Evaluation of four methods of flexor tendon repair for postoperative active mobilization

Active mobilization of repaired flexor tendons requires sufficient suture strength. This study was designed to investigate the suitability of four newly developed and comparatively strong tendon sutures for flexor tendon repair with active digital mobilization. Fifty fresh flexor digitorum profundus tendons were randomly assigned to five groups and repaired using the Tang, cruciate, Robertson, Silfverskiold, and modified Kessler suture methods. The repaired tendons were subjected to mechanical testing in an Instron tensile machine to determine the 2-mm gap formation force, ultimate strength, elastic modulus, and energy to failure of the sutures. The 2-mm gap formation forces of the sutures were 43.0 N for the Tang, 37.4 N for the cruciate, 25.0 N for the Robertson, 32.3 N for the Silfverskiold, and 21.2 N for the modified Kessler methods. The ultimate strength of the sutures was 53.6 N for the Tang, 46.3 N for the cruciate, 41.6 N for the Robertson, 41.0 N for the Silfverskiold, and 24.7 N for the modified Kessler methods. Statistically, the gap formation force and ultimate strength were the highest in the Tang, higher in the cruciate, and the lowest for the Robertson and the modified Kessler methods. The elastic modulus of the repaired tendons, as represented by the linear slope of the force-displacement curve, was also statistically the largest in the Tang, larger in the cruciate, and lowest for the Robertson and modified Kessler methods. Energy to failure was statistically the largest in the Tang, higher in the cruciate, lower in the Silfverskiold and the Robertson, and the lowest for the modified Kessler methods. It was concluded that significant differences exist in mechanical properties of the newly developed tendon suture methods. Among the methods for tendon repair that were tested, the Tang and the cruciate sutures were the best candidates for flexor tendon repair in the hand with postoperative active mobilization because of their superior tensile strength, elastic properties, energy to failure, and reasonable operation time.     

The effect of cryopreservation or heating on the mechanical properties and histomorphology of rat bone-patellar tendon-bone

The effects of cryopreservation on tendon allograft have been reported, but remain unclear, particularly the potential effects on mechanical properties and histological changes by ice crystal formation. There are also few studies about effects of heating for sterilization of tendon. We evaluated the effect of cryopreservation or heating on the mechanical properties and histomorphology of rat bone-patellar tendon-bones (BTBs). BTBs were processed by cryopreservation at −80°C for 3 weeks, or heating at 80°C for 10 min. Tensile testing and histomorphological examination were performed. The cryopreservation of tendons showed less influences on their mechanical properties. When cryopreserved BTBs in frozen state were fixed by freeze-substitution method, many spaces were observed in interfibrillar substances. These results suggest that the collagen fibers of cryopreserved tendons were histomorphologically affected by ice crystals. The heating of tendons completely destroyed the collagen fibers of the tendons and is therefore thought to be inappropriate for the sterilization of BTBs.     

Reduction of Tendon Adhesions following Administration of Adaprev,a Hypertonic Solution of Mannose-6-Phosphate: Mechanism of Action Studies

Repaired tendons may be complicated by progressive fibrosis, causing adhesion formation or tendon softening leading to tendon rupture and subsequent reduced range of motion. There are few therapies available which improve the gliding of damaged tendons in the hand. We investigate the role of Mannose 6-phosphate (M6P) in a 600 mM hypertonic solution (Adaprev) on tendon adhesion formation in vivo using a mouse model of severed tendon in conjunction with analysis of collagen synthesis, cellular proliferation and receptors involved in TGF beta signalling. Cytotoxicity was assessed by measuring tissue residency, mechanical strength and cell viability of tendons after treatment with Adaprev. To elicit potential modes of action, in vitro and ex vivo studies were performed investigating phosphorylation of p38, cell migration and proliferation. Adaprev treatment significantly (p<0.05) reduced the development of adhesions and improved collagen organisation without reducing overall collagen synthesis following tendon injury in vivo. The bioavailability of Adaprev saw a 40% reduction at the site of administration over 45 minutes and tendon fibroblasts tolerated up to 120 minutes of exposure without significant loss of cell viability or tensile strength. These favourable effects were independent of CI-MPR and TGF-β signalling and possibly highlight a novel mechanism of action related to cellular stress demonstrated by phosphorylation of p38. The effect of treatment reduced tendon fibroblast migration and transiently halted tendon fibroblast proliferation in vitro and ex vivo. Our studies demonstrate that the primary mode of action for Adaprev is potentially via a physical, non-chemical, hyperosmotic effect.     

