Radial half of extensor carpi radialis longus tendon as graft to elongate muscle tendon unit for correction of finger clawing

In 12 patients, the extensor carpi radialis longus muscle tendon unit was elongated using the radial half of the parent tendon so that it could reach the site of new insertion, the A1-A2 pulley of flexor sheath or lateral bands, after routing the transfer through the carpal tunnel. The tendon was of appropriate thickness and could be split into two halves to be used as a graft. Further splitting of the tendon into four tails was possible. The transferred slips retained adequate strength to activate the fingers after the operation. It is suggested that splitting of the extensor carpi radialis longus tendon to use one half as a tendon graft be considered in patients in whom extensor carpi radialis longus transfer is planned to correct finger clawing. This technique is simple, needs minor modification in the sequence of operative steps, reduces operating time, and saves the patient from postoperative discomfort, muscle herniation, and scarring at the donor site (usually the thigh).     

Informing tendon tissue engineering with embryonic development

Tendon is a strong connective tissue that transduces muscle-generated forces into skeletal motion. In fulfilling this role, tendons are subjected to repeated mechanical loading and high stress, which may result in injury. Tissue engineering with stem cells offers the potential to replace injured/damaged tissue with healthy, new living tissue. Critical to tendon tissue engineering is the induction and guidance of stem cells towards the tendon phenotype. Typical strategies have relied on adult tissue homeostatic and healing factors to influence stem cell differentiation, but have yet to achieve tissue regeneration. A novel paradigm is to use embryonic developmental factors as cues to promote tendon regeneration. Embryonic tendon progenitor cell differentiation in vivo is regulated by a combination of mechanical and chemical factors. We propose that these cues will guide stem cells to recapitulate critical aspects of tenogenesis and effectively direct the cells to differentiate and regenerate new tendon. Here, we review recent efforts to identify mechanical and chemical factors of embryonic tendon development to guide stem/progenitor cell differentiation toward new tendon formation, and discuss the role this work may have in the future of tendon tissue engineering.     

Stability of reconstructed paralyzed shoulders using a reflected long head biceps technique

A new tendon transfer technique is proposed for the reconstruction of the paralyzed shoulders secondary to Brachial Plexus Injury (BPI). In this tendon transfer, the long head of the biceps tendons is utilized as a bridging tendon graft. It is reflected at the exit of the bicipital groove, passed through the deltoid and directed to the trapezius. The technique is referred to here as the Reflected Long Head Bicepts (RLHB) technique. This study evaluated the effect of this tendon transfer on the anterior, posterior, and inferior stability of the reconstructed should using cadaveric specimens. It was shown that loading of the RLHB contributed significantly to anterior stability of the reconstructed shoulder for 90 deg elevation in the scapula plane. The mean displacement was reduced by 56 percent with RLHB loaded (p<0.01), by 56 percent with the rotator cuff loaded (p <0.005), and by 67 percent with both the RLHB and the rotator cuff loaded (p<0.004). For the post-operation conditions, variation of the directions of RLHB had no significant effect on joint displacement in response to anterior loading. The RLHB tendon also contributed to the posterior and inferior stability for the low and middle elevations in the plane of scapula. Two variations of the RLHB tendon transfer procedures, namely the "Sub-Deltoid" and the "Through-Deltoid" techniques, were introduced and studied. These two techniques did not seem to have significantly different effects on the displacement of the humeral head in response to both posterior and inferior loading. The results of this study seemed to support the clinical feasibility of this tendon transfer approach as far as the biomedical stability of the reconstruction is concerned.     

