title: Histological characteristics of ligament healing after bio-enhanced repair of the transected goat ACL.
abstract: BACKGROUND
  Recently, healing of a ruptured anterior cruciate ligament (ACL) is reconsidered. In a previous study, we have shown that the transected ACL can heal after treatment with the triple X locking suture alone or combined with small intestine submucosa (SIS). The first research question of this study was whether the healing ACLs in both groups show histological characteristics that are typical for ligament healing. Secondly, did the combined treatment with SIS lead to improved histological healing, in terms of the morphology of the fibrous synovial layer, the extracellular matrix (ECM), collagen fiber orientation, cellularity, ratio of myofibroblasts, and collagen type 3 staining. The hypothesis was that SIS enhances the healing by the scaffolding effect, endogenous growth factors, and chemoattractants.
  
  
  METHODS
  In the Suture group, the left ACL was transected and sutured with the triple X locking suture repair technique. In the Suture-SIS group, the left ACL underwent the same procedure with the addition of SIS. The right ACL served as internal control. Standard histology and immunostaining of α-smooth muscle actin (SMA) and collagen type 3 were used.
  
  
  RESULTS
  Microscopy showed that the fibrous synovial layer around the ACL was reestablished in both groups. The collagen fibers in the Suture-SIS group stained denser, were more compactly arranged, and the ECM contained fewer voids and fat vacuoles. Neovasculature running between the collagen fibers was observed in both experimental groups. Collagen type 3 stained less in the Suture-SIS group. The cellularity in the Suture group, Suture-SIS group and Control was 1265 ± 1034 per mm(2), 954 ± 378 per mm(2), 254 ± 92, respectively; 49%, 26% and 20% of the cells stain positive for α-SMA, respectively.
  
  
  CONCLUSIONS
  The healing ACL in both treated groups showed histological characteristics which are comparable to the spontaneously healing medial collateral ligament and showed that the ACL has a similar intrinsic healing response. Though, no definitive conclusions on the beneficial effects of the SIS scaffold on the healing process can be made.
authors.affiliation: Department of Orthopedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. nguyen.ortho.research@live.nl.
authors.forename: D Tan
authors.initials: DT
authors.lastname: Nguyen
authors.affiliation: Department of Orthopedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. sietskedellbrugge@hotmail.com.
authors.forename: Sietske
authors.initials: S
authors.lastname: Dellbrügge
authors.affiliation: Division of Clinical Immunology and Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. p.p.tak@amc.uva.nl.|GlaxoSmithKline, Stevenage, U.K. and University of Cambridge, Cambridge, UK. p.p.tak@amc.uva.nl.
authors.forename: Paul P
authors.initials: PP
authors.lastname: Tak
authors.affiliation: Department of Bioengineering, Musculoskeletal Research Center, University of Pittsburgh, Pittsburgh, USA. ddcenzo@pitt.edu.
authors.forename: Savio L-Y
authors.initials: SL
authors.lastname: Woo
authors.affiliation: Department of Orthopedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. l.blankevoort@amc.uva.nl.
authors.forename: Leendert
authors.initials: L
authors.lastname: Blankevoort
authors.affiliation: Department of Orthopedic Surgery, Orthopaedic Research Center Amsterdam, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. c.n.vandijk@amc.uva.nl.
authors.forename: Niek C
authors.initials: NC
authors.lastname: van Dijk
keywords: Anterior cruciate ligament; Bio-enhanced ACL repair; Healing; Primary repair; Small intestine submucosa