Low-dose CT imaging of radio-opaque markers for assessing human rotator cuff repair: accuracy, repeatability and the effect of arm position.

Previous studies have used radiostereometric analysis (RSA) to assess the integrity and mechanical properties of repaired tendons and ligament grafts. A conceptually similar approach is to use CT imaging to measure the 3D position and distance between implanted markers. The purpose of this study was to quantify the accuracy and repeatability of measuring the position and distance between metallic markers placed in the rotator cuff using low-dose CT imaging. We also investigated the effect of repeated or variable positions of the arm on position and distance measures. Six human patients had undergone rotator cuff repair and placement of tantalum beads in the rotator cuff at least one year prior to participating in this study. On a single day each patient underwent nine low-dose CT scans in seven unique arm positions. CT scans were analyzed to assess bias, precision and RMS error of the measurement technique. The effect of repeated or variable positions of the arm on the 3D position of the beads and the distance between these beads and suture anchors in the humeral head were also assessed. Results showed the CT imaging method is accurate and repeatable to within 0.7 mm. Further, measures of bead position and anchor-to-bead distance are influenced by arm position and location of the bead within the rotator cuff. Beads located in the posterior rotator cuff moved medially as much as 20 mm in abduction or external rotation. When clinically relevant CT arm positions such as the hand on umbilicus or at side were repeated, bead position varied less than 4 mm in any anatomic direction and anchor-to-bead distance varied +2.8 to -1.6 mm (RMS 1.3 mm). We conclude that a range of ± 3 mm is a conservative estimate of the uncertainty in anchor-to-bead distance for patients repeatedly scanned in clinically-relevant arm positions.

An analytical model for rotator cuff repairs.

BACKGROUND: Currently, natural and synthetic scaffolds are being explored as augmentation devices for rotator cuff repair. When used in this manner, these devices are believed to offer some degree of load sharing; however, no studies have quantified this effect. Furthermore, the manner in which loads on an augmented rotator cuff repair are distributed among the various components of the repair is not known, nor is the relative biomechanical importance of each component. The objectives of this study are to (1) develop quasi-static analytical models of simplified rotator cuff repairs, (2) validate the models, and (3) predict the degree of load sharing provided by an augmentation scaffold. METHODS: The individual components of the repair constructs were modeled as non-linear springs, and the model equations were formulated based on the physics of springs in series and parallel. The model was validated and used to predict the degree of load sharing provided by a scaffold. Parametric sensitivity analysis was used to identify which of the component(s)/parameter(s) most influenced the mechanical behavior of the augmented repair models. FINDINGS: The validated models predict that load will be distributed approximately 70-80% to the tendon repair and approximately 20-30% to the augmentation component. The sensitivity analysis suggests that the greatest improvements in the force carrying capacity of a tendon repair may be achieved by improving the properties of the bone-suture-tendon interface. Future studies will perform parametric simulation to illustrate the manner in which changes to the individual components of the repair, representing different surgical techniques and scaffold devices, may influence the biomechanics of the repair construct.

Homotypic variation of canine flexor tendons: implications for the design of experimental studies in animal models.

Water, collagen and glycosamimoglycan contents, cross-sectional area, stiffness and elastic modulus were carefully quantitated in flexor digitorum superficialis tendons from mature canines. From these data the within- and between-animal variability was estimated and used to demonstrate sample size calculations for both two-group and paired (within-animal) study designs. The estimated between-dog variance was typically 50% or less of the total variance for the parameters investigated. In other words, the correlation among the tendons within an animal for most measures was not strong. Therefore, for some variables (e.g., elastic modulus) in this animal and tendon model, there is no appreciable gain in statistical power by using a paired study design. A two-group design could be used, but any within-animal correlation must be accounted for in the analysis. For other variables such as collagen content, a paired design would gain substantial power.

Proteoglycans and glycosaminoglycan fine structure in the mouse tail tendon fascicle.

