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Spinal nerve fibrosis following injury or surgical intervention may play an important role in the pathophysiology of chronic back pain. In this current study, we demonstrate the role of biomechanical quantification of lumbar intraforaminal spinal nerve adhesion and tethering in the analysis of the post-laminectomy condition and describe a direct methodology to make this measurement. Twenty age-matched Sprague-Dawley male rats were divided into operative and non-operative (control) groups. Operative animals underwent a bilateral L5-L6 laminectomy with right-side L5-6 disc injury, a post-laminectomy pain model previously published by this lab. At eight weeks, animals were sacrificed and the strength of adhesion of the L5 intraforaminal spinal nerve to surrounding structures was quantified using a novel biomechanical methodology. Operative animals were found to have a significantly greater load to displace the intact right L5 spinal nerve through the intervertebral foramen when compared to control animals. The findings show that the post-laminectomy condition creates quantifiable fibrosis of the spinal nerve to surrounding structures and supports the conclusion that this fibrosis may play a role in the post-laminectomy pain syndrome.

Background Context: Failed back syndrome, a condition that affects 3-14% of postoperative spine patients, is characterized by the recurrence of radicular pain after spinal decompression. The source of this pain in some patients is thought by many investigators to be the result of epidural scarring and nerve root tethering, but this is controversial. We have previously demonstrated that in a disc-injury model the untreated postlaminectomy rats develop a significant proliferative fibrous response at 8 weeks with spinal nerve scarring to the disc and adjacent pedicle, and increased sensitivity to tactile allodynia testing in the related sensory dermatome. Topical high-molecular-weight hyaluronan (HMW HA) moderates both the proliferative fibrosis and the behavioral pain response., Purpose: Our purpose is to study the time-related changes in the proinflammatory cytokine and monocyte/macrophage profiles in the epidural space in the early postlaminectomy untreated and HMW HA gel treated groups., Study Design/setting: A modified rat laminectomy with disc injury model was employed to assess epidural fibrosis between and around the spinal nerves using a quantitative immunohistochemistry assessment approach along with correlative enzyme-linked immunosorbent assay analysis., Methods: Lumbar laminectomies at L5 and L6 with a L5-L6 disc injury were performed on 120 adult male Sprague-Dawley rats. The rats were then randomized into one of two groups: untreated and treated. The treatment group received a one-time topical application of 0.1 cc of HMW HA gel directly to the laminectomy site just before wound closure. The rats were then randomly subdivided into survival periods of 24 hours, 72 hours, and 7 days. Immunohistochemistry was performed on fresh frozen sections and stained for interleukin-1 beta (IL-1beta) and monocytes/macrophages (ED-1) using monoclonal antibodies and 3, 3' diaminobenzidine (DAB) chromogen. The amount of stain in each specimen was then quantified using the National Institutes of Health computer imaging analysis system., Results: The semiquantified data from the histological specimens demonstrated significant decreases in the IL-1beta and IL-6 infiltration observed at 24 hours in the epidural space and around the right nerve root (p=.0296 and 0.0195, respectively) in the HA gel treated group. Additionally, significant decreases in the monocyte/macrophage infiltration were observed at 72 hours in the epidural space around the left nerve root (p=.0039) and right nerve root (p=.0072) in the HA gel treated group. At 7 days, IL-1beta, IL-6, and macrophage infiltration of the wound had declined in both the HA gel and the untreated groups. The enzyme-linked immunosorbent assay data support the same pattern as seen in the histological results., Conclusion: These results demonstrate that treatment of postlaminectomy wounds with HMW HA gel decreases the number of monocytes and macrophages and the concentration of certain cytokines in the early inflammatory phase of healing. There are several plausible explanations for this effect. First, the HMW HA may block the interaction of short-chain low-molecular-weight HA with proinflammatory cell surface receptors. The interaction of these short-chain oligo-HA fragments, upon cell-surface receptor binding, induces changes in inflammatory cells that lead to increased cell motility and migration into the wound area. Second, the addition of exogenous HMW HA may cause a dilution effect in the wound, thereby decreasing the concentration of inflammatory cells in the extracellular matrix of the region of injury. Finally, the migration of inflammatory cells may be decreased in the viscous environment of the HMW HA. The first explanation is believed by the authors of this paper to be the more likely mechanism. HMW HA probably mutes the proinflammatory effects of the low-molecular weight fragments, leading to decreased inflammation, and thus decreased fibrosis and scar formation noted in the chronic model.

Background Context: A controversy exists about the mechanism of causation of the post-laminectomy pain syndrome. Some believe that epidural scarring, and attendant spinal nerve and nerve root scarring and tethering to the disc or pedicle at the site of surgery contributes to post-laminectomy pain in such patients. However, clinical outcome studies on this question are inconclusive and the assertion remains controversial. Definitive studies to help resolve the question are needed. Previously our laboratory has reported on a preclinical post-laminectomy model that mimics the postoperative proliferative fibrotic response grossly, as well as by biochemical assessment of the collagen content within the spinal canal. The post-laminectomy fibrotic response was attenuated in that study by application of a topical antifibrotic (high molecular weight hyaluronan gel) or by insertion of an absorbable roofing barrier (0.2-mm-thick Macropore sheet material) over the laminectomy defect before wound closure. The question remains of relevance of the attenuation of the fibrotic response to post-laminectomy chronic pain syndromes., Purpose: The purpose of this study is to evaluate the effect of therapeutic attenuation of proliferative scar within the spinal canal post laminectomy on the pain-related behavioral response in a preclinical rat model., Study Design/setting: An established L5-L6 rat laminectomy model with a unilateral L5-6 disc injury was employed to assess postoperative proliferative fibrosis of the L5 spinal nerves using quantitative biochemical hydroxyproline assessment of the collagen content in four experimental groups. These observations were correlated with gross descriptions of spinal nerve scarring or tethering. Associated manifestations of a sensory pain-related response in the L5 spinal nerve receptor area of the hind paws was studied using standard tactile allodynia assessment with the von Frey hair technique. The tactile allodynia findings were supplemented by weekly descriptors of behavioral pain manifestations., Methods: Bilateral laminectomies at L5 and L6 and a unilateral right disc injury (L5-6) were performed on 35 male adult Sprague-Dawley rats, weighing 400+ grams (approved by the VA Institutional Animal Care Use Committee). The study consisted of four groups: 1) normal nonoperative control; 2) a sham-operated group; 3) an untreated laminectomy-disc injury group; and 4) a laminectomy-disc injury treatment group in which 0.1 cc topical high molecular weight hyaluronan (HMW HA) gel was layered over the dura and into the laminectomy canal before closure. Before animals were entered into the study, they were checked for the presence of abnormal response to the tactile testing procedure of the L5 sensory receptor area. Animals exhibiting anomalous responses were excluded from the study. Behavioral testing for tactile allodynia was performed at weekly intervals post laminectomy beginning at 3 weeks. Pain-related behavior was characterized at weekly intervals. A behavioral test cage with a wire mesh floor allowed for tactile allodynia testing. Graduated von Frey hairs whose stiffness increased logarithmically from 0.41 to 15 g were used for tactile allodynia tests. The animals were killed 8 weeks postoperatively for analysis. The dissected spinal nerve and nerve root specimens were studied biochemically for hydroxyproline content to estimate total collagen in and around the L5 neural structures. Statistical analyses were performed using analysis of variance and a Fisher comparison t test., Results: The major observations on the untreated preclinical post-laminectomy rat model previously described by this laboratory were confirmed. All untreated animals developed a tail contracture concave toward the right (disc injury side) consistent with asymmetrical lumbar muscle spasm. Only one animal in the HA gel treatment group had a tail contracture. It was of mild degree and occurred in an animal that demonstrated slightly increased right L5 tactile sensitivity. Gross inspection of the dissected specimens demonstrated spinal nerve scarring and tethering to the disc and pedicle greater on the right than the left in untreated animals, findings that were markedly reduced in the treatment group. Collagen content of the L5 spinal nerve and nerve roots with attached scar were significantly lower in the HA gel treatment group than in the untreated laminectomy group (p=.0014). Pain behavioral testing of the L5 receptor area of the right hind paw in the untreated laminectomy group showed markedly increased sensitivity to tactile allodynia testing compared with the corresponding limb of the control group (p=.0001), to the corresponding limb of the sham group (p=.0001), and compared with the HMW HA gel treatment group (p=.0010). Comparisons of the pain behavioral data between the sham and the post-laminectomy HA gel treatment group and the control animals lacked statistical significance., Conclusion: This study supports the concept of a relationship between perineural fibrosis and radicular neuropathy in the model described, and emphasizes the role of disc injury and spinal nerve retraction in the post-laminectomy fibrotic process. Furthermore, it shows promise for preliminary assessment of interventions with other anti-inflammatory agents, for characterization of the neurochemical profile of the post-laminectomy pain state, and for exploration of newer pharmaceutical agents potentially useful in the prevention or management of the post-laminectomy syndrome. Post-laminectomy scar is but one of many potential causes of the post-laminectomy pain syndrome. Furthermore, a cautionary note must be emphasized as in all studies using preclinical models, conclusions drawn from the studies cannot be extended directly to patients without confirmatory clinical follow-up studies.

