Histological properties of autogenous hamstring grafts after anterior cruciate ligament reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

WU Bing ^1,2 ,  QIU Zhihe ² , LI Sheng ² , LIANG Daqiang ¹ , XU Jian ^1,2 , ZHONG Mingjin ^1,2 ,  LU Wei ^1,2 , WANG Daping ^1,2 , LIU Haifeng ^1,2 , ZHU Weimin ^1,2 , OUYANG Kan ^1,2 , LI Hao ^1,2

1. Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People’s Hospital), Shenzhen Guangdong, 518000, P.R.China;
2. Department of Medicine, Shenzhen University, Shenzhen Guangdong, 518061, P.R.China;

Corresponding author：

QIU Zhihe, Email: 1574938149@qq.com; LU Wei, Email: winerl@sina.com

Keywords：

Anterior cruciate ligament; graft; ligamentization; ultrastructure; histology

DOI：

10.7507/1002-1892.201802001

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ObjectiveTo investigate the histological characteristics of autogenous hamstring grafts after anterior cruciate ligament (ACL) reconstruction.MethodsThe patients who underwent arthroscopic single-bundle ACL reconstruction with autogenous hamstring tendons and were followed up at least 4 years and also underwent second-look arthroscopy between March 2017 and December 2017 and met the selection criteria were considered for enrollment. Graft quality under arthroscopy was evaluated as good remodeling group (GRG, the total scores were 4-6) and poor remodeling group (PRG, the total scores were 1-3) according to synovial and vascular coverage, the apparent tension of the grafts, the thickness and retear of the grafts. During the second-look arthroscopic procedures, ACL graft biopsies were performed. Normal ACL tissues harvested from the patients under 60 years old who underwent total knee arthroplasty were designated as normal controls. Graft vascularity, cellular morphology, cellular metabolism, and collagen fibril distribution were analyzed.ResultsThe 18 specimens (11 cases of GRG group and 7 cases of PRG group) and 9 native ACL biopsied tissue sample were enrolled into the study. Arthroscopy scores were 2-6 (mean, 4.7). The biology under light microscopy of GRG group was similar to that of native ACL in control group. There was no significant difference in the scores of graft vascularity and cellular morphology between GRG group and control group (P>0.05), while PRG group was significantly lower than the other two groups (P<0.05). Transmission electron microscope evaluation showed that GRG group and control group had better collagen fibril distribution and lower levels of cellular metabolism than PRG group (P<0.05). There was no significant difference in cellular metabolism between GRG and control groups (P>0.05), while collagen fibril distribution score of GRG group was significantly lower than that of control group (P<0.05).ConclusionWhile good remodeling grafts under arthroscopy in histological maturation period was proved to be more similar to normal ACL on ultrastructure properties under light and electron microscope, ultra structural differences regarding collagen fibril distribution still persist.

Citation： WU Bing, QIU Zhihe, LI Sheng, LIANG Daqiang, XU Jian, ZHONG Mingjin, LU Wei, WANG Daping, LIU Haifeng, ZHU Weimin, OUYANG Kan, LI Hao. Histological properties of autogenous hamstring grafts after anterior cruciate ligament reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(7): 873-879. doi: 10.7507/1002-1892.201802001 Copy

