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J Knee Surg 2021; 34(05): 561-569
DOI: 10.1055/s-0039-1700842
Original Article

The Effects of Tensioning of the Anterior Cruciate Ligament Graft on Healing after Soft Tissue Reconstruction

Richard Ma
1   Missouri Orthopaedic Institute, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
,
Michael Schaer
2   Department of Orthopaedic Surgery and Traumatology, Shoulder, Elbow and Orthopaedic Sports Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
,
Tina Chen
1   Missouri Orthopaedic Institute, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
,
Joseph Nguyen
3   Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York
,
Clifford Voigt
4   Department of Orthopaedic Surgery, Lennox Hill Hospital, New York
,
Xiang-Hua Deng
3   Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York
5   Tissue Engineering, Repair, and Regeneration Program, Hospital for Special Surgery, New York
,
Scott A. Rodeo
3   Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York
5   Tissue Engineering, Repair, and Regeneration Program, Hospital for Special Surgery, New York
› Author Affiliations Funding The study was funded by the Orthopaedic Research and Education Foundation. Portions of the study have been presented at Orthopaedic Research Society Annual Meeting.
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Abstract

The purpose of this study is to determine the effect of the magnitude of static mechanical tension on the anterior cruciate ligament (ACL) graft at the time of surgery on healing within the graft tunnels. Ninety male rats underwent unilateral ACL resection followed by reconstruction with a soft tissue tendon autograft. The ACL graft mechanical environment was modulated by different ACL graft pretension levels at the time of surgery (no pretension: 0N; moderate tension: 5N; over tension: 10N). External fixators were used to eliminate graft and joint motion during cage activity. Graft–tunnel healing was assessed at 3- and 6-week postoperatively, and articular joint surfaces were assessed at 9 weeks. Our results demonstrate that the ACL graft–tunnel healing was sensitive to different static graft pretension levels as demonstrated by different load-to-failure and stiffness properties among the different pretension levels. Pretensioning the graft to 5N (7–8% of the rat ACL ultimate load to failure) resulted in the best graft–tunnel healing as shown by higher graft–tunnel failure load and stiffness. Higher bone volume fraction was also seen in the 5N group relative to other pretension levels. Histological analysis of the graft–tunnel interface revealed differences in cellularity of the ACL graft between the 5N group and the other two groups. Furthermore, the highest graft pretension level (10N) resulted in loss of proteoglycan content among articular joint surfaces. In conclusion, we found that ACL graft–tunnel healing is sensitive to the magnitude of graft pretension at the time of surgery in a preclinical model of ACL reconstruction with joint immobilization. The combination of high-graft tension and immobilization is also deleterious for the articular surface. Further study is necessary to understand the interaction between the magnitude of graft tensioning and joint motion.

Keywords

anterior cruciate ligament healing - graft healing - graft pretension - bone tunnel healing - anterior cruciate ligament


Publication History

Received: 31 January 2019

Accepted: 18 September 2019

Article published online:
04 November 2019

© 2019. Thieme. All rights reserved.

