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Hart DA, Ahmed AS, Chen J, Ackermann PW. Optimizing tendon repair and regeneration: how does the in vivo environment shape outcomes following rupture of a tendon such as the Achilles tendon? Front Bioeng Biotechnol 2024; 12:1357871. [PMID: 38433820 PMCID: PMC10905747 DOI: 10.3389/fbioe.2024.1357871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Risk for rupture of the Achilles tendon, and other tendons increases with age. Such injuries of tissues that function in high load environments generally are believed to heal with variable outcome. However, in many cases, the healing does not lead to a good outcome and the patient cannot return to the previous level of participation in active living activities, including sports. In the past few years, using proteomic approaches and other biological techniques, reports have appeared that identify biomarkers that are prognostic of good outcomes from healing, and others that are destined for poor outcomes using validated criteria at 1-year post injury. This review will discuss some of these recent findings and their potential implications for improving outcomes following connective tissue injuries, as well as implications for how clinical research and clinical trials may be conducted in the future where the goal is to assess the impact of specific interventions on the healing process, as well as focusing the emphasis on regeneration and not just repair.
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Affiliation(s)
- David A. Hart
- Department of Surgery, Faculty of Kinesiology, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Aisha S. Ahmed
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Junyu Chen
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital of Sichuan University, Chengdu, China
| | - Paul W. Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Ackermann PW, Alim MA, Pejler G, Peterson M. Tendon pain - what are the mechanisms behind it? Scand J Pain 2023; 23:14-24. [PMID: 35850720 DOI: 10.1515/sjpain-2022-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 06/16/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Management of chronic tendon pain is difficult and controversial. This is due to poor knowledge of the underlying pathophysiology of chronic tendon pain, priorly known as tendinitis but now termed tendinopathy. The objective of this topical review was to synthesize evolving information of mechanisms in tendon pain, using a comprehensive search of the available literature on this topic. CONTENT This review found no correlations between tendon degeneration, collagen separation or neovascularization and chronic tendon pain. The synthesis demonstrated that chronic tendon pain, however, is characterized by excessive nerve sprouting with ingrowth in the tendon proper, which corresponds to alterations oberserved also in other connective tissues of chronic pain conditions. Healthy, painfree tendons are devoid of nerve fibers in the tendon proper, while innervation is confined to tendon surrounding structures, such as sheaths. Chronic painful tendons exhibit elevated amounts of pain neuromediators, such as glutamate and substance p as well as up-regulated expression and excitability of pain receptors, such as the glutamate receptor NMDAR1 and the SP receptor NK1, found on ingrown nerves and immune cells. Increasing evidence indicates that mast cells serve as an important link between the peripheral nervous system and the immune systems resulting in so called neurogenic inflammation. SUMMARY Chronic painful tendons exhibit (1) protracted ingrowth of sensory nerves (2) elevated pain mediator levels and (3) up-regulated expression and excitability of pain receptors, participating in (4) neuro-immune pathways involved in pain regulation. Current treatments that entail the highest scientific evidence to mitigate chronic tendon pain include eccentric exercises and extracorporeal shockwave, which both target peripheral neoinnervation aiming at nerve regeneration. OUTLOOK Potential mechanism-based pharmacological treatment approaches could be developed by blocking promotors of nerve ingrowth, such as NGF, and promoting inhibitors of nerve ingrowth, like semaphorins, as well as blocking glutamate-NMDA-receptor pathways, which are prominent in chronic tendon pain.
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Affiliation(s)
- Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Trauma, Acute Surgery and Orthopaedics, Stockholm, Sweden
| | - Md Abdul Alim
- Department of Public Health and Caring Sciences, General Medicine, Uppsala University, Uppsala, Sweden
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Pejler
- Department of Medical Biochemistry and Microbiology, Uppsala University, Uppsala, Sweden
- Department of Anatomy, Physiology and Biochemistry, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Magnus Peterson
- Department of Public Health and Caring Sciences, General Medicine, Uppsala University, Uppsala, Sweden
- Academic Primary Health Care, Region Uppsala, Sweden
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Merkel MFR, Hellsten Y, Magnusson SP, Kjaer M. Tendon blood flow, angiogenesis, and tendinopathy pathogenesis. TRANSLATIONAL SPORTS MEDICINE 2021. [DOI: 10.1002/tsm2.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Max Flemming Ravn Merkel
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Ylva Hellsten
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Stig Peter Magnusson
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Department of Orthopedic Surgery Copenhagen University Hospital ‐ Bispebjerg‐Frederiksberg University of Copenhagen Copenhagen Denmark
- Center for Healthy Aging Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Aufwerber S, Heijne A, Edman G, Silbernagel KG, Ackermann PW. Does Early Functional Mobilization Affect Long-Term Outcomes After an Achilles Tendon Rupture? A Randomized Clinical Trial. Orthop J Sports Med 2020; 8:2325967120906522. [PMID: 32206673 PMCID: PMC7076581 DOI: 10.1177/2325967120906522] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/03/2019] [Indexed: 12/15/2022] Open
Abstract