Effect of supraspinatus tendon repair technique on the infraspinatus tendon

Supraspinatus tendon tears are common and often propagate into larger tears that include the infraspinatus tendon, resulting in loss of function and increased pain. Previously, we showed that the supraspinatus and infraspinatus tendons mechanically interact through a range of rotation angles, potentially shielding the torn supraspinatus tendon from further injury while subjecting the infraspinatus tendon to increased risk of injury. Surgical repair of torn supraspinatus tendons is common, yet the effect of the repair on the infraspinatus tendon is unknown. Since we have established a relationship between strain in the supraspinatus and infraspinatus tendons the success of a supraspinatus tendon repair depends on its effect on the loading environment in the infraspinatus tendon. More specifically, the effect of transosseous supraspinatus tendon repair in comparison to one that utilizes suture anchors, as is commonly done with arthroscopic repairs, on this interaction through these joint positions will be evaluated. We hypothesize that at all joint positions evaluated, both repairs will restore the interaction between the two tendons. For both repairs, (1) increasing supraspinatus tendon load will increase infraspinatus tendon strain and (2) altering the rotation angle from internal to external will increase strain in the infraspinatus tendon. Strains were measured in the infraspinatus tendon insertion through a range of joint rotation angles and supraspinatus tendon loads, for the intact, transosseous, and suture anchor repaired supraspinatus tendons. Images corresponding to specific supraspinatus tendon loads were isolated for the infraspinatus tendon insertion for analysis. The effect of supraspinatus tendon repair on infraspinatus tendon strain differed with joint position. Altering the joint rotation did not change strain in the infraspinatus tendon for any supraspinatus tendon condition. Finally, increasing supraspinatus tendon load resulted in an increase in average maximum and decrease in average minimum principal strain in the infraspinatus tendon. There is a significant difference in infraspinatus tendon strain between the intact and arthroscopically (but not transosseous) repaired supraspinatus tendons that increases with greater loads. Results suggest that at low loads neither supraspinatus tendon repair technique subjects the infraspinatus tendon to potentially detrimental loads; however, at high loads, transosseous repairs may be more advantageous over arthroscopic repairs for the health of the infraspinatus tendon. Results emphasize the importance of limiting loading of the repaired supraspinatus tendon and that at low loads, both repair techniques restore the interaction to the intact supraspinatus tendon case.     

Collagen hydrolysis by a new Streptomyces species

A soil streptomycete hydrolysed collagen extracted from bovine Achilles tendon, calf skin, carp swim bladder and rat tail tendon. Enzyme activity was highest with rat tail tendon collagen as substrate. The taxonomy of the streptomycete was studied according to internationally approved methods. Comparative studies revealed that it resembled Streptomyces humidus , S. rochei and S. distatochromogenes in some respects, but differed in many cultural and physiological characteristics. Based on these differences the organism was given a new identity as Streptomyces species A.     

Aspirin promotes tenogenic differentiation of tendon stem cells and facilitates tendinopathy healing through regulating the GDF7/Smad1/5 signaling pathway

Tendinopathy is a common musculoskeletal system disorder in sports medicine, but regeneration ability of injury tendon is limited. Tendon stem cells (TSCs) have shown the definitive treatment evidence for tendinopathy and tendon injuries due to their tenogenesis capacity. Aspirin, as the representative of nonsteroidal anti-inflammatory drugs for its anti-inflammatory and analgestic actions, has been commonly used in treating tendinopathy in clinical, but the effect of aspirin on tenogenesis of TSCs is unclear. We hypothesized that aspirin could promote injury tendon healing through inducing TSCs tenogenesis. The aim of the present study is to make clear the effect of aspirin on TSC tenogenesis and tendon healing in tendinopathy, and thus provide new treatment evidence and strategy of aspirin for clinical practice. First, TSCs were treated with aspirin under tenogenic medium for 3, 7, and 14 days. Sirius Red staining was performed to observe the TSC differentiation. Furthermore, RNA sequencing was utilized to screen out different genes between the induction group and aspirin treatment group. Then, we identified the filtrated molecules and compared their effect on tenogenesis and related signaling pathway. At last, we constructed the tendinopathy model and compared biomechanical changes after aspirin intake. From the results, we found that aspirin promoted tenogenesis of TSCs. RNA sequencing showed that growth differentiation factor 6 (GDF6), GDF7, and GDF11 were upregulated in induction medium with the aspirin group compared with the induction medium group. GDF7 increased tenogenesis and activated Smad1/5 signaling. In addition, aspirin increased the expression of TNC, TNMD, and Scx and biomechanical properties of the injured tendon. In conclusion, aspirin promoted TSC tenogenesis and tendinopathy healing through GDF7/Smad1/5 signaling, and this provided new treatment evidence of aspirin for tendinopathy and tendon injuries.     

