The Effect of Sodium Hyaluronate plus Sodium Chondroitin Sulfate Solution on Peritendinous Adhesion and Tendon Healing: An Experimental Study

Successful restoration of failed Achilles tendon surgery with semitendinosus and gracilis tendon graft: a case report

Objective

This case presentation aims to highlight the challenges and outcomes associated with a partial tear of the Achilles tendon (AT) in an elite marathon runner. The objective was to restore tendon anatomy and optimize strength recovery through surgical intervention.

Method

We present the case of a marathon runner who suffered a partial AT tear and underwent an initial surgery that failed. A revision surgery was then performed using a semitendinosus and gracilis tendon graft.

Results

The patient underwent surgery 14 weeks after the initial AT injury, but unfortunately experienced a complete AT tear after 6 months. However, the novel aspect of this case is the successful restoration of the failed double-row suture technique through the utilization of a semitendinosus and gracilis tendon graft. Notably, the graft remained intact even under high tendon loading during the 2-year follow-up period.

Conclusion

Differential diagnosis should consider partial tears of the AT as a possible diagnosis in the patients with heel pain. Furthermore, it is crucial to prioritize a well-paced post-surgical rehabilitation process in AT surgeries. In cases of failed AT surgery, the utilization of gracilis and semitendinosus tendon grafts can serve as viable options for repairing reruptures.

Tamoxifen Prevents Peritendinous Adhesions: A Preliminary Report

Background

Scarless healing comprises the ultimate goal after an injury. Since tendon healing results in a fibrotic scar, an injured tendon can never regain the mechanical potential and strength of its uninjured form. A wide variety of studies focus on the tendon healing with an absent or minimal peritendinous adhesions. However, no simple method has managed it at all. Possible complex actions and peritendinous environmental events take place during the tendon healing process. Tamoxifen (TAM), besides its breast cancer-related usage, is a potent antifibrotic drug. Here, we aimed to reduce the peritendinous adhesion with TAM administration.

Methods

Achilles tendons of 44 Wistar albino rats were randomly distributed in 4 groups. In group 1, bilateral lower extremities were used as control and sham. Groups 2 and 3 were comprised of low-dose (1 mg/kg) and high-dose (40 mg/kg) systemic administration of TAM, respectively. Group 4 included local administration (1 mg/kg) of TAM. Biomechanical, macroscopical, and histopathological analyses were done and compared statistically. Biomechanically, the maximum force that led to tendon rupture was determined, and tensile force data were recorded via tensile testing device. Macroscopical and histopathological analysis were composed of the quantity, quality, and grade of peritendinous adhesions.

Results

Macroscopic and histopathologic findings revealed that groups 2 and 3 had a variety of values ranging between slight to severe adhesions. In group 2, almost half of the animals had moderate adhesions, whereas in group 3, the majority of the animals had moderate adhesions. There were no animals with moderate or severe adhesions in group 4. Statistically significant values were calculated between sham and control groups. Biomechanically, group 2 showed the most significant result. The tendons in group 2 had the highest stiffness when maximal force was applied to rupture the tendons. Henceforth, all these consequences were proven statistically.

Conclusion

We achieved less peritendinous adhesion with the local administration of TAM when compared to systemic administration of TAM. A better understanding of the peritendinous environmental process will reveal to develop new therapies in the prevention of peritendinous adhesions.

Comparing Effectiveness of Combination of Collagen Peptide Type-1, Low Molecular Weight Chondroitin Sulphate, Sodium Hyaluronate, and Vitamin-C Versus Oral Diclofenac Sodium in Achilles Tendinopathy: A Prospective Randomized Control Trial

Background

Achilles tendinopathy, a common cause of heel pain, is primarily considered mechanical in origin, but its pathogenesis and treatment lack consensus. Molecules such as collagen peptide type-1, low molecular weight chondroitin sulphate, sodium hyaluronate and vitamin C have been shown to act as building blocks of tendon structure, and oral supplementation of these have promising results in Achilles tendinopathy.

Methods

This study was a prospective randomized control trial to compare the effectiveness of oral diclofenac sodium versus a nutraceutical combination of collagen peptide type-1, chondroitin sulphate, sodium hyaluronate, and vitamin C in the treatment of Achilles tendinopathy on pain and ultrasonographic structures. A total of 40 patients satisfying inclusion and exclusion criteria were randomly allocated into two groups and were given the nutraceutical combination in group A and diclofenac sodium in group B. The patient evaluation was done at baseline, six-week, and 12-week intervals in terms of VAS (Visual Analogue Scale) and tendo-Achilles thickness by ultrasound.

