The document summarizes research on using biological adjuncts to enhance flexor tendon healing. It discusses how surgical techniques and rehabilitation have improved results but adhesion formation remains a challenge. Various adjuncts are explored including growth factors, platelet rich plasma, stem cells, and gene therapy which show potential to aid faster healing with less adhesions. Ultrasound, magnetic fields, and rhynchophylline have also demonstrated positive impacts on tendon repair in animal studies. Continued research seeks safer and more effective ways to biologically manipulate the healing process at the cellular level.
Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence?Dr Saseendar MD
Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence?
knee osteoarthritis, knee surgery, total knee replacement, osteoarthritis, knee pain, elderly,
https://kneesurgrelatres.biomedcentral.com/articles/10.1186/s43019-019-0016-0
By replacing all or a portion of the meniscus with donor cartilage, the patient can regain the natural “shock absorber” in the knee and experience many additional years of activity, even in the presence of arthritis. Being "bone on bone" does not always mean that the joint needs to be artificially replaced, often the "bone on bone" is isolated to a portion of the knee joint and this can be repaired using meniscus transplant alone or in combination with any of the Biologic Knee Replacement procedures.
Medical science, particularly in Orthopaedics has progressed
and seen tremendous revolutionary changes over
the last few decades. Starting from an era of no surgery,
it has refined to minimally invasive surgeries and keyhole
surgeries in almost all sub specialties of Orthopaedics.
Orthopedics is a Reconstructive Surgery. Mangled extremity is an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels). A Decision have to be made Amputation + Prosthesis Vs. Limb salvage procedure which includes Irrigation & Debridement, External fixation, Antibiotic bead spacers, Soft tissue coverage and finally Restoring Skeletal Stability by Salvage of Bone Defect
Bone substitutes and void fillers in managing Cystic bone tumors and tumor li...BhaskarBorgohain4
In clinical settings there are several fairly common bone tumors or tumor like conditions that can causes a pathological bony cavity. These cavity can lead to pathological fracture. Giant cell tumors, simple bone cyst( SBC, UBC), fibrous dysplasia, giant cell tumors (GCT), aneurysm bone cysts( ABC) are well known entity. Autologous bone grafting , allograft or various bone substitutes are being increasingly used to fill up such voids or cavity after curettage to provide immediate cavity obliteration, provide mechanical support and promote long term healing the cavity.
Describes current options for treatment of arthritis including stem cell treatments, Platelet Rich Plasma, hyaluronic and steroid injections as well as arthroscopy and joint replacement.
Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence?Dr Saseendar MD
Proximal Fibular Osteotomy for Knee Osteoarthritis - What is the evidence?
knee osteoarthritis, knee surgery, total knee replacement, osteoarthritis, knee pain, elderly,
https://kneesurgrelatres.biomedcentral.com/articles/10.1186/s43019-019-0016-0
By replacing all or a portion of the meniscus with donor cartilage, the patient can regain the natural “shock absorber” in the knee and experience many additional years of activity, even in the presence of arthritis. Being "bone on bone" does not always mean that the joint needs to be artificially replaced, often the "bone on bone" is isolated to a portion of the knee joint and this can be repaired using meniscus transplant alone or in combination with any of the Biologic Knee Replacement procedures.
Medical science, particularly in Orthopaedics has progressed
and seen tremendous revolutionary changes over
the last few decades. Starting from an era of no surgery,
it has refined to minimally invasive surgeries and keyhole
surgeries in almost all sub specialties of Orthopaedics.
Orthopedics is a Reconstructive Surgery. Mangled extremity is an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels). A Decision have to be made Amputation + Prosthesis Vs. Limb salvage procedure which includes Irrigation & Debridement, External fixation, Antibiotic bead spacers, Soft tissue coverage and finally Restoring Skeletal Stability by Salvage of Bone Defect
Bone substitutes and void fillers in managing Cystic bone tumors and tumor li...BhaskarBorgohain4
In clinical settings there are several fairly common bone tumors or tumor like conditions that can causes a pathological bony cavity. These cavity can lead to pathological fracture. Giant cell tumors, simple bone cyst( SBC, UBC), fibrous dysplasia, giant cell tumors (GCT), aneurysm bone cysts( ABC) are well known entity. Autologous bone grafting , allograft or various bone substitutes are being increasingly used to fill up such voids or cavity after curettage to provide immediate cavity obliteration, provide mechanical support and promote long term healing the cavity.
Describes current options for treatment of arthritis including stem cell treatments, Platelet Rich Plasma, hyaluronic and steroid injections as well as arthroscopy and joint replacement.
