Skip to main content
SpringerLink
Log in

Graft Remodeling and Bony Ingrowth After ACL Reconstruction

  • Living reference work entry
  • First Online:
Sports Injuries

Abstract

The following chapter will provide a concise overview about the biological changes of an autologous graft following reconstruction of the anterior cruciate ligament. Detailed attention is paid to the healing processes that occur at the intra-articular and at the intra-tunnel graft regions. The specific biological changes leading to adaptation of the intra-articular graft region towards an ACL-like structure and the formation of a neoinsertion of the ACL graft are outlined. Time-specific phases are defined, which show distinct differences in remodeling activity. Overall information of this chapter will help to understand when graft remodeling and incorporation will be completed and full functional recovery can be expected.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

Similar content being viewed by others

References

  • Amiel D, Kleiner JB, Roux RD et al (1986) The phenomenon of “ligamentization”: anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res 4:162–172

    Article  CAS  PubMed  Google Scholar 

  • Arai Y, Hara K, Takahashi T et al (2008) Evaluation of the vascular status of autogenous hamstring tendon grafts after anterior cruciate ligament reconstruction in humans using magnetic resonance angiography. Knee Surg Sports Traumatol Arthrosc 16:342–347. doi:10.1007/s00167-007-0478-6

    Article  PubMed  Google Scholar 

  • Ballock RT, Woo SL, Lyon RM et al (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

    Article  CAS  PubMed  Google Scholar 

  • 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 39:2476–2483. doi:10.1177/0363546511402662

    Article  PubMed  Google Scholar 

  • Dustmann M, Schmidt T, Gangey I et al (2008) The extracellular remodeling of free-soft-tissue autografts and allografts for reconstruction of the anterior cruciate ligament: a comparison study in a sheep model. Knee Surg Sports Traumatol Arthrosc 16:360–369. doi:10.1007/s00167-007-0471-0

    Article  CAS  PubMed  Google Scholar 

  • Falconiero RP, DiStefano VJ, Cook TM (1998) Revascularization and ligamentization of autogenous anterior cruciate ligament grafts in humans. Arthroscopy 14:197–205

    Article  CAS  PubMed  Google Scholar 

  • Fujiya H, Kousa P, Fleming BC et al (2011) Effect of muscle loads and torque applied to the tibia on the strain behavior of the anterior cruciate ligament: an in vitro investigation. Clin Biomech (Bristol, Avon) 26:1005–1011. doi:10.1016/j.clinbiomech.2011.06.006

    Article  Google Scholar 

  • Gohil S, Annear PO, Breidahl W (2007) Anterior cruciate ligament reconstruction using autologous double hamstrings: a comparison of standard versus minimal debridement techniques using MRI to assess revascularisation. A randomised prospective study with a one-year follow-up. J Bone Joint Surg Br 89:1165–1171. doi:10.1302/0301-620X.89B9.19339

    Article  CAS  PubMed  Google Scholar 

  • Goradia VK, Rochat MC, Grana WA et al (2000a) Tendon-to-bone healing of a semitendinosus tendon autograft used for ACL reconstruction in a sheep model. Am J Knee Surg 13:143–151

    CAS  PubMed  Google Scholar 

  • Goradia VK, Rochat MC, Kida M, Grana WA (2000b) Natural history of a hamstring tendon autograft used for anterior cruciate ligament reconstruction in a sheep model. Am J Sports Med 28:40–46

    CAS  PubMed  Google Scholar 

  • Grana WA, Egle DM, Mahnken R, Goodhart CW (1994) An analysis of autograft fixation after anterior cruciate ligament reconstruction in a rabbit model. Am J Sports Med 22:344–351

    Article  CAS  PubMed  Google Scholar 

  • Howell SM, Knox KE, Farley TE, Taylor MA (1995) Revascularization of a human anterior cruciate ligament graft during the first two years of implantation. Am J Sports Med 23:42–49

    Article  CAS  PubMed  Google Scholar 

  • Ishibashi Y, Toh S, Okamura Y et al (2001) Graft incorporation within the tibial bone tunnel after anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft. Am J Sports Med 29:473–479

    CAS  PubMed  Google Scholar 

  • Janssen RPA, van der Wijk J, Fiedler A et al (2011) Remodelling of human hamstring autografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19:1299–1306. doi:10.1007/s00167-011-1419-y

    Article  PubMed Central  PubMed  Google Scholar 

  • Jones JR, Smibert JG, McCullough CJ et al (1987) Tendon implantation into bone: an experimental study. J Hand Surg Br 12:306–312

    Article  CAS  PubMed  Google Scholar 

  • Kawakami H, Shino K, Hamada M et al (2004) Graft healing in a bone tunnel: bone-attached graft with screw fixation versus bone-free graft with extra-articular suture fixation. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-003-0484-2

