RESEARCH

Effects of a Single Application of Extractum Cepae on the

Peritendinous Adhesion
An Experimental Study in Rabbits
Yunus Dogramaci, MD,* Aydıner Kalacı, MD,* Esin Atik, MD,† Erdinc Esen, MD,‡
Muhammet Enes Altuğ, PhD,§ Ercument Onel, Med. Vet.,§ Ahmet Koç, PhD,† and AhmetNedim Yanat, MD*

tive adhesion may play an important role in preventing the periten-

Abstract: Peritendinous adhesion is an important cause of poor functional
dinous adhesion and improving the functional outcome. Several
outcome after flexor tendon repair. The objective of this study was to
studies have investigated the use of local applications to the injured
investigate the effect of a single intraoperative application of extractum
tendons including the aprotinin,2 human amniotic fluid,3 (beta)-
cepae, an extract of dietary onion, on the peritendinous adhesion, using a
amino-proprionitrile,4 hyaluronic acid,5 5-fluorouracil,6,7 man-
rabbit model of flexor tendon injury.
nose-6- phosphate,8 and the alginate solution.9
The first, second, and third digits of the right hind paw of 18 rabbits were
Extractum cepae, an onion extract which contains quercetin,
used for tendon operations. A standard partial division of the synovial sheath
has been studied extensively and seems to have an anti-inflamma-
and flexor tendon was done at zone II to stimulate the adhesion formation. In
tory effect by stabilizing mast cell membranes and an antiprolifera-
the treatment group (n ⫽ 9 rabbits, 27 tendons), the flexor tendon sheath was
tive effect in both normal and malignant cells of various types.10 –12
treated with 50 mg/mL of extractum cepae which was applied locally and
When given intraperitoneally to animals with ascitic tumors, quer-
allowed to infiltrate for 5 minutes, the skin was sutured without suturing the
cetin, revealed antitumor activity.13 When applied to the scars,
sheath and the tendons. The same operation was done for the control group
significant improvement in collagen organization has been shown in
(n ⫽ 9 rabbits, 27 tendons) and 1 mL of normal saline solution was applied
previous experimental studies.14 –18
locally. Biomechanical and histologic evaluations of the specimens were
We assumed that the extractum cepae may play a role in
done after 3 weeks. Tendons from the first toes were used for biomechanical
reducing the restrictive adhesions by exhibiting antiproliferative
studies. The second and third toe tendons were used for histopathologic
effects when applied locally to the injured flexor tendon.
evaluation. We have compared the peritendinous adhesions and the ultimate
forces in the control and treated tendons. There were no statistically signif-
MATERIALS AND METHODS
icant differences between the 2 groups with respect to the ultimate loads.
Experiments were performed on New Zealand white male
Adhesion formation was absent in 1 tendon (5.5%), slight in 8 (44.4%),
rabbits weighing 2.5 to 3 kg. The rabbits were randomly assigned to
moderate in 6 (33.3), and severe in 3 tendons (16.7%) in the extractum cepae
control and treatment groups. First, second, and third toes from right
treated group (n ⫽ 18); while in the control group (n ⫽ 18), it was absent in
hind paws of each rabbit were used in each group. The experimental
1 tendon (5.5%), slight in 1 tendon (5.5%), moderate in 3 (16.6%), and
protocols were approved by the local animal ethical committee of
severe in 13 (72.4%) tendons. There was a significant reduction (P ⫽ 0.01)
University of Mustafa Kemal. Animal care and experiments com-
in the peritendinous adhesion in the treated group comparing to the control
plied with the “Guide for the Care and Use of Laboratory Animals.”
group. The problem of adhesion formation may be minimized using a single
The rabbits were housed in a room kept at 24 ⫾ 1°C. All surgical
intraoperative application of extractum cepae.
interventions were carried out under aseptic conditions. Animals
Key Words: extractum cepae, tendon injury, prevention, peritendinous were anesthetized intramuscularly with 1 mg/kg atropine sulfate
adhesion (Atropan, Vetas, Turkey), 5 mg/kg xylazine hydrochloride (Rompun,
(Ann Plast Surg 2010;64: 338 –341) Bayer, Turkey), and 50 mg/kg ketamine hydrochloride (Alfamine,
Egevet, Turkey).
The hind paws were shaved, scrubbed, disinfected with pov-
idone-iodine solution, and draped, after which a tourniquet was

