Anterior cruciate ligament reconstruction using cryopreserved irradiated bone-ACL-bone-allograft transplants

Short-Term Evaluation of Bone-ACL-Bone Complex Allograft in ACL Reconstruction in a Rabbit Model

The study is to evaluate incorporation of a bone-anterior cruciate ligament-bone (B-ACL-B) allograft in anterior cruciate ligament (ACL) reconstruction in a rabbit model. A total of 61 New Zealand white rabbits were used, with 23 donor rabbits for harvesting B-ACL-B allografts and 38 recipient rabbits undergoing unilateral ACL reconstruction with B-ACL-B allograft. Animals were euthanized for biomechanical testing, micro-computed tomography examination, histological analysis, multi-photon microscopy and transmission electron microscopy testing at 2, 4 and 8 weeks after surgery. Gross inspection and radiographs confirmed the intact ACL allograft in the proper anatomic position. Progressive healing occurred between the bone block and the bone tunnel as demonstrated by a gradual increase in average bone volume fraction and total mineral density at 4 and 8 weeks. Histological analysis showed new bone formation at the bone block-tunnel interface, with maintenance of the native ACL enthesis. Ultrastructural analysis demonstrated the maintenance of overall collagen matrix alignment, while there was repopulation with smaller diameter collagen fibrils. There was no significant difference between 4 and 8 weeks in mean failure force (p = 0.39) or stiffness (p = 0.15) for the B-ACL-B allografts. This study demonstrates the restoration of the normal anatomy of the ACL and progressive graft incorporation and remodeling using a B-ACL-B allograft for ACL reconstruction in the rabbit knee.

Bone-ACL-bone allograft for anterior cruciate ligament reconstruction: Short-term evaluation in a rabbit model with microcomputed tomography

The standard grafts used for anterior cruciate ligament (ACL) reconstruction are tendon, either patellar tendon, hamstring, or quadriceps. However, the microstructure and composition of tendon differs from ligament. Ideally, the ACL would be replaced with the same tissue. To evaluate the incorporation of a bone-ACL-bone (B-ACL-B) graft for ACL reconstruction, we performed a controlled laboratory study in a rabbit model with microcomputed tomography (μCT). Forty-six New Zealand white rabbits were used, with 17 donor rabbits to harvest bilateral B-ACL-B allografts and 29 rabbits undergoing unilateral ACL reconstruction with B-ACL-B allograft. Knee specimens were collected for biomechanical testing (n = 14) at 4 and 8 weeks and for μCT analysis (n = 15) at 2, 4, and 8 weeks after surgery. Gross inspection and μCT examination confirmed bone blocks in the appropriate anatomic position. Biomechanical tests revealed no difference in mean load-to-failure force for B-ACL-B allografts between 4 and 8 weeks. Progressive healing occurred between the bone block and the tunnel as demonstrated by a gradual increase on average bone-volume fraction and total mineral density (TMD) in both femoral and tibial tunnels. Remodeling of the bone block was evidenced by a significant decrease in TMD of both tibial and femoral bone blocks. This is a report of a novel rabbit B-ACL-B allograft reconstruction model demonstrating early signs of graft remodeling and incorporation. Clinical Relevance: This study demonstrates ACL reconstruction using an anatomically matched ACL allograft, rather than a tendon graft, may be possible based on early findings in this lapine model.

Lateral slit delivery of bone marrow stromal cells enhances regeneration in the decellularized allograft flexor tendon

BACKGROUND/OBJECTIVE

Stem cell-based therapy has been applied to accelerate the revitalization of allograft tendon into a viable and functional tendon. Although many authors have proposed different methods to help the seeded stem cell distribution in the decellularized allograft, limited success has been achieved as tendon is a high dense connective tissue. We hypothesized that bone marrow stromal cells (BMSCs), seeded through the lateral slit, can regenerate the decellularized tendon (DCT) graft. The cell proliferation, cell viability, and tendon-specific gene expression are increased with the seeded cell density.

