Evaluation of an Autologous Tendon Graft Repair Method for Gap Healing of the Deep Digital Flexor Tendon in Horses

A sutured tenorrhaphy technique that incorporated an autologous tendon graft was compared mechanically and histologically with a sutured tenorrhaphy at 6, 12, and 24 weeks after repair. Tenorrhaphy was performed in the forelimb tendon of the deep digital flexor muscle and the graft was taken from the hindlimb tendon of the lateral digital extensor muscle; one forelimb site included the graft, whereas the other forelimb site was not grafted. Tenotomies were made immediately proximal to the insertion of the accessory ligament into the tendon of the deep digital flexor muscle. Grafted and nongrafted tenorrhaphies were sutured with 2 polydioxanone in a modified double locking-loop pattern. Limbs were supported with a bandage and an extended elevated heel shoe that maintained the dorsal hoof wall angle at 70° to 75°; this support was removed at 12 weeks and dorsal hoof wall angle was maintained at 40° to 45° for the remainder of the study. Gap formation (2.5 ±.3 cm) was evident at all tenorrhaphy sites at 3 days on ultrasound examination. In grafted repairs, the breaking stress was increased ( P <.001) between 6 weeks (2.56 ±.44 MPa) and 12 weeks (17.69 ± 7.68 MPa), with grafted tendon having a greater breaking stress than nongrafted tendon (8.77 ± 2.5 MPa; P <.05). No differences in breaking stress were evident at 24 weeks. At 12 weeks, repair tissue in grafted tendon was histologically more mature, had less cellularity, better fibroblast orientation and more homogeneous collagen matrix than nongrafted tendon. Polydioxanone suture was still evident histologically at 24 weeks and was associated with minimal cellular reaction. Incorporation of an autologous tendon graft improved the mechanical properties and histological quality of the repair tissue in equine flexor tenorrhaphies at 12 weeks but not at 24 weeks after repair.     

Healing characteristics of deep digital flexor tenorrhaphy within the digital sheath of horses

OBJECTIVE: To describe the healing characteristics of deep digital flexor tenorrhaphy within the digital sheath. STUDY DESIGN: Experimental study. ANIMALS: Five mature horses. METHODS: Right thoracic limb, deep digital flexor tenorrhaphy was performed within the digital sheath. Limbs were cast in partial flexion using a short limb cast for 6 weeks. Next, extended heel shoes were used for limb support for 14 weeks. Healing was evaluated by sequential ultrasonographic examinations, and limb use was evaluated by force plate analysis. At 26 weeks, mechanical strength and morphologic characteristics of the repair site were evaluated. RESULTS: Gap (mean, 0.93 cm.) formation was evident in unloaded limbs at 3 weeks. This increased markedly by 6 weeks and was 5 cm at 26 weeks. Demarcation between the deep and superficial flexor tendons decreased as the transected ends adhered to the dorsal surface of the superficial flexor tendon. The intrathecal space was reduced by fibrous tissue. Mean maximum load to failure of the repair tissue was 4,616 +/- 3,556 N, with a mean stress of 12.99 +/- 2.78 MPa. The repair consistently failed at the adhesion between the transected tendon and the superficial flexor tendon. CONCLUSIONS: Intrathecal tenorrhaphy with external coaptation (in partial limb flexion) for 6 weeks resulted in gap healing, fibrous adhesion between the deep and superficial flexor tendons, fibrous tissue reduction of the intrathecal space, and a pasture-sound horse at 26 weeks. CLINICAL RELEVANCE: Without improved methods for immobilizing the deep digital flexor tendon, intrathecal tenorrhaphy is unlikely to result in first intention tendon healing.     

Healing of Transected Equine Superficial Digital Flexor Tendons With and Without Tenorrhaphy

Healing of transected superficial digital flexor tendons was evaluated mechanically and histologically in eight horses. Tendons sutured with polyglyconate had higher loads at failure than nonsutured tendons at weeks 5 and 9. The tendon stress at failure (force per unit area) was higher in the sutured tendons at week 5 but not at week 9, reflecting the increased size of the scar at week 9. Histologically, scars after tenorrhaphy were consistently more mature than nonsutured tenotomy scars. The mean maturity score for sutured tendons was higher than for nonsutured tendons at weeks 5 and 9. Overall, these data support tenorrhaphy with absorbable suture.     

