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Burgio V, Casari S, Milizia M, Sanna F, Spezia G, Civera M, Rodriguez Reinoso M, Bertuglia A, Surace C. Mechanical properties of animal ligaments: a review and comparative study for the identification of the most suitable human ligament surrogates. Biomech Model Mechanobiol 2023; 22:1645-1683. [PMID: 37169958 PMCID: PMC10511400 DOI: 10.1007/s10237-023-01718-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/29/2023] [Indexed: 05/13/2023]
Abstract
The interest in the properties of animal soft tissues is often related to the desire to find an animal model to replace human counterparts due to the unsteady availability of human tissues for experimental purposes. Once the most appropriate animal model is identified, it is possible to carry out ex-vivo and in-vivo studies for the repair of ligamentous tissues and performance testing of replacement and support healing devices. This work aims to present a systematic review of the mechanical properties of ligaments reported in the scientific literature by considering different anatomical regions in humans and several animal species. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. Moreover, considering the lack of a standard protocol for preconditioning of tissues, this aspect is also addressed. Ninety-six studies were selected for the systematic review and analysed. The mechanical properties of different animal species are reported and summarised in tables. Only results from studies reporting the strain rate parameter were considered for comparison with human ligaments, as they were deemed more reliable. Elastic modulus, ultimate tensile stress, and ultimate strain properties are graphically reported identifying the range of values for each animal species and to facilitate comparison between values reported in the scientific literature in animal and human ligaments. Useful similarities between the mechanical properties of swine, cow, and rat and human ligaments have been found.
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Affiliation(s)
- V. Burgio
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - S. Casari
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - M. Milizia
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - F. Sanna
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - G. Spezia
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - M. Civera
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - M. Rodriguez Reinoso
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
| | - A. Bertuglia
- Department of Veterinary Science, University of Turin, Largo Paolo Braccini 2-5, 10095 Grugliasco, Italy
| | - C. Surace
- Department of Structural, Building and Geotechnical Engineering, Politecnico di Torino, 10129 Turin, Italy
- Department of Structural, Geotechnical and Building Engineering, Laboratory of Bio-Inspired Nanomechanics, Politecnico di Torino, Corso Duca Degli Abruzzi 24, 10129 Turin, Italy
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任 爽, 时 会, 张 家, 刘 振, 邵 嘉, 朱 敬, 胡 晓, 黄 红, 敖 英. [Finite element analysis of the graft stresses after anterior cruciate ligament reconstruction]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:865-870. [PMID: 34650286 PMCID: PMC8517673 DOI: 10.19723/j.issn.1671-167x.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To explore the stress distribution characteristics of the graft after anterior cruciate ligament (ACL) reconstruction, so as to provide theoretical reference for the surgical plan of ACL reconstruction. METHODS Based on 3D MRI and CT images, finite element models of the uninjured knee joint and knee joint after ACL reconstruction were established in this study. The uninjured knee model included femur, tibia, fibula, medial collateral ligament, lateral collateral ligament, ACL and posterior cruciate ligament. The ACL reconstruction knee model included femur, tibia, fibula, medial collateral ligament, lateral collateral ligament, ACL graft and posterior cruciate ligament. Linear elastic material properties were used for both the uninjured and ACL reconstruction models. The elastic modulus of bone tissue was set as 17 GPa and Poisson' s ratio was 0.36. The material properties of ligament tissue and graft were set as elastic modulus 390 MPa and Poisson's ratio 0.4. The femur was fixed as the boundary condition, and the tibia anterior tension of 134 N was applied as the loading condition. The stress states of the ACL of the intact joint and the ACL graft after reconstruction were solved and analyzed, including tension, pressure, shear force and von Mises stress. RESULTS The maximum compressive stress (6.34 MPa), von Mises stress (5.9 MPa) and shear stress (1.83 MPa) of the reconstructed ACL graft were all at the anterior femoral end. It was consistent with the position of maximum compressive stress (8.77 MPa), von Mises stress (8.88 MPa) and shear stress (3.44 MPa) in the ACL of the intact knee joint. The maximum tensile stress of the graft also appeared at the femoral end, but at the posterior side, which was consistent with the position of the maximum tensile stress of ACL of the uninjured knee joint. More-over, the maximum tensile stress of the graft was only 0.88 MPa, which was less than 2.56 MPa of ACL of the uninjured knee joint. CONCLUSION The maximum compressive stress, von Mises stress and shear stress of the ACL graft are located in the anterior femoral end, and the maximum tensile stress is located in the posterior femoral end, which is consistent with the position of the maximum tensile stress of the ACL of the uninjured knee joint. The anterior part of ACL and the graft bore higher stresses than the posterior part, which is consistent with the biomechanical characteristics of ACL.
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Affiliation(s)
- 爽 任
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 会娟 时
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 家豪 张
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 振龙 刘
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 嘉艺 邵
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 敬先 朱
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 晓青 胡
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 红拾 黄
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 英芳 敖
- />北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
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Yao SY, Cao MD, He X, Fu BSC, Yung PSH. Biological modulations to facilitate graft healing in anterior cruciate ligament reconstruction (ACLR), when and where to apply? A systematic review. J Orthop Translat 2021; 30:51-60. [PMID: 34611514 PMCID: PMC8458724 DOI: 10.1016/j.jot.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022] Open
Abstract
Background When and where to apply the biological modulations is effective to promote healing in the anterior cruciate ligament (ACL) reconstruction remains unclear. Purpose To perform a systematic review of preclinical animal studies on biological modulation in anterior cruciate ligament reconstruction (ACLR) concerning the time and site of delivery. Study design Systematic review of controlled laboratory studies. Methods PubMed, Ovid, and Scopus were searched until December 2020 using a combination of keywords and their synonym to retrieve all animal studies about biological modulation in ACLR. Studies that assessed mechanical strength after ACLR and compared with negative control were included. The methodological quality of animal studies was evaluated. Results 33 studies were included in this review and the majority reported mechanical strength improvement. 79 % of studies applied the biological modulations intra-operatively with different delivery systems used. For 21 % of post-operative delivery studies, intermittent delivery was tried. 21 of the included studies directly applied the biological modulations in the bone tunnels, 5 studies applied intra-articularly while 7 studies applied both in the bone tunnels and intra-articular part. Biological modulations applied intra-operatively and those applied in both parts showed better mechanical strength increase. A shift of the failure mode of pull-out from the bone tunnel in the early healing phase, to mid-substance rupture in the later phase was observed in most studies. Conclusion The improvement of the mechanical strength depends on how the biological modulations (delivery phase, delivery site, delivery form) are applied. The intra-operative delivery showed an overall higher mechanical strength increase and bone tunnel only delivery or intra-articular and bone tunnel both delivery are preferred than intra-articular only delivery. In addition, intra-articular and bone tunnel both delivery can have better mechanical strength increase for a long follow-up time. Thus, intra-operative application with a carrier to control release rate in both parts should be recommended. Further studies are needed to achieve a better healing outcome and more attention should be given to the intra-articular remodeling of the graft along with the tendon bone healing to increase the final mechanical strength. The Translational potential of this article Here, a systematic review of preclinical evidence of the time, site and the method the biological modulations being applied for ACLR to improve the graft healing would be performed. After reviewing the available studies, a choice of when and where to apply the biological modulations can achieve better mechanical strength after ACLR can be obtained. It provides evidence for both researchers and clinicians to decide when and where to apply the biological modulations can achieve their best effectiveness for ACLR before implementing. Promoting graft healing with targeted time and targeted site may reduce the risk of graft failure, safeguard return to sport.
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Affiliation(s)
- S Y Yao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - M D Cao
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - X He
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Bruma S C Fu
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Patrick S H Yung
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Yao S, Fu BSC, Yung PSH. Graft healing after anterior cruciate ligament reconstruction (ACLR). ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 25:8-15. [PMID: 34094881 PMCID: PMC8134949 DOI: 10.1016/j.asmart.2021.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/05/2021] [Accepted: 03/21/2021] [Indexed: 01/11/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) is a commonly performed procedure in Orthopaedic sports medicine. With advances in surgical techniques providing better positioning and fixation of the graft, subsequent graft failure to certain extent should be accounted by poor graft healing. Although different biological modulations for enhancement of graft healing have been tried in different clinical and animal studies, complete graft incorporation into bone tunnels and the “ligamentization” of the intra-articular part have not been fully achieved yet. Based on the understanding of graft healing process and its failure mechanism, the purpose of this review is to combine both the known basic science & clinical evidence, to provide a much clearer picture of the obstacle encountered in graft healing, so as to facilitate researchers on subsequent work on the enhancement of ACL graft healing.
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Affiliation(s)
- Shiyi Yao
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Bruma Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
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Lai VJ, Reynolds AW, Kindya M, Konicek J, Akhavan S. The Use of Suture Augmentation for Graft Protection in ACL Reconstruction: A Biomechanical Study in Porcine Knees. Arthrosc Sports Med Rehabil 2020; 3:e57-e63. [PMID: 33615248 PMCID: PMC7879175 DOI: 10.1016/j.asmr.2020.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/22/2020] [Indexed: 12/01/2022] Open
Abstract
Purpose To biomechanically evaluate the use of the suture augmentation construct at time 0 of ACL reconstruction. Methods Eighty porcine knees underwent ACL reconstruction using 2 techniques for graft fixation: a single suspensory construct (SSC), performed with a femoral button and tibial interference screw; and a double suspensory construct (DSC), with a femoral and tibial button. Each fixation technique was performed on 40 porcine knees divided into 4 subgroups. The first group had a nonaugmented ACL reconstruction, the second group had an ACL reconstruction with suture augmentation, and the third and fourth groups were the same as the first and second groups, with the graft resected 80% to simulate graft weakening. Ultimate load, yield load, stiffness, cyclic displacement values, and mode of failure were recorded for each graft. Results In a weakened graft model with 80% graft resection, there was a significant increase in ultimate strength (P < .001), yield strength (P < .001), and cyclic displacement (P < .001) with suture augmentation. There was no significant increase in stiffness with suture augmentation with either construct (P = .278). In the setting of an intact graft, there were no differences in either SSC or DCS groups with or without suture augmentation. Conclusions The addition of a suture to ACL reconstruction techniques resulted in minimal changes in baseline biomechanical characteristics while improving ultimate load, yield load, and cyclic displacement in a weakened graft model. Clinical Relevance Suture augmentation of ACL reconstruction may confer improved integrity of the graft and is worth consideration and future clinical study.
