Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
Knee Surgery, Sports Traumatology, Arthroscopy
Published in: Knee Surgery, Sports Traumatology, Arthroscopy 5/2012

01-05-2012 | Knee

Graft-dependent differences in the ligamentization process of anterior cruciate ligament grafts in a sheep trial

Authors: Hermann O. Mayr, Amelie Stoehr, Markwart Dietrich, Rüdiger von Eisenhart-Rothe, Robert Hube, Senta Senger, Norbert P. Suedkamp, Anke Bernstein

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 5/2012

Login to get access

Abstract

Purpose

The structural properties of the healing ligament are the determining factor for the stability of the reconstruction before, during, and after osseous integration of anterior cruciate ligament grafts. Over the course of ligamentization, the stability of synovialized grafts seems lower than that of non-synovialized patellar tendon grafts.

Methods

In an animal study on 42 sheep, 21 non-synovialized grafts (patellar tendon) and 21 synovialized grafts (flexor digitorum superficialis tendon) were performed to replace the anterior cruciate ligament. After 6, 12, and 24 weeks, 7 animals from each group were euthanized and investigated. Anteroposterior stability of the knee was assessed. After removal of all other soft tissues, the ACL was loaded to failure. Histology and histological analysis of the intra-articular graft region was then performed.

Results

There were no significant differences in the translation test comparing synovialized and non-synovialized grafts. After 6, 12, and 24 weeks, all transplants failed in the tensile test due to interligamentous rupture or avulsion. After 6 weeks, transplants did not show significant biomechanical differences. Load to failure and stiffness of the patellar tendon was more than twice those of synovialized tendon (P = 0.002) after 12 weeks. Histology revealed necrosis in patellar tendon specimens after 12 weeks. A significant increase in load to failure was determined in synovialized ligament grafts between 12 and 24 weeks (P = 0.005). Its load capacity then tended to be higher than that of patellar tendon grafts.

