Local administration of Trolox, a vitamin E analog, reduced tendon adhesion in a chicken model of flexor digitorum profundus tendon injury.

BACKGROUND: Hand flexor tendon injuries are compromised with tendon adhesion. Tendon adhesion forms between flexor tendon and tendon sheath, reduces the range of motion of fingers, and affects their function. Oxidative stress is increased in flexor tendon after injury and might play a role in tendon adhesion formation. Trolox (6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid), a water-soluble analog of vitamin E, is antioxidative. Trolox reduced oxidative stress and the expression of fibrotic cytokines in the bile gut ligation animal model. Vitamin C and Trolox are strong antioxidants, but they might also have prooxidant properties. The prooxidant properties of vitamin C and Trolox are different. In this study, our aim was to determine the effect of Trolox in reducing tendon adhesion formation. METHODS: Flexor digitorum profundus tendon injury was induced in 54 Kai-Mei Chicken according to a well-established protocol. After wound closure, an injection of 50 µL saline, 10mM Trolox, or 100mM Trolox was administered into the wound area. At 2 weeks or 6 weeks after the surgery, chicken feet were harvested for gliding test, high-resolution ultrasound measurement on a fibrotic area, and histology. RESULTS: At Week 2 after the surgery, Trolox has no effect on the flexion angle and gliding resistance, whereas a significant improvement was observed in the flexion angle and gliding resistance in the Trolox-treated groups at Week 6. However, no dose response was observed. In the ultrasound measurement, there was no significant difference in the fibrotic mass in the Trolox-treated group as compared to the saline group at Week 2. At Week 6, fibrotic mass was significantly reduced in both Trolox-treated groups. From the histological examination, the Trolox-treated groups presented a higher cellularity at Week 2 as compared to the saline group, and reduced fibrosis and adhesion at Week 6. CONCLUSION: Our results suggest that local administration of Trolox can reduce tendon adhesion, and a higher dose of Trolox did not have negative effects. CLINICAL SIGNIFICANCE: Trolox solution might be feasible to reduce tendon adhesion via intraoperative injection at the wound area during tendon repair.

Peri-tunnel bone loss: does it affect early tendon graft to bone tunnel healing after ACL reconstruction?

PURPOSE: The clinical relevance and mechanisms of local bone loss early post-anterior cruciate ligament (ACL) reconstruction remain unclear. The early spatial and temporal changes of peri-tunnel bone, its molecular mechanisms and its relationships with graft-bone tunnel healing were investigated in a 12-week-old rat model. METHODS: At various times, the reconstructed ACL complex was harvested for vivaCT imaging, biomechanical test, histology and immunohistochemical staining of CD68+ cells (a monocyte-macrophage lineage marker), MMP1 and MMP13. RESULTS: The peri-tunnel bone resorbed simultaneously with improvement of graft-bone tunnel healing. There were 30.1 ± 17.4, 46.8 ± 10.5 and 81.5 ± 12.3 % loss of peri-tunnel BMD as well as 43.2 ± 21.7, 78.7 ± 8.5 and 92.4 ± 17.7 % loss of peri-tunnel bone volume/total volume (BV/TV) at week 6 at the distal femur, epiphysis and metaphysis of tibia, respectively. MMP1, MMP13 and CD68+ cells were expressed at the graft-bone tunnel interface and peri-tunnel bone and increased with time post-reconstruction at the tibia. The ultimate load and stiffness of the healing complex positively correlated with tibial tunnel bone formation and negatively correlated with tibial peri-tunnel bone. Tunnel BV/TV at the tibial metaphysis and epiphysis showed the highest correlation with ultimate load (ρ = 0.591; p = 0.001) and stiffness (ρ = 0.427; p = 0.026) of the complex, respectively. CONCLUSION: There was time-dependent loss of peri-tunnel bone early post-reconstruction, with the greatest loss occurring at the tibial metaphysis. This was consistent with high expression of MMP1, MMP13 and CD68+ cells at the graft-bone tunnel interface and the peri-tunnel region. The significant loss of peri-tunnel bone, though not critically affecting early tunnel healing, suggested the need to protect the knee joint early post-reconstruction.

Local administration of alendronate reduced peri-tunnel bone loss and promoted graft-bone tunnel healing with minimal systemic effect on bone in contralateral knee.