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Affiliation(s)
- Vince J Lai
- Department of Orthopaedic Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, U.S.A
| | - Alan W Reynolds
- Department of Orthopaedic Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, U.S.A
| | - Michael Kindya
- Orthopaedic Associates of Osceola, Kissimmee, Florida, U.S.A
| | | | - Sam Akhavan
- Department of Orthopaedic Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, U.S.A
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Beveridge JE, Proffen BL, Karamchedu NP, Chin KE, Sieker JT, Badger GJ, Kiapour AM, Murray MM, Fleming BC. Cartilage Damage Is Related to ACL Stiffness in a Porcine Model of ACL Repair. J Orthop Res 2019; 37:2249-2257. [PMID: 31125133 PMCID: PMC6739195 DOI: 10.1002/jor.24381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 05/02/2019] [Indexed: 02/04/2023]
Abstract
Inferior anterior cruciate ligament (ACL) structural properties may inadequately restrain tibiofemoral joint motion following surgery, contributing to the increased risk of post-traumatic osteoarthritis. Using both a direct measure of ACL linear stiffness and an in vivo magnetic resonance imaging (MRI) T2 *-based prediction model, we hypothesized that cartilage damage and ACL stiffness would increase over time, and that an inverse relationship between cartilage damage and ACL stiffness would emerge at a later stage of healing. After either 6, 12, or 24 weeks (w) of healing after ACL repair, ACL linear stiffness was determined from the force-displacement relationship during tensile testing ex vivo and predicted in vivo from the MRI T2 *-based multiple linear regression model in 24 Yucatan minipigs. Tibiofemoral cartilage was graded postmortem. There was no relationship between cartilage damage and ACL stiffness at 6 w (R2 = 0.04; p = 0.65), 12 w (R2 = 0.02; p = 0.77), or when the data from all animals were pooled (R2 = 0.02; p = 0.47). A significant inverse relationship between cartilage damage and ACL stiffness based on both ex vivo measurement (R2 = 0.90; p < 0.001) and in vivo MRI prediction (R2 = 0.78; p = 0.004) of ACL stiffness emerged at 24 w. This result suggests that 90% of the variability in gross cartilage changes is associated with the repaired ACL linear stiffness at 6 months of healing. Clinical Significance: Techniques that provide a higher stiffness to the repaired ACL may be required to mitigate the post-traumatic osteoarthritis commonly seen after ACL injury, and MRI T2 * can be used as a noninvasive estimation of ligament stiffness. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2249-2257, 2019.
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Affiliation(s)
- Jillian E. Beveridge
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
| | - Benedikt L. Proffen
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - N. Padmini Karamchedu
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
| | - Kaitlyn E. Chin
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
| | - Jakob T. Sieker
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Ata M. Kiapour
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Martha M. Murray
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Braden C. Fleming
- Department of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital
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Kokubun T, Kanemura N, Murata K, Moriyama H, Morita S, Jinno T, Ihara H, Takayanagi K. Effect of Changing the Joint Kinematics of Knees With a Ruptured Anterior Cruciate Ligament on the Molecular Biological Responses and Spontaneous Healing in a Rat Model. Am J Sports Med 2016; 44:2900-2910. [PMID: 27507845 DOI: 10.1177/0363546516654687] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The poor healing capacity of a completely ruptured anterior cruciate ligament (ACL) has been attributed to an insufficient vascular supply, cellular metabolism, and deficient premature scaffold formation because of the unique intra-articular environment. However, previous studies have focused on intra-articular factors without considering extra-articular factors, including the biomechanical aspects of ACL-deficient knees. HYPOTHESIS Changing the joint kinematics of an ACL-ruptured knee will improve cellular biological responses and lead to spontaneous healing through the mechanotransduction mechanism. STUDY DESIGN Controlled laboratory study. METHODS A total of 66 skeletally mature Wistar rats were randomly assigned to a sham-operated group (SO), ACL-transection group (ACL-T), controlled abnormal movement group (CAM), and an intact group (IN). The ACL was completely transected at the midportion in the ACL-T and CAM groups, and the CAM group underwent extra-articular braking to control for abnormal tibial translation. The SO group underwent skin and joint capsule incisions and tibial drilling, without ACL transection and extra-articular braking. The animals were allowed full cage activity until sacrifice at 1, 2, 4, 6, and 8 weeks postoperatively for histological, molecular biological, and biomechanical assessment. RESULTS All injured ACLs in the ACL-T group were not healed, but those in the CAM group healed spontaneously, showing a typical ligament healing response. Regarding the molecular biological response, there was an upregulation of anabolic factors (ie, transforming growth factor-β) and downregulation of catabolic factors (ie, matrix metalloproteinase). Examination of the mechanical properties at 8 weeks after injury showed that >50% of the strength of the intact ACL had returned. CONCLUSION Our results suggest that changing the joint kinematics of knees with a ruptured ACL alters the molecular biological responses and leads to spontaneous healing. These data support our hypothesis that the mechanotransduction mechanism mediates molecular responses and determines whether the ACL will heal. CLINICAL RELEVANCE Elucidating the relationship between the mechanotransduction mechanism and healing responses in knees with completely ruptured ACLs may result in the development of novel nonsurgical treatment that enables the ACL to spontaneously heal in patients who are not suitable for reconstruction.
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Affiliation(s)
- Takanori Kokubun
- Department of Physical Therapy, Faculty of Health and Social Services, Saitama Prefectural University, Saitama, Japan .,Division of Rehabilitation Medicine, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naohiko Kanemura
- Department of Physical Therapy, Faculty of Health and Social Services, Saitama Prefectural University, Saitama, Japan
| | - Kenji Murata
- Department of Physical Therapy, Faculty of Health and Social Services, Saitama Prefectural University, Saitama, Japan
| | - Hideki Moriyama
- Department of Rehabilitation Science, Graduate School of Health Science, Kobe University, Hyogo, Japan
| | - Sadao Morita
- Division of Rehabilitation Medicine, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Jinno
- Division of Orthopaedics, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hidetoshi Ihara
- Department of Orthopaedic Surgery, Kyushu Rosai Hospital, Fukuoka, Japan
| | - Kiyomi Takayanagi
- Department of Physical Therapy, Faculty of Health and Social Services, Saitama Prefectural University, Saitama, Japan
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Gurlek AC, Sevinc B, Bayrak E, Erisken C. Synthesis and characterization of polycaprolactone for anterior cruciate ligament regeneration. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2016; 71:820-826. [PMID: 27987777 DOI: 10.1016/j.msec.2016.10.071] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/18/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Abstract
Anterior cruciate ligament (ACL) is the most frequently torn ligament in the knee, and complete healing is unlikely due to lack of vascularization. Current approaches for the treatment of ACL injuries include surgical interventions and grafting, however recent reports show that surgeries have 94% recurrency, and that repaired tissues are biomechanically inferior to the native tissue. These necessitate the need for new strategies for scar-free repair/regeneration of ACL injuries. Polycaprolactone (PCL) is a biodegradable and biocompatible synthetic polymer, which has been widely used in the connective tissue repair/regeneration attempts. Here, we report on the synthesis of PCL via ring opening polymerization using ε-caprolactone as the monomer, and ammonium heptamolybdate as a catalyst. The synthesized PCL was characterized using Fourier Transform Infrared Spectroscopy (FTIR) and Nuclear Magnetic Resonance (NMR) spectroscopy. It was then processed using electrospinning to form nanofiber-based scaffolds. These scaffolds were characterized in terms of surface as well as mechanical properties, and compared to the properties of commercially available PCL, and of native ACL tissue harvested from sheep. In addition, scaffolds fabricated with synthesized PCL were evaluated regarding their cell attachment capacity using human bone marrow mesenchymal stem cells (hBMSCs). Our findings demonstrated that the synthesized PCL is similar to its commercially available counterpart in terms of surface morphology and mechanical properties. In addition, fibrous scaffolds generated with electrospinning showed weaker mechanical properties visa vis native ACL tissue in terms of ultimate stress, and elastic modulus. Also, the synthesized PCL can accommodate cell attachment when tested with hBMSCs. Putting together, these observations reveal that the PCL synthesized in this study could be a good candidate as a biomaterial for ligament repair or regeneration.
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Affiliation(s)
- Ayse Cansu Gurlek
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
| | - Burcu Sevinc
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
| | - Ece Bayrak
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
| | - Cevat Erisken
- Department of Biomedical Engineering, TOBB University of Economics and Technology, Ankara, Turkey.
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Iliadis DP, Bourlos DN, Mastrokalos DS, Chronopoulos E, Babis GC. LARS Artificial Ligament Versus ABC Purely Polyester Ligament for Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2016; 4:2325967116653359. [PMID: 27453894 PMCID: PMC4933937 DOI: 10.1177/2325967116653359] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: Graft choice for anterior cruciate ligament (ACL) reconstruction is of critical importance. Various grafts have been used so far, with autografts long considered the optimal solution for the treatment of ACL-deficient knees. Limited data are available on the long-term survivorship of synthetic grafts. Purpose: To compare the functional outcome and survivorship of ACL reconstructions performed using the LARS (ligament augmentation and reconstruction system) ligament and the ABC (active biosynthetic composite) purely polyester ligament. Study Design: Case series; Level of evidence, 4. Methods: The results of 72 patients who underwent primary arthroscopic ACL reconstruction with the LARS ligament and 31 cases with an ABC purely polyester ligament were reviewed. The mean follow-up periods for the LARS and ABC groups were 9.5 and 5.1 years, respectively. A survivorship analysis of the 2 synthetic grafts was performed using the Kaplan-Meier method with a log-rank test (Mantel-Cox, 95% CI). Lysholm, Tegner activity, Knee injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) scores as well as laxity measurements obtained using a KT-1000 arthrometer were recorded for all intact grafts, and a Mann-Whitney U test was used for comparison reasons. Results: The rupture rates for LARS and ABC grafts were 31% (95% CI, 20%-42%) and 42% (95% CI, 25%-59%), respectively. For intact grafts, the mean Lysholm score was good for both groups (90 for the LARS group and 89 for the ABC group), with the majority of patients returning to their preinjury level of activities, and the mean IKDC score was 90 for the LARS group and 86 for the ABC group. Conclusion: The rupture rates of both LARS and ABC grafts were both high. However, the LARS ligament provided significantly better survivorship compared with the ABC ligament at short- to midterm follow-up (95% CI).
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Affiliation(s)
| | | | - Dimitrios S Mastrokalos
- First Orthopaedical Department, Athens University Medical School, General University Hospital "ATTIKON," Athens, Greece
| | | | - George C Babis
- Department of Orthopaedic Surgery, Konstantopoulio Hospital, Athens, Greece
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Central defect type partial ACL injury model on goat knees: the effect of infrapatellar fat pad excision. J Orthop Surg Res 2015; 10:137. [PMID: 26338041 PMCID: PMC4558767 DOI: 10.1186/s13018-015-0281-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 08/25/2015] [Indexed: 01/12/2023] Open
Abstract
Background The mid-substance central defect injury has been used to investigate the primary healing capacity of the anterior cruciate ligament (ACL) in a goat model. The sagittal plane stability on this model has not been confirmed, and possible effects of fat pad excision on healing have not been evaluated. We hypothesize that excising the fat pad tissue results in poorer ligament healing as assessed histologically and decreased tensile strength of the healing ligament. We further hypothesize that the creation of a central defect does not affect sagittal plane knee stability. Methods A mid-substance central defect was created with a 4-mm arthroscopic punch in the ACLs of right knees of all the subjects through a medial mini-arthrotomy. Goats were assigned to groups based on whether the fat pad was preserved (group 1, n = 5) or excised completely (group 2, n = 5). The left knees served as controls in each goat. Histopathology of the defect area along with measurement of type I collagen in one goat from each group were performed at 10th week postoperatively. The remaining knees were evaluated biomechanically at the 12th week, by measuring anterior tibial translation (ATT) of the knee joints at 90° of flexion and testing tensile properties (ultimate tensile load (UTL), ultimate elongation (UE), stiffness (S), failure mode (FM)) of the femur-ACL-tibia complex. Results and discussion Histopathology analysis revealed that the central defect area was fully filled macroscopically and microscopically. However, myxoid degeneration and fibrosis were observed in group 2 and increased collagen type I content was noted in group 2. There were no significant differences within and between groups in terms of ATT values (p = 0.715 and p = 0.149, respectively). There were no significance between or within groups in terms of ultimate tensile load and ultimate elongation; however, group 2 demonstrated greater stiffness than group 1 that was correlated with the fibrotic changes detected microscopically (p = 0.043). Conclusions The central defect type injury model was confirmed to be biomechanically stable in a goat model. Resection of the fat pad was noted to negatively affect defect healing and increase ligament stiffness in the central defect injury model.
