Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

DOI 10.1007/s00167-008-0560-8

KNEE

Graft remodeling and ligamentization after cruciate ligament

reconstruction
S. U. Scheffler F. N. Unterhauser A. Weiler

Received: 29 October 2007 / Accepted: 24 April 2008 / Published online: 31 May 2008
Springer-Verlag 2008

Abstract After reconstruction of the cruciate ligaments,

replacement grafts have to undergo several phases of
healing in the intra-articular graft region and at the site of
graft-to-bone incorporation. The changes in the biological
and mechanical properties of the healing graft in its intraarticular region are described as the ligamentization
process. Significant knowledge has been added in the
understanding of the several processes during the course
of graft healing and is summarized in this article. The
understanding of the spatial and time-dependent changes as
well as the differences between the different models of
graft healing are of significant importance to develop
strategies of improved treatment options in cruciate ligament surgery, so that full restoration of function and
mechanical strength of the intact cruciate ligaments will be
achieved.
Keywords Cruciate ligaments
Graft remodeling

Ligamentization

S. U. Scheffler (&)
F. N. Unterhauser

Center for Musculoskeletal Surgery, Charite,
University Medicine Berlin, Charite Campus Mitte,
Chariteplatz 1, 10117 Berlin, Germany
e-mail: sven.scheffler@gmx.net; sven.scheffler@charite.de
F. N. Unterhauser
e-mail: frank.unterhauser@charite.de
A. Weiler
Zentrum fur Spezielle Gelenkchirurgie, Am Tegeler Hafen 2,
13507 Berlin, Germany
e-mail: weiler@arthroskopie.de

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Introduction
The successful reconstruction of ligamentous structures in
the knee joint, such as the anterior or posterior cruciate
ligaments, requires understanding of several factors. These
are the mechanical properties of the selected graft tissue as
well as the mechanical behaviour and fixation strength of
its fixation materials. However, it is equally important
to understand the biological processes that occur during
graft remodeling, maturation and incorporation. They are
directly affecting the mechanical properties of the knee
joint after cruciate ligament reconstruction and, therefore,
determine the rehabilitation and time course until normal
function of the knee joint can be expected.
Several studies have analyzed the various changes that
occur during graft healing [1, 6, 8, 10, 14, 1922, 25, 26,
2933, 38, 39, 41, 4446, 53, 56]. Two main sites of
healing exist that should be separately assessed, since their
biological processes vary substantially: the intra-articular
graft remodeling, often referred to as ligamentization
and the intra-tunnel graft incorporation, which develops
either by bone-to-bone or by tendon-to-bone healing.
In the beginning of the last century Wilhelm Roux has
already described the law of functional adaptation,
elucidating on the fact that an organ will adapt itself
structurally to an alteration, quantitative or qualitative in
function [39], laying groundwork for later research on
ligamentization. He observed that soft-tissue structures,
such as ligaments and tendons, undergo specific changes in
their mechanical and biological properties, when they are
exposed to a different mechanical loading and biological
environment. Amiel et al. were among the first authors [2,
3], who analyzed the specific functional adaptation of an
ACL replacement graft and postulated the term ligamentizaton. They found a continuous development of a

Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

patellar tendon graft with different biological and

mechanical properties than the ACL into a structure that
closely resembled these properties of the intact ACL. They
defined several phases of characteristic changes: an early
phase with central graft necrosis and hypocellularity and no
detectable revascularization of the graft tissue, followed
by a phase of proliferation, the time of most intensive
remodeling and revascularization and finally, a ligamentization phase that provided characteristic restructuring of
the graft toward the properties of the intact ACL. Amiel
described this process as a transformation, not as a restoration of the native ACL, since characteristic differences
remained between replacement grafts and intact ACL. This
study laid the foundation for increased research efforts to
improve the understanding of the basic science of intraarticular ACL graft healing or ligamentization. It was
recognized that the combined healing of the intra-articular
remodeling and the intra-osseous graft incorporation were
dictating the mechanical function of the joint after ACL
reconstruction.
Most authors have adapted the different phases of
healing and have added significant knowledge to the
principle of ligamentization, which will be outlined in this
manuscript. Differences between basic science in vitro and
in vivo animal studies and human biopsy studies will be
explained and the importance of adequate postoperative
care following cruciate ligament reconstruction will be
highlighted.

