Replacement of the anterior cruciate

ligament using a synthetic prosthesis

An evaluation of graft biology in the dog
STEVEN P. ARNOCZKY,* DVM, Dipl ACVS, RUSSELL F. WARREN, MD, FACS, AND
JOSEPH P. MINEI, MD

From the Laboratory of Comparative Orthopaedics and Sports Medicine Research, The Hospital
for Special Surgery, affiliated with the New York Hospital, Cornell University Medical College,
New York, New York

ABSTRACT act as a scaffold on which connective tissue can proliferate

and form a new ligament.2,3,6, 13, 1719 In these cases the ability
The ACL of 21 adult mongrel dogs was replaced with of the material and design of a synthetic graft to induce
a knitted dacron velour prosthesis. The biologic fate of
tissue ingrowth and allow for functional orientation of the
these synthetic grafts was then evaluated at various
intervals from 1 to 12 months postoperatively using
neoligament is critical to the success of the prosthesis. While
carbon fibers have been said to induce the formation of a
routine histology and a vascular injection (Spalteholz)
neoligament with appropriate orientation, 1,2,9,13-15,25,26 little
technique. is known about the biology of other materials designed for
Following implantation the knitted dacron prosthesis ACL substitution.
was encapsulated with a vascular synovial tissue in a
It was the purpose of this study, therefore, to examine the
manner similar to that observed with autogenous pa-
tellar tendon grafts. This revascularization process was
biology of a knitted dacron velour prosthesis used to replace
the ACL in the dog.
followed by a proliferation of fibroblasts throughout the
extent of the prosthesis. While the grafts appeared to
support a fibrous tissue proliferation in and around the MATERIALS AND METHODS
design of the prosthesis, this tissue demonstrated only
a random orientation of collagen fibers as late as 1 year Twenty-one adult mongrel dogs weighing 20 to 30 kg were

postoperatively. It would appear, therefore, that al-
though the knitted dacron prosthesis is capable of
inducing and supporting tissue encapsulation and in-
growth, it does not allow for the functional orientation
of this tissue.
Intraarticular substitution of a prosthetic graft has long
been advocated as a method of ACL reconstruction.8 16 21
While autogenous tissuesgns Z3 (patellar tendon, fascia, etc.)
are the most commonly used grafts, synthetic materials such
obtained from a licensed dealer. Animals with any clinical
or roentgenographic evidence of a pathologic lesion of the
knee were excluded. The ACL of the right knee was replaced
with a knitted dacron velour prosthesis (Stryker Biomedical
Products, Kalamazoo, MI). Tissue ingrowth and vasculari-
zation of the prosthesis was evaluated at 1, 2, 3, 4, 5, 6, and
12 months postoperatively. Three animals were evaluated at
each time period. The animals were euthanatized with an
overdose of anesthetic and the knee joints processed as
described.

as polypropylene,17 dacron,
3 12 19 21
and carbon fibers 12
n-i5 25,26 are
being investigated as potential graft materials. Surgical technique
In many instances these synthetic materials are intended to
The dogs were anesthetized with intravenous sodium thia-
* Address correspondence and repnnt requests to Steven P Arnoczky,
mylal, intubated, and maintained on inhalation anesthesia
DVM, Director, Laboratory of Comparative Orthopaedics, The Hospital for (halothane, oxygen, and nitrous oxide). Using sterile tech-
Special Surgery, 535 East 70th Street, New York, NY 10021 nique, the right knee joint was approached through a lateral
1
2

parapatellar arthrotomy. The patella was retracted medially

and the ACL resected from its femoral and tibial attach-
ments. A 4 mm diameter knitted dacron velour prosthesis
(Fig. 1) was then used to replace the ACL. The prosthesis
was placed through a 3/~s inch hole drilled transversely

