Effects of Platelet Concentrate and a Bone Plug on the Healing of Hamstring Tendons in a Bone Tunnel

1

PLATELET CONCENTRATE AND BONE PLUG AS ENHANCERS OF

HAMSTRING TENDON AUTOGRAFT MATURATION IN ANTERIOR CRUCIATE

LIGAMENT RECONSTRUCTION

Authors:

1. Mario Orrego MD - Correspondence Author*†

Departamento de Traumatología Hospital Militar de Santiago.

Holanda 050, Vitacura, Santiago, Chile.

Phone: +56-2-3653059

Mail: [email protected].

2. Catalina Larrain MD*



3. Rodrigo Mardones MD*‡



Clínica Las Condes, Lo Fontecilla 0441, Las Condes, Santiago, Chile.

4. Julio Rosales MD*

Departamento de Radiología Hospital Militar de Santiago.


2

5. Luis Valenzuela MD*†



6. José Matas MD*



* Hospital Militar de Santiago

† Clínica Dávila

‡ Clínica Las Condes

3

PLATELET CONCENTRATE AND BONE PLUG AS ENHANCERS OF

HAMSTRING TENDON AUTOGRAFT MATURATION IN ANTERIOR CRUCIATE

LIGAMENT RECONSTRUCTION

ABSTRACT

- Background: The Semitendinosus and Gracilis tendon graft (ST-G) requires a longer maturation

period than its bone-tendon-bone (BTB) homologue. The use of enhancement factors as a Platelet

Concentrate and a Bone Plug would accelerate the maturation process.

- Methods: 108 patients requiring ACL reconstruction were prospectively randomized into 4 groups:

Control (27 patients), Platelet Concentrate (26 patients), Bone Plug (28 patients) and a combination

of Platelet Concentrate and Bone Plug (27 patients). Magnetic Resonance Imaging (MRI) studies

were carried out 3 and 6 months after surgery. Maturation of the graft was evaluated at the femoral

tunnel using MRI maturation criteria: intensity signal, osteoligamentous interface and widening of

the femoral tunnel.

- Results: At the 3rd month, no differences were found among the groups regarding MRI maturation

criteria. At the 6th month, in the Control group 76% of the patients had a low intensity signal, while

in the Platelet Concentrate group the low intensity signal was present in 100% of the patients (p =

0.036). No significant differences were observed regarding the interface among the various groups

in the study, despite there being a positive trend (absence of interface) with the use of the Platelet

Concentrate (87% of the patients with Platelet Concentrate vs. 65% of the patients in the Control

group). Tunnel widening was seen in 40% of the patients in the control group, 33% of the patients of

the Platelet Concentrate group, 20% of the patients of the group with Platelet Concentrate plus

Bone plug and in 12% of the patients of the Bone Patelet group (p = 0.047).

4

In all 108 cases there was maturation, comparing results obtained at the 3rd and 6th month,

regarding all parameters.

- Conclusions: The ST-G graft matured in all the groups between third and sixth month.

The maturation process evaluated with MRI increased within the use of the Platelet Concentrate as

measured by signal intensity.

The use of a Bone Plug effectively prevented tunnel widening.

The BP and PC combination does not have a synergic effect as compared to PC or BP individually.

- Level of Evidence: Level I, Randomized controlled trial.

Key Words: Reconstruction of the Anterior Cruciate Ligament, Semitendinosus, Gracilis, Platelet

Concentrate, Growth Factors, Bone Plug, Structural Bone Graft.

5

INTRODUCTION

Rupture of the anterior cruciate ligament (ACL) is the most frequent severe

traumatic injury of the knee. Numerous articles state that the general incidence is 1

for every 3000, with 100,000 to 200,000 new reconstructions per year in USA 1,2,3,4 .

The explosive growth of sports activities, as well as the greater range of age

groups who practice these activities, explains the rise on incidence and creates

concern about the future management of this pathology 5,6,7 .

In our country, reconstruction of the ACL has experienced a vertiginous

growth in the last decade in terms of frequency, variety of techniques and types of

grafts used to replace the ACL 8.

At present, most of the reconstructions are made with autografts or

allografts9. The “Gold Standard” for the autograft group is the use of the central third

of the knee extensor mechanism, a technique known as bone-tendon-bone (BTB)

10,11. Nevertheless, it is often associated with residual pain in the anterior pole of the

donor knee, as well as to a number of complications stemming from the harvesting

in the donor location 12,13,14,15. Therefore, other alternatives are being tried, such as

the use of semitendinous-gracilis, whose clinical results are equivalent 4,8,16.