Early graft healing phase

The biological changes from the time of cruciate ligament
reconstruction until around the 4th postoperative week can
be outlined as the early graft healing phase.
Most authors agreed, using different in vivo animal
models [3, 4, 7, 22, 42] that this time period is marked
by increasing necrosis, mainly in the centre of the graft
and hypocellularity. Ultrastructural cell changes, such as
mitochondrial swelling, dilatation of the endoplasmic
reticulum and intracytoplasmic deposition of lipids, as well
as macroscopic swelling and increased cross-sectional area,
illustrate these findings [7]. At the same time, no graft
revascularization can be observed [4, 23, 41, 57]. Graft
necrosis leads to a release of several cytokines, such as
TNF-a, interleukin 1-b, interleukin 6 as well as chemokines that trigger a cascade of growth factors expression,
which, in turn, result in cell migration and proliferation as
well as extracellular matrix synthesis and revascularization
[21, 24]. The remodeling process already begins between
the 1st and 2nd week when an influx of cells can be seen
into the grafts periphery [7, 22]. Its intensity increases
continuously with maximum remodeling activity during

835

the proliferation phase between 4 and 10 weeks. Kleiner

et al. [23] and later Yoshikawa et al. [57] were able to
demonstrate that all original graft cells did not maintain
viability and were completely replaced by 24 weeks. They
hypothesized that the source of cells were either the
synovial fluid, cells from the stump of the native ACL or
bone marrow elements originating from drilling maneuvers. Therefore, Arnoczky [4] suggested that preservation
of the ACL stump and the Hoffa fat pad might be beneficial, especially for the early healing period.
Even though beginning disintegration of collagen fibrils
and their orientation can be observed as early as 3 weeks
after reconstruction [7, 14], the grafts overall collagen
structure and its crimp pattern are still maintained [3]. This
explains the only slow decrease in the mechanical properties of the graft at this early healing phase [7, 32, 41].
During the early healing phase the mechanical strength
of the ligamentous reconstruction is becoming significantly
lower than that at the time of implantation and continuous
to losing mechanical strength until around the 6th postoperative week. While at the early healing phase between 2
and 4 weeks the lack of sufficient graft incorporation is the
weak site of the reconstruction with consistent failure by
graft pullout [13, 15, 32, 55], a shift toward the intraarticular graft region must be noted during the proliferative
healing phase when the maximum remodeling activity
seems to interfere with the mechanical strength of the
healing graft [13, 32, 51]. Even though there is deterioration in mechanical strength of the healing graft, the
importance of mechanical loading for the healing tissue has
been shown. Ohno et al. [31] found a significant loss of
tensile strength at 1 week already with further deterioration
until 6 weeks of healing when stress depriving the graft in
vivo. This loss in tensile strength was associated to splitting
and defragmentation of collagen bundles as early as 2
weeks. On the other side, overloading of the graft can also
lead to impaired graft healing. Tohyama et al. found that a
substantial increase of tendon stress resulted in substantially reduced tensile strength as early as 3 weeks, contrary
to only a slight increase in tendon stress, which did not
significantly impair the mechanical strength [46]. It is
agreed that ACL graft healing can only progress if
mechanical loading occurs, however the most adequate
magnitude at the varying phases of healing is still not
clearly defined.

Proliferation phase of graft healing

The proliferation phase is characterized by a maximum of
cellular activity and changes of the extra-cellular matrix,
which are paralleled by the lowest mechanical properties of
the reconstructed knee joint during healing. Since cellular

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Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

Fig. 1 ACL graft at 6 weeks of

healing (MassonGoldner
trichrome staining). a graft
hypercellularity (4009) with
b cellular invasion into the
periphery and remaining
acellular areas of the graft
(1009) and c hypervascularity
at the areas of increased cellular
density (1009,
immunohistochemistry, F VIII)