METHODS

Eighty-seven flexor digitorum profundus tendons were equally and randomly divided into 6 treatment groups that were seeded with low-density (2 × 107 cells/mL) and high-density (5 × 107 cells/mL) BMSCs through lateral slits cultured for 2 and 4 weeks, DCT without cells, and fresh live tendons. Tendons were evaluated for cell distribution, cell proliferation, cell viability, gene expression of Collagen I and Collagen III, tenogenic markers, and MMPs.

RESULTS

Histologic evaluation revealed BMSCs distributed from the lateral slit to the whole DCT. BMSCs were proliferated and kept viable in lateral slit decellularized tendon (LSDCT) in both seeded cell density groups after 2 and 4 weeks of culture. However, no significant differences in the cell proliferation between both cell density groups at 2 and 4 weeks of culture were observed. The lowest cell viability was found in the high-density group after 4 weeks of culture. BMSCs in LSDCT showed a significant tendency of higher gene expression of Collagen I, Collagen III, tenascin C, MMP2, MMP9, and MMP13 compared to normal tendons in both cell density groups at 2 and 4 weeks of culture.

CONCLUSION

BMSCs proliferated and remained viable after 2 and 4 weeks of culture with distribution throughout the lateral slits. Lateral slit preparation allows for the effective delivery and maintenance of mesenchymal cells with proliferation and generating a tenogenic behaviour of DCT in both the low and high cell densities in an in vitro model.

THE TRANSLATION POTENTIAL OF THIS ARTICLE

Revitalizing the implanted decellularized allograft is important for clinical application. In this study, we demonstrated that the DCT, with lateral slits, could harbour the seeded stem cell and stimulate proliferation with collagen synthesis. This evidence was presented for clinical application of the lateral slit technique, in DCT grafts, which would repopulate the seeded BMSCs during tendon and ligament reconstruction.

Allograft for knee ligament surgery: an American perspective

PURPOSE

Allografts are frequently use for ligamentous reconstruction at the knee. In the United States, tissue donation and distribution are highly regulated processes with thorough oversight from private and government entities. Allograft is widely available in the United States and allograft procurement is a large industry with varying procurement, sterilization, processing, and distribution procedures. It is important to understand allograft regulation and processing which may affect graft mechanical properties and biological graft integration.

METHODS

English-language literature, United States government and regulatory agency statues pertaining to allograft procurement, distribution, and usage were reviewed and the findings summarized.

RESULTS

During the processing of allograft, multiple factors including sterilization procedures, irradiation, storage conditions, and graft type all affect the biomechanical properties of the allograft tissue. Biological incorporation and ligamentization of allograft does occur, but at a slower rate compared with autograft. For ligamentous reconstruction around the knee, allograft offers shorter operative time, no donor-site morbidity, but has shown an increased risk for graft failure compared to autograft.

CONCLUSION

This article reviews the regulations on graft tissue within the United States, factors affecting the biomechanics of allograft tissue, differences in allograft tissue choices, and the use of allograft for anterior cruciate ligament reconstruction and multiligamentous knee injury reconstruction.

LEVEL OF EVIDENCE

V.

Revitalized and synovialized allograft for intrasynovial flexor tendon reconstruction in an in vivo canine model

This study was to test our hypothesis that flexor tendon reconstruction with an allograft revitalized with bone marrow stromal cells (BMSCs) and synovialized with carbodiimide derivatized autologous synovial fluid (cd-SYN) would result in better digit functional restoration than the conventional allograft tendon. A total of 32 flexor digital profundus tendons from the second and fifth digit of 16 dogs were created a repair failure model first. Then, failed-repaired tendons were reconstructed with either a revitalized-synovialized allograft tendon or a clinical standard autograft tendon (control group). The allograft tendon was seeded with autologous BMSCs in multiple slits and the graft surface was coated with cd-SYN. A 6 weeks after tendon reconstruction, the digits were harvested and evaluated for digit function, adhesion status, tendon gliding resistance, attachment strength, cell viability, and histologic factors. The allograft group had significantly improved digit function compared with the control group through decreased work of flexion, increased digit range of motion under 2-Newton force, and less adhesion score (p < .05). However, the distal attachment-site strength and stiffness in the allograft tendon were significantly weaker than the autografts (p < .05). No significant difference was found for gliding resistance. Histologically, allograft tendons coated with allograft had smoother surfaces and showed tendon-to-bone and tendon-to-tendon incorporation. Viable BMSCs were found in the tendon slits 6 weeks after the graft. In conclusion, cellular lubricant-based modification of allograft tendons improved digit function and reduced the adhesions compared with autograft for flexor tendon reconstruction. However, improvement of graft-to-host tendon healing is still challenging. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Large osteochondral lesions of the femoral condyles: Treatment with fresh frozen and irradiated allograft using the Mega OATS technique