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Liang R, Yang G, Kim KE, D'Amore A, Pickering AN, Zhang C, Woo SLY. Positive effects of an extracellular matrix hydrogel on rat anterior cruciate ligament fibroblast proliferation and collagen mRNA expression. J Orthop Translat 2015; 3:114-122. [PMID: 30035048 PMCID: PMC5982358 DOI: 10.1016/j.jot.2015.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 05/01/2015] [Accepted: 05/28/2015] [Indexed: 12/21/2022] Open
Abstract
Background/Objective We have previously shown that an extracellular matrix (ECM) bioscaffold derived from porcine small intestine submucosa (SIS) enhanced the healing of a gap injury of the medial collateral ligament as well as the central third defect of the patellar tendon. With the addition of a hydrogel form of SIS, we found that a transected goat anterior cruciate ligament (ACL) could also be healed. The result begs the research question of whether SIS hydrogel has positive effects on ACL fibroblasts (ACLFs) and thus facilitates ACL healing. Methods In the study, ECM-SIS hydrogel was fabricated from the digestion of decellularised and sterilised sheets of SIS derived from αGal-deficient (GalSafe) pigs. As a comparison, a pure collagen hydrogel was also fabricated from commercial collagen type I solution. The morphometrics of hydrogels was assessed with scanning electron microscopy. The ECM-SIS and collagen hydrogels had similar fibre diameters (0.105 ± 0.010 μm vs. 0.114 ± 0.004 μm), fibre orientation (0.51 ± 0.02 vs. 0.52 ± 0.02), and pore size (0.092 ± 0.012 μm vs. 0.087 ± 0.008 μm). The preservation of bioactive properties of SIS hydrogel was assessed by detecting bioactive molecules sensitive to processing and enzyme digestion, such as growth factors fibroblast growth factor-2 (FGF-2) and transforming growth factor-beta 1 (TGF-β1), with enzyme-linked immunosorbent assay. ACLFs were isolated and expanded in culture from explants of rat ACLs (n = 3). The cells were then seeded on the hydrogels and cultured with 0%, 1%, and 10% foetal bovine serum (FBS) for 3 days and 7 days. Cell attachment was observed using a light microscope and scanning electron microscopy, whereas cell proliferation and matrix production (collagen types I and III) were examined with bromodeoxyuridine assays and reverse transcription-polymerase chain reaction, respectively. Results The results showed that FGF-2 and TGF-β1 in the SIS hydrogel were preserved by 50% (65.9 ± 26.1 ng/g dry SIS) and 90% (4.4 ± 0.6 ng/g dry SIS) relative to their contents in ECM-SIS sheets, respectively. At Day 3 of culture, ACLFs on the SIS hydrogel were found to proliferate 39%, 31%, and 22% more than those on the pure collagen hydrogel at 0%, 1%, and 10% FBS, respectively (p < 0.05). Collagen type I mRNA expression was increased by 150%, 207%, and 100%, respectively, compared to collagen hydrogel (p < 0.05), whereas collagen type III mRNA expression was increased by 123% and 132% at 0% and 1% FBS, respectively (all p < 0.05) but not at 10% FBS. By Day 7, collagen type I mRNA expression was still elevated by 137% and 100% compared to collagen hydrogel at 1% and 10% FBS, respectively (p < 0.05). Yet, collagen type III mRNA levels were not significantly different between the two groups at any FBS concentrations. Conclusion Our data showed that the ECM-SIS hydrogel not only supported the growth of ACLFs, but also promoted their proliferation and matrix production relative to a pure collagen hydrogel. As such, ECM-SIS hydrogel has potential therapeutic value to facilitate ACL healing at the early stage after injury.
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Affiliation(s)
| | | | | | | | | | | | - Savio L-Y. Woo
- Corresponding author. Musculoskeletal Research Center, Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA.
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Leong NL, Kabir N, Arshi A, Nazemi A, Wu B, Petrigliano FA, McAllister DR. Evaluation of polycaprolactone scaffold with basic fibroblast growth factor and fibroblasts in an athymic rat model for anterior cruciate ligament reconstruction. Tissue Eng Part A 2015; 21:1859-68. [PMID: 25744933 DOI: 10.1089/ten.tea.2014.0366] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Anterior cruciate ligament (ACL) rupture is a common ligamentous injury often necessitating surgery. Current surgical treatment options include ligament reconstruction with autograft or allograft, which have their inherent limitations. Thus, there is interest in a tissue-engineered substitute for use in ACL regeneration. However, there have been relatively few in vivo studies to date. In this study, an athymic rat model of ACL reconstruction was used to evaluate electrospun polycaprolactone (PCL) grafts, with and without the addition of basic fibroblast growth factor (bFGF) and human foreskin fibroblasts. We examined the regenerative potential of tissue-engineered ACL grafts using histology, immunohistochemistry, and mechanical testing up to 16 weeks postoperatively. Histology showed infiltration of the grafts with cells, and immunohistochemistry demonstrated aligned collagen deposition with minimal inflammatory reaction. Mechanical testing of the grafts demonstrated significantly higher mechanical properties than immediately postimplantation. Acellular grafts loaded with bFGF achieved 58.8% of the stiffness and 40.7% of the peak load of healthy native ACL. Grafts without bFGF achieved 31.3% of the stiffness and 28.2% of the peak load of healthy native ACL. In this in vivo rodent model study for ACL reconstruction, the histological and mechanical evaluation demonstrated excellent healing and regenerative potential of our electrospun PCL ligament graft.
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Affiliation(s)
- Natalie Luanne Leong
- 1Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Nima Kabir
- 1Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Armin Arshi
- 1Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Azadeh Nazemi
- 2Department of Bioengineering, University of California, Los Angeles, Los Angeles, California
| | - Ben Wu
- 2Department of Bioengineering, University of California, Los Angeles, Los Angeles, California
| | - Frank A Petrigliano
- 1Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, California
| | - David R McAllister
- 1Department of Orthopedic Surgery, University of California, Los Angeles, Los Angeles, California
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Intra-articular remodelling of hamstring tendon grafts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:2102-8. [PMID: 23982759 PMCID: PMC4142140 DOI: 10.1007/s00167-013-2634-5] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 08/18/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE A summary is provided on the existing knowledge about the specific healing phases of the intra-articular hamstring tendon graft used for ACL reconstruction. Differences between human and animal in vivo studies are explained, and implications for the postoperative time period are laid out. METHODS A systematic review of the existing literature was performed on the topic of tendon remodelling of hamstring grafts in ACL reconstruction using Medline database. Publications between 1982 and 2012 were included. Special focus was directed on in vivo human and animal studies analysing intra-articular free tendon graft remodelling. RESULTS Animal and human in vitro and vivo researches have demonstrated three characteristic stages of graft healing after ACL reconstruction: an early graft healing phase with central graft necrosis and hypocellularity and no detectable revascularization of the graft tissue, followed by a phase of proliferation, the time of most intensive remodelling and revascularization and finally, a ligamentization phase with characteristic restructuring of the graft towards the properties of the intact ACL. However, a full restoration of either the biological or biomechanical properties of the intact ACL is not achieved. CONCLUSION Significant knowledge on human cruciate ligament remodelling has been added in the understanding of the processes during the course of graft healing. Most importantly, the remodelling process in humans is prolonged compared to animal studies. While today´s rehabilitation protocols are often extrapolated from findings of animal in vivo healing studies, current findings of human in vivo healing studies might require new post-operative regimens following hamstring ACL reconstruction.
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Arthroscopic single-bundle ACL reconstruction with modified double-layer bone-patellar tendon-bone allograft. Knee Surg Sports Traumatol Arthrosc 2013; 21:2066-71. [PMID: 23052125 DOI: 10.1007/s00167-012-2235-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 09/24/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The objective of present study was to introduce a modified double-layer bone-patellar tendon-bone (BPTB) allograft for arthroscopic single-bundle ACL reconstruction and investigate the clinical outcomes. METHODS From 2007 to 2009, a total of 136 patients underwent arthroscopic single-bundle ACL reconstructions with BPTB allograft. Of which, 66 patients were with double-layer BPTB allograft (Group 1), and 70 patients were with conventional BPTB allograft (Group 2). Clinical outcomes including Lachman and pivot-shift tests, KT-1000 arthrometer measurements, and Lysholm and Tegner activity scores were compared between the two groups at a 2-year minimum follow-up. RESULTS Forty-six patients in each group were at a two-year minimum follow-up. The mean side-to-side difference on the KT-1000 arthrometer was 1.2 ± 1.2 mm for group 1 and 2.1 ± 1.9 mm for group 2, with significant difference between the two groups (p = 0.017). The knee function was significantly better for group 1 than for group 2, because the mean Lysholm score was 94.2 ± 4.8 points versus 86.6 ± 7.1 points (p = 0.000), and the median Tegner score was 8 (range 5-10) points versus 6 (range 4-10) points (p = 0.001). CONCLUSIONS On the basis of the KT-1000 arthrometer evaluation and clinical measures, single-bundle ACL reconstruction with double-layer BPTB allograft achieves significantly lesser anterior laxity and better knee function than a single-layer allograft reconstruction. LEVEL OF EVIDENCE Therapeutic, retrospective comparative study, Level III.
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Morelli V, Bright C, Fields A. Ligamentous injuries of the knee: anterior cruciate, medial collateral, posterior cruciate, and posterolateral corner injuries. Prim Care 2013; 40:335-56. [PMID: 23668648 DOI: 10.1016/j.pop.2013.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This article discusses athletic injuries of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and posterolateral corner. Best evidence to date validates that conservative management of ACL ruptures is a reasonable strategy. Current data also seem to advocate nonoperative management of PCL injuries. All isolated MCL injuries, regardless of grade, are usually treated with a brief period of immobilization and symptomatic management. Although the surgical literature often advocates surgical treatment of posterolateral corner injuries, there have been no randomized trials substantiating that these injuries are best treated surgically.
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Affiliation(s)
- Vincent Morelli
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN 37208, USA.
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Mutsuzaki H, Sakane M, Nakajima H, Ochiai N. Calcium phosphate-hybridised tendon graft to reduce bone-tunnel enlargement after ACL reconstruction in goats. Knee 2012; 19:455-60. [PMID: 21514829 DOI: 10.1016/j.knee.2011.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 03/09/2011] [Accepted: 03/24/2011] [Indexed: 02/02/2023]
Abstract
Bone-tunnel enlargement can have a negative impact on long-term clinical success. To solve the problem, we developed a novel technique to improve tendon-bone healing by hybridising calcium phosphate (CaP) with a tendon graft using an alternate soaking process. The objective of this study was to analyse bone-tunnel enlargement, mechanical properties and histological features, especially the number of osteoclasts at the tendon-bone interface using a CaP-hybridised tendon graft and an untreated tendon graft 6 months after anterior cruciate ligament (ACL) reconstruction in goats. The percentage of bone-tunnel enlargement for the CaP group was decreased compared with that for the control group for the femoral side (p<0.05). The failure load was not statistically different between the CaP group and the control group, and was all midsubstance rupture for both groups. In the CaP group, cartilage layer was more observed at the tendon-bone interface of the joint aperture site than in the control group (p<0.05). Many osteoclasts on the femoral side of the tendon-bone interface in the control were observed compared with that in the CaP group (p<0.05). At the femoral side, the CaP-hybridised tendon graft reduced bone-tunnel enlargement associated with tendon-bone healing 6 months after ACL reconstruction in goats. Clinically, the CaP-hybridised tendon graft for ACL reconstruction can reduce bone-tunnel enlargement.