Organization of collagen bundles during tendon healing in rats treated with L-NAME

The Achilles tendon can support high tension forces and may experience lesions. The damaged tissue does not regenerate completely, with the organization and mechanical properties of the repaired tendon being inferior to those of a healthy tendon. Nitric oxide (NO) plays an important role in wound repair. We have examined the structural reorganization and repair in Achilles tendon after injury in rats treated with the NO synthase inhibitor L-NAME. The right Achilles tendon of male Wistar rats was partially transected. One group of rats was treated with L-NAME (~300 mg/kg per day, given in drinking water) for 4 days prior to tendon sectioning and throughout the post-operative period. Control rats received water without L-NAME. The tendons were excised at 7, 14, and 21 days post-injury and used to quantify hydroxyproline and for mechanical tests. Tendons were also processed for histomorphological analysis by polarized light microscopy, which showed that the collagen fibers were disorganized by day 7 in non-treated and L-NAME-treated rats. In non-treated rats, the organization of the extracellular matrix was more homogeneous by days 14 and 21 compared with day 7, although this homogeneity was less than that in normal tendon. In contrast, in injured tendons from L-NAME-treated rats, the collagen fibers were still disorganized on day 21. Tendons from treated rats had more hydroxyproline but lower mechanical properties compared with those from non-treated rats. Thus, NO modulates tendon healing, with a reduction in NO biosynthesis delaying reorganization of the extracellular matrix, especially collagen. T.C.T. and W.R.N were supported by studentships from CAPES, and S.H. was supported by a research fellowship from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).     

Dysfunctional tendon collagen fibrillogenesis in collagen VI null mice

Tendons are composed of fibroblasts and collagen fibrils. The fibrils are organized uniaxially and grouped together into fibers. Collagen VI is a non-fibrillar collagen expressed in developing and adult tendons. Human collagen VI mutations result in muscular dystrophy, joint hyperlaxity and contractures. The purpose of this study is to determine the functional roles of collagen VI in tendon matrix assembly. During tendon development, collagen VI was expressed throughout the extracellular matrix, but enriched around fibroblasts and their processes. To analyze the functional roles of collagen VI a mouse model with a targeted inactivation of Col6a1 gene was utilized. Ultrastructural analysis of Col6a1−/− versus wild type tendons demonstrated disorganized extracellular micro-domains and associated collagen fibers in the Col6a1−/− tendon. In Col6a1−/− tendons, fibril structure and diameter distribution were abnormal compared to wild type controls. The diameter distributions were shifted significantly toward the smaller diameters in Col6a1−/− tendons compared to controls. An analysis of fibril density (number/μm²) demonstrated a ~ 2.5 fold increase in the Col6a1−/− versus wild type tendons. In addition, the fibril arrangement and structure were aberrant in the peri-cellular regions of Col6a1−/− tendons with frequent very large fibrils and twisted fibrils observed restricted to this region. The biomechanical properties were analyzed in mature tendons. A significant decrease in cross-sectional area was observed. The percent relaxation, maximum load, maximum stress, stiffness and modulus were analyzed and Col6a1−/− tendons demonstrated a significant reduction in maximum load and stiffness compared to wild type tendons. An increase in matrix metalloproteinase activity was suggested in the absence of collagen VI. This suggests alterations in tenocyte expression due to disruption of cell-matrix interactions. The changes in expression may result in alterations in the peri-cellular environment. In addition, the absence of collagen VI may alter the sequestering of regulatory molecules such as leucine rich proteoglycans. These changes would result in dysfunctional regulation of tendon fibrillogenesis indirectly mediated by collagen VI.     

