Abstract
Using soft tissue grafts for anterior cruciate ligament (ACL) reconstruction, insertion site healing plays a crucial role in the long-term fate of the graft. It has been shown in an experimental animal study that using a soft tissue graft and anatomic graft fixation, a direct ligamentous insertion alike the native ACL developed 24 weeks postoperatively. Yet there are no reports on the long-term insertion site healing of anatomically fixed soft tissue grafts. The objective of this study was to evaluate graft insertion site healing, the intra-tunnel fate of the graft and its osseous replacement 2 years after ACL reconstruction in sheep. The left ACLs of six sheep were replaced by an autologous flexor tendon split graft and anatomically fixed with biodegradable poly-(d, l-lactide) interference screws. Animals received polychromic sequential labeling at different points in time to determine bone apposition per period. For evaluation of the insertion site healing and intra-tunnel changes, MRI scans were taken in vivo. Following sacrifice, radiographic imaging, conventional histology and fluorescence microscopy was undertaken. Most of the specimens showed a wide direct ligamentous insertion. It showed patterns alike the direct ligament insertion seen in intact ACLs. The intra-tunnel part of the graft had completely lost its tendon-like structure and in two cases, it was separated from the graft insertion by a thick bony layer. The biodegradable interference screw was fully degraded in all specimens. Ossification of the former drill tunnels was intense, showing only partial-length tunnel remnants in one femoral and three tibial specimens. As the graft heals to the joint surface and the aperture site is closed with soft tissue, mechanical stress of the intra-tunnel part of the graft is eliminated and the bone tunnel is protected from synovial fluid, resulting in osseous bridging of the tunnel aperture site, accelerated intra-tunnel graft resorption and its osseous replacement.
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References
Aglietti P, Zaccherotti G, Simeone AJ, Buzzi R (1998) Anatomic versus non-anatomic tibial fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Knee Surg Sports Traumatol Arthrosc 6:43–48
Becker W (1971) Electronmicroscopic studies of tendon insertion into bones. Arch Orthop Unfallchir 69:315–329
Biermann H (1956) Die Knochenbildung im Bereich periostaler-diaphysärer Sehnen- und Bandansätze. Z Zellforsch 46:635–671
Buelow JU, Siebold R, Ellermann A (2002) A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: extracortical versus anatomical fixation. Knee Surg Sports Traumatol Arthrosc 10:80–85
Clatworthy MG, Annear P, Bulow JU, Bartlett RJ (1999) Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports Traumatol Arthrosc 7:138–145
Cooper RR, Misol S (1970) Tendon and ligament insertion. A light and electron microscopic study. J Bone Joint Surg Am 52:1–20
Dolgo-Saburoff B (1929) Über Ursprung und Insertion der Skelettmuskeln. Anat Anz 68:80–87
Fahey M, Indelicato PA (1994) Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 22:410–414
Fink C, Zapp M, Benedetto KP, Hackl W, Hoser C, Rieger M (2001) Tibial tunnel enlargement following anterior cruciate ligament reconstruction with patellar tendon autograft. Arthroscopy 17:138–143
Fules PJ, Madhav RT, Goddard RK, Newman-Sanders A, Mowbray MA (2003) Evaluation of tibial bone tunnel enlargement using MRI scan cross-sectional area measurement after autologous hamstring tendon ACL replacement. Knee 10:87–91
Höher J, Moller HD, Fu FH (1998) Bone tunnel enlargement after anterior cruciate ligament reconstruction: fact or fiction? Knee Surg Sports Traumatol Arthrosc 6:231–240
Hunt P, Scheffler SU, Unterhauser FN, Weiler A (2004) A model of soft-tissue graft anterior cruciate ligament reconstruction in sheep. Arch Orthop Trauma Surg 16:16
Hurov JR (1986) Soft-tissue bone interface: how do attachments of muscles, tendons, and ligaments change during growth? A light microscopic study. J Morphol 189:313–325