through the proximal tibial crest and sutured on itself. The

prosthesis was then pulled through the joint and over the
top of the lateral femoral condyle (Fig. 2). With tension
applied to the prosthesis, the knee was tested for anterior
drawer movement. When no AP instability could be elicited,
the prosthesis was secured to the tissues of the lateral
femoral condyle with simple interrupted sutures of 3-0 stain-
less steel. The infrapatellar fat pad was incised and wrapped
around the prosthesis. The joint capsule was approximated
with interrupted sutures of chromic gut and the skin was
closed with interrupted sutures of 3-0 stainless steel. Post-
operatively the limbs were not immobilized and the animals
were housed in individual indoor runs where they were
allowed to exercise at will.
It should be noted that the dacron graft used in this study
was designed for use in the dog. The current clinical design
in humans uses a similar knitted dacron sleeve 8 mm in
diameter which is reinforced with an inner high-strength
core of four woven dacron tapes. This modification makes
the current clinical prosthesis stronger and stiffer but does
not change the character of the dacron surface.

Figure 2. Schematic drawing showing the orientation of the

within the knee joint of a dog. The graft is
prosthetic graft
passed through a drill hole in the tibial crest and sutured on
itself (a). The graft is then passed through the joint and over
the top of the lateral condyle where it is attached to the lateral
aspect of the condyle (b) with 3-0 stainless steel sutures.

Laboratory techniques
At the conclusion of each experimental period, one animal
from each group was used to evaluate the vascularization of
the synthetic prosthesis. This was done using a previously
described modified Spalteholz technique.’
Two animals from each experimental period were used to
evaluate tissue ingrowth into the prosthesis. In these ani-
mals the joint was examined for signs of degenerative
changes and the synthetic prosthesis and its associated soft
tissues were removed en bloc and fixed in 10% buffered
formalin. The tissues were then embedded in paraffin and 5
~m thick sections cut, stained with hematoxylin and eosin,
and examined by light and polarized light microscopy. A
portion of a 6 month specimen was fixed in formalin and
processed for scanning electron microscopy.
RESULTS

Figure 1. Longitudinal (A) and transverse (B) sections of the Postoperatively the animals favored the involved limb for
4 mm knitted dacron velour graft. approximately 2 weeks. A period of gradual weightbearing
 3

ensued, and by the 4th postoperative week the animals

showed only a mild degree of lameness. No lameness could
be noted after the 6th postoperative week.
At 1 month following transplantation, synovial tissue
began to surround the prosthesis. This vascular synovial
envelope originated in the area of the infrapatellar fat pad
and posterior soft tissues of the knee joint. The vessels of
the synovial sheath progressed from a proximal and distal
origin to the central, intraarticular portion of the graft (Fig.
3). While the entire graft appeared covered with synovial
tissue by 2 months, only moderate tissue ingrowth into the
synthetic material was noted at this time (Fig. 4).
By 3 months vessels could be seen throughout the inter-
stices of the dacron velour (Fig. 5). This vascular prolifera-
tion was accompanied by a proliferation of fibroblasts which
could be seen surrounding the dacron fibers (Fig. 6). Figure 3. Five millimeter thick sagittal section of a dog’s knee
This proliferation of tissue continued in the 4 and 5 month 1 month after replacement of the ACL with a knitted dacron
specimens. By 6 months portions of the graft were encap- prosthesis (Spalteholz x2). Note the vascular response of the
sulated with fibrous connective tissue (Fig. 7). Histology and infrapatellar fat pad (FP) and its contnbution of vessels into
scanning electron microscopy showed this vascular &dquo;scar&dquo; the prosthetic matenal. F, femur; T, tibia.
tissue to be present throughout the weave of the dacron
material in these areas (Figs. 8 and 9). These areas of
extensive tissue encapsulation were limited to the portions
of the graft that passed through the infrapatellar fat pad
and posterior soft tissues of the joint (Fig. 10). While his-
tologic examination revealed deposition of collagenous ma-
terial on the graft, polarized light microscopy demonstrated
only random orientation of collagen bundles at 6 months
(Fig. 11). The intraarticular portion of the graft (that within
the intercondylar notch), while covered with a layer of
synovial tissue, showed minimal tissue encapsulation (Fig.
12).
The 1 year specimens showed little difference from those
examined at 6 months. There was no significant increase in
tissue deposition around the prosthesis and the majority of
collagen fibers still demonstrated a random orientation un-
der polarized light microscopy.
The inflammatory response of the knee to the synthetic Figure 4. Photomicrograph of a longitudinal section of a
dacron prosthesis 2 months following implantation. Note the
material was minimal and the graft was intact in all speci-
vascular synovial covering of the graft at this time. (Hematox-
mens examined. However, in those animals sacrificed at 3
months or longer, the graft appeared stretched out and, ylin and eosin x100.)
clinically, the knee demonstrated mild to moderate AP lax-
ity. These animals were not lame but degenerative changes,
as evidenced by periarticular osteophyte formation, were

