Differential expression of transforming growth factor-beta receptors in a rabbit zone II flexor tendon wound healing model

Flexor tendon repair in zone II is complicated by adhesions that impair normal postoperative gliding. Transforming growth factor-beta (TGF-beta) is a family of growth factors that has been implicated in scar formation. The TGF-beta family of proteins binds to three distinct classes of membrane receptors, termed RI, RII, and RIII. In this study, we analyzed the temporal and spatial distribution of TGF-beta receptor isoforms (RI, RII, and RIII) in a rabbit zone II flexor tendon wound healing model.Twenty-eight adult New Zealand White rabbit forepaws underwent isolation of the middle digit flexor digitorum profundus tendon in zone II. The tendons underwent transection in zone II and immediate repair. The tendons were harvested at increasing time points: 1, 3, 7, 14, 28, and 56 days postoperatively (n = 4 at each time point). The control flexor tendons were harvested without transection and repair (n = 4). Immunohistochemical analysis was used to detect the expression patterns for TGF-beta receptors RI, RII, and RIII.Immunohistochemical staining of the transected and repaired tendons demonstrated up-regulation of TGF-beta RI, RII, and RIII protein levels. TGF-beta receptor production in the experimental group (transection and repair) was concentrated in the epitenon and along the repair site. Furthermore, the TGF-beta receptor expression levels peaked at day 14 and decreased by day 56 postoperatively. In contrast, minimal receptor expression was observed in the untransected and unrepaired control tendons.These data provide evidence that (1) TGF-beta receptors are up-regulated after injury and repair; (2) peak levels of TGF-beta receptor expression occurred at day 14 and decreased by day 56 after wounding and repair; and (3) both the tendon sheath and epitenon have the highest receptor expression, and both may play critical roles in flexor tendon wound healing. Understanding the up-regulation of TGF-beta isoforms and the up-regulation of their corresponding receptors during flexor tendon wound healing provides new targets for biomolecular modulation of postoperative scar formation.     

Functional, mechanical, and biochemical assessment of ultrasound therapy on tendon healing in the chicken toe

We studied the therapeutic effect of ultrasound treatment on the functional recovery of surgically repaired profundus tendon in the right third toe of mature White Leghorn hens. Ultrasound treatment was given daily for 5 minutes for a total of 20 treatment days, starting immediately after 4 weeks immobilization. Ultrasound (frequency 3.0 mHz; intensity 0.75 W/cm2) was delivered to the right leg by a 5-cm2 probe through distilled water in a bath kept at 35 degrees C. The flexion of the toe was measured preoperatively for 4 consecutive days and daily for 6 weeks after the start of ultrasound treatment for the calculation of percent of functional recovery of the flexor tendon. The non-ultrasound-treated group of birds went through the same manipulations except that no ultrasound was given when the right leg was immersed in the water bath. Ultrasound treatment significantly (p less than 0.01) improved the functional recovery of the repaired tendons (less than 5-mm gap) starting on the third week of treatment (94 +/- 2 percent) compared with the non-ultrasound-treated group (79 +/- 4 percent). Ultrasound treatment had no effect on gap formation or breaking (tensile) strength of the repaired tendons. It is concluded that ultrasound enhanced functional return of repaired flexor tendons in the hen, and the clinical implication is discussed.     

Marked innervation but also signs of nerve degeneration in between the Achilles and plantaris tendons and presence of innervation within the plantaris tendon in midportion Achilles tendinopathy

Objectives:

The plantaris tendon is increasingly recognised as an important factor in midportion Achilles tendinopathy. Its innervation pattern is completely unknown.

Methods:

Plantaris tendons (n=56) and associated peritendinous tissue from 46 patients with midportion Achilles tendinopathy and where the plantaris tendon was closely related to the Achilles tendon were evaluated. Morphological evaluations and stainings for nerve markers [general (PGP9.5), sensory (CGRP), sympathetic (TH)], glutamate NMDA receptor and Schwann cells (S-100β) were made.

Results:

A marked innervation, as evidenced by evaluation for PGP9.5 reactions, occurred in the peritendinous tissue located between the plantaris and Achilles tendons. It contained sensory and to some extent sympathetic and NMDAR1-positive axons. There was also an innervation in the zones of connective tissue within the plantaris tendons. Interestingly, some of the nerve fascicles showed a partial lack of axonal reactions.

