title: 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.
abstract: OBJECTIVE
  Tendon-to-bone healing of soft-tissue grafts has been described to progress by the development of a fibrous interzone that undergoes a maturation process leading to the development of an indirect type of ligament insertion. Previous studies used extra-articular models or fixation far away from the joint line; thus, no data are available investigating tendon-to-bone healing of a soft-tissue graft fixed anatomically. Therefore, we studied the tendon-to-bone healing of the anatomic soft-tissue graft interference fit fixation in a model of anterior cruciate ligament (ACL) reconstruction in sheep.
  
  
  METHODS
  Animal study.
  
  
  METHODS
  Thirty-five mature sheep underwent ACL reconstruction with an autologous Achilles tendon split graft. Grafts were directly fixed with biodegradable poly-(D,L-lactide) interference screws. Animals were euthanized after 6, 9, 12, 24, and 52 weeks and histologic evaluations were performed. Undecalcified specimens were evaluated under normal and polarized light. Additionally, animals received a polychrome sequential labeling (tetracycline, xylenol orange, and calcein green) to determine bone growth per time under fluorescent light.
  
  
  RESULTS
  Intratunnel histologic findings at 6 weeks showed a tendon-bone junction with only a partial fibrous interzone between the graft tissue and the surrounding bone. A mature intratunnel tendon-bone junction with a zone of fibrocartilage was found at 9 to 12 weeks. At the tunnel entrance site a wide regular ligamentous insertion site was seen in all specimens after 24 weeks. This insertion showed regular patterns such as the direct type of insertion of a normal ligament with a dense basophilic transition zone consisting of mineralized cartilage.
  
  
  CONCLUSIONS
  A fibrous interzone between the graft tissue and the bone tunnel was only partially developed, which is in contrast to all previous studies in which nonanatomic fixation was used. Thus, it is reasonable to assume that the tendon-to-bone healing in the present study may progress partially by direct-contact healing without the development of a fibrous interzone. To our knowledge, this is the first report describing the development of a direct type of ligament insertion after ACL replacement with a soft-tissue graft. This is in contrast to previous studies reporting the development of an indirect type of insertion when using nonanatomic fixation far away from the joint line. Thus, histologic data strongly indicate that anatomic interference fit fixation is beneficial for tendon-to-bone incorporation by leading to the development of a direct type of ligament insertion.
authors.affiliation: Trauma & Reconstructive Surgery, Sports Traumatology and Arthroscopy Service, Charité, Campus Virchow-Clinic, Humboldt-University of Berlin, Germany. andreas.weiler@charite.de
authors.forename: Andreas
authors.initials: A
authors.lastname: Weiler
authors.forename: Reinhard F G
authors.initials: RF
authors.lastname: Hoffmann
authors.forename: Hermann J
authors.initials: HJ
authors.lastname: Bail
authors.forename: Oliver
authors.initials: O
authors.lastname: Rehm
authors.forename: Norbert P
authors.initials: NP
authors.lastname: Südkamp
mesh_terms: D020341:Absorbable Implants; D000125:Achilles Tendon / Q000033:anatomy & histology / Q000637:transplantation*; D000818:Animals; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D001672:Biocompatible Materials / Q000627:therapeutic use; D001863:Bone Screws; D005260:Female; D016268:Internal Fixators; D007700:Kinetics; D007867:Leg Bones / Q000033:anatomy & histology* / Q000601:surgery; D008856:Microscopy, Fluorescence; D016348:Osseointegration; D011091:Polyesters / Q000627:therapeutic use; D019651:Plastic Surgery Procedures / Q000379:methods*; D012756:Sheep; D016896:Treatment Outcome; D014945:Wound Healing
chemical_list: D001672:Biocompatible Materials; D011091:Polyesters; C033616:poly(lactide)