mvc view to pdf itextsharp: Add text box in pdf document control Library system web page .net html console 92015006330-part1602

GHK-Cu improved antero-posterior knee laxity after ACL reconstruction in rat

Fu SC

1,2

, Cheuk YC

1,2

, Cheng WH

1,2

, Yung SH

1,2

, Chan KM

1,2

Department of Orthopaedics and Traumatology, Faculty of Medicine,

The Hong

Kong Jockey Club Sports Medicine and Health Sciences Centre, Faculty of Medicine,

The Chinese University of Hong Kong.

Introduction:

Anterior cruciate ligament reconstruction (ACLR) is a standard surgery for ACL

ruptures. Although knee laxity can be restored after surgery, biological healing of the

graft is often slow and can compromise the surgical outcomes.

Glycyl-L-histidyl-L-lysine-Cu (II)

(GHK-Cu) is a well-known activator of tissue

remodeling. In this study, the effect of GHK-Cu on ACLR was investigated in a

well-established rat model [1].

Materials and methods:

Unilateral ACLR using flexor digitorum longus tendon graft was performed in 12 rats,

which are assigned to either GHK group or saline group (n=6).The rats were given

weekly intra-articular injections with either saline or 0.3mg/ml GHK-Cu for 4 weeks.

Rats were sacrificed at week 6 post operation. Antero-posterior (A-P) knee laxity was

determined. Graft incorporation was examined by pull-out test.

Results:

After ACLR, rats treated with GHK-Cu resulted in a smaller side-to-side difference in

AP-knee laxity as compared to saline group (Mann-Whitney test, p=0.03), indicating a

better functional restoration. However, there was no significant difference in

ultimate load between GHK-Cu group and saline group (p=0.936). All grafts failed at

mid-substance during the pull-out test.

Discussion and conclusion:

GHK-Cu may improve A-P knee laxity after ACLR. Further studies are necessary to

investigate the underlying mechanisms and determine the optimal dose.

References:

[1] Fu SC, et al. KSSTA. 2012

Appendix IVC GHK HKOA

Add text box in pdf document - insert text into PDF content in C#.net, ASP.NET, MVC, Ajax, WinForms, WPF

XDoc.PDF for .NET, providing C# demo code for inserting text to PDF file

how to add text fields to pdf; how to insert text in pdf reader

Add text box in pdf document - VB.NET PDF insert text library: insert text into PDF content in vb.net, ASP.NET, MVC, Ajax, WinForms, WPF

Providing Demo Code for Adding and Inserting Text to PDF File Page in VB.NET Program

add text pdf file; adding text to pdf in reader

INTRA-ARTICULAR INJECTION OF TRIPEPTIDE COPPER COMPLEX GHK-CU (II) IMPROVED

GRAFT HEALING IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Sai-Chuen Fu

, Yau-Chuk Cheuk

, Wai-Hang Cheng

, Shu-Hang Yung

, Christer G Rolf

, Kai-Ming Chan

Department of Orthopaedics and Traumatology, Faculty of Medicine, Faculty of Medicine, The Chinese

University of Hong Kong.

Department of Orthopaedic Surgery, Huddinge University Hospital, CLINTEC,

Karolinska Institutet, Stockholm, Sweden

INTRODUCTION: Anterior cruciate ligament reconstruction (ACLR) is the standard treatment to restore knee

function. However, the biological healing of the graft is often slow and poor healing can lead to ACLR failure

and excessive knee laxity. If this process can be further enhanced, it will reduce the time of maturation of the

graft, and hence earlier returns to full activities and sports. In the present study, the possibilities of biological

augmentation of graft healing in ACLR were investigated. Recent findings show that bioactive small molecules

such as matrikines may also take part in tissue remodeling. Matrikines are small peptides liberated by partial

proteolysis of extracellular matrix macromolecules, which are able to regulate cell activities. Among different

classes of matrikines, Glycyl-Histidyl-Lysine (GHK) tripeptide and its copper (II) chelated form (GHK-Cu)

exhibit profound involvements in the tissue remodeling processes. GHK have been extensively used in the

cosmetic industry for skin tissue remodeling for years with its high safety profile in humans. GHK-Cu can

simultaneously activate the in vivo synthesis of matrix components, and the in vivo production of degradative

enzymes and the inhibitors. GHK-Cu can promote bone healing and promote implant attachment to bony tissues.