Conclusion:

New information on the innervation patterns for the plantaris tendon in situations with midportion Achilles tendinopathy has here been obtained. The peritendinous tissue was found to be markedly innervated and there was also innervation within the plantaris tendon. Furthermore, axonal degeneration is likely to occur. Both features should be further taken into account when considering the relationship between the nervous system and tendinopathy.     

Influence of a single loading episode on gene expression in healing rat Achilles tendons

Mechanical loading stimulates tendon healing via mechanisms that are largely unknown. Genes will be differently regulated in loaded healing tendons, compared with unloaded, just because of the fact that healing processes have been changed. To avoid such secondary effects and study the effect of loading per se, we therefore studied the gene expression response shortly after a single loading episode in otherwise unloaded healing tendons. The Achilles tendon was transected in 30 tail-suspended rats. The animals were let down from the suspension to load their tendons on a treadmill for 30 min once, 5 days after tendon transection. Gene expression was studied by Affymetrix microarray before and 3, 12, 24, and 48 h after loading. The strongest response in gene expression was seen 3 h after loading, when 150 genes were up- or downregulated (fold change ≥2, P ≤ 0.05). Twelve hours after loading, only three genes were upregulated, whereas 38 were downregulated. Fewer than seven genes were regulated after 24 and 48 h. Genes involved in the inflammatory response were strongly regulated at 3 and 12 h after loading; this included upregulation of iNOS, PGE synthase, and IL-1β. Also genes involved in wound healing/coagulation, angiogenesis, and production of reactive oxygen species were strongly regulated by loading. Microarray results were confirmed for 16 selected genes in a repeat experiment (N = 30 rats) using real-time PCR. It was also confirmed that a single loading episode on day 5 increased the strength of the healing tendon on day 12. In conclusion, the fact that there were hardly any regulated genes 24 h after loading suggests that optimal stimulation of healing requires a mechanical loading stimulus every day.     

Biomechanical analysis of intrinsic tendon healing in vitro and the effects of vitamins A and E

This in vitro study was designed to test the hypothesis that flexor tendons have an intrinsic capability to heal as judged by rigorously defined biomechanical criteria. Rabbit forepaw flexor tendons (n = 114) were transected and repaired in zone II and cultured in standard media or media supplemented with vitamin A or E. Tenorrhaphies were disrupted at 0, 2, 8, and 12 weeks after repair by fixed-speed tensiometry. The following parameters were calculated: true stress, true strain, and normalized energy absorption. Statistical analysis was by Student's t test. Peak stress (strength) increased equally in all groups over time (p less than 0.05), while normalized energy absorption (toughness) was markedly higher in the vitamin E-treated group after 2 weeks' incubation (p less than 0.05). These data represent the first biomechanical evidence of intrinsic tendon healing in vitro. Biomechanical methodology and vitamin effects are discussed in detail.     

Collagen fibril diameter distribution does not reflect changes in the mechanical properties of in vitro stress-deprived tendons

The purpose of this study was to determine if an association exists between the tensile properties and the collagen fibril diameter distribution in in vitro stress-deprived rat tail tendons. Rat tail tendons were paired into two groups of 21 day stress-deprived and 0 time controls and compared using transmission electron microscopy (n = 6) to measure collagen fibril diameter distribution and density, and mechanical testing (n =6) to determine ultimate stress and tensile modulus. There was a statistically significant decrease in both ultimate tensile strength (control: 17.95+/-3.99 MPa, stress-deprived: 6.79+/-3.91 MPa) and tensile modulus (control: 312.8+/-89.5 MPa, stress-deprived: 176.0+/-52.7 MPa) in the in vitro stress-deprived tendons compared to controls. However, there was no significant difference between control and stress-deprived tendons in the number of fibrils per tendon counted, mean fibril diameter, mean fibril density, or fibril size distribution. The results of this study demonstrate that the decrease in mechanical properties observed in in vitro stress-deprived rat tail tendons is not correlated with the collagen fibril diameter distribution and, therefore, the collagen fibril diameter distribution does not, by itself, dictate the decrease in mechanical properties observed in in vitro stress-deprived rat tail tendons.     

