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06. Baransel Saygi Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2008;14(2):103-109 The effect of dehydration and irrigation on the healing of Achilles tendon: an experimental study Dehidrasyon (kuruluk) ve irigasyonun (y›kama) Aflil tendon iyileflmesi üzerine etkileri: Deneysel çalıflma Baransel SA Y G I,1 Yakup YI L D I R I M,2 Cengiz ÇA B U K O ⁄ L U,3 Hasan KA R A,3 Saime Sezgin RA M A D A N,4 Tanıl ES E M E N L ‹ 5 BACKGROUND AMAÇ Air exposure is a factor that inhibits in vitro cellular prolifer- Hava teması tendonlarda canl›-d›fl› (in vitro) ortamda matriks ation and matrix synthesis in tendons. Aim of this experimen- sentezini ve hücre ilerlemesini azaltabilir ve hatta önleyebilir. tal study was to evaluate effect of dehydration and irrigation Bu çalıflmanın amacı, dehidrasyon ve irigasyonun Aflil tendon on healing of Achilles tendon. iyileflmesi üzerine etkisinin canl›-içi (in vivo) hayvan modeli METHODS üzerinde gösterilmesidir. Achilles tenotomy was done in forty-five Sprague-Dawley GEREÇ VE YÖNTEM rats. In control group, tendon was sutured immediately. In the K›rk befl adet Sprague-Dawley cinsi s›çan›n Aflil tenotomisi remaining two groups, the Achilles tendons were allowed to yapıldı. Kontrol grubunda, tendon hemen dikildi. Di¤er iki direct exposure of air. Irrigation of Achilles tendon was per- grubun cilt ve cilt altı dokuları ekarte edilerek Aflil tendon- formed in one of exposed groups, while irrigation was not larının do¤rudan hava ile teması sa¤landı. Bu gruplardan biri- done in other group. After 60 minutes, tendons of both groups ne irigasyon uygulanırken di¤erine uygulanmadı. 60 dakikalık were sutured same as control group. Rats were sacrificed at hava temasını takiben, her iki grubunda tendonları kontrol gru- postoperative day 28. Achilles tendons were dissected and his- buna da yapıldı¤ı gibi dikilerek yaraları kapatıldı. Operasyon tological and biomechanical evaluations were performed. sonrası 28. günde s›çanlar öldürüldü. Aflil tendonları parçalara RESULTS ayr›larak histolojik ve biyomekanik incelemelere alındı. Histological evaluation revealed intense fibrosis formation BULGULAR with adhesion of tendon to surrounding tissues in the air Hava teması sa¤lanan grupların histolojik incelemesinde, t e n- exposed groups. The quantity of angiogenesis and inflammato- donun çevre dokulara yapıflmasıyla birlikte yo¤un fibröz doku ry reaction were also higher in experimental groups regardless oluflumu oldu¤u görüldü. ‹rige edilmeyen ve edilen her iki d e- of irrigation. Air exposed tendons had higher tensile strength ney grubunda da yüksek oranda damarsallaflma ve e n f l a m a t u- however lower stiffness than control group in biomechanical var reaksiyon saptand›. Biyomekanik çalıflma da, hava temasına evaluation. u¤rayan tendonlarda kontrol grubuna göre daha yüksek geril- CONCLUSION me gücü buna karflın daha düflük bükülebilme oldu¤u görüldü. Air exposure decreases quality of healing by increasing fibro- SONUÇ sis and adherence formation. These negative effects of expo- Hava teması fibroz doku ve yapıflıklık oluflumuna sebebiyet sure to air were not counteracted by irrigation. However, air vererek iyileflme kalitesini düflürmektedir. ‹rigasyon, bu isten- exposure didn’t affect tensile strength of the healing. meyen etkileri ortadan kaldırmamaktadır. Buna ra¤men geril- me kuvveti hava temasından etkilenmemektedir. Key Words: Achilles tendon; air exposure; dehydration; tendon heal- Anahtar Sözcükler: Aflil tendonu; dehidrasyon; hava teması; irigasy- ing; irrigation; rats, Sprague-Dawley. on; s›çan, Sprague-Dawley cinsi; tendon iyileflmesi. 1Department of Orthopaedic Surgery, Fatih Sultan Mehmet Training and 1S.B. Fatih Sultan Mehmet E¤itim ve A r a fl t › r m a Hastanesi, Ortopedi ve R e s e a r c h H o s p i t a l , Is t a n b u l; 2Department of Orthopaedic Surgery, S e m a Travmatoloji Klini¤i, ‹stanbul; 2Özel Sema Hastanesi, Ortopedi ve H o s p i t a l , Is t a n b u l; 3Department of Orthopaedic Surgery, Yalova State Travmatoloji Klini¤i, ‹stanbul; 3S . B . Yalova Devlet Hastanesi, Ortopedi ve Hospital, Yalova; D e p a r t m e n tsof 4P a t h o l o g y and 5Orthopaedic Surgery, Travmatoloji Klini¤i, Ya l o v a; Marmara Üniversitesi, Tıp Fakültesi, Marmara University, Faculty of Medicine, Istanbul, all in Tu r k e y. 4Patoloji A n abilim Dalı, 5Ortopedi ve Travmatoloji A n abilim Dalı, ‹stanbul. Presented at the American Academy of Orthopaedic Surgeons (AAOS) 2007 y›l› Amerikan Ortopedi Cerrahlar› Akademisi toplant›s›nda 2007 Annual Meeting (February 14-18, 2007 San Diego, USA) . sunulmufltur (14-18 fiubat 2007, San Diego, A B D ) . Correspondence (‹letiflim): Baransel Sayg›, M.D. Oguzhan Cad. Çelik Sok. , No: 10-9, A d a t e p e - Mal t e p e, ‹ s t a n b u l, Tu r k e y. Tel: +90 - 2 1 6 - 5 7 8 3 0 00 e-mail ( e - p o s t a ) : b a r a n s e l s a y g i @ s u p e r o n l i n e . c o m 103 Ulus Travma Acil Cerrahi Derg In recent decades, spontaneous ruptures of the dures were performed under sterile conditions in an Achilles tendon have become more prevalent in animal operating facility at a room temperature of professional and recreational athletes as a result of 21 °C and a relative air humidity of approximately overuse and acute injuries.