“Periodontal Regeneration- New Vistas”- Guest lecture as a part of Dr NTRUHS Zonal CDE programme at SVS Institute of Dental Sciences, Mahabubnagar, India on 12/3/2013 and at Meghna Dental College, Nizamabad, India on 31/7/2013.
Presentation delivered at 2020 AAOS annual meeting by Dr Adnan Saithna, Professor of Orthopedic Surgery, Overland Park, Kansas. This randomised controlled study demonstrates that combined ACL and anterolateral ligament reconstruction is not associated with an increased risk of adverse events when compared to isolated ACL reconstruction
Adult Stem cells in Orthopaedics present and future perspectives.
Παρουσίαση του Δρ. Σταύρου Αλευρογιάννη που έγινε στο ξενοδοχείο Χίλτον, στις 12/06/15 στα πλαίσια Ημερίδας της Ελληνικής Εταιρείας Αναγεννητικής Ιατρικής, Αντιγήρανσης και Βιοτεχνολογίας, στο 41ο Πανελλήνιο Ιατρικό Συνέδριο.
"H θέση της αναγεννητική Ιατρικής στις παθήσεις Οστών και Αρθρώσεων"
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
The search for biological adjuncts to enhance flexor tendon healing
1. The search for biological adjuncts
to enhance flexor tendon healing
Alphonsus Chong
Associate Professor, Department of Orthopaedic Surgery, NUS
Group Chief, Hand and Reconstructive Microsurgery, NUHS
No relevant conflicts of interest to disclose
2. Flexor tendon results have improved greatly
• Flexor tendon repair, rehabilitation and
results have come a long way
• Better surgical technique and rehabilitation
with scientific basis and clinical results
• Still advancing:
• WALANT
• Pulley venting
• Evolving repair techniques
• Early active motion rehabilitation (Neiduski 2019)
Tang, Jin Bo. “New Developments Are Improving Flexor Tendon Repair:” Plastic and Reconstructive
Surgery 141, no. 6 (June 2018): 1427–37. https://doi.org/10.1097/PRS.0000000000004416.
3. Why adjuncts to tendon healing?
“Despite more recent minor alterations in suturing technique, uniformly
excellent results are still not achievable. Perhaps the next significant jump in
improved results lies in our understanding and manipulation of wound
healing at the cellular level and elimination of adhesions formation in the
repaired flexor tendon and digital sheath” (Kleinert 1995)
Kleinert, H. E., Špokevičius, S., & Papas, N. H. (1995). History of flexor tendon repair. The
Journal of Hand Surgery, 20(3), S46–S52. https://doi.org/10.1016/S0363-5023(95)80169-3
4. How can adjuncts to tendon repair help?
•Faster healing
•Less adhesions
•‘better’ healing
• Tendon loss
• tendinopathy
•Immobilization - ensures
repair integrity, but increases
adhesions
•Mobility - decreases
adhesions, increases strength,
but risks repair rupture
• Balance achieved by
protected mobilization
5. Tendon healing biology - cellular events
• Phases (Gelbermann)
• Inflammatory
• Fibroblastic
• Remodelling
• Extrinsic and intrinsic (Gelberman, Lundborg)
• Extrinsic Active earlier
• Predominance of extrinsic leads to scar formation
• Early motion helps intrinsic healing
6. Adhesion formation and prevention
• Injury (including surgery)
• Breaches cell basement
membrane
• sparks inflammatory response
• Interaction between
inflammatory response,
coagulation cascade, and
angiogenesis
• Hypoxia drives fibroblast
differentiation to adhesion
phenotype fibroblasts
Capella-Monsonís, H., Kearns, S., Kelly, J. et al. Battling
adhesions: from understanding to prevention. BMC biomed
eng 1, 5 (2019). https://doi.org/10.1186/s42490-019-0005-0
7. Non-biological adjuncts
• Biophysical modalities
• Ultrasound
• Early post repair increases range of movement, advanced scar
maturation and decreased inflammation around repair (Gan 1995)
• Magnetic Fields (see Henry 2008)
• Chemical
• Mannose-6-Phosphate
• Vitamin C (LK Hung)
• Rhynchophylline (QQ Yang)
• NSAIDs
• Physical barriers – to prevent adhesions
• Seprafilm – used in abdominal surgery
• Amnion
• Other barriers
8. Biological adjuncts
• Growth factors
• TGFß, PDGFs and others
• Combination
• Platelet rich plasma (PRP): autologous,
simple preparation and delivery
• Many biologically active factors – many
positively influencing tendon healing, but
some negative ones as well
• Cells
• Stem cells e.g.