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Affiliation(s)
- Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami Ami-machi, Inashiki-gun, Ibaraki 300-0394, Japan
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Fisher MB, Liang R, Jung HJ, Kim KE, Zamarra G, Almarza AJ, McMahon PJ, Woo SLY. Potential of healing a transected anterior cruciate ligament with genetically modified extracellular matrix bioscaffolds in a goat model. Knee Surg Sports Traumatol Arthrosc 2012; 20:1357-65. [PMID: 22143425 PMCID: PMC9583725 DOI: 10.1007/s00167-011-1800-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 11/17/2011] [Indexed: 01/14/2023]
Abstract
PURPOSE Biological augmentation to heal a torn anterior cruciate ligament (ACL) has gained significant interest. This study examined the potential advantages of using extracellular matrix (ECM) bioscaffolds from galactosyl-α(1,3)galactose deficient pigs to heal the transected ACL. METHODS In 16 skeletally mature goats, the ACL in the right hindlimb was transected and repaired. In 9 of these animals, an ECM sheet was wrapped around the injury site and with an ECM hydrogel injected into the transected site. The remaining 7 animals were treated with suture repair only. The left hindlimb served as a sham-operated control. RESULTS After 12 weeks, the healing ACL in the ECM-treated group showed an abundance of continuous neo-tissue formation, while only limited tissue growth was found after suture repair only. The cross-sectional area of the ACL from the ECM-treated group was similar to sham-operated controls (n.s.) and was 4.5 times those of the suture repair group (P < 0.05). The stiffness of the femur-ACL-tibia complexes from the ECM-treated group was 2.4 times those of the suture repair group (P < 0.05). Furthermore, these values reached 48% of the sham-operated controls (53 ± 19 N/mm and 112 ± 21 N/mm, respectively, P < 0.05). CONCLUSIONS The application of an ECM bioscaffold and hydrogel was found to accelerate the healing of a transected ACL following suture repair in the goat model with limited tissue hypertrophy and improvement in some of its biomechanical properties. Although more work is necessary to fully restore the function of the normal ACL, these early results offer a potential new approach to aid ACL healing.
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Affiliation(s)
- Matthew B. Fisher
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA
| | - Rui Liang
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA
| | - Ho-Joong Jung
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA,Department of Orthopaedic Surgery, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Kwang E. Kim
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA
| | - Giovanni Zamarra
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA
| | - Alejandro J. Almarza
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA
| | - Patrick J. McMahon
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA
| | - Savio L-Y. Woo
- Department of Bioengineering, Musculoskeletal Research Center, Swanson School of Engineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219, USA
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Kondo E, Yasuda K, Katsura T, Hayashi R, Kotani Y, Tohyama H. Biomechanical and histological evaluations of the doubled semitendinosus tendon autograft after anterior cruciate ligament reconstruction in sheep. Am J Sports Med 2012; 40:315-24. [PMID: 22088579 DOI: 10.1177/0363546511426417] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A sheep or goat anterior cruciate ligament (ACL) reconstruction model with the semitendinosus tendon autograft has not as of yet been established. HYPOTHESIS The semitendinosus tendon graft may be necrotized after ACL reconstruction until 12 weeks. Structural properties of the femur-graft-tibia complex may not be restored to the normal ACL level even at 12 months after surgery. STUDY DESIGN Controlled laboratory study. METHODS Thirty-eight mature sheep were used. In each animal, the right knee underwent ACL reconstruction using the semitendinosus tendon autograft. Two of them were not tested because of pneumonia. Twenty of 36 sheep were used for biomechanical evaluations. Five randomly selected animals were sacrificed at 0, 12, 24, or 52 weeks after surgery. In each animal, both the knees were harvested, and the left knee was used to obtain the control data. The remaining 16 sheep were used for histological evaluation. Two or 3 randomly selected animals were sacrificed at 0, 2, 6, 12, 24, or 52 weeks after surgery. RESULTS The tendon graft was predominantly acellular at 2 weeks. Although cell infiltration increased at 6 weeks, the core portion remained necrotic even at 12 weeks. At 24 and 52 weeks, the necrotic lesion disappeared in the core portion. In each period, the anteroposterior translation of the reconstructed knee remained significantly greater than that of the control (P < .0001). At 52 weeks, the maximum load of the femur-graft-tibia complex was significantly lower than that of the femur-ACL-tibia complex (P < .0001), although there was no significant difference in the cell density, the tissue dimensions, the stiffness, and the elongation at failure between the 2 complexes. CONCLUSION The sheep ACL reconstruction model showed predominant intrinsic fibroblast necrosis in the tendon autograft until 12 weeks. Although the structural properties of the femur-graft-tibia complex gradually improved, they were not completely restored to the femur-ACL-tibia complex level even at 52 weeks. CLINICAL RELEVANCE Remodeling of the semitendinosus tendon autograft after ACL reconstruction is not different from that of the bone-tendon-bone graft. This study has suggested that vigorous activity should not be permitted for patients in the early periods after ACL reconstruction using semitendinosus tendon autografts, which are necrotized and weakened after surgery.
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Affiliation(s)
- Eiji Kondo
- Department of Sports Medicine and Joint Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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Mutsuzaki H, Sakane M. Calcium phosphate-hybridized tendon graft to enhance tendon-bone healing two years after ACL reconstruction in goats. Sports Med Arthrosc Rehabil Ther Technol 2011; 3:31. [PMID: 22166674 PMCID: PMC3261087 DOI: 10.1186/1758-2555-3-31] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 12/14/2011] [Indexed: 11/16/2022]
Abstract
Background We developed a novel technique to improve tendon-bone attachment by hybridizing calcium phosphate (CaP) with a tendon graft using an alternate soaking process. However, the long-term result with regard to the interface between the tendon graft and the bone is unclear. Methods We analyzed bone tunnel enlargement by computed tomography and histological observation of the interface and the tendon graft with and without the CaP hybridization 2 years after anterior cruciate ligament (ACL) reconstruction in goats using EndoButton and the postscrew technique (CaP, n = 4; control, n = 4). Results The tibial bone tunnel enlargement rates in the CaP group were lower than those in the control group (p < 0.05). In the CaP group, in the femoral and tibial bone tunnels at the anterior and posterior of the joint aperture site, direct insertion-like formation that contained a cartilage layer without tidemarks was more observed at the tendon-bone interface than in the control group (p < 0.05). Moreover, the gap area between the tendon graft and the bone was more observed at the femoral bone tunnel of the joint aperture site in the control group than in the CaP group (p < 0.05). The maturation of the tendon grafts determined using the ligament tissue maturation index was similar in both groups. Conclusions The CaP-hybridized tendon graft enhanced the tendon-bone healing 2 years after ACL reconstruction in goats. The use of CaP-hybridized tendon grafts can reduce the bone tunnel enlargement and gap area associated with the direct insertion-like formation in the interface near the joint.
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Affiliation(s)
- Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan.
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Mutsuzaki H, Sakane M, Fujie H, Hattori S, Kobayashi H, Ochiai N. Effect of calcium phosphate–hybridized tendon graft on biomechanical behavior in anterior cruciate ligament reconstruction in a goat model: novel technique for improving tendon-bone healing. Am J Sports Med 2011; 39:1059-66. [PMID: 21220545 DOI: 10.1177/0363546510390427] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The authors developed a novel technique to improve tendon-bone attachment by hybridizing calcium phosphate with a tendon graft using an alternate soaking process. However, the long-term result is unclear regarding the function of the anterior cruciate ligament–reconstructed knee and the interface between the tendon and the bone. PURPOSE To clarify the effects of the calcium phosphate–hybridized tendon graft by analyzing the biomechanical behavior of the reconstructed knee, bone tunnel wall, and interface between the tendon and the bone, compared with the untreated knee at 1 year in goats. STUDY DESIGN Controlled laboratory study. METHODS The authors analyzed knee kinematics and in situ forces in a replacement graft, as well as computed tomography for new bone formation in the bone tunnel and histology of the tendon-bone interface, with and without the calcium phosphate-hybridized tendon graft. RESULTS In the calcium phosphate group, the anteroposterior translations in the reconstructed knees were shorter and the corresponding in situ forces greater than those in the control group at full extension and 60° of knee flexion. The in situ force in response to applied internal tibial torques in the calcium phosphate group at full extension was greater than that in the control group. More new bone formation in the bone tunnel and cartilage layer between the tendon-bone interface at the joint aperture site of the calcium phosphate group was observed than in the control group. CONCLUSION The calcium phosphate–hybridized tendon graft promotes knee stability because of the firm tendon-bone healing with cartilage layer and new bone formation. CLINICAL RELEVANCE Anterior cruciate ligament reconstruction using the calcium phosphate–hybridized tendon graft may lead to good long-term outcomes.
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Affiliation(s)
- Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, Ibaraki, Japan
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Janssen RPA, van der Wijk J, Fiedler A, Schmidt T, Sala HAGM, Scheffler SU. Remodelling of human hamstring autografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2011; 19:1299-306. [PMID: 21293848 PMCID: PMC3136699 DOI: 10.1007/s00167-011-1419-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Accepted: 01/24/2011] [Indexed: 02/05/2023]
Abstract
PURPOSE Histological analysis of the remodelling process of human hamstring tendon (HT) grafts after standardized anterior cruciate ligament reconstruction (ACLR) with an accelerated rehabilitation protocol. METHODS Sixty-seven patients underwent retrieval of mid-substance biopsies after clinically successful hamstring autograft ACLR. Samples were allocated to one of three groups depending on the time point of retrieval: group 1 (6-12 months; n = 15), group 2 (13-24 months; n = 16) and group 3 (>24 months; n = 11). Biopsies from native HT (n = 17) and ACL (n = 8) served as controls. Cellular density, vascular density and myofibroblast density and collagen fibril alignment were analysed by haematoxylin-eosin, Masson-Goldner-Trichrom and immunohistochemical staining protocols. RESULTS Compared with native HT (330.4/mm²), total cell number was increased in groups 1-3 (Group 1 = 482.0/mm² (P = 0.036); group 2 = 850.9/mm² (P = 0.005); and group 3 = 595.6/mm² (P = 0.043). There were no significant differences between the groups for vessel density. Myofibroblast density was higher in group 2 (199.6/mm²) compared with native HT (1.9/mm², P = 0.014). Collagen orientation was irregular up to 12 months. Thereafter, collagen orientation became more regular, adapting to, but not fully restoring, the appearance of the intact ACL. For the first 12 months, cells were predominantly ovoid. Ensuing cell morphology changed to spindle shaped in group 2 and predominantly narrow long cells over 24 months. CONCLUSION Human hamstring grafts showed typical stages of graft remodelling, which was not complete up to 2 years after ACLR. The remodelling process in humans was prolonged compared with the results obtained in several animal studies. LEVEL OF EVIDENCE Case-control study, Level III.