Bridging tendon defects using autologous tenocyte engineered tendon in a hen model

Tendon defects remain a major concern in plastic surgery because of the limited availability of tendon autografts. Whereas immune rejection prohibits the use of tendon allografts, most prosthetic replacements also fail to achieve a satisfactory long-term result of tendon repair. The tissue engineering technique, however, can generate different tissues using autologous cells and thus may provide an optimal approach to address this concern. The purpose of this study was to test the feasibility of engineering tendon tissues with autologous tenocytes to bridge a tendon defect in either a tendon sheath open model or a partial open model in the hen. In a total of 40 Leghorn hens, flexor tendons were harvested from the left feet and were digested with 0.25% type II collagenase. The isolated tenocytes were expanded in vitro and mixed with unwoven polyglycolic acid fibers to form a cell-scaffold construct in the shape of a tendon. The constructs were wrapped with intestinal submucosa and then cultured in Dulbecco's Modified Eagle Medium plus 10% fetal bovine serum for 1 week before in vivo transplantation. On the feet, a defect of 3 to 4 cm was created at the second flexor digitorum profundus tendon by resecting a tendon fragment. The defects were bridged either with a cell-scaffold construct in the experimental group ( n= 20) or with scaffold material alone in the control group ( n= 20). Specimens were harvested at 8, 12, and 14 weeks postrepair for gross and histologic examination and for biomechanical analysis. In the experimental group, a cordlike tissue bridging the tendon defect was formed at 8 weeks postrepair. At 14 weeks, the engineered tendons resembled the natural tendons grossly in both color and texture. Histologic examination at 8 weeks showed that the neo-tendon contained abundant tenocytes and collagen; most collagen bundles were randomly arranged. The undegraded polyglycolic acid fibers surrounded by inflammatory cells were also observed. At 12 weeks, tenocytes and collagen fibers became longitudinally aligned, with good interface healing to normal tendon. At 14 weeks, the engineered tendons displayed a typical tendon structure hardly distinguishable from that of normal tendons. Biomechanical analysis demonstrated increased breaking strength of the engineered tendons with time, which reached 83 percent of normal tendon strength at 14 weeks. In the control group, polyglycolic acid constructs were mostly degraded at 8 weeks and disappeared at 14 weeks. However, the breaking strength of the scaffold materials accounted for only 9 percent of normal tendon strength. The results of this study indicated that tendon tissue could be engineered in vivo to bridge a tendon defect. The engineered tendons resembled natural tendons not only in gross appearance and histologic structure but also in biomechanical properties.     

Early voluntary exercise does not promote healing in a rat model of Achilles tendon injury.

Mechanical stress is an important modulator of connective tissue repair. However, the effects on tendon healing are very poorly defined, preventing optimal use of mechanical stress. We hypothesized that early voluntary exercise initially retards tendon repair but results in a faster recovery rate at longer term. Male Wistar rats were injured by a collagenase injection in the Achilles tendon, and exercise was voluntarily performed on a running wheel. We observed the persistent presence of neutrophils in injured tendons of rats that began exercise immediately after the trauma [injured + early exercise (Inj+EEx)]. Early exercise also increased the concentration of ED1(+) macrophages in injured tendons after 3 and 7 days compared with ambulatory injured rats (Inj). Similar results were obtained with the subset of ED2(+) macrophages in the tendon core 3 days after the collagenase injection. Furthermore, collagen content returned to normal values more rapidly in the Inj+EEx tendons than in the Inj group, but this was not associated with an increase in cell proliferation. Surprisingly, Inj+EEx tendons roughly displayed lower stiffness and force at rupture point relative to Inj tendons at day 28. Injured tendons of rats that began exercise only from day 7 had better mechanical properties than those of early-exercised rats 28 days postinjury. We speculate that the persistence of the inflammatory response and undue mechanical loading in the Inj+EEx tendons led to fibrosis and a loss of tendon function.     

Biomechanical studies of the rabbit patellar tendon after removal of its one-fourth or a half.

Effects of the overstressing induced by the harvest of grafts from the patellar tendon on the mechanical properties and morphometry of remaining tendon were studied using a rabbit model. The width of the patellar tendon was reduced by one-fourth or one-half equally removing the medial and lateral portions; by this surgery, the cross-sectional area was decreased by 25 or 50 percent from the original area. After all the rabbits were allowed unrestricted activities in cages for 3 to 12 weeks, their patellar tendons were harvested for mechanical and histological studies. The one-fourth removal induced no significant changes in the mechanical properties, but significantly increased the cross-sectional area. In the case of one-half removal, tensile strength and tangent modulus did not change in some tendons, although the cross-sectional area increased significantly. In the other central half tendons, mechanical strength decreased markedly, while the cross-sectional area increased; hypercellular areas and breakage of collagen bundles were observed in these tendons. These results indicate that the patellar tendon has an ability of functionally adapting to overstressing by changing the cross-sectional area, while keeping the mechanical properties unchanged, if the extent of overstressing is less than 30 percent.     

