Tendon-Healing in a Bone Tunnel
Tendon-Healing in a Bone Tunnel
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2006
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我们的研究在狗模型中评估了肌腱到骨的愈合。20只成年杂种狗将手指伸肌腱移植到胫骨近端干骺端4.8毫米的钻孔中。在5个时间段（移植后2、4、8、12和26周）各处死4只狗，评估肌腱-骨界面的组织学和生物力学特征。连续的组织学分析显示骨和肌腱之间胶原纤维连续性的逐步重建。在肌腱和骨之间，沿着骨隧道的长度有一层细胞纤维组织；这一层在愈合过程中逐渐成熟和重组。将肌腱连接到骨头上的胶原纤维类似于Sharpey纤维。高分辨率x线片显示肌腱周围的小梁骨重塑。在第2周、第4周和第8周的时间里，所有的标本都因从骨隧道中拔出肌腱而失效。在移植后的第2周至第12周之间，界面的强度显着逐渐增加。在12周和26周的时间内，所有标本都因肌腱从夹钳中拔出或肌腱中层断裂而失败。强度的逐渐增加与骨长入的程度、矿化程度和愈合组织的成熟程度有关。临床意义：由于移植后早期移植骨固定部位在机械上是最薄弱的部位，因此目前尚未或将不会从与本文主题直接或间接相关的商业方获得任何形式的益处。没有收到支持这项研究的资金。1993年2月15日，加利福尼亚旧金山，骨科研究学会年会上，1992年6月21日至26日，加拿大安大略省多伦多，英语世界骨科协会联合会议上，发表海报。特殊外科医院，纽约东70街535号，纽约10021。§密歇根州立大学兽医学院比较骨科研究实验室，密歇根州东兰辛48824。愈合过程（例如，重建前交叉韧带的半腱肌和股薄肌腱移植）将使我们更好地了解如何改善移植物与骨的初始固定。它还可以帮助确定改善肌腱移植生物愈合反应的方法。此外，本研究的发现可以帮助临床医生对韧带重建患者的早期负重或活动范围康复模式进行规划，并有助于决定何时移除用于移植物附着的内固定装置。我们建议愈合的韧带在重建后至少保护8周。许多重建手术的成功依赖于肌腱和韧带与骨的牢固愈合或附着。虽然膝关节韧带置换手术的组织学、血管、生化和生物力学特征已被广泛研究，但对骨-肌腱移植界面的特征知之甚少。特别是，愈合的组织学机制和骨-肌腱界面的生物力学特征的知识是稀疏的。据我们所知，很少有研究调查软组织到骨骼的愈合。Kernwein等人67报道，在动物模型中，通过骨化和肌腱入骨，肌腱被锚定在钻孔中。Whiston和Walmsley以及Forward和Cowan报道，肌腱与骨的附着是通过肌腱周围的痂形成结缔组织套，然后成纤维细胞逐渐侵入移植肌腱而发生的。在最近的一项研究中，Hausman等人没有发现骨性长入移植肌腱或骨化的证据，他们得出结论，干骺端骨和肌腱不能一起愈合。一些研究提供了肌腱移植物纳入骨隧道的证据，但这些研究都没有记录愈合的组织学机制或软组织与骨愈合的生物力学特征。此外，据我们所知，尚无关于生理负荷下移植物愈合的研究。然而，它已经很好地确立了公元前796年。A. rodeo等人；骨与关节外科杂志图1 A：狗膝盖外侧侧面图，显示长指伸肌腱连接股骨外侧髁。肌腱从股骨髁上急剧脱离。未显示其上的筋膜和软组织。B：将指长伸肌腱从股骨外侧髁上剥离，并在胫骨近端做一个斜钻孔。C：前视图显示肌腱通过胫骨近端钻孔被拉紧，并在张力下用4-0不锈钢缝线连接到胫骨内侧。移植物的组织学和生物力学重塑的复杂过程依赖于对移植物施加机械力。本研究的目的是描述在生理负荷下愈合肌腱移植物的组织学和生物力学特性。材料与方法本研究选用20只成年杂种狗，每只体重在20 - 30公斤之间。这些狗是从美国农业部有执照的经销商处获得的，按照美国国立卫生研究院制定的照顾和使用实验动物的标准，被安置在特殊外科医院的实验动物护理设施中。将双后肢膝关节的指伸肌腱从其股止点处剥离，通过骨隧道植入胫骨近端干骺端。分别于2周、4周、8周、12周和26周处死4只狗，评估肌腱-骨界面的生物力学和组织学特征。
Our study evaluated tendon-to-bone healing in a dog model. Twenty adult mongrel dogs had a transplantation of the long digital extensor tendon into a 4.8-millimeter drill-hole in the proximal tibial metaphysis. Four dogs were killed at each of five timeperiods (two, four, eight, twelve, and twenty-six weeks after the transplantation), and the histological and biomechanical characteristics of the tendon-bone interface were evaluated. Serial histological analysis revealed progressive reestablishment of collagen-fiber continuity between the bone and the tendon. A layer of cellular, fibrous tissue was noted between the tendon and the bone, along the length of the bone tunnel; this layer progressively matured and reorganized during the healing process. The collagen fibers that attached the tendon to the bone resembled Sharpey fibers. High-resolution radiographs showed remodeling of the trabecular bone that surrounded the tendon. At the two, four, and eight-week time-periods, all specimens had failed by pull-out of the tendon from the bone tunnel. The strength of the interface was noted to have significantly and progressively increased between the second and the twelfth week after the transplantation. At the twelve and twenty-six-week time-periods, all specimens had failed by pull-out of the tendon from the clamp or by mid-substance rupture of the tendon. The progressive increase in strength was correlated with the degree of bone ingrowth, mineralization, and maturation of the healing tissue, noted histologically. CLINICAL RELEVANCE: Since the site at which a graft is fixed to bone is, mechanically, the weakest area in the early post-transplant period, knowledge of the *No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. tRead at the Annual Meeting of the Orthopaedic Research Society, San Francisco, California, February 15, 1993, and a poster presentation at the Combined Meeting of the Orthopaedic Associations of the English-Speaking World, Toronto, Ontario, Canada, June 21 through 26, 1992. IThe Hospital for Special Surgery, 535 East 70th Street, New York, N.Y. 10021. §The Laboratory for Comparative Orthopaedic Research, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan 48824. healing process (for example, of semitendinosus and gracilis tendon grafts in the reconstruction