P eritendinous adhesion is the main cause of poor functional

outcome after tendon injuries. The presence of tendon and sheath
injuries, immobilization, and suture materials significantly predis-
pose to adhesion formation.1 Fibrotic adhesions that form during the
healing of tendon prevent tendon excursion, and thus increase the
work of flexion and result in bad functional outcome and loss of
joint motion.2 The local targeting of cells contributing to the restric-
Received February 3, 2009, and accepted for publication, after revision, May 23,
2009.
From the *Departments of Orthopaedics and Traumatology, and †Pathology,
Mustafa Kemal University, Antakya, Hatay, Turkey; ‡Department of Ortho-
paedics and Traumatology, Gazi University, Ankara, Turkey; and §Depart-
ment of Surgery, Mustafa Kemal University, Antakya, Hatay, Turkey.
Reprints: Yunus Dogramaci, MD, Department of Orthopaedics and Traumatol-
ogy, Mustafa Kemal University, 31100, Antakya, Hatay, Turkey. E-mail:
yunus_latif@yahoo.com.
Copyright © 2010 by Lippincott Williams & Wilkins
ISSN: 0148-7043/10/6403-0338
DOI: 10.1097/SAP.0b013e3181afa428
applied above the os calcis. Under a 6⫻ magnification, separate
longitudinal midline skin incisions were made on the volar aspect of
the proximal phalanx of each toe, and carefully dissected to expose
the synovial sheath. To access the flexor digitorum profundus, the
sheath was incised transversely between the A2 and A3 pulleys
distal to the flexor digitorum superficialis bifurcation.
A standard partial division of the flexor digitorum profundus
tendon (approximately 50%) was done.
In the treatment group, the flexor tendon and sheath was
treated with 1 mL of extractum cepae (50 mg/mL, Merz Group
Services, Reinheim, Germany) which was applied locally to the
injured tendon-sheath and allowed to infiltrate for 5 minutes. In the
control group, the sheath and tendon was treated with 1 mL of
normal saline, which was applied locally for the same period. The
tendon and sheath incisions were not repaired. Skin closure was with
5-0 nylon interrupted sutures. The operated hind limbs were immo-
bilized below the knee with a plaster cast with the ankle in neutral
position.

338 | www.annalsplasticsurgery.com Annals of Plastic Surgery • Volume 64, Number 3, March 2010
Annals of Plastic Surgery • Volume 64, Number 3, March 2010 Effects of Single Application of Extractum Cepae

After 3 weeks the rabbits were killed with high doses of 14

Ketamin hydrochloride 200 mg/kg (Alfamine, Egevet, Turkey)
given intravenously. All tendons were removed through previous 12
surgical incisions. After the skin incision, the tissue plane around the
synovial sheath was dissected and the tendon/sheath complex was
divided proximal to the metacarpophalangeal joint and distally at the 10
level of the distal phalanx insertion, respectively. The tendons used
for biomechanical testing were wrapped in saline-soaked gauze and 8
biomechanical testing was done on the same day.
Histologic Evaluation 6