It can also act as chemoattractant for repair cells and induce wound angiogenesis. It is possible that GHK-Cu can

promote graft healing in ACLR.

METHODS: The animal experiments in this study were approved by the Animal Experimentation Ethics

Committee in authors’ institution (Ref. no.: 11/054/GRF and 460611). The procedures of ACLR were performed

on the right knee according to our previous study. Seventy-two male Sprague Dawley rats (12 weeks old, 400-

450g) were used. Intra-articular injection (50µl per injection) of saline or GHK-Cu solution (0.3 or 3 mg/ml) was

performed weekly from 2nd week to 5th week post operation. At 6 or 12 weeks post-operation, the rats were

euthanized to harvest knee specimens for static anterior-posterior (AP) knee laxity test and graft pull-out test

(n=8). Histological scoring on H&E stained sections was performed (n=4) with polarization microscopy. A 2-

way ANOVA was used to analyze the effect of time and treatment on the outcome measures. Statistical

significance was accepted at α=0.05

RESULTS: At 6 weeks post operation, rats treated with 0.3 or 3 mg/ml GHK-Cu resulted in a significantly

smaller side-to-side difference in AP-knee laxity as compared to saline group, but no difference in AP laxity was

detected at 12 weeks post operation (p=0.531) (Figure 1). There was no significant difference in pull-out strength

of the graft complex between GHK-Cu groups and saline group at 6 and 12 weeks post operation (p=0.301,

0.834), however, the stiffness of the graft complex was significantly higher in 0.3 mg/ml GHK-Cu as compared

to saline group at 6 weeks post operation (p=0.007). All grafts failed at mid-substance during the pull-out test.

Histological examination showed that graft incorporation and bone healing inside tunnels was significantly better

in the GHK-Cu treated groups. Graft degeneration as shown by decreased collagen birefringence was less severe

in the 0.3 mg/ml GHK-Cu group as compared to saline group, but significantly increased cell recruitment to graft

mid-substance in 3 mg/ml GHK-Cu group also rendered poor graft integrity (Figure 2).

DISCUSSION: Our study suggests that GHK-Cu may improve graft healing in ACLR. GHK-Cu may improve

tissue remodeling in graft mid-substance and graft tunnel interface, but extensive tissue remodeling may not be

beneficial as shown in 3 mg/ml GHK-Cu group. Further studies are necessary to investigate the underlying

mechanisms for the observed effects of GHK-Cu. As restoration of A-P knee laxity after ACLR was improved at

earlier time point, biological enhancement in graft healing by GHK-Cu may imply earlier return to normal

activity after operation. However, as the pull-out strength was not improved, high demand activities may not be

warranted safe. There are still plenty of rooms for biological augmentation of graft healing in ACLR.

Figure 1

Figure 2

Appendix IVD GHK ISLT

VB.NET PDF Text Box Edit Library: add, delete, update PDF text box

Protect. Password: Set File Permissions. Password: Open Document. Edit Digital Highlight Text. Add Text. Add Text Box. Drawing Markups. PDF Print. Work with

how to add text field to pdf form; add text to pdf using preview

C# PDF Text Box Edit Library: add, delete, update PDF text box in

NET SDK library for adding text box to PDF document in .NET WinForms application. A web based PDF annotation application able to add text box comments to adobe

add text to pdf in preview; adding text fields to a pdf

ITSP 6.0

Ref. No.-ITS/444/09

Date/Time of Receipt-

(For Official Use)

Application for

the Innovation and Technology Fund

Innovation and Technology Support Programme

- Tier 3 -

Development of a Vitamin-C Surgical Irrigation Solution to

Improve Healing Outcomes of Surgical Repair of Tendon and

Ligament Injuries

Submitted by

The Chinese University of Hong Kong

Appendix V ITF proposal on vitamin C irrigation solution

C# PDF Annotate Library: Draw, edit PDF annotation, markups in C#.

installed. Support to add text, text box, text field and crop marks to PDF document. Able class. C#.NET: Add Text Box to PDF Document. Provide

adding text field to pdf; add text to pdf without acrobat

C# WPF PDF Viewer SDK to annotate PDF document in C#.NET

Line color. Select the line color when drawing annotations on PDF document. 15. Description. 17. Text box. Click to add a text box to specific location on PDF page

how to add a text box in a pdf file; adding text to pdf in preview

ITSP 6.0

Page 1 of 25

Section A

–

Basic Information

(When an application is approved, the information in this section will be published at the ITF website (denoted with #)

and/or carried forward as pre-filled data in the related progress/final reports.)