Kakapo,a Novel Cytoskeletal-associated Protein Is Essential for the Restricted Localization of the Neuregulin-like Factor,Vein, at the Muscle–Tendon Junction Site

In the Drosophila embryo, the correct association of muscles with their specific tendon cells is achieved through reciprocal interactions between these two distinct cell types. Tendon cell differentiation is initiated by activation of the EGF-receptor signaling pathway within these cells by Vein, a neuregulin-like factor secreted by the approaching myotube. Here, we describe the cloning and the molecular and genetic analyses of kakapo, a Drosophila gene, expressed in the tendons, that is essential for muscle-dependent tendon cell differentiation. Kakapo is a large intracellular protein and contains structural domains also found in cytoskeletal-related vertebrate proteins (including plakin, dystrophin, and Gas2 family members). kakapo mutant embryos exhibit abnormal muscle-dependent tendon cell differentiation. A major defect in the kakapo mutant tendon cells is the failure of Vein to be localized at the muscle–tendon junctional site; instead, Vein is dispersed and its levels are reduced. This may lead to aberrant differentiation of tendon cells and consequently to the kakapo mutant deranged somatic muscle phenotype.     

Vastus medialis myocutaneous and myocutaneous-tendinous composite flaps

This report describes a new myocutaneous territory and introduces a new myocutaneous flap based on the vastus medialis muscle. Dissection, arterial dye perfusion, and specimen angiography of 32 fresh cadaver legs defined a vastus medialis myocutaneous territory directly overlying the muscle and also defined a segment of quadriceps femoris tendon vascularized by the muscle. This vascular unit provides a myocutaneous flap for closure of anterior knee defects. This flap can also be designed as a composite myocutaneous-tendinous flap by inclusion of the vascularized quadriceps femoris tendon segment, which allows reconstruction of missing patellar tendon segments. The distal advancement flap design with retention of motor innervation preserves vastus medialis contribution to knee extension. Clinical applications of vastus medialis myocutaneous and myocutaneous-tendinous flaps are illustrated by their use in three patients with knee defects and patellar tendon losses. The potential value of vascularized tendon (versus vascular free tendon grafts) for patellar tendon reconstruction is discussed.     

Effect of disuse on the ultrastructure of the achilles tendon in rats

We examined the influence exerted, through disuse of the hindlimb, on the collagen fibres of the achilles tendon in rats. With disuse the body mass decreased by 28%, and the mass of soleus muscle decreased by 20%. A decrease in the surface area and diameter was observed in the experimental group when compared to the control group. A histogram of the collagen fibres showed a decrease of the thick fibres in the experimental group. The maximum surface area of collagen fibres in the experimental group was seen to be only 43% of that of the control group. These results showed a decrease in the thickness of the collagen fibres of the achilles tendon through disuse. This seemed to suggest that resistance to tension is decreased by disuse.     

Analysis of the gliding pattern of the canine flexor digitorum profundus tendon through the A2 pulley

Friction between a tendon and its pulley was first quantified using the concept of the arc of contact. Studies of human tendons conformed closely to a theoretical nylon cable/nylon rod model. However, we observed differences in measured friction that depended on the direction of motion in the canine model. We hypothesized that fibrocartilaginous nodules in the tendon affected the measurements and attempted to develop a theoretical model to explain the observations we made. Two force transducers were connected to each end of the canine flexor digitorum profundus tendon and the forces were recorded when it was moved through the A2 pulley toward a direction of flexion by an actuator and then reversed a direction toward extension. The changes of a force as a function of tendon excursion were evaluated in 20 canine paws. A bead cable/rod model was developed to simulate the canine tendon-pulley complex. To interpret the results, a free-body diagram was developed. The two prominent fibrocartilaginous nodules in the tendon were found to be responsible for deviation from a theoretical nylon cable gliding around the rod model, in a fashion analogous to the effect of the patella on the quadriceps mechanism. A bead cable/rod model qualitatively reproduced the findings observed in the canine tendon-pulley complex. Frictional coefficient of the canine flexor tendon-pulley was 0.016+/-0.005. After accounting for the effect created by the geometry of two fibrocartilaginous nodules within the tendon, calculation of frictional force in the canine tendon was possible.     