Kernwein GA (1942) A study of tendon implantations into bone. Surg Gynecol Obstet 75:794–796
Knese K-H, Biermann H (1958) Die Knochenbildung an Sehnen und Bandansätzen im Bereich ursprünglich chondraler Apophysen. Z Zellforsch 49:142–187
L’Insalata JC, Klatt B, Fu FH, Harner CD (1997) Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc 5:234–238
Logan M, Williams A, Myers P (2003) Is bone tunnel osseointegration in hamstring tendon autograft anterior cruciate ligament reconstruction important? Arthroscopy 19:E1–3
Nagano M, Yoshia S, Kuroda R, Kurosaka M, Mizuno K (1997) Remodeling and healing process of bone- patellar tendon- bone graft in a bone tunnel: a histological study in dogs.43 rd Meeting of the Orthopaedic Reseach Society, San Francisco, CA. Trans Orthop Res Soc 22:78
Nebelung W, Becker R, Merkel M, Ropke M (1998) Bone tunnel enlargement after anterior cruciate ligament reconstruction with semitendinosus tendon using Endobutton fixation on the femoral side. Arthroscopy 14:810–815
Otsuka H, Ishibashi Y, Tsuda E, Sasaki K, Toh S (2003) Comparison of three techniques of anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Differences in anterior tibial translation and tunnel enlargement with each technique. Am J Sports Med 31:282–288
Peyrache MD, Djian P, Christel P, Witvoet J (1996) Tibial tunnel enlargement after anterior cruciate ligament reconstruction by autogenous bone-patellar tendon-bone graft. Knee Surg Sports Traumatol Arthrosc 4:2–8
Pinczewski LA, Clingeleffer AJ, Otto DD, Bonar SF, Corry IS (1997) Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament. Arthroscopy 13:641–643
Rahn B (1976) [Die polychrome Sequenzmarkierung des Knochens]. Nova Acta Leopol 44:249–255
Rahn B, Perren S (1971) Xylenol orange: A fluorochrome useful in polychrome sequential labelling of calcifying tissue. Stain Technol 46:125–129
Robert H, Es-Sayeh J, Heymann D, Passuti N, Eloit S, Vaneenoge E (2003) Hamstring insertion site healing after anterior cruciate ligament reconstruction in patients with symptomatic hardware or repeat rupture: a histologic study in 12 patients. Arthroscopy 19:948–954
Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF (1993) Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 75:1795–1803
Sakai H, Yajima H, Hiraoka H, Fukuda A, Hayashi M, Tamai K, Saotome K (2003) The influence of tibial fixation on tunnel enlargement after hamstring tendon anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 6:6
Schneider H (1956) Zur Struktur der Sehnenansatzzonen. Z Anat 119:431–456
Webster KE, Feller JA, Hameister KA (2001) Bone tunnel enlargement following anterior cruciate ligament reconstruction: a randomised comparison of hamstring and patellar tendon grafts with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 9:86–91
Weiler A, Hoffmann RF, Bail HJ, Rehm O, Sudkamp 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 18:124–135
Weiler A, Peine R, Pashmineh-Azar A, Abel C, Sudkamp 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 18:113–123
Weiler A, Peters G, Mäurer J, Unterhauser FN, Südkamp NP (2001) 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 29:751–761
Weiler A, Unterhauser FN, Faensen B, Hunt P, Bail HJ, Haas NP (2002) Comparison of tendon-to-bone healing using extracortical and anatomic interference fit fixation of soft tissue grafts in a sheep model of acl reconstruction.48th Annual Meeting of the Orthopaedic Reseach Society, Dallas, TX, USA. Trans Orthop Res Soc 27:173
Zysk SP, Fraunberger P, Veihelmann A, Dorger M, Kalteis T, Maier M, Pellengahr C, Refior HJ (2003) Tunnel enlargement and changes in synovial fluid cytokine profile following anterior cruciate ligament reconstruction with patellar tendon and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc 20:20
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Hunt, P., Rehm, O. & Weiler, A. 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, 1245–1251 (2006). https://doi.org/10.1007/s00167-006-0082-1
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DOI: https://doi.org/10.1007/s00167-006-0082-1