1. Project Title#

1.1. English (not more than 20 words):

Development of a Vitamin-C Surgical Irrigation Solution to Improve Healing Outcomes of

Surgical Repair of Tendon and Ligament Injuries

1.2. Chinese (not more than 30 words):

開發維س素 C 沖洗液以促進肌腱及韌൅損傷的術後癒合

2. Abstract#

(Please provide a brief summary of the objectives, R&D methodology and the impacts and benefits of the project.)

2.1. English (not more than 200 words):

Tendon and ligament injuries are very common sporting and occupational injuries. Surgical

repair provides a mechanically stable micro-environment for the tendons or ligaments to

heal, but the healing outcomes are always compromised by the low innate healing capacity.

Thus it is important to study potential treatments to promote the innate healing capacity.

We discovered that surgical irrigation with vitamin C solution may be able to improve

healing in animal models. Conventional surgical irrigation solution only acts as neutral fluid

to cleanse the surgical sites. Limited modifications of surgical irrigation solution have been

proposed to reduce infection or bleeding, but there is no investigation to develop irrigation

solution with an added value to improve healing outcomes. We propose to develop a new

formula of vitamin C supplemented surgical irrigation solution which can promote tendon

and ligament healing. Pre-clinical studies in well-established animal models will be used to

evaluate the effects of the new irrigation solution, and the results will be used to apply for

patents. In the next stage of the product development, clinical trials could be conducted

with industrial collaboration.

2.2. Chinese (not more than 300 words):

肌腱及韌൅損傷是十分ൄ見的運動創傷和職業性勞損Ζ手術修復雖然為肌腱及韌൅損傷提供

了穩定的癒合微環境，但癒合成效往往受制於自身癒合能力不足Ζ故此，促進自身癒合能力

便成為改善療效的重要課題Ζ我們發現利ش維س素 C 沖洗肌腱創口有可能促進癒合Ζ一般沖

洗液僅為沖洗創口的中性液體；一些經改良的沖洗液配方能減少流血或感染風險，但是能夠

促進癒合的沖洗液則屬創新意念Ζ有見及此，我們建議研發一種嶄新的維س素 C 沖洗液以促

進肌腱及韌൅損傷的術後癒合Ζ我們利ش經多年驗證的動物模型，去收集有關維س素 C 沖洗

液在促進肌腱及韌൅癒合方面的實驗數據，作為申請專利註冊的基礎Ζ我們將於下一步進行

臨床測試，並與工業界共同開發有關產品Ζ

3. Objectives

(Please state in clear and specific terms the technological challenges and what the proposal aims to achieve.)

1. To develop a value-added surgical irrigation solution with Vitamin C supplementation in

order to improve healing outcomes of tendon and ligament surgeries

2. To evaluate the effects of vitamin C supplemented solution in animal models of tendon and

ligament injuries

3. To apply for patent on the formula of vitamin C supplemented solution and its application on

tendon and ligament surgeries

4. R&D Methodology

Appendix V ITF proposal on vitamin C irrigation solution

.NET PDF Document Viewing, Annotation, Conversion & Processing

PDF Write. Insert text, text box into PDF. Edit, delete text from PDF. Insert images into PDF. Add, Update, Delete form fields programmatically. Document Protect

how to add text fields to a pdf document; add text to pdf online

C# WinForms Viewer: Load, View, Convert, Annotate and Edit PDF

Highlight PDF text. • Add text to PDF document in preview. • Add text box to PDF file in preview. • Draw PDF markups. PDF Protection.

add text to pdf in acrobat; adding text to a pdf form

ITSP 6.0

Page 2 of 25

(Please provide a brief description of the technology to be developed and/or the innovative use of existing

technologies. Details should be provided in Section C.)

