Abstract
The treatment of posterior cruciate ligament (PCL) injuries remains controversial. Due to various problems, PCL reconstruction has not consistently produced the knee stability desired. Biological graft tissue undergoes a remarkable healing process comprising different phases. The strength of autogenous graft material decreases soon after operation. During this early healing phase synthetic augmentation could protect the graft tissue from overloading or overstretching, supporting the tissue revitalization and remodeling process. In order to evaluate the morphological effects of the ligament augmentation device (LAD) on a free patellar tendon autograft in PCL reconstruction, a comparative study in sheep was conducted. In 24 mature sheep, the PCL was replaced with either a patellar tendon autograft alone or a patellar tendon autograft augmented by the LAD. The LAD was fixed at both ends. After the operation the animals were not immobilized. Tibial fixation was released 8 weeks postoperation. The autografts of both groups were histologically evaluated after 2, 6, 16, 26, 52, and 104 weeks. In addition to necrotic and degenerative alterations, a remarkable inflammatory reaction could be seen in the LAD-augmented autografts early postoperation. Compared with the nonaugmented autografts, tissue formation and remodeling were delayed in the augmented group. After 1 and 2 years, the morphology of the autograft tissue was similar in both the augmented and nonaugmented group and differed from that of a normal PCL. The LAD was surrounded by a chronic inflammatory reaction, and collagen fiber ingrowth into the LAD was not observed. Using transmission electron microscopy, small diameter collagen fibrils were predominant in the graft tissue of both groups. Thus, a better remodeling of the autograft tissue in the presence of the LAD could not be demonstrated in this particular study. The value of synthetic augmentation of biological grafts in PCL reconstruction seems to be questionable at present.
Similar content being viewed by others
References
Amendola A, Fowler P (1992) Allograft anterior cruciate ligament reconstruction in a sheep model. Am J Sports Med 20:336–346
Amiel D, Frank C, Harwood F, Fronek J, Akeson WH (1984) Tendons and ligaments: a morphological and biochemical comparison. J Orthop Res 1:257–265
Amiel D, Kleiner JB, Akeson WH (1986) The natural history of the anterior cruciate ligament autograft of patellar tendon origin. Am J Sports Med 14:449–462
Amoczky SP, Tarvin GB, Marshall JL (1982) Anterior cruciate ligament replacement using patellar tendon. J Bone Joint Surg [Am] 64:217–224
Asahina S, Muneta T, Skai H, Hokama R, Takakuda K, Ishibashi T, Yamamoto H, Furuya K (1992) Biomechanical and histological study of ACL reconstruction augmented with LAD in rabbits. Trans Orthop Res Soc 17:247
Ballock RT, Woo SL-Y, Lyon RM, Hollis JM, Akeson WH (1989) Use of patellar tendon autograft for anterior cruciate ligament reconstruction in the rabbit: a long-term histologic and biomechanical study. J Orthop Res 7:474–485
Bosch U, Kasperczyk WJ (1992) Healing of the patellar tendon autograft after posterior cruciate ligament reconstruction — a process of ligamentization? Am J Sports Med 20:558–566
Bosch U, Decker B, Kasperczyk W, Oestem HJ, Tscherne H (1989) Biological aspects of long-term failure of autografts after cruciate ligament replacement. Arch Orthop Trauma Surg 108:368–372
Bosch U, Kasperczyk WJ, Oestern HJ, Tscherne H (1994) Biology of PCL healing. Sports Med Arthrosc Rev 2:88–99
Bosch U, Decker B, Möller HD, Kasperczyk WJ, Oestern HJ, Tscheme H (1995) Collagen fibril organization in the patellar tendon autograft after posterior cruciate ligament reconstruction. Am J Sports Med 23:196–202
Bush-Joseph CA, Bach BR (1994) Arthroscopic assisted posterior cruciate ligament reconstruction using patellar tendon autograft. Sports Med Arthrosc Rev 2:106–119
Butler DL, Grood ES, Noyes FR, Olmstead ML, Hohn RB, Arnoczky SP, Siegel MG (1989) Mechanical properties of primate vascularized vs. nonvascularized patellar tendon grafts; changes over time. J Orthop Res 7:68–79
Claes L, Dürselen L, Bensel R (1991) Theoretische Überlegungen zur Biomechanik der Bandaugmentation. Abstract, Workshop: Die wissenschaftlichen Grundlagen des Bandersatzes, Reisensburg, p 12
Claes L, Dürselen L, Rübenacker S (1994) Vergleichende Untersuchungen zum prothetischen Ersatz des vorderen Kreuzbandes und medialen Seitenhandes mit 6 verschiedenen Bandersatzmaterialien. Hefte Unfallchirurg 234:173–192
Clancy WG, Narechania RG, Rosenberg TD, Gmeiner JG, Wisnefske DD, Lange TA (1981) Anterior and posterior cruciate ligament reconstruction in rhesus monkeys. J Bone Joint Surg [Am] 63:1270–1284