Background Context: The relevance of epidural fibrosis to failed back surgical outcomes remains controversial. Previous studies on the correlation between epidural fibrosis and clinical outcome after laminectomy are inconclusive, and clinical approaches applied to reduce postlaminectomy spinal canal scarring have produced mixed outcomes., Purpose: Improved preclinical models are required to address the fundamental question of the relationship between postlaminectomy fibrosis and chronic pain. This study is directed at establishing small animal postlaminectomy models characterized by significantly reduced scar within the spinal canal postoperatively. Such preclinical models are offered as a platform for future studies to explore the potential relationship between postlaminectomy epidural fibrosis and persistent neuropathy with its potential for altered spinal mechanisms for pain processing, so-called spinal facilitation. Such experiments could be constructed in these models for comparison of pain behavior and its underlying neurochemistry both in the presence and absence of extensive postlaminectomy epidural scar., Study Design/setting: A modified rat laminectomy model was employed to assess epidural fibrosis using a quantitative biochemical collagen assessment approach along with correlative histology. This group served as the control for comparison with groups in which antifibrotic measures were employed. We compared antifibrotic efficacy of a bioabsorbable roofing barrier sheet placed over the laminectomy defect with topical high-molecular-weight hyaluronan (HMW HA) gel, each applied postoperatively to prevent proliferative epidural scarring. Routine biomechanical tensile strength testing was employed to assess wound-healing strength., Methods: A bilateral laminectomy (L5 and L6) with associated unilateral disc injury (L5-L6) was performed in 98 male Harlan Sprague-Dawley rats. The laminectomy models described incorporated a unilateral disc injury at L5-L6 because herniated disc material has been shown to contribute proinflammatory cytokines in the postoperative wound. Five groups were employed for the study: 1) normal controls without surgery; 2) a laminectomy-disc injury group without treatment; 3) a laminectomy-disc injury group treated with topical HMW HA gel; 4) a laminectomy-disc injury group treated with 0.2-mm thick bioabsorbable roofing barrier sheet in which a protected space was maintained between overlying paraspinous muscles and the dura and 5) a 0.02-mm thin barrier sheet treatment group in which the sheet was placed directly on the dura. The animals were sacrificed at 3- and 8-week postoperative intervals for analysis. The dissected specimens were studied biochemically for hydroxyproline content to estimate total collagen within the canal and on the dura between L4 and L7. Additional specimens were prepared histologically and stained with Masson-Goldner Trichrome stain to confirm presence of proliferative collagen and to describe the presence or absence of wound-healing scar adherence to the dura. The surgical incisions were studied biomechanically by uniaxial tensile testing to determine ultimate force, strain and prefailure stiffness. Statistics were performed using analysis of variance., Results: Gross appearance and histology studies showed that the untreated laminectomy group demonstrated postoperative scar formation that is adherent between the wound and the dorsum of the dura mater in both 3- and 8-week groups. Proliferative scar was substantially increased grossly between the 3- and 8-week intervals. By gross observation there was adherence of the L5 spinal nerve to the underlying disc and adjacent pedicle on the disc injury side. Gross observation of treatment groups, in contrast, disclosed that both the 0.2-mm thick roofing barrier sheet and topical HMW HA gel each prevented scar attachment to the dural sleeve at both the 3- and 8-week postoperative intervals. Furthermore, both the HMW HA gel and 0.2-mm thick roofing barrier sheet treatment groups had significant reduction of total collagen content in the laminectomy specimens measured biochemically at the two time periods compared with the untreated controls. Histologically, the HMW HA gel and the 0.2-mm thick barrier sheet findings were consistent with the gross observations concerning lack of adherence between scar of the overlying wound and the dura. Notably, both the 0.2- and the 0.02-mm barrier sheets became enveloped by a fibrotic envelope consistent with a foreign body reaction. In the group in which the 0.02-mm thin sheet was placed within the canal on top of the dura, there was an increase of fibrosis around the sheet within the canal leading to a space-occupying mass within the canal. Although the 0.2-mm thick roofing barrier placed external to the canal became enveloped by scar, it appeared to attract proliferative scar away from the epidural space, leaving the dura relatively free of scarring or adherence to overlying tissues. The mechanical properties of the incisional wound increased significantly between 3 and 8 weeks. The ultimate strength, stress, strain and stiffness of the several groups were similar at each time point., Conclusion: These results provide two preclinical rat laminectomy models of potential usefulness for the future study of the relevance of epidural fibrosis to behaviorally defined pain states, and for the study of the potential of an altered neurochemical signature in postlaminectomy pain conditions. Such preclinical models have become standard in studies of pain behavior and its neurochemistry in preclinical sciatic nerve and spinal nerve injury models, and should be of utility in the studies of postlaminectomy fibrosis. There was progressive scar proliferation and maturation in the untreated postlaminectomy group in the postoperative interval between 3 and 8 weeks. HMW HA gel applied topically and a 0.2-mm thick bioabsorbable Macropore sheet used as a roofing barrier each significantly reduced postlaminectomy proliferative scar without affecting the integrity of incisional wound healing. However, if the 0.02-mm thin barrier sheet used in this study is placed within the canal in contact with the dura and adjacent to the pedicles, the process of reabsorption results in a fibrotic mass within the canal. The preferred barrier sheet placement for this model is clearly in a roofing position bridging over the open epidural space. It must be placed in a manner to block off the paraspinous muscle healing response and still leave a gap between the sheet and the dura.

Chronic low back pain with sciatica complicating post laminectomy surgery is poorly understood. It is likely that some aspects of persistent pain of the syndrome results from spinal facilitation in which there is lowering of pain excitation levels. A small animal preclinical model is needed that mimics the clinical condition to permit detailed studies of the underlying altered neurochemistry of the sensory pathways. We propose herein a rat laminectomy model containing the elements required for study of the neurobiology of the condition. The model consists of a surgical laminectomy that includes L5 spinal nerve manipulation and disc injury, elements necessarily employed in human disc herniation surgery. At 8 weeks post laminectomy the proposed model demonstrates paraspinous muscle spasm, tail contracture, behavioral pain behavior, tactile allodynia, epidural and nerve root scarring, and nerve root adherence by scar to the underlying disc and adjacent pedicle. Two underlying pain facilitation states are invoked in the clinical condition: (1) an inflammatory state required to achieve wound healing; and (2) a nerve injury state resulting from nerve manipulation and subsequent epidural scarring, spinal nerve scarring, and spinal nerve tethering to the adjacent disc and pedicle. Both pain facilitation states are active in the model.