1.	Pinczewski L, Roe J, Salmon L. Why autologous hamstring tendon reconstruction should now be considered the gold standard for anterior cruciate ligament reconstruction in athletes. Br J Sports Med, 2009, 43(5): 325-327.
2.	Tian S, Wang Y, Wang B, et al. Anatomic double-bundle anterior cruciate ligament reconstruction with a Hamstring tendon autograft and fresh-frozen allograft: A prospective, randomized, and controlled study. Arthroscopy, 2016, 32(12): 2521-2531.
3.	Gupta R, Bahadur R, Malhotra A, et al. Anterior cruciate ligament reconstruction using Hamstring tendon autograft with preserved insertions. Arthrosc Tech, 2016, 5(2): e269-e274.
4.	Lee JK, Lee S, Lee MC. Outcomes of anatomic anterior cruciate ligament reconstruction: bone-quadriceps tendon graft versus double-bundle Hamstring tendon graft. Am J Sports Med, 2016, 44(9): 2323-2329.
5.	Hui C, Salmon LJ, Kok A, et al. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for " isolated” anterior cruciate ligament tear. Am J Sports Med, 2011, 39(1): 89-98.
6.	Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med, 2007, 35(4): 564-574.
7.	Mascarenhas R, Tranovich M, Karpie JC, et al. Patellartendon anterior cruciate ligament reconstruction in the high-demand patient: Evaluation of autograft versus allograft reconstruction. Arthroscopy, 2010, 26(9 suppl): S58-S66.
8.	Ahn JH, Kang HW, Choi KJ. Outcomes after double-bundle anterior cruciate ligament reconstruction. Arthroscopy, 2018, 34(1): 220-230.
9.	Snaebjörnsson T, Hamrin SE, Sundemo D, et al. Adolescents and female patients are at increased risk for contralateral anterior cruciate ligament reconstruction: a cohort study from the Swedish National Knee Ligament Register based on 17,682 patients. Knee Surgery Sports Traumatology Arthroscopy, 2017, 25(12): 3938-3944.
10.	Amiel D, Kleiner JB, Roux RD, et al. The phenomenon of " ligamentization”: anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res, 1986, 4(2): 162-172.
11.	Claes S, Verdonk P, Forsyth R, et al. The " ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med, 2011, 39(11): 2476-2483.
12.	Abe S, Kurosaka M, Iguchi T, et al. Light and electron microscopic study of remodeling and maturation process in autogenous graft for anterior cruciate ligament reconstruction. Arthroscopy, 1993, 9(4): 394-405.
13.	Falconiero RP, DiStefano VJ, Cook TM. Revascularization and ligamentization of autogenous anterior cruciate ligament grafts in humans. Arthroscopy, 1998, 14(2): 197-205.
14.	Rougraff B, Shelbourne KD, Gerth PK, et al. Arthroscopic and histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med, 1993, 21(2): 277-284.
15.	Sánchez M, Anitua E, Azofra J, et al. Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology. Arthroscopy, 2010, 26(4): 470-480.
16.	Scheffler SU, Unterhauser FN, Weiler A. Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2008, 16(9): 834-842.
17.	Papageorgiou CD, Ma CB, Abramowitch SD, et al. A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med, 2001, 29(5): 620-626.
18.	Kondo E, Yasuda K. Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability. Arthroscopy, 2007, 23(11): 1198-1209.
19.	Lee JH, Bae DK, Song SJ, et al. Comparison of clinical results and second-look arthroscopy findings after arthroscopic anterior cruciate ligament reconstruction using 3 different types of grafts. Arthroscopy, 2010, 26(1): 41-49.
20.	Weiler A, Peters G, Mäurer J, et al. 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, 2001, 29(6): 751-761.
21.	Dong S, Xie G, Zhang Y, et al. Ligamentization of autogenous Hamstring grafts after anterior cruciate ligament reconstruction: Midterm versus long-term results. Am J Sports Med, 2015, 43(8): 1908-1917.
22.	Middleton K, Hamilton T, Irrgang J, et al. Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1467-1482.
23.	Cho S, Muneta T, Ito S, et al. Electron microscopic evaluation of two-bundle anatomically reconstructed anterior cruciate ligament graft. J Orthop Sci, 2004, 9(3): 296-301.
24.	Zaffagnini S, De Pasquale V, Marchesini R, et al. Electron microscopy of the remodelling process in Hamstring tendon used as ACL graft. Knee Surg Sports Traumatol Arthrosc, 2010, 18(8): 1052-1058.
25.	Schindler OS. The story of anterior cruciate ligament reconstruction: part 1. J Perioper Pract, 2012, 22(5): 163-171.
26.	Wells HC, Edmonds RL, Kirby N, et al. Collagen fibril diameter and leather strength. J Agric Food Chem, 2013, 61(47): 11524-11531.
27.	Yang JH, Chang M, Kwak DS, et al. In vivo three-dimensional imaging analysis of femoral and tibial tunnel locations in single and double bundle anterior cruciate ligament reconstructions. Clin Orthop Surg, 2014, 6(1): 32-42.

