ÖNDER İSMET KILIÇOĞLU, GÖKSEL DİKMEN, Özgür KOYUNCU, Bilge BİLGİÇ, Aziz Kaya ALTURFAN

Effects of demineralized bone matrix on tendon-bone healing: an in vivo, experimental study on rabbits

Amaç: Bu çalışmanın amacı demineralize kemik matriksinin (DKM) tendon-kemik iyileşmesi üzerindeki etkilerini araştırmak idi. Çalışma planı: On iki Yeni Zelanda tavşanının her iki bacağında uzun dijital ekstansör tendon tibia proksimalinde açılan tünelin içine askı dikiş yöntemi ile tespit edildi. Sağ tibialarda tendon tünele yerleştirilmeden önce tünel içine tavşan kaynaklı DKM enjekte edildi. Sol tibialar ise kontrol grubu olarak alındı ve sadece uzun dijital ekstansör tendonları tünel içerisinde tespit edildi. Üçüncü, 6. ve 9. haftalarda 4’er adet tavşan rastgele şekilde intravenöz yüksek doz (200 mg/kg) pentotal ile sakrifiye edildi ve tavşanların her iki bacağı histolojik inceleme için alındı. Örnekler histopatolojik açıdan fibrokartilaj oluşumu, yeni kemik oluşumu, tendonun kemik tünel içerisindeki tutunması ve Sharpey lifleri oluşumu açısından bir skorlama sistemi ile kör ve bağımsız bir şekilde değerlendirildi. Bulgular: Üçüncü haftada DKM grubunda Sharpey lifleri, fibrokartilaj ve yeni kemik oluşumu skorlarının kontrol grubuna göre daha fazla olduğu gözlendi. Altıncı ve 9. haftalarda ise histolojik değerlendirme parametreleri açısından gruplar arasında istatiksel anlamlı farklılık saptanmadı (p>0.05). Çıkarımlar: Demineralize kemik matriksinin kemik tünel hayvan modelinde tendon-kemik iyileşmesi sürecinin ilk 3 haftasında yeni kemik oluşumunu ve Sharpey liflerinin sayısını arttırdığı görüldü.

Demineralize kemik matriksinin tendon-kemik iyileşmesi üzerine etkileri: Tavşanlarda in vivo deneysel çalışma

Objective: The aim of this study was to investigate the effects of demineralized bone matrix (DBM) on tendon-bone healing. Methods: The extensor digitorum longus tendon was fixed with pegged suture technique in a tunnel at the proximal tibia in both legs of 12 New Zealand rabbits. Rabbit DBM was applied in the tunnel on the right limbs before fixation (study group), while the fixation was performed without DBM in the left legs (control group). Randomly, four rabbits were sacrificed at the 3rd, four rabbits at the 6th and the remaining four rabbits at the 9th week with an intravenous high dose (200 mg/kg) pentothal and both legs were collected for histological analysis. Each specimen was blindly and independently examined to assess fibrocartilage formation, new bone formation, tendon graft bonding to adjacent tissue and Sharpey’s fiber formation. A scoring system was used for quantification of histopathological analysis. Results: The DBM group showed higher number of Sharpey’s fibers, slightly increased fibrocartilage formation and new bone formation scores than the control group in the 3rd week. All histological scores were similar in both groups in the 6th and 9th weeks (p>0.05). Conclusion: DBM increased new bone formation and the number of Sharpey’s fibers in a bone tunnel animal model within the first three weeks of tendon-bone healing process.