However, this technique does have some theoretical disadvantages, mainly those

related to slower maturation and integration within the bone tunnels

17,18,19,20,21,22,23,24; difficulties in fixation and greater residual lassitude of the graft

12,14,25,26,27,28,29 . The use of bone plugs at the ends of the graft have resulted in better

integration to the tunnels in vitro 30,31 and in vivo studies21,31,32,33,34,35,36,37, 38,39,40,41.

6

Ligament autograft maturation process goes through the various stages

common to all healing process (inflammation; proliferation or reparation; and

remodeling) 42,43,44. Studies have shown that growth factors are present in each of

these stages 45,46,47,48,49 . Growth factors are protein chains released by the many

cells involved in this process. These factors activate membrane receptors in the cell

walls (integrines). Their main roles are to stimulate cell differentiation from stem cells

and to act as mitogenic, quimiotactic and stimulating elements in the production of

collagen matrixes. There are five main mega-families of growth factors involved in

the muscle-skeletal repair process, platelet-derived growth factor (PDGF),

transforming growth factor beta (TGF- ), insulinic growth factor (IGF), basic

fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF) 44.

Numerous animal model studies have shown that the healing process can be

enhanced by adding one or more of these growth factors 3,44,49,50,51,52,53,54,55,56,57,58,59.

In particular, their use on ligamentous tissue has been shown to have a positive

effect on the hystological aspect and on the biomechanical endurance in various

models 54,60,61,62,63

One of the best sources of growth factors are blood platelets, which release

large quantities of activated microgranules, which are rich in growth factors, during

fibrin clot formation 64. Platelet-concentrate-rich samples have been used in humans

and animals to accelerate the healing process 27,46,50,52,64,65,66,67,68,69,70. In clinical

practice, several authors related to maxillofacial surgery have shown the usefulness

of platelet-rich plasma obtained from autologous samples taken from patients who

undergo implant procedures 71,72. Its use is currently being explored for muscle-

skeletal pathologies 3,45,49,50,51,54,59,62,63,67,73,74,75 .

7

The objective of this study is to evaluate the potential enhancing effect of the

platelet concentrate and/or the bone plug when the ACL is reconstructed using an

ST-G graft.

MATERIALS AND METHODS

Study Design

A double-blind, prospectively randomized study was performed.

One hundred and sixteen (116) patients who had been operated on by the

same team of Hospital Militar de Santiago surgeons were prospectively included in

the study between January 2005 and December 2006. Of the 116 patients included

in the study, 86% (99/116) were males and 14% (17/116) were females. The

average age of the patients was 30 years, ranging from 15 to 57 years old. In 60% of

the cases (70/116) the injured knee was the right one, while 40% of the patients had

been injured in their left knees. In 63% (73/116) of the cases, the injury had been

caused while engaging in contact sports. The inclusion criteria were: a mature

skeleton; clinical instability and MRI showing total rupture of the ACL, without any

other associated capsulo-ligamentosus injuries; and voluntary acceptance to

participate in the study, according to the protocol authorized by the hospital’s ethics

committee.

The patients were randomly divided into 4 groups of 29 people each. Eight (8)

of the patients included in the study were lost during the follow-up, so the final

sample included 108 people, who were divided as follows:

8

- Group I, Control: ACL Reconstruction with quadruple ST-G fixed proximally

with a biodegradable transfixing screw (Arthrex, Naples, Florida) and a

distally biodegradable interferencial screw (Arthrex, Naples, Florida) (Figure

N°1). 27 patients

- Group II, ACL Reconstruction plus Platelet Concentrate GPS II ® (PC)

(Biomet…) 26 patients

- Group III, ACL Reconstruction plus Bone Plug (BP) Biomet Trefin kit ®

(Biomet….) 28 patients

- Group IV, ACL Reconstruction plus Platelet Concentrate and Bone Plug (PC

+ BP). 27 patients

These four groups were comparable.

Surgical Technique

Collection of Platelet Concentrate (PC):

A blood sample of 67 cc of blood was taken from the patient during anesthetic

induction in order to collect the PC and the thrombin.

1. PC: 3 cc of an anti-clotting agent is added to 57 cc of blood using the

Biomet GPS II® kit, to which an ultra-filtering system is added in order to obtain a

higher platelet concentration. The sample is spun during 15 minutes and, after this

period, approximately 10 ml of PC are collected.

9

2. Thrombin: 10 ml of the patient’s blood (without the anti-clotting agent) are

poured into the test tube. After the sample clots are added, it is centrifuged at 200

RPM during 5 minutes and, after this period, the skim is collected. Ten parts of this

product are mixed with one part of Calcium Chloride (10:1).

Once the process is completed, the application system is set up (Figure N°2).