Background: Emergent irrigation and debridement has been accepted as a mainstay of open fracture treatment. The purpose of this study was to evaluate the infectious outcome of open tibia fractures relative to the time from injury to operative irrigation and debridement., Methods: One hundred seventy-eight patients with 191 consecutive fractures were retrospectively reviewed. Of these, 103 patients with 106 fractures were available for this study, with an average follow-up of 10.23 months., Results: Results revealed 21.7% type I fractures, 43.4% type II fractures, 16.0% type IIIa fractures, 11.3% type IIIb fractures, and 7.5% type IIIc fractures. Of all fracture types, 22.6% became infected and 5.7% went on to have osteomyelitis. The average time to treatment was not significantly different in infected versus noninfected fractures across fracture types. No infection occurred when the time to surgery was within 2 hours; however, no significant increase in infection was discovered with respect to patients treated after 6 hours compared with those treated within 6 hours., Conclusion: The results support the Gustilo grading system of open fractures as a significant prognostic indicator for infectious complication. We continue to support the emergent treatment of open tibia fractures.

The number of chondrogenic cells available locally is an important factor in the repair process for cartilage defects. Previous studies demonstrated that the number of transplanted rabbit perichondrial cells (PC) remaining in a cartilage defect in vivo, after being carried into the site in a polylactic acid (PLA) scaffold, declined markedly within two days. This study examined the ability of in vitro culture of PC/PLA constructs to enhance subsequent biomechanical stability of the cells and the matrix content in an in vitro screening assay. PC/PLA constructs were analyzed after 1 h, 1 and 2 weeks of culture. The biomechanical adherence of PC to the PLA scaffold was tested by subjecting the PC/PLA constructs to a range of flow velocities (0.25-25 mm/s), spanning the range estimated to occur under conditions of construct insertion in vivo. The adhesion of PC to the PLA carrier was increased significantly by 1 and 2 weeks of incubation, with 25 mm/s flow causing a 57% detachment of cells after 1 h of seeding, but only 7% and 16% after 1 and 2 weeks of culture, respectively (p<0.001). This adherence was associated with marked deposition of glycosaminoglycan and collagen. These findings suggest that pre-incubation of PC-laden PLA scaffolds markedly enhances the stability of the indwelling cells.

A recurring problem in tissue transplantation therapies for articular cartilage defects is the lack of integration between the implant and the host cartilage. Previous studies have shown that in vitro integration between explants of calf cartilage is markedly higher than that between fetal cartilage, despite similarly high levels of deposition of newly synthesized collagen. The aim of this study was to determine if cellular biosynthesis and extracellular matrix each contribute to these development-associated differences in integrative repair in vitro. The approach taken was to examine integration between specific combinations of cartilage explants that were apposed for two weeks. The cartilage matrix showed different propensities for repair, as integration of calf live cartilage to calf devitalized cartilage was greater than that of calf live cartilage to fetal devitalized cartilage. An inhibiting factor appeared to be present in fetal cartilage matrix since guanidine treatment of fetal devitalized cartilage was able to enhance its integration. The difference between integration to living cartilage and integration to devitalized cartilage, for calf and fetal tissue, indicated that the biosynthetic contribution to integration by calf cartilage was greater than the biosynthetic contribution by fetal cartilage. Thus, the increasing level of integration between fetal and fetal cartilage, fetal and calf cartilage, and calf and calf cartilage appeared to reflect both biosynthetic and matrix differences. Therapeutic strategies to enhance integration to cartilage may thus target both the extracellular components and the cellular biosynthetic activities of implants and host cartilage.

Objectives: The objectives of this research were to determine whether the integrative repair of bovine cartilage explants was dependent on developmental stage, and whether observed differences in integration with developmental stage were related to deposition of newly synthesized collagen and lysyl oxidase-mediated collagen cross-linking., Methods: Pairs of fetal, newborn calf, and adult bovine cartilage blocks were cultured in partial apposition for 2 weeks in medium supplemented with serum, ascorbate, and [3H]proline. Following culture, mechanical integration between apposed cartilage blocks was assessed by measuring adhesive strength in a single-lap shear configuration. Formation and stabilization of newly synthesized protein and collagen was investigated by determination of [3H]proline and [3H]hydroxyproline in tissue digests and guanidine extracts., Results: Calf cartilage exhibited a relatively high integrative repair phenotype, achieving an adhesive strength that was three--four-fold that of adult or fetal specimens. The low and high integrative repair phenotypes appeared related in part to different levels of collagen biosynthesis, which was approximately four--five-fold higher in calf cartilage samples than in the adult. However, fetal cartilage also exhibited a high level of biosynthesis. The different integrative repair phenotypes were not associated with marked differences in the kinetics of chemical stabilization of newly synthesized collagen, as the proportion of incorporated [3H]proline and newly-formed [3H]hydroxyproline that was resistant to extraction by 4M guanidine-HCl following culture was similar for cartilage from all developmental stages. Integration of calf cartilage appeared to depend on lysyl oxidase-mediated collagen cross-link formation, since inclusion of beta-aminopropionitrile (BAPN) in the culture medium completely eliminated development of adhesive strength. BAPN treatment also increased the percentage of newly synthesized protein in the guanidine extracts from 10% to 36% of the total, and that of newly synthesized collagen from 2% to 20%, while having only slight inhibitory effects on overall protein and collagen biosynthesis., Conclusion: The finding that cartilage exhibits enhanced integrative repair at a certain developmental stage suggests that it may ultimately be possible to enhance repair when needed in clinical situations., (Copyright 2002 OsteoArthritis Research Society International.)

Variations in certain mesenchymal tissue healing processes are not widely recognized. The current review summarizes key differences in healing mechanisms and healing potential after injury to soft tissues having different healing outcomes.

Numerous studies have demonstrated the capacity of mechanical strains to modulate cell behavior through several different signaling pathways. Understanding the response of ligament fibroblasts to mechanically induced strains may provide useful knowledge for treating ligament injury and improving rehabilitation regimens. Biomechanical studies that quantify strains in the anterior cruciate and medial collateral ligaments have shown that these ligaments are subjected to 4-5% strains during normal activities and can be strained to 7.7% during external application of loads to the knee joint. The objective of this study was to characterize the expression of types I and III collagen in fibroblast monolayers of anterior cruciate and medial collateral ligaments subjected to equibiaxial strains on flexible growth surfaces (0.05 and 0.075 strains) by quantifying levels of mRNA encoding these two proteins. Both cyclic strain magnitudes were studied under a frequency of 1 Hz. The results indicated marked differences in responses to strain regimens not only between types I and III collagen mRNA expression within each cell type but also in patterns of expression between anterior cruciate and medial collateral ligament cells. Whereas anterior cruciate ligament fibroblasts responded to cyclic strains by expression of higher levels of type-I collagen message with almost no significant increases in type-III collagen, medial collateral ligament fibroblasts exhibited statistically significant increases in type-III collagen mRNA at all time points after initiation of strain with almost no significant increases in type-I collagen. Furthermore, differences in responses by fibroblasts from the two ligaments were detected between the two strain magnitudes. In particular, 0.075 strains induced a time-dependent increase in type-III collagen mRNA levels in medial collateral ligament fibroblasts whereas 0.05 strains did not. The strain-induced changes in gene expression of these two collagens may have implications for the healing processes in ligament tissue. The differences may explain, in part, the healing differential between the anterior cruciate and medial collateral ligaments in vivo.

