Summary. This study describes the use of a quasi-static, 6DOF knee loading simulator using cadaveric specimens. Muscle force profiles yield repeatable results. Intra-articular pressure and contact area are dependent on loading condition and ACL integrity. Introduction. Abnormal contact mechanics of the tibiofemoral joint is believed to influence the development and progression of joint derangements. As such, understanding the factors that regulate joint stability may provide insight into the underlying injury mechanisms. Muscle action is believed to be the most important factor since it is the only dynamic regulator of joint stability. Furthermore, abnormal muscle control has been experimentally linked to the development of OA [Herzog, 2007] and in vivo ACL strain [Fleming, 2001]. However, the individual contributions to knee joint contact mechanics remain unclear. Thus, the purpose of this study was to examine the effects of individual muscle contributions on the tibiofemoral contact mechanics using an in-vitro experimental protocol. Methodology. Contact mechanics of 6 fresh frozen cadaver knee specimens were evaluated using the UofO Oxford knee loading device. Various combinations of quadriceps-hamstring co-contraction ratios were applied to the knee while it was “suspended” between the hip and foot components of the device. Loads of six muscle groups were computed using a hill-type musculoskeletal model [Buchanan, 2004]. Simulated ground reaction forces were also applied to the knee to represent force profiles of weight acceptance during gait as it has been shown to produce peak knee joint force in the gait cycle [Shelburne et al., 2006]. For respective medial and lateral joint compartments, the mean contact area (MC-CA and LC-CA), mean contact pressure (MC-CP and LC-CP), peak pressure (MC-PP and LC-PP), and centre of force displacement (MC-COFD and LC-COFD) were determined using a 4011 piezoelectric sensor form Tekscan (Tekscan Inc. Boston, MA). Additionally, the ACL was resected and measurements were repeated. Pearson correlations (r) examined the reliability of measurements as well as the effect an ACL transection on articular loads. Results. Positive correlations were computed for the following: COFD with intact ACL (r=0.99), COFD with resected ACL (r=0.82), MC-COFD pre vs. post ACL- resection (0.91). Furthermore, preliminary results indicated a positive correlation between MC-CA and ACL integrity (r=0.97). Discussion. The repeatability of the measured dependant variables validates the use of the knee-loading device. Interestingly, contact mechanics are more variable post ACL resection for a given muscle loading condition, indicating a decrease in knee joint stability. Also, the COFD is dependent on the different ratios of muscle loads applied to the knee, which demonstrates the importance of muscle action to the modulation of contact forces

ACL injured patients show variability in the ability to perform functional activities (Button et al., 2006). It is unknown whether this is due to differences in physical capability or whether fear of re-injury plays a role. Fear of re-injury is not commonly addressed in rehabilitation. This study aimed to investigate whether fear of re-injury impacts rehabilitation of ACL injured patients. An initial group of five ACL reconstructed participants (ACLR, age: 30±11 years, weight: 815±115 N, height: 1.74±0.07 m, all male), five ACL deficient participants (ACLD, age: 31±12 years, weight: 833±227 N, height: 1.80±0.11 m, four male and one female), and five healthy controls (age: 30±3 years, weight: 704±126 N, height: 1.70±0.09 m, three male and two female) were compared. Fear of re-injury was assessed using the Tampa Scale for Kinesiophobia (Kvist, 2004). Quadriceps strength was measured on a Biodex dynamometer. Functional activity was assessed by a single legged maximum distance hop (on the injured leg for ACL patients). Motion analysis was performed with a VICON system, and a Kistler force plate. Hop distance was calculated using the ankle position. The peak knee extension moment during landing, and the knee angle at this peak moment were calculated in VICON Nexus. The ACLD group scored worse on the Tampa scale for Kinesiophobia than the ACLR group (32±4 and 26±4). The ACLD patients did not hop as far as the ACLR and control groups (1.0±0.3, 1.3±0.1 and 1.4±0.3 m). The peak knee extension moments during landing were lowest in the ACLD group (263±159 Nm), slightly higher in the control group (354±122 Nm) and highest in the ACLR group (490±222 Nm), while knee flexion angles at these moments were similar (ACLD: 28±11, ACLR: 33±7 and control: 36±13 degrees). The ACLD group had weaker quadriceps than the control group, while the ACLR group was stronger (143±44 Nm, 152±42, and 167±50 Nm respectively). Fear of re-injury and decreased quadriceps strength potentially both impact on the functional performance of ACL injured patients. Rehabilitation of ACL injured patients could therefore be improved by addressing strength and fear of re-injury. Future research with more participants will further clarify this