    Google Scholar 

  • Kleiner JB, Amiel D, Roux RD, Akeson WH (1986) Origin of replacement cells for the anterior cruciate ligament autograft. J Orthop Res 4:466–474

    Article  CAS  PubMed  Google Scholar 

  • Kleiner JB, Amiel D, Harwood FL, Akeson WH (1989) Early histologic, metabolic, and vascular assessment of anterior cruciate ligament autografts. J Orthop Res 7:235–242

    Article  CAS  PubMed  Google Scholar 

  • Kobayashi M, Watanabe N, Oshima Y et al (2005) The fate of host and graft cells in early healing of bone tunnel after tendon graft. Am J Sports Med 33:1892–1897

    Article  PubMed  Google Scholar 

  • Kondo E, Yasuda K, Katsura T et al (2012) Biomechanical and histological evaluations of the doubled semitendinosus tendon autograft after anterior cruciate ligament reconstruction in sheep. Am J Sports Med 40:315–324. doi:10.1177/0363546511426417

    Article  PubMed  Google Scholar 

  • Kuroda R, Kurosaka M, Yoshiya S, Mizuno K (2000) Localization of growth factors in the reconstructed anterior cruciate ligament: immunohistological study in dogs. Knee Surg Sports Traumatol Arthrosc 8:120–126

    Article  CAS  PubMed  Google Scholar 

  • Liu SH, Panossian V, al-Shaikh R et al (1997) Morphology and matrix composition during early tendon to bone healing. Clin Orthop Relat Res 339:253–260

    Article  PubMed  Google Scholar 

  • Majima T, Yasuda K, Tsuchida T et al (2003) Stress shielding of patellar tendon: effect on small-diameter collagen fibrils in a rabbit model. J Orthop Sci 8:836–841. doi:10.1007/s00776-003-0707-x

    Article  PubMed  Google Scholar 

  • 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 33:1166–1173. doi:10.1177/0363546504271973

    Article  PubMed  Google Scholar 

  • Mayr HO, Stoehr A, Dietrich M et al (2012) Graft-dependent differences in the ligamentization process of anterior cruciate ligament grafts in a sheep trial. Knee Surg Sports Traumatol Arthrosc 20:947–956. doi:10.1007/s00167-011-1678-7

    Article  PubMed  Google Scholar 

  • Nebelung W, Becker R, Urbach D et al (2003) Histological findings of tendon-bone healing following anterior cruciate ligament reconstruction with hamstring grafts. Arch Orthop Trauma Surg 123:158–163. doi:10.1007/s00402-002-0463-y

    CAS  PubMed  Google Scholar 

  • Ng GY, Oakes BW, Deacon OW et al (1995) Biomechanics of patellar tendon autograft for reconstruction of the anterior cruciate ligament in the goat: three-year study. J Orthop Res 13:602–608

    Article  CAS  PubMed  Google Scholar 

  • Ng GY, Oakes BW, Deacon OW et al (1996) Long-term study of the biochemistry and biomechanics of anterior cruciate ligament-patellar tendon autografts in goats. J Orthop Res 14:851–856

    Article  CAS  PubMed  Google Scholar 

  • Ohno K, Yasuda K, Yamamoto N et al (1993) Effects of complete stress-shielding on the mechanical properties and histology of in situ frozen patellar tendon. J Orthop Res 11:592–602

    Article  CAS  PubMed  Google Scholar 

  • Papageorgiou CD, Ma CB, Abramowitch SD et al (2001) A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med 29:620–626

    CAS  PubMed  Google Scholar 

  • Rodeo SA, Arnoczky SP, Torzilli PA et al (1993) Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am 75:1795–1803

    CAS  PubMed  Google Scholar 

  • Rodeo SA, Kawamura S, Kim HJ et al (2006) 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 34:1790–1800. doi:10.1177/0363546506290059

    Article  PubMed  Google Scholar 

  • Rougraff BT, Shelbourne KD (1999) Early histologic appearance of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 7:9–14

    Article  CAS  PubMed  Google Scholar 

  • 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 21:277–284

    Article  CAS  PubMed  Google Scholar 

  • Sánchez M, Anitua E, Azofra J et al (2010) Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology. Arthroscopy 26:470–480. doi:10.1016/j.arthro.2009.08.019

    Article  PubMed  Google Scholar 

  • Scheffler SU, Dustmann M, Gangey I, et al. (2005) The biological healing and restoration of the mechanical properties of free soft-tissue allografts lag behind autologous ACL reconstruction in the sheep model. In: Washington, D.C., USA, p abstract no.0236