Background: Functional deficits and health-related impairments are common after an Achilles tendon rupture (ATR). Rehabilitation protocols vary greatly, and few studies have allowed loading in combination with ankle motion immediately after surgery (ie, early functional mobilization [EFM]). It is unclear whether EFM may counteract the negative impact of ankle immobilization after an ATR. Purpose: The primary aim of this study was to assess the efficacy of EFM compared with standard treatment (ie, 2 weeks of unloading in a plaster cast followed by 4 weeks of weightbearing in an orthosis) regarding patient-reported and functional outcomes in patients with an ATR after acute operative repair. The secondary aim was to explore whether the occurrence of deep venous thrombosis (DVT) during the 2 postoperative treatments affected outcomes. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 135 patients who underwent ATR repair, randomized to either EFM, including immediate postoperative loading and ankle motion, or standard treatment, were evaluated with functional tests and 5 self-administered outcome questionnaires at 6 and 12 months postoperatively. Results: At 6 months, the EFM group scored higher on the RAND 36-Item Health Survey (RAND-36) questionnaire subscales of general health and vitality (P < .05) compared with the control group. No significant differences between the groups were found on disease-specific questionnaires (Achilles tendon Total Rupture Score [ATRS] and Foot and Ankle Outcome Score [FAOS]). At 12 months, no significant differences on any of the patient-reported outcome measures or the functional heel-rise test were seen between the groups. The RAND-36 subscale of general health, however, exhibited higher values in the EFM group (82.6 ± 16.9) than the control group (77.1 ± 17.0) (P = .051) at 12 months after the injury. Patients sustaining DVT postoperatively had lower self-reported outcomes on the ATRS, FAOS, and RAND-36 questionnaires at 6 and 12 months compared with patients not having sustained DVT (all P < .05). Conclusion: This study demonstrated that an accelerated postoperative protocol with immediate loading and ankle motion resulted in better general health and vitality at 6 months. However, there were no differences between the groups in the recovery of heel-rise function. Future studies should focus on the means to reduce the risk of DVT to improve patient outcomes after ATR. Registration: NCT02318472 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Function Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Stockholm, Sweden
| | - Annette Heijne
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Edman
- Department of Research and Development, Norrtälje Hospital, Tiohundra, Norrtälje, Sweden.,Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | | | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
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Aufwerber S, Heijne A, Grävare Silbernagel K, Ackermann PW. High Plantar Force Loading After Achilles Tendon Rupture Repair With Early Functional Mobilization. Am J Sports Med 2019; 47:894-900. [PMID: 30742483 DOI: 10.1177/0363546518824326] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Mechanical loading is essential for tendon healing and may explain variability in patient outcomes after Achilles tendon rupture (ATR) repair. However, there is no consensus regarding the optimal postoperative regimen, and the actual amount of loading during orthosis immobilization is unknown. PURPOSE The primary aim of this study was to assess the number of steps and the amount of loading in a weightbearing orthosis during the first 6 weeks after surgical ATR repair. A secondary purpose was to investigate if the amount of loading was correlated to fear of movement and/or experience of pain. STUDY DESIGN Case series; Level of evidence, 4. METHODS Thirty-four patients (mean ± SD age, 38.8 ± 8.7 years) with ATR repair were included. Early functional mobilization was allowed postoperatively in an orthosis with adjustable ankle range of motion. During the first postoperative 2 weeks, patient-reported loading and pain were assessed with a visual analog scale and step counts with a pedometer. At the 2- and 6-week follow-up, a mobile force sensor was used for measuring plantar force loading, and the Tampa Scale for Kinesiophobia was used to examine fear of movement. RESULTS Between the first and second weeks, there was a significant increase in the mean number of daily steps taken (from 2025 to 2753, P < .001) as well as an increase in self-reported loading (from 20% to 53%, P < .001). Patient self-reported loading was significantly associated with the plantar force measurement (rho = 0.719, P < .001). At 6 weeks, loading was 88.2% on the injured limb versus the uninjured limb. Fear of movement was not correlated with pedometer data, subjective loading, pain, or force data. Patients with less pain during activity, however, reported significantly higher subjective load and took more steps ( P < .05). CONCLUSION This is the first study to demonstrate the actual loading patterns during postoperative functional mobilization among patients with surgically repaired ATR. The quick improvements in loading magnitude and frequency observed may reflect improved tendon loading essential for healing. Pain, rather than fear of movement, was associated with the high variability in loading parameters. The data of this study may be used to improve ATR rehabilitation protocols for future studies. REGISTRATION NCT02318472 (ClinicalTrials.gov).
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Affiliation(s)
- Susanna Aufwerber
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Functional Area Occupational Therapy and Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden
| | - Annette Heijne
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | | | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Orthopedic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Herbst E, Imhoff FB, Foehr P, Milz S, Plank C, Rudolph C, Hasenpusch G, Geiger JP, Aneja MK, Groth K, Vogt S, Imhoff AB, Schmitt A. Chemically Modified Messenger RNA: Modified RNA Application for Treatment of Achilles Tendon Defects. Tissue Eng Part A 2018; 25:113-120. [PMID: 29676227 DOI: 10.1089/ten.tea.2017.0443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Different regenerative medicine approaches for tendon healing exist. Recently, especially gene therapy gained popularity. However, potential mutagenic and immunologic effects might prevent its translation to clinical research. Chemically modified mRNA (cmRNA) might bypass these limitations of gene therapy. Therefore, the purpose of this study was to evaluate the early healing properties of Achilles tendon defects in rats treated with basic fibroblast growth factor (bFGF) cmRNA. Forty male Lewis rats were used for the study and randomly assigned to two study groups: (1) treatment with cmRNA coding for bFGF and (2) noncoding cmRNA control. Protein expression was measured using in vivo bioluminescence imaging at 24, 48, and 72 h, as well as 14 days. Animals were euthanized 2 weeks following surgery. Biomechanical, histological, and immunohistological analyses were performed with the significance level set at p < 0.05. Protein expression was evident for 3 days. At 14 days, bioluminescence imaging revealed only little protein expression. Biomechanically, tendons treated with bFGF cmRNA showed a construct stiffness closer to the healthy contralateral side when compared with the control group (p = 0.034), without any significant differences in terms of load to failure. Hematoxylin and eosin staining detected no side effects of the treatment, as signs of inflammation, or necrosis. Furthermore, it revealed the shape of the nuclei to be more oval in the bFGF group in the tendon midsubstance (p = 0.043) with a reduced cell count (p = 0.035). Immunohistological staining for type I, II, III, and IV collagen did not differ significantly between the two groups. In conclusion, this pilot study demonstrates the feasibility of a novel messenger RNA (mRNA)-based therapy for Achilles tendon defects using chemically modified mRNA coding for bFGF.