In this project, we will develop a new value-added surgical irrigation solution with vitamin C

(L-ascorbic acid) supplementation. Basically, surgical irrigation solution should be isotonic,

non-viscous, non-toxic and non-antigenic. Vitamin C in the form of sodium L-ascorbate enjoys a

very high safety profile and high solubility, which make it possible to constitute isotonic solution

(290-310 mOsm/L) for surgical irrigation. Since the reduced form of L-ascorbate confers most

of its biochemical activities, auto-oxidation of vitamin C into dihydroascorbate may entail a loss

in bioactivities. In the first stage, we’ll formulate the vitamin C irrigation solution in 3 different

doses at physiological osmolarity and pH, and test the product stability with respect to pH and

ascorbate concentration under different storage conditions (i.e. temperature). In the second

stage, the effects of vitamin C irrigation solution on tendon and ligament healing will be

assessed in our well-established rat models of patellar tendon injury and anterior cruciate

ligament (ACL) reconstruction respectively. As a well-known antioxidant, we have previously

shown that vitamin C supplementation reduced the extent of oxidative stress in injured tendons.

We speculate that modulation of post-surgical oxidative stress may be beneficial to tendon and

ligament healing by promoting neovascularization and alleviating the extent of inflammation.

The early effects of the vitamin C irrigation solution will be evaluated by histological

examination of inflammatory infiltration, measurement of serum C-reactive protein

(CRP)/interleukin-6 (IL-6) and 3-D Doppler ultrasound imaging for neovascularization; while the

final healing outcomes will be assessed by histology, mechanical test and gait analysis. In the

third stage, we shall patent the vitamin C irrigation solution in the US patent office and the

China patent office based on our pre-clinical experimental data.

5. Deliverables#

(Please set out the deliverables, itemized as appropriate, together with their detailed technical specifications, of the

project.)

5.1. English

1. Pre-clinical evidences for the effectiveness of Vitamin C-supplemented surgical

irrigation solution to optimize healing outcomes for tendon and ligament surgeries.

2. Patents for the application of Vitamin C supplemented irrigation solution in tendon and

ligament surgeries to be filed in the patent offices in US and PRC.

5.2. Chinese

1. 收集有關維س素 C 沖洗液能促進肌腱及韌൅術後癒合的臨床前實驗證據

2. 有關維س素 C 沖洗液ش於肌腱及韌൅修復手術的專利註冊（美國Ε中國）

6. Dissemination Plan

(Please provide a brief description of the activities that would be undertaken to promote the project deliverables to

the target users. Details should be provided in Section C.)

Since collection of pre-clinical data and application of patent are the primary goals of this

project, the results could not be disclosed until the patents are filed. When the patents are filed,

we plan to commercialize the prototype of vitamin C irrigation solution in the following steps:

1. Disclose our findings by submitting reports to International conferences and/or

peer-reviewed journal.

2. Promotion of the patented technology (vitamin C irrigation solution) by printing a pamphlet to

be distributed in the Hong Kong Med Fair 2011.

3. With the patents and plan for clinical trial, we shall contact the local and international

manufacturers of surgical irrigation solution to seek for industrial collaboration for production

and marketing.

Appendix V ITF proposal on vitamin C irrigation solution

C# WPF Viewer: Load, View, Convert, Annotate and Edit PDF

Highlight PDF text in preview. • Add text to PDF document. • Insert text box to PDF file. • Draw markups to PDF document. PDF Protection.

how to add text to a pdf document using acrobat; how to add text to pdf file

C# PDF Sticky Note Library: add, delete, update PDF note in C#.net

Allow users to add comments online in ASPX webpage. Able to change font size in PDF comment box. which bring users quick and efficient working with PDF Document.

adding text to pdf form; adding text to a pdf document

ITSP 6.0

Page 3 of 25

Section B

–

Implementation Schedule

(When an application is approved, the information in this section will be published at the ITF website (denoted with #)

and/or carried forward as pre-filled data in the related progress/final reports.)

1. Overall Schedule#

(When planning the project commencement date, please consider that it may take of a few months to approve an

application.)

Commencement date (dd/mm/yyyy)

1/9/2010

Completion date (dd/mm/yyyy)

31/8/2011

Project duration (month)

2. Project Milestones#

(Please set out individual milestones to be achieved at different stages of implementation. Detailed account should

be provided Section C.)