Conclusion

The stability of synovialized ligament grafts is significantly lower than that of non-synovialized patellar tendon grafts after 12 weeks. This difference is compensated after 24 weeks. The significantly lower load to failure of synovialized compared with non-synovialized grafts after 12 weeks may be clinically relevant for the rehabilitation process of anterior cruciate ligament grafts in humans.
Literature
1.
Abe S, Kurosaka M, Iguchi T, Yoshiya S, Hirohata K (1993) Light and electron microscopic study of remodeling and maturation process in autogenous graft for anterior cruciate ligament reconstruction. Arthroscopy 9(4):394–405PubMedCrossRef
2.
Andersson D, Samuelsson K, Karlsson J (2009) Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials. Arthroscopy 25(6):653–685PubMedCrossRef
3.
Bosch U, Kasperczyk WJ (1992) Healing of the patellar tendon autograft after posterior cruciate ligament reconstruction—a process of ligamentization? An experimental study in a sheep model. Am J Sports Med 20(5):558–566PubMedCrossRef
4.
Bradley JP, Klimkiewicz JJ, Rytel MJ, Powell JW (2002) Anterior cruciate ligament injuries in the National Football League: epidemiology and current treatment trends among team physicians. Arthroscopy 18(5):502–509PubMedCrossRef
5.
Claes S, Verdonk P, Forsyth R, Bellemans J (2011) The “Ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med 22 (PubMed PMID: 21515806)
6.
Claes L (1994) Empfehlung für tierexperimentelle Untersuchungen zum Bandersatz. Hefte zu der Unfallchirurg 234:206–210
7.
Dhert WJ, Thomsen P, Blomgren AK, Esposito M, Ericson LE, Verbout AJ (1998) Integration of press-fit implants in cortical bone: a study on interface kinetics. J Biomed Mater Res 41:574–583PubMedCrossRef
8.
Dürselen L, Häfner M, Ignatius A, Kraft K, Hollstein E, Pokar S, Dauner M, Claes L, Friemert B (2006) Biological response to a new composite polymer augmentation device used for cruciate ligament reconstruction. J Biomed Mater Res B Appl Biomater 76(2):265–272PubMed
9.
Falconiero RP, DiStefano VJ, Cook TM (1998) Revascularization and ligamentization of autogenous anterior cruciate ligament grafts in humans. Arthroscopy 14(2):197–205PubMedCrossRef
10.
Faul F, Erdfelder E, Lang AG, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39(2):175–191PubMedCrossRef
11.
12.
Hunt P, Rehm O, Weiler A (2006) Soft tissue graft interference fit fixation: observations on graft insertion site healing and tunnel remodeling 2 years after ACL reconstruction in sheep. Knee Surg Sports Traumatol Arthrosc 14(12):1245–1251PubMedCrossRef
13.
Hunt P, Scheffler SU, Unterhauser FN, Weiler A (2005) A model of soft-tissue graft anterior cruciate ligament reconstruction in sheep. Arch Orthop Trauma Surg 125(4):238–248PubMedCrossRef
14.
Jansen JA, Dhert WJ, van der Waerden JP, von Recum AF (1994) Semi-quantitative and qualitative histologic analysis method for the evaluation of implant biocompatibility. J Invest Surg 7:123–134PubMedCrossRef
15.
Janssen RP, van der Wijk J, Fiedler A, Schmidt T, Sala HA, Scheffler SU (2011) Remodelling of human hamstring autografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19(8):1299–1306PubMedCrossRef
16.
Johnson LL (1993) The outcome of a free autogenous semitendinosus tendon graft in human anterior cruciate reconstructive surgery: a histological study. Arthroscopy 9(2):131–142PubMedCrossRef
17.
Kartus J, Movin T, Karlsson J (2001) Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy 17(9):971–980PubMedCrossRef
18.
Marumo K, Saito M, Yamagishi T, Fujii K (2005) The “ligamentization” process in human anterior cruciate ligament reconstruction with autogenous patellar and hamstring tendons: a biochemical study. Am J Sports Med 33(8):1166–1173PubMedCrossRef
19.
Mayr HO, Dietrich M, Fraedrich F, Hube R, Nerlich A, von Eisenhart-Rothe R, Hein W, Bernstein A (2009) Microporous pure beta-tricalcium phosphate implants for press-fit fixation of anterior cruciate ligament grafts: strength and healing in a sheep model. Arthroscopy 25(9):996–1005PubMedCrossRef
20.
Mayr HO, Hube R, Bernstein A, Seibt AB, Hein W, von Eisenhart-Rothe R (2007) Beta-tricalcium phosphate plugs for press-fit fixation in ACL reconstruction-a mechanical analysis in bovine bone. Knee 14(3):239–244PubMedCrossRef
21.
Mayr HO, Beck T, Hube R, Jäger A, von Eisenhart-Rothe R, Bernstein A, Plitz W, Hein W (2005) Axial load in case of press-fit fixation of the ACL graft—a fundamental study. Z Orthop Ihre Grenzgeb 143(5):556–560PubMedCrossRef
22.
Meller R, Brandes G, Drögemüller C, Fritz F, Schiborra F, Fehr M, Hankemeier S, Krettek C, Hurschler C (2009) Graft remodeling during growth following anterior cruciate ligament reconstruction in skeletally immature sheep. Arch Orthop Trauma Surg 129(8):1037–1046PubMedCrossRef
23.
Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS (1984) Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Jt Surg Am 66(3):344–352
24.
O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL (1991) Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Jt Surg Am 73(2):278–286
