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Xiao H, Wen B, Yan D, Li Q, Yang Y, Yin X, Chen D, Liu J. Hot spots and frontiers in bone-tendon interface research: a bibliometric analysis and visualization from 2000 to 2023. Front Surg 2024; 10:1326564. [PMID: 38327873 PMCID: PMC10847327 DOI: 10.3389/fsurg.2023.1326564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/19/2023] [Indexed: 02/09/2024] Open
Abstract
Objective In this research, we investigated the current status, hotspots, frontiers, and trends of research in the field of bone-tendon interface (BTI) from 2000 to 2023, based on bibliometrics and visualization and analysis in CiteSpace, VOSviewer, and a bibliometric package in R software. Methods We collected and organized the papers in the Web of Science core collection (WoSCC) for the past 23 years (2000-2023), and extracted and analyzed the papers related to BTI. The extracted papers were bibliometrically analyzed using CiteSpace for overall publication trends, authors, countries/regions, journals, keywords, research hotspots, and frontiers. Results A total of 1,995 papers met the inclusion criteria. The number of papers published and the number of citations in the field of BTI have continued to grow steadily over the past 23 years. In terms of research contribution, the United States leads in terms of the number and quality of publications, number of citations, and collaborations with other countries, while the United Kingdom and the Netherlands lead in terms of the average number of citations. The University of Leeds publishes the largest number of papers, and among the institutions hosting the 100 most cited papers Hospital for Special Surgery takes the top spot. MCGONAGLE D has published the highest number of papers (73) in the last 10 years. The top three clusters include #0 "psoriatic arthritis", #1 "rotator cuff repair", and #2 "tissue engineering". The structure and function of the BTI and its key mechanisms in the healing process are the key to research, while new therapies such as mechanical stimulation, platelet-rich plasma, mesenchymal stem cells, and biological scaffolds are hot topics and trends in research. Conclusion Over the past 23 years, global research on the BTI has expanded in both breadth and depth. The focus of research has shifted from studies concentrating on the structure of the BTI and the disease itself to new therapies such as biomaterial-based alternative treatments, mechanical stimulation, platelet-rich plasma, etc.
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Affiliation(s)
- Hao Xiao
- XiangYa School of Medicine, Central South University, Changsha, China
| | - Boyuan Wen
- XiangYa School of Medicine, Central South University, Changsha, China
| | - Dong Yan
- XiangYa School of Medicine, Central South University, Changsha, China
| | - Quansi Li
- XiangYa School of Medicine, Central South University, Changsha, China
| | - Yujie Yang
- XiangYa School of Medicine, Central South University, Changsha, China
| | - Xianye Yin
- XiangYa School of Medicine, Central South University, Changsha, China
| | - Deyu Chen
- School of Journalism and Communication, Hunan University, Changsha, China
| | - Jiachen Liu
- XiangYa School of Medicine, Central South University, Changsha, China
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Center of System Biology and Data Information, School of Basic Medical Science, Central South University, Changsha, Hunan, China
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Desai T, Babu S S, S KY, Nedumparampil MM, George AJ, Sekaran P, Pilar A, Amaravathi RS. Periosteum-Augmented Soft-Tissue Graft for Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2024; 13:102809. [PMID: 38312870 PMCID: PMC10837788 DOI: 10.1016/j.eats.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/26/2023] [Indexed: 02/06/2024] Open
Abstract
Soft-tissue grafts are an option for anterior cruciate ligament reconstruction. One of the major drawbacks of soft-tissue grafts is the delay in the osteointegration and ligamentization of the implanted graft. Enveloping the ends of the graft with periosteum sleeves can hasten the osteointegration process and help in quicker rehabilitation of the patient. This article describes a simple and unique way to augment the soft-tissue graft with periosteum for anterior cruciate ligament reconstruction.
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Affiliation(s)
- Tarun Desai
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Surendra Babu S
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Kaushik Y. S
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Mevin Mathew Nedumparampil
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | | | | | - Anoop Pilar
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
| | - Rajkumar S. Amaravathi
- Division of Sports Injuries, Regenerative Medicine & Joint Preservation, St John’s Medical College, Bangalore, India
- Department of Orthopaedics, St John’s Medical College, Bangalore, India
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Eriksson K, Cristiani R. Anatomical hamstring tendons ACL reconstruction with the "linking rings" technique. J ISAKOS 2023; 8:57-58. [PMID: 35963530 DOI: 10.1016/j.jisako.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 10/15/2022]
Abstract
Hamstring tendons (HTs) are one of the most commonly used autografts for anterior cruciate ligament (ACL) reconstruction (ACLR). However, the tendon-to-bone healing of the HTs grafts within the bone tunnels has always been a concern. Periosteum contains pluripotent stem cells with osteogenic and chondrogenic potential which can allow a direct, stronger and faster healing of the HTs graft within the bone tunnels. In this technical note, we present a modification of anatomical ACLR with the semitendinosus tendon (ST) graft and periosteum augmentation using the "linking rings" technique. The ST is harvested together with periosteum from its distal insertion. An additional free periosteal flap is harvested from the proximal tibia, below the ST insertion. The two free ends of the ST are then linked with a strong non-resorbable suture forming a ring and then folded again creating a quadruple construct with two loops at each end. The periosteum is then wrapped and sutured around the quadruple ST graft on both sides of the linking rings near the femoral and tibial tunnel opening. A technical pearl is to use one artery clamp inside the double rings at the graft ends, pull apart simultaneously and equal the tension between the strands. Another technical pearl is to not pull the periosteum to obtain the flaps, but to use instead a periosteal elevator to preserve the cambium layer which contains the pluripotent stem cells.