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Affiliation(s)
- Elmar Herbst
- 1 Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany.,2 Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian B Imhoff
- 1 Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Peter Foehr
- 3 Department of Orthopaedics and Sports Orthopaedics, Biomechanical Laboratory, Technical University of Munich, Munich, Germany
| | - Stefan Milz
- 4 Department of Anatomy, Ludwig-Maximilian University (LMU), Munich, Germany
| | | | | | | | | | | | | | - Stephan Vogt
- 6 Department of Orthopaedic Sports Medicine, Hessing Stiftung Augsburg, Augsburg, Germany
| | - Andreas B Imhoff
- 1 Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
| | - Andreas Schmitt
- 1 Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany
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Legrand A, Kaufman Y, Long C, Fox PM. Molecular Biology of Flexor Tendon Healing in Relation to Reduction of Tendon Adhesions. J Hand Surg Am 2017; 42:722-726. [PMID: 28709791 DOI: 10.1016/j.jhsa.2017.06.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 06/12/2017] [Indexed: 02/02/2023]
Abstract
Tendon injuries are encountered after major and minor hand trauma. Despite meticulous repair technique, adhesion formation can occur, limiting recovery. Although a great deal of progress has been made toward understanding the mechanism of tendon healing and adhesions, clinically applicable solutions to prevent adhesions remain elusive. The goal of this paper is to review the most recent literature relating to the tendon healing and adhesion prevention.
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Affiliation(s)
- Anais Legrand
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA; Division of Plastic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Yoav Kaufman
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA; Division of Plastic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Chao Long
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA; Division of Plastic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Paige M Fox
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA; Division of Plastic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
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Hammerman M, Blomgran P, Dansac A, Eliasson P, Aspenberg P. Different gene response to mechanical loading during early and late phases of rat Achilles tendon healing. J Appl Physiol (1985) 2017; 123:800-815. [PMID: 28705996 DOI: 10.1152/japplphysiol.00323.2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 11/22/2022] Open
Abstract
Mechanical loading stimulates tendon healing both when applied in the inflammatory phase and in the early remodeling phase of the process, although not necessarily via the same mechanisms. We investigated the gene response to mechanical loading in these two phases of tendon healing. The right Achilles tendon in rats was transected, and the hindlimbs were unloaded by tail suspension. The rats were exposed to 5 min of treadmill running 3 or 14 days after tendon transection. Thereafter, they were resuspended for 15 min or 3 h until euthanasia. The controls were suspended continuously. Gene analysis was first performed by microarray analysis followed by quantitative RT-PCR on selected genes, focusing on inflammation. Fifteen minutes after loading, the most important genes seemed to be the transcription factors EGR1 and C-FOS, regardless of healing phase. These transcription factors might promote tendon cell proliferation and differentiation, stimulate collagen production, and regulate inflammation. Three hours after loading on day 3, inflammation was strongly affected. Seven inflammation-related genes were upregulated according to PCR: CCL20, CCL7, IL-6, NFIL3, PTX3, SOCS1, and TLR2. These genes can be connected to macrophages, T cells, and recruitment of leukocytes. According to Ingenuity Pathway Analysis, the recruitment of leukocytes was increased by loading on day 3, which also was confirmed by histology. This inflammation-related gene response was not seen on day 14 Our results suggest that the immediate gene response after mechanical loading is similar in the early and late phases of healing but the late gene response is different.NEW & NOTEWORTHY This study investigates the direct effect of mechanical loading on gene expression during different healing phases in tendon healing. One isolated episode of mechanical loading was studied in otherwise unloaded healing tendons. This enabled us to study a time sequence, i.e., which genes were the first ones to be regulated after the loading episode.
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Affiliation(s)
- Malin Hammerman
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Parmis Blomgran
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Arie Dansac
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Pernilla Eliasson
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
| | - Per Aspenberg
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linkoping University, Linköping, Sweden
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Ahmed AS, Li J, Abdul AMD, Ahmed M, Östenson CG, Salo PT, Hewitt C, Hart DA, Ackermann PW. Compromised Neurotrophic and Angiogenic Regenerative Capability during Tendon Healing in a Rat Model of Type-II Diabetes. PLoS One 2017; 12:e0170748. [PMID: 28122008 PMCID: PMC5266316 DOI: 10.1371/journal.pone.0170748] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/10/2017] [Indexed: 12/15/2022] Open
Abstract
Metabolic diseases such as diabetes mellitus type-II (DM-II) may increase the risk of suffering painful connective tissue disorders and tendon ruptures. The pathomechanisms, however, by which diabetes adversely affects connective tissue matrix metabolism and regeneration, still need better definition. Our aim was to study the effect of DM-II on expressional changes of neuro- and angiotrophic mediators and receptors in intact and healing Achilles tendon. The right Achilles tendon was transected in 5 male DM-II Goto-Kakizaki (GK) and 4 age-matched Wistar control rats. The left Achilles tendons were left intact. At week 2 post-injury, NGF, BDNF, TSP, and receptors TrkA, TrkB and Nk1 gene expression was studied by quantitative RT-PCR (qRT-PCR) and their protein distribution by immunohistochemistry in intact and injured tendons. The expression of tendon-related markers, Scleraxis (SCX) and Tenomodulin (TNMD), was evaluated by qRT-PCR in intact and injured tendons. Injured tendons of diabetic GK rats exhibited significantly down-regulated Ngf and Tsp1 mRNA and corresponding protein levels, and down-regulated Trka gene expression compared to injured Wistar controls. Intact tendons of DM-II GK rats displayed reduced mRNA levels for Ngf, Tsp1 and Trkb compared to corresponding intact non-diabetic tendons. Up-regulated Scx and Tnmd gene expression was observed in injured tendons of normal and diabetic GK rats compared to intact Wistar controls. However, these molecules were not up-regulated in injured DM-II GK rats compared to their corresponding controls. Our results suggest that DM-II has detrimental effects on neuro- and angiotrophic pathways, and such effects may reflect the compromised repair seen in diabetic Achilles tendon. Thus, novel approaches for regeneration of injured, including tendinopathic, and surgically repaired diabetic tendons may include therapeutic molecular modulation of neurotrophic pathways such as NGF and its receptors.
