Skip to main content
SpringerLink
Log in

“Biological failure” of the anterior cruciate ligament graft

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Anterior cruciate ligament (ACL) reconstruction has the best chance for success when the graft undergoes extensive biologic remodeling and incorporation after implantation. There are many factors that can lead to graft failure and possible revision surgery. These include patient selection; surgical technique such as graft placement and tensioning; the use of allograft versus autograft; mechanical factors such as secondary restraint laxity; lack of a correct, carefully controlled post-operative rehabilitation program; and biological factors. When a patient presents with knee instability following ligament reconstruction and there is no history of a new trauma or identifiable technical error, biological failure should be considered. However, the biologic response of the grafted tissue is closely linked to the mechanical and biochemical environment into which the graft is placed. Thus, the “biological failure” of the ACL graft is a complex pathological entity whose cause is not fully understood. Failure may be initiated by early extensive graft necrosis, disturbances in revascularization, problems in cell repopulation and proliferation, and as well difficulties in the ligamentization process. However, further study of the biological characterization of a failed graft placed in a correct mechanical environment is warranted.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Rovere GD, Adair DM (1983) Anterior cruciate-deficient knees: a review of the literature. Am J Sports Med 11(6):412

    Article  PubMed  CAS  Google Scholar 

  2. Wetzler M, Bartolozzi A, Gillespie M, Rubenstein D, Ciccotti M, Miller L (1996) Revision anterior cruciate ligament reconstruction. Oper Techn Orthop 6:181

    Article  Google Scholar 

  3. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE Jr (2004) Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter? A systematic review. Am J Sports Med 32(8):1986

    Article  PubMed  Google Scholar 

  4. Howe JG, Johnson RJ, Kaplan MJ, Fleming B, Jarvinen M (1991) Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I. Long-term followup. Am J Sports Med 19(5):447

    Article  PubMed  CAS  Google Scholar 

  5. Holmes PF, James SL, Larson RL, Singer KM, Jones DC (1991) Retrospective direct comparison of three intraarticular anterior cruciate ligament reconstructions. Am J Sports Med 19(6):596

    Article  PubMed  CAS  Google Scholar 

  6. Johnson DL, Coen MJ (1995) Revision ACL surgery. Etiology, indications, techniques, and results. Am J Knee Surg 8(4):155

    PubMed  CAS  Google Scholar 

  7. Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD (1996) Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res 325:100

    Article  PubMed  Google Scholar 

  8. Getelman MH, Friedman MJ (1999) Revision anterior cruciate ligament reconstruction surgery. J Am Acad Orthop Surg 7(3):189

    PubMed  CAS  Google Scholar 

  9. McFarland EG (1993) The biology of anterior cruciate ligament reconstructions. Orthopedics 16(4):403

    PubMed  CAS  Google Scholar 

  10. Borynsenko M, Beringer T (1989) Functional histology. In: Anatomy of Tendons, 3rd edn. Little, Brown and Company, Boston, pp 105–112

  11. Daniel DM, Akeson W, O’Connor J (1990) Knee ligaments, structure, function, injury, and repair. Raven Press, New York

    Google Scholar 

  12. Amiel D, Frank C, Harwood F, Fronek J, Akeson W (1984) Tendons and ligaments: a morphological and biochemical comparison. J Orthop Res 1(3):257

    Article  PubMed  CAS  Google Scholar 

  13. Amiel D, Kleiner JB, Roux RD, Harwood FL, Akeson WH (1986) The phenomenon of “ligamentization”: anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res 4(2):162

    Article  PubMed  CAS  Google Scholar 

  14. Arnoczky SP, Tarvin GB, Marshall JL (1982) Anterior cruciate ligament replacement using patellar tendon. An evaluation of graft revascularization in the dog. J Bone Joint Surg Am 64(2):217

    PubMed  CAS  Google Scholar 

  15. Hunt P, Scheffler SU, Unterhauser FN, Weiler A (2005) A model of soft-tissue graft anterior cruciate ligament reconstruction in sheep. Arch Orthop Trauma Surg 125(4):238

    Article  PubMed  Google Scholar 

  16. 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(8):1166

    Article  PubMed  Google Scholar 

  17. 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(1):9

    Article  PubMed  CAS  Google Scholar 

  18. 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(2):277

    Article  PubMed  CAS  Google Scholar 

  19. Falconiero RP, DiStefano VJ, Cook TM (1998) Revascularization and ligamentization of autogenous anterior cruciate ligament grafts in humans. Arthroscopy 14(2):197