An Ex Vivo Biomechanical Study Comparing Strength Characteristics of a New Technique with the Three‐Loop Pulley for Equine Tenorrhaphy

Objective: To test single cycle to failure tensile strength characteristics of 6 suture material–pattern combinations in equine superficial digital flexor (SDF) tenorrhaphy, specifically to compare a 10‐strand modification of the Savage core suture technique with the 3‐loop pulley technique. Study Design: Ex vivo mechanical experiment comparing 3 different suture patterns with 2 different materials. Sample Population: Forelimb and hindlimb SDF tendons (n=48) harvested from adult Thoroughbred and Standardbred horses of mixed age and gender. Methods: Six suture material–pattern combinations were evaluated: (1) 10‐strand Savage, size 2 polydioxanone (PDS); (2) 10‐strand Savage, size 2 polyglactin 910 (PG910); (3) 10‐strand Savage, size 2 PDS with Lin‐locking epitenon suture, size 2–0 PDS; (4) 10‐strand Savage size 2 PG910 with Lin‐locking epitenon suture, size 2–0 PDS; (5) 3‐loop pulley, size 2 PDS; and (6) 3‐loop pulley, size 2 PG910. Maximum load at failure (N), gap at failure (mm), and mode of failure (suture breakage or pull through) were evaluated for each of the 6 suture material–pattern combinations and underwent statistical analysis to determine significance of differences and interactions of the measured data. Results: The 10‐strand Savage technique failed at a mean load of 872 N (804–939, 95% CI). The 10‐strand Savage with Lin‐locking failed at a significantly greater mean load of 998 N (930–1065, 95% CI). The 3‐loop pulley pattern failed with a mean load of 337 N (270–405, 95% CI). There were significant interactions between the technique and suture material used. Conclusion: The 10‐strand Savage technique for repair of transected cadaver SDF tendons has superior strength characteristics with or without the epitenon suture when compared to the 3‐loop pulley. Suture material and pattern interactions were observed with PG 910 conferring higher strength for the 10‐strand Savage whereas PDS did so for the 3‐loop pulley.     

Strength Characteristics and Failure Modes of Locking-Loop and Three-Loop Pulley Suture Patterns in Equine Tendons

Size 3-0 polydioxanone was used as a single strand, single braid (3 strands), or double braid (6 strands) to create six suture material-pattern combinations for equine tenorrhaphy: single-strand locking loop, single-braid locking loop, double-braid locking loop, single-strand three-loop pulley, single-braid three-loop pulley, and double-braid three-loop pulley. Maximum load to failure for the single-strand locking loop (46.1 +/- 2.9 newtons [N]) was less than for all other sutures (range, 103-155 N). The load required to form a 2 mm gap between tendon ends was greater for the single-braid three-loop pulley (66.7 +/- 6.9 N) and double-braid three-loop pulley (85.4 +/- 17.7 N) than any other sutures. The load required to produce a 10 mm gap was least for the single-strand locking loop (34.3 +/- 3.9 N) and greatest for the double-braid three-loop pulley (131.5 +/- 27.5 N). Gap between tendon ends at maximum load was greater for the single-braid (18.1 +/- 0.9 mm) and double-braid (19.2 +/- 2.2 mm) locking loops than for any other sutures. Suture material broke in 53% of the locking-loop tests but in only 17% of the three-loop pulley tests. Tendon matrix disruption accounted for 43% of the locking-loop failures and 77% of the three-loop pulley failures. The three-loop pulley pattern provided more support, less tendon distraction, and less tendon matrix constriction and distortion than the locking-loop pattern.(ABSTRACT TRUNCATED AT 250 WORDS)     

A Comparison of Nylon, Polybutester, and Polyglyconate Suture Materials for Long Digital Flexor Tenorrhaphy in Chickens

Digital flexor tenorrhaphies were performed in 32 8-week-old chickens with polyglyconate, polybutester, or nylon. There was no difference in maximum loads to failure at weeks 4 or 8. Polyglyconate and polybutester tenorrhaphies were significantly stronger at week 8 than all tenorrhaphies at week 4. Nylon tenorrhaphies at week 8 were not significantly stronger than any tenorrhaphy at week 4. The tenorrhaphies consistently had immature scars at week 4 and more mature scars at week 8. Scar maturity was not appreciably different between any of the suture materials at week 4 or week 8. There was no apparent difference in tissue reactivity to any of the suture materials at weeks 4 or 8.     