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Affiliation(s)
- Karl Eriksson
- Department of Orthopaedics, Stockholm South Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
| | - Riccardo Cristiani
- Capio Artro Clinic, FIFA Medical Centre of Excellence, Sophiahemmet Hospital, Valhallavägen 91, 11486, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Stockholm Sports Trauma Research Center, Karolinska Institute, Stockholm, Sweden.
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Kitchen BT, Mitchell BC, Cognetti DJ, Siow MY, Howard R, Carroll AN, Bastrom TP, Edmonds EW. Outcomes After Hamstring ACL Reconstruction With Suture Tape Reinforcement in Adolescent Athletes. Orthop J Sports Med 2022; 10:23259671221085577. [PMID: 35425845 PMCID: PMC9003649 DOI: 10.1177/23259671221085577] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Previous studies have suggested that suture tape-reinforced anterior cruciate ligament (ACL) grafts may have higher ultimate failure loads without stress-shielding. In patients at high risk for graft failure, such as adolescents, the addition of suture tape could have beneficial outcomes. Hypothesis: Suture tape reinforcement (STR) of ACL grafts in adolescent patients would lead to fewer graft ruptures during early recovery, without hindering subjective outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on adolescent patients with a minimum 2-year follow-up after hamstring tendon autograft ACL reconstruction; enrolled were patients from both before (n = 40) and after (n = 40) a shift in surgical technique that added STR. Both the no-STR and the STR cohorts were contacted yearly to obtain patient-reported outcome data for visual analog scale (VAS; range, 0-10) for pain score, Single Assessment Numeric Evaluation, Lysholm score, Tegner activity score, patient satisfaction score (range, 0-100), and return to previous level of sport (yes/no). The cohorts were then matched based on follow-up duration, excluding those with follow-up of <2 years and >3 years to maintain consistency in duration of follow-up. Graft failure was defined as either graft rupture or recurrent instability symptoms, and failures occurring from index procedure to the 3-year mark were recorded for calculations of failure rate. Results: There were no differences between cohorts in mean age [STR, 15.7 years (range, 9.5-18.7 years); no STR, 14.9 years (range, 9.3-18.8 years)], follow-up duration, laterality, or graft size. While not statistically significant, 2 (5%) patients in the STR cohort experienced graft rupture compared with 7 (17.5%) patients in the no-STR cohort. The Tegner score was significantly higher in the STR cohort (P = .017); no between-group differences were seen on the other outcome scores. A subanalysis of the STR cohort comparing small-diameter grafts (<8 mm) with grafts ≥8 mm also demonstrated no difference in outcome measures, with 1 graft failure in each cohort. Conclusion: Study outcomes indicated that patients treated with ACL reconstruction and STR experienced a significant improvement in Tegner scores while at the same time maintaining the other subjective outcomes.
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Affiliation(s)
- Brock T. Kitchen
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
| | - Brendon C. Mitchell
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Daniel J. Cognetti
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Matthew Y. Siow
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Roland Howard
- Department of Orthopaedic Surgery, University of California-San Diego, San Diego, California, USA
| | - Alyssa N. Carroll
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
| | - Tracey P. Bastrom
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
| | - Eric W. Edmonds
- Division of Orthopaedic Surgery, Rady Children’s Hospital, San Diego, California, USA
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Luo Y, Zhang C, Wang J, Liu F, Chau KW, Qin L, Wang J. Clinical translation and challenges of biodegradable magnesium-based interference screws in ACL reconstruction. Bioact Mater 2021; 6:3231-3243. [PMID: 33778201 PMCID: PMC7966853 DOI: 10.1016/j.bioactmat.2021.02.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/07/2021] [Accepted: 02/23/2021] [Indexed: 12/27/2022] Open
Abstract
As one of the most promising fixators developed for anterior cruciate ligament (ACL) reconstruction, biodegradable magnesium (Mg)-based interference screws have gained increasing attention attributed to their appropriate modulus and favorable biological properties during degradation after surgical insertion. However, its fast degradation and insufficient mechanical strength have also been recognized as one of the major causes to limit their further application clinically. This review focused on the following four parts. Firstly, the advantages of Mg or its alloys over their counterparts as orthopaedic implants in the fixation of tendon grafts in ACL reconstruction were discussed. Subsequently, the underlying mechanisms behind the contributions of Mg ions to the tendon-bone healing were introduced. Thirdly, the technical challenges of Mg-based interference screws towards clinical trials were discussed, which was followed by the introduction of currently used modification methods for gaining improved corrosion resistance and mechanical properties. Finally, novel strategies including development of Mg/Titanium (Ti) hybrid fixators and Mg-based screws with innovative structure for achieving clinically customized therapies were proposed. Collectively, the advancements in the basic and translational research on the Mg-based interference screws may lay the foundation for exploring a new era in the treatment of the tendon-bone insertion (TBI) and related disorders.
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Affiliation(s)
- Ying Luo
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, 510006, China
| | - Chao Zhang
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, 510006, China
| | - Jue Wang
- Hanglok-Tech Co., Ltd., Hengqin New Area, China
| | - Fangfei Liu
- State Key Laboratory for Advanced Metals and Materials, University of Science and Technology Beijing, Beijing, 100083, China
| | - Kelvin Wingho Chau
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Ling Qin
- Musculoskeletal Research Laboratory, Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Jiali Wang
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, 510006, China
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Okazaki Y, Abe N, Makiyama K, Furumatsu T, Miyazawa S, Ozaki T. Histologic Evaluation of Tibial Attachment in 11-Year Double-Bundle ACL Reconstruction with Hamstring Tendons: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00010. [PMID: 33826555 DOI: 10.2106/jbjs.cc.20.00509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 49-year-old woman injured her anterior cruciate ligament (ACL) as a high-school student. Double-bundle ACL reconstruction (DBACLR) using hamstring tendon grafts was performed because of recurrent instability. Eleven years after DBACLR, total knee arthroplasty was performed because of osteoarthritis progression. Histologic analysis was completed to observe the osteointegration of the tendon in the obtained proximal tibia. The tibial tunnel showed Sharpey-like fibers anteriorly, connecting the tendon graft and lamellar bone, whereas the intraarticular exit revealed well-aligned chondrocytes posteriorly, indicating chondral metaplasia of the tendon graft. CONCLUSION Tendon-bone healing can regenerate both fibrous insertion and chondral metaplasia in DBACLR.