    Article  PubMed  CAS  Google Scholar 

  20. Alm A, Gillquist J, Stromberg B (1974) The medial third of the patellar ligament in reconstruction of the anterior cruciate ligament. A clinical and histologic study by means of arthroscopy or arthrotomy. Acta Chir Scand Suppl 445:5

    PubMed  CAS  Google Scholar 

  21. Alm A, Gillquist J (1974) Reconstruction of the anterior cruciate ligament by using the medial third of the patellar ligament. Treatment and results. Acta Chir Scand 140(4):289

    PubMed  CAS  Google Scholar 

  22. Malinin TI, Levitt RL, Bashore C, Temple HT, Mnaymneh W (2002) A study of retrieved allografts used to replace anterior cruciate ligaments. Arthroscopy 18(2):163

    Article  PubMed  Google Scholar 

  23. Corsetti JR, Jackson DW (1996) Failure of anterior cruciate ligament reconstruction: the biologic basis. Clin Orthop Relat Res 325:42

    Article  PubMed  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  25. Bosch U, Kasperczyk WJ (1992) Healing of the patellar tendon autograft after posterior cruciate ligament reconstruction—a process of ligamentization? An experimental study in a sheep model. Am J Sports Med 20(5):558

    Article  PubMed  CAS  Google Scholar 

  26. Shino K, Kawasaki T, Hirose H, Gotoh I, Inoue M, Ono K (1984) Replacement of the anterior cruciate ligament by an allogeneic tendon graft. An experimental study in the dog. J Bone Joint Surg Br 66(5):672

    PubMed  CAS  Google Scholar 

  27. Kawamura S, Ying L, Kim HJ, Dynybil C, Rodeo SA (2005) Macrophages accumulate in the early phase of tendon-bone healing. J Orthop Res 23(6):1425

    PubMed  CAS  Google Scholar 

  28. 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(2):120

    Article  PubMed  CAS  Google Scholar 

  29. Higuchi H, Shirakura K, Kimura M et al (2006) Changes in biochemical parameters after anterior cruciate ligament injury. Int Orthop 30(1):43

    Article  PubMed  CAS  Google Scholar 

  30. Cameron M, Buchgraber A, Passler H et al (1997) The natural history of the anterior cruciate ligament-deficient knee. Changes in synovial fluid cytokine and keratan sulfate concentrations. Am J Sports Med 25(6):751

    Article  PubMed  CAS  Google Scholar 

  31. Arnoczky SP, Warren RF, Ashlock MA (1986) Replacement of the anterior cruciate ligament using a patellar tendon allograft. An experimental study. J Bone Joint Surg Am 68(3):376

    PubMed  CAS  Google Scholar 

  32. Yoshiya S, Andrish JT, Manley MT, Bauer TW (1987) Graft tension in anterior cruciate ligament reconstruction. An in vivo study in dogs. Am J Sports Med 15(5):464

    Article  PubMed  CAS  Google Scholar 

  33. Merkel PA, Koroshetz WJ, Irizarry MC, Cudkowicz ME (1995) Cocaine-associated cerebral vasculitis. Semin Arthritis Rheum 25(3):172

    Article  PubMed  CAS  Google Scholar 

  34. Misery L (2004) Nicotine effects on skin: are they positive or negative? Exp Dermatol 13(11):665

    Article  PubMed  CAS  Google Scholar 

  35. Gullihorn L, Karpman R, Lippiello L (2005) Differential effects of nicotine and smoke condensate on bone cell metabolic activity. J Orthop Trauma 19(1):17

    Article  PubMed  Google Scholar 

  36. Baker RR, Pereira da Silva JR, Smith G (2004) The effect of tobacco ingredients on smoke chemistry. Part I: Flavourings and additives. Food Chem Toxicol 42(Suppl):S3

    PubMed  CAS  Google Scholar 

  37. Karim A, Pandit H, Murray J, Wandless F, Thomas NP (2006) Smoking and reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 88(8):1027

    Article  PubMed  CAS  Google Scholar 

  38. Hulstyn M, Fadale PD, Abate J, Walsh WR (1993) Biomechanical evaluation of interference screw fixation in a bovine patellar bone-tendon-bone autograft complex for anterior cruciate ligament reconstruction. Arthroscopy 9(4):417

    Article  PubMed  CAS  Google Scholar 

  39. Yoshikawa T, Tohyama H, Enomoto H, Matsumoto H, Toyama Y, Yasuda K (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(9):804