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Affiliation(s)
- Rob P. A. Janssen
- Orthopaedic Center Máxima, Máxima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands
| | - Jasper van der Wijk
- Orthopaedic Center Máxima, Máxima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands
| | - Anja Fiedler
- Department of Orthopaedic Surgery and Traumatology, Center for Musculoskeletal Surgery, Charité, Campus Mitte, University Medicine Berlin, Charité Platz 1, 10117 Berlin, Germany
| | - Tanja Schmidt
- Department of Orthopaedic Surgery and Traumatology, Center for Musculoskeletal Surgery, Charité, Campus Mitte, University Medicine Berlin, Charité Platz 1, 10117 Berlin, Germany
| | - Harm A. G. M. Sala
- Orthopaedic Center Máxima, Máxima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands
| | - Sven U. Scheffler
- Department of Orthopaedic Surgery and Traumatology, Center for Musculoskeletal Surgery, Charité, Campus Mitte, University Medicine Berlin, Charité Platz 1, 10117 Berlin, Germany
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Mutsuzaki H, Sakane M, Hattori S, Kobayashi H, Ochiai N. Firm anchoring between a calcium phosphate-hybridized tendon and bone for anterior cruciate ligament reconstruction in a goat model. Biomed Mater 2009; 4:045013. [DOI: 10.1088/1748-6041/4/4/045013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chang CB, Seong SC, Kim TK. Preoperative magnetic resonance assessment of patellar tendon dimensions for graft selection in anterior cruciate ligament reconstruction. Am J Sports Med 2009; 37:376-82. [PMID: 19036719 DOI: 10.1177/0363546508324971] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A bone patellar tendon bone autograft is one of the standard graft choices for anterior cruciate ligament reconstruction. However, its use can be limited when the patellar tendon is too narrow or too long. HYPOTHESIS A preoperative assessment of patellar tendon dimensions using magnetic resonance imaging would be accurate and reliable. Patients undergoing anterior cruciate ligament reconstruction would have wide ranges of patellar tendon dimensions, and a significant proportion of patients would have a too narrow and/or too long patellar tendon as the graft choice. There would be a demographic predictor to identify the patients with inappropriate patellar tendon dimensions. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS The accuracy and reliability of magnetic resonance assessments of patellar tendon dimensions were assessed by comparing the intraoperative measurements using a ruler in 55 knees and 10 knees, respectively. Data from the magnetic resonance assessments in 147 knees undergoing anterior cruciate ligament reconstruction were used for the normative documentation of the patellar tendon dimensions (width, thickness, and length) and identification of demographic predictors for the dimensions. RESULTS Preoperative magnetic resonance assessments of the patellar tendon dimensions were accurate and reliable. Korean patients undergoing anterior cruciate ligament reconstruction had wide variations in patellar dimensions, and a significant portion of the patients had an inappropriate patellar tendon (longer than 5 cm in 4.1% and narrower than 27 mm at middle portion in 15.6%) for the graft source. Patient height was the predictor used for patellar tendon width. The mathematical equation used to estimate the width based on patient height was: tendon width at middle portion (mm) = 0.202 x patient height (cm) - 5.07. CONCLUSION Preoperative magnetic resonance assessment of patellar tendon dimensions can be a valuable tool with satisfactory accuracy and reliability when the autologous patellar tendon is considered as the graft source for anterior cruciate ligament reconstruction.
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Affiliation(s)
- Chong Bum Chang
- Joint Reconstruction Center, Seoul National University, Bundang Hospital, Seongnamsi, Gyunggido, Korea
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Zantop T, Ferretti M, Bell KM, Brucker PU, Gilbertson L, Fu FH. Effect of tunnel-graft length on the biomechanics of anterior cruciate ligament-reconstructed knees: intra-articular study in a goat model. Am J Sports Med 2008; 36:2158-66. [PMID: 18669984 DOI: 10.1177/0363546508320572] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In anterior cruciate ligament (ACL) reconstruction using hamstring grafts, the graft can be looped, resulting in an increased graft diameter but reducing graft length within the tunnels. HYPOTHESIS After 6 and 12 weeks, structural properties and knee kinematics after soft tissue ACL reconstruction with 15 mm within the femoral tunnel will be significantly inferior when compared with the properties of ACL reconstruction with 25 mm in the tunnel. STUDY DESIGN Controlled laboratory study. METHODS In an intra-articular goat model, 36 ACL reconstructions using an Achilles tendon split graft were performed with 15-mm (18 knees) and 25-mm (18 knees) graft length in the femoral tunnel. Animals were sacrificed 6 weeks and 12 weeks after surgery and knee kinematics was tested. In situ forces as well as the structural properties were determined and compared with those in an intact control group. Histologic analyses were performed in 2 animals in each group 6 and 12 weeks postoperatively. Statistical analysis was performed using a 2-factor analysis of variance test. RESULTS Anterior cruciate ligament reconstructions with 15 mm resulted in significantly less anterior tibial translation after 6 weeks (P < .05) but not after 12 weeks. Kinematics after 12 weeks and in situ forces of the replacement grafts at both time points showed no statistically significant differences. Stiffness, ultimate failure load, and ultimate stress revealed no statistically significant differences between the 15-mm group and the 25-mm group. CONCLUSION The results suggest that there is no negative correlation between short graft length (15 mm) in the femoral tunnel and the resulting knee kinematics and structural properties. CLINICAL RELEVANCE Various clinical scenarios exist in which the length of available graft that could be pulled into the bone tunnel (femoral or tibial) could be in question. To address this concern, this study showed that reducing the tendon graft length in the femoral bone tunnel from 25 mm to 15 mm did not have adverse affects in a goat model.
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Affiliation(s)
- Thore Zantop
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Scheffler SU, Unterhauser FN, Weiler A. Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2008; 16:834-42. [PMID: 18516592 DOI: 10.1007/s00167-008-0560-8] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Accepted: 04/24/2008] [Indexed: 10/22/2022]
Abstract
After reconstruction of the cruciate ligaments, replacement grafts have to undergo several phases of healing in the intra-articular graft region and at the site of graft-to-bone incorporation. The changes in the biological and mechanical properties of the healing graft in its intra-articular region are described as the ligamentization process. Significant knowledge has been added in the understanding of the several processes during the course of graft healing and is summarized in this article. The understanding of the spatial and time-dependent changes as well as the differences between the different models of graft healing are of significant importance to develop strategies of improved treatment options in cruciate ligament surgery, so that full restoration of function and mechanical strength of the intact cruciate ligaments will be achieved.
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Affiliation(s)
- S U Scheffler
- Center for Musculoskeletal Surgery, Charité, University Medicine Berlin, Charité Campus Mitte, Chariteplatz 1, 10117, Berlin, Germany.
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Petrou G, Chardouvelis C, Kouzoupis A, Dermon A, Petrou H, Tilkeridis C, Gavras M. Reconstruction of the anterior cruciate ligament using the polyester ABC ligament scaffold. ACTA ACUST UNITED AC 2006; 88:893-9. [PMID: 16798991 DOI: 10.1302/0301-620x.88b7.17671] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
We carried out a prospective study of 71 patients who had undergone reconstruction of the anterior cruciate ligament with the ABC scaffold. Their mean age was 28 years (18 to 50). All had either sub-acute or chronic traumatic deficiency of the ligament. The mean period of follow-up was five years (four to seven). Assessment included the use of the International Knee Documentation Committee score, the modified Lysholm score, the Tegner Activity score, the Knee Injury and Osteoarthritis Outcome score and measurement with the KT-1000 arthrometer. Two patients had mild recurrent synovitis. There were no infections and no failures of the ligament. During the period of study, two patients sustained a traumatic fracture of a femoral condyle. The implants retained their integrity in both cases. All patients returned to their previous or enhanced levels of daily activity by three months after operation and 56 (79%) achieved their pre-injury level of sporting activity by six months. The patients who were competing in National level sports returned to play at one level less after operation than before. The Lysholm score showed that 58% of the patients (41) were excellent, 34% (24) good, and 8% (6) fair, with a mean post-operative score of 93. According to the International Knee Documentation Committee score, 35% of knees (25) were ‘normal’, 52% (37) ‘nearly normal’ and 13% (9) ‘abnormal’. Complete satisfaction was noted in 90% of patients (64). The development of osteoarthritis and the management of anterior cruciate deficiency associated with laxity of the medial collateral ligament remains uncertain. Our results indicate that in the medium-term, the ABC ligament scaffold is suitable and effective when early and safe return to unrestricted activities is demanded. We acknowledge the current general hostility towards reconstruction of the anterior cruciate ligament with artificial materials following reports of early failure and chronic synovitis associatiated with the production of particulate debris. We did not encounter these problems.
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Affiliation(s)
- G Petrou
- Department of Orthopaedic Surgery, "A. Fleming" General Hospital, 25 Martiou Str., No. 14, Melissia 15127, Athens, Greece.
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Caviglia H. Tissue engineering in musculoskeletal problems related to haemophilia. Haemophilia 2006; 12 Suppl 3:122-7. [PMID: 16684007 DOI: 10.1111/j.1365-2516.2006.01269.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article is a review of how advances in tissue engineering can be applied to the musculoskeletal pathology of patients with haemophilia. This article will also explain the theory that the deterioration of joints in patients with haemophilia is due to biological and mechanical causes. Current concepts of tissue engineering would be to replace the degenerated and damaged tissue by live cells, using them as a biological implant. However, before these new technologies are applied, an appropriate control of their indication and results is required.
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Affiliation(s)
- H Caviglia
- National Academy of Medicine, J. A. Pacheco De Melo 3081, Buenos Aires, Argentina.
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Marumo K, Saito M, Yamagishi T, Fujii K. The "ligamentization" process in human anterior cruciate ligament reconstruction with autogenous patellar and hamstring tendons: a biochemical study. Am J Sports Med 2005; 33:1166-73. [PMID: 16000668 DOI: 10.1177/0363546504271973] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is little information documenting whether the phenomenon of "ligamentization," as proposed by Amiel, occurs in the human anterior cruciate ligament after clinically effective reconstruction. To clarify this point, we analyzed biochemical differences between the native anterior cruciate ligament; the patellar, semitendinosus, and gracilis tendons; and anterior cruciate ligaments reconstructed with autografts. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Fifty patients who underwent arthroscopically assisted anterior cruciate ligament reconstruction using either semitendinosus and gracilis tendon or bone-patellar tendon-bone autografts were selected for the study. Samples of grafted tissue were collected during arthroscopy and quantitatively analyzed for collagen content and the amount of reducible and nonreducible crosslinks at 4 to 6 postoperative months in patients with semitendinosus and gracilis tendon grafts and at 11 to 13 months in all patients with semitendinosus and gracilis tendon or bone-patellar tendon-bone grafts. RESULTS The total collagen content and nonreducible/reducible crosslink ratios increased significantly during the postoperative period (P < .05). The dihydroxylysinonorleucine/hydroxylysinonorleucine ratio was 3.11 +/- 0.56 in the native anterior cruciate ligament, 1.21 +/- 0.47 in the patellar tendon, and 3.59 +/- 1.58 in the anterior cruciate ligaments reconstructed with bone-patellar tendon-bone autografts 1 year after surgery. The dihydroxylysinonorleucine/hydroxylysinonorleucine ratio in both semitendinosus and gracilis tendons was less than 1.0. However, in anterior cruciate ligaments reconstructed with semitendinosus and gracilis tendon autografts, it was 2.34 +/- 0.98 at 4 to 6 months and 3.43 +/- 1.61 at 11 to 13 months after the operation. CONCLUSIONS After anterior cruciate ligament reconstruction with autografts, biochemical characteristics of the graft resembled those of the native anterior cruciate ligament. These findings suggest that, regarding the amount of collagen crosslinks and their architecture, the phenomenon of ligamentization occurs in the successfully reconstructed human anterior cruciate ligament within 1 year after operation.