The isolated mouse tail tendon fascicle, a functional and homogenous volume of tendon extracellular matrix, was utilized as an experimental system to examine the structure function relationships in tendon. Our previous work using this model system demonstrated relationships between mean collagen fibril diameter and fascicle mechanical properties in isolated tail tendon fascicles from three different groups of mice (3-week and 8-week control and 8-week Mov13 transgenic) K.A. Derwin, L.J. Soslowsky, J. Biomech. Eng. 121 (1999) 598-604. These groups of mice were chosen to obtain tendon tissues with varying collagen fibril structure and/or biochemistry, such that relationships with material properties could be investigated. To further investigate the molecular details of matrix composition and organization underlying tendon function, we report now on the preparation, characterization, and quantitation of fascicle PGs (proteoglycans) from these three groups. The chondroitin sulfate/dermatan sulfate (CS/DS)-substituted PGs, biglycan and decorin, which are the abundant proteoglycans of whole tendons, were also shown to be the predominant PGs in isolated fascicles. Furthermore, similar to the postnatal maturation changes in matrix composition previously reported for whole tendons, isolated fascicles from 8-week mice had lower CS/DS PG contents (both decorin and biglycan) and a higher collagen content than 3-week mice. In addition, CS/DS chains substituted on PGs from 8-week fascicles were shorter (based on a number average) and richer in disulfated disaccharide residues than chains from 3-week mice. Fascicles from 8-week Mov13 transgenic mice were found to contain similar amounts of total collagen and total CS/DS PG as age-matched controls, and CS/DS chain lengths and sulfation also appeared normal. However, both decorin and biglycan in Mov13 tissue migrated slightly faster on sodium dodecyl sulfate polyacrylamide gel electorphoresis (SDS-PAGE) than the corresponding species from 8-week control, and biglycan from the 8-week Mov 13 fascicles appeared to migrate as a more polydisperse band, suggesting the presence of a unique PG population in the transgenic tissue. These observations, together with our biomechanical data [Derwin and Soslowsky, 1999] suggest that compensatory pathways of extracellular matrix assembly and maturation may exist, and that tissue mechanical properties may not be simply determined by the contents of individual matrix components or collagen fibril size.

A quantitative investigation of structure-function relationships in a tendon fascicle model.

These studies sought to investigate quantitative relationships between the complex composite structure and mechanical properties of tendon. The isolated mouse tail tendon fascicle was chosen as an appropriate model for these so-called "structure-function" investigations. Specifically, collagen fibril diameters and mechanical properties were measured in fascicles from immature (3 week) control, adult (8 week) control, and adult (8 week) MovI3 transgenic mice. Results demonstrated a moderate correlation between mean fibril diameter and fascicle stiffness (r = 0.73, p = 0.001) and maximum load (r = 0.75, p < 0.001), whereas a weak correlation with fascicle modulus (r = 0.39, p = 0.11) and maximum stress (r = 0.48, p = 0.04). An analysis of pooled within-group correlations revealed no strong structure-function trends evidenced at the local or group level, indicating that correlations observed in the general structure-function analyses were due primarily to having three different experimental groups, rather than significant correlations of parameters within the groups.

A new optical system for the determination of deformations and strains: calibration characteristics and experimental results.

Many types of optical strain measurement systems have been used for the determination of deformations and strains in soft biological tissues. The purpose of this investigation is to report a new optical strain measurement system developed in our laboratory which offers distinct advantages over systems developed in the past. Our optical strain system has demonstrated excellent performance in calibration and experimental tests. Calibration tests illustrate the system's accuracy to 0.05% strain at 3.52% strain and 0.18% strain at 11.74% strain. Further, this system can measure strains to within 2% measurement error for strains in a 0-11.74% range when 100 microns increments of motion are used for calibration. The resolution of our system appears to be at least as good as the linear micrometer (2 microns) used as a calibrating standard. Errors in strain measurement due to whole specimen rotation or translation are quantified. Rotations about an in-plane axis perpendicular to the direction of strain and translations in/out of the plane of focus result in the largest sources of error. Finally, in an in vitro biomechanical study of the rabbit Achilles tendon, experimental failure strains are 4.3 +/- 0.9% using this system.

Nociceptive role of substance-P in the knee joint of a patient with congenital insensitivity to pain.

This case report describes the immunocytochemical examination of tissue from a 9-year-old black child diagnosed with congenital insensitivity to pain at age 5. A recent fall and resulting patella fracture required surgical treatment. Biopsies of the distal pole and surrounding soft tissue, as well as a sample of his patellofemoral joint fluid, were taken at the time of partial patellectomy and analyzed for substance-P (SP). Morphologic staining of the patella showed a grossly degenerated patellofemoral articular surface. Examination of tissue sections stained either immunocytochemically with diaminobenzidine DAB or by a rhodamine fluorescent labeling technique showed no evidence of SP-positive nerve fibers. Furthermore, only a trace amount of SP (7.29 pg/ml) was detected in a sample of the patient's knee joint synovial fluid. This patient's absence of pain sensation in conjunction with the absence of SP nerve fibers in stained patella sections and identification of only trace levels of SP in his synovial fluid, further implicates this neuropeptide in nociceptive innervation of diarthrodial joints.