The extracellular matrix (ECM) is the primary biomechanical environment that interacts with tendon cells (tenocytes). Stresses applied via muscle contraction during skeletal movement transfer across structural hierarchies to the tenocyte nucleus in native uninjured tendons. Alterations to ECM structural and mechanical properties due to mechanical loading and tissue healing may affect this multiscale strain transfer and stress transmission through the ECM. This study explores the interface between dynamic loading and tendon healing across multiple length scales using living tendon explants. Results show that macroscale mechanical and structural properties are inferior following high magnitude dynamic loading (fatigue) in uninjured living tendon and that these effects propagate to the microscale. Although similar macroscale mechanical effects of dynamic loading are present in healing tendon compared to uninjured tendon, the microscale properties differed greatly during early healing. Regression analysis identified several variables (collagen and nuclear disorganization, cellularity, and F-actin) that directly predict nuclear deformation under loading. Finite element modeling predicted deficits in ECM stress transmission following fatigue loading and during healing. Together, this work identifies the multiscale response of tendon to dynamic loading and healing, and provides new insight into microenvironmental features that tenocytes may experience following injury and after cell delivery therapies.
In tendon, type‐I collagen assembles together into fibrils, fibers, and fascicles that exhibit a wavy or crimped pattern that uncrimps with applied tensile loading. This structural property has been observed across multiple tendons throughout aging and may play an important role in tendon viscoelasticity, response to fatigue loading, healing, and development. Previous work has shown that crimp is permanently altered with the application of fatigue loading. This opens the possibility of evaluating tendon crimp as a clinical surrogate of tissue damage. The purpose of this study was to determine how fatigue loading in tendon affects crimp and mechanical properties throughout aging and between tendon types. Mouse patellar tendons (PT) and flexor digitorum longus (FDL) tendons were fatigue loaded while an integrated plane polariscope simultaneously assessed crimp properties at P150 and P570 days of age to model mature and aged tendon phenotypes (
- NSF-PAR ID:
- 10116998
- Publisher / Repository:
- Wiley Blackwell (John Wiley & Sons)
- Date Published:
- Journal Name:
- Journal of Orthopaedic Research
- Volume:
- 38
- Issue:
- 1
- ISSN:
- 0736-0266
- Page Range / eLocation ID:
- p. 36-42
- Format(s):
- Medium: X
- Sponsoring Org:
- National Science Foundation
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INTRODUCTION: Quadriceps tendon autografts have experienced a rapid rise in popularity for anterior cruciate ligament (ACL) reconstruction due to advantages in graft sizing and potential improvement in biomechanics. While there is a growing body of literature on use of quadriceps tendon grafts, deeper investigation into the biomechanical properties of stitch techniques in this construct has been limited. The purpose of this study was to evaluate the performance of a novel suture needle against different conventional suture needles by comparing the biomechanical properties of two commonly used stitch methods, a whip stitch, and a locking stitch in quadriceps tendon. It was hypothesized that the new device would be capable of creating both whip stitches and locking stitches that are biomechanically equivalent to similar stitch techniques performed with conventional needle products. METHODS: This was a controlled biomechanical study. A total of 24 matched pair cadaveric knees were dissected and a total of 48 quadriceps tendons were harvested and tested. All tendon grafts were standardized to the same size. Samples were then randomized into the following groups, keeping the matched pairs together: (Group 1, n=16) consisted of Company W’s novel two-part suture needle design, (Group 2, n=16) consisted of Company A suture, and (Group 3, n=16) consisted of Company B suture. For each group, the matched pairs were categorized into subgroups to be instrumented with either a whip stitch or a locking stitch. Two fellowship-trained surgeons performed all stitching, where they each instrumented 8 tendon grafts per group. For instrumentation, the grafts were clamped to a preparation stand in accordance with the manufacturer’s recommendations for passing each suture needle. A skin marker was used to identify and mark five evenly spaced points, 0.5 cm apart, as a guide to create a 5-stitch series. For Group 1, the whip stitch as well as the locking whip stitch were performed with a novel 2-part needle. For Group 2, the whip stitch was performed with loop suture needle and the locking stitch was krackow with a curved needle. Similarly, for Group 3, the whip stitch was performed with loop suture needle and the locking stitch was krackow with a curved needle (Figure 1). Cyclical testing was performed using a servohydraulic testing machine (MTS Bionix) equipped with a 5kN load cell. A standardized length of tendon, 7 cm, was coupled to the MTS actuator by passing it through a cryoclamp cooled by dry ice to a temperature of -5°C (Figure 2). All testing samples were then pre-conditioned to normalize viscoelastic effects and testing variability through application of cyclical loading to 25-100 N for three cycles. The samples were then held at 89 N for 15 minutes. Thereafter, the samples were loaded to 50-200 N for 500 cycles at 1 Hz. If samples survived, they were ramped to failure at 20 mm/min. Displacement and force data was collected