Number of Specimen
Second and third toes were used for histopathologic evalua-
tions. The tendon/sheath complexes went through a standard proce- 4
dure of fixation using 10% neutral formalin and decalcification
solution for a period of 48 hours, which allowed the excision of the
specimens. The tendons were cut longitudinally and embedded in 2
Treatment group
paraffin after routine processing. Serial sections were prepared and
stained with hematoxylin and eosin. 0 Control group
The grading scale of Tang et al19 was used to evaluate the extent None Minimal Medium Severe
and severity of the formation of adhesions in the peritendinous region
(Table 1). In this grading system the adhesions were evaluated both Adhesion grades
quantitatively and qualitatively. The extents of the adhesions were
FIGURE 1. Schematic presentation of the adhesion grades in
classified into 4 grades: no adhesions, slight (minimal) adhesions,
the control and treated tendons.
moderate (medium) adhesions, and severe adhesions.
An experienced histopathologist performed the review as a
blind observer without having any information about the tendons.
TABLE 2. Histopathologic Evaluation Results of the Control
Biomechanical Tests and Extractum Cepae-Treated Group
The first toes were selected to test the ultimate load of the Adhesion Grades
injured tendon. Tendons were vertically held in the nonslipping jaws
of soft tissue clamps, which were mounted onto a material testing Non Minimum Medium Severe
machine (model TIRA test 24500; Demgen, Werkzeugbau, GmbH, N n (%) n (%) n (%) n (%)
Schwerte, Germany). All specimens were subsequently loaded to Group 1 (treatment) 18 1 (5.6) 8 (44.4) 6 (33.3) 3 (16.7)
failure point at a static rate of 20 mm/min and force versus displace- Group 2 (control) 18 1 (5.5) 1 (5.5) 3 (16.6) 13 (72.4)
ment data was recorded.
Biomechanical data were analyzed using the Mann-Whit-
ney-U test. The ␹2 test was used to analyze the histologic results. A
significant difference was found in ultimate load between the 2
P value of less than 0.05 was considered statistically significant.
group (P ⫽ 0.323).
Biomechanical Results Histopathologic Findings
Ultimate load of the tendons was (47.11 ⫾ 1.33 N) for the
Adhesion formation was absent in 1 tendons (5.5%), slight in
treatment group and (46.16 ⫾ 1.54 N) for the control group. No
8 (44.4%), moderate in 6 (33.3), and severe in 3 tendons (16.7%) in
group I (treated tendons); while in group II (untreated tendons), it
was absent in 1 tendon (5.5%), slight in 1 tendons (5.5%), moderate
TABLE 1. Criteria Described by Tang et al19; A Histologic in 3 (16.6%), and severe in 13 (72.4%) (Fig. 1, Table 2).
Evaluation of Adhesions There was significantly less adhesions (severe and medium
grade) in the treatment group compared with control group (P ⫽ 0.01).
Points Features of Adhesion
Quantity DISCUSSION
0 No apparent adhesions Various pharmacologic agents have been experimented to
1 A number of scattered filaments minimize the restrictive adhesion and improve the functional out-
2 A large number of filaments come after flexor tendon injuries. The reduction in synovial reaction
3 Countless filaments and adhesion formation using “one touch” technique has been
Quality
proved in previous experimental studies.2,6,7
In our study, we tested the hypothesis that the use of extrac-
0 No apparent adhesions
tum cepae will be safe and reduce the extent of peritendinous
1 Regular, elongated, fine, filamentous adhesion formation after tendon injuries. For this purpose, a rabbit
2 Irregular, mixed, shortened, filamentous flexor tendon injury model was used.
3 Dense, not filamentous Histopathologically, extractum cepae treated group showed
Grading of adhesions significantly less adhesion (Fig. 2) compared with the control group
0 None (Fig. 3). In the treatment group, less fibrosis and less adhesion
1–2 Slight (minimal) formation revealed that less reaction and adhesion occurred around
3–4 Moderate (medium) the tendon in this group. The tendon, incision site, and the skin
5–6 Severe healed completely in both groups and no infection was observed in
either group.