present in all knee joints.

DISCUSSION

The task of creating a prosthetic ligament to replace the

ACL remains an intriguing challenge to the orthopaedic
researcher.24 Many materials and designs have been
proposed’ S 7 9 10 12 15,17 19 20 22 24 26 and much of the literature
regarding these prostheses has centered around their bio-
mechanical evaluation..3 7,10 17 24
While the mechanical properties of a prosthetic ligament
10
are critical to its function and longevity within the knee,’

biologic interaction of the prosthesis with the joint environ- Figure 5. India ink injection specimen showing the vascular
ment is also important. This is especially true if the pros- ingrowth into the interstices of the graft at 3 months.

Figure 6. Photomicrograph of a transverse section of a dacron
graft 3 months following implantation. Connective tissue cells
can be seen surrounding the deeper fibers of the graft.
(Hematoxylin and eosin x 100.)
Figure 7. Cross-section of a dacron graft 6 months following
implantation. The section is taken where the graft passes
through the infrapatellar fat pad. Note the marked tissue
encapsulation.
Figure 8. Scanning electron micrograph of the specimen m
Figure 7. Note the encapsulation of the graft and the presence
of connective tissue throughout the weave of the material.
(x160.)
thetic ligament is intended to act as a scaffold on which a
neoligament can proliferate.
For a prosthetic graft to act successfully as a ligamentous
scaffold, it should be both inductive and conductive to tissue
ingrowth. That is, the prosthesis should induce the ingrowth
of tissue by the surface characteristics of the material,
support (or conduct) this ingrowth through the design of the
prosthesis, and allow for the functional orientation of this
new tissue. Several studies have demonstrated the ability of
carbon fibers to induce the formation of neotendon on its
surface and permit the functional orientation of this new
2,13-15, 25
tissue.
The ability of a knitted dacron velour material to promote
and support tissue ingrowth has been well-documented in
vascular surgery.&dquo; 11 21 It has been shown that proliferating
fibroblasts readily become locked into the loops of velour
(Fig. 13) and that fibroblasts are better able to migrate on
the trellis of the loosely knit filaments.5 21
The results of this study demonstrated that, following
implantation, the knitted dacron ligament was encapsulated
with vascular synovial tissue which originated from the
vascular tissues of the infrapatellar fat pad and posterior
soft tissues of the joint. This revascularization pattern is
similar to that observed with biologic graft materials.4 The
tissue encapsulation was greatest in the areas adjacent to
the infrapatellar fat pad and posterior soft tissues. The
central, intraarticular portion of the prosthesis, while show-
ing evidence of cellular migration and vascularization within
its substance, showed minimal tissue encapsulation. This
lack of tissue accretion on the surface of the prosthesis in
this area may be due to the frictional motion of the prosthe-
sis against the adjacent posterior cruciate ligament and/or
femoral condyle during joint motion, or the inability of the
encapsulating connective tissue to proliferate to any great
extent away from the vascular soft tissues of the knee joint
(infrapatellar fat pad, posterior synovial tissues). In a pros-
thesis that relies on the ingrowth of tissue to provide addi-
tional mechanical strength, this central, intraarticular por-
tion may represent a weak link in the system and may be a
site of potential failure. Indeed, the stretching out of the
graft observed in those animals at 3 months or longer
appeared to have occurred in the central, intraarticular
portion of the prosthesis. Another study using dacron pros-
thesis for the replacement of the ACL in dogs noted that
while the grafts supported tissue ingrowth, fatigue failure
occurred before sufficient tissue was incorporated to
strengthen the prosthesis.&dquo;
In the areas of the prosthesis where tissue encapsulation
did occur, the tissue showed random orientation and ap-