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Affiliation(s)
- Yuki Okazaki
- Department of Orthopaedic Surgery and Sport Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan.,Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Nobuhiro Abe
- Department of Orthopaedic Surgery and Sport Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Kimihiko Makiyama
- Department of Orthopaedic Surgery and Sport Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Takayuki Furumatsu
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Shinichi Miyazawa
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama, Japan
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7
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Effect of Muscle Cell Preservation on Viability and Differentiation of Hamstring Tendon Graft In Vitro. Cells 2021; 10:cells10040740. [PMID: 33801626 PMCID: PMC8065441 DOI: 10.3390/cells10040740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/02/2021] [Accepted: 03/25/2021] [Indexed: 11/24/2022] Open
Abstract
Muscle tissue is often removed during hamstring tendon graft preparation for anterior cruciate ligament (ACL) reconstruction. The purpose of the study was to test whether preservation of muscle remnants on a tendon graft is beneficial to the graft healing process following ACL reconstruction. Co-culturing of tendon-derived cells (TDCs) and muscle-derived cells (MDCs) was performed at various ratios, and their potential for cell viability and multilineage differentiation was compared to a single TDC cell group. Ligamentous and chondrogenic differentiation was most enhanced when a small population of MDCs was co-cultured with TDCs (6:2 co-culture group). Cell viability and osteogenic differentiation were proportionally enhanced with increasing MDC population size. MDCs co-cultured with TDCs possess both the ability to enhance cell viability and differentiate into other cell lineages.
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Abstract
PURPOSE OF REVIEW We reviewed the recent literature to identify and summarize new research surrounding anterior cruciate ligament reconstruction (ACLR) with augmentation in the form of additional soft tissue procedures or biologic augmentation. Specifically, we wanted to review the failure rates of these procedures in both the primary and revision settings. METHODS The databases Embase, PubMed, and Medline were searched on August 13, 2018, for English-language studies that reported on the use of anterior cruciate ligament reconstruction (primary and revision) in conjunction with either soft tissue or biologic augmentation. The studies were systematically screened and data abstracted in duplicates. RECENT FINDINGS Advancements in ACLR surgery, including soft tissue augmentation, may decrease primary and revision surgery failure rates for high-risk patients. The use of biological augmentation has shown histologic and radiographic improvements. These differences, however, have failed to be statistically significant and have not resulted in clinically significant improvements in outcome. The limited body of evidence has shown that the addition of soft tissue procedures may in fact lower the risk of graft re-rupture rates particularly in revision or in patients wishing to return to high-risk sports and activities. The use of biologic augmentation although promising in laboratory studies has yet to show any significant clinical results and therefore will require further studies to prove any efficacy.
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Struewer J, Roessler PP, Schuettler KF, Ruppert V, Stein T, Timmesfeld N, Paletta JRJ, Efe T. Influence of cyclical mechanical loading on osteogenic markers in an osteoblast-fibroblast co-culture in vitro: tendon-to-bone interface in anterior cruciate ligament reconstruction. INTERNATIONAL ORTHOPAEDICS 2013; 38:1083-9. [PMID: 24248270 DOI: 10.1007/s00264-013-2165-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 10/20/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE We aimed to evaluate the influence of cyclical mechanical loading on osteoblasts and fibroblasts, and co-cultures of both in vitro, simulating the conditions of the tendon-to-bone interface in anterior cruciate ligament reconstruction. METHODS Osteoblast-like cells (OBL) and tendon-derived rodent fibroblasts (TDF) were cultured alone or in co-culture to simulate the tendon-to-bone interface. Cyclical loading was applied for one hour twice a day for three days, with a frequency of 1 Hz and 3 % strain. Alkaline phosphatase (AP), osteocalcin (OC), collagen type 1 (COL1A1), and bone morphogenetic protein 2 (BMP-2) gene expression and protein deposition were detected by real-time polymerase chain reaction (qPCR) and immunocytochemical analysis. RESULTS Mechanical loading significantly decreased AP, OC, and COL1A1 gene expression in both OBL and TDF, compared to non-loaded culture. However, mechanical load increased gene expression of the same marker genes including BMP-2 during co-culture. Immunocytochemistry demonstrated increased deposition of corresponding proteins in the same range, independent of culture conditions. Higher depositions of BMP-2 were shown under loading conditions for osteoblast and TDF monocultures. Prolongation of mechanical loading resulted in cell detachment and spheroid formation. CONCLUSION Cyclical mechanical loading caused downregulation of genes involved in osteointegration and osteoinduction, such as OC, ALP, and COL1A1 in monocultures of osteoblasts and fibroblasts; co-cultures lacked this phenomenon. Immunocytochemistry and qPCR analysis showed slight upregulations of marker genes and corresponding proteins. This might be due to the potential stabilising effects of osteoblast-fibroblast cross talk in the co-culture environment, simulating fibrocartilage formation at the tendon-to-bone interface.