Per iod

Milestones

From

(dd/mm/yyyy)

1/9/2010

15/10/2010

Formulation of vitamin C irrigation solution and test for basic

properties and stability

16/10/2010

15/2/2011

Investigation of efficacy of different dosages of Vitamin C

irrigation solution in rat model of patellar tendon injury

16/2/2011

15/6/2011

Investigation of efficacy of different dosages of Vitamin C

irrigation solution in rat model of ACL reconstruction

1/4/2011

31/8/2011

Data analysis and applying patents in PRC/US

1/7/2011

31/8/2011

Preparation for final report of the project and submissions to

international conferences and peer-reviewed journals

Appendix V ITF proposal on vitamin C irrigation solution

C# HTML5 PDF Viewer SDK to annotate PDF document online in C#.NET

Name. Description. 1. Add sticky note. Click to add a sticky note to PDF document. 4. Strikethrough text. Click to strikethrough text on PDF page. 6. Add text box

how to add text to pdf file with reader; how to add text box to pdf

VB.NET PDF - Annotate PDF with WPF PDF Viewer for VB.NET

Line color. Select the line color when drawing annotations on PDF document. 15. Description. 17. Text box. Click to add a text box to specific location on PDF page

adding text to pdf file; add text to pdf file online

ITSP 6.0

Page 4 of 25

Section C

–

Project Details

1. Background

1.1. General background leading to this project. Please provide supporting documents,

such as published papers by members of the project team or other researchers.

Musculoskeletal disorders are leading cause of disability around the world, accounting for 25% of total

cost of illness

. In Hong Kong, 49428 cases (3.2%) of discharges/death related to diseases of the

musculoskeletal system and connective tissue in 2007

. The increased recreational sport and elite

consideration have drawn more societal concerns on effective treatment for sport injuries, including various

forms of ligament and tendon injuries, which have taken up significant health care resources. However,

medical research to improve healing outcomes of tendon and ligament injuries is far lagged behind. Our

research team has investigated tendon and ligament healing since 1995. In the past 14 years, we received 9

Research Grant Committee Earmarked grants and 7 CUHK direct grants, generating 88 publications in

peer-reviewed journals. (Annex No.1)

Tendon and ligament injuries are notorious with the slow healing rate and compromised mechanical

restoration. We have studied tendon healing in a rat model of patellar tendon healing up to 6 months post

injury

. This rat model mimics the clinical case of patellar tendon injury when the central-one third of the

patellar tendon was used as a graft for ACL reconstruction. In this animal model and in tendon cell culture

studies, we have investigated the effects of growth factors

31,37,17,14,22,27,26,23

, traditional Chinese herbal

medicine

and biophysical intervention

to promote tendon healing. Recently we also investigated the

beneficial effects of mesenchymal stem cells, biomaterials and bisphophanates (a class of drugs that inhibit

bone resorption) in rabbit

2,11

and rat models of ACL reconstruction (Annex no.2). With these studies, we

established numerous techniques for histological, biochemical and mechanical assessments of tendon and

ligament healing.

In our previous study, we found that cellular activities are changing in different healing stages

, and

earlier application of biophysical intervention exhibited better effects to improve healing outcomes

. Natural

healing process of tendon and ligament injuries involves four different stages: inflammation, cell recruitment,

granulation and remodeling. Previous attempts to promote tendon and ligament healing mainly targeted on

latter events such as enhancement of cell proliferation and matrix synthesis

23,26,31

; but modulation of earlier

events, especially in the inflammatory stage, has not been explored. Anti-inflammatory treatments are

commonly prescribed to tendon and ligament injuries to relieve symptoms; but its negative effects on tendon

and ligament healing are now clear, since some pro-inflammatory mediators (i.e. prostaglandins) are crucial to

trigger early healing events such as neo-vascularization

. It is possible that optimization of these early

healing events during the inflammatory stage of healing will be a more effective way to improve the

healing outcomes. During inflammatory stage of tendon and ligament healing, inflammatory cells are

recruited to the injured sites to tackle with potential microbial infection and clear the damaged tissues. At this

stage, significant oxidative stress prevails and neovascularization occurs. Neovascularization is the most

important event in this early healing stage by bringing healing cells, nutrients and oxygen for the repair

process. Since overwhelming oxidative stress is harmful to tendon cells

, reduction of oxidative stress by

antioxidants such as vitamin C (L-ascorbic acid) may exert protective effects. In addition to its powerful

antioxidant activity, vitamin C also exerted protection on vascular cells by modulation of nitric oxide synthase

expression, enhancement of cell growth, attachment and migration in vascular smooth muscles cell

