Abstract
Background
Flexor tendon grafting is often required to reconstruct a failed tendon repair. Previous reports have demonstrated flexor grafts coated with lubricants such as carbodiimide derivatized hyaluronic acid (cd-HA) decrease adhesion formation and improve digit function. However, whether this surface modification would affect graft adhesion and cellularity is unknown.
Questions/Purposes
Adhesion score and the cellularity of the graft of untreated and cd-HA surface-modified autograft and allograft tendons were studied using a canine forepaw in vivo model.
Methods
The peroneus longus tendons (n = 6) and flexor digitorum profundus tendons (n = 8) were used as extrasynovial autograft and intrasynovial allograft, respectively. The flexor digitorum profundus (FDP) tendons in the second and fifth digits in each dog were reconstructed with one digit treated with cd-HA and the other treated with saline as a control. Six weeks after surgery, the grafted tendons were harvested for histological evaluation with hematoxylin and eosin staining. During dissection, the adhesions were observed and scored.
Results
The adhesion score was greatest in the extrasynovial autograft without surface modification and the least in the intrasynovial allograft with surface modification. Autograft tendons had a higher cell density than the allografts regardless of surface treatment. Cd-HA graft treatment did not affect cellularity when compared with controls.
Conclusions
Our observations suggest surface modification of a tendon graft with cd-HA decreased the adhesion formation without altering the cellularity in either autologous or allograft tendon. We therefore presume this surface modification would not adversely affect graft healing.
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References
Abrahamsson SO, Gelberman RH, Amiel D, Winterton P, Harwood F. Autogenous flexor tendon grafts: fibroblast activity and matrix remodeling in dogs. J Orthop Res. 1995;13:58–66.
Abrahamsson SO, Gelberman RH, Lohmander SL. Variations in cellular proliferation and matrix synthesis in intrasynovial and extrasynovial tendons: an in vitro study in dogs. J Hand Surg [Am]. 1994;19:259–265.
Asencio G, Abihaidar G, Leonardi C. Human composite flexor tendon allografts. A report of two cases. J Hand Surg [Br]. 1996;21:84–88.
Bertelli JA, Santos MA, Kechele PR, Rost JR, Tacca CP. Flexor tendon grafting using a plantaris tendon with a fragment of attached bone for fixation to the distal phalanx: a preliminary cohort study. J Hand Surg [Am]. 2007;32:1543–1548.
Bishop AT, Cooney WP 3rd, Wood MB. Treatment of partial flexor tendon lacerations: the effect of tenorrhaphy and early protected mobilization. J Trauma. 1986;26:301–312.
Cameron RR, Conrad RN, Sell KW, Latham WD. Freeze-dried composite tendon allografts: an experimental study. Plast Reconstr Surg. 1971;47:39–46.
Coyle MP Jr, Leddy TP, Leddy JP. Staged flexor tendon reconstruction fingertip to palm. J Hand Surg [Am]. 2002;27:581–585.
Duffy FJ, Seiler JG, Hergrueter CA, Kandel J, Gelberman RH. Intrinsic mitogenic potential of canine flexor tendons. J Hand Surg [Br]. 1992;17:275–277.
Finsen V. Two-stage grafting of digital flexor tendons: a review of 43 patients after 3 to 15 years. Scand J Plast Reconstr Surg Hand Surg. 2003;37:159–162.
Hasslund S, Jacobson JA, Dadali T, Basile P, Ulrich-Vinther M, Soballe K, Schwarz EM, O’Keefe RJ, Mitten DJ, Awad HA. Adhesions in a murine flexor tendon graft model: autograft versus allograft reconstruction. J Orthop Res. 2008;26:824–833.
Ikeda J, Zhao C, Sun Y-L, An K-N, Amadio PC. Carbodiimide-derivatized hyaluronic acid surface modification of lyophilized flexor tendon: a biomechanical study in a canine in vitro model. J Bone Joint Surg Am. 2010;92:388–395.
Leversedge FJ, Zelouf D, Williams C, Gelberman RH, Seiler JG 3rd. Flexor tendon grafting to the hand: an assessment of the intrasynovial donor tendon—a preliminary single-cohort study. J Hand Surg [Am]. 2000;25:721–730.
Liu TK, Yang RS. Flexor tendon graft for late management of isolated rupture of the profundus tendon. J Trauma. 1997;43:103–106.
