus tendons were also resected from rhesus and Japanese monkeys bred in Primate Research Institute, Kyoto University. The wraparound regions of the insertion tendons of the peroneus longus muscle in contact with the cuboid bone were used as the peroneus longus tendon. After ashing with nitric acid and perchloric acid, element contents were determined with an inductively coupled plasma-atomic emission spectrometer. It was found that there were no significant correlations between age and the seven elements, such as Ca, P, S, Mg, Zn, Fe, and Na, in the peroneus longus tendons of Thai and Japanese. The Ca content higher than 10 mg/g was contained in seven cases out of 34 peroneus longus tendons of Thai (incidence = 20.6%) and in one case out of 22 peroneus longus tendons of Japanese (incidence = 4.5%), respectively. All of the peroneus longus tendons with the Ca content higher than 10 mg/g were found in Thai and Japanese men. In the peroneus longus tendons of monkeys, the Ca and P content increased suddenly at 2 years of age and reached to about 40 mg/g at 5 years of age. Thereafter, the Ca and P content did not increase in the peroneus longus tendons of monkeys at old age. Regarding the relationships among element contents, significant direct correlations were found among the contents of Ca, P, Mg, Zn, and Na in Thai and monkeys, whereas significant inverse correlations were found between S and element contents, such as Ca, P, Mg, Zn, and Na, in Thai and monkeys.
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Affiliation(s)
- Yoshiyuki Tohno
- Laboratory of Cell Biology, Department of Anatomy, Nara Medical University School of Medicine, Kashihara, Nara, 634-8521, Japan.
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Abstract
Noninsertional Achilles tendinitis is a distinct clinical entity, frequently characterized by swelling, pain, and lower limb dysfunction. This condition can be frustrating to treat, for the patient and the physician alike, as reflected in the various treatments, both conservative and surgical, that have been described. Although many patients with Achilles tendinitis can be successfully treated with nonoperative methods, persistent symptoms require surgical treatment, such as tenotomy, debridement, or repair.
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Affiliation(s)
- G Andrew Murphy
- Department of Orthopaedic Surgery, Campbell Clinic, University of Tennessee, Memphis, Tennessee, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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