• Mesenchymal stem cells
• Other cells e.g. tenocytes
• Gene therapy
https://www.researchgate.net/publication/331116076_Mechanisms_of_Action_
of_Multipotent_Mesenchymal_Stromal_Cells_in_Tendon_Disease/figures?lo=1
9. Growth factor supplementation
• Single growth factors
• TGF-Beta and its pathways
• PDGF
• bFGF
• IGF
• VEGF (see Kollitz)
• Combination of growth factors
• IGF, PDGF, bFGF
• Limitations
• Dosing, availability and persistent at
the repair site
Costa, M. A., Wu, C., Pham, B. V., Chong, A. K. S., Pham, H. M., & Chang, J.
(2006). Tissue engineering of flexor tendons: Optimization of tenocyte
proliferation using growth factor supplementation. Tissue Engineering, 12(7),
1937–1943. https://doi.org/10.1089/ten.2006.12.1937
10. Platelet rich plasma
• Platelets, bioactive factors (e.g. TGF-Beta, HGF), plasma, and some cells
• Platelets contain large amounts of GFs
• Pros: Autologous, simple to prepare and deliver
• Cons: variable in contents (see Dohan 2009)
• L-PRP vs P-PRP: leukocytes negatively affect tendon healing (e.g. increase
inflammation)
• PRPLP vs PRPHP
• Many in vitro studies show positive effects on tendon proliferation,
differentiation, anabolic effects and decreased inflammation
• In-vivo studies some mixed results
11. Platelet rich fibrin on rabbit
flexor tendon healing
• Platelet rich plasma – autologous
but uses bovine thrombin
• Platelet rich fibrin – completely
autologous
• Fibrin network – cell migration,
controlled release of growth factors
• Applications in dental surgery
• No increase in AROM, lower load
and stress to failure
• Other studies
• No benefit (Kollitz 2014)
• Limitations: dosing, half-life, competing
and compensatory mechanisms
Liao, J. C. Y., He, M., Gan, A. W. T., & Chong, A. K. S. (2017). The Effects of Autologous Platelet-Rich Fibrin
on Flexor Tendon Healing in a Rabbit Model. The Journal of Hand Surgery, 42(11), 928.e1-928.e7.
https://doi.org/10.1016/j.jhsa.2017.06.098
12. Cell therapy
• Different cell sources
• Tenocytes
• Limited
• Need separate procedure for harvest
and expansion
• Stem cells
• MSCs - supply from fat/ bone marrow
• Autologous still needs a separate
procedure
• vs allogeneic
• But other concerns like safety and
immune response
https://www.researchgate.net/publication/331116076_Mechanisms_of_Action_
of_Multipotent_Mesenchymal_Stromal_Cells_in_Tendon_Disease/figures?lo=1
13. Allogeneic bMSCs positively influence tendon healing
• Rabbit Achilles tendon primary
repair
• Randomized to bMSCs or control
• bMSC group
• Cells remain viable up to 6
weeks
• At 3/52, better:
• morphometric parameters
• material properties
• Same at 6/52 and 12/52
• “faster” but not “finally stronger”
Chong, A. K. S., Ang, A. D., Goh, J. C. H., Hui, J. H. P., Lim, A. Y. T., Lee, E. H., & Lim, B. H. (2007). Bone
marrow-derived mesenchymal stem cells influence early tendon-healing in a rabbit achilles tendon
model. J Bone Joint Surg Am, 89(1), 74–81. https://doi.org/10.2106/JBJS.E.01396
Viable cells
1 week
3 weeks
6 weeks
Better material properties
Better nuclear morphometric parameters
at 3 weeks in bMSC group
Nuclear Aspect Ratio = b/a
a b
Nuclear Orientation Angle
14. Gene therapy
• 2021: inflection point – beginning
to see therapeutics reach regular
clinical use after decades of
research
• Possible sequence of adoption –
see below
• In tendon healing
• VEGF (Mao 2017), bFGF (Tang 2008)
• Overcomes half-life problem
Mao, W., Wu, Y., Yang, Q. et al. Modulation of digital flexor tendon healing by vascular endothelial growth
factor gene transfection in a chicken model. Gene Ther 24, 234–240 (2017).