Clancy WG, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD (1983) Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. J Bone Joint Surg [Am] 65:310–322
Cross MJ, Powell JF (1984) Long-term followup of posterior cruciate ligament rupture: a study of 116 cases. Am J Sports Med 12:292–297
Dandy DJ, Posey RJ (1982) The long-term results of unrepaired tears of the posterior cruciate ligament. J Bone Joint Surg [Br] 64:92–94
Decker B, Bosch U, Kasperczyk W, Oestem HJ, Reale E (1991) Ultrastructural changes of the patellar tendon as a cruciate ligament substitute (one year and two year results). J Submicrosc Cytol Pathol 23:9–21
Decker B, Bosch U, Gässler N, Tugtekin I, Kapserczyk W, Reale E (1994) Histochemical aspects of the proteoglycans of patellar tendon autografts used to replace the posterior cruciate ligament. Matrix Biol 14:101–111
Dommelen BA van, Fowler P (1989) Anatomy of the posterior cruciate ligament. Am J Sports Med 17:24–29
Fowler PJ, Messieh SS (1987) Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med 15:553–557
Girgis FG, Marshall JL, Al Monajem ARS (1975) The cruciate ligaments of the knee joint. Clin Orthop 106:216–231
Hanley P, Lew WD, Lewis JL, Hunter RE, Kirstukas S, Kowalczyk C (1989) Load sharing and graft forces in ACL reconstructions with the LAD. Am J Sports Med 17:414–422
Hughston JC, Andrews JR, Cross MJ, Moschi A (1986) Classifications of knee ligament instabilities. Part I: the medial compartment and cruciate ligaments. J Bone Joint Surg [Am] 58:159–172
Jackson DW, Grood ES, Arnoczky SP, Butler DL, Simon TM (1987) Cruciate reconstruction using freeze dried anterior cruciate ligament allograft and a ligament augmentation device (LAD). Am J Sports Med 15:528–538
Kannus P, Bergfeld J, Järvinen M, Johnson RJ, Pope M, Renström P, Yasuda K (1991) Injuries to the posterior cruciate ligament of the knee. Sports Med 12:110–131
Kasperczyk WJ, Bosch U, Oestern HJ, Tscherne H (1994) Die Biomechanik des heilenden, autogenen Patellarsehnentransplantates und die Bedeutung einer Augmentation — eine tierexperimentelle Studie zum Ersatz des hinteren Kreuzbandes. Hefte Unfallchirurg 234:98–135
Keller PM, Shelbourne KD, McCarroll JR, Rettig AC (1993) Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med 21:132–136
Kennedy JC, Roth JH, Mendenhall HV, Sanford JB (1980) Presidential address. Intraarticular replacement in the anterior cruciate ligament-deficient knee. Am J Sports Med 8:1–8
Lew WD, Engebretsen L, Lewis JL, Hunter RE, Kowalczyk C (1990) Method for setting total graft force and load sharing in augmented ACL grafts. J Orthop Res 8:702–711
Lipscomb AB, Anderson AF, Norwig ED, Horis WD, Brown DL (1993) Isolated posterior cruciate ligament reconstruction. Am J Sports Med 21:490–496
McCarthy JA, Blomstrom G, Shively RL, Steadman J, France P, Stonebrook S (1991) Maturation of biologic ACL reconstructions: the effect of augmentation over time. Trans Orthop Res Soc 16:202
McPherson GK, Mendenhall HV, Gibbons DF, Plenk H, Rottmann W, Sanford JB, Kennedy JC, Roth JH (1985) Experimental mechanical and histologic evaluation of the Kennedy ligament augmentation device. Clin Orthop 196:186–195
Newton PO, Horibe S, Woo SL-Y (1990) Experimental studies on anterior cruciate ligament autografts and allografts. In: Daniel D, Akeson WH, O'Connor J (eds) Knee ligaments: structure, function, injury, and repair. Raven, New York, pp 389–399
O'Connor JJ (1993) Can muscle co-contraction protect knee ligaments after injury and repair. J Bone Joint Surg [Br] 75:41–48
Olson E, Kang JD, Fu FH, Georgescu HI, Mason GC, Evans CH (1988) The biochemical and histological effects of artificial ligament wear particles. In vitro and in vivo studies. Am J Sports Med 16:558–579
Parolie JM, Bergfeld JA (1986) Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 14:35–38
Poumaras J, Symeonides PP (1991) The results of surgical repair of acute tears of the posterior cruciate ligament. Clin Orthop 267:103–107
Riel KA, Ulm K, Bernett P (1991) Die Bedeutung der synthetischen (Kennedy-LAD) Augmentation beim vorderen Kreuzbandersatz. Unfallchirurg 94:351–354
Roth JH, Kennedy JC, Lockstadt H, McCallum CI, Cunning LA (1985) Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction. Am J Sports Med 13:321–336
Torg JS, Barton TM, Pavlov H, Stine R (1989) Natural history of the posterior cruciate ligament-deficient knee. Clin Orthop 246:208–216
Author information
Authors and Affiliations
Additional information
Supported by the Deutsche Forschungsgemeinschaft
Rights and permissions
About this article
Cite this article
Bosch, U., Kasperczyk, W.J., Decker, B. et al. The morphological effects of synthetic augmentation in posterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 115, 176–181 (1996). https://doi.org/10.1007/BF00434549
Received:
Issue Date:
DOI: https://doi.org/10.1007/BF00434549