Biomechanical and structural response of healing Achilles tendon to fatigue loading following acute injury

Achilles tendon injuries affect both athletes and the general population, and their incidence is rising. In particular, the Achilles tendon is subject to dynamic loading at or near failure loads during activity, and fatigue induced damage is likely a contributing factor to ultimate tendon failure. Unfortunately, little is known about how injured Achilles tendons respond mechanically and structurally to fatigue loading during healing. Knowledge of these properties remains critical to best evaluate tendon damage induction and the ability of the tendon to maintain mechanical properties with repeated loading. Thus, this study investigated the mechanical and structural changes in healing mouse Achilles tendons during fatigue loading. Twenty four mice received bilateral full thickness, partial width excisional injuries to their Achilles tendons (IACUC approved) and twelve tendons from six uninjured mice were used as controls. Tendons were fatigue loaded to assess mechanical and structural properties simultaneously after 0, 1, 3, and 6 weeks of healing using an integrated polarized light system. Results showed that the number of cycles to failure decreased dramatically (37-fold, p<0.005) due to injury, but increased throughout healing, ultimately recovering after 6 weeks. The tangent stiffness, hysteresis, and dynamic modulus did not improve with healing (p<0.005). Linear regression analysis was used to determine relationships between mechanical and structural properties. Of tendon structural properties, the apparent birefringence was able to best predict dynamic modulus (R²=0.88–0.92) throughout healing and fatigue life. This study reinforces the concept that fatigue loading is a sensitive metric to assess tendon healing and demonstrates potential structural metrics to predict mechanical properties.     

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).     

Effects of transforming growth factor-β1 and vascular endothelial growth factor 165 gene transfer on Achilles tendon healing

Repaired Achilles tendons typically take weeks before they are strong enough to handle physiological loads. Gene therapy is a promising treatment for Achilles tendon defects. The aim of the present study was to evaluate the histological/biomechanical effects of Transforming growth factor-β1 (TGF-β1) and vascular endothelial growth factor 165 (VEGF₁₆₅) gene transfer on Achilles tendon healing in rabbits. Bone Marrow-Derived Mesenchymal Stem Cells (BMSCs) were transduced with adenovirus carrying human TGF-β1 cDNA (Ad-TGF-β1), human VEGF₁₆₅ cDNA (Ad-VEGF₁₆₅), or both (PIRES-TGF-β1/VEGF₁₆₅) Viruses, no cDNA (Ad-GFP), and the BMSCs without gene transfer and the intact tendon were used as control. BMSCs were surgically implanted into the experimentally injured Achilles tendons. TGF-β1 distribution, cellularity, nuclear aspect ratio, nuclear orientation angle, vascular number, collagen synthesis, and biomechanical features were measured at 1, 2, 4, and 8 weeks after surgery. The TGF-β1 and TGFβ1/VEGF₁₆₅ co-expression groups exhibited improved parameters compared with other groups, while the VEGF₁₆₅ expression group had a negative impact. In the co-expression group, the angiogenesis effects of VEGF₁₆₅ were diminished by TGF-β1, while the collagen synthesis effects of TGF-β1 were unaltered by VEGF₁₆₅. Thus treatment with TGF-β1 cDNA-transduced BMSCs grafts is a promising therapy for acceleration and improvement of tendon healing, leading to quicker recovery and improved biomechanical properties of Achilles tendons.     

A cryo-jaw designed for in vitro tensile testing of the healing Achilles tendons in rats

We present a simple but very secure non-compressive clamping device for in vitro tensile testing of the Achilles tendon in rats. Biomechanical studies were performed on 178 native and injured specimens without any registration of slippage out of the clamp. The average tensile strength of the native rat Achilles tendon was determined to be 48 N (+/-11 N) and its displacement to failure averaged 0.8 mm (+/-0.2 mm). The mean values for tensile strength within the injured tendons increased with time and were above the native tendon values from week 2 and later. Correspondingly, the displacement to failure decreased with time.     

Biomechanics of tendon healing

The biomechanics of tendon healing was investigated with unsutured rat achilles tendons. After two, three, and four weeks of healing tensile parameters were assayed with a bone-muscle-tendon-bone preparation elongated to failure at a controlled physiological strain rate.

In the third week of healing, stiffness, strength, and energy absorbing capacity all increased approximately 50%. These changes correlated with early fibroplasia.

In the fourth week of healing, strength, energy absorbing capacity and elongation to failure all increased relatively more than stiffness. Histologically, larger fibers with better longitudinal alignment developed during this period.