To illuminate the effect of titanium particles on osteoblast function, we compared the adhesion force of neonatal rat calvarial osteoblasts on fibronectin-coated glass after incubation with titanium particles (80% had diameters of less than 5 microm). The cells were incubated with the particles for 1.5-72 hours. Using a micropipette single-cell manipulation system, we showed that the adhesion force of the osteoblasts to fibronectin-coated glass (1.0 microg/ml) was significantly affected by the presence of particulate debris. The adhesion force of the cells incubated with titanium particles for less than 4 hours was not significantly affected by exposure to the particles; after 4 hours, however, it was significantly reduced relative to that of controls. Aspiration of particle-challenged osteoblasts into the micropipette demonstrated that the particles were not stripped from the cell surface and therefore confirmed that the osteoblasts had ingested them. During aspiration, the particles traveled through the cytoplasm rather than on the cell surface. When the osteoblasts were exposed to the particles and cytochalasin D, they exhibited much lower adhesion forces than did the controls or the cells exposed to titanium particles only; this indicates an important role of actin filaments in the osteoblastic response to particles. Staining for F-actin also indicated an influence of internalized titanium particulate on cytoskeletal arrangement and cell spreading. Furthermore, with standard Northern blotting techniques, levels of mRNA for collagen type I and fibronectin were significantly reduced as early as 4 hours after exposure to particles compared with levels in controls, and this effect continued to 72 hours. These data indicate that direct exposure of osteoblasts to titanium particles, which we propose to be ingested by the osteoblasts, can significantly decrease osteoblast adhesion force; this may lead to decreased cellular activity and gene expression of fibronectin and collagen type I in the presence of titanium wear debris.

A novel method of quantitating cell migration has been proposed for the potential utilization of tissue engineered scaffolds. Applying Alt's conservation law to describe the motion of first passage ACL and MCL cells, we have developed a quantitative method to assess innate differences in the motility of cells from these two ligamentous tissues. In this study, first passage ACL and MCL cells were cultured from four mature New Zealand white rabbits. One side of the cell monolayer was scraped completely away to create a wound model. The cell moved into the cell-free area, and cell density profiles were analyzed at 6 h and 12 h. Values of the random motility coefficient (mu) were then estimated by curve fitting the 6 h and 12 h data to a mathematical model, derived from the conservation law of cell flux. During 6 h of incubation in medium supplemented with 1% FBS, MCL cells (mu(MCL) = 4.63 +/- 0.65 X 10(-6) mm(2)/sec) were significantly (p < 0.05) more mobile than ACL cells (mu(ACL) = 2.51 +/- 0.31 X 10(-6) mm(2)/sec). At 12 h, the MCL cells also appeared to move faster (mu(ACL) = 4.39 +/- 0.63 X 10(-6) mm(2)/sec, mu(MCL) = 6.59 +/- 1.47 X 10(-6) mm(2)/sec), but the difference was not statistically significant (p = 0.18). Exposure of the cells to growth factors PDGF-BB or bFGF for 6 h had no significant effect on the migration of the ACL and MCL cells. However, exposure of the ACL cells (p < 0.05) and the MCL cells (p = 0.19) to 1 ng/mL of PDGFBB for 12 h enhanced their migration. Incubation with a high concentration (100 ng/mL) of PDGF-BB or bFGF at concentrations tested (1 or 100 ng/mL) for 12 h, produced little or no migratory stimulation on these ligament cells. Our findings support the previous qualitative observations made by numerous investigators. The novel methodology developed in this study may provide a basis for tissue engineering, and the results may be applied to tissue reconstruction techniques of the knee ligaments.

Chondrocyte transplantation is a clinical procedure for cartilage repair. Transplanted cells may have difficulty attaching to the surface of chondral lesions because of the anti-adhesive properties of the proteoglycan rich matrix. This study used micromanipulation methods to determine if pretreatment of cartilage with chondroitinase ABC affects chondrocyte adhesion to cartilage and if chondrocytes adhere preferentially to the superficial, middle, or deep layers of cartilage. Bovine chondrocytes were transplanted in vitro on articular cartilage sections cut perpendicular to the articular surface. At various times between 15 and 75 minutes after seeding, a micropipette micromanipulation system was used to measure the adhesion force of individual chondrocytes to cartilage. The chondrocyte adhesion force increased with chondroitinase ABC treatment and seeding time but generally was similar for the different regions of articular cartilage (superficial, middle, deep layer) to which the cells were attached. For normal cartilage, the adhesion force increased from 1.29 +/- 0.24 mdyne after 15 to 30 minutes seeding to 5.29 +/- 0.25 mdyne after 60 to 75 minutes. Treatment with chondroitinase ABC at certain concentrations and durations (1.0 U/mL for 5 minutes or 0.5 or 1 U/mL for 15 minutes) led to an increase in adhesion force, whereas relatively low concentration or treatment time (0.25 U/mL for 15 minutes or 0.5 U/mL for 5 minutes) had little or no detectable effect. The increase in adhesion attributable to chondroitinase ABC treatment appeared most marked (+144% to +292%) for short (15 to 30 minutes) seeding durations but was still significant (+46%) for the longest seeding period (60 to 75 minutes) studied after the 1 U/mL for 15 minute treatment condition. These results provide direct biomechanical evidence that enzymatic treatment of a cartilage surface can enhance chondrocyte adhesion.

Fibroblasts embedded in the amorphous healing tissue matrix of ligaments migrate into damaged sites during the inflammatory process that precedes the formation of new connective tissue after ligament injury. Cell motility involved in this migration is strongly influenced by cellular adhesion to proteins of the extracellular matrix. The adhesion mechanism of interest in this study is the attachment of fibroblasts from the anterior cruciate and medial collateral ligaments to types I and III collagen, two fibrillar collagens secreted by fibroblasts during tissue repair. Types I and III collagen constitute a major portion of these ligaments and are assembled by fibroblasts into long cable-like fibrils in the extracellular space. In this study, a micropipette aspiration technique was used to measure the force required to separate fibroblasts of the anterior cruciate and medial collateral ligaments from substrates composed of type I or III collagen, each at a concentration of 2 or 5 microg/ml. Approximately 1,200 fibroblasts from the anterior cruciate ligament and 1,600 from the medial collateral ligament were used, and the adhesion force and area of these cells were determined. Fibroblasts from the anterior cruciate ligament exhibited greater adhesion force than did those from the medial collateral ligament for all concentrations of types I and III collagen. In addition, the adhesiveness of fibroblasts from both ligaments was dependent on seeding time for all experimental conditions. To determine the adhesiveness per unit area, defined here as the adhesion strength, the adhesion force was normalized by the adhesion area. At early seeding times (15-45 minutes), fibroblasts from the anterior cruciate ligament exhibited greater adhesion strength on surfaces coated with type-I collagen than did those from the medial collateral ligament. However, for both collagen substrates, adhesion strength for fibroblasts from the anterior cruciate ligament decreased with seeding time whereas that for fibroblasts from the medial collateral ligament remained relatively constant for all seeding periods (15-75 minutes).

Between December 1983 and August 1991, 55 consecutive patients (55 knees) who underwent articular cartilage transplantation to their damaged knees were enrolled in the study. Average followup was 75 months (range, 11-147 months). Eight-two percent were younger than 45 years of age. Patients were evaluated through an 18-point scale, with 6 points each allocated to pain, range of motion, and function. An excellent knee was pain free, had full range of motion, and permitted unlimited activity. A good knee allowed full time employment and moderate activity. Eleven of 15 (73%) allografts transplanted 10 or more years ago were still good or excellent at the time of last followup. Overall, 45 of 55 (76%) knees that received the transplants were rated good or excellent. Specifically, 36 of 43 (84%) patients with unipolar transplants regained normal use of their resurfaced knee. The results after bipolar resurfacing were less encouraging, with only six of 12 (50%) knees rated good or excellent. The described technique of osteochondral shell allograft resurfacing of the knee capitalize on the different healing potentials of bone and cartilage by transplanting the viable articular cartilage organ in its entirety along with just enough of the underlying bone to allow for graft incorporation through creeping substitution. The results support the use of fresh osteochondral shell allograft transplantation for the treatment of large, full thickness articular cartilage defects to the medial or lateral femoral condyles and to the patella.