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MESH Headings
- Achilles Tendon/injuries
- Achilles Tendon/metabolism
- Achilles Tendon/physiopathology
- Animals
- Brain-Derived Neurotrophic Factor/genetics
- Brain-Derived Neurotrophic Factor/metabolism
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/physiopathology
- Disease Models, Animal
- Gene Expression
- Male
- Neovascularization, Physiologic/physiology
- Nerve Growth Factor/genetics
- Nerve Growth Factor/metabolism
- Rats
- Rats, Wistar
- Receptor, trkA/genetics
- Receptor, trkA/metabolism
- Receptor, trkB/genetics
- Receptor, trkB/metabolism
- Receptors, Neurokinin-1/genetics
- Receptors, Neurokinin-1/metabolism
- Substance P/genetics
- Substance P/metabolism
- Tendon Injuries/metabolism
- Tendon Injuries/physiopathology
- Wound Healing/physiology
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Affiliation(s)
- Aisha S. Ahmed
- Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden
| | - Jian Li
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Alim M. D. Abdul
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Mahmood Ahmed
- Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Center for Family and Community Medicine (CeFAM), Huddinge, Sweden
| | - Claes-Göran Östenson
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Paul T. Salo
- McCaig Institute for Bone & Joint Health, University of Calgary, Calgary, AB, Canada
| | - Carolyn Hewitt
- McCaig Institute for Bone & Joint Health, University of Calgary, Calgary, AB, Canada
| | - David A. Hart
- McCaig Institute for Bone & Joint Health, University of Calgary, Calgary, AB, Canada
| | - Paul W. Ackermann
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Solna, Stockholm, Sweden
- * E-mail:
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12
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Domeij-Arverud E, Ackermann PW. Deep Venous Thrombosis and Tendon Healing. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 920:221-8. [PMID: 27535264 DOI: 10.1007/978-3-319-33943-6_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tendon metabolism after acute Achilles tendon rupture (ATR) is associated with major complications related to immobilization, which results in reduced circulation, high risk of deep venous thrombosis (DVT), impaired healing and functional deficits.DVT has been demonstrated to occur in up to 50 % of the patients with ATR. Suffering from a DVT during tendon healing has been demonstrated as an independent predictive factor for impaired patient outcome at 1 year after ATR, suggesting that specific interventions are warranted to prevent DVT. Since pharmacological DVT prophylaxis has low or no effect during lower leg immobilization it is speculated whether adjuvant treatment with intermittent pneumatic compression (IPC) applied during lower limb immobilization can reduce the incidence of DVT.IPC, which acts through mechanical, chemical and molecular mechanisms, has been demonstrated to enhance neuro-vascular ingrowth in a tendon repair model and stimulate collagen production leading to improved maximum force during healing.Recently, a prospective randomized trial compared adjuvant IPC applied under an orthosis versus plaster cast only in ATR patients. The study found at 2 weeks post-operatively 21 % DVTs in the IPC-group compared to 37 % in the control group. Patients that received no IPC treatment exhibited an almost threefold increased odds for DVT, independently of age. Furthermore, using microdialysis technique, adjuvant IPC treatment was shown to increase the metabolic healing activity at 2 weeks post-ATR.Tendon healing is impaired by reduced circulation and DVT. The demonstration that adjuvant IPC effectively reduced DVT incidence, and also is capable of enhancing the metabolic response suggests that IPC treatment may not only be a viable means of prophylaxis against DVT, but possibly also a method of promoting healing.
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Affiliation(s)
- Erica Domeij-Arverud
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden.
- Department of Orthopedic Surgery, Danderyd Hospital, Stockholm, SE-17176, Sweden.
| | - Paul W Ackermann
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-17176, Stockholm, Sweden
- Department of Orthopedic Surgery, Karolinska University Hospital, SE-17176, Stockholm, Sweden
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13
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Thomopoulos S, Parks WC, Rifkin DB, Derwin KA. Mechanisms of tendon injury and repair. J Orthop Res 2015; 33:832-9. [PMID: 25641114 PMCID: PMC4418182 DOI: 10.1002/jor.22806] [Citation(s) in RCA: 308] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 12/13/2014] [Indexed: 02/04/2023]
Abstract
Tendon disorders are common and lead to significant disability, pain, healthcare cost, and lost productivity. A wide range of injury mechanisms exist leading to tendinopathy or tendon rupture. Tears can occur in healthy tendons that are acutely overloaded (e.g., during a high speed or high impact event) or lacerated (e.g., a knife injury). Tendinitis or tendinosis can occur in tendons exposed to overuse conditions (e.g., an elite swimmer's training regimen) or intrinsic tissue degeneration (e.g., age-related degeneration). The healing potential of a torn or pathologic tendon varies depending on anatomic location (e.g., Achilles vs. rotator cuff) and local environment (e.g., intrasynovial vs. extrasynovial). Although healing occurs to varying degrees, in general healing of repaired tendons follows the typical wound healing course, including an early inflammatory phase, followed by proliferative and remodeling phases. Numerous treatment approaches have been attempted to improve tendon healing, including growth factor- and cell-based therapies and rehabilitation protocols. This review will describe the current state of knowledge of injury and repair of the three most common tendinopathies--flexor tendon lacerations, Achilles tendon rupture, and rotator cuff disorders--with a particular focus on the use of animal models for understanding tendon healing.