Aim. The aim of this study is to outline the steps and techniques required to create a patient specific 3D printed guide for the accurate placement of the origin of the femoral tunnel for single bundle ACL reconstruction. Introduction. Placements of the femoral tunnels for ACL reconstruction have changed over the years. Most recently there has been a trend towards placing the tunnels in a more anatomic position. There has been subsequent debate as to where this anatomic position should be. The problem with any attempt at consensus over the placement of an anatomic landmark is that each patient has some variation in their positioning and therefore a fixed point for all has compromise for all as it is an average. Our aim was to attempt to make a cost effective and quick custom guide that could allow placement of the center of the patients’ newly created femoral tunnel in the mid position of their contralateral native ACL femoral footprint. Materials & Methods. We took a standard protocol MRI scan of a patient's knee without ACL injury transferred the DICOM files to a personal computer running OsiriX (Pixmeo, Geneva, Switzerland.) and analysed it for a series of specific anatomical landmarks. OsiriX is an image processing software dedicated to DICOM images. We marked the most posterior edge of the articular cartilage on the lateral wall of the notch (1), the most anterior edge of the articular cartilage of the lateral wall of the notch (2), the most inferior edge of the articular cartilage of the lateral wall of the notch (3) and the center of the femoral footprint of the native ACL. Distances were then calculated to determine the position relative to the three articular cartilage points of the center of the ACL footprint. These measurements and points were then utilised to create a 3D computer aided design (CAD) model of a custom guide. This was done using the 3D CAD program 123Design (Autodesk Ltd., Farnbourgh, Hampshire). This 3D model was then exported as an STL file suitable for 3D printing. The STL file was then uploaded to an online 3D printing service and the physical guide was created in transparent acrylic based photopolymer, PA220 plastic and 316L stainless steel. The models created were then measured using vernier calipers to confirm the accuracy of the final guides. Results. The MRI data showed point 1 (AP), point 2 (distal-ACL), point 3 (Ant-ACL) and point 4 (Post-ACL) at a distance of 59.83, 15, 45.8 and 13.9 respectively. For the 3D CAD model, points 1, 2, 3 and 4 were at a distance of 59.83, 15, 45.8 and 13.9 respectively. For the PA220 plastic model, points 1, 2, 3 and 4 were at a distance of 59.86, 14.48, 45.85 and 13.79 respectively. For the 316L stainless steel model, points 1, 2, 3 and 4 were at a distance of 59.79, 14.67, 45.64 and 13.48 respectively. Lastly, for the photopolymer model, points 1, 2, 3 and 4 were at a distance of 59.86, 14.2, 45.4 and 13.69 respectively. The p-value comparing MRI/CAD vs. PA220 was p=0.3753; for the comparison between MRI/CAD vs. 316L, p=0.0683; lastly for the comparison between MRI/CAD Vs. Photopolymer, p=0.3450. The models produced were accurate with no statistical difference in size and positioning of the center of the ACL footprint from the original computer model and to the position of the ACL from the MRI scans. The costs for the models 3D printed were £3.50 for the PA220 plastic, £15 for the transparent photopolymer and £25 for the 316L stainless steel. The time taken from MRI to delivery for the physical models was 7 days. Discussion. Articles regarding the creation of 3D printed custom ACL guides from the patients contralateral knee do not feature in current literature. There has been much research on custom guides for other orthopaedic procedures such as in total knee arthroplasty for the accurate placement of implants. There has also been research published on the creation of custom cutting jigs from CT for complex corrective osteotomy surgery. This study serves as the first step and a proof of concept for the accurate creation of patient specific 3D printed guides for the anatomical placement of the femoral tunnel for ACL reconstruction. The guides were easy to create and produce taking only a week and with a cost of between £3.50 and £25. The design of the guides was to allow the tip of a standard Chondro Pick (Arthrex inc., Naples, Florida.) (3mm) used to mark the starting point of the femoral tunnel to enter through the guide. The next step for this research is to create guides from cadaveric matched knees and utilise the guides to carry out the creation of the femoral tunnels and to analyse of the placement of the tunnel in relation to the contralateral knee

