Effects of Advanced Glycation Endproducts on the Mechanical Properties of Posterior Tibialis in Individuals with Diabetes Mellitus
Authors: Zellers Jennifer A. , Eekhoff Jeremy , Walk Remy , Tang Simon Y. , Hastings Mary K. , Lake Spencer 
Published: October 2019

Category: Diabetes Introduction/Purpose: Advanced glycation endproducts (AGEs) accumulate in tendon tissue in individuals with diabetes mellitus (DM). Although AGEs have been shown to impact tendon function by decreasing collagen sliding, this relationship has not been explored in humans with diabetes. Despite the prevalence of foot deformity in this population and implications of posterior tibialis dysfunction, the mechanical behavior of the posterior tibialis tendon has only been reported in a small (n=5), cadaveric study that did not report DM status. Therefore, the purpose of this study is to determine the effects of DM-associated AGEs accumulation on the mechanical properties of the posterior tibialis tendon. Methods: Posterior tibialis tendons were collected from individuals with and without DM undergoing lower extremity amputation. A 1-2 mm tendon transection was used for AGEs quantification. AGEs were quantified via fluorescence following papain digestion and hydrolyzation as described previously. Fluorescence was compared to a quinine standard to calculate AGEs content, which was normalized to sample wet weight. Tensile mechanical testing was completed with the remaining specimen (˜25 mm long). Tendon cross-sectional area was measured with a non-contact laser scanning device. Specimens were preloaded to 10 N and preconditioned for 10 cycles at 6% strain, subjected to stress-relaxation at 6% strain for 10 minutes, and loaded with a triangular waveform to a maximum of 10% strain at a rate of 1% strain per second. Individual values and group descriptive statistics are reported for AGEs content and mechanical testing. Relationships between AGEs content and various mechanical testing parameters were evaluated using Spearman correlation. Results: Six individuals (5 with DM, 4 male, mean(SD) age: 56(5)years) were included. AGEs content was increased in DM tendon (DM: 20.5(5.1), non-DM: 9.5 ng quinine/mg wet weight). Compared to non-DM tendon, DM tendons had larger cross-sectional area (DM: 44.3(4.9), non-DM: 11mm2). From stress relaxation, DM tendons had smaller peak (DM: 0.41(0.25), non-DM: 1.16 MPa) and equilibrium stress (DM: 0.23(0.13), non-DM: 0.83 MPa), and larger percent relaxation (DM: 46(6)%, non-DM: 29%)(Figure 1-A). DM tendons had decreased maximum stress at 10% strain (DM: 0.63(0.45), non-DM: 1.75 MPa), increased linear stiffness (DM: 35.2(27.6), non-DM: 19.2N/mm), and decreased linear modulus (DM: 8.5(7.0), non-DM: 20.1 MPa)(Figure 1-B, C) compared to non- DM tendon. Hysteresis (i.e., energy loss upon unloading) was higher in DM tendons (DM: 0.35(0.05), non-DM: 0.22), and positively correlated to AGEs (rho=0.943, p=0.005, Figure 1-D). Conclusion: Posterior tibialis tendons with DM exhibited increased AGEs content and altered mechanical properties. DM tendons were less stiff when accounting for cross-sectional area but had 2-4x the cross-sectional area of non-DM tendon, with inconsistent patterns in total tendon stiffness potentially attributable to several factors. DM tendons showed impaired energy storage and return, which was most strongly associated with AGEs. Non-DM samples were limited and the linear modulus was smaller than previously reported, however, all but one DM tendon had a modulus less than 50% of the non-DM sample. Future work will explore the mechanisms of AGEs-associated DM tendon impairments.