This study presents morphometric analyses of the collagen fibril diameters of rabbit anterior cruciate and medial collateral knee ligaments of New Zealand White rabbits (young, age two months and adult, age thirty-six to forty months). Measurements were made from transmission electron micrographs of transverse ligament sections of approximately 50,000x magnification. Statistically significant differences in the mean fibril diameters were found between the anterior cruciate and medial collateral ligaments of the thirty-six to forty month old animals (.069 +/- .005, .092 +/- .016 mm, p < .1); however, no statistical significance was found for differences between these ligaments in two month old animals (.077 +/- .006, .082 +/- .009, p > .1). These data support the idea that known differences in fibril distributions of adult rabbit anterior cruciate and medial collateral ligaments develop with maturation, and may reflect both the cellular environment in which the fibrocytes of these ligaments are subject to, as well as the developmental genetic program of these cell populations.

Exogenously administered growth factors such as platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-beta) and basic fibroblast growth factor (bFGF) have been shown to affect connective tissue healing in vivo, but their intrinsic role in the healing response has not been established. In the present study, immunohistochemistry with antibodies directed against these growth factors showed that expression of PDGF, TGF-beta 1 and bFGF was increased in and around the wound site in the rabbit medial collateral ligament (MCL) seven days following surgical injury. The strong expression of PDGF correlated with the observed increased cellularity consistent with this growth factor's mitogenic and chemotactic properties. Expression of these growth factors was also increased in wounded rabbit anterior cruciate ligaments (ACL) at seven days following surgical injury, but such expression was limited to the edge of the ACL injury site and was of lesser intensity relative to the MCL. This study suggests that PDGF and TGF-beta 1, and to a lesser extent bFGF, are actively involved during the early stage of MCL healing, but have a more limited presence in the injured rabbit ACL.

The Academic Orthopaedic Society met in April 1994 to discuss manpower issues in orthopaedics. The members developed an approach using the Delphi system to define and obtain consensus on the characteristics of the ideal residency. Six categories of educational attributes were included: General; Clinical Management; Skills and Technical Aspects; Rehabilitation; Basic Science and Research; and Educational Environment. The following year a questionnaire was sent to more than 125 programs in an attempt to have residents and staff anonymously self score their residencies according to the standards defined by the Delphi panels. The results obtained from the 745 responders from 73 programs validate effectively the characteristics of the ideal program and also show the variation among the programs.

Stress deprivation secondary to immobilization leads to atrophic changes in periarticular soft tissues. The changes in ligaments include a disorganization of collagen and cellular ultrastructure with varied biochemical alterations resulting in a functionally weaker tissue. This study tests the hypothesis that alterations in fibronectin (Fn) and the expression of its integrin receptor alpha5beta1 in ligament fibroblasts accompany the extracellular matrix remodeling which occurs in stress-deprived knee ligaments. The left knees of eighteen New Zealand white rabbits were surgically immobilized in acute flexion. Fibroblasts within three nine week and three twelve week stress-deprived anterior cruciate ligaments (ACLs) and medial collateral ligaments (MCLs) demonstrated markedly increased immunostaining for the beta1 and alpha5 integrin subunits, as compared to fibroblasts in the contralateral unoperated control ligaments. The effects of stress deprivation on the concentration of Fn was measured by competitive ELISA on the remaining twelve rabbits. Decreases in Fn of 54.0 percent and 63.7 percent occurred in the ACL after nine and twelve weeks of stress deprivation when compared to contralateral controls. The MCL had less of a decrease, losing 37.7 percent and 41.7 percent at nine and twelve weeks, respectively. These results suggest an important role for the Fn-specific integrin receptor alpha5beta1 in remodeling stress-deprived periarticular ligamentous tissue, and the importance of maintaining normal stresses on periarticular ligaments to prevent the degradation of extracellular matrix components such as Fn.

The influence of signal pathways involved in the adhesion of fibroblasts from the anterior cruciate and medial collateral ligaments to fibronectin was investigated. Specific emphasis was paid to the cyclic adenosine monophosphate and Ca2+/phospholipid pathways to determine the signaling mediated by integrin receptors during cell binding and spreading on a fibronectin-coated glass surface and to compare the roles of these two pathways in integrin-mediated adhesion in fibroblasts from the two ligaments. Individual cell adhesion strengths were determined using a micropipette-micromanipulation system after the cells were treated with signal pathway inhibiting agents. Adhesion in fibroblasts from the medial collateral ligament was significantly reduced by inhibiting agents for Gi protein, protein kinase A, protein kinase C, protein kinase G, phospholipase C, and calmodulin, which suggests a crucial role for cyclic adenosine monophosphate and Ca2+/phospholipid signaling in integrin-mediated adhesion of these fibroblasts. Adhesion in fibroblasts from the anterior cruciate ligament, however, was reduced only by a protein kinase C inhibiting agent and was increased by inhibiting agents for protein kinase A, protein kinase G, and calmodulin, which suggests only a partial role of Ca2+/phospholipid signaling in integrin-mediated adhesion of these fibroblasts. On the basis of additional parallel studies on the role of intracellular calcium in integrin-mediated adhesion, medial collateral ligament and anterior cruciate ligament fibroblast adhesion was calcium dependent throughout the 60 minute time course of adhesion experiments. Fibroblasts from the medial collateral ligament demonstrated a 2.2-fold increase in cytosolic free calcium upon binding to fibronectin, whereas fibroblasts from the anterior cruciate ligament demonstrated no significant increase in calcium. Overall, the study of the intrinsic differences between anterior cruciate ligament and medial collateral ligament fibroblasts in their signal pathways upon binding to fibronectin may reveal information important for further explaining the lack of functional healing response in the anterior cruciate ligament after injury.

We have determined the effects of tropomodulin (Tmod), talin, vinculin, and alpha-actinin on ligament fibroblast adhesion. The anterior cruciate ligament (ACL), which lacks a functional healing response, and the medial collateral ligament (MCL), a functionally healing ligament, were selected for this study. The micropipette aspiration technique was used to determine the forces needed to separate ACL and MCL cells from a fibronectin-coated surface. Delivery of exogenous tropomodulin, an actin-filament capping protein, into MCL fibroblasts significantly increased adhesion, whereas its monoclonal antibody (mAb) significantly decreased cell adhesiveness. However, for ACL fibroblasts, Tmod significantly reduced adhesion, whereas its mAb had no effect. mAbs to talin, vinculin, and alpha-actinin significantly decreased the adhesion of both ACL and MCL cells with increasing concentrations of antibody, and also reduced stress fiber formation and cell spreading rate as revealed by immunofluorescence microscopy. Disruption of actin filament and microtubule assembly with cytochalasin D and colchicine, respectively, also significantly reduced adhesion in ACL and MCL cells. In conclusion, both ACL and MCL fibroblast adhesion depends on cytoskeletal assembly; however, this dependence differs between ACL and MCL fibroblasts in many ways, especially in the role of Tmod. These results add yet another possible factor in explaining the clinical differences in healing between the ACL and the MCL.