Comparison of carbon fibre and nylon suture for repair of transected flexor tendons in the horse

Carbon fibre-polylactic acid composites and monofilament non-absorbable suture material were compared for the repair of surgically transected superficial digital flexor tendons in 10 horses. All surgical wounds healed by first intention. The repaired tendons were enlarged, the carbon implanted tendons being larger than those sutured. The horses were killed at six, eight, 12,20 or 24 weeks. Greater fibrous thickening occurred in tendons repaired with carbon fibre, especially at 12 weeks postoperatively. Carbon fibre incited a greater histological response with macrophages, lymphocytes, plasma cells, eosinophils and fibroblasts. The fibrous tissue in the repair sites appeared to mature and the collagen to align at a similar rate irrespective of the method of repair. Only that tissue within and immediately surrounding the carbon bundles was immature at six months. There was minimal tendency for carbon filaments to separate and those that did were often surrounded by epithelioid macrophages forming a granuloma. Massive eosinophil concentrations were present between each granuloma. With each sequential test period the sutured tendons became increasingly stronger than the carbon implanted tendons. This may have been because of the immature core of tissue associated with the carbon bundles. No carbon particles were detected in draining lymph nodes.     

Luxation of the superficial digital flexor tendon in a cat

Superficial digital flexor luxation has been described in dogs, horses, and cattle. To the authors' knowledge, it has not been reported in cats. In the case of this report, monofilament nonabsorbable suture material was used to repair a laterally luxating superficial digital flexor tendon in a cat. The repair was similar to that which has been described in dogs. Whereas many etiologies of superficial tendon luxation have been proposed in dogs, trauma was believed to have contributed to the tendon luxation in this cat.     

Quantitative effect of tenorrhaphy on intrinsic vasculature of the equine superficial digital flexor tendon

OBJECTIVE: To compare effects of the locking-loop suture pattern (LLP) and 3-loop pulley (3LP) suture pattern for tenorrhaphy on the intrinsic vasculature of the superficial digital flexor tendon (SDFT) of horses in vitro after surgery. SAMPLE POPULATION: 16 forelimbs obtained from 8 mature horses. PROCEDURE: Tenotomy and subsequent tenorrhaphy was performed in anesthetized horses. Following systemic administration of heparin, horses were euthanatized and the limbs were removed and placed under tension to load the flexor tendons. The intrinsic vasculature was then perfused with a mixture of barium sulfate and water. Four-millimeter sections of the SDFT were prepared for microangiographic analysis. Mean vessel density was calculated for each section by use of a grid consisting of 1.5-mm2 vascular assessment squares (VAS). Comparisons were made among the control, LLP and 3LP groups. RESULTS: Mean +/- SD vessel density was 3.11 +/- 0.38, 1.47 +/- 0.47, and 2.01 +/- 0.63 perfused vessels/1.5 mm2 for control, LLP and 3LP groups, respectively. Significant differences in vascular density were detected between the control and 3LP groups, control and LLP groups, and LLP and 3LP groups. CONCLUSIONS AND CLINICAL RELEVANCE: Use of the LLP and 3LP pattern has deleterious effects in vitro on the intrinsic vasculature of the SDFT. However, the 3LP pattern was less disruptive to the intrinsic vasculature, compared with the effects for the LLP. Use of the 3LP tenorrhaphy suture pattern in clinical situations may result in less damage to the intrinsic vasculature of the SDFT of horses during convalescence.     