1. Pinczewski L, Roe J, Salmon L. Why autologous hamstring tendon reconstruction should now be considered the gold standard for anterior cruciate ligament reconstruction in athletes. Br J Sports Med, 2009, 43(5): 325-327.
2. Tian S, Wang Y, Wang B, et al. Anatomic double-bundle anterior cruciate ligament reconstruction with a Hamstring tendon autograft and fresh-frozen allograft: A prospective, randomized, and controlled study. Arthroscopy, 2016, 32(12): 2521-2531.
3. Gupta R, Bahadur R, Malhotra A, et al. Anterior cruciate ligament reconstruction using Hamstring tendon autograft with preserved insertions. Arthrosc Tech, 2016, 5(2): e269-e274.
4. Lee JK, Lee S, Lee MC. Outcomes of anatomic anterior cruciate ligament reconstruction: bone-quadriceps tendon graft versus double-bundle Hamstring tendon graft. Am J Sports Med, 2016, 44(9): 2323-2329.
5. Hui C, Salmon LJ, Kok A, et al. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for " isolated” anterior cruciate ligament tear. Am J Sports Med, 2011, 39(1): 89-98.
6. Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med, 2007, 35(4): 564-574.
7. Mascarenhas R, Tranovich M, Karpie JC, et al. Patellartendon anterior cruciate ligament reconstruction in the high-demand patient: Evaluation of autograft versus allograft reconstruction. Arthroscopy, 2010, 26(9 suppl): S58-S66.
8. Ahn JH, Kang HW, Choi KJ. Outcomes after double-bundle anterior cruciate ligament reconstruction. Arthroscopy, 2018, 34(1): 220-230.
9. Snaebjörnsson T, Hamrin SE, Sundemo D, et al. Adolescents and female patients are at increased risk for contralateral anterior cruciate ligament reconstruction: a cohort study from the Swedish National Knee Ligament Register based on 17,682 patients. Knee Surgery Sports Traumatology Arthroscopy, 2017, 25(12): 3938-3944.
10. Amiel D, Kleiner JB, Roux RD, et al. The phenomenon of " ligamentization”: anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res, 1986, 4(2): 162-172.
11. Claes S, Verdonk P, Forsyth R, et al. The " ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med, 2011, 39(11): 2476-2483.
12. Abe S, Kurosaka M, Iguchi T, et al. Light and electron microscopic study of remodeling and maturation process in autogenous graft for anterior cruciate ligament reconstruction. Arthroscopy, 1993, 9(4): 394-405.
13. Falconiero RP, DiStefano VJ, Cook TM. Revascularization and ligamentization of autogenous anterior cruciate ligament grafts in humans. Arthroscopy, 1998, 14(2): 197-205.
14. Rougraff B, Shelbourne KD, Gerth PK, et al. Arthroscopic and histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med, 1993, 21(2): 277-284.
15. Sánchez M, Anitua E, Azofra J, et al. Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gross morphology and histology. Arthroscopy, 2010, 26(4): 470-480.
16. Scheffler SU, Unterhauser FN, Weiler A. Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2008, 16(9): 834-842.
17. Papageorgiou CD, Ma CB, Abramowitch SD, et al. A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med, 2001, 29(5): 620-626.
18. Kondo E, Yasuda K. Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability. Arthroscopy, 2007, 23(11): 1198-1209.
19. Lee JH, Bae DK, Song SJ, et al. Comparison of clinical results and second-look arthroscopy findings after arthroscopic anterior cruciate ligament reconstruction using 3 different types of grafts. Arthroscopy, 2010, 26(1): 41-49.
20. Weiler A, Peters G, Mäurer J, et al. 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, 2001, 29(6): 751-761.
21. Dong S, Xie G, Zhang Y, et al. Ligamentization of autogenous Hamstring grafts after anterior cruciate ligament reconstruction: Midterm versus long-term results. Am J Sports Med, 2015, 43(8): 1908-1917.
22. Middleton K, Hamilton T, Irrgang J, et al. Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1467-1482.
23. Cho S, Muneta T, Ito S, et al. Electron microscopic evaluation of two-bundle anatomically reconstructed anterior cruciate ligament graft. J Orthop Sci, 2004, 9(3): 296-301.
24. Zaffagnini S, De Pasquale V, Marchesini R, et al. Electron microscopy of the remodelling process in Hamstring tendon used as ACL graft. Knee Surg Sports Traumatol Arthrosc, 2010, 18(8): 1052-1058.
25. Schindler OS. The story of anterior cruciate ligament reconstruction: part 1. J Perioper Pract, 2012, 22(5): 163-171.
26. Wells HC, Edmonds RL, Kirby N, et al. Collagen fibril diameter and leather strength. J Agric Food Chem, 2013, 61(47): 11524-11531.
27. Yang JH, Chang M, Kwak DS, et al. In vivo three-dimensional imaging analysis of femoral and tibial tunnel locations in single and double bundle anterior cruciate ligament reconstructions. Clin Orthop Surg, 2014, 6(1): 32-42.

Chinese Journal of Reparative and Reconstructive Surgery

Histological properties of autogenous hamstring grafts after anterior cruciate ligament reconstruction

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