Graft remodeling and ligamentization after cruciate ligament reconstruction
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 intra‐articular 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.
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The mechanical properties of an implanted graft, regardless of graft type, do not return to normal after anterior cruciate ligament reconstruction surgery.
“However, the mechanical properties of the implanted graft, regardless of graft type, do not return to normal after ACLR surgery [3–5].”
Restoration of the mechanical strength of an intact anterior cruciate ligament is not achieved even after 2 years after anterior cruciate ligament reconstruction.
“Although the implanted graft reportedly undergoes remodeling after 1 year, restoration of the mechanical strength of an intact ACL is not achieved even after 2 years [3, 4].”
A human case study that retrieved a patellar tendon autograft found that a significant portion of the implanted graft sustained necrosis and acellularity 18 months after index surgery.
“A human case study that retrieved a patellar tendon autograft found that a significant portion of the implanted graft sustained necrosis and acellularity 18 months after index surgery [4].”
During the healing process of implanted tendon grafts following ACL reconstruction, graft necrosis occurs early, leading to the invasion of extrinsic fibroblasts.
“During the healing process of implanted tendon grafts following ACL reconstruction, graft necrosis occurs early in the process, leading to the invasion of extrinsic fibroblasts.”
An endpoint of graft maturation has yet to be detected.
“Over the years, fibroblast proliferation forms reparative scar tissue; however, an endpoint of graft maturation has yet to be detected [4, 53, 54].”
Cites
Histological Changes in the Human Anterior Cruciate Ligament After Rupture*
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Analysis of a Semitendinosus Autograft in a Rabbit Model
Blickenstaff, K. R., Grana, W. A., & Egle, D. (1997) · The American Journal of Sports Medicine · doi:10.1177/036354659702500420 · Cited by 164 · see citing works
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van Melick, N., van Cingel, R. E. H., Brooijmans, F., Neeter, C., van Tienen, T., Hullegie, W., & Nijhuis-van der Sanden, M. W. G. (2016) · British Journal of Sports Medicine · doi:10.1136/bjsports-2015-095898 · Cited by 918 · see citing works
Remodelling of human hamstring autografts after anterior cruciate ligament reconstruction
Janssen, R. P. A., van der Wijk, J., Fiedler, A., Schmidt, T., Sala, H. A. G. M., & Scheffler, S. U. (2011) · Knee Surgery, Sports Traumatology, Arthroscopy · doi:10.1007/s00167-011-1419-y · Cited by 109 · see citing works
Self-citationFu, S., Cheuk, Y., Chiu, W. V., Yung, S., Rolf, C. G., & Chan, K. (2015) · Journal of Orthopaedic Research · doi:10.1002/jor.22831 · Cited by 25 · see citing works
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Park, J., Soh, H., Jang, Y.-K., Lee, Y. S., Lee, M.-K., Kim, H., Kim, T.-H., Alkhelaifi, K., Kim, T.-J., & Lee, J. K. (2025) · Stem Cell Research & Therapy · doi:10.1186/s13287-025-04760-1 · Cited by 3 · see citing works
- Authors
- Scheffler, S. U., Unterhauser, F. N., & Weiler, A.
- Affiliations
- Stiftung Charité (DE)
- Zentrum für Spezielle Gelenkchirurgie Am Tegeler Hafen 2 13507 Berlin Germany
- Corresponding author
- Scheffler, S. U.
- Venue
- Knee Surgery, Sports Traumatology, Arthroscopy
- Publisher
- Wiley
- Published
- 2008-05-31
- Volume
- 16
- Issue
- 9
- Pages
- 834-842
- ISSN
- 0942-2056 (ISSN-L)
- 1433-7347
- OpenAlex
- W2091151986
- Cited by
- 266
- References
- 2
- Citations by year
- 2026: 20 · 2025: 18 · 2024: 19 · 2023: 14 · 2022: 22 · 2021: 22 · 2020: 20 · 2019: 19 · 2018: 11 · 2017: 14 · 2016: 16 · 2015: 11 · 2014: 15 · 2013: 11 · 2012: 14
- FWCI
- 1.13
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Knee Surgery Sports Traumatology Arthroscopy (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Knee injuries and reconstruction techniques
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Tendon Structure and Treatment
- Health Sciences › Medicine › Urology › Periodontal Regeneration and Treatments
- Keywords
- cruciate ligament reconstruction, graft remodeling, ligamentization, graft healing, graft mechanical properties
- MeSH terms
- Animals, Collagen, Humans, Regeneration, Tendons, Anterior Cruciate Ligament, Cell Proliferation
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