Adding the PC: Once the quadruple ST-G graft is prepared, 5 cc of the PC

are added between the strands of the graft, helping it to adhere and integrate itself

by repeatedly puncturing it throughout its whole length with a N° 21 needle.

Next, the graft with the concentrate is inserted along the bone tunnels (Figure

N°3). Once it is fixed, 1 cc of PC is injected into the femoral tunnel.

Collection of the Bone Plug:

Using the trefin kit (Biomet,…..) (Figure N°4-A) when the tibia tunnel is made,

a spongy plug of approximately 7 mm in diameter and 30 mm long is obtained

(Figure N°4-B). This plug is compacted into its final dimensions of 2.5 mm x 25 mm

(Figure N°4-C). Once the ST-G graft is fixed, the plug is placed interferentially at the

level of the femoral tunnel (Figure N°5).

Imaging Assessment:

Patients were assessed on the basis of sagital MRI (General Electric® 2 T)

sections in T2. This was done by a radiologist, blinded to the groups, specialized in

muscle-skeletal images, 3 months and 6 months after surgery 75,76.

10

The following variables were analyzed:

- Graft Signal Intensity: In sagital sections in T2 we analized the graft’s signal

intensity at the femoral tunnel. There were high intensity signals, intensity similar to

the synovial fluid (Figure N°6-A), intermediate intensity signals, comparable to the

muscle’s (Figure N°6-B) and low intensity signals, equivalent to the posterior

cruciate ligament (Figure N°6-C). According to Weiler et al 79 a mature graft should

have a low intensity signal 77,78,79.

- Osteoligamentous Interface: In MRI axial and sagital sections in T2 we look for

the presence of interface, appearing as a high-intensity halo, between the graft and

the bone femoral tunnel (Figure N°7). The absence of an interface reflects major

integration of the graft, meaning a more mature graft 79,80.

- Tunnel Widening: The width of the femoral tunnel was measured in sagital MRI

sections in T2 at the third and sixth month after surgery. A difference greater than 2

mm between the two measures was considered to be positive. The lack of widening

of the femoral tunnel means a more integrated and mature graft (Figure N°8) 20.

Data Analysis:

The data obtained from the study were analized using chi-square’s test and

Fisher’s Exact test. Our power analysis was XX patients each group.

11

RESULTS:

IMAGING RESULTS AT THREE MONTHS:

- Signal Intensity: in the control group 12 of the 27 patients (44%) had a low intensity

signal; in the Bone Plug group 11 of the 28 patients (43%), in the Platelet

Concentrate group 12 of the 26 patients (46%) and in the Bone Plug plus Platelet

Concentrate group 11 of the 27 patients (40%) had a low intensity signal. The values

and statistic analysis are shown in Table N°1 and Graphic N°1. No significant

differences were found among the groups.

- Osteoligamentous Interface: in the control group 12 of the 27 patients (44%)

showed no interface; in the Bone Plug group 12 of the 28 patients (43%), in the

Platelet Concentrate group 11 of the 26 patients (42%) and in the Bone Plug plus

Patelet Concentrate 11 of the 27 patients (42%) showed no interface. The values



IMAGINOLOGIC RESULTS AT SIX MONTHS:

- Signal Intensity: in the control group 21 of the 27 patients (77%) had a low intensity

signal; in the Bone Plug group 25 of the 28 patients (89%), in the Platelet


Concentrate group 25 of the 27 patients (93%) had a low intensity signal. The values

12

and statistic analysis are shown in Table N°1 and Graphic N°1. The difference

between the control and the Platelet Concentrate group were statistically significant

(p = 0.036). No significant differences were found among the other groups.

- Osteoligamentous Interface: in the control group 18 of the 27 patients (67%)

showed no interface; in the Bone Plug group 19 of the 28 patients (68%), in the

Platelet Concentrate group 23 of the 26 patients (88%) and in the Bone Plug plus

Patelet Concentrate 19 of the 27 patients (70%) showed no interface. The values



- Tunnel Widening: in the control group 16 of the 27 patients (59%) showed no

tunnel widening; in the Bone Plug group 25 of the 28 patients (89%), in the Platelet


Concentrate group 22 of the 27 patients (81%) showed no tunnel widening. The

values and statistic analysis are shown in Table N°3 and Graphic N°3. The

difference between the control and the Bone Plug group were statistically significant

(p = 0.047). No significant differences were found among the other groups.

The data obtained at the third month and at the sixth month (intensity signal

and osteoligamentous interface) were compared finding statistically significant

differences in all variables, which reflects a progression of the maturation of the

graft.