32,13,37

Extremely low levels of ascorbate occur in patients and animals after trauma and infection, and early repletion

requires injection of supraphysiological doses of ascorbate

19.28

. These evidence suggest that early

supplementation of vitamin C may have beneficial effects for wound healing. A recent study reported that

intraperitoneal injection of high dose vitamin C promote Achilles tendon healing as revealed by histological

findings

. In a chicken model of flexor tendon repair, we found that a single bolus injection of vitamin C after

surgical repair could reduce the extent of tendon adhesion and hence promote functional restoration. It

suggests that local application of vitamin C at very early stages of healing (after surgical repair) can promote

tendon and probably ligament healing, since oxidative stress and neovascularization are important

determinants for both tendon and ligament healing. As Vitamin C has a very high safety profile

, it gains the

merits of high applicability for clinical use. Since surgical irrigation saline (sterile isotonic sodium chloride

solution) is used for draining and cleansing during surgical operation, it may be the best carrier for vitamin C

during surgical operation. In the present research project, we propose to develop the use of vitamin C

irrigation solution to promote tendon and ligament healing. pre-clinical trials will be performed in animal

Appendix V ITF proposal on vitamin C irrigation solution

ITSP 6.0

Page 5 of 25

models with the advanced assessment methods we have established.

1.2. Any previously related project(s) undertaken by your organization and/or key project

team members in the past five years and supported by the ITF or any other funding

sources in Hong Kong and around the world? If yes, please briefly describe the

relevant/related project(s) and the source(s) of funding obtained for it (them).

In the past 5 years, our project team members have received 4 grants from General Research Fund

(formerly competitive earmarked grant, Research Grant Committee) which are related to the present

proposal (Annex no.1):

Use of Bisphosphonate to Inhibit Local Bone Resorption and Improve Healing of Tendon Graft to Bone

Tunnel. (PI: Prof. Lui PPY, duration: 2009-2011)

In this project, we established a rat model of ACL reconstruction with histological examination on decalcified

samples of the graft incorporation and mechanical test for the ultimate loading of the reconstructed ACL. The

temporal changes of the healing outcomes were recorded. This information will be useful for the present

research project.

Augmentation of Tendon Graft Healing within Bone Tunnel Using In-Situ Setting, Calcium Phosphate

Bone Cement Complement with Autologous Mesenchymal Stem Cells (PI: Prof. Chan KM, duration:

2007-2009)

In this project, we used a rabbit model of ACL reconstruction to investigate the effects of stem cells and

biomaterials. The surgical techniques were modified for the establishment of the rat model of ACL

reconstruction.

The use of antioxidants to reduce tendon adhesion (PI: Prof. Hung LK, duration (2007-2009)

In this project, we evaluated the effect of peritendinous vitamin C/vitamin E injection (immediately after

surgical repair) on the development of tendon adhesion. The results showed that vitamin C given as a single

bolus injection can reduce the extent of tendon adhesion probably thorough its anti-oxidant effects. It inspired

our idea to develop vitamin C irrigation solution to promote tendon and ligament healing in the present

proposal.

An experimental study on the use of low intensity pulsed ultrasound to optimize patellar tendon healing

in a rat model (PI: Prof. LK Hung, duration:2004-2007)

In this project, we used a well-established rat model of patellar tendon injury to evaluate the effect of

therapeutic ultrasound. We found that earlier biophysical intervention by LIPUS exhibited better effects to

improve healing outcomes. The time points of different healing stages in this model (inflammation,

granulation and remodeling) were defined, which will be used as references for sampling time points in the

present proposal.

1.3. Any other R&D work or projects similar to this application done or being carried out

by other parties in Hong Kong and around the world? If yes, please set out the

findings and explain how your approach is compared to others in terms of

technological superiority, production costs, market acceptability, etc.