Momose T, Amadio PC, Sun YL, Zhao C, Zobitz ME, Harrington JR, An KN. Surface modification of extrasynovial tendon by chemically modified hyaluronic acid coating. J Biomed Mater Res. 2002;59:219–224.
Noguchi M, Seiler JG 3rd, Boardman ND 3rd, Tramaglini DM, Gelberman RH, Woo SL. Tensile properties of canine intrasynovial and extrasynovial flexor tendon autografts. J Hand Surg [Am]. 1997;22:457–463.
Peacock EE Jr, Madden JW. Human composite flexor tendon allografts. Ann Surg. 1967;166:624–629.
Seiler JG 3rd, Chu CR, Amiel D, Woo SL, Gelberman RH. The Marshall R. Urist Young Investigator Award. Autogenous flexor tendon grafts. Biologic mechanisms for incorporation. Clin Orthop Relat Res. 1997;345:239–247.
Singer M, Maloon S. Flexor tendon injuries: the results of primary repair. J Hand Surg [Br]. 1988;13:269–272.
Smith P, Jones M, Grobbelaar A. Two-stage grafting of flexor tendons: results after mobilisation by controlled early active movement. Scand J Plast Reconstr Surg Hand Surg. 2004;38:220–227.
Stark HH, Anderson DR, Zemel NP, Boyes JH, Ashworth CR, Rickard TA. Bridge flexor tendon grafts. Clin Orthop Relat Res. 1989;242:51–59.
Strickland JW. Management of acute flexor tendon injuries. Orthop Clin North Am. 1983;14:827–849.
Sun YL, Yang C, Amadio PC, Zhao C, Zobitz ME, An KN. Reducing friction by chemically modifying the surface of extrasynovial tendon grafts. J Orthop Res. 2004;22:984–989.
Tejwani SG, Shen W, Fu FH. Soft tissue allograft and double-bundle reconstruction. Clin Sports Med. 2007;26:639–660.
Uchiyama S, Amadio PC, Coert JH, Berglund LJ, An KN. Gliding resistance of extrasynovial and intrasynovial tendons through the A2 pulley. J Bone Joint Surg Am. 1997;79:219–224.
Zhao C, Amadio PC, Momose T, Couvreur P, Zobitz ME, An KN. The effect of suture technique on adhesion formation after flexor tendon repair for partial lacerations in a canine model. J Trauma Inj Infect Crit Care. 2001;51:917–921.
Zhao C, Amadio PC, Momose T, Couvreur P, Zobitz ME, An KN. Effect of synergistic wrist motion on adhesion formation after repair of partial flexor digitorum profundus tendon lacerations in a canine model in vivo. J Bone Joint Surg Am. 2002;84:78–84.
Zhao C, Amadio PC, Zobitz ME, Momose T, Couvreur P, An KN. Effect of synergistic motion on flexor digitorum profundus tendon excursion. Clin Orthop Relat Res. 2002;396:223–230.
Zhao C, Sun Y-L, Amadio PC, Tanaka T, Ettema AM, An K-N. Surface treatment of flexor tendon autografts with carbodiimide-derivatized hyaluronic acid. An in vivo canine model. J Bone Joint Surg Am. 2006;88:2181–2191.
Zhao C, Sun Y-L, Ikeda J, Kirk RL, Thoreson AR, Moran SL, An K-N, Amadio PC. Improvement of flexor tendon reconstruction with carbodiimide-derivatized hyaluronic acid and gelatin-modified intrasynovial allografts: study of a primary repair failure model. J Bone Joint Surg Am. 2010;92:2817–2828.
Acknowledgments
We thank Drs Y. L. Sun, S. L. Moran, K. N. An, and P. C. Amadio and Ms Ramona L. Kirk for their great contributions and assistance on animal surgeries and care, data collection and interpretation, and manuscript editing.
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The institution of one of the authors (CZ) received funding from the Orthopedic Research Education Foundation and the Musculoskeletal Transplant Foundation.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the animal protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.
This work was performed at the Mayo Clinic, Rochester, MN, USA.
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Karabekmez, F.E., Zhao, C. Surface Treatment of Flexor Tendon Autograft and Allograft Decreases Adhesion Without an Effect of Graft Cellularity: A Pilot Study. Clin Orthop Relat Res 470, 2522–2527 (2012). https://doi.org/10.1007/s11999-012-2437-x
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DOI: https://doi.org/10.1007/s11999-012-2437-x