of the anterior cruciate ligament) will lead to a better understanding of how to improve the initial fixation of graft to bone. It also can aid in the identification of methods to improve the biological healing response of tendon grafts. In addition, the findings of the current study can help clinicians in the planning of early weight-bearing or range-of-motion rehabilitation modalities for patients who have had a reconstruction of a ligament and aid in the decision of when to remove an internal fixation device that has been used for the attachment of a graft. We recommend that a healing ligament be protected for at least eight weeks after a reconstruction. The success of many reconstructive operative procedures relies on the firm healing or attachment of tendon and ligament to bone. While the histological, vascular, biochemical, and biomechanical characteristics of ligament-substitution procedures in the knee have been widely investigated, little is known about the character of the bone-tendon graft interface. In particular, knowledge of the histological mechanism of healing and of the biomechanical characteristics of the bone-tendon interface is sparse. To our knowledge, few studies have investigated the healing of soft tissue to bone. Kernwein et al.67 reported that, in an animal model, tendon became anchored in a drill-hole by means of ossification and incorporation of the tendon into the bone. Whiston and Walmsley as well as Forward and Cowan reported that the attachment of tendon to bone occurred by formation of a connectivetissue sleeve of callus around the tendon followed by progressive invasion of fibroblasts into the transplanted tendon. In a more recent study, Hausman et al. found no evidence of osseous ingrowth into, or ossification of, the transplanted tendon, and they concluded that metaphyseal bone and tendon do not heal together. Several studies have provided evidence that a tendon graft is incorporated into a bone tunnel, but none of these studies have documented the histological mechanism of healing or the biomechanical characteristics of the healing of soft-tissue to bone. Furthermore, we know of no study of the healing of a graft under physiological load. However, it has been well established that the A B C I 796 5. A. RODEO ET AL. THE JOURNAL OF BONE AND JOINT SURGERY FIG. 1 A: Drawing of the lateral aspect of the knee of a dog, showing the long digital extensor tendon attached to the lateral femoral condyle. The tendon was sharply detached from the femoral condyle. Overlying fascia and soft tissue are not shown. B: The long digital extensor tendon has been detached from the lateral femoral condyle, and an oblique drill-hole has been made in the proximal part of the tibia. C: Anterior view showing the tendon pulled taut through the drill-hole in the proximal part of the tibia and attached under tension to the medial aspect of the tibia with 4-0 stainless-steel suture. complex processes of histological and biomechanical remodeling of a graft depend on the application of mechanical forces to the graft’. The present study was done to characterize the histological and biomechanical properties of a healing tendon graft that has been placed under physiological load. Materials and Methods Twenty adult mongrel dogs, each weighing between twenty and thirty kilograms, were used in the current study. The dogs were obtained from a licensed United States Department of Agriculture dealer and were housed in the facility for the care of laboratory animals at The Hospital for Special Surgery, in accordance with the standards established by the National Institutes of Health for the care and use of laboratory animals. The long digital extensor tendon of the knee joint of both hindlimbs was detached from its femoral insertion and was transplanted, through a bone tunnel, into the proximal tibial metaphysis. Four dogs were killed at two, four, eight, twelve, and twenty-six weeks, and the biomechanical and histological characteristics of the tendon-bone interface were evaluated.