The Effect of Six Knotting Methods on the Biomechanical Properties of Three Large Diameter Absorbable Suture Materials

Objective— To evaluate the effect of 6 different knotting methods on the mechanical properties of 3 large absorbable suture materials used in large animal surgery. Study Design— In vitro mechanical study. Sample Population— Knotted suture loops (n=15 per group). Methods— Suture loops were created between two low‐friction pulleys with either 2 polydioxanone, 2 polyglactin 910 or 3 polyglactin 910. Strands were tied using 1 of 6 knotting technique: square knot, surgeon knot, clamped surgeon's knot, sliding half‐hitch knot (HH), Delimar knot and self‐locking knot (SLK). A single cycle to failure test was performed on each suture loop with a distraction rate of 100 mm/min. Failure modes were evaluated and breaking strength, elongation to failure and stiffness were compared. Results— All loops except two HH failed at the knot by acute breaking. The double‐stranded SLK was both stronger and stiffer than all other knots for each suture material. Clamping the first throw of the surgeon knot decreased load to failure significantly (143.11 ± 8.64 N) compared with not clamping (159.21 ± 6.14 N) for polydioxanone. Stiffness and elongation to failure were respectively lower and increased for 2 polydioxanone compared with both polyglactin 910 materials for all knotting techniques. Conclusions— Knotting techniques do influence structural properties of suture loops. The double strand loop conferred stiffer and stronger properties to the SLK Clinical Relevance— Clamping the first throw of polydioxanone should be avoided when tying a suture under tension even using large diameter suture materials. Using a SLK might be considered as a useful alternative when excessive tension is present.     

Mechanical Properties of Four Suture Patterns for Transected Equine Tendon Repair

Thirty-six superficial digital flexor tendons from nine fresh equine cadavers were transected and sutured with size 2 monofilament nylon. Nine tendons were repaired with each of four suture patterns: single-locking loop, double-locking loop, triple-locking loop, or three-loop pulley. The times required for application, tensile strengths, resistance to distraction (gap), and modes of failure were analyzed. The mean times required were: single-locking loop, 3 mins, 15 secs; double-locking loop, 4 mins, 15 secs; triple-locking loop, 10 mins, 50 secs; and three-loop pulley, 4 mins. The double-locking loop, triple-locking loop, and three-loop pulley suture patterns were stronger than the single-locking loop. The triple-locking loop and three-loop pulley patterns were close in strength and only the triple-locking loop was stronger than the double-locking loop. The three-loop pulley had the greatest resistance to gap formation and its mode of failure was different from the others. The three-locking loop suture patterns failed by suture breakage but the three-loop pulley failed first by suture pull-out and then by suture breakage.     

A Comparative Study Evaluating Three Bioscaffold Augmentation Devices Used for Superficial Digital Flexor Tenorrhaphy in Donkeys (Equus Asinus) by Magnetic Resonance Imaging and Ultrasonography

Little is known about using magnetic resonance imaging (MRI) in evaluating the healing properties of superficial digital flexor tenorrhaphy in equines. The present study was designed to carry out in vivo comparative evaluation of normal and repaired superficial digital flexor tendon (SDFT) in donkeys, based on MRI, ultrasonography, clinical and histopathological features. Eighteen clinically healthy donkeys were assigned for three treatment trials (n = 6) using three bioscaffold materials (bovine pericardium xenograft, tendon allograft, and allograft shielding by bovine pericardium), in addition to six healthy donkeys to serve as control group. Clinical signs for each animal were scored, and the sum of all clinical indexes was calculated. MRI and ultrasonographic examinations of each donkey were carried out at 45 and 90 days postoperatively in the three treated groups, and were compared with those in the control group. Both clinical and imaging characteristics were compared and statistically analyzed at each time point. The echogenicity (P < .0039), cross-sectional area (P < .0490), and fiber alignment (P < .0077) were different at 45 and 90 days postoperatively in the shielding group than in the other two groups, with no difference in the histological features in comparison with the control group, based on the median and range analysis at 90 days postoperatively. In conclusion, MRI and ultrasonography initiate a new paradigm in monitoring the healing progression and case prognosis of SDFT tenorrhaphy with the bioscaffold augmentation devices, either xenogenic or allogenic, which provided a good alternative technique and an accelerated SDFT healing with minimal adhesions in donkeys.     