proliferation has already begun during the early healing

period, there is a continuous transition between these two
phases. However, with the most characteristic changes
occurring between the 4th and 12th postoperative week,
this phase is referred to as the proliferation phase of ACL
graft healing.
During this phase, cellularity constantly increases and
substantially surpasses that of the intact ACL as it was
observed in various in vivo animal models [5, 18, 42, 49,
55]. Cell clusters are found at the perimeter of the graft
around 6 weeks with large acellular areas remaining in the
grafts center (Fig. 1). These hypercellular regions were
shown to consists of mesenchymal stem cells [42] and
activated fibroblasts [24] that are actively secreting several
growth factors, such as bFGF, TGF-b-1 and isoforms of
PDGF to initiate and maintain graft remodeling. Kuroda
et al. [24] found that the release of these growth factors
peaks between the 3rd and 6th week and almost completely
ceases at 12 weeks of healing, which lends further explanation for the maximum remodeling activity during this
proliferation phase. Slowly, a more even distribution of
cells throughout the graft develops thereafter. Cell numbers
are still increased, but recede toward the intact ACL cellularity at the end of the proliferation phase [40, 55]. An
increased number of specific fibroblasts, so-called myofibroblasts, are also found during this healing phase [50, 54].
These fibroblasts have the ability to exert isometric tension
on its surrounding cellular and extra-cellular matrix. In the
intact ACL they seem to be responsible for the crimping
structure of the collagen fibers [28]. These contractile

123

fibroblasts are progressively expressed during the first three

postoperative months [40, 54] in the healing ACL graft,
when they seem to be responsible for the restoration of the
in situ tension that is required for the later ligamentization
process.
At the same time of increased cellular proliferation,
intense revascularization of the graft tissue is found from
the 4th postoperative week on [4, 10, 40, 49, 51] (Fig. 3).
Yoshikawa et al. [56] showed up-regulated expression of
VEGF, a potent stimulator of angiogenesis, already at 23
weeks post reconstruction, which is triggered by hypoxia
during the avascular necrosis of the early healing phase
[19]. However, they did not find a significant increase in
vascular outgrowth before the 4th and 8th week, confirming the descriptive findings of other previously published
studies. Petersen [35] and Unterhauser et al. [49] independently showed that revascularization progresses from
the periphery of the graft toward the entire graft diameter at
the end of the proliferation phase around 12 weeks of
healing (Fig. 3). Vascular density then returns to values of
the intact ACL during the phase of ligamentization by
6 months [35, 49]. It is assumed that this intense revascularization triggers and retains the maximal remodeling
activity. It has been a matter of debate, whether such
increased revascularization is beneficial to the healing of
the graft. Recent studies found that up-regulation of
revascularization, e.g., by exogenous application of VEGF,
enhanced cellular infiltration and fibroblast expression
during the proliferation phase of healing, but this also
induced a significant deterioration to the mechanical

Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

837

Fig. 2 Change in collagen

crimp during graft healing
(polarized light microscopy
2009, sheep model adapted
from Ref. [40])

properties of the graft [57]. Several other authors were able

to relate the increased revascularization [51] and extracellular infiltration [45] to the decline in the grafts
mechanical properties. These findings support the reports
of numerous other studies that all found the mechanical
properties to be at its minimum around the proliferation
phase of healing at 68 weeks [5, 6, 13, 15, 18, 32, 36, 40,
42, 47, 53, 55]. Also, the loss of regular collagen orientation and crimp pattern, which has progressed since the
early healing phase has been identified to play a role in the
reduction of the mechanical strength of the healing graft
and it is not until the ligamentization phase that a slow
restoration of the collagen orientation and crimp pattern
can be observed [3, 18, 40, 55] (Fig. 2). At the same time a

significant decrease in collagen fibril density was shown,

which is followed by increased collagen synthesis [43] and
a subsequent return to values of the intact ACL at 12 weeks
[55]. However, during the restoration of collagen density a
shift can be observed from large diameter collagen fibrils
(that are dominating in the intact ACL, patellar or hamstring tendon graft) to small diameter fibrils [17, 23, 48,
55], which were shown to provide less mechanical strength
than large diameter fibrils [12, 33]. Bosch et al. also found
an increased expression of collagen type III in the healing
graft [8], which might add further knowledge why a full
restoration of the mechanical strength of the intact cruciate
ligaments has not been observed in any in vivo model even
after 2 years of healing.

