The Effect of Sodium Hyaluronate plus Sodium Chondroitin Sulfate Solution on Peritendinous Adhesion and Tendon Healing: An Experimental Study

Abstract

Background: Adhesion formation following tendon injury is a serious clinical problem. Aims: In this experimental study, the effects of the combination of sodium hyaluronate (HA) and chondroitin sulfate (CS) on peritendinous adhesion and tendon healing were evaluated. Study Design: Animal experimentation. Methods: Twenty-one mature Sprague Dawley male rats were randomly divided into three equal groups. The rats’ Achilles tendons were cut and repaired with a modified Kessler technique. About 0.25 and 0.50 mL of the HA and CS (HA+CS) combination were injected subcutaneously into the repair site of the rats in groups 1 and 2, respectively, on days 0, 3, 7, and 10. The subjects in group 3 were used as the control group. At 6 weeks, all rats were euthanized. The tenotomy site was examined macroscopically in all animal subjects. Four samples were assigned to the histopathological examination group, and the others were assigned to the biomechanical assessment group. Results: Inflammation and adhesion in both treatment groups were observed at a lower rate than in the control group. The collagen filaments in both treatment groups were regular and the number was low when compared to the control group. However, there was no statistically significant difference between group 1 and the control group. The quantity, quality, and grade of the adhesions were statistically significantly lower in group 2 when compared with the other groups. The mean maximum stress strength in group 2 was statistically significantly higher than that in group 1 and the control group. Conclusion: Local administration of the HA+CS combination solution is a valid tool for preventing peritendinous adhesion after extrasynovial tendon repair such as Achilles tendon, and is a treatment option in such cases.

Keywords

• Chondroitin sulfate, hyaluronate, peritendinous adhesion, tendon healing

References

1. 1. Taras JS, Gray RM, Culp RW. Complications of flexor tendon injuries. Hand Clin 1994;10:93-109.
2. 2. Ferguson RE, Rinker B. The Use of a hydrogel sealant on flexor tendon repairs to prevent adhesion formation. Ann Plast Surg 2006;56:54-8. [CrossRef]
3. 3. Menderes A, Mola F, Tayfur V, Vayvada H, Barutcu A. Prevention of peritendinous adhesions following flexor tendon injury with seprafilm. Ann Plast Surg 2004;53:560-4. [CrossRef]
4. 4. Kirker KR, Luo Y, Nielson JH, Shelby J, Prestwich GD. Glycosaminoglycan hydrogel films as bio-interactive dressings for wound healing. Biomaterials 2002;23:3661-71. [CrossRef]
5. 5. Stark HH, Boyes JH, Johnson L, Ashworth CR. The use of paratenon, polyethylene film, or silastic sheeting to prevent restricting adhesions to tendons in the hand. J Bone Joint Surg Am 1977;59:908-13.
6. 6. Zhao C, Sun YL, Amadio PC, Tanaka T, Ettema AM, An KN. Surface treatment of flexor tendon autografts with carbodiimidederivatized hyaluronic acid. An in vivo canine model. J Bone Joint Surg Am 2006;88:2181-91. [CrossRef]
7. 7. Komurcu M, Akkus O, Basbozkurt M, Gur E, Akkas N. Reduction of restrictive adhesions by local aprotinin application and primary sheath repair in surgically traumatized flexor tendons of the rabbit. J Hand Surg Am 1997;22:826-32. [CrossRef]
8. 8. Akali A, Khan U, Khaw PT, McGrouther AD. Decrease in adhesion formation by a single application of 5-fluorouracil after flexor tendon injury. Plast Reconstr Surg 1999;103:151-8. [CrossRef]

9. 9. Bates SJ, Morrow E, Zhang AY, Pham H, Longaker MT, Chang J. Mannose-6-phosphate, an inhibitor of transforming growth factor-beta, improves range of motion after flexor tendon repair. J Bone Joint Surg Am 2006;88:2465-72. [CrossRef]
10. 10. Herzog M, Lindsay WK, McCain WG. Effect of beta-aminoproprionitrile on adhesions following digital flexor tendon repair in chickens. Surg Forum 1970;21:509-11.
11. 11. Ozgenel GY. The effects of a combination of hyaluronic and amniotic membrane on the formation of peritendinous adhesions after flexor tendon surgery in chickens. J Bone Joint Surg Br 2004;86:301-7. [CrossRef]
12. 12. Fraser JR, Laurent TC, Laurent UB. Hyaluronan: its nature, distribution, functions and turnover. J Intern Med 1997;242:27-33. [CrossRef]
13. 13. Riley GP, Harrall RL, Constant CR, Chard MD, Cawston TE, Hazleman BL. Glycosaminoglycans of human rotator cuff tendons: changes with age and in chronic rotator cuff tendinitis. Ann Rheum Dis 1994;53:367-76. [CrossRef]
14. 14. Hagberg L, Gerdin B. Sodium hyaluronate as an adjunct in adhesion prevention after flexor tendon surgery in rabbits. J Hand Surg Am 1992;17:935-41. [CrossRef]
15. 15. Taguchi M, Zhao C, Sun YL, Jay GD, An KN, Amadio PC. The effect of surface treatment using hyaluronic acid and lubricin on the gliding resistance of human extrasynovial tendons in vitro. J Hand Surg Am 2009;34:1276-81. [CrossRef]
16. 16. Özer H, Taşkesen A, Kul O, Selek HY, Turanlı S, Köse K. Effect of glucosamine chondroitine sulphate on repaired tenotomized rat Achilles tendons. Eklem Hastalik Cerrahisi 2011;22:100-6.
17. 17. Oryan A, Moshiri A, Meimandiparizi AH. Effects of sodiumhyaluronate and glucosamine-chondroitin sulfate on remodeling stage of tenotomized superficial digital flexor tendon in rabbits: a clinical, histopathological, ultrastructural, and biomechanical study. Connect Tissue Res 2011;52:329-39. [CrossRef]
18. 18. Costantini E, Lazzeri M, Pistolesi D, Del Zingaro M, Frumenzi E, Boni A, et al. Morphological changes of bladder mucosa in patients who underwent instillation with combined sodium hyaluronic Acid-chondroitin sulphate (ialuril®). Urol Int 2013;91:81-8. [CrossRef]
19. 19. Frenkel S, DiCesare PE. Efficacy of chondroprotective agents. Curr Opin Orthop 2002;13:9-1. [CrossRef]
20. 20. Chen L, Ling PX, Jin Y, Zhang TM. Hyaluronic acid in combination with chondroitin sulfate and hyaluronic acid improved the degeneration of synovium and cartilage equally in rabbits with osteoarthritis. Drug Discov Ther 2011;5:190-4. [CrossRef]
21. 21. Meyers SA, Seaber AV, Glisson RR, Nunley JA. Effect of hyaluronic acid/chondroitin sulfate on healing of full-thickness tendon lacerations in rabbits. J Orthop Res 1989;7:683-9. [CrossRef]
22. 22. Rydell N, Balazs EA. Effect of intra-articular injection of hyaluronic acid on the clinical symptoms of osteoarthritis and on granulation tissue formation. Clin Orthop Relat Res 1971;80:25-32. [CrossRef]
23. 23. Tang JB, Shi D, Zhag QG. Biochemical and histologic evaluation of tendon sheath management. J Hand Surg Am 1996;21:900-8. [CrossRef]
24. 24. Ozboluk S, Ozkan Y, Ozturk A, Ozdemir RM, Yanık K. The effects of human amniotic membrane and periosteal autograft on tendon healing: experimental study in rabbits. J Hand Surg Eur Vol 2010;35:262-8. [CrossRef]