peared to be more like scar tissue than a neoligament. The
tissue which grew in and around the prosthesis was fibro-
vascular in nature containing abundant vessels and fibro-
blasts, and a randomly oriented collagen matrix. This failure
of the connective tissue surrounding the prosthesis to orient
in a functional direction has been alluded to in another
study in which a dacron prosthesis was used to augment
patellar tendon grafts used to replace the ACL in dogs.’ In
that study biomechanical evaluation of the augmented and
unaugmented grafts 6 months following surgery revealed
that the dacron-augmented patellar tendon grafts failed at
an average load of 15.2 kg while the unaugmented graft
failed at an average load of 21.4 kg.’ It was theorized that
Figure 9. Photomicrograph of a transverse section of a dacron
prosthesis 6 months following implantation. Note the pres-
ence of connective tissue throughout the weave of the ma-
terial. (Hematoxylin and eosin x40.)
Figure 10. Five millimeter thick sagittal section of a dog’s
knee 6 months following replacement of the ACL with a
dacron prosthesis (Spalteholz x2). Note the marked vascular
encapsulation and ingrowth in the areas of the infrapatellar
fat pad (FP). F, femur; T, tibia.
Figure 11. Photomicrograph of a longitudinal section of a
dacron graft 6 months following implantation (polarized light).
Note the lack of orientation of the collagen fibers in the tissue
encapsulating the graft. (Hematoxylin and eosin x100.)
Figure 12. Dacron graft 6 months following implantation. Note
the minimal tissue encapsulation adjacent to where the graft
passes the femoral condyle and posterior cruciate ligament
(arrow).
Figure 13. Photomicrograph of a dacron graft following in
vitro seeding of the graft with fibroblasts in tissue culture.
Note the way the fibroblasts become attached to the material
(x250). (From: Brodey GA, Eisinger M, Arnoczky SP, Warren
RF: In vitro fibroblast seeding of a prosthetic anterior cruciate
ligament. Trans Orthop Res Soc 8: 34, 1983.)
the dacron prosthesis acted as a stress shield, preventing the
patellar tendon graft from exposure to mechanical forces
and resulting in the partial resorption of the tendon graft.’
In the present study the lack of functional orientation of
the tissue encapsulating the prosthesis suggests that this
tissue was not exposed to the mechanical stimulus necessary
for tissue remodeling. This could be due to the fact that the
initial stiffness of the graft provided a stress-shielding effect
or the subsequent stretching out of the prosthesis rendered
the connective tissue-prosthetic composite nonfunctional
and, thus, unstressed.
It would appear, therefore, that for a tissue-augmented
prosthesis to succeed, it must be strong enough to withstand
6
the mechanical forces placed on it during normal joint
function, yet elastic enough to permit the gradual transfer
of these forces to allow for tissue remodeling and orientation.
To date, this remains an elusive goal.
CONCLUSIONS
Following transplantation the prosthetic ligament was en-
capsulated with vascular synovial tissue and the ensuing
vascular and cellular proliferation completely enveloped the
graft with fibrous connective tissue. This revascularization
pattern is similar to that observed with biologic graft mate-
rials. Therefore, it would appear that, as in biologic grafts,
the preservation and use of the infrapatellar fat pad and
synovial tissues would optimize tissue ingrowth into the
prosthesis.
While the synthetic material readily permits connective
tissue ingrowth, there appeared to be an insufficient expo-
sure of this connective tissue to tensile forces, resulting in
the failure of the collagen to become functionally aligned.
The results of this study would suggest that synthetic liga-
ments designed to support the growth of a neoligament must
not only provide for adequate connective tissue ingrowth
but must also allow exposure of this connective tissue to
joint forces so that a functional new ligament can be formed.
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