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The substantially reduced mechanical properties of

healing grafts in animal models seem to contradict the
successful clinical outcomes after ACL reconstruction with
immediate aggressive rehabilitation in humans. Several
human biopsy studies found significant differences
between the remodeling activity of human ACL grafts
during the first 3 months and the healing graft in animal
models. While the healing phases of animal models (graft
necrosis, recellularization, revascularization) are also
found in human ACL graft biopsies [20, 37], the remodeling activity of human ACL grafts seems to be reduced.
The complete loss and replacement of all intrinsic graft
cells by extrinsic cells has not been observed shown in the
human healing ACL graft [20, 37]. Rougraff et al. [37]
found viable intrinsic graft cells in human biopsy specimens at all time points between 3 and 8 weeks after ACL
reconstruction. Also, the excessive graft necrosis observed
in animal studies, could not be confirmed in humans, where
necrosis or degeneration never involved more than 30% of
the grafts biopsies. Large areas of the human healing graft
seem to stay unchanged displaying tendinous structure with
normal collagen alignment and crimp pattern [20]. These
areas were histologically identical to the native graft tissue,
suggesting survival of portions of the original graft. Neovascularization was also found, but did not seem to be as
excessive as in the animal model [20]. Loss of collagen
organization was only detected in areas of neovascularization in human biopsies, which corresponds to the
findings in animal models. These findings might explain
why early loading and aggressive rehabilitation during
the first three postoperative months after human ACL
reconstruction did not result in a significant increase in
failure rates. However, human biopsy studies confirm
the remodeling cascade of (very limited) graft necrosis,
recellularization, revascularization and changes in collagen
crimp and composition during the early healing and proliferation phases [58], suggesting that also the human ACL
graft might have its lowest mechanical strength around 68
weeks postoperatively. It will have to be determined what
loading of the healing graft is most appropriate at this
phase of healing. It must be high enough to stimulate graft
cells to produce cellular and extra-cellular components for
preservation of graft stability, but without compromising
graft integrity, which might result into early stretch-out of
the ACL reconstruction.

Ligamentization phase of graft healing

The ligamentization phase follows directly after the proliferation phase and involves the ongoing process of
continuous remodeling of the healing graft toward the
morphology and mechanical strength of the intact cruciate

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Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

ligaments. A clear endpoint of this phase cannot be defined

since certain changes still occur even years after reconstruction. It is still a matter of debate, whether a full
restoration of the biological and mechanical properties of
the intact ACL is possible or whether it is more a transformation of graft tissue that resembles but not fully
replicates the properties of the intact ACL.
It was shown in animal studies that cellularity slowly
returns to values of the intact ACL between 3 and 6 months
after reconstruction [10, 40, 49, 51]. The typical ovoid
shape of metabolically active fibroblasts slowly changes
into the less metabolically active shape of linear spindle
like fusiform cells that are normally seen in the intact ACL.
Vascularity throughout the graft decreases and returns
to values of the intact ACL and vessels become evenly
distributed throughout the entire graft between 6 and 12
months [4, 10, 40, 49, 51, 56] (Fig. 3). It has also been
shown in rabbit, dog and sheep models [3, 30, 51, 52] for
certain extra-cellular matrix proteins, such as glycosaminoglycans, and collagen cross-links, that the healing graft
undergoes a transformation from its initial tissue properties, e.g., a patellar tendon or free soft-tissue tendon graft,
to properties of the intact ACL during this ligamentization
phase [3, 30] as early as 6 months. While certain biological
features of the healing graft have been reported to return
to the morphology of the intact ACL, several differences
remain, especially regarding the extra-cellular matrix.
Collagen fibers regain their organization into fascicles after
complete loss of alignment and initial dense packaging
during the ligamentization phase, which microscopically
resembles the appearance of the intact ACL around 612
months after reconstruction [40, 54]. But their initial loss in
collagen crimp and strict parallel alignment of the proliferation phase is only partially restored. A regular crimp of
the collagen fibers can be seen as early as 6 months, but
even after 2 years its frequency stays increased compared
to the intact ACL as shown in sheep [40, 54]. The change
from a bimodal distribution of small and dominating large
collagen fibers of the patellar or hamstring tendon graft
to a unimodal pattern of only small collagen fibers of
the healing graft does not change during the phase of
ligamentization [18, 25, 55] (Fig. 4). The heterogeneous
composition of collagen fibers of varying diameter of the
intact ACL is never restored [1]. The increased synthesis of
collagen type III of the proliferation phase decreases during
the ligamentization phase, but continues to sustain in significantly higher concentrations than in the intact ACL
even at 2 years [7, 34]. Ng et al. found in a dog model of
ACL reconstruction that type III collagen also remained
increased in the remodeling graft at 1 year, but returned to
values of the intact ACL by 3 years, suggesting that the
ligamentization process might continue longer than previously expected [30]. Type III collagen is normally found in

Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

839

Fig. 3 Revascularization
during graft healing

Fig. 4 Collagen remodeling of

a sheep ACL graft (continuous
shift from the bimodal collagen
diameter distribution of the
initial soft-tissue graft (sheep
long flexor tendon) to a
unimodal small diameter
collagen fibril distribution at
52 weeks and comparison to the
heterogenous collagen fibril
diameter of the intact ACL)

scar or early ligamentous repair tissue and has a lower

mechanical strength than type I collagen. The findings of
persistency of small diameter collagen fibrils and increased

type III collagen content are, therefore, especially important to understand why all animal models demonstrated
significantly lower mechanical properties of the healing

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graft than that of the intact ACL even after long-term

healing of up to 2 years [7, 13, 18, 30, 40, 51, 53]. It has
been shown that the mechanical properties of the ACL
reconstructed knee joints improve substantially during the
phase of ligamentization and reach their final maximum
properties at around 1 year. But until now there has not
been a single animal study that demonstrated that the
structural properties (e.g., failure load, stiffness) of the
healing graft could surpass 5060% of the intact ACL [5, 6,
10, 13, 18, 29, 30, 32, 40, 51, 53]. Some studies were able
to show that these compromised mechanical properties
would still allow for restoration of anteriorposterior (ap)laxity to the laxity of the contra-lateral intact ACL [53], but
others observed significant lower ap-laxity even 3 years
after reconstruction [29]. In summary, in animal models
overall restoration of graft integrity and histological
appearance is completed between 6 and 12 months of
healing, acquiring similar morphology of the intact ACL.
This is also substantiated by the mechanical properties that
reach their maximum strength around 12 months without
any further significant changes thereafter. However, characteristic differences, especially in extra-cellular matrix
composition, remain and do not reach the initial mechanical strength of the intact ACL.
While human biopsy studies showed substantial differences from animal models for the proliferation phase, the
ligamentization phase seems to be rather similar in both
models in terms of biological progression. However, the
timeline of these biological changes appears to be different
between human and animal models. Rougraff et al. [38]
analyzed 23 biopsies of human patellar tendon ACL
reconstruction between 3 weeks and 6.5 years postoperatively. They found that necrosis took place in much smaller
areas of the graft at 3 and 6 week biopsies than it was
shown in animal models. However, they found that overall
degeneration, even though limited compared to animal
models, increased until 610 months and only slowly
disappeared between 1 and 3 years postoperatively.
Neovascularity and hypercellularity only slowly appeared
and carried on until 10 months, which differs from observations in animal models. Some non-biopsy studies that
evaluated graft revascularization, using gandolinium
enhanced MRI during the course of healing for 2 years
[16], could not detect any revascularization except from the
periligamentous ACL graft tissue, which is in contrast to
the findings of Weiler et al. [51], who analyzed his sheep
ACL reconstruction also with gandolinium enhanced MRI
and could detect significantly upregulated neovascularization during the first three postoperative months. This
underlines the differences in remodeling activity between
humans and animal models, even though all human biopsy
studies have shown that neovascularisation does occur, but
that the extent of vascularity might be below the threshold

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Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