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Affiliation(s)
- Johannes Struewer
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Baldingerstrasse, 35043, Marburg, Germany
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Chizari M, Wang B, Snow M, Barrett M. MECHANICAL ASPECTS OF A SINGLE-BUNDLE TIBIAL INTERFERENCE SCREW FIXATION IN A TENDON GRAFT ACL RECONSTRUCTION. BIOMEDICAL ENGINEERING: APPLICATIONS, BASIS AND COMMUNICATIONS 2012. [DOI: 10.4015/s101623721000202x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Numerical methods applicable to the tibia bone and soft tissue biomechanics of an anterior cruciate ligament (ACL) reconstructed knee are presented in this paper. The aim is to achieve a better understanding of the mechanics of an ACL reconstructed knee. The paper describes the methodology applied in the development of an anatomically detailed three-dimensional ACL reconstructed knee model for finite element analysis from medical image data obtained from a computed tomography scan. Density segmentation techniques are used to geometrically define the knee bone structure and the encapsulated soft tissues configuration. Linear and nonlinear elastic constitutive material models are implemented to mechanically characterize the behavior of the biological materials. Preliminary numerical results for the model qualitative evaluation are presented.
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Affiliation(s)
- Mahmoud Chizari
- School of Engineering, College of Physical Sciences, University of Aberdeen, Aberdeen, UK
| | - Bin Wang
- School of Engineering, College of Physical Sciences, University of Aberdeen, Aberdeen, UK
| | - Martyn Snow
- Department of Orthopaedics, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Mel Barrett
- School of MACE, University of Manchester, Manchester, UK
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Chizari M, Snow M, Wang B. Post-operative analysis of ACL tibial fixation. Knee Surg Sports Traumatol Arthrosc 2009; 17:730-6. [PMID: 19132350 DOI: 10.1007/s00167-008-0685-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 11/11/2008] [Indexed: 11/26/2022]
Abstract
The main aims of the study were to describe the mechanical behaviour of the bone and tendon graft in ACL reconstruction. We also wanted to evaluate the stresses upon the tendon and try to relate these to modes of healing observed in animal studies. An MRI scan of a knee from a 22-year-old male patient, 3 months post ACL reconstruction, was used to generate a finite element model for assessing the stresses on the tendon and bone. A 200 N force, equivalent to the force during normal gait, was placed on the graft and the stress distribution recorded. The maximum stress was found on the tendon graft at the proximal end of the tibial tunnel. Direct tendon healing, which has been observed in animal studies, maybe as a result of the increased stress in this area.
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Affiliation(s)
- Mahmoud Chizari
- School of Engineering, University of Aberdeen, Aberdeen, UK.
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A long-term study of anterior cruciate ligament allograft reconstruction. Knee Surg Sports Traumatol Arthrosc 2009; 17:818-22. [PMID: 19421736 DOI: 10.1007/s00167-009-0808-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2008] [Accepted: 04/06/2009] [Indexed: 12/20/2022]
Abstract
We retrospectively reviewed the long-term clinical outcome of unilateral arthroscopic anterior cruciate ligament (ACL) allograft reconstruction. From October 1995 to December 1997, 64 arthroscopic ACL reconstructions were performed. Multiligamentous knee injuries and ACL injuries in polytrauma patients were excluded and out of the remaining 60 patients 55 were available for follow-up. Three patients had suffered a rerupture caused by major trauma. One patient had a rerupture without significant trauma and one failure was caused by deep infection. These five patients were revised. Fifty patients (36 males, 14 females) were included in the final follow-up. At the time of evaluation, the mean duration of follow-up was 10 years and 6 months. All patients were examined by an independent examiner. Seven patients had an extension lag (<5 degrees) and all patients had a knee flexion of at least 120 degrees, with a mean flexion of 135 +/- 5 degrees compared to 135 +/- 8 degrees. At the time of follow-up, the median IKDC score was 97 (74-100). The Lysholm scoring scale had a median value of 95 (76-100). The median sports level on the Tegner scale was 6 (4-9). The one-leg-hop test showed a mean value of 95 +/- 5%. One patient did not perform the one-leg-hop test because of recent surgery to the Achilles tendon. In conclusion, the tibialis anterior or tibialis posterior tendon allograft ACL reconstruction produced good clinical results in the majority of patients at long-term follow-up.
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13
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Graft healing in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2008; 16:935-47. [PMID: 18633596 DOI: 10.1007/s00167-008-0584-0] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 06/30/2008] [Indexed: 12/21/2022]
Abstract
Graft healing within the bone tunnel after anterior cruciate ligament (ACL) reconstruction is still a complex, poorly understood biological process that is influenced by multiple surgical and postoperative variables. However, remarkable advances in knowledge of this process have been made based primarly on animal models. According to the findings of this review, some surgical and postoperative variables are known to directly affect time-course and quality of graft-tunnel healing. The type of graft, graft motion, and fixation methods have shown to directly affect time-course and quality of graft-tunnel healing. Therefore, the application of early and aggressive rehabilitation protocols should be cautious when using soft-tissue graft, allografts, and direct or aperture type of fixation for ACL reconstruction. With regard to graft placement, several cadaveric models showed biomechanical advantages of a more anatomical graft location; however, there are no studies that explore the relationship between graft placement and healing process. The precise effect of graft tensioning, graft/tunnel diameter disparity, and graft length within the bone tunnel in the graft healing process remains unclear and requires more research. To enhance graft-tunnel healing, tissue-engineering approaches, including the use of growth factors, mesenchymal stem cells, and periosteum graft augmentation, have been tested on animal models. These have shown promising results in terms of enhancement of bone-graft healing rate.