Results

Both nutraceutical combination and diclofenac reduced pain in persons with Achilles tendinopathy. The nutraceutical combination had a statistically significant better outcome in reducing pain at the end of 12 weeks. On ultrasound, both the interventions reduced Achilles tendon anteroposterior and mediolateral thickness by the end of 12 weeks. Although there was no absolute significant intergroup difference, the percentage change was more in the nutraceutical group in the case of anteroposterior thickness.

Conclusion

Combining collagen peptide type-1, low molecular weight chondroitin sulphate, sodium hyaluronate, and vitamin C is more effective than oral diclofenac in controlling pain in Achilles tendinopathy.

The Role of Hyaluronic Acid in Sport-Related Tendinopathies: A Narrative Review

Tendinopathy is a complex clinical condition with a rising incidence and prevalence, particularly during sports practice. For the return to play in affected patients, adequate functional and structural recovery of the tendon is the ultimate goal, avoiding the high risk of recurrence. In this perspective, local therapies alongside exercise are showing promising results. Despite evidence suggesting hyaluronic acid (HA) injections as effective in the treatment of tendinopathy, current recommendations about the management of this condition do not include this intervention. HA seems to be an effective therapeutic option for the management of sport-related tendinopathies, but further studies with a larger sample size are needed to confirm available findings. In this narrative review, we analyzed available literature about the rationale of the use of HA in the management of tendon injury and, particularly, in sport-related tendinopathies.

Quercetin reduces tendon adhesion in rat through suppression of oxidative stress

Background

Tendon adhesion is one of the most common clinical problems, which poses a considerable challenge to orthopedics doctors. Quercetin (QUE) as a popular drug at present, it has various biological functions, including anti-inflammatory, anti-ischemic, anti-peroxidation, and antioxidant. The purpose of this study was to investigate the effect of quercetin on tendon adhesion and whether quercetin can inhibit oxidative stress.

Method

Thirty-six rats were randomly divided into three groups, including control group, low QUE (50 mg/kg/day) group, and high QUE (100 mg/kg/day) group. After 1 week, the levels of SOD, MDA and GPx were measured. The degree of tendon adhesion was assessed by macroscopic evaluation and histological evaluation. After 4 weeks. Besides, the pharmacological toxicity of quercetin to main organs were evaluated by histological analysis.

Results

The extent of superoxide dismutase (SOD) and glutathione peroxidase (GPx) of tendon tissue in high QUE group was significantly higher than those of low QUE group and control group. And the extent of malondialdehyde (MDA) of tendon tissue in high QUE group was significantly lower than that of low QUE group and control group. By macroscopic evaluation and histological analysis, the extent of tendon adhesion in high QUE group was lower than low QUE group and control group. However, there were no significant changes of the major organs through histological analysis.

Conclusions

Quercetin may be a good and safe strategy in preventing tendon adhesion. But further clinical research is needed before its recommendation in the prevention and treatment of tendon adhesion.

Evaluation of a new collagen-based medical device (ElastiCo®) for the treatment of acute Achilles tendon injury and prevention of peritendinous adhesions: An in vitro biocompatibility and in vivo investigation

Tendon healing still represents a challenge for clinicians because it is slow and incomplete. The most injured is the Achilles tendon, and surgery is the therapeutic strategy often adopted because it provides a quicker functional recovery. Peritendinous adhesions are the main complication of surgery with hyperplasia and chemotaxis of fibroblasts. A biomaterial that blocks fibroblast migration, without interfering with the passage of cytokines and growth factors, might be useful. The present study evaluated the biocompatibility of a new Type I collagen-based scaffold (ElastiCo®) and its ability to promote Achilles tendon healing, inhibiting adhesion formation. After verifying in vitro biocompatibility, physical, and mechanical properties of the scaffold, an in vivo study was performed in 28 rats, operated to induce an acute lesion in both Achilles tendons. One tendon was treated with the suture only and the contralateral one with suture wrapped with ElastiCo® film. After 8 and 16 weeks, it was observed that ElastiCo® reduced internal and external peritendinous adhesions and Collagen III content and increased Collagen I. Elastic modulus increased with both treatments over time. Current results highlighted the clinical translationality of ElastiCo® that could improve the quality of life in patients affected by Achilles tendon lesions surgically treated.

Comparison of surgical outcomes between rotator cuff repair with and without rotator interval capsular release for rotator cuff tears to prevent and improve postoperative stiffness: a meta-analysis

BACKGROUND

A common complication of rotator cuff (RC) repair is a postoperative stiffness. Postoperative stiffness may develop and lead to inferior functional outcomes. Rotator cuff repair with additional rotator interval (RI) capsular release can be done to prevent postoperative stiffness in rotator cuff tears. However, routine rotator interval capsular release in rotator cuff repair is controversial. Therefore, we conducted a systematic review and meta-analysis to compare the postoperative outcomes between RC repair with and without RI capsular release for RC tears with and without concomitant stiffness.