Fatigue loading of tendon results in collagen kinking and denaturation but does not change local tissue mechanics

Fatigue loading is a primary cause of tendon degeneration, which is characterized by the disruption of collagen fibers and the appearance of abnormal (e.g., cartilaginous, fatty, calcified) tissue deposits. The formation of such abnormal deposits, which further weakens the tissue, suggests that resident tendon cells acquire an aberrant phenotype in response to fatigue damage and the resulting altered mechanical microenvironment. While fatigue loading produces clear changes in collagen organization and molecular denaturation, no data exist regarding the effect of fatigue on the local tissue mechanical properties. Therefore, the objective of this study was to identify changes in the local tissue stiffness of tendons after fatigue loading. We hypothesized that fatigue damage would reduce local tissue stiffness, particularly in areas with significant structural damage (e.g., collagen denaturation). We tested this hypothesis by identifying regions of local fatigue damage (i.e., collagen fiber kinking and molecular denaturation) via histologic imaging and by measuring the local tissue modulus within these regions via atomic force microscopy (AFM). Counter to our initial hypothesis, we found no change in the local tissue modulus as a consequence of fatigue loading, despite widespread fiber kinking and collagen denaturation. These data suggest that immediate changes in topography and tissue structure – but not local tissue mechanics – initiate the early changes in tendon cell phenotype as a consequence of fatigue loading that ultimately culminate in tendon degeneration.     

Matrix metalloproteinase activities and their relationship with collagen remodelling in tendon pathology.

Our aim was to correlate the activity of matrix metalloproteinases (MMPs) with denaturation and the turnover of collagen in normal and pathological human tendons. MMPs were extracted from ruptured supraspinatus tendons (n=10), macroscopically normal ("control") supraspinatus tendons (n=29) and normal short head of biceps brachii tendons (n=24). Enzyme activity was measured using fluorogenic substrates selective for MMP-1, MMP-3 and enzymes with gelatinolytic activity (MMP-2, MMP-9 and MMP-13). Collagen denaturation was determined by alpha-chymotrypsin digestion. Protein turnover was determined by measuring the percentage of D-aspartic acid (% D-Asp). Zymography was conducted to identity specific gelatinases. MMP-1 activity was higher in ruptured supraspinatus compared to control supraspinatus and normal biceps brachii tendons (70.9, 26.4 and 11.5 fmol/mg tendon, respectively; P<0.001). Gelatinolytic and MMP-3 activities were lower in normal biceps brachii and ruptured supraspinatus compared to control supraspinatus (gelatinase: 0.18, 0.23 and 0.82 RFU/s/mg tendon respectively; P<0.001; MMP-3: 9.0, 8.6 and 55 fmol/mg tendon, respectively; P<0.001). Most gelatinase activity was shown to be MMP-2 by zymography. Denatured collagen was increased in ruptured supraspinatus compared to control supraspinatus (20.4% and 9.9%, respectively; P<0.001). The % D-Asp content increased linearly with age in normal biceps brachii but not in control supraspinatus and was significantly lower in ruptured supraspinatus compared to age-matched control tendons (0.33 and 1.09% D-Asp, respectively; P<0.01). We conclude that the short head of biceps brachii tendons show little protein turnover, whereas control supraspinatus tendons show relatively high turnover mediated by the activity of MMP-2, MMP-3 and MMP-1. This activity is thought to represent a repair or maintenance function that may be associated with an underlying degenerative process caused by a history of repeated injury and/or mechanical strain. After tendon rupture, there was increased activity of MMP-1, reduced activity of MMP-2 and MMP-3, increased turnover and further deterioration in the quality of the collagen network. Tendon degeneration is shown to be an active, cell-mediated process that may result from a failure to regulate specific MMP activities in response to repeated injury or mechanical strain.     