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Wang INE, Shan J, Choi R, Oh S, Kepler CK, Chen FH, Lu HH. Role of osteoblast-fibroblast interactions in the formation of the ligament-to-bone interface. J Orthop Res 2007; 25:1609-20. [PMID: 17676622 DOI: 10.1002/jor.20475] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The anterior cruciate ligament (ACL) inserts into bone through a characteristic fibrocartilagenous interface, which is essential for load transfer between soft and hard tissues. This multi-tissue interface is lost post ACL reconstruction, and the lack of an anatomic fibrocartilage interface between graft and bone remains the leading cause of graft failure. Currently, the mechanism of interface formation is not known. As a fibrocartilage-like tissue is found within the bone tunnel post ACL reconstruction, we hypothesize that fibroblast-osteoblast interactions at the graft-to-bone junction play a role in fibrocartilage formation. To test this hypothesis, a co-culture model permitting osteoblast-fibroblast communications was used to determine the effects of heterotypic interactions on cell phenotype and the development of fibrocartilage-relevant markers in vitro. It was found that co-culture decreased cell proliferation and osteoblast-mediated mineralization, while inducing fibroblast-mediated mineralization. Moreover, the expression of interface-relevant markers such as collagen type II and aggrecan were detected. Our findings suggest that osteoblast-fibroblast interactions may lead to cell trans-differentiation and eventual fibrocartilage formation. These results provide new insight into the mechanism of fibrocartilage formation, which are critical for interface tissue engineering and achieving biological fixation of soft tissue grafts to bone.
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Affiliation(s)
- I-Ning E Wang
- Biomaterials and Interface Tissue Engineering Laboratory, Department of Biomedical Engineering, Columbia University, 1210 Amsterdam Avenue, 351 Engineering Terrace Building, MC 8904, New York, New York 10027, USA
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Spalazzi JP, Doty SB, Moffat KL, Levine WN, Lu HH. Development of controlled matrix heterogeneity on a triphasic scaffold for orthopedic interface tissue engineering. ACTA ACUST UNITED AC 2007; 12:3497-508. [PMID: 17518686 DOI: 10.1089/ten.2006.12.3497] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Biological fixation of orthopedic soft tissue grafts to bone poses a significant clinical challenge. The clinical success of soft tissue-based grafts for anterior cruciate ligament (ACL) reconstruction is limited by the lack of functional graft integration with subchondral bone. Soft tissues such as the ACL connect to subchondral bone via a complex interface whereby three distinct tissue regions (ligament, fibrocartilage, and bone) work in concert to facilitate load transfer from soft to hard tissue while minimizing stress concentration at the interface. Although a fibrovascular tissue forms at the graft-to-bone interface following surgery, this tissue is nonphysiologic and represents a weak link between the graft and bone. We propose that the re-establishment of the native multi-tissue interface is essential for biological graft fixation. In vivo observations and our in vitro monolayer co-culture results suggest that osteoblast-fibroblast interaction is important for interface regeneration. This study focuses on the design of a triphasic scaffold system mimicking the multi-tissue organization of the native ACL-to-bone interface and the evaluation of osteoblast-fibroblast interactions during three-dimensional co-culture on the triphasic scaffold. We found that the triphasic scaffold supported cell proliferation, migration and phenotypic matrix production while maintaining distinct cellular regions and phase-specific extracellular matrix deposition over time. This triphasic scaffold is designed to guide the eventual reestablishment of an anatomically oriented and mechanically functional fibrocartilage interfacial region directly on biological and synthetic soft tissue grafts. The results of this study demonstrate the feasibility of multi-tissue regeneration on a single scaffold, and the potential of interface tissue engineering to enable the biological fixation of soft tissue grafts to bone.
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Affiliation(s)
- Jeffrey P Spalazzi
- Biomaterials and Interface Tissue Engineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, New York, USA
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16
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Steckel H, Starman JS, Baums MH, Klinger HM, Schultz W, Fu FH. The double-bundle technique for anterior cruciate ligament reconstruction: a systematic overview. Scand J Med Sci Sports 2006; 17:99-108. [PMID: 17076829 DOI: 10.1111/j.1600-0838.2006.00600.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In traditional anterior cruciate ligament reconstruction, there is a subset of patients complaining of knee instability, especially rotational instability, and athletes not able to return to their preinjury level of sports activity. Currently, controversy exists over the usefulness of the double bundle technique (DBT) in addressing these problems. In order to evaluate the DBT, we completed a literature review from 1969 to February 2006 focusing on anatomy, magnetic resonance imaging, graft incorporation, biomechanics, kinematics, surgical techniques, complications and outcome. The DBT is not a standardized technique, which makes it difficult to compare results. Cadaver studies have proven biomechanical advantages with respect to ap-stability, but assessing the rotational stability remains difficult. There is a lack of available outcome studies with sufficient follow-up to demonstrate the potential advantages of DBT. The theoretical advantages of DBT require careful evaluation with outcome, biomechanical and kinematic studies. In addition, studies are needed to address issues such as graft incorporation and complications. An advantage offered by DBT is the possibility to identify rupture patterns that can lead to surgical preservation of an intact and augmentation of an injured bundle. The approach of augmentating a single bundle technique reconstruction with adequate anterior-posterior but poor rotational stability is promising.
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Affiliation(s)
- H Steckel
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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Heyde CE, Wiechmann V, Pyschik M, Gosse A. [Histological findings for human tibial bone-tendon healing after hamstring transplantation. Investigation of tibial insertion after reconstruction of anterior cruciate ligaments with hamstring transplantation near joint fixation using bioresorbable interference screws]. Unfallchirurg 2006; 109:377-82. [PMID: 16607503 DOI: 10.1007/s00113-006-1064-y] [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: 11/25/2022]
Abstract
Ruptures of hamstring reconstructed anterior cruciate ligaments required additional surgery in five cases over a 4 year period. All transplants were primarily fixed with bioresorbable interference screws close to the joint. The average age was 31 years (range: 18-42), the average interval between primary surgery and rupture of the transplant was 13.2 months (range: 8-24) after an adequate re-trauma. After complete removal of the tibial insertion, a histological investigation was carried out. We stained the tissue-sections following the haematoxylin-eosin, Masson-Goldner and van Gieson protocols. All cases revealed direct healing with grow-over Sharpey-like fibers close to the joint, corresponding to a fibrous tendon insertion and far from the joint the formation of fibrous or cartilage callus.