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Affiliation(s)
- Stavros Thomopoulos
- Washington University, Department of Orthopedic Surgery, Saint Louis, MO,Corresponding Authors: Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, . Kathleen A. Derwin, Ph.D., Cleveland Clinic Lerner Research Institute, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, Ohio 44195, Phone: 216-445-5982,
| | - William C. Parks
- Cedars Sinai Medical Center, Department of Medicine, Los Angeles, CA
| | | | - Kathleen A. Derwin
- Cleveland Clinic Lerner Research Institute, Cleveland, OH,Corresponding Authors: Stavros Thomopoulos, Ph.D., Washington University, Department of Orthopaedic Surgery, 660 South Euclid, Campus Box 8233, St. Louis, MO 63110, Phone: 314-362-8605, . Kathleen A. Derwin, Ph.D., Cleveland Clinic Lerner Research Institute, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, Ohio 44195, Phone: 216-445-5982,
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14
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Wieser K, Farshad M, Meyer DC, Conze P, von Rechenberg B, Gerber C. Tendon response to pharmaco-mechanical stimulation of the chronically retracted rotator cuff in sheep. Knee Surg Sports Traumatol Arthrosc 2015; 23:577-84. [PMID: 24792077 DOI: 10.1007/s00167-014-3037-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 04/22/2014] [Indexed: 01/18/2023]
Abstract
PURPOSE Chronic tearing of tendons is associated with molecular and structural alterations causing biomechanical changes, which compromise musculotendinous function and become limiting factors for tendon repair. This study investigated the histological response of chronically retracted sheep rotator cuff tendons to mechanical and pharmacological stimulation in view of tendon repair. METHODS Sixteen weeks after experimental release of the infraspinatus tendon in 20 sheep, the retracted musculotendinous unit was subjected to continuous traction either with [anabolic steroids (nandrolone) group/insulin-like growth factor (IGF) group] or without (control group) additional pharmacological treatment during 6 weeks. A new degeneration score for tendinous tissues (DSTT), based on established knowledge on histological changes associated with tendon degeneration, was used for histological analysis at the time of tendon release, at the beginning of continuous re-lengthening and at repair in all animals. RESULTS The DSTT score (inter-observer correlation: r = 0.83), quantifiably representing tendon degeneration, improved from 15.5 (SD 1.3) points before to 9.8 (SD 3.8) points after re-lengthening. It improved in a qualitatively and quantitatively similar fashion if pharmacological stimulation was added. The nandrolone group improved from 13.7 (SD 1.6) to 9.8 (SD 1.9) and the IGF group from 13.3 (SD 3.6) to 8.8 (SD 1.8) points. CONCLUSION Mechanical stimulation significantly reduced tissue degeneration. However, the addition of a pharmacological stimulation with anabolic steroids or IGF had neither a measurable positive nor negative effect on the degenerative process. Therefore, this investigation does neither support the additional pharmacological use of the anabolic steroid nandrolone or of IGF decanoate for restoration of tendon degeneration, nor otherwise provide evidence for additional tendon damage, if those substances are used to alter the muscular metabolism.
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Affiliation(s)
- Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland,
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15
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Thorpe CT, Chaudhry S, Lei II, Varone A, Riley GP, Birch HL, Clegg PD, Screen HRC. Tendon overload results in alterations in cell shape and increased markers of inflammation and matrix degradation. Scand J Med Sci Sports 2014; 25:e381-91. [DOI: 10.1111/sms.12333] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2014] [Indexed: 12/22/2022]
Affiliation(s)
- C. T. Thorpe
- Institute of Bioengineering; School of Engineering and Materials Science; Queen Mary University of London; London UK
| | - S. Chaudhry
- Institute of Bioengineering; School of Engineering and Materials Science; Queen Mary University of London; London UK
| | - I. I. Lei
- Institute of Bioengineering; School of Engineering and Materials Science; Queen Mary University of London; London UK
| | - A. Varone
- Institute of Bioengineering; School of Engineering and Materials Science; Queen Mary University of London; London UK
| | - G. P. Riley
- School of Biological Sciences; University of East Anglia; Norwich UK
| | - H. L. Birch
- Institute of Orthopaedics and Musculoskeletal Science; University College London; Stanmore UK
| | - P. D. Clegg
- Department of Musculoskeletal Biology; Institute of Ageing and Chronic Disease; University of Liverpool; Neston UK
| | - H. R. C. Screen
- Institute of Bioengineering; School of Engineering and Materials Science; Queen Mary University of London; London UK
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16
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Jielile J, Aibai M, Sabirhazi G, Shawutali N, Tangkejie W, Badelhan A, Nuerduola Y, Satewalede T, Buranbai D, Hunapia B, Jialihasi A, Bai J, Kizaibek M. Active Achilles tendon kinesitherapy accelerates Achilles tendon repair by promoting neurite regeneration. Neural Regen Res 2014; 7:2801-10. [PMID: 25317130 PMCID: PMC4190862 DOI: 10.3969/j.issn.1673-5374.2012.35.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 11/04/2012] [Indexed: 01/09/2023] Open
Abstract
Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7–21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy.