detectable with gandolinium enhanced MRI. Overall,

Rougraff et al. [38] concluded that the proliferation phase
seemed to be delayed compared to animal models with the
highest remodeling activity between 3 and 10 months.
Identical findings were made by Falconiero et al. [11] using
patellar tendon and hamstring tendon ACL reconstruction.
They found that hypercellularity and hypervascularity had
not returned to control intact ACL values before 612
months with fiber alignment being restored around 6
months. No details are given on ultrastructural differences
between the healing graft and the intact ACL in this study.
Full histological maturity was not found before 12 months
of healing. Other studies [1, 38] even found increased
cell counts and differing fiber alignment beyond 3 years
with graft being indistinguishable from the intact ACL
as late as in 3 year biopsies. Human biopsy studies that
analyzed changes of the extracellular matrix observed
changes that are in line with the findings of animal models.
Marumo et al. [27] found that the collagen cross-links
(dihydroxylysinonorleucine/hydroxylysinonorleucine ratios)
of patellar tendon and hamstring tendon autografts had
changed from time 0, when they were significantly different from the intact ACL, to 1 year postoperatively, when
both grafts had acquired cross-link ratios that were identical to the intact ACL, confirming the ligamentization
process found in animal models. Interestingly, biopsy
specimens taken at 6 months still showed significantly
different cross-link ratios of the healing grafts compared to
the intact ACL, which is different from the earlier crosslink restoration found in animal models. This also confirms
the differing timeline of the remodeling of human ACL
grafts. Regarding collagen remodeling, Zaffagnini et al.
[58], Cho et al. [9] and Abe et al. [1] independently confirmed the findings of Weiler et al. [55] and others [18, 25]
that patellar tendon [1, 58] and hamstring tendon [9] ACL
grafts showed a replacement of large by small diameter
fibrils, which did not change even after more than 2 years
after reconstruction, confirming the observations made in
animal models. They concluded similar to the findings by
Bosch et al. in the animal model that ACL grafts undergo a
process of adaptation rather than full restoration of the
intact ACLs biological properties.
It is important to understand that the results of graft
healing studies in animal models cannot be directly applied
to the human ACL patient. The biological processes are
similar, but the intensity of graft remodeling in humans is
significantly lower than in animal models. Graft integrity is
much less compromised during the early healing and proliferation phase in human ACL grafts, which might allow
for the assumption that the mechanical properties are also
substantially higher than in animal models during the first
three postoperative months. Regardless of any model,
whether human or animal, an adaptation of the healing

Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

graft toward the intact ACL occurs. However, a full restoration of either the biological or mechanical properties of
the intact ACL does not seem to be achieved. Still, clinical
outcome studies have clearly shown that patients can return
to even most strenuous activities after primary ACL
reconstruction at 6 months. This is confirmed by human
biopsy studies that revealed an intact, fully viable graft at
this time point. However, no final conclusions can be
drawn on the mechanical strength of healing ACL grafts in
humans with no available techniques for in vivo measurement of their mechanical properties.
Even though it is not fully understood what the exact
mechanisms are that guide the ligamentization process, it
seems to be most important that knee joint mechanics are
restored by cruciate ligament reconstruction, so that the
loading conditions of the intact ACL are precisely replicated. Only, if the reconstruction can restore the anatomy
of the intact cruciate ligaments, knee joint motion will
provide the same mechanical stimulus to the healing ACL
graft as to the intact ACL. Only then adequate moderate
remodeling will occur that will maintain initial graft
integrity and (partial) cell viability, while initiating cellular
and extra-cellular proliferation and differentiation to adapt
the graft to its new biological and mechanical environment.
It will have to be determined what loading is adequate for
the graft at its different phases of healing, so that it can
continue to function exactly as the structure it reconstructed. Future research will have to be directed to (a)
optimizing cruciate ligament reconstructions to fully
restore the anatomy and function while providing the
mechanical strength of the intact cruciate ligaments, (b)
developing biological treatment options that impact on
graft healing especially during the early and proliferation
phase to optimize extra-cellular matrix remodeling and
avoid excessive remodeling activity that might impair
mechanical integrity of the healing graft and (c) to better
differentiate the good from the bad remodeling
changes, so that the time to return to full activity without
any restrictions can be reduced.
References
1. Abe S et al (1993) Light and electron microscopic study of
remodeling and maturation process in autogenous graft for
anterior cruciate ligament reconstruction. Arthroscopy 9(4):394
405
2. Amiel D et al (1984) Tendons and ligaments: a morphological
and biochemical comparison. J Orthop Res 1(3):257265
3. Amiel D et al (1986) The phenomenon of ligamentization:
anterior cruciate ligament reconstruction with autogenous patellar
tendon. J Orthop Res 4(2):162172
4. 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):217224