13

DISCUSSION

Biological solutions to these types of injuries are being used with increasing

frequency in clinical practice3,45,49,50,51,54,59,62,63,67,73,74. However, most studies and

experimental models are done employing animals, and make frequent references to

growth factors3,44,49,50,51,52,53,54,55,56,57,58,59. Clearly, there still remain many unknowns

in this line of works. Also, there is a surprising shortage of published works regarding

the use of platelet concentrate27,46,50,52,64,65,66,67,68,69,70. This study was designed to

analyze experimental evidence on the use of autologous elements (bone plug and

platelet concentrate), which do not put the patient at risk or compromise the results

of conventional surgery, and which can be theoretically useful in aiding the natural

healing process. As far as the platelet concentrate and its large content of growth

factors is concerned, its use seems reasonable, given that the proportions or

interactions of various growth factors are not being altered. It has been shown, that

not only the proportion of growth factors, but the timing and duration of their

interaction can have a positive or negative impact on the final outcome. The use of a

bone plug is based on the mechanical knowledge regarding graft behavior inside the

tunnels. This plug acts as a natural interferential fixation, which does not add any

exogenous inflammatory phenomena, as sometimes happens with bioabsorbable

materials. In addition, it is fixed close to the articular surface and it should

theoretically reduce the “bunji” and windshield wiper effects, which are frequent in

this type of surgery and are related to the tunnel widening

phenomenon17,21,30,31,32,33,34,35,36,37, 38,39,40,41.

14

The results that were obtained in the study are encouraging, though not

sufficiently conclusive. A positive trend was noticed when these elements were

used. Paradoxically, however, the combination of both elements does not appear to

be as beneficial, which could suggest that they interfere with each other. The

potential difficulties faced by the radiologist when interpreting images, in relation to

the bone plug and graft maturation in the femoral tunnel, must also be considered.

Finally, the factors that have been recognized as having the greatest

influence on this healing process are the environment and the presence of

transportation media for stem cells, either with or without growth factors. This

interaction was not studied by our group given the difficulty of homogenizing and

controlling all these variables.

CONCLUSION

The use of a platelet concentrate or of a bone plug, each on its own, favorably

influences ST-G graft maturation in the ACL reconstruction.

ACKNOWLEDGMENTS

Juan Durruty MD

Hernán Sudy MD

Matías Salineros MD

Alexander Tomic MD

15

BIBLIOGRAFÍA:

1. Insall & Scott. “Surgery of the knee” Edición en español. Marbán , 2004

2. Brown CH Jr, Carson EW. Revision anterior cruciate ligament surgery. Clin Sports Med. 1999

Jan;18(1):109-71.

3. Petrigliano FA, McAllister DR, Wu BM. Tissue engineering for anterior cruciate ligament

reconstruction: a review of current strategies. Arthroscopy. 2006 Apr;22(4):441-51.

4. Herrington L, Wrapson C, Matthews M, Matthews H. Anterior cruciate ligament reconstruction,

hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from

surgery. Knee. 2005 Jan;12(1):41-50.

5. Durruty J, Valenzuela L, Matas J, Orrego M, Melo R. Reconstrucción de ligamento cruzado anterior

en pacientes mayores de 40 años. Rev Chilena Ortop y Traum 2005;46:66-72.

6. Barber FA, Elrod BF, McGuire DA, Paulos LE. Is an anterior cruciate ligament reconstruction

outcome age dependent? Arthroscopy. 1996 Dec;12(6):720-5.

7. Stein DA, Brown H, Bartolozzi AR. Age and ACL reconstruction revisited. Orthopedics. 2006

Jun;29(6):533-6.

8. Figueroa D, Cavo R, Mardones R. Estudio Comparativo de la reconstrucción del ligamento cruzado

anterior con técnica Hueso-Tendón patelar-Hueso v/s Doble Semitendinoso-Gracilis. Seguimiento

mayor de 1 año. Rev Chilena Ortop y Traum 2003 44:153-159.

9. Betz RR. Limitations of autograft and allograft: new synthetic solutions. Orthopedics. 2002

May;25(5 Suppl):s561-70.

10. Jones KG. Reconstruction of the anterior cruciate ligament. A technique using the central one-third

of the patellar ligament. J Bone Joint Surg Am. 1963 Jul;45:925-32.

11. Clancy WG Jr, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction

using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint

Surg Am. 1982 Mar;64(3):352-9.

16

12. Aglietti P, Giron F, Buzzi R, Biddau F, Sasso F. Anterior cruciate ligament reconstruction: bone-

patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A

prospective, randomized clinical trial. J Bone Joint Surg Am. 2004 Oct;86-A(10):2143-55.