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Affiliation(s)
- Jiasharete Jielile
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Minawa Aibai
- Urumqi Center for Disease Control and Prevention, Urumqi 830026, Xinjiang Uyghur Autonomous Region, China
| | - Gulnur Sabirhazi
- Xinjiang Institute of Ecology and Geography, Chinese Academy of Sciences, Urumqi 830011, Xinjiang Uyghur Autonomous Region, China
| | - Nuerai Shawutali
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Wulanbai Tangkejie
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Aynaz Badelhan
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Yeermike Nuerduola
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Turde Satewalede
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Darehan Buranbai
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Beicen Hunapia
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Ayidaer Jialihasi
- Department of Microsurgical Repair and Reconstruction, First Teaching Hospital of Xinjiang Medical University & Sports Medicine Research Center, Research Institute of Orthopedics of Xinjiang Uyghur Autonomous Region, Urumqi 830054, Xinjiang Uyghur Autonomous Region, China
| | - Jingping Bai
- Department of Orthopedics, Third Teaching Hospital of Xinjiang Medical University, Urumqi 830011, Xinjiang Uyghur Autonomous Region, China
| | - Murat Kizaibek
- The Research Institute of Kazakh Traditional Medicine of Ili Kazakh Autonomous Prefecture of Xinjiang, Yining 835000, Ili Kazakh Autonomous Prefecture of Xinjiang, China
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Franklin SL, Dean BJF, Wheway K, Watkins B, Javaid MK, Carr AJ. Up-regulation of Glutamate in Painful Human Supraspinatus Tendon Tears. Am J Sports Med 2014; 42:1955-62. [PMID: 24872365 DOI: 10.1177/0363546514532754] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pain related to rotator cuff tendinopathy is a common problem, but little is known regarding the origin and cause of pain from the tendon substance. No study to date has looked at the association between tissue changes and patient outcomes. PURPOSE To describe the peripheral neuronal phenotype in painful rotator cuff tears and to determine correlations between tissue changes and clinical outcome measures. STUDY DESIGN Controlled laboratory study. METHODS Tissue samples of the supraspinatus were taken from patients undergoing surgery to repair a rotator cuff tendon tear. Patients were classified as having small/medium or large/massive tears. Control tissue was obtained from patients undergoing surgery for posttraumatic shoulder instability. Immunohistochemical techniques were performed using antibodies to known nociceptive and neuronal markers as well as general tissue structural markers. RESULTS There was no correlation between tissue changes and patient-reported outcomes. A significant increase in the expression of glutamate was seen in tendon tears. There were differences in the expression of metabotropic and ionotropic glutamate receptors. Expression changes were also observed for markers of the sensory and autonomic systems; however, no differences were found in neurotrophins. CONCLUSION Glutamate and the glutaminergic system play a key role in painful human tendon tears; however, the exact role is still uncertain, as glutamate is highly involved in both pain and metabolic pathways. CLINICAL RELEVANCE This study has identified a number of markers that could be potential therapeutic targets.
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Affiliation(s)
- Sarah L Franklin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Benjamin J F Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Kim Wheway
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Bridget Watkins
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Hara Y, Ikoma K, Kido M, Sukenari T, Arai Y, Fujiwara H, Kawata M, Kubo T. Diffusion tensor imaging assesses triceps surae dysfunction after achilles tenotomy in rats. J Magn Reson Imaging 2014; 41:1541-8. [DOI: 10.1002/jmri.24707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 06/30/2014] [Accepted: 06/30/2014] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yusuke Hara
- Department of Orthopaedics; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Kazuya Ikoma
- Department of Orthopaedics; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Masamitsu Kido
- Department of Orthopaedics; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Tsuyoshi Sukenari
- Department of Orthopaedics; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Yuji Arai
- Department of Orthopaedics; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Hiroyoshi Fujiwara
- Department of Orthopaedics; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Mitsuhiro Kawata
- Department of Anatomy and Neurobiology; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Toshikazu Kubo
- Department of Orthopaedics; Graduate School of Medical Science, Kyoto Prefectural University of Medicine; Kyoto Japan
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Ahmed AS, Li J, Schizas N, Ahmed M, Ostenson CG, Salo P, Hewitt C, Hart DA, Ackermann PW. Expressional changes in growth and inflammatory mediators during Achilles tendon repair in diabetic rats: new insights into a possible basis for compromised healing. Cell Tissue Res 2014; 357:109-17. [PMID: 24797839 DOI: 10.1007/s00441-014-1871-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 03/13/2014] [Indexed: 01/21/2023]
Abstract
Dysregulation of growth and inflammatory mediators might contribute to defective tissue homeostasis and healing, as commonly observed in sedentary lifestyles and in conditions such as diabetes mellitus type-2. The present study aims to assess expression changes in growth and inflammatory mediators in the intact and healing Achilles tendon of type-2 diabetic rats. The study utilized 11 male diabetic Goto-Kakizaki (GK) and 10 age- and sex-matched Wistar control rats. The right Achilles tendon was transected in all animals, whereas the left Achilles tendon remained intact. At 2 weeks post-injury, intact and injured tendons were assessed for gene expression for VEGF, Tβ-4, TGF-β1, IGF-1, COX-2, iNOS, HIF-1α, and IL-1β by quantitative reverse transcription plus the polymerase chain reaction, and their protein distribution was studied by immunolocalization. In injured tendons of diabetic GK rats, VEGF and Tβ-4 mRNA and corresponding protein levels were significantly down-regulated compared with those of injured Wistar controls. Compared with intact tendons of diabetic GK rats, TGF-β1, IGF-1, and COX-2 RNA levels were higher, whereas iNOS mRNA levels were lower in injured tendons of diabetic GK rats. Within Wistar controls, healing at 2 weeks post-injury led to significantly down-regulated VEGF and iNOS mRNA levels in injured tendons, whereas TGF-β1 and HIF-1α mRNA levels increased compared with intact tendons. Thus, dysregulation of inflammatory and growth mediators occurs in type-2 diabetes injured tendons. Our data suggest that therapeutic modulation of Tβ-4 and VEGF represent a new regenerative approach in operated, injured, or degenerative tendon diseases in diabetes.