841
5. Ballock RT et al (1989) Use of patellar tendon autograft for
anterior cruciate ligament reconstruction in the rabbit: a longterm histologic and biomechanical study. J Orthop Res 7(4):474
485
6. Blickenstaff KR, Grana WA, Egle D (1997) Analysis of a semitendinosus autograft in a rabbit model. Am J Sports Med
25(4):554559
7. Bosch U, Kasperczyk WJ (1992) Healing of the patellar tendon
autograft after posterior cruciate ligament reconstructiona
process of ligamentization? An experimental study in a sheep
model. Am J Sports Med 20(5):558566
8. Bosch U et al (1994) The patellar tendon graft for PCL reconstruction. Morphological aspects in a sheep model. Acta Orthop
Belg 60(Suppl 1):5761
9. Cho S et al (2004) Electron microscopic evaluation of two-bundle
anatomically reconstructed anterior cruciate ligament graft.
J Orthop Sci 9(3):296301
10. Clancy WG Jr et al (1981) Anterior and posterior cruciate ligament reconstruction in rhesus monkeys. J Bone Joint Surg Am
63(8):12701284
11. Falconiero RP, DiStefano VJ, Cook TM (1998) Revascularization
and ligamentization of autogenous anterior cruciate ligament
grafts in humans. Arthroscopy 14(2):197205
12. Flint MH et al (1984) Collagen fibril diameters and glycosaminoglycan content of skinsindices of tissue maturity and
function. Connect Tissue Res 13(1):6981
13. Goradia VK et al (2000) Tendon-to-bone healing of a semitendinosus tendon autograft used for ACL reconstruction in a sheep
model. Am J Knee Surg 13(3):143151
14. Goradia VK et al (2000) Natural history of a hamstring tendon
autograft used for anterior cruciate ligament reconstruction in a
sheep model. Am J Sports Med 28(1):4046
15. Grana WA et al (1994) An analysis of autograft fixation after
anterior cruciate ligament reconstruction in a rabbit model. Am J
Sports Med 22(3):344351
16. Howell SM et al (1995) Revascularization of a human anterior
cruciate ligament graft during the first two years of implantation.
Am J Sports Med 23(1):4249
17. Jackson DW et al (1991) The effects of in situ freezing on the
anterior cruciate ligament. An experimental study in goats.
J Bone Joint Surg Am 73(2):201213
18. Jackson DW et al (1993) A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament
reconstruction in the goat model. Am J Sports Med 21(2):176185
19. Jackson JR et al (1997) Expression of vascular endothelial growth
factor in synovial fibroblasts is induced by hypoxia and interleukin 1beta. J Rheumatol 24(7):12531259
20. Johnson LL (1993) The outcome of a free autogenous semitendinosus tendon graft in human anterior cruciate reconstructive
surgery: a histological study. Arthroscopy 9(2):131142
21. Kawamura S et al (2005) Macrophages accumulate in the early
phase of tendon-bone healing. J Orthop Res 23(6):14251432
22. Kleiner JB et al (1986) Origin of replacement cells for the
anterior cruciate ligament autograft. J Orthop Res 4(4):466474
23. Kleiner JB et al (1989) Early histologic, metabolic, and vascular
assessment of anterior cruciate ligament autografts. J Orthop Res
7(2):235242
24. Kuroda R et al (2000) Localization of growth factors in the
reconstructed anterior cruciate ligament: immunohistological
study in dogs. Knee Surg Sports Traumatol Arthrosc 8(2):120
126
25. Liu SH et al (1995) Collagen in tendon, ligament, and bone
healing. A current review. Clin Orthop Relat Res 318:265278
26. Majima T et al (2003) Stress shielding of patellar tendon: effect
on small-diameter collagen fibrils in a rabbit model. J Orthop Sci
8(6):836841