A preliminary study on the effect of ultrasound therapy on the healing of surgically severed achilles tendons in five dogs

This study was conducted on the left Achilles tendon in five clinically normal dogs. The Achilles tendon was surgically exposed and severed 3-4 cm proximal to the point of its insertion. Tenorrhaphy was undertaken by the application of three sutures on the various tendon units of the Achilles tendon using single locking-loop sutures with polyamide no. 1-0. The superficial digital flexor tendon was sutured with catgut using two horizontal mattress sutures. No ultrasound therapy was used in the animals of group I (control). Ultrasound therapy was given to the animals of group II (treated) starting from the third day post-operatively at 0.5 W/cm2 for 10 min daily for 10 days. A cortical screw was used for immobilization of the tibiotarsal joint which was removed 4 weeks after tenorrhaphy. Post-operatively, healing of the Achilles tendon was monitored using clinical observations, ultrasonography, gross and histomorphological observations at various intervals up to 120 days in both groups. Clinically, the dogs showed significant lameness for the first 4-5 days, which disappeared earlier in the ultrasound-treated (group II) animals than the controls (group I). Extension and flexion of the hock joint were found to be near normal at 6 weeks after the repair of the Achilles tendon. Ultrasonography showed anechoic to hypo-echoic echo-texture on days 3 and 7 after repair. By day 40, the echo-texture started to improve to hypo-echoic in group II, but in group I anechoic areas were still observed. However, the tendon showed near normal mottled hypo- to hyper-echoic texture in both groups by day 120. Gross observations suggested that the Achilles tendon in group II showed comparatively fewer adhesions than in group I animals. Histologically, in group II (treated), on day 40, the union was comparatively better without any inflammatory reaction. Bundle formation had begun in the ultrasound-treated animals which was not observed in the control animals. By day 90, more compact parallel bundle formation had taken place with minimum cellularity. Bundle formation was in its advanced stage in the treated animals. By day 120, the tendon tissue was comparatively acellular and looking like a normal tendon. The use of the cortical screw provided good immobilization and ultrasound therapy at 0.5 W/cm2 enhanced the Achilles tendon healing in dogs.     

Achilles Tendon Repair in Dogs Using the Semitendinosus Muscle: Surgical Technique and Short-Term Outcome in Five Dogs

Objective— To describe augmentation of primary Achilles tendon repair using suture with a semitendinosus muscle flap and report outcome in 5 dogs.
Study Design— Prospective clinical study.
Animals— Dogs (n=5) with Achilles tendon rupture (n=6).
Methods— After tendon repair with #2 polypropylene in a 3-loop pulley suture pattern, the lateral one-half of the semitendinosus muscle was transected from the ischium, rotated distally then sutured with #2 polypropylene to the calcaneus in a 3-loop pulley pattern. The epitenon was sutured to the muscle flap fascia with interrupted sutures. All dogs had a bivalved cast for 2 weeks then a cranial splint for 2–6 weeks. Lameness scores (0=stands and walks normally to 4=non-weight-bearing lameness, plantigrade stance on affected pelvic limb) were determined every 2–3 weeks postoperatively for 12 weeks. Outcome was determined from telephone questionnaire of owners.
Results— Four had lameness scores of 0, the 5th had a score of 1 at 12 weeks. Three owners were very satisfied with outcome. Minor complications included cast sores (2 dogs), infection (2), and acute swelling (1); 1 major complication occurred (infection resulting in reoperation).
Conclusions— Semitendinosus flap augmentation resulted in early return to function without prolonged postoperative immobilization. Three dogs returned to full work/activity after repair.
Clinical Relevance— Augmentation of primary Achilles tendon repair with a semitendinosus flap can be considered in dogs with chronic rupture but further investigation of the long-term outcome using this technique is needed.     