Mechanical properties of rat tail tendon in relation to proximal-distal sampling position and age

The mechanical properties of 3, 15 and 25 month-old rat tail tendons were investigated in relation to proximal-distal sampling location along the fibre length. For the 15 and 25 month-old tendons maximum load as well as collagen content per mm fibre length (unit collagen) increased markedly from the proximal to the distal location. A linear regression analysis of the collagen content and mechanical parameters (maximum load, maximum slope of the load-strain curve and energy absorption) showed that these parameters were linearly correlated to the collagen content. However, normalization of the mechanical parameters with regard to the collagen content did not cancel the dependency of the parameters on proximal-distal sampling location. Normalized load and energy values for the 3 month-old tendons and normalized slope values for the 15 and 25 month-old tendons were found to decrease from proximal to distal location. These findings showed that tail tendons are heterogeneous along their length in respect to mechanical strength. The regression analysis also indicated the existence of an inverse relationship between unit collagen and mechanical quality of the collagen. Alternatively, the mechanical properties of tendon fibres might be influenced by other components than collagen.     

The role of repair tension on tendon to bone healing in an animal model of chronic rotator cuff tears

Rotator cuff tendon tears are one of the most common shoulder injuries. Although surgical repair is typically beneficial, re-tearing of the tendons frequently occurs. It is generally accepted that healing is worse for chronic tears than acute tears, but the reasons for this are unknown. One potential cause may be the large tensions that are sometimes required to repair chronically torn tendons back to bone (i.e., repair tension). Therefore, the objective of this study was to utilize an animal model of chronic rotator cuff repairs to investigate the role of increased repair tension on tendon to bone healing. We hypothesized that an increase in repair tension would be related to detrimental changes to the healing insertion site. To test this hypothesis, the supraspinatus tendon of rats was surgically detached and then repaired immediately or after a delay of 2, 4, or 16 weeks. The repair tension was measured using a tensiometer and the mechanical properties, collagen organization, and protein expression of the healing insertion site were evaluated 4 and/or 16 weeks following repair. We found that the repair tension increased with time following detachment, and was related to a decrease in the failure properties and viscoelastic peak stress and an increase in cross-sectional area and stiffness of the insertion site. Therefore, repair tension should be minimized in the clinical setting. Future studies will include additional animal model studies involving the relationship between tension and muscle properties and a clinical study investigating the role of repair tension on repair failure.     

Is the tendon embryogenesis process resurrected during tendon healing?

The process of embryonic tendon development, including the nature and purpose of collagen fibril segments, is reviewed. It is proposed that tendon fibrillogenesis of repair is related to the fibrillogenesis of tendon embryonic development. The assembly of collagen fibril segment units into longer fibers occurs on the surface of tendon fibroblasts in embryonic tendon development. The biochemist's view of tendon healing, whereby the spontaneous polymerization of tropocollagen monomers regenerates lost tendon collagen fibers, needs to be reconsidered. Furthermore, the importance of direct fibroblast involvement in collagen fiber reassembly during tendon healing needs to be studied in tendon intrinsic regenerative repair.     

Cross-Linking in Collagen by Nonenzymatic Glycation Increases the Matrix Stiffness in Rabbit Achilles Tendon

Nonenzymatic glycation of connective tissue matrix proteins is a major contributor to the pathology of diabetes and aging. Previously the author and colleagues have shown that nonenzymatic glycation significantly enhances the matrix stability in the Achilles tendon (Reddy et al., 2002, Arch. Biochem. Biophys., 399, 174–180). The present study was designed to gain further insight into glycation-induced collagen cross-linking and its relationship to matrix stiffness in the rabbit Achilles tendon. The glycation process was initiated by incubating the Achilles tendons (n = 6) in phosphate-buffered saline containing ribose, whereas control tendons (n = 6) were incubated in phosphate-buffered saline without ribose. Eight weeks following glycation, the biomechanical attributes as well as the degree of collagen cross-linking were determined to examine the potential associations between matrix stiffness and molecular properties of collagen. Compared to nonglycated tendons, the glycated tendons showed increased maximum load, stress, strain, Young''s modulus of elasticity, and toughness indicating that glycation increases the matrix stiffness in the tendons. Glycation of tendons resulted in a considerable decrease in soluble collagen content and a significant increase in insoluble collagen and pentosidine. Analysis of potential associations between the matrix stiffness and degree of collagen cross-linking showed that both insoluble collagen and pentosidine exhibited a significant positive correlation with the maximum load, stress, and strain, Young''s modulus of elasticity, and toughness (r values ranging from .61 to .94) in the Achilles tendons. However, the soluble collagen content present in neutral salt buffer, acetate buffer, and acetate buffer containing pepsin showed an inverse relation with the various biomechanical attributes tested (r values ranging from .22 to .84) in the Achilles tendons. The results of the study demonstrate that glycation-induced collagen cross-linking is directly associated with the increased matrix stiffness and other mechanical attributes of the tendon.     