At the end of four weeks the tendon's strength was approximately 25% of normal.

To summarize, the return of stiffness in a healing tendon preparation correlated with the presence of fibroplasia and the return of other tensile parameters was a function of the amount and organization of the fibroplasia.     

p38 MAPK Signaling in Postnatal Tendon Growth and Remodeling

Tendon is a dynamic tissue whose structure and function is influenced by mechanical loading, but little is known about the fundamental mechanisms that regulate tendon growth and remodeling in vivo. Data from cultured tendon fibroblasts indicated that the p38 MAPK pathway plays an important role in tendon fibroblast proliferation and collagen synthesis in vitro. To gain greater insight into the mechanisms of tendon growth, and explore the role of p38 MAPK signaling in this process, we tested the hypotheses that inducing plantaris tendon growth through the ablation of the synergist Achilles tendon would result in rapid expansion of a neotendon matrix surrounding the original tendon, and that treatment with the p38 MAPK inhibitor SB203580 would prevent this growth. Rats were treated with vehicle or SB203580, and subjected to synergist ablation by bilateral tenectomy of the Achilles tendon. Changes in histological and biochemical properties of plantaris tendons were analyzed 3, 7, or 28 days after overload, and comparisons were made to non-overloaded animals. By 28 days after overload, tendon mass had increased by 30% compared to non-overloaded samples, and cross-sectional area (CSA) increased by around 50%, with most of the change occurring in the neotendon. The expansion in CSA initially occurred through the synthesis of a hyaluronic acid rich matrix that was progressively replaced with mature collagen. Pericytes were present in areas of active tendon growth, but never in the original tendon ECM. Inhibition of p38 MAPK resulted in a profound decrease in IL6 expression, and had a modest effect on the expression of other ECM and cell proliferation genes, but had a negligible impact on overall tendon growth. The combined results from this study provided novel insights into tendon mechanobiology, and suggest that p38 MAPK signaling does not appear to be necessary for tendon growth in vivo.     

Mechanical properties of collagen fascicles from the rabbit patellar tendon

Tensile and viscoelastic properties of collagen fascicles of approximately 300 microns in diameter, which were obtained from rabbit patellar tendons, were studied using a newly designed micro-tensile tester. Their cross-sectional areas were determined with a video dimension analyzer combined with a CCD camera and a low magnification microscope. There were no statistically significant differences in tensile properties among the fascicles obtained from six medial-to-lateral locations of the patellar tendon. Tangent modulus, tensile strength, and strain at failure of the fascicles determined at about 1.5 percent/s strain rate were 216 +/- 68 MPa, 17.2 +/- 4.1 MPa, and 10.9 +/- 1.6 percent (mean +/- S.D.), respectively. These properties were much different from those of bulk patellar tendons; for example, the tensile strength and strain at failure of these fascicles were 42 percent and 179 percent of those of bulk tendons, respectively. Tangent modulus and tensile strength of collagen fascicles determined at 1 percent/s strain rate were 35 percent larger than those at 0.01 percent/s. The strain at failure was independent of strain rate. Relaxation tests showed that the reduction of stress was approximately 25 percent at 300 seconds. These stress relaxation behavior and strain rate effects of collagen fascicles differed greatly from those of bulk tendons. The differences in tensile and viscoelastic properties between fascicles and bulk tendons may be attributable to ground substances, mechanical interaction between fascicles, and the difference of crimp structure of collagen fibrils.     

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.     

Elastic properties of human Achilles tendon are correlated to muscle strength.

The purpose of this study was to investigate whether the mechanical properties of the Achilles tendon were correlated to muscle strength in the triceps surae in humans. Twenty-four men and twelve women exerted maximal voluntary isometric plantar flexion (MVIP) torque. The elongation (DeltaX) and strain of the Achilles tendon (epsilon), the proximal part of which is the composite of the gastrocnemius tendon and the soleus aponeurosis, at MVIP were determined from the displacement of the distal myotendinous junction of the medial gastrocnemius using ultrasonography. The Achilles tendon force at MVIP (F) was calculated from the MVIP torque and the Achilles tendon moment arm. There were no significant differences in either the F-DeltaX or F-epsilon relationships between men and women. DeltaX and epsilon were 9.8 +/- 2.6 mm and 5.3 +/- 1.6%, respectively, and were positively correlated to F (r = 0.39, P < 0.05; r = 0.39, P < 0.05), which meant that subjects with greater muscle strength could store more elastic energy in the tendon. The regression y-intercepts for the F-DeltaX (P < 0.01) and F-epsilon (P < 0.05) relationship were significantly positive. These results might indicate that the Achilles tendon was stiffer in subjects with greater muscle strength, which may play a role in reducing the probability of tendon strain injuries. It was suggested that the Achilles tendon of subjects with greater muscle strength did not impair the potential for storing elastic energy in tendons and may be able to deliver the greater force supplied from a stronger muscle more efficiently. Furthermore, the difference in the Achilles tendon mechanical properties between men and women seemed to be correlated to the difference in muscle strength rather than gender.     