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  • References

  • 1 Abramowitch SD, Papageorgiou CD, Withrow JD, Gilbert TW, Woo SL. The effect of initial graft tension on the biomechanical properties of a healing ACL replacement graft: a study in goats. J Orthop Res 2003; 21 (04) 708-715
    CrossrefPubMedGoogle Scholar
  • 2 Arneja S, McConkey MO, Mulpuri K. et al. Graft tensioning in anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Arthroscopy 2009; 25 (02) 200-207
    CrossrefPubMedGoogle Scholar
  • 3 Heis FT, Paulos LE. Tensioning of the anterior cruciate ligament graft. Orthop Clin North Am 2002; 33 (04) 697-700
    CrossrefPubMedGoogle Scholar
  • 4 Mae T, Shino K, Nakata K. et al. Optimization of graft fixation at the time of anterior cruciate ligament reconstruction. Part I: effect of initial tension. Am J Sports Med 2008; 36 (06) 1087-1093
    CrossrefPubMedGoogle Scholar
  • 5 Tohyama H, Yasuda K. Significance of graft tension in anterior cruciate ligament reconstruction. Basic background and clinical outcome. Knee Surg Sports Traumatol Arthrosc 1998; 6 (Suppl. 01) S30-S37
    CrossrefPubMedGoogle Scholar
  • 6 Magnussen RA, Granan LP, Dunn WR. et al. Cross-cultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surg Sports Traumatol Arthrosc 2010; 18 (01) 98-105
    CrossrefPubMedGoogle Scholar
  • 7 McRae SM, Chahal J, Leiter JR, Marx RG, Macdonald PB. Survey study of members of the Canadian Orthopaedic Association on the natural history and treatment of anterior cruciate ligament injury. Clin J Sport Med 2011; 21 (03) 249-258
    CrossrefPubMedGoogle Scholar
  • 8 Boylan D, Greis PE, West JR, Bachus KN, Burks RT. Effects of initial graft tension on knee stability after anterior cruciate ligament reconstruction using hamstring tendons: a cadaver study. Arthroscopy 2003; 19 (07) 700-705
    CrossrefPubMedGoogle Scholar
  • 9 Brady MF, Bradley MP, Fleming BC. et al. Effects of initial graft tension on the tibiofemoral compressive forces and joint position after anterior cruciate ligament reconstruction. Am J Sports Med 2007; 35 (03) 395-403
    CrossrefPubMedGoogle Scholar
  • 10 Yoshiya S, Andrish JT, Manley MT, Bauer TW. Graft tension in anterior cruciate ligament reconstruction. An in vivo study in dogs. Am J Sports Med 1987; 15 (05) 464-470
    CrossrefPubMedGoogle Scholar
  • 11 Labs K, Perka C, Schneider F. The biological and biomechanical effect of different graft tensioning in anterior cruciate ligament reconstruction: an experimental study. Arch Orthop Trauma Surg 2002; 122 (04) 193-199
    CrossrefPubMedGoogle Scholar
  • 12 Bedi A, Kovacevic D, Fox AJ. et al. Effect of early and delayed mechanical loading on tendon-to-bone healing after anterior cruciate ligament reconstruction. J Bone Joint Surg Am 2010; 92 (14) 2387-2401
    CrossrefPubMedGoogle Scholar
  • 13 Brophy RH, Kovacevic D, Imhauser CW. et al. Effect of short-duration low-magnitude cyclic loading versus immobilization on tendon-bone healing after ACL reconstruction in a rat model. J Bone Joint Surg Am 2011; 93 (04) 381-393
    CrossrefPubMedGoogle Scholar
  • 14 Rodeo SA, Kawamura S, Kim HJ, Dynybil C, Ying L. Tendon healing in a bone tunnel differs at the tunnel entrance versus the tunnel exit: an effect of graft-tunnel motion?. Am J Sports Med 2006; 34 (11) 1790-1800
    CrossrefPubMedGoogle Scholar
  • 15 Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. Tensile properties of the human femur-anterior cruciate ligament-tibia complex. The effects of specimen age and orientation. Am J Sports Med 1991; 19 (03) 217-225
    CrossrefPubMedGoogle Scholar
  • 16 Aune AK, Nordsletten L, Ekeland A. Structural capacity of the knee to anterior cruciate ligament failure during quadriceps contraction. An in vivo study in the rat. J Biomech 1996; 29 (07) 891-897
    CrossrefPubMedGoogle Scholar
  • 17 Zong JC, Ma R, Wang H. et al. The effect of graft pretensioning on bone tunnel diameter and bone formation after anterior cruciate ligament reconstruction in a rat model: evaluation with micro-computed tomography. Am J Sports Med 2017; 45 (06) 1349-1358
    CrossrefPubMedGoogle Scholar
  • 18 Brophy RH, Kovacevic D, Imhauser CW. et al. Effect of short-duration low-magnitude cyclic loading versus immobilization on tendon-bone healing after ACL reconstruction in a rat model. J Bone Joint Surg Am 2011; 93 (04) 381-393
    CrossrefPubMedGoogle Scholar
  • 19 Rodeo SA, Kawamura S, Kim HJ, Dynybil C, Ying L. Tendon healing in a bone tunnel differs at the tunnel entrance versus the tunnel exit: an effect of graft-tunnel motion?. Am J Sports Med 2006; 34 (11) 1790-1800
    CrossrefPubMedGoogle Scholar
  • 20 Rodeo SA, Kawamura S, Ma CB. et al. The effect of osteoclastic activity on tendon-to-bone healing: an experimental study in rabbits. J Bone Joint Surg Am 2007; 89 (10) 2250-2259
    PubMedGoogle Scholar
  • 21 Arnoczky SP, Lavagnino M, Egerbacher M, Caballero O, Gardner K. Matrix metalloproteinase inhibitors prevent a decrease in the mechanical properties of stress-deprived tendons: an in vitro experimental study. Am J Sports Med 2007; 35 (05) 763-769
    CrossrefPubMedGoogle Scholar
  • 22 Raïf M. Effect of cyclic tensile load on the regulation of the expression of matrix metalloproteases (MMPs -1, -3) and structural components in synovial cells. J Cell Mol Med 2008; 12 (6A): 2439-2448
    CrossrefPubMedGoogle Scholar
  • 23 Wyatt KE, Bourne JW, Torzilli PA. Deformation-dependent enzyme mechanokinetic cleavage of type I collagen. J Biomech Eng 2009; 131 (05) 051004
    CrossrefPubMedGoogle Scholar
  • 24 Huang C, Yannas IV. Mechanochemical studies of enzymatic degradation of insoluble collagen fibers. J Biomed Mater Res 1977; 11 (01) 137-154
    CrossrefPubMedGoogle Scholar
  • 25 Fu SC, Cheng WH, Cheuk YC. et al. Effect of graft tensioning on mechanical restoration in a rat model of anterior cruciate ligament reconstruction using free tendon graft. Knee Surg Sports Traumatol Arthrosc 2013; 21 (05) 1226-1233
    CrossrefPubMedGoogle Scholar
  • 26 Fleming BC, Brady MF, Bradley MP, Banerjee R, Hulstyn MJ, Fadale PD. Tibiofemoral compression force differences using laxity- and force-based initial graft tensioning techniques in the anterior cruciate ligament-reconstructed cadaveric knee. Arthroscopy 2008; 24 (09) 1052-1060
    CrossrefPubMedGoogle Scholar