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Affiliation(s)
- Keishi Marumo
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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Hunt P, Scheffler SU, Unterhauser FN, Weiler A. A model of soft-tissue graft anterior cruciate ligament reconstruction in sheep. Arch Orthop Trauma Surg 2005; 125:238-48. [PMID: 15024579 DOI: 10.1007/s00402-004-0643-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2003] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Since there is to our knowledge no clinically valid and reproducible animal model of soft-tissue anterior cruciate ligament (ACL) reconstruction currently available, we developed one in sheep, in terms of graft suitability, postsurgical recovery, and knee stability. MATERIALS AND METHODS To find a suitable graft, anatomical dissections of the hind limbs of 7 sheep were performed. After a pilot study in 3 sheep, we reconstructed the ACL with an ipsilateral, longitudinally split, superficial digital flexor tendon autograft and anatomic graft fixation in 42 sheep (study 1) and with a full, superficial digital flexor tendon autograft and extracortical graft fixation in 48 sheep (study 2). Follow-up examinations ranged from 6 to 104 weeks (study 1) and 3 to 24 weeks (study 2). RESULTS All animals tolerated the graft harvest well and returned to physiological movement after about 4 weeks. Only 1 out of 93 ACL reconstructions failed. At final follow-up, the anteroposterior (AP) drawer displacement in both studies had almost regained the value of the intact contralateral knee. Maximum load-to-failure improved over time in both studies but was significantly lower at all time points compared with the intact ACL and the graft tissues. Tensile stress was significantly lower at final follow-up in both studies compared with the intact ACL and graft tissues. It attained 43.3% of the intact ACL and 58.3% of the graft tissue in study 1 and 28.9% and 22.8% in study 2, respectively. CONCLUSION The flexor tendon is suitable, and sheep appear to be an appropriate animal model for soft-tissue graft ACL reconstruction. They tolerate the graft harvest well and quickly return to full weight-bearing and physiological movement. Their knees become stable without showing signs of macroscopically evident osteoarthritis.
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Affiliation(s)
- Patrick Hunt
- Sports Traumatology and Arthroscopy Service, Trauma & Reconstructive Surgery, Charité, Campus Virchow Clinic, Humboldt University, Berlin, Germany
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Milano G, Mulas PD, Sanna-Passino E, Careddu GM, Ziranu F, Fabbriciani C. Evaluation of bone plug and soft tissue anterior cruciate ligament graft fixation over time using transverse femoral fixation in a sheep model. Arthroscopy 2005; 21:532-9. [PMID: 15891717 DOI: 10.1016/j.arthro.2005.02.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the mechanical role of bone-anterior cruciate ligament (ACL) graft junction in comparison with primary fixation of the graft. TYPE OF STUDY Ex vivo controlled biomechanical study. METHODS An ACL reconstruction was performed on 2 groups of 40 sheep each. The ACL graft was patellar tendon in group 1, and free tendon in group 2. Load-to-failure tests were performed at 1, 2, 3, and 6 months. Each group was divided into 2 subgroups: In subgroup A the femoral fixation devices were removed before testing and in subgroup B they were left in place. RESULTS At 1 month, structural properties of subgroup 2A were significantly lower than other subgroups. Until the third month, structural properties of each subgroup were significantly lower than normal ACL. Grafts always failed at midsubstance, except for subgroup 2A at 1 month, which pulled out of the femoral tunnel. CONCLUSIONS Bone plug incorporation was stronger than graft strength at 1 month whereas soft tissue tendon incorporation was not stronger than graft until 2 months. At 3 months, both groups failed at approximately 30% of the native ACL strength, and at 6 months, both groups were nearly equal in terms of load to failure and stiffness. CLINICAL RELEVANCE High fixation strength and stiffness of ACL graft does not allow earlier return to sports activities.
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Affiliation(s)
- Giuseppe Milano
- Department of Orthopaedics, University of Sassari, Sassari, Italy.
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31
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See EKN, Ng GYF, Ng COY, Fung DTC. Running exercises improve the strength of a partially ruptured Achilles tendon. Br J Sports Med 2005; 38:597-600. [PMID: 15388547 PMCID: PMC1724906 DOI: 10.1136/bjsm.2003.007120] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To examine the effects of running and swimming exercises on the functional performance and mechanical strength of a recovering Achilles tendon. METHODS 30 Sprague-Dawley rats had surgical transection of their right medial Achilles tendon. The rats were divided into running (n = 11), swimming (n = 10), and control (n = 9) groups. The running and swimming groups were given daily exercise training, starting from the fifth day after the injury; the control group did not exercise throughout the period of the experiment. An Achilles functional index (AFI) was recorded before the operation and on the third, 10th, and 30th days after the operation. On the 30th day, the rats were killed and their Achilles tendons harvested for biomechanical testing of load relaxation properties, stiffness, and ultimate tensile strength (UTS). The AFI data were analysed by two way analysis of variance; load relaxation, stiffness, and UTS data were analysed by multivariate analysis, with alpha at 0.05. RESULTS The UTS of the running group was higher than in the control group (p = 0.015), while there was no significant difference between the swimming and control groups (p = 0.228). Differences in stiffness and load relaxation were non-significant (p = 0.823 and 0.633, respectively). The AFI results did not differ among the three groups (p = 0.242). CONCLUSIONS Running exercises can improve the strength of partially ruptured Achilles tendons at 30 days after injury.
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Affiliation(s)
- E K N See
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
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Woo SLY, Abramowitch SD, Kilger R, Liang R. Biomechanics of knee ligaments: injury, healing, and repair. J Biomech 2005; 39:1-20. [PMID: 16271583 DOI: 10.1016/j.jbiomech.2004.10.025] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Accepted: 10/20/2004] [Indexed: 02/08/2023]
Abstract
Knee ligament injuries are common, particularly in sports and sports related activities. Rupture of these ligaments upsets the balance between knee mobility and stability, resulting in abnormal knee kinematics and damage to other tissues in and around the joint that lead to morbidity and pain. During the past three decades, significant advances have been made in characterizing the biomechanical and biochemical properties of knee ligaments as an individual component as well as their contribution to joint function. Further, significant knowledge on the healing process and replacement of ligaments after rupture have helped to evaluate the effectiveness of various treatment procedures. This review paper provides an overview of the current biological and biomechanical knowledge on normal knee ligaments, as well as ligament healing and reconstruction following injury. Further, it deals with new and exciting functional tissue engineering approaches (ex. growth factors, gene transfer and gene therapy, cell therapy, mechanical factors, and the use of scaffolding materials) aimed at improving the healing of ligaments as well as the interface between a replacement graft and bone. In addition, it explores the anatomical, biological and functional perspectives of current reconstruction procedures. Through the utilization of robotics technology and computational modeling, there is a better understanding of the kinematics of the knee and the in situ forces in knee ligaments and replacement grafts. The research summarized here is multidisciplinary and cutting edge that will ultimately help improve the treatment of ligament injuries. The material presented should serve as an inspiration to future investigators.
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Affiliation(s)
- Savio L-Y Woo
- Department of Bioengineering, Musculoskeletal Research Center, University of Pittsburgh, Pittsburgh, PA 15219, USA.
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Ng GYF, Fung DTC, Leung MCP, Guo X. Comparison of single and multiple applications of GaAlAs laser on rat medial collateral ligament repair. Lasers Surg Med 2004; 34:285-9. [PMID: 15022259 DOI: 10.1002/lsm.20015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES To examine single versus multiple applications of the gallium aluminum arsenide (GaAlAs) laser on the healing of surgically injured medial collateral ligaments (MCLs) in rats. STUDY DESIGN/MATERIALS AND METHODS Sixteen rats were studied, with 12 receiving surgical transection to their right MCL and 4 receiving a sham injury. Group 1 (n = 4) received a single dose of GaAlAs laser therapy (wavelength 660 nm, average power 8.8 mW, pulse 10 kHz, dosage 31.6 J/cm(2)) directly to their MCL during surgery. Group 2 (n = 4) received 9 doses of GaAlAs laser therapy applied transcutaneously on alternate days (wavelength 660 nm, average power 8.8 mW, pulse 10 kHz, dosage 3.5 J/cm(2)). The controls (Group 3, n = 4) received one session of placebo laser at the time of surgery, with the laser equipment shut down, while the sham injured Group 4 (n = 4) received no treatment. Biomechanical tests for structural stiffness, ultimate tensile strength (UTS), and load-relaxation were done at 3 weeks after injury. The stiffness and UTS data were normalized by expressing as a percentage of the left side of each animal before statistical analysis. RESULTS The load-relaxation data did not show any differences between the groups (P = 0.18). The normalized stiffness levels of Groups 2 (81.08+/-11.28%) and 4 (92.66+/-13.19%) were significantly higher (P = 0.025) than that of the control Group 3 (58.99+/-15.91%). The normalized UTS of Groups 2 (81.38+/-5.68%) and 4 (90.18+/-8.82%) were also significantly higher (P = 0.012) than that of the control (64.49+/-9.26%). Although, Group 1 had higher mean stiffness and UTS values than the control, no statistically significant difference was found between these two groups. CONCLUSIONS Multiple laser therapy improves the normalized strength and stiffness of repairing rat MCLs at 3 weeks after injury. The multiple treatments seem to be superior to a single treatment when the cumulative dosages are comparable between the two modes of application.
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Affiliation(s)
- Gabriel Y F Ng
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong.
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Weiler A, Förster C, Hunt P, Falk R, Jung T, Unterhauser FN, Bergmann V, Schmidmaier G, Haas NP. The influence of locally applied platelet-derived growth factor-BB on free tendon graft remodeling after anterior cruciate ligament reconstruction. Am J Sports Med 2004; 32:881-91. [PMID: 15150033 DOI: 10.1177/0363546503261711] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ligaments and tendons do not gain mechanical properties of the native tissue after injury or grafting. PURPOSE To determine the influence of platelet-derived growth factor on tendon graft remodeling. STUDY DESIGN Laboratory animal study. METHODS Forty-eight sheep underwent anterior cruciate ligament reconstruction and were sacrificed after 3, 6, 12, and 24 weeks. In 6 animals at each time point, platelet-derived growth factor was locally delivered via coated sutures. After mechanical testing, tissue samples were taken for histologic, immunohistochemical, and electron microscopy evaluations. RESULTS With platelet-derived growth factor treatment, cross-sectional area was significantly lower at 3 and 12 weeks. Load to failure was significantly higher at 6 weeks. Tensile stress was significantly higher at 3 and 12 weeks. Crimp length was significantly higher at 3 and 6 weeks. Vascular density was significantly higher at 6 weeks. Electron microscopy showed a significantly higher collagen fibril amount at 12 weeks. Differences in these parameters at other time points were not significant. CONCLUSIONS There were alterations in several but not all time points. The local application of platelet-derived growth factor alters the tissue's mechanical properties during free tendon graft remodeling after anterior cruciate ligament reconstruction. Growth factors present a promising tool toward the complete mechanical restitution of a healing ligament substitute.
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Affiliation(s)
- Andreas Weiler
- Sports Traumatology & Arthroscopy Service, Trauma & Reconstructive Surgery, Charité, Humboldt-University of Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Li AY, Ng GY. Overview of Anterior Cruciate Ligament Rehabilitation and its Evolution in Hong Kong in the Past 8 Years. Hong Kong Physiother J 2004. [DOI: 10.1016/s1013-7025(09)70045-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abramowitch SD, Yagi M, Tsuda E, Woo SLY. The healing medial collateral ligament following a combined anterior cruciate and medial collateral ligament injury--a biomechanical study in a goat model. J Orthop Res 2003; 21:1124-30. [PMID: 14554228 DOI: 10.1016/s0736-0266(03)00080-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The ideal treatment of a combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injury to the knee is still debated. In particular, the question of whether reconstruction of the ACL can provide the knee with sufficient multidirectional stability to allow for effective MCL healing needs to be better elucidated. Therefore, the first objective of this study was to quantify the changes in the function of goat knees between time-zero and 6 weeks following a combined ACL/MCL injury treated with ACL reconstruction. Using a robotic/universal force-moment sensor testing system, the kinematics of the knee and in situ forces in the ACL/ACL graft as well as in the sham-operated and healing MCL were evaluated in response to (1) a 67 N anterior-posterior (A-P) tibial load and (2) a 5 Nm varus-valgus (V-V) moment. The second objective was to evaluate the structural properties of the healing femur-MCL-tibia complex (FMTC) and the mechanical properties of the healing MCL at 6 weeks under uniaxial tension. In response to the 67 N A-P tibial load, the A-P translations for the experimental knee increased by as much as 4.5 times from time-zero to 6 weeks (p<0.05). Correspondingly, the in situ forces in the ACL graft decreased by as much as 45% (p<0.05). There was no measurable changes of the in situ force in the healing MCL. In response to a 5 Nm V-V moment, V-V rotations were twice as much as controls, but similar for both time periods. From time-zero to 6 weeks, the in situ forces in the ACL graft dropped by over 71% (p<0.05), while the in situ force in the healing MCL was as much as 35+/-19 N. In terms of the structural properties of the healing FMTC, the stiffness and ultimate load values at 6 weeks reached 53% and 29% of sham-operated contralateral controls, respectively (p<0.05). For the mechanical properties of the healing MCL substance, the values for tangent modulus and tensile strength were only 13% and 10% of sham-operated controls, respectively (p<0.05). These results suggest that the ACL graft stabilized the knee initially, but became loose over time. As a result, the healing MCL may have been required to take on excessive loads and was unable to heal sufficiently as compared to an isolated MCL injury.