Why are mammalian tendons so thick?

The maximum stresses to which a wide range of mammalian limb tendons could be subjected in life were estimated by considering the relative cross-sectional areas of each tendon and of the fibres of its muscle. These cross-sectional areas were derived from mass and length measurements on tendons and muscles assuming published values for the respective densities. The majority of the stresses are low. The distribution has a broad peak with maximum frequency at a stress of about 13 MPa, whereas the fracture stress for tendon in tension is about 100 MPa. Thus, the majority of tendons are far thicker than is necessary for adequate strength. Much higher stresses are found among those tendons which act as springs to store energy during locomotion. The acceptability of low safety factors in these tendons has been explained previously (Alexander, 1981). A new theory explains the thickness of the majority of tendons. The muscle with its tendon is considered as a combined system which delivers mechanical energy: the thickness of the tendon is optimized by minimizing the combined mass. A thinner tendon would stretch more. To take up this stretch, the muscle would require longer muscle fibres, which would increase the combined mass. The predicted maximum stress in a tendon of optimum thickness is about 10 MPa, which is within the main peak of the observed stress distribution. Individual variations from this value are to be expected and can be understood in terms of the functions of the various muscles.     

Tensor fasciae latae perforator flap for reconstruction of composite Achilles tendon defects with skin and vascularized fascia

The surgical management of large defects of the Achilles tendon and overlying skin is very demanding and necessitates, as a rule, a free vascularized graft. The ideal characteristics of a thin layer of skin and a strong tendon component, combined with a reliable blood supply and minimal morbidity at the donor site, have only been partially met by all previous grafts used in this situation. The authors performed reconstructions in five patients with large defects of the Achilles tendon and overlying skin by using a perforator flap derived from the tensor fasciae latae flap. A vascularized skin-subcutis-fascia lata flap could be raised by dissecting out two to three perforating arteries through the tensor fasciae latae muscle to the ascending branch of the lateral circumflex femoral artery; the muscle was left in situ in the process. All the flaps took well without complications. At final examination after an average of 20 months, the reconstructed Achilles tendon showed good functional results, although there was a 50 to 70 percent reduction in power during plantar flexion when compared with the normal side. A very good aesthetic result could be obtained after a debulking operation was performed on the skin flap.     

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.     

A finite element model predicts the mechanotransduction response of tendon cells to cyclic tensile loading

The importance of fluid-flow-induced shear stress and matrix-induced cell deformation in transmitting the global tendon load into a cellular mechanotransduction response is yet to be determined. A multiscale computational tendon model composed of both matrix and fluid phases was created to examine how global tendon loading may affect fluid-flow-induced shear stresses and membrane strains at the cellular level. The model was then used to develop a quantitative experiment to help understand the roles of membrane strains and fluid-induced shear stresses on the biological response of individual cells. The model was able to predict the global response of tendon to applied strain (stress, fluid exudation), as well as the associated cellular response of increased fluid-flow-induced shear stress with strain rate and matrix-induced cell deformation with strain amplitude. The model analysis, combined with the experimental results, demonstrated that both strain rate and strain amplitude are able to independently alter rat interstitial collagenase gene expression through increases in fluid-flow-induced shear stress and matrix-induced cell deformation, respectively.     