Tenocyte contraction induces crimp formation in tendon-like tissue

Tendons are composed of longitudinally aligned collagen fibrils arranged in bundles with an undulating pattern, called crimp. The crimp structure is established during embryonic development and plays a vital role in the mechanical behaviour of tendon, acting as a shock-absorber during loading. However, the mechanism of crimp formation is unknown, partly because of the difficulties of studying tendon development in vivo. Here, we used a 3D cell culture system in which embryonic tendon fibroblasts synthesise a tendon-like construct comprised of collagen fibrils arranged in parallel bundles. Investigations using polarised light microscopy, scanning electron microscopy and fluorescence microscopy showed that tendon constructs contained a regular pattern of wavy collagen fibrils. Tensile testing indicated that this superstructure was a form of embryonic crimp producing a characteristic toe region in the stress–strain curves. Furthermore, contraction of tendon fibroblasts was the critical factor in the buckling of collagen fibrils during the formation of the crimp structure. Using these biological data, a finite element model was built that mimics the contraction of the tendon fibroblasts and monitors the response of the Extracellular matrix. The results show that the contraction of the fibroblasts is a sufficient mechanical impulse to build a planar wavy pattern. Furthermore, the value of crimp wavelength was determined by the mechanical properties of the collagen fibrils and inter-fibrillar matrix. Increasing fibril stiffness combined with constant matrix stiffness led to an increase in crimp wavelength. The data suggest a novel mechanism of crimp formation, and the finite element model indicates the minimum requirements to generate a crimp structure in embryonic tendon.     

Influence of decorin on the mechanical, compositional, and structural properties of the mouse patellar tendon

The interactions of small leucine-rich proteoglycans (SLRPs) with collagen fibrils, their association with water, and their role in fibrillogenesis suggests that SLRPs may play an important role in tendon mechanics. Some studies have assessed the role of SLRPs in the mechanical response of the tendon, but the relationships between sophisticated mechanics, assembly of collagen, and SLRPs have not been well characterized. Decorin content was varied in a dose dependent manner using decorin null, decorin heterozygote, and wild type mice. Quantitative measures of mechanical (tension and compression), compositional, and structural changes of the mouse patellar tendon were evaluated. Viscoelastic, tensile dynamic modulus was increased in the decorin heterozygous tendons compared to wild type. These tendons also had a significant decrease in total collagen and no structural changes compared to wild type. Decorin null tendons did not have any mechanical changes; however, a significant decrease in the average fibril diameter was found. No differences were seen between genotypes in elastic or compressive properties, and all tendons demonstrated viscoelastic mechanical dependence on strain rate and frequency. These results suggest that decorin, a member of the SLRP family, plays a role in tendon viscoelasticity that cannot be completely explained by its role in collagen fibrillogenesis. In addition, reductions in decorin do not cause large changes in indentation compressive properties, suggesting that other factors contribute to these properties. Understanding these relationships may ultimately help guide development of tissue engineered constructs or treatment modalities.     

Development of ligament tissue biodegradable devices: A review

This bibliographic review is focused on ligament tissue rehabilitation, its anatomy–physiology, and, mainly, on the dimensioning considerations of a composite material solution. The suture strength is problematic during the tissue recovering, implying reduction of mobility for several months. However, early postoperative active mobilization may enable a faster and more effective recovering of tissue biomechanical functions. As the risk of tendon rupture becomes a significant concern, a repair technique must be used to withstand the tensile forces generated by active mobilization. However, to avoid stress shielding effect on ligament tissue, an augmentation device must be designed on stiffness basis, that preferably will decrease. Absorbable biocomposite reinforcements have been used to allow early postoperative active mobilization and avoid the shortcomings of current repair solutions. Tensile strength decrease of the repair, during the initial inflammatory phase, is expected, derived from oedema and tendon degradation. In the fibroblastic phase, stiffness and strength will increase, which will stabilize during the remodeling phase.The reinforcement should be able to carry the dynamic load due to locomotion with a mechanical behavior similar to the undamaged natural tissue, during all rehabilitation process. Moreover, the degradation rate must also be compatible with the ligament tissue recovering. The selection and combination of different biodegradable materials, in order to make the biocomposite reinforcement functionally compatible to the damaged sutured tissue, in terms of mechanical properties and degradation rate, is a major step on the design process. Modelling techniques allow pre-clinical evaluation of the reinforcement functional compatibility, and the optimization by comparison of different composite solutions in terms of biomechanical behavior.     