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Dogramaci et al
FIGURE 2. A longitudinal section from the extractum cepae-
treated tendon, showing almost no adhesion and a less cel-
lular synovial sheath. The synovial space is well-preserved
(hematoxylin and eosin, original magnification ⫻10).
FIGURE 3. Longitudinal section from the control group,
showing increased cellularity of the sheath, obliteration of
the synovial space and dense ingrowth of adhesion from the
synovial sheath into the tendon substance (hematoxylin and
eosin, original magnification ⫻10).
No significant difference was found in ultimate load between the
extractum cepae applied and the control group. The aim of the ultimate
load evaluation at this period was to assess the effects of the applied
extractum cepae on the biomechanical properties of the healing ten-
dons. From these biomechanical results it was found that a single
application of extractum cepae did not change the ultimate load of
the tendons, and thus the tensile strength of the tendons were not
affected adversely. The local application of extractum cepae had not
affected the skin healing, as healing was complete in both groups
and no infection was observed in either group.
The use of antimetabolite and antiproliferative agents in
preventing the peritendinous adhesion has been experimented in
previous studies. Akali et al6 had assessed the effect of a single,
5-minute intraoperative application of 5-fluorouracil on digital
flexor tendon adhesions in a rabbit model of flexor tendon injury. In
another experimental study, using a rabbit model, Khan et al7 had
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Annals of Plastic Surgery • Volume 64, Number 3, March 2010
examined the effects of treating the synovial sheath with antimetab-
olite 5-flurouracil for a period of 5 minutes. They found that
restrictive adhesion and local inflammation can be modulated by
using this simple single touch technique. In a rabbit flexor tendon
injury model, Bates et al9 found that a single intraoperative dose of
mannose-6-phosphate, a natural inhibitor of TGF-␤, improved the
postoperative range of motion.
In the current study, we used extractum cepae, a material of
plant origin, extracted from the dietary onion, Allium cepae. It
contains quercetin, which has been used for the treatment of post
surgical hypertrophic scarring.14,15 It has also been used safely in
the treatment and prevention of scars in children who had undergone
thoracic surgery.16,17 In a rabbit ear models, Saulis et al, has noted
a significant improvement in the collagen organization in the Allium
cepae-treated scars.18
Quercetin is the active derivative of extractum cepae which is
a flavonoid compound, which is found in various foods of plant
origin. Humans consuming high amounts of fruit and vegetable diets
may ingest up to 1 g of these compounds daily.20 The mechanism of
action of quercetin includes inhibition of mutagenesis, modulation
of enzyme activities, inhibition of DNA formation, free-radical
scavenging, and effects on cell proliferation and tumor growth.20
Castillo et al11 had searched the effect of quercetin on mice bearing
abdominal tumors derived from a human pharyngeal squamous cell
carcinoma line. The mice were given a daily intraperitoneal injection
of different doses of quercetin. All doses tested demonstrated a
selective and significant inhibition of tumor cell growth. In another
study, Choi et al found that breast cancer cell growth was inhibited
and cancer cells performed apoptosis (cancer cell suicide) when
exposed to quercetin.21
One of the possible mechanisms of action of allium (onion)
derivatives is the inhibition of the enzyme cytochrome P450 2E1,
which activates a number of carcinogens.22 Avila et al found that
quercetin down-regulates the expression of mutant p53 protein to
nearly undetectable levels in human breast cancer cell lines.23 The
inhibition of expression of p53 was found to arrest the cells in the
G2-M phase of the cell cycle. This down-regulation was found to be
much less in cells with an intact p53 gene.24 The G1 checkpoint
controlled by the p53 gene is a major site for the control of cellular
proliferation. Quercetin has been found to arrest human leukemic
T-cells in the late G1 phase of the cell cycle.25 Flavonoids are also
considered as potential antioxidants. Boyle et al had investigated the in
vivo antioxidant effects of flavonoids from foods.26 They found that
flavonoid glucosides were significantly elevated in plasma after inges-
tion of the onion meal and the increases were associated with an
increased resistance of lymphocyte DNA to DNA strand breakage.
In conclusion, this pilot study suggests that extractum cepae,
may be used to inhibit the formation of peritendinous adhesions,
however, further studies are necessary to understand the exact
mechanism of action in the peritendinous adhesions and in vivo
studies are necessary to evaluate the effects of dietary onion intake
after tendon injuries.
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