The biomechanical, biochemical, and morphological properties of the anterior cruciate and medial collateral ligaments are dramatically altered in response to deprivation of normal physical forces and joint motion. Integrin adhesion receptors are known to play important roles in the tissue remodeling that occurs in the course of normal wound repair. We propose that integrins play a similar role in the remodeling of the extracellular matrix in stress-deprived periarticular ligaments. This study tests the hypothesis that altered expression of integrins on ligament fibroblasts accompanies this remodeling. The left knees of 15 New Zealand White rabbits were surgically immobilized in acute flexion and the right knees served as controls (no operation). The anterior cruciate and medial collateral ligaments were harvested at 1, 3, 5, 9, or 12 weeks after immobilization. Sections from the ligaments were immunostained with monoclonal antibodies specific for the integrin subunits beta 1, alpha 5, alpha 6, and alpha v, as well as with a negative control antibody. Fibroblasts within both the stress-deprived anterior cruciate and medial collateral ligaments demonstrated markedly increased staining for the beta 1, alpha 5, and alpha v subunits, as compared with the controls. The increased staining was greatest at 9 weeks in the anterior cruciate ligament and at 12 weeks in the medial collateral ligament. Western blot study of ligament proteins extracted with sodium dodecyl sulfate demonstrated an increased amount of beta 1 subunit protein in both ligaments from knees that were stress deprived for 9 and 12 weeks, as compared with the control ligaments.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of immobilization of the knee joint on the mechanical and ultrastructural properties of the anterior cruciate ligament have not been well documented. Our goal was to determine these effects in a rabbit model and to assess the effect of knee flexion angle during immobilization. The knee joint was immobilized in either 170 degrees or 105 degrees of flexion, and new methodologies were utilized to determine the mechanical properties of the anterior cruciate ligament. In specimens from knees that had been immobilized, the cross-sectional area of the ligament was 74% of the control value. The stress-strain curve was altered slightly, and the strain at failure increased 32-40%. The modulus and stress at failure did not decrease significantly. There was no significant difference between the mechanical properties of the knees immobilized at 170 degrees and 105 degrees of flexion. Histological and ultrastructural evaluation demonstrated changes in the shape and intracellular make-up of the fibroblasts from the ligament after immobilization. This cellular response may account for the alterations in the mechanical properties of the anterior cruciate ligament.

The adhesiveness of fibroblasts from the human anterior cruciate and medial collateral ligaments to the laminin molecule was studied, with particular emphasis on the intrinsic differences between fibroblasts from the two ligaments. Cellular adhesion strength, adhesion area, laminin concentration, and seeding time were examined. Cell adhesion to laminin anchored with poly-D-lysine to a cleaned cover glass was measured with a micropipette micromanipulation system after seeding. The adhesion strength of fibroblasts from the anterior cruciate ligament to laminin was greater than and significantly different from that of fibroblasts from the medial collateral ligament, depending on the laminin concentration. Fibroblasts from the anterior cruciate ligament also exhibited an increase in adhesion strength, dependent on laminin concentration of as much as 30 micrograms/ml, at which the laminin receptors were thought to be saturated. Fibroblasts from the medial collateral ligament did not show such an increase except at laminin concentrations of 5-10 micrograms/ml. There was no significant difference in adhesion area between fibroblasts from the two ligaments except after 45 minutes at a laminin concentration of 40 micrograms/ml. For both, the adhesion to laminin showed little correlation to seeding time during periods of as long as 60 minutes. Measurements of adhesion area also failed to show a significant correlation to seeding time for fibroblasts from either ligament at laminin concentrations of 20 and 40 micrograms/ml. Adhesion strength normalized by adhesion area had no correlation to seeding time.(ABSTRACT TRUNCATED AT 250 WORDS)

The differential capacities of the anterior cruciate and medial collateral ligaments to heal may be related to differences in cellular function. This study tested the hypothesis that differential expression of integrins occurs in these ligaments after injury. The integrins are a family of cell surface receptors that mediate adhesion, migration, and other cellular functions critical to the healing of a wound. A similar complement and amount of the beta 1 subfamily of integrins are known to be present on the unperturbed anterior cruciate and medial collateral ligaments in humans and rabbits. A partial laceration was surgically created in these two ligaments in 12 anesthetized New Zealand White rabbits. Immunohistochemistry was performed on sections from the ligaments at 1, 3, 7, and 10 days after injury, using monoclonal antibodies directed against the integrin subunits beta 1, alpha 5, alpha 6, and alpha v. Between 3 and 7 days, the wounded medial collateral ligament demonstrated a striking increase in staining for the beta 1, alpha 5, and alpha v subunits on the fibroblasts, within the repair site, and on capillary endothelium. Increased staining was most marked for the beta 1 subunit and less marked for the alpha 5 and alpha v subunits. The alpha 6 subunit stained exclusively vascular structures within the healing medial collateral ligament. In marked contrast, the anterior cruciate ligament, which does not mount an effective repair response, demonstrated no comparable alteration of integrin expression from baseline levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Study Design: The efficacy of various interpositional membranes for prevention of extradural adhesion was investigated by a new animal model that quantified the biomechanical effect of scar formation. Twenty-one dogs were treated with autologous free fat graft, hyaluronic acid or no interpositional membrane after undergoing two-level laminotomy, nerve root exploration, and disk injury. An additional 11 dogs that did not undergo spine surgeries served as control animals., Objectives: Inter-animal variability in inherent propensity to form scar was first measured before any spine surgery. Twelve weeks after spine surgery, the lumbosacral spine of each dog was harvested en bloc for biomechanical testing of extradural adhesion ultimate load. Scar stiffness coefficient was also calculated., Summary of Background Data: Adhesion ultimate load was significantly less in the nonoperative control group when compared with the fat graft and no interpositional membrane group, but not when compared with the hyaluronic acid group. A beneficial effect of hyaluronic acid in lowering adhesion ultimate load was demonstrated, although a statistically significant difference from the fat graft and no interpositional membrane groups was not reached. No difference in scar stiffness coefficient was found between the four groups., Methods: A new experimental model allowing objective biomechanical quantification of the effect of postoperative scar was described. Ultimate load of adhesions to both nerve roots and dura was measured. A biochemical assay that determined collagen content was also used to assess inter-animal propensity to form scar after a standardized surgical insult. Results were compared with other relevant studies., Results: Findings suggest a beneficial effect of hyaluronic acid in decreasing the biomechanical strength of extradural adhesions following laminotomy, nerve root exploration, and disk injury when compared with use of fat graft or no interpositional membrane. These results support other recent investigations that study the use of hyaluronic acid treatment in a laminectomy model. The adverse consequence of intraoperative epidural bleeding was also demonstrated., Conclusions: The new experimental model described in the current study was reproducible and permitted objective quantification of the effect of postoperative adhesion rather than measuring its mere presence. A beneficial effect of hyaluronic acid treatment and a lack of such beneficial effect of free fat graft interpositional membrane was suggested. The importance of avoiding active epidural bleeding was also evident.

The adhesive interactions of cells with other cells and the extracellular matrix (ECM) play a fundamental role in the organization of cells in differentiated organs, cell motility, and the healing process. The adhesion characteristics of ligament fibroblasts depend on the expression of cell surface molecules and their interaction with the ECM. Although many receptors mediating the effects of ECM components on ligament cell function remain poorly defined, it is known that fibronectin (FN) allows ligament cells to adhere through the VLA-5 receptor (alpha 5 beta 1). A direct measurement of the adhesion between anterior cruciate ligament (ACL) or medial collateral ligament (MCL) fibroblasts and fibronectin matrix proteins was achieved by using a micromanipulation technique to determine the force required to detach an ACL or MCL cell from fibronectin-coated glass. We have found that the adhesion strength is not random, but has well-defined functional relationships with the FN concentration and the seeding time (time allowed for the cell to establish attachment). The adhesion strength (i.e., force required to detach) of ACL cells shows a stronger dependence on FN concentration (1, 2, and 5 micrograms/ml) for short seeding times (15-30 min) than for long seeding times (38-75 min). For MCL cells, the effect of the seeding time on adhesion strength was apparent for all concentrations. For all the seeding times studied and FN concentrations used, MCL cells had higher adhesion strength than ACL cells. The adhesion strengths of ACL and MCL fibroblasts to FN are correlated to cell adhesion area.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To perform a comprehensive analysis of the integrin forms expressed by normal human articular chondrocytes., Methods: Cartilage sections and collagenase-released chondrocytes were probed with a comprehensive panel of integrin isoform-specific monoclonal antibodies (MAb), using in situ immunohistochemistry techniques, indirect immunofluorescence and flow cytometry, and immunoprecipitation/sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE)., Results: Chondrocytes in cartilage sections reacted with MAb specific for the alpha 5, alpha v, and beta 1 integrin subunits and the alpha v beta 3 and alpha v beta 5 heterodimers. They also reacted with a polyclonal antibody specific for the intracytoplasmic portion of the alpha 1 subunit. MAb specific for the alpha v subunit reacted more strongly with chondrocytes near the articular surface than with those in deeper layers of cartilage, and the alpha v beta 3-specific MAb reacted exclusively with chondrocytes within the most superficial 30 microns of cartilage. Flow cytometric analysis and SDS-PAGE analysis of immunoprecipitates prepared from extracts of cell-surface radioiodinated chondrocytes confirmed the above observations, and additionally revealed the presence of the alpha 3 beta 1 integrin., Conclusion: Normal human articular chondrocytes prominently display substantial quantities of the alpha 1 beta 1, alpha 5 beta 1, and alpha v beta 5 integrin heterodimers, as well as lesser quantities of the alpha 3 beta 1 and alpha v beta 3 heterodimers. The alpha v subunit-containing integrins are detected more readily on the more superficial chondrocytes than on chondrocytes deep within cartilage. These observations provide the basis for analysis of the role of chondrocyte integrins in cartilage homeostasis and in the pathogenesis of joint diseases.