Cell therapy for tendinitis, experimental and clinical report

To compare cultured bone marrow mesenchymal cells (cBMSC), bone marrow mononucleated cells (BMMNCs), and placebo to repair collagenase-induced tissue damage in an equine model of experimental tendonitis, 6 Standardbred horses with no signs of previous SDF tendon injury have been recruited. Three weeks after collagenase treatment an average of either 5.5 x 10(6) cBMSCs or 122.3 x 10(6) BMMNCs, saline solution (placebo) or fibrin glue were injected intralesionally in random order. Horses were stall rested for 21 weeks, and tendon ultrasound scans performed before and during this period. Horses were euthanized and tendons harvested for histology and immunohistochemistry. Data observed in this study showed effectiveness of cBMSC and BMMNC in regenerating tendon tissue after collagenase -induced tendonitis. Both cBMSC and BMMNC transplantation resulted in qualitatively similar regeneration of tendon extracellular matrix in terms of type I/III collagen ratio, fiber orientation, and COMP expression. After this favourable results, 20 horses were recruited referred for spontaneous lesions of the flexor tendons or the suspensory ligament. Horses were treated with autologous graft of BMMNCs.After treatment the. the exercise program allowed was 8 weeks stall rest, 4 weeks hand walking, 4 weeks trotting, 4 weeks of gradually raising of exercise level then horses were gone back to race. US characteristics of lesions started to improve at T3. CSA-l, FPS and TLS were better in all patients, with an appreciable filling of lesions indicated by a decreasing of CSA-l and increasing of TLS. When horses started the exercise program T8 tendon architecture improved, demonstrated by their longitudinal alignment and length. At T6, and persistently in later follow-up, no lameness was evident by clinical examination. At time of writing 12 patients (60%) were go back to races, while other 8 (40%) are under controlled exercise program. Re-injury rate was assessed at 25%. All the owners judged good to excellent the outcome in term of athletic success.     

A Histological Evaluation of Rabbit Tendons Sutured Using the Bunnell Pattern

Development of ischemia in healing tendons was assessed in 18 rabbits. One superficial digital flexor tendon in each rabbit was incised and anastomosed using a Bunnell pattern. The repair site was enclosed in a porous, woven Dacron tube before skin closure. The limb was immobilized with a cast. Rabbits were euthanized 1, 4, and 8 weeks after surgery, and tendons were harvested and examined microscopically. Regions of the tendon included in the suture pattern were ischemic and acellular at 1 week, while adjacent areas still containing patent vessels remained viable. Within 4 weeks, a well vascularized neotendon with collagen bundles organized parallel to the long axis of the tendon developed along the periphery and between the opposed tendon ends. After 8 weeks, the ischemic regions of the tendon had not revascularized or become integrated with the neotendon. Adjacent collagen bundles not originally included in the Bunnell pattern were integrated with neotendon collagen fibers.     

A Study of the Biomechanical Properties of the Adult Equine Linea Alba: Relationship of Tissue Bite Size and Suture Material to Breaking Strength

The purposes of this study were to mechanically determine the optimal tissue bite size and to evaluate seven suture materials at their largest commercially available size for breaking strength and stiffness using cadaveric adult equine linea alba. Soft tissues were removed from the abdominal fascia of 16 adult horses. Individual test sections were created from the entire linea alba and labeled (1 through 6) starting at the umbilicus and extending craniad. A single biomechanical test was performed on each test section. Tissue bite size (3, 6, 9, 12, 15, 18, and 21 mm) significantly altered breaking strength directly in a logarithmic fashion (P < .0001; R²= 0.94). Tissue bite size accounted for 44% and linea alba thickness for 24% of the variability in breaking strength of the equine linea alba. The optimal tissue bite size for adult horses was 15 mm from the edge of the linea alba based on lack of significant gain in breaking strength. There were no differences in breaking strength among horses, horses weight, or left and right test sections. Test sections taken from near or at the umbilicus had greater breaking strength (P < .005) and thicker linea alba (P < .001) when compared with more cranial test sections. Linea alba thickness alone accounted for 34% of the variability in breaking strength associated with test section position. There were no differences in linea alba stiffness among tissue bite sizes. All suture loops failed before complete fascial disruption, and 52 of 56 (93%) suture loops failed at the knot. Suture breaking strength and stiffness were significantly affected by the type of suture material examined (P < .0001). Size 5 polyester had a greater breaking strength and stiffness compared with the other suture materials tested. The next strongest suture materials were size 3 polyglactin 910 and size 2 polyglycolic acid, which were similar in breaking strengths and stiffness. Size 2 nylon was significantly weaker in breaking strength when compared with the other suture materials.     

