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First published on July 6, 2005, doi:10.1177/0363546504271973
This version was published on August 1, 2005
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The American Journal of Sports Medicine 33:1166-1173 (2005)
© 2005 American Orthopaedic Society for Sports Medicine

The "Ligamentization" Process in Human Anterior Cruciate Ligament Reconstruction With Autogenous Patellar and Hamstring Tendons

A Biochemical Study

Keishi Marumo, MD*,{dagger}, Mitsuru Saito, MD{dagger}, Tsuneo Yamagishi, MD{ddagger} and Katsuyuki Fujii, MD{dagger}

From the {dagger} Department of Orthopaedic Surgery, The Jikei University School of Medicine, Tokyo, Japan, and the {ddagger} Department of Orthopaedic Surgery, Mutual Benefit Association for Tokyo Metropolitan Employees, Aoyama Hospital, Tokyo, Japan

* Address correspondence to Keishi Marumo, MD, Department of Orthopaedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461 Japan (e-mail: marumo.kc{at}jikei.ac.jp).

Background: There is little information documenting whether the phenomenon of "ligamentization," as proposed by Amiel, occurs in the human anterior cruciate ligament after clinically effective reconstruction. To clarify this point, we analyzed biochemical differences between the native anterior cruciate ligament; the patellar, semitendinosus, and gracilis tendons; and anterior cruciate ligaments reconstructed with autografts.

Study Design: Cohort study; Level of evidence, 2.

Methods: Fifty patients who underwent arthroscopically assisted anterior cruciate ligament reconstruction using either semitendinosus and gracilis tendon or bone–patellar tendon–bone autografts were selected for the study. Samples of grafted tissue were collected during arthroscopy and quantitatively analyzed for collagen content and the amount of reducible and nonreducible crosslinks at 4 to 6 postoperative months in patients with semitendinosus and gracilis tendon grafts and at 11 to 13 months in all patients with semitendinosus and gracilis tendon or bone–patellar tendon–bone grafts.

Results: The total collagen content and nonreducible/reducible crosslink ratios increased significantly during the postoperative period (P < .05). The dihydroxylysinonorleucine/hydroxylysinonorleucine ratio was 3.11 ± 0.56 in the native anterior cruciate ligament, 1.21 ± 0.47 in the patellar tendon, and 3.59 ± 1.58 in the anterior cruciate ligaments reconstructed with bone–patellar tendon–bone autografts 1 year after surgery. The dihydroxylysinonorleucine/hydroxylysinonorleucine ratio in both semitendinosus and gracilis tendons was less than 1.0. However, in anterior cruciate ligaments reconstructed with semitendinosus and gracilis tendon autografts, it was 2.34 ± 0.98 at 4 to 6 months and 3.43 ± 1.61 at 11 to 13 months after the operation.

Conclusions: After anterior cruciate ligament reconstruction with autografts, biochemical characteristics of the graft resembled those of the native anterior cruciate ligament. These findings suggest that, regarding the amount of collagen crosslinks and their architecture, the phenomenon of ligamentization occurs in the successfully reconstructed human anterior cruciate ligament within 1 year after operation.

Key Words: anterior cruciate ligament (ACL) • ligamentization • collagen crosslinks • patellar tendon • semitendinosus tendon • gracilis tendon • biochemical study • reconstruction






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