The surgical treatment of a young adult with a localized defect in the articular cartilage of the knee most commonly employs arthroscopic shaving and/or subchondral drilling. Fresh osteochondral allografting is an alternative that is being performed with increasing frequency. As of June 1993, fresh osteochondral allografts have been used in 90 knees in our institution. Thirty-eight of these knees have been evaluated two or more years postoperatively, and a successful result was obtained in 76%. If the lesion was confined to the medial condyle, the success rate was 86%, but when both reciprocal surfaces were replaced (bipolar) the success rate was 56%.

Explants from rabbit anterior cruciate ligaments (ACL) and medial collateral ligaments (MCL) were utilized to compare the relative rates that fibroblasts migrate onto glass and plastic culture surfaces in vitro. During the first two weeks in culture, a monolayer of cells appeared on the periphery of all the ACL and MCL explants. From 45 to 134 hrs in culture, the mean total MCL cell count per explant was 6-12 times greater than that for the ACL on the plastic culture dishes, and this difference was even greater for the cells attached to the glass cover slides over the explants. These differences were significant at the p < .005 level. The rates of cell proliferation were quite similar for primary cultures of ACL and MCL grown in the same medium as that used for the migration assay. The large difference in cell number at early times of culture is thus due to the more rapid MCL cell migration out of the explants, and not to a difference in the rate of cell proliferation. These data support the hypothesis that differences in cell migration rate play a role in the greater healing capacity of the MCL as compared with the ACL. The assay described in this work may then be useful in assessing factors that promote wound healing.

A new apparatus was developed to compress the anterior compartment selectively and reproducibly in humans. Thirty-five normal volunteers were studied to determine short-term thresholds of local tissue pressure that produce significant neuromuscular dysfunction. Local tissue fluid pressure adjacent to the deep peroneal nerve was elevated by the compression apparatus and continuously monitored for 2-3 h by the slit catheter technique. Elevation of tissue fluid pressure to within 35-40 mm Hg of diastolic blood pressure (approximately 40 mm Hg of in situ pressure in our subjects) elicited a consistent progression of neuromuscular deterioration including, in order, (a) gradual loss of sensation, as assessed by Semmes-Weinstein monofilaments, (b) subjective complaints, (c) reduced nerve conduction velocity, (d) decreased action potential amplitude of the extensor digitorum brevis muscle, and (e) motor weakness of muscles within the anterior compartment. Generally, higher intracompartmental pressures caused more rapid deterioration of neuromuscular function. In two subjects, when in situ compression levels were 0 and 30 mm Hg, normal neuromuscular function was maintained for 3 h. Threshold pressures for significant dysfunction were not always the same for each functional parameter studied, and the magnitudes of each functional deficit did not always correlate with compression level. This variable tolerance to elevated pressure emphasizes the need to monitor clinical signs and symptoms carefully in the diagnosis of compartment syndromes. The nature of the present studies was short term; longer term compression of myoneural tissues may result in dysfunction at lower pressure thresholds.

The integrins are a family of adhesion-mediating cell surface receptors that play critical roles in cell-extracellular matrix interactions and have been shown to be important in the healing response in several tissues. We have studied integrin expression in normal human and rabbit anterior cruciate (ACL) and medial collateral (MCL) ligaments of the knee as a preamble to studies of beta 1-integrin expression in healing ligaments. Histologic sections of human and rabbit ACL and MCL were probed for integrin expression utilizing integrin-specific monoclonal antibodies (mAbs) followed by immunoperoxidase detection. Staining of human specimens with mAbs revealed the presence of beta 1-, alpha 1-, and alpha 5-integrin chains on the tissue fibroblasts of both ACL and MCL, while staining of rabbit specimens with rabbit integrin-reactive monoclonals revealed the presence of beta 1- and alpha 5-integrin on these ligaments. Equivalent amounts of the integrins studied were present on normal ACL and MCL. We conclude that the rabbit is an appropriate model for analyzing the expression and functional role of integrins in ligament wound healing.

The poor healing abilities of the anterior cruciate ligament (ACL) in contrast to those of the medial collateral ligament (MCL) are well known. Different intrinsic properties of the constituent cells of these ligaments have been proposed to be one of the factors in the differential repair mechanisms. To examine this hypothesis, we have established primary cell lines of ACL and MCL from the tissue explants of approximately similar dimensions and have studied their behavior in vitro. The outgrowth of cells from ACL explants was slower than from MCL explants, as shown by the size of the surrounding clusters of cells. Both ACL and MCL cultures exhibited typical fibroblastic morphology. No significant differences were observed in either attachment or growth of cells from the attached explants derived from various segments of ACL and MCL. Growth curves of ACL and MCL cultures at both passage numbers 2 and 6 showed a slower rate of proliferation of ACL cells than MCL cells (p less than 0.005). DNA synthesis measured in terms of [3H]thymidine incorporation (CPM/10(3) cells) of both log phase (ACL = 607.5 +/- 5.4 vs. MCL = 1356.4 +/- 11.3) and confluent (ACL = 83.0 +/- 3.6 vs. MCL = 189.8 +/- 5.4) cultures, supports the conclusion that differential proliferation rates of these cells exist in culture. FITC-phalloidin staining (for actin) of later passage cultures (P3-P5) showed a spread-out appearance of ACL cells and an elongated appearance of MCL cells. Relatively more stress fibers were seen within ACL cells. SDS-PAGE and Western blot analysis of cellular proteins revealed higher actin (43 kDa) content in ACL cells than in MCL cells. In vitro wound closure assay was performed by creating a uniform wound of 0.6 mm width in the confluent layer of ACL and MCL cultures. By 48 h postwounding, cell-free zones created in ACL cultures were occupied partially by single cells in a nonconfluent fashion. In contrast, the wounded zone in the MCL cultures was almost completely covered by the cells. Results presented in this report demonstrate a lower proliferation and migration potential of ACL cells in comparison with MCL cells. These differences in intrinsic properties of ACL and MCL cells that were observed in vitro might contribute to the differential healing potentials of these ligaments in vivo.

Fresh osteochondral shell allografting is conceived as an interim response to the localized loss of articular cartilage in young patients for whom there is no reasonable alternative after conservative procedures have failed. The concept is not new and has been investigated extensively in in vivo animal investigations. The functional and anatomic results of these studies, however, have been consistently unsatisfactory because of technical deficiencies and supposed immunogenic responses. The results of early clinical studies were variable, and despite more recent clinical work, the procedure has been considered at least investigational by some. The purpose of this study is to retrospectively review a series of patients treated with osteochondral allografting of the femoral condyle with particular emphasis on those done more than five years ago. No tissue-typing blood-group matching or gender distinction was made and immunosuppressant agents were not used. Size matching of the donor and recipient were essential to provide an orthotopic graft. Twelve knees were operated on more than five years ago. Of these twelve, three are not available for review. Nine knees have been observed for an average of 66 months and eight are rated good or excellent by a standardized rating scale. One knee rated poor seems to be the result of a technical deficiency. Since 1983, 37 fresh osteochondral allografts of the femoral condyle have been performed in 36 patients. Twenty-five of these have been performed in the last five years and the results to date are summarized.