BACKGROUND

The purpose of this study was to review the clinical results of irradiated fresh frozen osteochondral allografts for large osteochondral defects of the knee using the Mega-OATS technique.

METHODS

Nine patients with a mean age of 32.1±6.6 (18 to 44) underwent Mega-OATS transplantation with irradiated (2.5Mrad), fresh frozen distal femur allograft. Three patients also underwent ACL-reconstruction; one patient a high tibial osteotomy. The underlying indication was osteochondrosis dissecans in four and trauma in five patients. The defect size was 25×25mm in three patients and 30×30 in six patients and the depth ranged from eight to 14mm. All OCD lesions were located on the medial femoral condyle; two of the traumatic lesions were located on the lateral femoral condyle. Clinical outcome was assessed using the Lysholm and IKDC scores. Radiographic incorporation was evaluated using serial radiographs and MR imaging at one year post surgery. All patients were reviewed at three, six, 12, and 24months following surgery.

RESULTS

The Lysholm (IKDC) score improved significantly (p=0.02 resp. p=0.007) within and between patients during the follow-up period from 40.9 (37) to 90.9 (87.1) at 2years. Radiographic union was observed in all patients at three months; on MR imaging at one year osseous integration was observed in eight patients. Graft subsidence with loss of the overlying cartilage was observed in one and subchondral cystic changes at the implantation side were seen in another patient.

CONCLUSION

The results of this case series suggest that irradiated osteochondral allograft provides significant medium-term clinical improvement in patients treated for large osteochondral lesions of the femoral condyles.

LEVEL OF EVIDENCE

IV, case series.

Influence of sterilisation methods on collagen-based devices stability and properties

Sterilisation is essential for any implantable medical device in order to prevent infection in patients. The selection of the most appropriate sterilisation method depends on the nature and the physical state of the material to be sterilised; the influence of the sterilisation method on the properties of the device; and the type of the potential contaminant. In this context, herein we review the influence of ethylene oxide, γ-irradiation, e-beam irradiation, gas plasma, peracetic acid and ethanol on structural, biomechanical, biochemical and biological properties of collagen-based devices. Data to-date demonstrate that chemical approaches are associated with cytotoxicity, whilst physical methods are associated with degradation, subject to the device physical characteristics. Thus, the sterilisation method of choice is device dependent.

Bony incorporation of soft tissue anterior cruciate ligament grafts in an animal model: autograft versus allograft with low-dose gamma irradiation

BACKGROUND

The effect of low-dose gamma irradiation on healing of soft tissue allografts remains largely unknown.

HYPOTHESIS

The authors hypothesized that soft tissue allograft healing to bone would be delayed compared with that of autograft tissue and that low-dose (1.2 Mrad) gamma irradiation would not affect the healing response of allograft tissue after anterior cruciate ligament (ACL) reconstruction.

STUDY DESIGN

Controlled laboratory study.

METHODS

Forty-eight New Zealand White rabbits underwent bilateral ACL reconstructions with semitendinosus tendon graft. Sixteen rabbits were reconstructed with autografts and the remainder with allografts. The 32 allograft rabbits each received 1 irradiated allograft (1.2 Mrad), with the contralateral leg receiving a nonirradiated allograft. Animals were euthanized at 2 weeks or 8 weeks postoperatively. Tensile stiffness, maximum load, and displacement at maximum load were measured. Tibial and femoral segments were sectioned perpendicular to the tunnel axis allowing for histologic and histomorphometric analyses at the tendon-bone interface.