    Article  PubMed  CAS  Google Scholar 

  40. Spindler KP, Imro AK, Mayes CE, Davidson JM (1996) Patellar tendon and anterior cruciate ligament have different mitogenic responses to platelet-derived growth factor and transforming growth factor beta. J Orthop Res 14(4):542

    Article  PubMed  CAS  Google Scholar 

  41. Schmidt CC, Georgescu HI, Kwoh CK et al (1995) Effect of growth factors on the proliferation of fibroblasts from the medial collateral and anterior cruciate ligaments. J Orthop Res 13(2):184

    Article  PubMed  CAS  Google Scholar 

  42. Lee J, Green MH, Amiel D (1995) Synergistic effect of growth factors on cell outgrowth from explants of rabbit anterior cruciate and medial collateral ligaments. J Orthop Res 13(3):435

    Article  PubMed  CAS  Google Scholar 

  43. DesRosiers EA, Yahia L, Rivard CH (1996) Proliferative and matrix synthesis response of canine anterior cruciate ligament fibroblasts submitted to combined growth factors. J Orthop Res 14(2):200

    Article  PubMed  CAS  Google Scholar 

  44. Abe S, Kurosaka M, Iguchi T, Yoshiya S, Hirohata K (1993) Light and electron microscopic study of remodeling and maturation process in autogenous graft for anterior cruciate ligament reconstruction. Arthroscopy 9(4):394

    Article  PubMed  CAS  Google Scholar 

  45. Oakes B (1993) Collagen ultrastructure inthe normal ACL and in ACL graft. The anterior cruciate ligament: current and future conceps. Raven Press, New York, p 209

    Google Scholar 

  46. Shino K, Oakes BW, Horibe S, Nakata K, Nakamura N (1995) Collagen fibril populations in human anterior cruciate ligament allografts. Electron microscopic analysis. Am J Sports Med 23(2):203

    Article  PubMed  CAS  Google Scholar 

  47. Jackson DW, Grood ES, Goldstein JD et al (1993) A comparison of patellar tendon utograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports Med 21(2):176

    Article  PubMed  CAS  Google Scholar 

  48. Fahey M, Indelicato PA (1994) Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 22(3):410

    Article  PubMed  CAS  Google Scholar 

  49. Thompson WO, Harner CD, Jamison JP et al. (1994) The immunological response to fresh forzen tendon after graft ACL reconstruction. Trans Orthop Res Soc 19:624

    Google Scholar 

  50. Shelbourne KD, Nitz P (1990) Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 18(3):292

    Article  PubMed  CAS  Google Scholar 

  51. Beynnon BD, Uh BS, Johnson RJ et al (2005) Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med 33(3):347

    Article  PubMed  Google Scholar 

  52. Beynnon BD, Johnson RJ, Fleming BC (2002) The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res 402:9

    Article  PubMed  Google Scholar 

  53. Fujimoto E, Sumen Y, Urabe Y et al (2004) An early return to vigorous activity may destabilize anterior cruciate ligaments reconstructed with hamstring grafts. Arch Phys Med Rehabil 85(2):298

    Article  PubMed  Google Scholar 

  54. Beynnon BD, Uh BS, Johnson RJ, Fleming BC, Renstrom PA, Nichols CE (2001) The elongation behavior of the anterior cruciate ligament graft in vivo. A long-term follow-up study. Am J Sports Med 29(2):161

    PubMed  CAS  Google Scholar 

  55. Johnson DL, Harner CD, Maday M, Fu FH (1994) Revision ACL surgery. In: Fu FH. Harner CD, Vince KG (eds) Knee surgery. Williams and Wilkins, Baltimore, pp 877–896

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Unité de Orthopédie et Traumatologie du Sport, Service de Chirurgie Orthopédique et Traumatologie de l’Appareil Moteur, Hôpitaux Universitaires de Genève, 24, rue Micheli-du-Crest, 1211, Genève 14, Switzerland

    J. Ménétrey, V. B. Duthon, T. Laumonier & D. Fritschy

Authors
  1. J. Ménétrey
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. V. B. Duthon
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. T. Laumonier
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. D. Fritschy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. Ménétrey.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ménétrey, J., Duthon, V.B., Laumonier, T. et al. “Biological failure” of the anterior cruciate ligament graft. Knee Surg Sports Traumatol Arthr 16, 224–231 (2008). https://doi.org/10.1007/s00167-007-0474-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-007-0474-x

Keywords

Search

Navigation