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Affiliation(s)
- Steven D Abramowitch
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Ng COY, Ng GYF, See EKN, Leung MCP. Therapeutic ultrasound improves strength of achilles tendon repair in rats. ULTRASOUND IN MEDICINE & BIOLOGY 2003; 29:1501-1506. [PMID: 14597348 DOI: 10.1016/s0301-5629(03)01018-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The purpose of this study was to evaluate the effects of therapeutic ultrasound on structural properties and functional performance of Achilles tendon healing. Thirty Sprague-Dawley rats with surgical hemitransected Achilles tendon were studied. Ten were treated daily with 1 MHz continuous ultrasound at 1.0 W/cm2 for 4 min, 11 at 2.0 W/cm2 for 4 min and nine served as control without treatment. Achilles functional index (AFI) was recorded preoperatively and on postoperative days 3, 10 and 30. On day 30, the rats were sacrificed and Achilles tendons were tested for load-relaxation, stiffness and ultimate tensile strength (UTS). Results showed that UTS of both low-dose (p=0.023) and high-dose (p=0.002) groups was significantly greater than in controls. No significant differences in AFI (p=0.179), load-relaxation (p=0.205) and stiffness (p=0.842) were found among groups. These findings suggested that both low- and high-dose therapeutic ultrasound accelerate the healing process of ruptured tendon.
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Affiliation(s)
- Christine O Y Ng
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong
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Abramowitch SD, Papageorgiou CD, Withrow JD, Gilbert TW, Woo SLY. The effect of initial graft tension on the biomechanical properties of a healing ACL replacement graft: a study in goats. J Orthop Res 2003; 21:708-15. [PMID: 12798072 DOI: 10.1016/s0736-0266(02)00265-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
While a number of in vitro studies have shown that the tension on an anterior cruciate ligament (ACL) replacement graft at the time of fixation has an affect on joint stability, most in vivo studies have reported little or no long-term difference in outcome. The objectives of this study were to (1) establish a large animal model in which differences in knee stability are present at time-zero after ACL reconstruction with grafts fixed at a low (5 N) and high (35 N) initial tension and to (2) quantitatively determine if these initial effects remain after six weeks of healing and if the tensile properties of an ACL replacement graft are influenced by initial graft tension. Seventeen skeletally mature female Saanan breed goats were used. Using the robotic/UFS testing system, the knee kinematics and in situ forces in the replacement graft in response to an externally applied 67 N anterior-posterior (A-P) tibial load were evaluated at time-zero and after six weeks of healing. Afterward, the femur-ACL graft-tibia complexes (FGTCs) from the six-week group were tested under uniaxial tension so that the stress relaxation and structural properties of the FGTC were obtained. At time-zero, knees fixed with a high initial graft tension could better reproduce the A-P translation of the intact knee in response to the 67 N A-P tibial load. Further, in situ forces in these grafts were also closer to those in the intact ACL under the same external loading condition. After six weeks of healing, the A-P translation of the knee and in situ forces in the replacement grafts became similar for the low and high tension groups, while both were significantly different from controls. Further, the percentage of stress relaxation as well as the stiffness, ultimate load at failure, ultimate elongation at failure, and energy absorbed of the FGTCs for both reconstruction groups were not significantly different from each other, but were significantly different from controls. These results demonstrate that while the high initial graft tension could better replicate the normal knee kinematics at time-zero, these effects may diminish during the early graft healing process.
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Affiliation(s)
- Steven D Abramowitch
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Pittsburgh, PA 15213, USA
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Abramowitch SD, Papageorgiou CD, Debski RE, Clineff TD, Woo SLY. A biomechanical and histological evaluation of the structure and function of the healing medial collateral ligament in a goat model. Knee Surg Sports Traumatol Arthrosc 2003; 11:155-62. [PMID: 12774152 DOI: 10.1007/s00167-002-0336-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2002] [Accepted: 11/06/2002] [Indexed: 10/20/2022]
Abstract
This study evaluated the healing process of an isolated medial collateral ligament (MCL) rupture at 12 weeks in a goat model. Using a robotic/UFS testing system, knee kinematics in multiple degrees of freedom and in situ forces in the healing MCL in response to (1) a 67-N anterior tibial load and (2) a 5-Nm valgus moment were evaluated as a function of angles of knee flexion. Then a uniaxial tensile test of femur-MCL-tibia complexes (FMTCs) was preformed to obtain the structural properties of the FMTC and mechanical properties of the healing MCL substance. The histological appearance of the healing MCL was also examined for collagen and cell organization. The anterior tibial translation in response to a 67-N anterior tibial load was found to range from 1.9 to 2.4 mm, which was not significantly different from the sham-operated, contralateral control knee. In response to a 5-Nm valgus moment, however, MCL injury caused a 40% or more increase in valgus rotations over sham-operated controls for all angles of knee flexion tested. The magnitudes of the in situ forces in the healing MCLs for neither external loading conditions differed from sham-operated controls. For the structural properties of the healing FMTC, the stiffness returned to sham-operated control levels, but ultimate load at failure remained 60% of sham-operated control values. In terms of mechanical properties of the healing MCL, its tangent modulus and stress at failure were only 40% of sham-operated control values. Histologically, the collagen and cell organization at the femoral and tibial insertions as well as the midsubstance remained disorganized. Comparing these data to those previously reported at 6 weeks, there was a marked improvement in the in situ forces in the healing MCL and of the stiffness of the FMTC. Also, the data obtained for the goat model revealed a faster healing process than those for the rabbit model. These findings suggest that greater post-injury activity levels may render the goat to be a better animal model for studying the healing process of the MCL.
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Affiliation(s)
- Steven D Abramowitch
- Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of Pittsburgh, E1641 Bioscience Tower, 210 Lothrop Street, P.O. Box 71199, Pittsburgh, PA 15213, USA
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Fung DTC, Ng GYF, Leung MCP, Tay DKC. Therapeutic low energy laser improves the mechanical strength of repairing medial collateral ligament. Lasers Surg Med 2002; 31:91-6. [PMID: 12210592 DOI: 10.1002/lsm.10083] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Low energy laser therapy has been shown to enhance collagen production but its effect on tissue strength is not well reported. We tested the effects of therapeutic laser on the strength of healing medial collateral ligaments (MCLs) in rats. STUDY DESIGN/MATERIALS AND METHODS Twenty-four rats received surgical transection to their right MCL and eight received sham operation. After surgery, 16 received a single dose of gallium aluminum arsenide laser to their transected MCL for 7.5 minutes (n = 8) or 15 minutes (n = 8) and eight served as control with placebo laser, while the sham group didn't receive any treatment. The MCLs were biomechanically tested at either 3 or 6 weeks post-operation. RESULTS The normalized ultimate tensile strength (UTS) and stiffness of laser and sham groups were larger than control (P < 0.001). The UTS of laser and sham groups were comparable. Laser and sham groups had improved in stiffness from 3 to 6 weeks (P < 0.001). CONCLUSIONS A single dose of low energy laser therapy improves the UTS and stiffness of repairing MCL at 3 and 6 weeks after injury.
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Affiliation(s)
- Dicky T C Fung
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
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Boorman RS, Thornton GM, Shrive NG, Frank CB. Ligament grafts become more susceptible to creep within days after surgery: evidence for early enzymatic degradation of a ligament graft in a rabbit model. ACTA ORTHOPAEDICA SCANDINAVICA 2002; 73:568-74. [PMID: 12440502 DOI: 10.1080/000164702321022866] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Clinical evidence suggests that some ligament grafts stretch after surgery. Our purpose in this study was to quantify early postoperative creep behavior of ligament autografts in an animal model, and to explore potential mechanisms of that behavior. 38 New Zealand white rabbits underwent a unilateral, fresh, anatomic medial collateral ligament (MCL) autograft procedure and were killed immediately (time-zero), at 2 days, 3 weeks, or 8 weeks after surgery (n = 7-11 in each group). We compared the creep behavior of the autografts to normal MCLs (n = 8). An additional 7 MCL specimens were incubated for 2 days in a low concentration collagenase solution and then similarly creep-tested. All grafts were slower to recover their original length after creep than either normal ligaments or time-zero controls. These grafts started to become more vulnerable to elongation in cyclic and static creep tests within 2 days of surgery, compared to time-zero controls. This vulnerability to creep increased over the next 3 weeks, and was maintained at 8 weeks of healing. 2-day collagenase-soaked MCL specimens had the same creep strains as the 2-day autografts. These results suggest that even fresh anatomic ligament autografts become vulnerable to creep within a few days after surgery by mechanisms that may involve degradative enzymes such as collagenase.
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Affiliation(s)
- Richard S Boorman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, USA
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Cummings JF, Grood ES. The progression of anterior translation after anterior cruciate ligament reconstruction in a caprine model. J Orthop Res 2002; 20:1003-8. [PMID: 12382966 DOI: 10.1016/s0736-0266(02)00033-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Large post-operative anterior-posterior translations are frequently reported after quadruped anterior cruciate ligament (ACL) reconstructions. To determine when the translation increases occur and the mechanism responsible, we followed the anterior and posterior translation limits in 18 goat knees for six months. Reconstructions were performed using grafts 4 or 7 mm wide placed in initially tight or lax positions. The anterior and posterior translation limits at 50 N were monitored using Roentgen stereophotogrammetric analysis. Graft bone block stability and soft tissue segment lengths were also assessed. Large (> 2 mm) increases in anterior translation were noted in 71% of the subjects at two weeks, and in 88% at eight weeks. The translations in the lax and tight groups were indistinguishable after two weeks. Joints with wide grafts had less anterior translation compared to narrow grafts at all time periods, but were significant different only at 26 weeks. The posterior translation limit moved anteriorly over the 26 weeks. Eight of nine joints had stable graft bone markers and/or increases in graft soft tissue lengths. In conclusion, increased anterior translation occurred soon after ACL reconstruction, was associated with graft soft tissue changes, and appeared to be reduced by larger grafts. A post-surgical decrease in posterior translation limit was also observed.
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Affiliation(s)
- J F Cummings
- Department of Biomechanical Engineering, University of Cincinnati, OH 45221-0048, USA.