throughout testing. Metrics of interest were total elongation (mm), stiffness (N/mm), ultimate failure load (N) and failure mode. Data are presented as averages plus/minus standard deviation. A one-way analysis of variance (ANOVA) with a Tukey pairwise comparison post hoc analysis was used to evaluate differences between the various stitching methods. Statistical significance was set at P = .05. RESULTS SECTION: For the whip stitch methods, the total elongation was found to be equivalent across all methods (W: 36 ± 10 mm; A: 32 ± 18 mm; B: 33 ± 8 mm). The stiffness of Company A (103 ± 11 N/mm) method was significantly larger than Company W (64 ± 8 N/mm; p=.001), whereas stiffness of whip stitch by Company W was equivalent to Company B (80 ± 32 N/mm). The ultimate failure load was equivalent across all whip stitch methods (W: 379 ± 31 mm; A: 412 ± 103 mm; B: 438 ± 63 mm). For the locking stitch method, the total elongation (W: 26 ± 10 mm; A: 14 ± 2 mm; B: 29 ± 5 mm), stiffness (W: 75 ± 11 N/mm; A: 104 ± 23 N/mm; B: 79 ± 10 N/mm) and ultimate load (W: 343 ± 22 N; A: 369 ± 30 N; B: 438 ± 63 N) were found to be equivalent across all methods. The failure mode for all groups is in Table 1. The common mode of failure across study groups and stitch configuration was suture breakage. However, the whip stitch from Company A and Company B had varied failure modes. DISCUSSION: Products from the three manufacturers were found to produce biomechanically equivalent whip stitches and locking stitches with respect to elongation and ultimate failure load. The only significant difference observed was that the whip stitch created with Company A’s product had a higher stiffness than Company W’s product, which could have been due to differences in the suture material. In this cadaveric quadriceps tendon model, it was shown that when using Company W’s novel two-part suture needle, users were capable of creating whip stitches and locking stitches that achieved equivalent biomechanical performance compared to similar stitch techniques performed with conventional needle products. A failure mode limited solely to suture breakage for methods completed with Company W’s needle product suggest a reliable suture construct with limited tissue damage. SIGNIFICANCE/CLINICAL RELEVANCE: Having a suture needle device with the versatility to easily perform different stitching constructs may provide surgeons an advantage needed to improve clinical outcomes. The data presented illustrates a strong new suture technique that has equivalent performance when compared to conventional needle devices and has promising applications in graft preparation for ligament and tendon reconstruction.more » « less
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ABSTRACT Overuse‐induced tendinopathy is highly prevalent in the general population. Percutaneous fenestration, or dry needling, techniques have been increasing in popularity, but despite their current use, there are no controlled laboratory studies to provide fundamental support for this practice. The objective of this study was to establish a model for percutaneous needling of the rat supraspinatus tendon using ultrasound guidance and to evaluate the biological response of needling healthy tendon. A total of 44 male Sprague–Dawley rats (477 ± 39 g) were used to evaluate the effect of dry needling on healthy supraspinatus tendon properties. Ten rats were reserved as un‐needled control animals, and the remaining animals underwent either mild or moderate bilateral needling protocols and were sacrificed at 1 or 6 weeks post‐needling (
n = 8–10/group). Color Doppler ultrasound imaging was performed to analyze blood flow within the tendon. Histological and immunohistochemical analyses were used to determine cellular, inflammatory, and extracellular matrix properties of the tissue. Finally, quasi‐static tensile mechanical analysis was performed to obtain viscoelastic, structural, and material properties to evaluate the tendon healing outcome. Data were tested for normality, and then two‐way analysis of variance tests were performed followed by post hoc tests for multiple comparisons. Both the mild and moderate needling groups caused a transient healing response at early time points as shown by a statistically significant (p < 0.05) reduction in mechanical properties, and increase in blood flow, inflammation, and production of collagen III and glycosaminoglycans as compared to the control. Furthermore, mild needling properties returned to or exceeded pre‐needling values at the 6‐week time point. Clinical significance: Needling the rat supraspinatus tendon is a feasible technique that causes a transient healing response followed by a return to, or improvement of, normal tendon properties, indicating potential applicability in understanding the effects of current practices utilizing dry needling of tendons in humans. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2035–2042, 2019 -