13. Aune AK, Holm I, Risberg MA, Jensen HK, Steen H. Four-strand hamstring tendon autograft

compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A

randomized study with two-year follow-up. Am J Sports Med. 2001 Nov-Dec;29(6):722-8.

14. Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior

cruciate ligament reconstruction. Am J Sports Med. 2003 Jul-Aug;31(4):564-73.

15. Pinczewski LA, Deehan DJ, Salmon LJ, Russell VJ, Clingeleffer A. A five-year comparison of

patellar tendon versus four-strand hamstring tendon autograft for arthroscopic reconstruction of the

anterior cruciate ligament. Am J Sports Med. 2002 Jul-Aug;30(4):523-36.

16. Calvisi V, Lupparelli S, Padua R. Patellar Tendon Autograft versus hamstring tendon autograft in

arthroscopic anterior cruciate ligament reconstruction: appraisal of the evidence. J Orthopaed

Traumatol 2006 Jun;7:103-107.

17. Fauno P, Kaalund S. Tunnel widening after hamstring anterior cruciate ligament reconstruction is

influenced by the type of graft fixation used: a prospective randomized study. Arthroscopy. 2005

Nov;21(11):1337-41.

18. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE Jr. Anterior cruciate

ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really

matter? A systematic review. Am J Sports Med. 2004 Dec;32(8):1986-95.

19. Nebelung W, Becker R, Merkel M, Ropke M. Bone tunnel enlargement after anterior cruciate

ligament reconstruction with semitendinosus tendon using Endobutton fixation on the femoral side.

Arthroscopy. 1998 Nov-Dec;14(8):810-5.

20. Wilson TC, Kantaras A, Atay A, Johnson DL. Tunnel enlargement after anterior cruciate ligament

surgery. Am J Sports Med. 2004 Mar;32(2):543-9.

21. Buelow JU, Siebold R, Ellermann A. A prospective evaluation of tunnel enlargement in anterior

cruciate ligament reconstruction with hamstrings: extracortical versus anatomical fixation. Knee

Surg Sports Traumatol Arthrosc. 2002 Mar;10(2):80-5.

17

22. Laxdal G, Kartus J, Eriksson BI, Faxen E, Sernert N, Karlsson J. Biodegradable and metallic

interference screws in anterior cruciate ligament reconstruction surgery using hamstring tendon

grafts: prospective randomized study of radiographic results and clinical outcome. Am J Sports

Med. 2006 Oct;34(10):1574-80.

23. Giron F, Aglietti P, Cuomo P, Mondanelli N, Ciardullo A. Anterior cruciate ligament reconstruction

with double-looped semitendinosus and gracilis tendon graft directly fixed to cortical bone: 5-year

results. Knee Surg Sports Traumatol Arthrosc. 2005 Mar;13(2):81-91.

24. Clatworthy MG, Annear P, Bulow JU, Bartlett RJ. Tunnel widening in anterior cruciate ligament

reconstruction: a prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports

Traumatol Arthrosc. 1999;7(3):138-45.

25. L'Insalata JC, Klatt B, Fu FH, Harner CD. Tunnel expansion following anterior cruciate ligament

reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports

Traumatol Arthrosc. 1997;5(4):234-8.

26. Giurea M, Zorilla P, Amis AA, Aichroth P. Comparative pull-out and cyclic-loading strength tests of

anchorage of hamstring tendon grafts in anterior cruciate ligament reconstruction. Am J Sports

Med. 1999 Sep-Oct;27(5):621-5.

27. Kanazawa T, Soejima T, Murakami H, Inoue T, Katouda M, Nagata K. An immunohistological study

of the integration at the bone-tendon interface after reconstruction of the anterior cruciate ligament

in rabbits. J Bone Joint Surg Br. 2006 May;88(5):682-7.

28. Deehan DJ, Cawston TE. The biology of integration of the anterior cruciate ligament. J Bone Joint

Surg Br. 2005 Jul;87(7):889-95.

29. Zavras TD, Race A, Amis AA. The effect of femoral attachment location on anterior cruciate

ligament reconstruction: graft tension patterns and restoration of normal anterior-posterior laxity

patterns. Knee Surg Sports Traumatol Arthrosc. 2005 Mar;13(2):92-100.

30. Howell SM, Roos P, Hull ML. Compaction of a bone dowel in the tibial tunnel improves the fixation

stiffness of a soft tissue anterior cruciate ligament graft: an in vitro study in calf tibia. Am J Sports

Med. 2005 May;33(5):719-25.