METHOD

We searched all comparative studies that compared postoperative outcomes (VAS, CS, ASES, complications and ROM at 3, 6 and 12 months) of RC repair with and without RI capsular release for RC tears with and without concomitant stiffness from PubMed and Scopus databases from inception to the February 1, 2020.

RESULTS

Seven of 255 studies (six comparative studies and one RCT) (N = 803 patients) were eligible; 2 and 5 studies were included in the pooling of RC repair and RI release without concomitant stiffness and stiffness, respectively; 2, 6, 3, 6, 3, 5, 7, 7, and 7 studies were included in pooling of VAS, CS, ASES at 6 and 12 months and range of motion (internal, external rotation and forward flexion) at 3, 6 and 12 months, respectively. The UMD of VAS, CS and ASES scores at 6- and 12-month follow-up for the RC repair and RI release group was 0.48 (95% CI: 0.05, 0.90), 0.93 (-1.70, 3.56), -2.27 (-5.30, 0.76), -0.04 (-0.24, 0.15), 1.66 (0.77, 2.55) and 1.58 (0.21, 2.96) scores when compared to RC repair alone with and without concomitant stiffness. In terms of ROM, forward flexion for the RC repair and RI release group was -4.60 (-10.61, 1.41), -7.11 (-15.47, 1.25) and -0.70 (-2.51, -1.11) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. For external rotation, RC repair and RI release were -0.12 (-8.27, 8.03), -3.98 (-12.09, 4.14) and -2.65 (-5.35, 0.04) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. For internal rotation in RC repair and RI release, the values were -1.22 (-1.97, - 0.48), -1.01 (-1.79, -0.23) and -0.19 (-1.13, 0.74) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. There were no differences with a RR of 0.92 (0.46, 1.84) between the two groups in terms of complications. After subgroup analysis, RC repair with RI release had no clinically significant differences for pain, function and ROM when compared to RC repair alone in RC tear patients with and without preoperative stiffness.

CONCLUSIONS

RC repair with RI release in patients with and without preoperative stiffness had no statistically significant differences for pain, function (CS and ASES) and range of motion (FF, ER and IR) when compared to RC repair alone in RC injury patients.

LEVEL OF EVIDENCE

II.

Gene Silencing via PDA/ERK2-siRNA-Mediated Electrospun Fibers for Peritendinous Antiadhesion

Sustained delivery of small interfering RNA (siRNA) is a challenge in gene silencing for managing gene-related disorders. Although nanoparticle-mediated electrospun fibers enable sustainable gene silencing, low efficiency, loss of biological activity, toxicity issues, and complex electrospinning techniques are all bottlenecks of these systems. Preventing peritendinous adhesion is crucial for their successful use, which involves blocking cellular signaling via physical barriers. Here, a multifunctional, yet structurally simple, cationic 2,6-pyridinedicarboxaldehyde-polyethylenimine (PDA)-mediated extracellular signal-regulated kinase (ERK)2-siRNA polymeric delivery system is reported, in the form of peritendinous antiadhesion electrospun poly-l-lactic acid/hyaluronan membranes (P/H), with the ability to perform sustained release of bioactive siRNA for long-term prevention of adhesions and ERK2 silencing. After 4 days of culture, the cell area and proliferation rate of chicken embryonic fibroblasts on siRNA+PDA+P/H membrane are significantly less than those on P/H and siRNA+P/H membranes. The in vivo results of average optical density of collagen type III (Col III) and gene expression of ERK2 and its downstream SMAD3 in the siRNA+PDA+P/H group are less than those of P/H and siRNA+P/H groups. Consequently, siRNA+PDA+P/H electrospun membrane can protect the bioactivity of ERK2-siRNA and release it in a sustained manner. Moreover, adhesion formation is inhibited by reducing fibroblast proliferation and Col III deposition, and downregulating ERK2 and its downstream SMAD3.

Tetramethylpyrazine Improves Postoperative Tissue Adhesion: A Drug Repurposing

Plants are known to possess plenty of pharmacological activities as a result of various phytoconstituents. Tetramethylpyrazine (TMP), one of the most widely used medicinal compound isolated from traditional Chinese herb, is usually employed for anti-oxidation, anti-inflammation, anti-platelet aggregation, anti-lipid, anti-fibrosis, as well as activating blood, removing stasis, dilating small arteries, improving microcirculation and antagonizing calcium. In the present paper, the anti-adhesion effect of TMP were reviewed. TMP was found to play a multi-target and muti-link role in anti-adhesion by inhibiting hyperplasia of collagen and overexpression of adhesion-related factors and reducing the concentration of white blood cells and fibrin in plasma. Because previous studies mostly focused on in vitro experiments and animal experiments, there is an urgent need for clinical research with abundant indicators to further prove its anti-adhesion potency. Future basic research should concentrate on the development of TMP as a biological material.