https://doi.org/10.1038/gt.2017.12
VEGF: smoother Stronger
16. Additional References
1. Dohan Ehrenfest, D. M., Rasmusson, L., & Albrektsson, T. (2009). Classification of platelet concentrates: From pure platelet-rich plasma (P-
PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends in Biotechnology, 27(3), 158–167. https://doi.org/10.1016/j.tibtech.2008.11.009
2. Gan, B. S., Huys, S., Sherebrin, M. H., & Scilley, C. G. (1995). The Effects of Ultrasound Treatment on Flexor Tendon Healing in the Chicken
Limb. Journal of Hand Surgery, 20(6), 809–814. https://doi.org/10.1016/S0266-7681(95)80054-9
3. Henry, S. L., Concannon, M. J., & Yee, G. J. (2008). The effect of magnetic fields on wound healing: Experimental study and review of the
literature. Eplasty, 8, e40.
4. Kollitz, K. M., Parsons, E. M., Weaver, M. S., & Huang, J. I. (2014). Platelet-Rich Plasma for Zone II Flexor Tendon Repair. HAND, 9(2), 217–
224. https://doi.org/10.1007/s11552-013-9583-9
5. Leong, N. L., Kator, J. L., Clemens, T. L., James, A., Enamoto‐Iwamoto, M., & Jiang, J. (2020). Tendon and Ligament Healing and Current
Approaches to Tendon and Ligament Regeneration. Journal of Orthopaedic Research, 38(1), 7–12. https://doi.org/10.1002/jor.24475
6. Neiduski, R. L., & Powell, R. K. (2019). Flexor tendon rehabilitation in the 21st century: A systematic review. Journal of Hand Therapy,
32(2), 165–174. https://doi.org/10.1016/j.jht.2018.06.001
7. Singh, R., Rymer, B., Theobald, P., & Thomas, P. B. M. (2015). A review of current concepts in flexor tendon repair: Physiology,
biomechanics, surgical technique and rehabilitation. Orthopedic Reviews, 7(4). https://doi.org/10.4081/or.2015.6125
18. History
• 980-1037 AD: Avicenna – direct tendon repair forgotten (Kleinert)
• Subsequently repair avoided
• – Galen held it lead to convulsions: probably not differentiating tendons from
nerves
• 18-19th Century: von Haller, Syme, Nicoladoni and others described
repair techniques
• Bunnell 1940s:
• Tendon grafting instead of primary repair
• Kleinert 1950s-70s – primary repair can give good results
19. Assessment of outcomes
• Strickland
• Buck-Gramcko
• TAM
• ASSH
• The scores do not correlate well. In
extreme examples, the same AROM
can be classified as poor or
excellent depending on the score
used.
• Present the actual AROM rather
than score used
Hahn, P., Kirchberger,M. C., Unglaub, F., & Spies, C. K. (2016).[How Congruent is the Rating of the Resultsof Flexor Tendon Injury Repairs Using the Scores by Buck-Gramcko,Strickland, and the American
Society for Surgery of the Hand?].Handchirurgie,Mikrochirurgie,PlastischeChirurgie:Organ Der DeutschsprachigenArbeitsgemeinschaftFur Handchirurgie: OrganDer Deutschsprachigen
ArbeitsgemeinschaftFur MikrochirurgieDer PeripherenNerven Und Gefasse:Organ Der V...,48(5), 290–295. https://doi.org/10.1055/s-0042-111892
20. The use of outcome scores for flexor tendon
• Various methods of grading motion qualitative outcomes
• Quantitative physician assessments: ASSH, Strickland, Strickland-Glogovac –
does not reflect patient outcomes (VAS, DASH)
• DIPJ AROM and Total AROM correlate better with patient perceived outcomes
(VAS and DASH)
• Variation in practice seen
• UK study
Karjalainen, T., Jokinen, K., Sebastin, S. J., Luokkala, T., Kangasniemi, O.-P., & Reito, A. (2019). Correlations Among
Objectively Measured Impairment, Outcome Classification Systems, and Subjectively Perceived Disability After Flexor
Tendon Repair. The Journal of Hand Surgery, 44(5), 361–365. https://doi.org/10.1016/j.jhsa.2018.06.010
22. Biophysical stimulation
• Ultrasound
• Early post repair increases range of movement, advanced scar maturation and
decreased inflammation around repair (Gan 1995)
• Magnetic Fields (see Henry 2008)
• Prevent adhesions
• Wrap?
• Application?