18

31. Brown GA, Pena F, Grontvedt T, Labadie D, Engebretsen L. Fixation strength of interference screw

fixation in bovine, young human, and elderly human cadaver knees: influence of insertion torque,

tunnel-bone block gap, and interference. Knee Surg Sports Traumatol Arthrosc. 1996;3(4):238-44.

32. Barber FA, Spruill B, Sheluga M. The effect of outlet fixation on tunnel widening. Arthroscopy. 2003

May-Jun;19(5):485-92.

33. Caborn DN, Nyland J, Selby J, Tetik O. Biomechanical testing of hamstring graft tibial tunnel

fixation with bioabsorbable interference screws. Arthroscopy. 2003 Nov;19(9):991-6.

34. Brand J Jr, Weiler A, Caborn DN, Brown CH Jr, Johnson DL. Graft fixation in cruciate ligament

reconstruction. Am J Sports Med. 2000 Sep-Oct;28(5):761-74.

35. Matsumoto A, Howell SM, Liu-Barba D. Time-related changes in the cross-sectional area of the

tibial tunnel after compaction of an autograft bone dowel alongside a hamstring graft. Arthroscopy.

2006 Aug;22(8):855-60.

36. Tecklenburg K, Burkart P, Hoser C, Rieger M, Fink C. Prospective evaluation of patellar tendon

graft fixation in anterior cruciate ligament reconstruction comparing composite bioabsorbable and

allograft interference screws. Arthroscopy. 2006 Sep;22(9):993-9.

37. Harvey A, Thomas NP, Amis AA. Fixation of the graft in reconstruction of the anterior cruciate

ligament. J Bone Joint Surg Br. 2005 May;87(5):593-603.

38. Klein J, Lintner D, Downs D, Vavrenka K. The incidence and significance of femoral tunnel

widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross

pin fixation. Arthroscopy 2003 May;19(5):470-6)

39. Weiler et al.: Current Concepts for hamstring tendon fixation in cruciate ligament surgery. Chirurg

71:1034-1044, 2000.

40. Matsumoto, Akio M.D.; Howell, Stephen M. M.D. The WasherLoc and Bone Dowel: A Rigid,

Slippage-Resistant Tibial Fixation Device for a Soft Tissue Anterior Cruciate Ligament Graft.

Techniques in Orthopaedics. 2005 Sept;20(3):278-282.

41. Robert H, Es-Sayeh J. The role of periosteal flap in the prevention of femoral widening in anterior

cruciate ligament reconstruction using hamstring tendons. Knee Surg Sports Traumatol Arthrosc.

2004 Jan;12(1):30-5.

19

42. Rodeo SA . Tendon healing in a bone tunnel. J Bone Joint Surg Am 1993 75:1795.

43. Marumo K, Saito M, Yamagishi T, Fujii K. The "ligamentization" process in human anterior cruciate

ligament reconstruction with autogenous patellar and hamstring tendons: a biochemical study. Am J

Sports Med. 2005 Aug;33(8):1166-73.

44. Letson AK, Dahners LE. The effect of combinations of growth factors on ligament healing. Clin

Orthop Relat Res. 1994 Nov;(308):207-12.

45. Angel MJ, Sgaglione NA, Grande DA. Clinical applications of bioactive factors in sports medicine:

current concepts and future trends. Sports Med Arthrosc. 2006 Sep;14(3):138-45.

46. Aspenberg P, Virchenko O. Platelet concentrate injection improves Achilles tendon repair in rats.

Acta Orthop Scand. 2004 Feb;75(1):93-9.

47. Weiler A, Hoffmann RF, Bail HJ, Rehm O, Sudkamp NP. 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. 2002 Feb;18(2):124-35.

48. Weiler A, Peine R, Pashmineh-Azar A, Abel C, Sudkamp NP, Hoffmann RF. 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. 2002 Feb;18(2):113-23.

49. Anderson K, Seneviratne AM, Izawa K, Atkinson BL, Potter HG, Rodeo SA. Augmentation of

tendon healing in an intraarticular bone tunnel with use of a bone growth factor. Am J Sports Med.

2001 Nov-Dec;29(6):689-98.

50. Ju YJ, Tohyama H, Kondo E, Yoshikawa T, Muneta T, Shinomiya K, Yasuda K. Effects of local

administration of vascular endothelial growth factor on properties of the in situ frozen-thawed

anterior cruciate ligament in rabbits. Am J Sports Med. 2006 Jan;34(1):84-91.

51. Woo S, Abramowitch S, Kilger R, Liang R. Biomechanics of knee ligaments: injury, healing, and

repair. J Biomech. 2006;39:1-20.

52. Molloy T, Wang Y, Murrell AC. The Roles of Growth Factors in Tendon and Ligament Healing.

Sports Med 2003 33(5):381-394.