25.
Papageorgiou CD, Ma CB, Abramowitch SD, Clineff TD, Woo SL (2001) A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med 29(5):620–626PubMed
26.
Pendegrass CJ, Oddy MJ, Cannon SR, Briggs T, Goodship AE, Blunn GW (2004) A histomorphological study of tendon reconstruction to a hydroxyapatite-coated implant: regeneration of a neo-enthesis in vivo. J Orthop Res 22(6):1316–1324PubMedCrossRef
27.
Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J (2007) A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med 35(4):564–574PubMedCrossRef
28.
Radford WJP, Amis AA, Stead AC (1996) The ovine stifle as a model for human cruciate ligament surgery. Vet Comp Orthop Traumatol 9:134–139
29.
Risberg MA, Holm I (2009) The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up. Am J Sports Med 37(10):1958–1966PubMedCrossRef
30.
Romeis B, Böck P (1989) Mikroskopische Technik. 17. Auflage. Urban u. Schwarzenberg, München
31.
Rougraff B, Shelbourne KD, Gerth PK, Warner J (1993) Arthroscopic and histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med 21(2):277–284PubMedCrossRef
32.
Sánchez M, Anitua E, Azofra J, Prado R, Muruzabal F, Andia I (2010) Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology. Arthroscopy 26(4):470–480PubMedCrossRef
33.
Scheffler SU, Unterhauser FN, Weiler A (2008) Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16(9):834–842PubMedCrossRef
34.
Scheffler SU, Schmidt T, Gangéy I, Dustmann M, Unterhauser F, Weiler A (2008) Fresh-frozen free-tendon allografts versus autografts in anterior cruciate ligament reconstruction: delayed remodeling and inferior mechanical function during long-term healing in sheep. Arthroscopy 24(4):448–458PubMedCrossRef
35.
Scheffler SU, Südkamp NP, Göckenjan A, Hoffmann RF, Weiler A (2002) Biomechanical comparison of hamstring and patellar tendon graft anterior cruciate ligament reconstruction techniques: the impact of fixation level and fixation method under cyclic loading. Arthroscopy 18(3):304–315PubMedCrossRef
36.
Scranton PE Jr, Lanzer WL, Ferguson MS, Kirkman TR, Pflaster DS (1998) Mechanisms of anterior cruciate ligament neovascularization and ligamentization. Arthroscopy 14(7):702–716PubMedCrossRef
37.
Shelbourne KD, Patel DV (1999) Treatment of limited motion after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 7(2):85–92PubMedCrossRef
38.
Shelbourne KD, Gray T (1997) Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two-to nine-year followup. Am J Sports Med 25(6):786–795PubMedCrossRef
39.
Schumacher M, Schulgen G (2002) Methodik klinischer Studien: Methodische Grundlagen der Planung, Durchführung und Auswertung. Springer, Berlin, pp 43–45 (ISBN 3-540-43306-6)
40.
van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ (2010) Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18(8):1128–1144PubMedCrossRef
41.
Weiler A, Peine R, Pashmineh-Azar A, Abel C, Südkamp NP, Hoffmann RF (2002) 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 18(2):113–123PubMedCrossRef
42.
Weiler A, Hoffmann RF, Bail HJ, Rehm O, Südkamp NP (2002) Tendon healing in a bone tunnel. Part II: histologic analysis after biodegradable interference fit fixation in a model of anterior cruciate ligament reconstruction in sheep. Arthroscopy 18(2):124–135PubMedCrossRef
43.
Wissing H, Stürmer KM, Breidenstein G (1990) Die Wertigkeit verschiedener Versuchstierspezies für experimentelle Untersuchungen am Knochen. Hefte zur Unfallheilkunde, Heft, 212: 479–488
44.
Zaffagnini S, De Pasquale V, Marchesini Reggiani L, Russo A, Agati P, Bacchelli B, Marcacci M (2010) Electron microscopy of the remodelling process in hamstring tendon used as ACL graft. Knee Surg Sports Traumatol Arthrosc 18(8):1052–1058PubMedCrossRef
Metadata
Title
Graft-dependent differences in the ligamentization process of anterior cruciate ligament grafts in a sheep trial
Authors
Hermann O. Mayr
Amelie Stoehr
Markwart Dietrich
Rüdiger von Eisenhart-Rothe
Robert Hube
Senta Senger
Norbert P. Suedkamp
Anke Bernstein
Publication date
01-05-2012
Publisher
Springer-Verlag
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 5/2012
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-011-1678-7

Other articles of this Issue 5/2012

Knee Surgery, Sports Traumatology, Arthroscopy 5/2012 Go to the issue

Knee

Tension band wire fixation for anterior cruciate ligament avulsion fracture: biomechanical comparison of four fixation techniques

Shoulder

Long-term outcomes after repair of recurrent post-traumatic anterior shoulder instability: comparison of arthroscopic transglenoid suture and open Bankart reconstruction

Knee

History, clinical findings, magnetic resonance imaging, and arthroscopic correlation in meniscal lesions

Knee

Patellofemoral and tibiofemoral articular cartilage and subchondral bone health following arthroscopic partial medial meniscectomy

Knee

Static rotational and sagittal knee laxity measurements after reconstruction of the anterior cruciate ligament

Knee

Analysis of failed surgery for patellar instability in children with open growth plates