INTRODUCTION: In practice, the use of a whip stitch versus a locking stitch in anterior cruciate ligament (ACL) graft preparation is based on surgeon preference. Those who prefer efficiency and shorter stitch time typically choose a whip stitch, while those who require improved biomechanical properties select a locking stitch, the gold standard of which is the Krackow method. The purpose of this study was to evaluate a novel suture needle design that can be used to perform two commonly used stitch methods, a whip stitch, and a locking stitch, by comparing the speed of graft preparation and biomechanical properties. It was hypothesized that adding a locking mechanism to the whip stitch would improve biomechanical performance but would also require more time to complete due to additional steps required for the locking technique. METHODS: Graft preparation was performed by four orthopaedic surgeons of different training levels where User 1 and User 2 were both attendings and User’s 3 and 4 were both fellows. A total of 24 matched pair cadaveric knees were dissected and a total of 48 semitendinosus tendons were harvested. All grafts were standardized to the same size. Tendons were randomly divided into 4 groups (12 tendons per group) such that each User performed analogous stitch on matched pair: Group 1, User 1 and User 3 performed whip stitches; Group 2, User 1 and User 3 performed locking stitches; Group 3, User 2 and User 4 performed whip stitches; Group 4, User 2 and User 4 performed locking stitches. For instrumentation, the two ends of tendon grafts were clamped to a preparation stand. A skin marker was used to mark five evenly spaced points, 0.5 cm apart, as a guide to create a 5-stitch series. The stitches were performed with EasyWhip, a novel two-part suture needle which allows one to do both a traditional whip stitch and a locking whip stitch, referred to as WhipLock (Figure 1). The speed for graft preparation was timed for each User. Biomechanical testing was performed using a servohydraulic testing machine (MTS Bionix) equipped with a 5kN load cell (Figure 2). A standardized length of tendon, 10 cm, was coupled to the MTS actuator by passing it through a cryoclamp cooled by dry ice to a temperature of -5°C. All testing samples were pre-conditioned to normalize viscoelastic effects and testing variability through application of cyclical loading to 25-100 N for three cycles. The samples were then held at 89 N for 15 minutes. Thereafter, the samples were loaded to 50-200 N for 500 cycles at 1 Hz. If samples survived, they were ramped to failure at 20 mm/min. Displacement and force data was collected throughout testing. Metrics of interest were peak-to-peak displacement (mm), stiffness (N/mm), ultimate failure load (N) and failure mode. Data are presented as averages and standard deviations. A Wilcoxon signed-rank test was used to evaluate the groups for time to complete stitch and biomechanical performance. Statistical significance was set at P = .05. RESULTS SECTION: In Group 1, the time to complete the whip stitch was not significantly different between User 1 and User 3, where the average completion time was 1 min 13 sec. Similarly, there were no differences between Users when performing the WhipLock (Group 2) with an average time of 1 min 49 sec. In Group 3 (whip stitch), User 2 took 1 min 48 sec to complete the whip stitch, whereas User 4 took 1 min 25 sec (p=.033). The time to complete the WhipLock stitch (Group 4) was significantly different, where User 2 took 3 min and 44 sec, while User 4 only took 2 min 3 sec (p=.002). Overall, the whip stitch took on average 1 min 25 sec whereas the WhipLock took 2 min 20 sec (p=.001). For whip stitch constructs, no differences were found between Users and all stitches were biomechanically equivalent. Correspondingly, for WhipLock stitches, no differences were found between Users and all suture constructs were likewise biomechanically equivalent. Averages for peak-to-peak displacement (mm), stiffness (N/mm), and ultimate failure load (N) are presented in Table 1. Moreover, when the two stitch methods were compared, the WhipLock constructs significantly increased stiffness by 25% (p <.001), increased ultimate failure load by 35% (p<.001) and reduced peak-to-peak displacement by 55% (p=.001). The common mode of failure for grafts with whip stitch failed by suture pullout from tendon (18/24), where a few instances occurred by suture breakage (6/24). Tendon grafts with WhipLock stitch commonly failed by suture breakage (22/24), where two instances of combined tendon tear and suture breakage were noted. DISCUSSION: The WhipLock stitch significantly increased average construct stiffness and ultimate failure load, while significantly reducing the peak-to- peak displacement compared to the whip stitch. These added strength benefits of the WhipLock stitch took 55 seconds more to complete than the whip stitch. No statistically significant difference in biomechanical performance was found between the Users. Data suggests equivalent stitch performance regardless of the time to complete stitch and surgeon training level. SIGNIFICANCE/CLINICAL RELEVANCE: Clinically, having a suture needle device available which can be used to easily perform different constructs including one with significant strength advantages regardless of level of experience is of benefit.more » « less
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Abstract Tendons are unique dense connective tissues with discrete zones having specific structure and function. They are juxtaposed with other tissues (e.g., bone, muscle, and fat) with different compositional, structural, and mechanical properties. Additionally, tendon properties change drastically with growth and development, disease, aging, and injury. Consequently, there are unique challenges to performing high quality histological assessment of this tissue. To address this need, histological assessment was one of the breakout session topics at the 2022 Orthopaedic Research Society (ORS) Tendon Conference hosted at the University of Pennsylvania. The purpose of the breakout session was to discuss needs from members of the ORS Tendon Section related to histological procedures, data presentation, knowledge dissemination, and guidelines for future work. Therefore, this review provides a brief overview of the outcomes of this discussion and provides a set of guidelines, based on the perspectives from our laboratories, for histological assessment to assist researchers in their quest to utilize these techniques to enhance the outcomes and interpretations of their studies.