Growth-related changes in the mechanical properties of collagen fascicles from rabbit patellar tendons

Growth-related changes in the mechanical properties of collagen fascicles (approximately 300 microm in diameter) were studied using patellar tendons obtained from skeletally immature 1 and 2 months old and matured 6 months old rabbits. Tensile properties were determined using a specially designed micro-tensile tester. In each age group, there were no significant differences in the properties among cross-sectional locations in the tendon. Tangent modulus and tensile strength significantly increased with age; the rates of their increases between 1 and 2 months were higher than those between 2 and 6 months. The tangent modulus and tensile strength were positively correlated with the body weight of animals. However, growth-related changes in the mechanical properties were different between collagen fascicles and bulk patellar tendons, which may be attributable to such non-collagenous components as ground substances and also to mechanical interactions between collagen fascicles.     

Collagen fibril size and crimp morphology in ruptured and intact Achilles tendons.

The present study examined the hypothesis that collagen fibril diameter and crimp angle in ruptured human Achilles tendons differed from that of intact ones. Tissue samples were obtained from the central core (distal core) and the posterior periphery (distal superficial) at the rupture site, and the proximally intact (proximal superficial) part of the tendon in 10 subjects (38+/-8 years) with a complete tendon rupture. For comparisons corresponding tissue samples were procured from age (38+/-7 years) and gender matched intact Achilles tendons during routine forensic autopsy. The cross-sectional area density and diameter distribution of fibrils were analyzed using stereological techniques of digitized electron microscopy biopsy cross-sections, while crimp angle was measured by the changing banding pattern of collagen fibers when rotated between crossed polars. Nine of 10 persons with tendon ruptures reported that the injury did not occur during exceedingly large forces, and none experienced any symptoms in the days or months prior to the injury. Fibril diameter distribution showed no region-specific differences in either the ruptured or intact tendons for either group. However, in the distal core there were fewer fibrils in the ruptured compared to the intact tendons in 60-150 nm range, P<0.01. Similarly, in the distal superficial portion there were fewer fibrils in the ruptured compared to the intact tendons in the 90-120 nm range, 2P<0.05, while there were no differences in the proximal superficial tendons. Crimp angle did not display any region-specific differences, or any difference between the rupture and intact tendons. In conclusion, these data suggest that although crimp morphology is unchanged there appears to be a site-specific loss of larger fibrils in the core and periphery of the Achilles tendon rupture site. Moreover, the lack of symptoms prior to the rupture suggests that clinical tendinopathy is not an etiological factor in complete tendon ruptures.     

Human patellar tendon stiffness is restored following graft harvest for anterior cruciate ligament surgery

Minimising post-operative donor site morbidity is an important consideration when selecting a graft for surgical reconstruction of the torn anterior cruciate ligament (ACL). One of the most common procedures, the bone-patellar tendon-bone (BPTB) graft involves removal of the central third from the tendon. However, it is unknown whether the mechanical properties of the donor site (patellar tendon) recover. The present study investigated the mechanical properties of the human patellar tendon in 12 males (mean±S.D. age: 37±14 years) who had undergone surgical reconstruction of the ACL using a BPTB graft between 1 and 10 years before the study (operated knee; OP). The uninjured contralateral knee served as a control (CTRL). Patellar tendon mechanical properties were assessed in vivo combining dynamometry with ultrasound imaging. Patellar tendon stiffness was calculated from the gradient of the tendon's force–elongation curve. Tendon stiffness was normalised to the tendon's dimensions to obtain the tendon's Young's modulus. Cross-sectional area (CSA) of OP patellar tendons was larger by 21% than CTRL tendons (P<0.01). Patellar tendon stiffness was not significantly different between OP and CTRL tendons, but the Young's modulus was lower by 24% in OP tendons (P<0.01). A compensatory enlargement of the patellar tendon CSA, presumably due to scar tissue formation, enabled a recovery of tendon stiffness in the OP tendons. The newly formed tendon tissue had inferior properties as indicated by the reduced tendon Young's modulus, but it increased to a level that enabled recovery of tendon stiffness.