20

53. Schmidmaier G, Wildermann B, Gabelein T, Heeger J, Kandziora F, Haas N, Raschke M.

Synergistic effect of IGF-1 and TGF-B1 on fracture healing in rats. Acta Orthop Scand

2003;74(5):604-610.

54. Kondo E, Yasuda K, Yamanaka M, Minami A, Tohyama H. Effects of administration of exogenous

growth factors on biomechanical properties of the elongation-type anterior cruciate ligament injury

with partial laceration. Am J Sports Med. 2005 Feb;33(2):188-96.

55. Schmidmaier G, Widermann B, Ostapowicz D, Kandziora F, Stange R, Haas N, Raschke M. Long-

term effects of local growth factor (IGF-I and TGF-ß1) treatment on fracture healing. J Orthop Res

2004 22;514-519.

56. Siebrecht M, De Rooij P, Arm D, Olsson M, Aspenberg P. Platelet Concentrate Increases Bone

Ingrowth into Porous Hydroxyapatite. Orthopedics 2002;Feb;25(2):169-172.

57. Murray M, Bennet R, Zhang X, Spector M. Cell Outgrowth from de Human ACL in vitro: Regional

Variation and response to TGF-B1. J Orthop Res 2002;20:875-880.

58. Lane JM. Bone morphogenic protein science and studies. J Orthop Trauma. 2005 Nov-Dec;19(10

Suppl):S17-22.

59. Yamazaki S, Yasuda K, Tomita F, Tohyama H, Minami A. The effect of transforming growth factor-

beta1 on intraosseous healing of flexor tendon autograft replacement of anterior cruciate ligament

in dogs. Arthroscopy. 2005 Sep;21(9):1034-41.

60. Mihelic R, Pecina M, Jelic M, Zoricic S, Kusec V, Simic P, Bobinac D, Lah B, Legovic D, Vukicevic

S. Bone morphogenetic protein-7 (osteogenic protein-1) promotes tendon graft integration in

anterior cruciate ligament reconstruction in sheep. Am J Sports Med. 2004 Oct-Nov;32(7):1619-25.

61. Yasuda K, Tomita F, Yamazaki S, Minami A, Tohyama H. The effect of growth factors on

biomechanical properties of the bone-patellar tendon-bone graft after anterior cruciate ligament

reconstruction: a canine model study. Am J Sports Med. 2004 Jun;32(4):870-80.

62. Martinek V, Latterman C, Usas A, Abramowitch S, Woo SL, Fu FH, Huard J. Enhancement of

tendon-bone integration of anterior cruciate ligament grafts with bone morphogenetic protein-2

gene transfer: a histological and biomechanical study. J Bone Joint Surg Am. 2002 Jul;84-

A(7):1123-31.

21

63. Laurencin CT, Freeman JW. Ligament tissue engineering: an evolutionary materials science

approach. Biomaterials. 2005 Dec;26(36):7530-6.

64. Tischler, Michael. Platelet Rich Plasma. The Use of Autologous Growth Factors to Enhance Bone

and Soft Tissue Grafts. New York Dental Journal 68:22-24, 2002.

65. Betsholtz C, Karlsson L, Lindahl P. Developmental roles of platelet-derived growth factors.

Bioessays. 2001 Jun;23(6):494-507.

66. Murray M, Rice K, Wright RJ, Spector M. The effect of selected growth factors on human anterior

cruciate ligament cell interactions with a three-dimensional collagen-GAG scaffold. J Orthop Res

2003 21:238-244.

67. Murray MM, Spindler KP, Devin C, Snyder BS, Muller J, Takahashi M, Ballard P, Nanney LB,

Zurakowski D. Use of a collagen-platelet rich plasma scaffold to stimulate healing of a central

defect in the canine ACL. J Orthop Res. 2006 Apr;24(4):820-30.

68. Nagumo A, Yasuda K, Numazaki H, Azuma H, Tanabe Y, Kikuchi S, Harata S, Tohyama H. Effects

of separate application of three growth factors (TGF-beta1, EGF, and PDGF-BB) on mechanical

properties of the in situ frozen-thawed anterior cruciate ligament. Clin Biomech (Bristol, Avon). 2005

Mar;20(3):283-90.

69. Hildebrand KA, Woo SL, Smith DW, Allen CR, Deie M, Taylor BJ, Schmidt CC. The effects of

platelet-derived growth factor-BB on healing of the rabbit medial collateral ligament. An in vivo

study. Am J Sports Med. 1998 Jul-Aug;26(4):549-54.