The anterior cruciate ligament (ACL) does not heal after an interstitial tear, in contrast to the medial collateral ligament (MCL), whose interstitial tears heal readily. The light microscopic and ultrastructural differences between the cells of the two ligaments were studied in rabbit knees to observe the healing characteristics of the two ligaments. A rabbit knee was chosen because the rabbit ACL, like that of humans, does not heal following interstitial injury. The cells populating the MCL have the characteristics of fibroblasts. The cells of the ACL resemble fibrocartilage cells. The phenotypic differences in the cells of the two ligaments may be important determinants of the differences in healing.

Anterior cruciate (ACL) and medial collateral (MCL) ligaments from control and immobilized rabbit knee joints were examined using transmission electron microscopy. The fibroblasts of these two tissues were distinct in control ligaments, but these differences in fibroblast morphology were less obvious after immobilization. The most drastic changes took place in the ACL; the ACL fibroblasts from control ligaments were ovoid-shaped, while after immobilization they were spindle-shaped with extensive cytoplasmic extensions. These cellular changes corroborate previously demonstrated changes in the mechanical properties of these ligaments seen following immobilization, and are consistent with biochemical studies.

Unlabelled: Infusion lines (to elevate intracompartmental pressure experimentally) and wick catheters (to monitor the pressure produced) were inserted into hind-limb muscle compartments in twenty-six dogs. A padded plaster cast was then applied. The effect of the cast on intracompartmental pressure and volume and the effect of first splitting the cast and then cutting the padding were determined. Three different padding were used: dry Webril, Webril soaked in blood and Betadine (povidone-iodine), and Webril soaked in blood and Betadine and then dried. The cast was found to restrict expansion of the compartment volume by approximately 40 per cent. The most significant reductions in pressure in all groups occurred after the cast was cut and spread (mean reduction, 65 per cent). An additional pressure reduction of 10 to 20 per cent occurred after cutting the Webril. After removal of the cast, all limbs maintained some residual elevation of the intracompartmental pressure., Clinical Relevance: This study demonstrates the need in clinical practice for continued evaluation and monitoring of a limb even after the cast has been completely removed because of signs and symptoms of a compartmental syndrome.

Ossifying fibromas involving the tibia were seen in two patients. In both patients, the radiographic appearance of the lesions suggested fibrous dysplasia, but histopathologic evaluation demonstrated findings similar to ossifying fibroma of the mandible and facial bones. Radiologic and pathologic recognition of this entity is necessary for proper treatment.

A canine flexor tendon repair model was used to study the magnitude of early tendon excursion, the consistency of tendon gliding, and the amount of repair site elongation when protected early motion techniques were used. Tendon excursion of 3.8 +/- 1.1 mm was maintained with limited passive flexion and extension movements on a consistent basis throughout the first 14 days. There was no significant repair site deformation in 11 of 12 tendons and little variation in the range of tendon gliding during this period.

Complete midsubstance injuries of medial collateral ligaments of matched New Zealand white rabbits were allowed to heal without repair or immobilization for various lengths of time. Morphological and biochemical parameters were used to evaluate healing as compared with normal unoperated and sham operated ligaments. Results showed incomplete healing at the longest term follow-up (14 weeks) with significant biochemical abnormalities. Although there was a trend toward normal, recovery from injury was much slower than previously reported.

Intracompartmental pressures were measured by the wick catheter technique in sixty-five compartments of twenty-seven patients who were clinically suspected of having acute compartment syndromes. A pressure of thirty millimeters of mercury or more was used as an indication for decompressive fasciotomy. The range of normal pressure was from zero to eight millimeters of mercury. Eleven of these patients were diagnosed as actually having compartment syndromes and in these patients, twenty-seven compartments were decompressed. Only two patients had significant sequelae. In the sixteen patients (thirty-eight compartments) whose pressures remained less than thirty millimeters of mercury, fasciotomy was withheld and compartment syndrome sequelae did not develop in any patient. Intraoperatively the wick catheter was used continuously in eight patients to document the effectiveness of decompression. Fasciotomy consistently restored pressures to normal except in the buttock and deltoid compartments, where epimysiotomy was required to supplement the fasciotomy. Continuous intraoperative monitoring of pressure by the wick catheter technique allowed us to select the few cases in which primary closure of wounds was appropriate and to decide which patients were best treated with secondary closure.

This study examines the effect of delayed exposure to hyperbaric oxygen on muscle necrosis and edema development following compartment syndromes in the canine hindlimb. Compartment syndromes (100 mm Hg for 8 h) were generated in one anterolateral compartment of six anesthetized dogs. After a 2-h delay, three 1-h hyperbaric oxygen treatments (2 atm absolute pure oxygen) were given during the next 12 h. Two days later, technetium-99m stannous pyrophosphate (99mTc Sn-PYP) was injected intravenously; 3 h later, samples were obtained from the pressurized and contralateral control muscles, weighed for edema development, counted for 99mTC Sn-PYP uptake, and evaluated histologically. Hyperbaric oxygen treatments, even when delayed 2 h, reduced muscle necrosis and intramuscular edema to negligible levels (p less than 0.05) compared with untreated animals. In addition, muscle morphology remained essentially normal in all hyperbaric oxygen-treated animals. We conclude that even if hyperbaric oxygen treatments are delayed 2 h, edema and muscle necrosis are reduced significantly in a model compartment syndrome.

The objective of this study was to examine the effect of position of the knee and ankle on intracompartmental pressures in the leg. Slit catheters were introduced bilaterally into all four muscle compartments of the lower extremities of six healthy volunteers. Intracompartmental pressures were monitored with the catheters while the ankle joint was passively held in full dorsiflexion, full plantar flexion, or neutral with the knee flexed 90 or 10 degrees or fully extended. Statistical analysis revealed that intracompartmental pressure increased significantly in all four compartments when the ankle was passively dorsiflexed. Pressure in the superficial posterior and lateral compartments was dependent on knee position and in the deep posterior and anterior compartments it was independent of knee position. In addition, pressure in the deep posterior compartment decreased significantly when the ankle was placed in full plantar flexion, and that finding was independent of knee position. Anterior compartment pressure was not significantly elevated by full passive plantar flexion of the ankle.

This study examined the effect of exposures to hyperbaric oxygen on the development of the edema and necrosis of muscle that are associated with compartment syndromes that are complicated by hemorrhagic hypotension. A compartment syndrome (twenty millimeters of mercury for six hours) was induced by infusion of autologous plasma in the anterolateral compartment of the left hind limb of seven anesthetized dogs while the mean arterial blood pressure was maintained at sixty-five millimeters of mercury after 30 per cent loss of blood volume. These dogs were treated with hyperbaric oxygen (two atmospheres of pure oxygen) and were compared with six dogs that had an identical compartment syndrome and hypotensive condition but were not exposed to hyperbaric oxygen. Forty-eight hours later, edema was quantified by measuring the weights of the muscles (the pressurized muscle compared with the contralateral muscle), and necrosis of muscle was evaluated by measuring the uptake of technetium-99m stannous pyrophosphate. The ratio for edema was significantly (p = 0.01) greater in dogs that had not been exposed to hyperbaric oxygen (1.15 +/- 0.01) than in the dogs that had been treated with hyperbaric oxygen (1.01 +/- 0.03), and the ratio for necrosis of muscle was also significantly (p = 0.04) greater in dogs that had not had hyperbaric oxygen (1.96 +/- 0.41) than in those that had been treated with hyperbaric oxygen (1.05 +/- 0.11). Comparisons were also made with the muscles of four normal control dogs and separately with the muscles of six normotensive dogs that had an identical compartment syndrome and normal blood pressure and were not treated with hyperbaric oxygen.(ABSTRACT TRUNCATED AT 250 WORDS)