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Affiliation(s)
- C-E Heyde
- Klinik für Unfall- und Wiederherstellungschirurgie, Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin.
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Harvey A, Thomas NP, Amis AA. Fixation of the graft in reconstruction of the anterior cruciate ligament. ACTA ACUST UNITED AC 2005; 87:593-603. [PMID: 15855357 DOI: 10.1302/0301-620x.87b5.15803] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- A Harvey
- Royal Bournemouth Hospital, Castle Lane, Bournemouth BH7 7DW, UK.
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Laxdal G, Kartus J, Hansson L, Heidvall M, Ejerhed L, Karlsson J. A prospective randomized comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction. Arthroscopy 2005; 21:34-42. [PMID: 15650664 DOI: 10.1016/j.arthro.2004.09.014] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using central-third, bone-patellar tendon-bone (BPTB group), 3-strand semitendinosus (ST group), or 4-strand semitendinosus/gracilis (ST/G group) autografts. TYPE OF STUDY Prospective randomized trial. METHODS A randomized series of 134 patients, all with unilateral ACL rupture was included in the study. In all 3 groups, interference screw fixation of the graft was used at both ends and 125 of 134 (93%) of the patients returned for the follow-up examination after 26 months (range, 20 to 43 months). The preoperative assessments in all 3 groups were similar in terms of gender, Tegner activity level, Lysholm score, KT-1000 measurements, 1-leg hop test, and the knee-walking test. RESULTS At follow-up, the knee-walking test was significantly worse in the BPTB group than in the ST group (P = .0004) and ST/G group (P < .0001). Furthermore, the knee-walking test was significantly worse at follow-up than preoperatively in the BPTB group (P < .0001). The corresponding findings were not made in the other 2 groups. A significant reduction in knee laxity and an increase in activity level compared with the preoperative assessments were found in all 3 groups, without any significant differences between the groups. CONCLUSIONS Two years after ACL reconstruction, the use of ST and ST/G autografts rendered significantly less discomfort during the knee-walking test than the use of BPTB autografts. However, in terms of functional outcome and knee laxity, the groups displayed no significant differences. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Gauti Laxdal
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg, Stockholm, Sweden
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Chen CH, Chen WJ, Shih CH, Chou SW. Arthroscopic anterior cruciate ligament reconstruction with periosteum-enveloping hamstring tendon graft. Knee Surg Sports Traumatol Arthrosc 2004; 12:398-405. [PMID: 15060762 DOI: 10.1007/s00167-004-0498-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2003] [Accepted: 01/07/2004] [Indexed: 01/16/2023]
Abstract
Tendon-bone incorporation of a tendon graft within the bone tunnel is of priority concern when using for anterior cruciate ligament (ACL) reconstruction. Superior healing process and stronger healing strength can be achieved when periosteum is sutured on the tendon inserted into a bone tunnel. We applied this idea to ACL reconstruction for enhancing tendon graft-bone tunnel healing. This is a prospective clinical outcome study with this surgical technique at minimal 2 years follow-up. Periosteum-enveloping hamstring tendon graft has been used in 68 patients. Data from 62 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of Lachman and anterior drawer test with a positive pivot-shift test. Clinical assessments included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented testing, thigh muscle assessment, and radiographic evaluation. The median Lysholm knee score was 59 (40-70) and 94 (60-100) points (P<0.01) before and after surgery. After reconstruction, 81% of patients were able to return to moderate or strenuous activity. Four (6%) patients were found to exhibit grade 2 or more ligament laxity. Complete range of motion could be achieved in 86% of patients. Three patients (5%) had positive pivot shift. Finally, 92% of patients were assessed as normal or nearly normal rating by IKDC guideline. Bone tunnels enlargement of more than 1 mm was identified in 5% of femoral tunnels and 6% of tibial tunnels. The study shows that a satisfactory result can be achieved with the periosteum-enveloping hamstring tendon graft in ACL reconstruction. Periosteum can be easily harvested at the proximal tibia from a routine incision for hamstring tendon harvesting. Besides the potential for improving tendon-bone healing, enveloped periosteum may help to seal the intra-articular tunnel opening in the early postoperative period, and thus avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be reduced.
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Affiliation(s)
- Chih-Hwa Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsin Street, Kweishan, 333 Taoyuan, Taiwan.
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Youn I, Jones DG, Andrews PJ, Cook MP, Suh JKF. Periosteal augmentation of a tendon graft improves tendon healing in the bone tunnel. Clin Orthop Relat Res 2004:223-31. [PMID: 15021159 DOI: 10.1097/00003086-200402000-00037] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Secure fixation of tendon or ligament to bone has been a challenging problem. The periosteum is an osteogenic organ that regulates bone growth and remodeling at the outer surface of cortical bone and also is known to play an important role in forming a tendon insertion site to bone. Therefore, we hypothesized that a freshly harvested periosteum can be used as a stimulative scaffold to biologically reinforce the attachment of tendon graft to bone. Using a rabbit hallucis longus tendon and calcaneus process model, we found that a periosteal augmentation of a tendon graft could enhance the structural integrity of the tendon-bone interface, when the periosteum is placed between the tendon and bone interface with the cambium layer facing toward the bone. Clinically, the use of an autogenous periosteum patch would be an optimal choice for biologic augmentation of the tendon graft in the bone tunnel, because the tissue is readily available for harvest from the patient's body.