Experimental Diabetes Induces Structural,Inflammatory and Vascular Changes of Achilles Tendons

This study aims to demonstrate how the state of chronic hyperglycemia from experimental Diabetes Mellitus can influence the homeostatic imbalance of tendons and, consequently, lead to the characteristics of tendinopathy. Twenty animals were randomly divided into two experimental groups: control group, consisting of healthy rats and diabetic group constituted by rats induced to Diabetes Mellitus I. After twenty-four days of the induction of Diabetes type I, the Achilles tendon were removed for morphological evaluation, cellularity, number and cross-sectional area of blood vessel, immunohistochemistry for Collagen type I, VEGF and NF-κB nuclear localization sequence (NLS) and nitrate and nitrite level. The Achilles tendon thickness (µm/100g) of diabetic animals was significantly increased and, similarly, an increase was observed in the density of fibrocytes and mast cells in the tendons of the diabetic group. The average number of blood vessels per field, in peritendinous tissue, was statistically higher in the diabetic group 3.39 (2.98) vessels/field when compared to the control group 0.89 (1.68) vessels/field p = 0.001 and in the intratendinous region, it was observed that blood vessels were extremely rare in the control group 0.035 (0.18) vessels/field and were often present in the tendons of the diabetic group 0.89 (0.99) vessels/field. The immunohistochemistry analysis identified higher density of type 1 collagen and increased expression of VEGF as well as increased immunostaining for NFκB p50 NLS in the nucleus in Achilles tendon of the diabetic group when compared to the control group. Higher levels of nitrite/nitrate were observed in the experimental group induced to diabetes. We conclude that experimental DM induces notable structural, inflammatory and vascular changes in the Achilles tendon which are compatible with the process of chronic tendinopathy.     

The influence of indomethacin on collagen synthesis during tendon healing in the rabbit

The influence of indomethacin on collagen synthesis in intact and healing plantaris longus tendons in the rabbit was investigated. Forty-four male New Zealand White rabbits were subjected to a standardized trauma (tenetomy + repair) on the left hindlimb. Half of the animals were subsequently treated with indomethacin, 10 mg/kg per day orally, and the other half with placebo. After 2 and 4 weeks the rabbits were injected intravenously with 3H-proline and killed 18 h later. Indomethacin affected the collagen metabolism differently depending on whether the tendons were involved in wound healing or not. In intact tendons the drug caused a small general inhibition of collagen synthesis. In the healing tendon there was a shift towards the synthesis of more insoluble collagen with little effect on the total synthesis. After 4 weeks there was also a slight but significant decrease in the amount of hydroxyproline in the most soluble collagen fraction from the tenotomized, indomethacin treated tendons.     

The influence of indomethacin on collagen synthesis during tendon healing in the rabbit

The influence of indomethacin on collagen synthesis in intact and healing plantaris longus tendons in the rabbit was investigated. Forty-four male New Zealand White rabbits were subjected to a standardized trauma (tenetomy + repair) on the left hindlimb. Half of the animals were subsequently treated with indomethacin, 10 mg/kg per day orally, and the other half with placebo. After 2 and 4 weeks the rabbits were injected intravenously with ³H-proline and killed 18 h later. Indomethacin affected the collagen metabolism differently depending on whether the tendons were involved in wound healing or not. In intact tendons the drug caused a small general inhibition of collagen synthesis. In the healing tendon there was a shift towards the synthesis of more insoluble collagen with little effect on the total synthesis. After 4 weeks there was also a slight but significant decrease in the amount of hydroxyproline in the most soluble collagen fraction from the tenotomized, indomethacin treated tendons.