The effect of focused extracorporeal shock wave therapy on collagen matrix and gene expression in normal tendons and ligaments

Reasons for performing study: Extracorporeal shock wave therapy (ESWT) is frequently used in equine practice, but little is known about its biological action. Objectives: To study the effects of ESWT on matrix structure and gene expression levels in normal, physiologically loaded tendinous structures in ponies. Methods: Six Shetland ponies, free of lameness and with ultrasonographically normal flexor and extensor tendons and suspensory ligaments (SL), were used. ESWT was applied at the origin of the suspensory ligament and the mid‐metacarpal region of the superficial digital flexor tendon (SDFT) 6 weeks prior to sample taking, and at the mid‐metacarpal region (ET) and the insertion on the extensor process of the distal phalanx (EP) of the common digital extensor tendon 3 h prior to tendon sampling. In all animals one forelimb was treated and the other limb was used as control. After euthanasia, tendon tissue was harvested for real‐time PCR to determine gene expression levels and additional samples were taken for histological evaluation and biochemical analyses Results: Histologically a disorganisation of the normal collagen structure was observed 3 h after ESWT, remnants of which were still visible after 6 weeks. While degraded collagen levels showed an increase at 3 h post treatment (P = 0.012) they were reduced at 6 weeks post ESWT (P = 0.039). Gene expression for both COL1 (P = 0.004) and MMP14 (P = 0.020) was upregulated at 6 weeks after treatment. Conclusions: Exposure of normal tendinous tissue to ESWT is not uneventful; it leads to a disorganisation of matrix structure and changes in degraded collagen levels. The upregulation of COL1 expression 6 weeks after ESWT may be indicative for repair. Potential relevance: The observed disorganisation of the collagen network warrants caution when using ESWT. Exposing noninjured tissue to ESWT should be avoided and it may be advisable to restrict exercise in recently treated patients. However, the induced tissue disorganisation might also be a trigger for repair in chronic tendinopathies.     

An evaluation of two autologous tendon grafting techniques in ponies

OBJECTIVE: To compare the healing and mechanical strength of a multiple split autologous tendon graft (MG) to a whole autologous tendon graft (WG) in the deep digital flexor tendon of ponies. STUDY DESIGN: In vitro evaluation of two different tendon-grafting techniques. ANIMALS OR SAMPLE POPULATION: Six ponies of mixed gender and age. METHODS: Tenotomies performed in forelimb deep digital flexor tendons (DDFT) distal to the insertion of the accessory ligament (AL-DDFT) were repaired with free autologous grafts from the hindlimb lateral digital extensor tendon (LDET). Grafts were either whole (WG) or split into three longitudinal strips (multiple graft, MG). Tendons and graft sites were collected and loaded (2.54 cm/s) to failure at either 4 or 8 weeks after surgery. Cross-sectional area was determined by both impression cast (IC) and an inkblot (IB) method. Tissue maturity and inflammation were evaluated by microscopy. RESULTS: Gap formation was a consistent finding in all repair sites. No statistical differences were found in healing or mechanical variables between MG and WG techniques. The failure stress for the 8-week repairs (15.51 +/- 3.1 MPa IB and 11.73 +/- .77 MPa IC, 16.13 +/- 2.2 MPa IB and 10.22 +/- .76 MPa IC for MG and WG, respectively) were significantly greater (P <.0005) than for 4-week repairs (3.71 +/- 1.7 MPa IB and 2.68 +/- 1.44 MPa IC, 2.81 +/- 1.46 MPa IB and 2.3 +/- 1.7 MPa IC for MG and WG, respectively). The repair tissue was more mature (P <.05) at 8 weeks than at 4 weeks, but there was no significant difference in inflammatory responses at 4 and 8 weeks. CONCLUSIONS: There was a sixfold increase in strength between 4 and 8 weeks of healing, but no significant difference in healing or strength between the MG and WG techniques. CLINICAL RELEVANCE: In ponies, autologous tendon grafting contributes to a strong repair during the early convalescent period, but splitting a tendon graft seemingly offers no appreciable advantage over use of a whole graft.