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Affiliation(s)
- Aisha S Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, 17177, Stockholm, Sweden,
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20
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Holm C, Kjaer M, Eliasson P. Achilles tendon rupture - treatment and complications: A systematic review. Scand J Med Sci Sports 2014; 25:e1-10. [DOI: 10.1111/sms.12209] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2014] [Indexed: 12/26/2022]
Affiliation(s)
- C. Holm
- Institute of Sports Medicine Copenhagen; Bispebjerg Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - M. Kjaer
- Institute of Sports Medicine Copenhagen; Bispebjerg Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
| | - P. Eliasson
- Institute of Sports Medicine Copenhagen; Bispebjerg Hospital; Faculty of Health Sciences; University of Copenhagen; Copenhagen Denmark
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21
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Anti-inflammatory cytokine profile in early human tendon repair. Knee Surg Sports Traumatol Arthrosc 2013; 21:1801-6. [PMID: 22983752 DOI: 10.1007/s00167-012-2197-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 08/27/2012] [Indexed: 12/22/2022]
Abstract
PURPOSE The aim of this study was to assess inflammation and the presence and relative levels of cytokines, which may be involved in regulating early human Achilles tendon healing. METHODS Nine patients with acute Achilles tendon rupture were included, operated on and post-operatively immobilized. Two weeks post-operatively, microdialysis of the peritendinous interstitial compartment was performed in the healing and intact contralateral Achilles tendons. Quantification of tumour necrosis factor (TNF)-α, interferon (IFN)-γ, interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12p70 and IL-17A was accomplished using a cytometric bead array. Prostaglandin (PG) E2 levels were measured by enzyme immunoassay. RESULTS None of the patients displayed detectable PGE2 levels. Pro-inflammatory cytokines were below detection levels (IFNγ, IL-12, and IL-17) or did not differ between injured and control tendons (IL-1β and TNF). Notably, IL-6, IL-8 and IL-10 concentrations in the healing Achilles tendon were significantly elevated: 13-fold (p = 0.009), 28-fold (p = 0.02), and 3.7-fold (p = 0.03), respectively. CONCLUSION At 2 weeks post-human Achilles tendon rupture, healing is characterized by a resolving inflammatory phase and up-regulation of IL-6, IL-8 and IL-10. The absence of inflammation suggests that at this time point, these cytokines may be associated with anti-inflammatory and regenerative effects on the tendon healing process.
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22
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Ackermann PW. Neuronal regulation of tendon homoeostasis. Int J Exp Pathol 2013; 94:271-86. [PMID: 23718724 PMCID: PMC3721458 DOI: 10.1111/iep.12028] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 04/16/2013] [Indexed: 12/25/2022] Open
Abstract
The regulation of tendon homoeostasis, including adaptation to loading, is still not fully understood. Accumulating data, however, demonstrates that in addition to afferent (sensory) functions, the nervous system, via efferent pathways which are associated with through specific neuronal mediators plays an active role in regulating pain, inflammation and tendon homeostasis. This neuronal regulation of intact-, healing- and tendinopathic tendons has been shown to be mediated by three major groups of molecules including opioid, autonomic and excitatory glutamatergic neuroregulators. In intact healthy tendons the neuromediators are found in the surrounding structures: paratenon, endotenon and epitenon, whereas the proper tendon itself is practically devoid of neurovascular supply. This neuroanatomy reflects that normal tendon homoeostasis is regulated from the tendon surroundings. After injury and during tendon repair, however, there is extensive nerve ingrowth into the tendon proper, followed by a time-dependent emergence of sensory, autonomic and glutamatergic mediators, which amplify and fine-tune inflammation and regulate tendon regeneration. In tendinopathic condition, excessive and protracted presence of sensory and glutamatergic neuromediators has been identified, suggesting involvement in inflammatory, nociceptive and hypertrophic (degenerative) tissue responses. Under experimental and clinical conditions of impaired (e.g. diabetes) as well as excessive (e.g. tendinopathy) neuromediator release, dysfunctional tendon homoeostasis develops resulting in chronic pain and gradual degeneration. Thus there is a prospect that in the future pharmacotherapy and tissue engineering approaches targeting neuronal mediators and their receptors may prove to be effective therapies for painful, degenerative and traumatic tendon disorders.
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Affiliation(s)
- Paul W Ackermann
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden.
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Greve K, Domeij-Arverud E, Labruto F, Edman G, Bring D, Nilsson G, Ackermann PW. Metabolic activity in early tendon repair can be enhanced by intermittent pneumatic compression. Scand J Med Sci Sports 2012; 22:e55-63. [DOI: 10.1111/j.1600-0838.2012.01475.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2012] [Indexed: 12/22/2022]
Affiliation(s)
- K. Greve
- Integrative Orthopedic Laboratory; Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
| | - E. Domeij-Arverud
- Integrative Orthopedic Laboratory; Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
| | - F. Labruto
- Section of Diagnostic Imaging; Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
| | - G. Edman
- Center of Molecular Medicine (CMM); Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
| | - D. Bring
- Integrative Orthopedic Laboratory; Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
| | - G. Nilsson
- Integrative Orthopedic Laboratory; Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
| | - P. W. Ackermann
- Integrative Orthopedic Laboratory; Department of Molecular Medicine and Surgery; Karolinska Institutet; Stockholm; Sweden
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Legerlotz K, Jones ER, Screen HRC, Riley GP. Increased expression of IL-6 family members in tendon pathology. Rheumatology (Oxford) 2012; 51:1161-5. [PMID: 22337942 PMCID: PMC3380247 DOI: 10.1093/rheumatology/kes002] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Histological examination of pathological tendon generally does not reveal signs of inflammation. However, the inflammatory cytokine IL-6 has been shown to be expressed in ruptured rotator cuff tendon. The aim of this study was to investigate the expression of IL-6 family members in painful posterior tibialis tendon (PTT) and in painful and ruptured Achilles tendon (AT) compared with normal tendon. METHODS AT samples were obtained from cadavers (normal) or from patients undergoing surgical procedures to treat chronic painful tendinopathy or ruptured tendon. PTT samples were obtained from patients undergoing surgery for other reasons (normal) and from patients with PTT dysfunction (painful). Total RNA was extracted and mRNA expression was analysed by quantitative real-time PCR. RESULTS Collagen type I α-chain I (COL1A1) expression was increased in both painful PTT and AT compared with normal. Ciliary neurotrophic factor levels were increased in painful PTT only. In the painful AT, cyclooxygenase-2 (COX2) and IL-6 expression increased compared with normal. In the ruptured AT, levels of VEGF A, COX2, oncostatin-M, leukaemia inhibitory factor and IL-6 expression were higher compared with both normal and painful AT. IL-6R expression decreased in both painful and ruptured AT compared with normal. CONCLUSION Painful AT and PTT show different expression patterns, indicating a substantial difference between those two tendinopathies. Inflammatory markers are up-regulated in painful and particularly in ruptured AT, pointing towards a role of inflammation not only in rupture healing, but also in Achilles tendinopathy.