[1] The controversy 60-65%. Forty-five female Sprague-Dawley rats, regarding the pathophysiology and treatment of this aged seven months, and weighing an average of injury continues. Although there are advocators of 280 grams, were used in the experiment. The ani- non-operative approach,[2,3] the choice of treatment mals were anesthetized by a mixture of ketamine for patients less than fifty years is primarily opera- (35 mg/kg) and xylazine hydrochloride (5 mg/kg) tive.[4,5] administered intraperitoneally. The animals were given an intraperitoneal injection of cefazolin 30 The repair phases of the Achilles tendon during mg/kg. The skin over and around the right Achilles the healing period were investigated extensively in tendon was shaved and thoroughly scrubbed. The experimental studies.[6-8] Tendon inflammation sub- sides before the 7th postoperative day[9,10] and the tendon was approached by a medial skin incision phase of fibroplasia begins between the second and and freed from the surrounding tissue. After resect- third weeks of the healing that precedes the longi- ing the tendon of the plantaris muscle, the Achilles tudinal alignment of the collagen formation.[8] Both tendon was transected 5 mm above its insertion into intrinsic and extrinsic factors can be influential on the calcaneum. The animals were then randomly the healing process of the tendon. Variations in the divided into 3 groups. In the control group (group distribution and duration of forces within tendons, 1), the severed ends of the tendon were approximat- trauma and ischemia have been shown to be associ- ed by utilizing no. 3/0 Ethibond suture with Kessler ated with variations in the histology and the tensile technique and the skin was closed. In the other 2 strength of tendon healing. Drying was noted as one groups, the skin over the Achilles tendon was of the factors detrimental to some features of the retracted and pinned to a plate of cork, allowing the tendon direct exposure to room air. In one of the tendon. Freeze dried allografts lost more than half exposed groups, the Achilles tendon was irrigated of their initial tensile strength relative to the control with 3 drops of physiological saline solution every value.[10] The initial ultimate tensile stress and lon- five minutes (group 2), while irrigation was not gitudinal strain were found to be greater for frozen done in the other group (group 3). Rats were kept allografts than for freeze-dried tendons.[11] warm during the exposure period. After sixty min- Connective tissues tend to get dry as they are utes of exposure, wounds were irrigated diffusely exposed to air. Dehydration of the Achilles tendon and tendons were sutured, using the same method due to air exposure is frequently encountered dur- as the control, in both groups. To control the move- ing the open surgical repair. The sensitivity of ten- ment in the talocrural joint, a suture was inserted don tissue to dehydration should be considered dur- through the tibiofibular fork and placed between ing tendon surgery. Irrigation is one of the measures the calcaneum and the plantar aponeurosis in all commonly utilized to prevent dehydration of the g r o u p s.[7] The suture was tightened to fix the tendon assuming to counteract the deleterious talocrural joint in the equinus position. Before clo- effects of drying. Tendon exposure to air could have sure of the wound, a bacteriological culture was cellular and biomechanical effects on tendon heal- obtained by rolling a swab over the tendon and the ing which may have clinical implications. Thus, it surrounding soft tissues. Animals received is essential to be cognizant about the consequences intraperitoneal cefazolin 30 mg/kg twice daily for a of tendon drying on tendon healing. week. They were housed in plastic cages where In this study, the effects of dehydration and irri- they could move about freely, and received food gation on the healing of the Achilles tendon were and water ad libitum. Daily inspections of the ani- examined histologically and biomechanically in an mals and the wound area were performed in order in vivo animal model. to check for signs of any infection. The rats were sacrificed at postoperative day 28.
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