To the best of our knowledge, we are the first group proposing the addition of Vitamin C in surgical

irrigation solution. From a search in the free patent online (http://www.freepatentsonline.com/), only two

expired and one current items related to surgical irrigation saline was found (US4504493, US4872865,

US20060205657). Modifications of surgical irrigation saline have been proposed in other aspects, including

addition of antiseptics to reduce chance of infection

, detergents

and supplementation of epinephrine to

reduce bleeding

30,34

. However, up-to-date there are no reports describing the feasibility of modified surgical

irrigation solution to optimize tendon/ligament healing.

A recent study reported intraperitoneal injection of high dose vitamin may promote Achilles tendon

healing as revealed by histological findings

. Instead of systemic administration by intraperitoneal injection,

we investigated the effect of peritendinous injection of vitamin C on tendon adhesion in a chicken model of

flexor tendon repair

and positive results were reported

(Annex no.3). Due to the difficulty to keep injected

vitamin C in peri-tendinous space, we propose to supplement vitamin C in irrigation solution in the present

proposal. This will simplify the application procedure and circumvent the problem of leakage. In a pilot study

we showed that irrigation of 5 ml vitamin C solution significantly increased neovascularization into tendon

wound in the rat model of patellar tendon injury (Annex no.4, 5). It suggested that vitamin C supplementation

may be an added value to surgical irrigation solution for a better healing outcome.

Appendix V ITF proposal on vitamin C irrigation solution

ITSP 6.0

Page 6 of 25

With its safety profile

, low cost and potential beneficial effects to promote tendon and ligament

injuries, vitamin C irrigation solution would have an advantage in terms of cost, technological feasibility and

market acceptability, as compared to all commercially available surgical irrigation saline. It is foreseeable that

extra intra-operative care will be achieved by this value-added surgical irrigation solution.

1.4. Any pilot work has already done by your organization and/or project team members

in preparation for this project? If yes, please describe the work done.

Our team has established a full range of experimental techniques to evaluate the healing outcomes of tendon

and ligament injuries in rat models:

Animal models

A well-established rat model of patellar tendon injury will be used for evaluation of the effects of vitamin C

irrigation solution on tendon injuries. We have published 12 papers (Annex 1)on this model and monitored the

structural and functional restoration of the injured tendons up to 6 months post injury. The healing outcomes of

patellar tendon injuries are evaluated by histology and mechanical tests as routine. For evaluation on ligament

injuries, we have established a rat model of ACL reconstruction with characterization on histology and

mechanical properties of the graft. A conference abstract based on this model was accepted by International

Symposium of tendon and Ligament X to be held on 5 Feb 2010. (Annex no.2)

Measurement of neovascularization in healing patellar tendon by High resolution 3-D Doppler

ultrasound imaging

We developed the use of high resolution ultrasound imaging to monitor tendon healing in rat patellar tendon

injury (Annex no.6). The changes in wound size, tendon swelling and echo textures of the healing tendon were

monitored up to day 42 post injury. Since the extent of neovascularization is deterministic for healing

outcomes, we also developed a quantitative measurement of vascularity in the tendon wound by 3-D Doppler

ultrasound imaging

(Annex no.7). These techniques will be used to evaluate the effects of vitamin C

irrigation solution.

Animal gait analysis to measure painful response associated with tendon and ligament injuries

We have developed the use of video-assisted gait analysis to monitor painful responses in a rat model with

collagenase-induced patellar tendon injuries. We found that the injured rats exhibited abnormal gait

parameters on both the injured limbs and the contralateral control limbs as compared to the control group with

saline injection

(Annex no.8). Gait changes associated with pain could also be monitored in rat models of

knee injuries, including ACL deficiency and traumatic patellar tendon injuries. As a result, video-assisted gait

analysis will be employed to evaluate functional changes related to the healing outcomes of injured ACL or

patellar tendons after supplementation of vitamin C in surgical irrigation solution.

Effects of Vitamin C injection on tendon adhesion in a chicken model of flexor tendon repair.

On the potentials of vitamin C supplementation to optimize tendon healing, we have almost completed an

Earmarked grant entitled

“

the use of antioxidants to reduce tendon adhesion

”

. In a chicken model of flexor

tendon repair, we established a new method to evaluate the severity of tendon adhesion (Annex no.10). We

also found that local injection of vitamin C could reduce oxidative stress and reduce tendon adhesion, which

was demonstrated as a decrease in gliding resistance and improved range of motion

(Annex no.3). Based on

these findings, we propose that supplementation of vitamin C in surgical irrigation solution may be also be

useful in other tendon and ligament injuries, and a pilot study was performed in a rat model of patellar tendon

injury.