123

842
27. Marumo K et al (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):11661173
28. Murray MM et al (2000) Histological changes in the human
anterior cruciate ligament after rupture. J Bone Joint Surg Am 82A(10):13871397
29. Ng GY et al (1995) Biomechanics of patellar tendon autograft for
reconstruction of the anterior cruciate ligament in the goat: threeyear study. J Orthop Res 13(4):602608
30. Ng GY et al (1996) Long-term study of the biochemistry and
biomechanics of anterior cruciate ligament-patellar tendon autografts in goats. J Orthop Res 14(6):851856
31. Ohno K et al (1993) Effects of complete stress-shielding on the
mechanical properties and histology of in situ frozen patellar
tendon. J Orthop Res 11(4):592602
32. Papageorgiou CD 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(5):620626
33. Parry DA, Barnes GR, Craig AS (1978) A comparison of the size
distribution of collagen fibrils in connective tissues as a function
of age and a possible relation between fibril size distribution and
mechanical properties. Proc R Soc Lond B Biol Sci
203(1152):305321
34. Petersen W, Laprell H (2000) Insertion of autologous tendon
grafts to the bone: a histological and immunohistochemical study
of hamstring and patellar tendon grafts. Knee Surg Sports Traumatol Arthrosc 8(1):2631
35. Petersen W et al (2003) The angiogenic peptide vascular endothelial growth factor (VEGF) is expressed during the remodeling
of free tendon grafts in sheep. Arch Orthop Trauma Surg
123(4):168174
36. Rodeo SA et al (1993) Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg
Am 75(12):17951803
37. 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):914
38. Rougraff B et al (1993) Arthroscopic and histologic analysis of
human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am J Sports Med 21(2):277284
39. Roux W (1905) Die Entwicklungsmechanik; ein neuer Zweig der
biologischen Wissenschaft, vols I & II. Wilhelm Engelmann,
Leipzig
40. Scheffler SU 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. Trans
Orthop Res
41. Shino K, Horibe S (1991) Experimental ligament reconstruction
by allogeneic tendon graft in a canine model. Acta Orthop Belg
57(Suppl 2):4453
42. Shino K 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(5):672681
43. Spindler KP et al (1996) Distribution of cellular repopulation and
collagen synthesis in a canine anterior cruciate ligament autograft. J Orthop Res 14(3):384389

123

Knee Surg Sports Traumatol Arthrosc (2008) 16:834842

44. Tohyama H, Yasuda K (1998) Significance of graft tension in
anterior cruciate ligament reconstruction. Basic background and
clinical outcome. Knee Surg Sports Traumatol Arthrosc 6(Suppl
1):S30S37
45. Tohyama H, Yasuda K (2000) Extrinsic cell infiltration and
revascularization accelerate mechanical deterioration of the
patellar tendon after fibroblast necrosis. J Biomech Eng
122(6):594599
46. Tohyama H, Yasuda K (2002) The effect of increased stress on
the patellar tendon. J Bone Joint Surg Br 84(3):440446
47. Tomita F 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(5):461476
48. Tsuchida T et al (1997) Effects of in situ freezing and stressshielding on the ultrastructure of rabbit patellar tendons. J Orthop
Res 15(6):904910
49. Unterhauser FN et al (2003) Endoligamentous revascularization
of an anterior cruciate ligament graft. Clin Orthop Relat Res
(414):276288
50. Unterhauser FN et al (2004) Alpha-smooth muscle actin containing contractile fibroblastic cells in human knee arthrofibrosis
tissue. Winner of the AGA-DonJoy Award 2003. Arch Orthop
Trauma Surg 124(9):585591
51. Weiler A 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(6):751761
52. Weiler A 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(2):124135
53. Weiler A et al (2002) Tendon healing in a bone tunnel. Part I:
biomechanical results after biodegradable interference fit fixation
in a model of anterior cruciate ligament reconstruction in sheep.
Arthroscopy 18(2):113123
54. Weiler A et al (2002) Alpha-smooth muscle actin is expressed by
fibroblastic cells of the ovine anterior cruciate ligament and its
free tendon graft during remodeling. J Orthop Res 20(2):310317
55. Weiler A et al (2004) The influence of locally applied plateletderived growth factor-BB on free tendon graft remodeling after
anterior cruciate ligament reconstruction. Am J Sports Med
32(4):881891
56. Yoshikawa T 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(9):804810
57. Yoshikawa T et al (2006) Effects of local administration of
vascular endothelial growth factor on mechanical characteristics
of the semitendinosus tendon graft after anterior cruciate ligament reconstruction in sheep. Am J Sports Med 34(12):1918
1925
58. Zaffagnini S et al (2007) Neoligamentization process of BTPB
used for ACL graft: histological evaluation from 6 months to 10
years. Knee 14(2):8793

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