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Affiliation(s)
- Inchan Youn
- Department of Biomedical Engineering, Tulane University, New Orleans, LA 70118, USA
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Robert H, Es-Sayeh J. The role of periosteal flap in the prevention of femoral widening in anterior cruciate ligament reconstruction using hamstring tendons. Knee Surg Sports Traumatol Arthrosc 2004; 12:30-5. [PMID: 13680104 DOI: 10.1007/s00167-003-0380-9] [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] [Received: 10/08/2002] [Accepted: 02/10/2003] [Indexed: 10/26/2022]
Abstract
Tunnel widening in anterior cruciate ligament reconstruction has been reported for many years, whatever the type of plasty (allo- or autograft) or graft (patellar or hamstring tendons). Recently, the hypothesis has been formulated that widening would be responsible for later laxity of the knees. Micromobility of the graft or biological factors are classically responsible for the enlargement. In order to improve the biological conditions around the graft within the tunnel, we have developed a surgical technique using a periosteal flap. The periosteal flap is harvested at the superior and medial metaphysis of the tibia and wrapped around the proximal part of the four strands of gracilis and semitendinosus tendons near the outlet of the femoral tunnel. Forty-one patients with isolated rupture of the ACL were included in a prospective and randomized study: the first group of 20 patients had femoral fixation by Transfix and resorbable screw, the second group of 21 patients had femoral fixation by Transfix and periosteal flap. The diameters of the tunnel were measured between the sclerotic margins at the tunnel entrance and 1 cm above, and compared to the peroperative drill size. The percentage change in diameter was calculated as: (tunnel diameter-drill size)/drill size. The two groups of patients were comparable as to gender, side, age, KT-1000 side to side difference, femoral tunnel diameter and follow-up. At 2.5 months and 11 months postoperatively on average, there was a significant reduction of enlargement at the outlet of the tunnel with the use of a periosteal flap but widening was constant.
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Affiliation(s)
- Henri Robert
- Centre Hospitalier du Nord Mayenne, 5 rue Roullois, 53100 Mayenne, France.
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Robert H, Es-Sayeh J, Heymann D, Passuti N, Eloit S, Vaneenoge E. Hamstring insertion site healing after anterior cruciate ligament reconstruction in patients with symptomatic hardware or repeat rupture: a histologic study in 12 patients. Arthroscopy 2003; 19:948-54. [PMID: 14608313 DOI: 10.1016/j.arthro.2003.09.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Our goal was to characterize the type of biologic anchor of hamstring tendons to the femoral tunnel in cases of transfixion fixation for the anterior cruciate ligament (ACL) reconstruction. The histologic bone-hamstring tendon anchorage is not yet clearly understood despite many experimental and some clinical studies. It constitutes the weak point of the ACL reconstruction. The type of fixation, either distant from the joint such as transfixion fixation or at the tunnel entrance such as aperture fixation will determine a specific tendon-bone healing process. TYPE OF STUDY Histological study. METHODS We performed ACL reconstruction with 4 strands of semitendinosus and gracilis tendons fastened by a transfixion fixation. Femoral fixation was secured by transfixion (Transfix; Arthrex, Naples, CA) and tibia fixation by a biodegradable interference screw and 2 staples. Between 3 and 20 months after surgery, we performed 12 hamstring tendon biopsies (in 9 men and 3 women; mean age, 29 years). Biopsies were performed 2 cm from the femoral outlet in 10 patients undergoing hardware removal or by coring the femoral tunnel in 2 cases of repeat rupture. In 8 cases, the femoral device was removed for persistent lateral pain, in 2 cases for instability of the hardware, and in 2 cases a repeat rupture of the graft occurred. The samples were taken by coring a tunnel 5 mm in diameter, with a tubular harvester, along the femoral Transfix axis. Each fragment was stained with H&E, Solochrome cyanine, or Masson-trichrome, and microscopical examination was performed, including polarized light. RESULTS At 3 months (in 1 case), a fibrovascular interface was seen between the tendon and uncalcified osteoid with very few collagen fibers. At 5 and 6 months (in 2 cases), some Sharpey-like fibers and less immature woven bone was seen. Maturity of the secondary insertion was seen after at least 10 months in 5 cases. In 2 cases, no contact was seen at the biopsy site despite good clinical stability. The 2 remaining cases underwent repeat rupture at the midsubstance of the graft at 12 and 17 months after surgery. In the first case, the tendon-bone fixation was limited at the outlet of the femoral tunnel with no fixation inside the tunnel. In the second case, the fixation was continuous with Sharpey fibers along the tunnel. CONCLUSIONS According to our histologic results in patients, the time to obtain a mature indirect anchorage at the top of the tunnel was 10 to 12 months, which is much longer than in reported animal models (6 to 24 weeks). To our knowledge, this is the first clinical study reporting the histologic type of femoral ligament insertion 2 cm from the outlet of the tunnel with hamstring autograft for ACL reconstruction.
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Affiliation(s)
- Henri Robert
- Centre Hospitalier du Nord Mayenne, Mayenne, France.