70. Weiler A, Forster C, Hunt P, Falk R, Jung T, Unterhauser FN, Bergmann V, Schmidmaier G, Haas

NP. The influence of locally applied platelet-derived growth factor-BB on free tendon graft

remodeling after anterior cruciate ligament reconstruction. Am J Sports Med. 2004 Jun;32(4):881-

91.

71. Anitua E. Plasma rich in growth factors: preliminary results of use in the preparation of future sites

for implants. Int J Oral Maxillofac Implants. 1999 Jul-Aug;14(4):529-35.

72. Velich N, Németh Z, Hrabak K, Suba Z, Szabo G. Repair of Bony Defect With Combination

Biomaterials. The Journal of Craniofacial Surgery 2004 Jan;15:11-15.

22

73. Murray MM, Spindler KP, Abreu E, Muller JA, Nedder A, Kelly M, Frino J, Zurakowski D, Valenza

M, Snyder BD, Connolly SA. Collagen-platelet rich plasma hydrogel enhances primary repair of the

porcine anterior cruciate ligament. J Orthop Res. 2007 Jan;25(1):81-91.

74. Westerhuis RJ, Van Bezooijen RL, Kloen P. Use of Bone morphogenetic proteins in traumatology.

Injury 2005;36:1405-1412.

75. Fules PJ, Madhav RT, Goddard RK, Newman-Sanders A, Mowbray MA. Evaluation of tibial bone

tunnel enlargement using MRI scan cross-sectional area measurement after autologous hamstring

tendon ACL replacement. Knee. 2003 Mar;10(1):87-91.

76. Lee SY, Matsui N, Yoshida K, Doi R, Matsushima S, Wakami T, Fujii M, Yoshiya S, Kurosaka M,

Yamamoto T. Magnetic resonance delineation of the anterior cruciate ligament of the knee:

flexed knee position within a surface coil. Clin Imaging. 2005 Mar-Apr;29(2):117-22.

77. Nakamae A, Deie M, Yasumoto M, Adachi N, Kobayashi K, Yasunaga Y, Ochi M. Three-

dimensional computed tomography imaging evidence of regeneration of the semitendinosus tendon

harvested for anterior cruciate ligament reconstruction: a comparison with hamstring muscle

strength. J Comput Assist Tomogr. 2005 Mar-Apr;29(2):241-5.

78. Weiler A, Peters G, Maurer J, Unterhauser FN, Sudkamp NP. 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 Nov-Dec;29(6):751-61.

79. Uchio Y, Ochi M, Adachi N, Kawasaki K, Kuriwaka M. Determination of time of biologic fixation after

anterior cruciate ligament reconstruction with hamstring tendons. Am J Sports Med. 2003 May-

Jun;31(3):345-52.

80. Song EK, Rowe SM, Chung JY, Moon ES, Lee KB. Failure of osteointegration of hamstring tendon

autograft after anterior cruciate ligament reconstruction. Arthroscopy. 2004 Apr;20(4):424-8.

23

ANEXOS: Figure N°1:

Reconstruction of ACL with quadruple ST-G graft fixed proximally with a

biodegradable transfixing screw and distally with a biodegradable

interferential screw.

24

Figure N°2:

A

A B C

A. Preparation of the PC. After subjecting the sample to centrifugal force,

a PC sample is taken by means of a sterile technique.

B. Preparation of thrombin: After the sample clots, it is spun and the

thrombin is skimmed from the top.

C. The system is then set up and a platelet-rich plasma mix is obtained

25

Figure N°3:

A B

A. ST-G graft in PC clot.

B. Insertion of the PC-covered ST-G graft.

26

Figure N°4:

A

B C

A. Biomet trefin kit used to obtain the bone plug

B. Compacted bone plug obtained from drilling the tibia tunnel

C. Recovery of bone plug.

27

Figure N°5:

Interferential insertion of the Bone Plug through the femoral tunnel by means of

an arthroscopic portal.

Figure N°6:

28

A. MRI with high intensity signal in the femoral tunnel. Signal corresponds to

articular fluid.

B. MRI with low intensity signal, similar to the posterior cruciate ligament.

Figure N°7:

29

Osteoligamentous interface in the femoral tunnel.

Figure N°8:

30

Femoral tunnel widening between 3 and 6 months. It is considered as widening

when the difference is greater than 2mm.

Table Nº1

31

3M: Third month. 6M: sixth month

Graphic Nº1

Table Nº2

32


Graphic Nº2

Table Nº3

33


Graphic Nº3

Effects of Platelet Concentrate and a Bone Plug on the Healing of Hamstring Tendons in a Bone Tunnel

Documents

Transcript of Effects of Platelet Concentrate and a Bone Plug on the Healing of Hamstring Tendons in a Bone Tunnel