Stretching Skeletal Muscle: Chronic Muscle Lengthening through Sarcomerogenesis

Skeletal muscle responds to passive overstretch through sarcomerogenesis, the creation and serial deposition of new sarcomere units. Sarcomerogenesis is critical to muscle function: It gradually re-positions the muscle back into its optimal operating regime. Animal models of immobilization, limb lengthening, and tendon transfer have provided significant insight into muscle adaptation in vivo. Yet, to date, there is no mathematical model that allows us to predict how skeletal muscle adapts to mechanical stretch in silico. Here we propose a novel mechanistic model for chronic longitudinal muscle growth in response to passive mechanical stretch. We characterize growth through a single scalar-valued internal variable, the serial sarcomere number. Sarcomerogenesis, the evolution of this variable, is driven by the elastic mechanical stretch. To analyze realistic three-dimensional muscle geometries, we embed our model into a nonlinear finite element framework. In a chronic limb lengthening study with a muscle stretch of 1.14, the model predicts an acute sarcomere lengthening from 3.09m to 3.51m, and a chronic gradual return to the initial sarcomere length within two weeks. Compared to the experiment, the acute model error was 0.00% by design of the model; the chronic model error was 2.13%, which lies within the rage of the experimental standard deviation. Our model explains, from a mechanistic point of view, why gradual multi-step muscle lengthening is less invasive than single-step lengthening. It also explains regional variations in sarcomere length, shorter close to and longer away from the muscle-tendon interface. Once calibrated with a richer data set, our model may help surgeons to prevent muscle overstretch and make informed decisions about optimal stretch increments, stretch timing, and stretch amplitudes. We anticipate our study to open new avenues in orthopedic and reconstructive surgery and enhance treatment for patients with ill proportioned limbs, tendon lengthening, tendon transfer, tendon tear, and chronically retracted muscles.     

Terminal tendon cell differentiation requires the glide/gcm complex

Locomotion relies on stable attachment of muscle fibres to their target sites, a process that allows for muscle contraction to generate movement. Here, we show that glide/gcm and glide2/gcm2, the fly glial cell determinants, are expressed in a subpopulation of embryonic tendon cells and required for their terminal differentiation. By using loss-of-function approaches, we show that in the absence of both genes, muscle attachment to tendon cells is altered, even though the molecular cascade induced by stripe, the tendon cell determinant, is normal. Moreover, we show that glide/gcm activates a new tendon cell gene independently of stripe. Finally, we show that segment polarity genes control the epidermal expression of glide/gcm and determine, within the segment, whether it induces glial or tendon cell-specific markers. Thus, under the control of positional cues, glide/gcm triggers a new molecular pathway involved in terminal tendon cell differentiation, which allows the establishment of functional muscle attachment sites and locomotion.     

Analysis of tendinous actuation in balancing the maximal fingertip force for normal and abnormal forefinger system

This work displayed the force capabilities of the musculoskeletal system of the forefinger under external loading. Different states of normal and pathological fingers are studied. We evaluated the impact of losing musculo-tendon unit strength capacities in terms of maximal output fingertip force and tendon tensions distribution. A biomechanical model for a static force analysis is developed through anatomical and kinematic studies. An optimisation approach is then used to determine tendon tension distribution when performing an isometric task. Furthermore, pathological fingers with common cases of injured flexors and extensors are analysed. The method of simulation for forefinger abnormities is described. Furthermore, the simulation results are interpreted.     

Analysis of tendinous actuation in balancing the maximal fingertip force for normal and abnormal forefinger system

This work displayed the force capabilities of the musculoskeletal system of the forefinger under external loading. Different states of normal and pathological fingers are studied. We evaluated the impact of losing musculo-tendon unit strength capacities in terms of maximal output fingertip force and tendon tensions distribution. A biomechanical model for a static force analysis is developed through anatomical and kinematic studies. An optimisation approach is then used to determine tendon tension distribution when performing an isometric task. Furthermore, pathological fingers with common cases of injured flexors and extensors are analysed. The method of simulation for forefinger abnormities is described. Furthermore, the simulation results are interpreted.     

The implications of the adaptable fatigue quality of tendons for their construction,repair and function

Different tendons are (i) subject to very different stresses from their muscles and (ii) differ in their susceptibility to fatigue damage. The fatigue quality of each tendon is matched to the stress it experiences, so that, in life, all tendons are similarly prone to damage. On-going damage must be routinely repaired to maintain homeostasis and prevent damage from becoming symptomatic. The discovery of major differences in fatigue quality among tendons, which had previously seemed fairly similar in their mechanical properties, raises a wide range of new questions. (A) What structural and chemical differences underlie the variations in fatigue quality? (B) What molecular structure in the tendon is damaged and how is repair organised? (C) Is fatigue quality adaptable and if so what is the trigger for adaptation? Putting these questions into context leads to an integrated review of tendon, including structure and chemistry, the turnover of proteins, the cross-linking of collagen and the response of tenocytes to load on the tendon.