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Gobbi A, Tuy B, Mahajan S, Panuncialman I. Quadrupled bone-semitendinosus anterior cruciate ligament reconstruction: a clinical investigation in a group of athletes. Arthroscopy 2003; 19:691-9. [PMID: 12966375 DOI: 10.1016/s0749-8063(03)00685-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The hypothesis of our study was that a quadrupled bone-semitendinosus (STB) graft could provide a clinically stable construct, allow recovery of normal limb strength, give high patient satisfaction with early return to active sports, and involve low donor-site morbidity. TYPE OF STUDY Outcomes study. METHODS Anterior cruciate ligament (ACL) reconstruction with an STB graft was performed on 80 athletes with isolated ACL injury from January 1996 to December 1999. Femoral fixation was obtained with EndoButton (Smith & Nephew, Andover, MA) and tibial fixation with Fastlok (Neoligaments, Leeds, England). At a mean follow-up time of 36 months (range, 24-52 months), patients were evaluated using standard knee scores (Noyes, Lysholm, Tegner, and International Knee Documentation Committee [IKDC] rating) and functional strength tests; postoperative pain rating; knee radiographs performed after surgery and at final follow-up; magnetic resonance imaging (MRI) at 3 to 6 months; isokinetic flexion-extension and internal-external rotation tests at 3, 6, and 12 months; and computed laxity analysis at final evaluation. RESULTS At final evaluation, subjective knee rating was 87%, kneeling test was positive in 7%, and Werner score was 44 of 50 (range, 30-48). Lachman test was negative in 90% at final evaluation. Sensory changes were present in 30% at 3 months, and 10% had definite hyposthesia. Computed laxity analysis revealed 90% with less than 3 mm side-to-side difference. Isokinetic testing showed normal hamstring and quadriceps peak torques at 12 months. The one-leg hop test and vertical jump were normal by 6 months. At final evaluation, average Noyes score was 88 (range, 65-100); Lysholm score, 91 (range, 70-100); postoperative Tegner rating, 6.5 (range, 5-9); and preinjury Tegner rating, 7.5 (range, 7-10). IKDC score showed 72 knees normal or nearly normal, 7 abnormal, and 1 severely abnormal. Sixty-five percent of patients returned to the same preinjury sports level. CONCLUSIONS The quadrupled bone-semitendinosus graft is a viable graft for ACL reconstruction and should be considered, especially for patients with extensor mechanism problems.
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Affiliation(s)
- Alberto Gobbi
- Orthopaedic Arthroscopic Surgery International, Milano, Italy.
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Nebelung W, Becker R, Urbach D, Röpke M, Roessner A. Histological findings of tendon-bone healing following anterior cruciate ligament reconstruction with hamstring grafts. Arch Orthop Trauma Surg 2003; 123:158-63. [PMID: 12734713 DOI: 10.1007/s00402-002-0463-y] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2001] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of the study was the histological examination of tendon-bone healing of hamstring grafts after anterior cruciate ligament (ACL) reconstruction. METHODS During five arthroscopies done 6-14 months after ACL reconstructions, biopsies of the wall of the former drilled femoral canal were obtained. Four patients were primarily operated on using a suspending device (Endobutton, Acufex Microsurgical, Mansfield, MA, USA, and Transfix, Arthrex, Naples, FL, USA) for femoral fixation, one patient was reconstructed with a biodegradable interference screw directly inserted between the tendon and the wall of the canal. Biopsies were obtained using a tube harvester during re-arthroscopy. Three grafts were stable, two grafts were unstable, and revision of the ACL was performed. RESULTS Histologically, in the four cases of reconstruction with a button or a rectangular pin, biopsies resembled granulation tissue without insertion of fibers between the tendon tissue and the bony wall. A wide area of woven bone was noted adjacent to the pre-existing lamellar bone. In contrast, the tendon-bone junction in the knee reconstructed with a biodegradable interference screw resembled a zone of metaplastic fibrous cartilage between the tendon graft and the lamellar bone. Collagen fibers connecting the tendon-bone interface occurred under polarized light microscopy. CONCLUSION We conclude that the use of hamstring grafts for ACL reconstruction can lead to different histological pattern of tendon-bone healing. Micromotion of the hamstring graft inside the drilled canal can be play a role in tendon-bone healing.
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Affiliation(s)
- W Nebelung
- Marienkrankenhaus Düsseldorf-Kaiserswerth, An St Swidbert 17, 40489 Düsseldorf, Germany.
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Yamakado K, Kitaoka K, Nakamura T, Yamada H, Hashiba K, Nakamura R, Tomita K. Histologic analysis of the tibial bone tunnel after anterior cruciate ligament reconstruction using solvent-dried and gamma-irradiated fascia lata allograft. Arthroscopy 2001; 17:32. [PMID: 11600972 DOI: 10.1053/jars.2001.24694] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Anterior cruciate ligament (ACL) reconstruction using free tendon graft requires biologic fixation in the bone tunnel. This report describes the intratunnel histology retrieved from a 47-year-old woman who underwent high tibial osteotomy 17 months after ACL reconstruction using a hybrid graft (a solvent-dried and gamma-irradiated fascia lata allograft as a core wrapped with iliotibial autograft). The patient underwent revision because of pain resulting from osteoarthrotic change, and the graft appeared to be taut and healthy on second-look arthroscopy. The sample was taken from the site of the metaphyseal osteotomy site. Histologic examination of the samples was performed with a light microscope (H&E and Masson trichrome stain). Biologic fixation of the graft to the bone was evident from observation of collagen fiber continuities, resembling Sharpey fibers. Integration of the autograft and allograft seemed to have occurred; the junction between the allograft and the autograft could not be determined. However, there was a difference in ligamentization depending on location. In the peripheral region of the graft (the autograft region), the collagen fibers showed a distinct crimped pattern; the fibroblasts were arranged regularly along the major axis of the collagen fiber bundle. In the central part of the graft (the allograft region), remodeling seemed to be delayed. There were acellular, bubbly or myxoid degeneration areas in which the fiber bundles were less oriented and there was increased vascularity.
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Affiliation(s)
- K Yamakado
- Department of Orthopaedic Surgery, School of Medicine, Kanazawa University, Kanazawa, Japan.
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