Effects of vitamin C irrigation solution on patellar tendon healing

In a pilot study, we compared the effect of vitamin C irrigation saline (30 mg/mL) on tendon healing with

normal saline as control. During the surgical procedure of induction of patellar tendon injury, either 5 ml of

vitamin C saline or normal saline was used to cleanse the wound. The patellar tendons were washed before

injury was induced, during the removal of central-one-third of the patellar tendon, and after the fascia was

closed by sutures. The preliminary data showed that vitamin C irrigation (n=6) significantly increased

neovascularization in the tendon wound at day 4 post injury as compared to normal saline irrigation saline

group (n=6) (Annex no.4 & 5). It suggests that vitamin C irrigation solution may have a positive effect on the

Appendix V ITF proposal on vitamin C irrigation solution

ITSP 6.0

Page 7 of 25

healing outcomes of patellar tendon injury.

1.5. Any request for funding support for this application previously rejected by ITF,

Research Grants Council (RGC) and/or other Government-administered funding

schemes? If yes, please set out the project reference of the previous application.

No, this is a new project.

1.6. If this application is a previously rejected application under ITF, any major differences

of this application vis-à-vis the previous one? Please explain how these differences

have addressed the previously raised concerns.

Not applicable.

1.7. Any attempt made or being made to seek funding support for this project from other

funding sources in Hong Kong and around the world (e.g. RGC, Applied Research

Fund, Environment and Conservation Fund, etc.)? Please advise any known results

of the application(s).

No.

References:

1. Fu SC, Hung LK, Lee YW, Mok TY, Chan KM. (2010) A novel approach to measure tendon adhesion

by video-assisted gliding test in a chicken model. J Hand Surg (Eur). (Accepted)

2. Lui PP, Lee YW, Mok TY, Cheuk YC, Fu SC, Ho G, Chan KM. (2010) The effect of alendronate on the

mechanical strength of the tendon graft to bone tunnel complex after ACL reconstruction. ISL&T X

2010 Hong Kong.

3. Chan KM, Fu SC. (2009) Anti-inflammatory management for tendon injuries – friends or foes? Sports

Med Arthrosc Rehabil Ther Technol. 1:23.

4. Health Facts of Hong Kong 2009 Edition. (2009) Department of Health, Hong Kong SAR.

5. Fu SC, Chan KM, Chan LS, Fong DT, Lui PP. (2009) The use of motion analysis to measure

pain-related behaviour in a rat model of degenerative tendon injuries. J Neuosci Methods.

179(2):309-18.

6. Fu SC, Hung LK, Shum A, Lee YW, Mok TY, Lui PP, Chan KM. (2009) Local vitamin C injection

reduced tendon adhesion in a chicken model of injured flexor digitorum profundus tendon injury.

ISL&T IX 2009 Las Vegas.

7. Ömeroğlu S, Peker T, Türközkan N, Ömeroğlu H. (2009) High-dose vitamin C supplementation

accelerates the Achilles tendon healing in healthy rats. Arch Orthop Trauma Surg 129:281-286.

8. Owens BD, White DW, Wenke JC (2009) Comparison of irrigation solutions and devices in a

contaminated musculoskeletal wound survival model. J Bone Joint Surg Am 91:92-8.

9. Wen CY, Qin L, Lee KM, Chan KM. (2009) Peri-graft bone mass and connectivity as predictors for

the strength of tendon-to-bone attachment after anterior cruciate ligament reconstructions. Bone.

45(3):545-52.

10. Wen CY, Qin L, Lee KM, Chan KM. (2009) The use of brushite calcium phosphate cement for

enhancement of bone-tendon integration in an anterior cruciate ligament reconstruction rabbit model.

J Biomed Mater Res B Appl Biomater. 89B(2):466-74.

11. Wen CY, Qin L, Lee KM, Wong MW, Chan KM. (2009) Influence of bone adaptation on

tendon-to-bone healing in bone tunnel after anterior cruciate ligament reconstruction in a rabbit

Appendix V ITF proposal on vitamin C irrigation solution

Documents you may be interested

mvc view to pdf itextsharp : Add text box in pdf document control Library system web page .net html console 92015006330-part1602