Continued systemic administration of alendronate was reported to reduce peri-tunnel bone resorption and promoted graft-bone tunnel healing at the early stage post-anterior cruciate ligament (ACL) reconstruction. However, systemic increase in bone mineral density (BMD) in the contralateral intact knee was observed. We tested if single local administration of alendronate into the bone tunnel during ACL reconstruction could achieve similar benefits yet without the systemic effect on bone. Seventy-two rats with unilateral ACL reconstruction were divided into three groups: saline, low-dose (6 µg/kg) and mid-dose (60 µg/kg) alendronate. For local administration, alendronate was applied to the bone tunnels for 2 min before graft insertion and repair. At weeks 2 and 6, the reconstructed complex was harvested for high-resolution computed tomography (vivaCT) imaging followed by biomechanical test or histology. Our results showed that local administration of low-dose alendronate showed comparable benefits on the reduction of peri-tunnel bone loss, enhancement of bone tunnel mineralization, tunnel graft integrity, graft osteointegration and mechanical strength of the reconstructed complex at early stage post-reconstruction, yet with minimal systemic effect on mineralized tissue at the contralateral intact knee. A single local administration of alendronate at the low-dose therefore might be used to promote early tunnel graft healing post-reconstruction.

Local vitamin-C injection reduced tendon adhesion in a chicken model of flexor digitorum profundus tendon injury.

BACKGROUND: Adhesion formation is a complication of hand flexor tendon repair. Normal gliding function of flexor tendons can be impaired by an excessive fibrotic response, which may be caused by intraoperative and postoperative hemorrhage. As tissue damage and hemorrhage can disturb redox regulation, thereby favoring fibrotic responses, the purpose of this study was to investigate if antioxidants can reduce tendon adhesion by antagonizing oxidative stress. METHODS: Flexor digitorum profundus tendon injury was induced in fifty-seven chickens. In twelve chickens, oxidative stress preinjury, immediately after injury, and two and six weeks postinjury (n = 3 at each time period) was estimated by measuring tissue levels of the reduced form of glutathione (GSH) and oxidized glutathione (glutathione disulfide [GSSG]) in the proximal interphalangeal joint. In the remaining chickens, 50 µL of saline solution or vitamin-C solution (5 or 50 mg/mL) was injected into the wound immediately after closure of the tendon sheath. Samples were harvested at two weeks (n = 6 in each group) or six weeks (n = 6 in each group) postinjury for a gliding test, ultrasound imaging, and histological examination. Three chickens from each group were killed at two weeks postinjury for GSH and GSSG measurements to evaluate the treatment effects on postoperative oxidative stress. RESULTS: The GSH level was significantly decreased at two and six weeks postinjury, and the GSSG level was significantly increased at six weeks postinjury. Both 5 and 50-mg/mL vitamin C led to higher tissue levels of GSH at two weeks postinjury, as compared with that in the saline solution group, but no significant change in the GSSG level was detected. Chickens with vitamin-C supplementation showed no significant improvement in gliding resistance and no significant reduction of the fibrotic size at two weeks postinjury, but they did show significant improvement in gliding resistance at six weeks postinjury and the 5-mg/mL vitamin-C group showed a significant reduction of the fibrotic size at six weeks. Histological examination showed less peritendinous adhesion in the vitamin-C groups. CONCLUSIONS: Our results suggest that local injection of vitamin-C solution can reduce the extent of adhesion of healing tendons, probably by redox modulation, in a chicken model.

Effect of graft tensioning on mechanical restoration in a rat model of anterior cruciate ligament reconstruction using free tendon graft.

PURPOSE: Initial graft tensioning is important in anterior cruciate ligament reconstruction (ACLR), but its effect on graft healing is still not clear. Since all previous animal studies on graft tensioning used bone-patellar tendon-bone, this study aimed to investigate the effect of initial graft tensioning on ACLR using tendon graft. METHODS: Fifty-five Sprague-Dawley rats underwent ACLR using flexor digitorum longus tendon graft. A constant force of 2 or 4 N was applied during graft fixation. At 0, 2, and 6 weeks, knee samples were harvested (n = 6) for static knee laxity test and graft pull-out test. Histological examination was performed at 2 and 6 weeks post-injury (n = 4). RESULTS: At time zero, knee laxity was restored by ACLR with 2 or 4 N tensioning as compared to ACL-deficient group (p < 0.001), and the 4 N group exhibited a better restoration as compared to 2 N group (p = 0.031). At week 2 post-operation, the 4 N group still exhibited a better restoration in knee laxity (p = 0.001) and knee stiffness (p = 0.002) than the 2 N group; the graft pull-out force (p = 0.032) and stiffness (p = 0.010) were also higher. At week 6 post-operation, there was no significant difference between the 2 and 4 N group in knee laxity and graft pull-out strength. Histological examination showed that the beneficial effect of higher initial graft tension may be contributed by maintenance of graft integrity at mid-substance and reduction in adverse peri-graft bone changes in the femoral tunnel region. CONCLUSIONS: A higher initial graft tension favours the restoration of knee laxity and promotes graft healing in ACLR using free tendon graft in the rat model.