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Abstract
We studied the subject and treatment contributions to anterior cruciate ligament (ACL) reconstruction biomechanics by reexaming the results of two bilateral reconstruction studies. Bilateral reconstruction allows a comparison between treatments exposed to the same subject related healing factors. The studies examined the effects of gamma irradiation and the effects of initial graft size and initial graft laxity. In both studies different treatments were applied to contralateral limbs. We found that the subject was the best predictor of outcome, while the surgical treatments had little influence on outcome. There was a large variation between subjects despite similar treatments, and little difference between contralateral limbs despite different surgical treatments. At 26 weeks, the graft cross sectional area and modulus were most strongly influenced (p < 0.002) by the subject. We interpret this as a subject related factor is regulating the quantity and quality of the healing tissue. Potential sources of subject related factors include the subject's pre-operative condition, the activity during the post-operative period, and an intrinsic biologic response. By better understanding the source of subject variation, more successful and consistent ACL reconstructions might be achieved.
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Affiliation(s)
- J F Cummings
- Department of Biomechanical Engineering, University of Cincinnati, OH 45221-0048, USA.
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Jackson DW, Simon TM. Donor cell survival and repopulation after intraarticular transplantation of tendon and ligament allografts. Microsc Res Tech 2002; 58:25-33. [PMID: 12112419 DOI: 10.1002/jemt.10118] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The specific cells within ligaments and tendons are important to maintain the unique structural and material properties of these tissues. The use of tendon and ligament allografts with living cells for ligament reconstruction would be desirable assuming that these cells would survive after transplantation and continue to function. We assessed the fate of donor cells in fresh allografts of the patellar and anterior cruciate ligaments after transplantation. The cells in these allografts used to reconstruct the anterior cruciate ligament did not survive. This was demonstrated using a DNA probe technique that clearly distinguished donor cells from host cells in the Spanish goat model. The donor cells were replaced by host cells in a rapid manner. The host cells that repopulated the allografts assumed the histologic similarity to the fibroblasts they replace. Simultaneous full-thickness skin transplants in the same animals were not rejected during the interval of rapid loss of donor DNA from the allografts. The absence of rejection of the skin grafts at the one-week interval suggests that no pre-existing antibody associated with an immune reaction was responsible for the rapid loss of DNA in the allografts. The clinical basis for utilizing intra-articular allografts with living donor cells needs further justification to account for their increased expense, more complicated surgical logistics, and higher potential risk of disease transmission.
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MESH Headings
- Animals
- Cartilage, Articular/cytology
- Cartilage, Articular/metabolism
- Cartilage, Articular/pathology
- Cartilage, Articular/surgery
- Cell Survival
- DNA/analysis
- DNA/chemistry
- Goats
- Graft Survival
- Knee Joint/cytology
- Knee Joint/metabolism
- Knee Joint/pathology
- Knee Joint/surgery
- Ligaments/cytology
- Ligaments/metabolism
- Ligaments/transplantation
- Ligaments, Articular/cytology
- Ligaments, Articular/metabolism
- Ligaments, Articular/pathology
- Ligaments, Articular/surgery
- Models, Animal
- Molecular Weight
- Skin Transplantation
- Tendons/cytology
- Tendons/metabolism
- Tendons/transplantation
- Transplantation, Autologous
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Affiliation(s)
- Douglas W Jackson
- Orthopaedic Research Institute and the Southern California Center for Sports Medicine, Long Beach, California 90806, USA.
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Cummings JF, Grood ES, Levy MS, Korvick DL, Wyatt R, Noyes FR. The effects of graft width and graft laxity on the outcome of caprine anterior cruciate ligament reconstruction. J Orthop Res 2002; 20:338-45. [PMID: 11918314 DOI: 10.1016/s0736-0266(01)00119-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We studied how initial graft size and initial graft laxity affected the biomechanics of anterior cruciate ligament (ACL) reconstruction at six months. Sixteen goats had bilateral reconstructions staged eight weeks apart. Autografts 4 and 7 mm wide were taken from the central patellar tendon (PT). Lax grafts were created by adding 4 mm slack to the graft before fixing. We reconstructed each joint using a combination of width and laxity treatments. Both factors were changed for the contralateral joint and all combinations appeared with equal frequency. At six months we measured the joint extension limit, anterior-posterior (AP) translation, and osteoarthritic changes. The grafts were then tested to failure to determine their mechanical properties. After six months the difference in initial treatments had disappeared: there was no difference in graft cross-section due to the different initial widths and there was no difference in joint AP translation due to the initial graft laxity. We did observe that wide grafts were associated with a block to extension, decreased joint AP translation, and increased articular cartilage damage and osteophyte formation. While AP translation was reduced, it was correlated with decreased extension, possibly indicating an increase in scar tissue formation rather than a more functional graft. Neither graft width nor graft laxity produced differences in any graft mechanical properties. This suggests that the use of larger grafts to prevent increased AP translation has undesirable complications. Ultimately, we conclude that neither of these surgical treatments strongly affects the biomechanical result of caprine ACL reconstruction.
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Affiliation(s)
- J F Cummings
- Department of Biomedical Engineering, Noyes-Giannestras Biomechanics Laboratories, University of Cincinnati, OH 45221-0048, USA.
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Weiler A, Unterhauser FN, Bail HJ, Hüning M, Haas NP. Alpha-smooth muscle actin is expressed by fibroblastic cells of the ovine anterior cruciate ligament and its free tendon graft during remodeling. J Orthop Res 2002; 20:310-7. [PMID: 11918311 DOI: 10.1016/s0736-0266(01)00109-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Contractile fibroblastic cells expressing the alpha-smooth muscle actin isoform, so-called myofibroblasts, have been identified to play a possible role during the healing of the medial collateral ligament by means of restoring the tissues in situ strain via extracellular matrix contraction. Recently, these cells have also been identified to be a normal part of the human anterior cruciate ligament. It has been hypothesized that myofibroblasts play a role in the wrinkling of the extracellular matrix. The goal of the present study was to identify myofibroblasts in the intact ovine anterior cruciate ligament and a free autologous tendon graft during remodeling after anterior cruciate ligament reconstruction. In 36 mature merino sheep the anterior cruciate ligament was replaced with an ipsilateral Achilles tendon split graft. Midsubstance tissue samples were immunostained for alpha-smooth muscle actin at 6, 9, 12, 24, 52, and 104 weeks. Myofibroblasts were identified in the intact ovine anterior cruciate ligament as well as in the Achilles tendon graft prior to implantation. During remodeling the first myofibroblasts were found at six weeks within newly formed fiber bundles. At 24, 52, and 104 weeks myofibroblast distribution and cell density were similar to those of the intact ovine anterior cruciate ligament. These findings indicate that alpha-smooth muscle actin containing fibroblastic cells are a regular part of the intact as well as the remodeled anterior cruciate ligament. There is evidence that myofibroblasts may be involved in maintaining tissue homeostasis in the mature ligament e.g., by means of crimp formation. The presence of these cells during the early remodeling may further indicate that alpha-smooth muscle actin containing fibroblastic cells are involved in the earliest stages of fiber bundle formation. The role and function of this special cell type for the anterior cruciate ligament needs to be further clarified.
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Affiliation(s)
- Andreas Weiler
- Unfall & Wiederherstellungschirurgie, Charité, Humboldt Universität zu Berlin, Germany.
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Weiler A, Peine R, Pashmineh-Azar A, Abel C, Südkamp NP, Hoffmann RFG. Tendon healing in a bone tunnel. Part I: Biomechanical results after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep. Arthroscopy 2002; 18:113-23. [PMID: 11830804 DOI: 10.1053/jars.2002.30656] [Citation(s) in RCA: 195] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Interference fit fixation of soft-tissue grafts has recently raised strong interest because it allows for anatomic graft fixation that may increase knee stability and graft isometry. Although clinical data show promising results, no data exist on how tendon healing progresses using this fixation. The purpose of the present study was to investigate anterior cruciate ligament (ACL) reconstruction biomechanically using direct tendon-to-bone interference fit fixation with biodegradable interference screws in a sheep model. TYPE OF STUDY Animal study. METHODS Thirty-five mature sheep underwent ACL reconstruction with an autologous Achilles tendon split graft. Grafts were directly fixed with poly-(D,L-lactide) interference screws. Animals were euthanized after 6, 9, 12, 24, and 52 weeks and standard biomechanical evaluations were performed. RESULTS All grafts at time zero failed by pullout from the bone tunnel, whereas grafts at 6 and 9 weeks failed intraligamentously at the screw insertion site. At 24 and 52 weeks, grafts failed by osteocartilaginous avulsion. At 24 weeks, interference screws were macroscopically degraded. At 6 and 9 weeks tensile stress was only 6.8% and 9.6%, respectively, of the graft tissue at time zero. At 52 weeks, tensile stress of the reconstruction equaled 63.8% and 47.3% of the Achilles tendon graft at time zero and the native ACL, respectively. A complete restitution of anterior-posterior drawer displacement was found at 52 weeks compared with the time-zero reconstruction. CONCLUSIONS It was found that over the whole healing period the graft fixation proved not to be the weak link of the reconstruction and that direct interference fit fixation withstands loads without motion restriction in the present animal model. The weak link during the early healing stage was the graft at its tunnel entrance site, leading to a critical decrease in mechanical properties. This finding indicates that interference fit fixation of a soft-tissue graft may additionally alter the mechanical properties of the graft in the early remodeling stage because of a possible tissue compromise at the screw insertion site. Although mechanical properties of the graft tissue had not returned to normal at 1 year compared with those at time zero, knee stability had returned to normal at that time. There was no graft pullout after 24 weeks, indicating that screw degradation does not compromise graft fixation.
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Affiliation(s)
- Andreas Weiler
- Trauma & Reconstructive Surgery, Sports Traumatology, and Arthroscopy Service, Charité, Campus Virchow-Clinic, Humboldt-University of Berlin, Germany.
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Weiler A, Peters G, Mäurer J, Unterhauser FN, Südkamp NP. Biomechanical properties and vascularity of an anterior cruciate ligament graft can be predicted by contrast-enhanced magnetic resonance imaging. A two-year study in sheep. Am J Sports Med 2001; 29:751-61. [PMID: 11734489 DOI: 10.1177/03635465010290061401] [Citation(s) in RCA: 180] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Magnetic resonance imaging has been used to determine graft integrity and study the remodeling process of anterior cruciate ligament grafts morphologically in humans. The goal of the present study was to compare graft signal intensity and morphologic characteristics on magnetic resonance imaging with biomechanical and histologic parameters in a long-term animal model. Thirty sheep underwent anterior cruciate ligament reconstruction with an autologous Achilles tendon split graft and were sacrificed after 6, 12, 24, 52, or 104 weeks. Before sacrifice, all animals underwent plain and contrast-enhanced (gadolinium-diethylenetriamine pentacetic acid) magnetic resonance imaging (1.5 T, proton density weighted, 2-mm sections) of their operated knees. The signal/noise quotient was calculated and data were correlated to the maximum load to failure, tensile strength, and stiffness of the grafts. The vascularity of the grafts was determined immunohistochemically by staining for endothelial cells (factor VIII). We found that high signal intensity on magnetic resonance imaging reflects a decrease of mechanical properties of the graft during early remodeling. Correlation analyses revealed significant negative linear correlations between the signal/noise quotient and the load to failure, stiffness, and tensile strength. In general, correlations for contrast-enhanced measurements of signal intensity were stronger than those for plain magnetic resonance imaging. Immunohistochemistry confirmed that contrast medium enhancement reflects the vascular status of the graft tissue during remodeling. We conclude that quantitatively determined magnetic resonance imaging signal intensity may be a useful tool for following the graft remodeling process in a noninvasive manner.
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Affiliation(s)
- A Weiler
- Trauma and Reconstructive Surgery, Sports Traumatology and Arthroscopy Service, Charité, Humboldt-University of Berlin, Germany
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