RESULTS

There were no significant differences between the maximum load or stiffness values among all groups at 8 weeks. At 2 weeks, autograft exhibited significantly (P < .01) lower maximum load than did the nonirradiated grafts. Regarding histology, at both 2- and 8-week time points, autograft tendon displayed more advanced degenerative and remodeling processes in comparison with irradiated allograft and nonirradiated allograft.

DISCUSSION

The maximum load and stiffness of a healing tendon allograft in ACL reconstruction appear to be unaltered by low-dose (1.2 Mrad) irradiation. At 8 weeks, there were no biomechanical differences in tendon-bone healing of allografts when compared with autograft controls. Histologic analyses suggested a faster remodeling response in autograft specimens in comparison with allografts at both time points.

CLINICAL RELEVANCE

The findings support the contention that low-dose gamma irradiation is safe for sterilization of ACL soft tissue allografts without compromise of graft properties at early time points.

Comparison of revision rates in bone-patella tendon-bone autograft and allograft anterior cruciate ligament reconstruction

This study compared the revision rates after autograft and allograft bone-patella tendon-bone anterior cruciate ligament (ACL) reconstruction. All bone-patella tendon-bone ACL reconstructions performed by a single surgeon between January 2000 and December 2006 were identified by retrospective chart review. Two hundred twenty-three patients met the inclusion criteria and 173 patients were available for follow-up. One hundred forty-two patients underwent bone-patella tendon-bone autograft reconstruction, and 31 patients underwent bone-patella tendon-bone allograft reconstruction. At a mean follow-up of 49 months (range, 11-91 months), revision rates were 0.7% (1/142) in the bone-patella tendon-bone autograft group versus 9.7% (3/31) in the bone-patella tendon-bone allograft group (P=.02). Subjective International Knee Documentation Committee (IKDC) scores of nonrevised (surviving) grafts in the bone-patella tendon-bone autograft group were 98.3 versus 95.2 in the bone-patella tendon-bone-allograft group (P=.0006). Tegner scores of nonrevised grafts in the bone-patella tendon-bone-autograft group were 6.2 vs 6.5 in the bone-patella tendon-bone-allograft group (P=.03). Fourteen of the 31 (45%) allografts were irradiated and all failures occurred in irradiated grafts. When irradiated grafts were excluded, no difference in revision rates was found. Anterior cruciate ligament reconstruction with the use of bone-patella tendon-bone allografts is associated with a higher revision rate when compared to bone-patella tendon autograft reconstruction. In addition, when comparing surviving grafts, the subjective IKDC scores are higher in the autograft group. When irradiated grafts are excluded, no difference in revision rates was found. Surgeons should be aware of the higher revision rate associated with allograft ACL reconstruction when counseling patients on graft options.

Effectiveness of three extraction techniques in the development of a decellularized bone–anterior cruciate ligament–bone graft

In this study, porcine bone-anterior cruciate ligament-bone (B-ACL-B) grafts were decellularized using one of three protocols incorporating surfactants lauryl sulfate (SDS), Triton X-100, and/or an organic solvent (tributyl phosphate (TnBP)). The effectiveness of Triton-SDS, Triton-Triton or Triton-TnBP treatments in removing cellular materials was determined and possible changes in biochemical composition and mechanical properties due to each treatment were investigated. Treatment with Triton-SDS was most effective at removing cell nuclei and intracellular protein (vimentin) from the ACL but affected both the collagen and glycosaminoglycan (GAG) components of the extracellular matrix while increasing the tensile stiffness of the ligament. Triton-Triton was the least effective of the three treatments in terms of cellular extraction, but did not significantly change the mechanical and biochemical properties of the ACL. Triton-TnBP matched the level of decellularization achieved by Triton-SDS in terms of visible cell nuclei; however, the extraction of intracellular vimentin was less consistent. TnBP treatment also slightly decreased the collagen content of the ACL but did not alter its mechanical properties. Overall, all three decellularization treatments maintained adequate mechanical and biochemical properties of B-ACL-B grafts to justify the further investigation of all three decellularization protocols. The selection of a superior treatment will depend on future studies of the propensity of treated tissues for repopulation by host ACL fibroblasts and, ultimately, on any immunogenic and/or remodeling host response induced in vivo.