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Affiliation(s)
- Kirsten Legerlotz
- School of Biological Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK.
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Eliasson P, Andersson T, Aspenberg P. Influence of a single loading episode on gene expression in healing rat Achilles tendons. J Appl Physiol (1985) 2011; 112:279-88. [PMID: 21998267 DOI: 10.1152/japplphysiol.00858.2011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Pernilla Eliasson
- Orthopaedics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden.
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Liu B, Luo C, Ouyang L, Mu S, Zhu Y, Li K, Zhan M, Liu Z, Jia Y, Lei W. An Experimental Study on the Effect of Safflower Yellow on Tendon Injury-Repair in Chickens. J Surg Res 2011; 169:e175-84. [DOI: 10.1016/j.jss.2011.03.079] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Revised: 03/28/2011] [Accepted: 03/31/2011] [Indexed: 11/28/2022]
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Berglund ME, Hart DA, Reno C, Wiig M. Growth factor and protease expression during different phases of healing after rabbit deep flexor tendon repair. J Orthop Res 2011; 29:886-92. [PMID: 21246620 DOI: 10.1002/jor.21330] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 11/11/2010] [Indexed: 02/04/2023]
Abstract
The purpose of the study was to contribute to the mapping of molecular events during flexor tendon healing, in particular the growth factors insulin-like growth factor-1 (IGF-1), vascular endothelial growth factor (VEGF) and nerve growth factor (NGF), matrix metalloproteinases (MMP-3 and MMP-13) and their inhibitors (tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-3, and the protease cathepsin K. In a rabbit model of flexor tendon injury, the mRNA expression for the growth factors, MMPs and TIMPs were measured in tendon and tendon sheath tissue at several time points (3, 6, 21, and 42 days) representing different phases of the healing process. We found that MMP-13 remained increased during the study period, whereas MMP-3 returned to normal levels within the first week after injury. TIMP-3 was down-regulated in the tendon sheaths. Cathepsin K was up-regulated in tendons and sheaths after injury. NGF was present in both tendons and sheaths, but unaltered. IGF-1 exhibited a late increase in the tendons, while VEGF was down-regulated at the later time points. In conclusion, we have demonstrated the presence of NGF in flexor tendons. MMP-13 expression appears to play a more protracted role in flexor tendon healing than MMP-3. The relatively low levels of endogenous IGF-1 and VEGF mRNA following injury support their potential beneficial role as exogenous modulators to optimize tendon healing and strength without increasing adhesion formation.
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Affiliation(s)
- M E Berglund
- Department of Hand Surgery, Uppsala University, Uppsala, Sweden.
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Andia I, Sanchez M, Maffulli N. Tendon healing and platelet-rich plasma therapies. Expert Opin Biol Ther 2010; 10:1415-26. [DOI: 10.1517/14712598.2010.514603] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Carlsson O, Schizas N, Li J, Ackermann PW. Substance P injections enhance tissue proliferation and regulate sensory nerve ingrowth in rat tendon repair. Scand J Med Sci Sports 2010; 21:562-9. [PMID: 20459473 DOI: 10.1111/j.1600-0838.2009.01080.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Tendon healing is characterized mostly by slow rehabilitation and, as in tendinopathy, aberrant, protracted sensory nerve ingrowth. This study investigated whether administration of the sensory neuropeptide substance P (SP) could enhance healing and modulate sensory nerve plasticity after Achilles tendon rupture. Fifty-four male Sprague-Dawley rats were allocated to three groups, all receiving six daily injections post-rupture of; (1) SP (10(-6) mol/kg body weight)+endopeptidase inhibitors captopril and thiorphan, (2) captopril/thiorphan only and (3) saline control. At 1, 3 and 6 weeks post-rupture tendon healing was evaluated by assessments of fibroblast proliferation, collagen III-LI (like) occurrence, diameter of newly organized collagen and sensory nerve fiber ingrowth. At 1 week, the SP-treated group exhibited increased occurrence of collagen III-LI (P=0.03) and of organized collagen (P=0.04) compared with control. At 3 weeks, the SP group notably displayed reduced SP-nerve fiber ingrowth (P=0.02), and higher fibroblast density (P=0.004). Both the SP and captopril/thiorphan groups demonstrated increase in collagen fiber organization compared with control (P=0.02 and 0.004, respectively). At 6 weeks, no significant differences were observed between the groups. SP supply in tendon repair promotes early tissue proliferation and regulation of endogenous sensory nerve ingrowth, suggesting implications for novel treatment in tendinopathy.
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Affiliation(s)
- O Carlsson
- Orthopedic Laboratory, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska Institutet, Stockholm, Sweden
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