Tendon Inversion Improves Tendon-to-Bone Healing in a Rat Bicep Tenodesis Model

PurposeTendon- or ligament-to-bone repair remains a surgical challenge. While bone tunnel fixation is a common surgical technique whereby soft tissue is expected to heal against a bone tunnel interface, contemporary methods have yet to recapitulate biomechanical similarity to the native enthesis. In this study, we aim to demonstrate that inside-out longitudinal tendon inversion may improve bone tunnel healing with the hypothesis that inversion removes the gliding epitenon surface from the healing interface thereby improving tunnel interface healing. Methods40 male Sprague-Dawley rats underwent either native tendon tenodesis (control group) or tendon inversion tenodesis (experimental group). Interface tissue was harvested 8 weeks post-operatively. Biomechanical testing was performed to assess tensile strength and modes of failure. Histology was performed to assess tissue architecture, and immunohistochemistry was used confirmed abrogation of epitendinous lubricin from interface tissue. ResultsNeither surgical intervention led to discernible adverse effects on animal health. Maximum tensile strength increased after tendon inversion compared to control surgery. The extracellular matrix protein lubricin was reduced with tendon inversion, and specimens with tendon inversion had greater healing scores and collagen fibril alignment at the healing interface. ConclusionsTendon inversion improves bone tunnel healing in rats. Clinical RelevanceOur findings suggest that longitudinal tendon inversion, or inverse tubularization, in a rat biceps tenodesis model improves tendon-to-bone healing in part due to disruption of the epitendinous surface at the bone healing interface. This work provides molecular insight into future improvements for tendon-to-bone repair surgical techniques.