Do Nonsteroidal Anti-Inflammatory Drugs Affect Tissue Healing After Arthroscopic Anterior Cruciate Ligament Reconstruction?

Background

Experimental studies have reported nonsteroidal anti-inflammatory drugs (NSAIDs) could impair tendon healing. The purpose of this study was to investigate whether NSAIDs could affect recovery of knee joint function in patients after anterior cruciate ligament (ACL) reconstruction.

Material/Methods

We enrolled 40 patients treated with celecoxib and 40 patients treated with tramadol, who underwent ACL reconstruction from January 2011 to December 2017. Visual analogue scale (VAS) and functional outcomes were collected and evaluated. The follow-up period was 12 months.

Results

In both groups, all patients obtained pain release after surgery, compared with that before surgery. But no significant differences were observed between the 2 groups in VAS scores. We also did not find any differences between the 2 groups at 1 year of follow-up, in terms of anterior drawer test, Lachman test, side-to-side laxity assessed by KT-2000, IKDC score, Lysholm score, and Tegner scale. However, the celecoxib group showed a reduced incidence of nausea compared to the tramadol group (P=0.048).

Conclusions

The use of NSAIDs after ACL reconstruction is relatively safe and could decrease adverse side effects which were caused by opioid drugs.

The effect of sodium hyaluronate-chondroitin sulfate combined solution on cartilage formation in osteochondral defects of the rabbit knee: an experimental study

Objective

In focal cartilage lesions, multipotent mesenchymal stem cells in bone marrow are aimed to be moved into the defect area using subchondral drilling or microfracture method. However, repaired tissue insufficiently fills the defect area or cannot meet natural hyaline tissue functions, due to fibrous structure. We investigated the effect of a combined solution of sodium hyaluronate + chondroitin sulfate (HA+CS) administered intra-articularly after subchondral drilling on newly formed cartilage in rabbits with focal osteochondral defects.

Materials and methods

A total of 32 New Zealand White mature rabbits, whose weights ranged from 2.5 to 3 kg, were randomly divided into four groups. Full-thickness osteochondral defect was formed in the left-knee medial femur condyles of all rabbits. Subchondral drilling was then performed. The following treatment protocol was administered intra-articularly on knee joints on days 7, 14, and 21 after surgery: group 1, 0.3 mL combined solution of HA+CS (20 mg CS combined with 16 mg HA/mL); group 2, 0.3 mL HA (16 mg/mL); group 3, 0.3 mL CS (20 mg/mL); and group 4 (control group), 0.3 mL saline solution. In the sixth week, all animals were killed and then evaluated histopathologically and biochemically.

Results

There was significant articular cartilage formation in the HA+CS group compared to the HA, CS, and control groups. Hyaline cartilage formation was observed only in the HA+CS group. Cartilage-surface continuity and smoothness were significantly higher in the HA+CS and HA groups compared to the other groups. Normal cartilage mineralization was found to be significantly higher in the HA+CS group compared to the other groups. Increased levels of VEGFA and IL-1β in synovial fluid were observed in the HA+CS group.

Conclusion

After subchondral drilling, intra-articular HA-CS combination therapy is a good choice to promote better quality new cartilage-tissue formation in the treatment of focal osteochondral defects.

The Effect of Sodium Hyaluronate on Ligamentation and Biomechanical Property of Tendon in Repair of Achilles Tendon Defect with Polyethylene Terephthalate Artificial Ligament: A Rabbit Tendon Repair Model

The Achilles tendon is the most common ruptured tendon of human body. Reconstruction with polyethylene terephthalate (PET) artificial ligament is recommended in some serious cases. Sodium hyaluronate (HA) is beneficial for the healing of tendon injuries. We aimed to determine the effect of sodium hyaluronate in repair of Achilles tendon defect with PET artificial ligament in an animal tendon repair model. Sixteen New Zealand White rabbits were divided into two groups. Eight rabbits repaired with PET were assigned to PET group; the other eight rabbits repaired with PET along with injection of HE were assigned to HA-PET group. All rabbits were sacrificed at 4 and 8 weeks postoperatively for biomechanical and histological examination. The HA-PET group revealed higher biomechanical property compared with the PET group. Histologically, more collagen tissues grew into the HA-PET group compared with PET group. In conclusion, application of sodium hyaluronate can improve the healing of Achilles tendon reconstruction with polyethylene terephthalate artificial ligament.