    Google Scholar 

  • Scheffler SU, Schmidt T, Gangéy I et al (2008a) 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 24:448–458. doi:10.1016/j.arthro.2007.10.011

    Article  PubMed  Google Scholar 

  • Scheffler SU, Unterhauser FN, Weiler A (2008b) Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16:834–842. doi:10.1007/s00167-008-0560-8

    Article  CAS  PubMed  Google Scholar 

  • Shelburne KB, Pandy MG (1998) Determinants of cruciate-ligament loading during rehabilitation exercise. Clin Biomech (Bristol, Avon) 13:403–413

    Article  Google Scholar 

  • Shino K, Horibe S (1991) Experimental ligament reconstruction by allogeneic tendon graft in a canine model. Acta Orthop Belg 57(Suppl 2):44–53

    PubMed  Google Scholar 

  • Shino K, Kawasaki T, Hirose H et al (1984) Replacement of the anterior cruciate ligament by an allogeneic tendon graft. An experimental study in the dog. J Bone Joint Surg Br 66:672–681

    CAS  PubMed  Google Scholar 

  • Tohyama H, Yasuda K (2002) The effect of increased stress on the patellar tendon. J Bone Joint Surg Br 84:440–446

    Article  CAS  PubMed  Google Scholar 

  • Tomita F, Yasuda K, Mikami S et al (2001) Comparisons of intraosseous graft healing between the doubled flexor tendon graft and the bone-patellar tendon-bone graft in anterior cruciate ligament reconstruction. Arthroscopy 17:461–476

    Article  CAS  PubMed  Google Scholar 

  • Unterhauser FN, Bail HJ, Höher J et al (2003) Endoligamentous revascularization of an anterior cruciate ligament graft. Clin Orthop Relat Res 414:276–288

    Article  PubMed  Google Scholar 

  • Vogrin M, Rupreht M, Dinevski D et al (2010) Effects of a platelet gel on early graft revascularization after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind, clinical trial. Eur Surg Res 45:77–85. doi:10.1159/000318597

    Article  CAS  PubMed  Google Scholar 

  • Weiler A, Peters G, Maurer J et al (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

    CAS  PubMed  Google Scholar 

  • Weiler A, Hoffmann RFG, Bail HJ et al (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

    Article  PubMed  Google Scholar 

  • Yamakado K, Kitaoka K, Yamada H et al (2002) The influence of mechanical stress on graft healing in a bone tunnel. Arthrosc J Arthrosc Relat Surg 18:82–90. doi:10.1053/jars.2002.25966

    Article  Google Scholar 

  • Yoshikawa T, Tohyama H, Enomoto H, et al. (2004) Temporal changes in relationships between fibroblast repopulation, VEGF expression and angiogenesis in the patellar tendon graft after anterior cruciate ligament reconstruction. In: San Francisco, USA, p Paper 0236

    Google Scholar 

  • Yoshikawa T, Tohyama H, Enomoto H et al (2006) Expression of vascular endothelial growth factor and angiogenesis in patellar tendon grafts in the early phase after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 14:804–810. doi:10.1007/s00167-006-0051-8

    Article  CAS  PubMed  Google Scholar 

  • Zaffagnini S, De Pasquale V, Marchesini Reggiani L et al (2007) Neoligamentization process of BTPB used for ACL graft: histological evaluation from 6 months to 10 years. Knee 14:87–93. doi:10.1016/j.knee.2006.11.006

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Sporthopaedicum, Charite Universitatsmedizin, Bismarckstrasse 45-47, 10627, Berlin, Germany

    Sven Scheffler

  2. Klinik für Orthopädie und Unfallchirurgie, Städtische Klinikum Brandenburg, Hochstrasse 29, 14770, Hochstrasse, Brandenburg an der Havel, Germany

    Roland Becker

Authors
  1. Sven Scheffler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roland Becker
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sven Scheffler .

Editor information

Editors and Affiliations

  1. Dept. Orthopedics & Traumatology, Hacettepe University Fac. Medicine, Ankara, Turkey

    Mahmut Nedim Doral

  2. Gothenburg, Sweden

    Jon Karlsson

Rights and permissions

Reprints and permissions

Copyright information

© 2013 Springer-Verlag Berlin Heidelberg

About this entry

Cite this entry

Scheffler, S., Becker, R. (2013). Graft Remodeling and Bony Ingrowth After ACL Reconstruction. In: Doral, M., Karlsson, J. (eds) Sports Injuries. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-36801-1_98-1

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-36801-1_98-1

  • Received:

  • Accepted:

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Online ISBN: 978-3-642-36801-1

  • eBook Packages: Springer Reference MedicineReference Module Medicine

Publish with us

Policies and ethics

Search

Navigation