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      Ligamentization of Autogenous Hamstring Grafts After Anterior Cruciate Ligament Reconstruction : Midterm Versus Long-term Results

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          Abstract

          In previous studies, unimodal, small-diameter collagen fibrils have been commonly observed as the final collagen ultrastructure of the implanted grafts used in anterior cruciate ligament (ACL) reconstruction. However, the native ACL and hamstring tendon show bimodal collagen fibril distribution, consisting of both large- and small-diameter collagen fibrils.

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          Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology.

          Mikel Sánchez, Eduardo Anitua, Juan Azofra … (2010)
          To investigate whether the application of a particular platelet-rich plasma preparation rich in growth factors (PRGF) during anterior cruciate ligament (ACL) surgery gives a potential advantage for better tendon graft ligamentization. This study included 37 volunteers who underwent either conventional (control group, n = 15) or PRGF-assisted (n = 22) ACL reconstruction with an autogenous hamstring and required second-look arthroscopy to remove hardware or loose bodies, treat meniscal tears or plica syndrome, or resect cyclops lesions at 6 to 24 months after ACL surgery. The gross morphologies of the grafts were evaluated on second-look arthroscopy by use of the full arthroscopic score (0 to 4 points) to evaluate graft thickness and apparent tension (0 to 2 points) plus synovial coverage (0 to 2 points). At the same time, biopsy specimens were harvested uniformly from the grafted tendons. In these specimens the histologic transformation of the tendon graft to ACL-like tissue was evaluated by use of the Ligament Tissue Maturity Index, and a score to assess the progression of new connective tissue enveloping the graft was created by use of 3 criteria previously used to characterize changes during ligament healing: cellularity, vascularity, and collagen properties. The overall arthroscopic evaluation of PRGF-treated grafts showed an excellent rating in 57.1% of the knees (score of 4) and a fair rating in 42.9% (score of 2 or 3). In contrast, evaluation of untreated grafts showed an excellent rating in 33.3% of the knees, a fair rating in 46.7%, and a poor rating in 20% (score of 0 or 1). Overall, arthroscopic evaluations were not statistically different between PRGF and control groups (P = .051). PRGF treatment influenced the histologic characteristics of the tendon graft, resulting in tissue that was more mature than in controls (P = .024). Histologically evident newly formed connective tissue enveloping the graft was present in 77.3% of PRGF-treated grafts and 40% of controls. The appearance of the connective tissue envelope changed with increasing time from surgery. On the basis of the histologic findings, we suggest that the remodeling of PRGF-treated grafts involves the formation of synovial-like tissue enveloping the graft. This tissue is eventually integrated in the remodeled tendon graft, conferring a similar appearance to the normal ACL. The use of PRGF influenced the histologic characteristics of tendon grafts, resulting in more remodeling compared with untreated grafts. We have shown temporal histologic changes during the 6- to 24-month postoperative period of graft maturation, with newly formed connective tissue enveloping most grafts treated with PRGF. Level III, case-control study. Copyright 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
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            A Comparison of the Size Distribution of Collagen Fibrils in Connective Tissues as a Function of Age and a Possible Relation between Fibril Size Distribution and Mechanical Properties

            G. Barnes, A. S. Craig, D. A. D. Parry (1978)
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              Surgery for anterior cruciate ligament deficiency: a historical perspective.

              Oliver Schindler (2011)
              The anterior cruciate ligament (ACL) has entertained scientific minds since the Weber brothers provided biomechanical insight into the importance of the ACL in maintaining normal knee kinematics. Robert Adams described the first clinical case of ACL rupture in 1837 some 175 years to date, followed by Mayo-Robson of Leeds who performed the first ACL repair in 1895. At that time, most patients presented late and clinicians started to appreciate signs and symptoms and disabilities associated with such injuries. Hey Groves of Bristol provided the initial description of an ACL reconstruction with autologous tissue graft in 1917, almost as we know it today. His knowledge and achievements were, however, not uniformly appreciated during his life time. What followed was a period of startling ingenuity which created an amazing variety of different surgical procedures often based more on surgical fashion and the absence of a satisfactory alternative than any indication that continued refinements were leading to improved results. It is hence not surprising that real inventors were forgotten, good ideas discarded and untried surgical methods adopted with uncritical enthusiasm only to be set aside without further explanation. Over the past 100 years, surgeons have experimented with a variety of different graft sources including xenograft, and allografts, whilst autologous tissue has remained the most popular choice. Synthetic graft materials enjoyed temporary popularity in the 1980 and 1990s, in the misguided belief that artificial ligaments may be more durable and better equipped to withstand stresses and strains. Until the 1970s, ACL reconstructions were considered formidable procedures, often so complex and fraught with peril that they remained reserved for a chosen few, never gaining the level of popularity they are enjoying today. The increasing familiarity with arthroscopy, popularised through Jackson and Dandy, and enhancements in surgical technology firmly established ACL reconstruction as a common procedure within the realm of most surgeons' ability. More recently, the principle of anatomic ACL reconstruction, aiming at the functional restoration of native ACL dimensions and insertion sites, has been introduced, superseding the somewhat ill-advised concept of isometric graft placement. Double-bundle reconstruction is gaining in popularity, and combined extra- and intra-articular procedures are seeing a revival, but more accurate and reliable pre- and post-operative assessment tools are required to provide customised treatment options and appropriate evaluation and comparability of long-term results. Modern ACL surgery is united in the common goal of re-establishing joint homoeostasis with normal knee kinematics and function which may ultimately assist in reducing the prevalence of post-operative joint degeneration. This review hopes to provide an insight into the historical developments of ACL surgery and the various controversies surrounding its progress. Level of evidence V.
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                Author and article information

                Journal
                Title: The American Journal of Sports Medicine
                Abbreviated Title: Am J Sports Med
                Publisher: SAGE Publications
                ISSN (Print): 0363-5465
                ISSN (Electronic): 1552-3365
                Publication date Created: July 31 2015
                Publication date (Electronic): June 2015
                Publication date (Print): August 2015
                Volume: 43
                Issue: 8
                Pages: 1908-1917
                Affiliations
                [1 ]Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China.
                Article
                DOI: 10.1177/0363546515584039
                PubMed ID: 26033971
                SO-VID: 5207af0c-8205-4645-803c-b20f37be2931
                Copyright © © 2015
                License:

                http://journals.sagepub.com/page/policies/text-and-data-mining-license

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