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1. Rodeo SA, Kawamura S, Ma CB, Deng XH, Sussman PS, Hays P, et al. The effect of osteoclastic activity on tendon-to- bone healing: an experimental study in rabbits. J Bone Joint Surg Am 2007;89:2250-9.
2. Amiel D, Woo SL, Harwood FL, Akeson WH. The effect of immobilization on collagen turnover in connective tissue: a biochemical-biomechanical correlation. Acta Orthop Scand 1982;53:325-32.
3. Schneeberger AG, von Roll A, Kalberer F, Jacob HA, Gerber C. Mechanical strength of arthroscopic rotator cuff repair techniques: an in vitro study. J Bone Joint Surg Am 2002;84- A:2152-60.
4. Koh JL, Szomor Z, Murrell GA, Warren RF. Supplementation of rotator cuff repair with a bioresorbable scaffold. Am J Sports Med 2002;30:410-3.
5. Gerber C, Schneeberger AG, Beck M, Schlegel U. Mechanical strength of repairs of the rotator cuff. J Bone Joint Surg Br 1994;76:371-80.
6. Gallie WE, Le Mesurier AB. A clinical and experimental study of the free transplantation of fascia and tendon. J Bone Joint Surg 1922;4:600-12.
7. Grana WA, Egle DM, Mahnken R, Goodhart CW. An analy- sis of autograft fixation after anterior cruciate ligament recon- struction in a rabbit model. Am J Sports Med 1994;22:344-51.
8. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. Tendon-healing in a bone tunnel. A biomechanical and histo- logical study in the dog. J Bone Joint Surg Am 1993;75:1795- 803.
9. Rodeo SA, Suzuki K, Deng XH, Wozney J, Warren RF. Use of recombinant human bone morphogenetic protein-2 to enhance tendon healing in a bone tunnel. Am J Sports Med 1999;27:476-88.
10. Lim JK, Hui J, Li L, Thambyah A, Goh J, Lee EH. Enhancement of tendon graft osteointegration using mes- enchymal stem cells in a rabbit model of anterior cruciate ligament reconstruction. Arthroscopy 2004;20:899-910.
11. Bedi A, Fox AJ, Kovacevic D, Deng XH, Warren RF, Rodeo SA. Doxycycline-mediated inhibition of matrix metallopro- teinases improves healing after rotator cuff repair. Am J Sports Med 2010;38:308-17.
12. Bedi A, Kovacevic D, Hettrich C, Gulotta LV, Ehteshami JR, Warren RF, et al. The effect of matrix metalloproteinase inhi- bition on tendon-to-bone healing in a rotator cuff repair model. J Shoulder Elbow Surg 2010;19:384-91.
13. Yeh WL, Lin SS, Yuan LJ, Lee KF, Lee MY, Ueng SW. Effects of hyperbaric oxygen treatment on tendon graft and tendon-bone integration in bone tunnel: biochemical and his- tological analysis in rabbits. J Orthop Res 2007;25:636-45.
14. Mutsuzaki H, Sakane M, Nakajima H, Ito A, Hattori S, Miyanaga Y, et al. Calcium-phosphate-hybridized tendon directly promotes regeneration of tendon-bone insertion. J Biomed Mater Res A 2004;70:319-27.
15. Kyung HS, Kim SY, Oh CW, Kim SJ. Tendon-to-bone tun- nel healing in a rabbit model: the effect of periosteum aug- mentation at the tendon-to-bone interface. Knee Surg Sports Traumatol Arthrosc 2003;11:9-15.
16. Van de Putte KA, Urist MR. Osteogenesis in the interior of intramuscular implants of decalcified bone matrix. Clin Orthop Relat Res 1965;(43):257-70.
17. Veillette CJ, McKee MD. Growth factors – BMPs, DBMs, and buffy coat products: are there any proven differences amongst them? Injury 2007;38 Suppl 1:S38-48.
18. Urist MR. Bone: formation by autoinduction. Science 1965;150:893-9.
19. Peel SA, Hu ZM, Clokie CM. In search of the ideal bone mor- phogenetic protein delivery system: in vitro studies on dem- ineralized bone matrix, purified, and recombinant bone mor- phogenetic protein. J Craniofac Surg 2003;14:284-91.
20. Chakkalakal DA, Strates BS, Mashoof AA, Garvin KL, Novak JR, Fritz ED, et al. Repair of segmental bone defects in the rat: an experimental model of human fracture healing. Bone 1999; 25:321-32.
21. Block JE, Russell JL. Spine fusion with demineralized bone. J Neurosurg 1998;88:354-6.
22. Killian JT, Wilkinson L, White S, Brassard M. Treatment of unicameral bone cyst with demineralized bone matrix. J Pediatr Orthop 1998;18:621-4.
23. Liu SH, Panossian V, al-Shaikh R, Tomin E, Shepherd E, Finerman GA, et al. Morphology and matrix composition dur- ing early tendon to bone healing. Clin Orthop Relat Res 1997; (339):253-60.
24. Chen CH, Liu HW, Tsai CL, Yu CM, Lin IH, Hsiue GH. Photoencapsulation of bone morphogenetic protein-2 and periosteal progenitor cells improve tendon graft healing in a bone tunnel. Am J Sports Med 2008;36:461-73.
25. Poynton AR, Zheng F, Tomin E, Lane JM, Cornwall GB. Resorbable posterolateral graft containment in a rabbit spinal fusion model. J Neurosurg 2002;97(4 Suppl):460-3.
26. Sundar S, Pendegrass CJ, Blunn GW. Tendon bone healing can be enhanced by demineralized bone matrix: a functional and histological study. J Biomed Mater Res B Appl Biomater 2009;88:115-22.
27. Rodeo SA, Potter HG, Kawamura S, Turner AS, Kim HJ, Atkinson BL. Biologic augmentation of rotator cuff tendon- healing with use of a mixture of osteoinductive growth factors. J Bone Joint Surg Am 2007;89:2485-97.