• PRP
23. Low Intensity Pulsed Ultrasound (LIPUS)
• Low intensity avoids thermal
effects
• Acoustic cavitation, biological
signalling
• LIPUS: 1-3 MHz, 0.02-1 W/cm2
SATA (Spatial average,
Temporal average) @ 5-20
mins a day
Jiang, X., Savchenko, O., Li, Y., Qi, S., Yang, T., Zhang, W., & Chen, J. (2019). A Review of Low-Intensity Pulsed Ultrasound for
Therapeutic Applications. IEEE Transactions on Biomedical Engineering, 66(10), 2704–2718.
https://doi.org/10.1109/TBME.2018.2889669
24. Magnetic Field and tendon healing
• Some evidence it can help bone and wound healing
• Early evidence it can help tendon healing (see Henry 2008)
• Pulsed magnetic field of low amplitude: increases tensile strength in rat
Achilles tendon
• But also conflicting information from other studies
• Mechanisms unclear
• Vascular effect
• Best protocol unclear
• Static vs PEMF
• Strength: 23 Gauss to 400 Gauss
Henry, S. L., Concannon, M. J., & Yee, G. J. (2008). The effect
of magnetic fields on wound healing: Experimental study and
review of the literature. Eplasty, 8, e40
25. Biophysical considerations
• Article focuses on PEMF (time-varying low frequency EMF)
• Used for:
• Adjuvant for MSK injuries
• Neurological conditions
• Cancer – prevents angiogenesis
• ‘biophysical dosimetry’ needed for different conditions likely to be different
• “Biological windows” concept
• Also consideration of waveforms:
• Sine vs semi-sine
• Pulsed signal
• Target – cell memberane – signal transduction
• Calcium ion Markov, M. S. (2007). Pulsed electromagnetic field therapy
history, state of the art and future. The Environmentalist,
27(4), 465–475. https://doi.org/10.1007/s10669-007-9128-2
26. Rhynchophylline improves flexor tendon
repair in chickens
• Tetracyclic oxindole alkaloid
• Active ingredient in Uncaria/ Cat’s claw/ Gambier
• Investigated as candidate drug for CVS/CNS diseases
• Previously shown to prevent intra-abdominal
adhesions
• In Flexor tendons to:
• Inhibited adhesion (via adhesion score)
• Tendon healing
• Gliding excursion
Yang, Q. Q., Zhang, L., Ju, F., & Zhou, Y. L. (2021). Sustained-Release Hydrogel-Based Rhynchophylline Delivery System
Improved Injured Tendon Repair. Colloids and Surfaces B: Biointerfaces, 111876.
https://doi.org/10.1016/j.colsurfb.2021.111876
27. Different types of PRP
• Choukroun’s PRF as the
simplest and open access
technique
Dohan Ehrenfest, D. M., Rasmusson, L., & Albrektsson, T. (2009). Classification of platelet concentrates: From pure
platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin (L-PRF). Trends in Biotechnology, 27(3), 158–167.
https://doi.org/10.1016/j.tibtech.2008.11.009
28. PRF: second generation platelet
concentrate
• Issues with commercial fibrin
glues - safety
• Autologous fibrin prep
• Complex procedures
• Amount?
• PRF
• Must be fast to centrifuge – else
non-usable product
• Structure different
• ? Contains more bioactive
substances?
Fig. 4. Theoretical computer modelling of condensed tetramolecular
or bilateral fibrin branch junctions. Note the rigidity of this architecture
(D-TEP v1.3).
Fig. 5. Theoretical computer modelling of trimolecular or equilateral
fibrin branch junctions. Note the flexibility of this net architecture (D-
TEP v1.3).
Dohan, D. M., Choukroun, J., Diss, A., Dohan, S. L., Dohan, A. J. J., Mouhyi, J., & Gogly, B. (2006). Platelet-rich
fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 101(3), e37–e44.
https://doi.org/10.1016/j.tripleo.2005.07.008
29. Mesenchymal stem cells increases tendon healing rate in rabbits
after primary repair
NZW Rabbits (female, 13wks)
bMSC culture
bm aspiration
allogeneic
ex-vivo expansion
Histology Biomechanics
Harvest @ 3, 6 & 12 weeks
foot
Sharp division at mid-
substance of Achilles
tendon followed by
repair
foot
Fibrin only
Fibrin & bMSC
Chong AK, Ang AD, Goh JCH, Hui JHP, Lim AY, Lee EH, Lim BH, Journal of Bone and Joint Surgery, 2007
30. Results
1 week
3 weeks
6 weeks
Tendon long axis
1 2 Better nuclear morphometric parameters at 3
weeks in bMSC group
3
Nuclear Aspect Ratio = b/a
a b
Nuclear Orientation Angle