Summary. Nearly one-third of patients in this series with an ACL rupture requiring reconstruction had evidence of MPFL injury. This should be considered when patients are seen, and when MRI scans are reviewed/reported. Introduction. The Medial Patello-Femoral Ligament (MPFL) is the largest component of the medial parapatellar ligamentous complex. The senior surgeon felt that there was an anecdotally high rate of MPFL injury amongst his patients undergoing Anterior Cruciate Ligament (ACL) repair, but no discussion of this in the present literature. Method. A literature search was performed; although there were both scanty radiographic and anatomical studies of the MPFL, we found no literature looking at ACL and MPFL concurrent injury rates. The Magnetic Resonance Imaging (MRI) scans of fifty consecutive ACL reconstruction patients were retrospectively reviewed. Two independent radiologists were asked to review the scans looking specifically for evidence of MPFL rupture or Injury. The degree of injury was rated as rupture or by degree of sprain as applicable. One patient was excluded due to motion artefact limiting certainty. Results. Of the remaining forty-nine patients, 35 (71%) were intact, but fourteen (29%) showed evidence of injury. Five (10%) had a low-grade sprain, six (12%) had high-grade sprain, and three (6%) had complete rupture. The radiologists also noted that there was some variation in scanning protocols, and those with fat suppressed scans had better diagnostic value; this offered an opportunity to change the scanning practice. Conclusion. Nearly one-third of patients in this series with an ACL rupture requiring reconstruction had evidence of MPFL injury. This should be considered when patients are seen, and when MRI scans are reviewed/reported. Further, we would suggest that fat suppression sequences are included as standard to improve imaging quality

The Pivot-shift test is a clinical test for knee instability for patinets with Anterior cruciate ligament (ACL), however the test has low inter-observer reliability. Dynamic radiostereometry (dRSA) imaging is a highly precise method for objective evaluation of joint kinematics. The purpose of the study was to quantify precise knee kinematics during Pivot-shift test by use of the non-invasive dynamic RSA imaging. Eight human donor legs with hemipelvis were evaluated. Ligament lesion intervention of the ACL was performed during arthroscopy and anterolateral ligament (ALL) section was performed as a capsular incision. Pivot-shift test examination was recorded with dRSA on ligament intact knees, ACL-deficient knees and ACL+ALL-deficient knees. A Pivot-shift pattern was identifyable after ligament lesion as a change in tibial posterior drawer velocity from 7.8 mm/s in ligament intact knees, to 30.4 mm/s after ACL lesion, to 35.1 mm/s after combined ACL-ALL lesion. The anterior-posterior drawer excursion increased from 2.8 mm in ligament intact knees, to 7.2 mm after ACL lesion, to 7.6 mm after combined lesion. Furthermore a change in tibial rotation was found, with increasing external rotation at the end of the pivot-shift motion going from intact to ACL+ALL-deficient knees. This experimental study demonstrates the feasibility of RSA to objectively quantify the kinematic instability patterns of the knee during the Pivot-shift test. The dynamic parameters found through RSA displayed the kinematic changes from ACL to combined ACL-ALL ligament lesion

The anterior cruciate ligament (ACL) is the connective tissue located at the end of long bones providing stability to the knee joint. After tear or rupture clinical reconstruction of the tissue remains a challenge due to the particular mechanical properties required for proper functioning of the tissue. The outstanding mechanical properties of the ACL are characterized by a viscoelastic behavior responsible of the dissipation of the loads that are transmitted to the bone. These mechanical properties are the result of a very specialized graded extracellular matrix that transitions smoothly between the heterotypic cells, stiffness and composition of the ACL and the adjacent bone. Thus, mimicking the zonal biochemical composition, cellular phenotype and organization are key to reset the proper functioning of the ACL. We have previously shown how the biochemical composition presented to cells in electrospun scaffolds results in haptokinesis, reverting contact-guidance effects. [1]. Here, we demonstrate that contact guidance can also be disrupted by structural parameters in aligned wavy scaffolds. The presentation of a wavy fiber arrangement affected the cell organization and the deposition of a specific ECM characteristic of fibrocartilage. Cells cultured in wavy scaffolds grew in aggregates, deposited an abundant ECM rich in fibronectin and collagen II, and expressed higher amounts of collagen II, X and tenomodulin as compared to aligned scaffolds. In-vivo implantation in rabbits of triphasic scaffolds accounting for aligned-wavy-aligned zones showed a high cellular infiltration and the formation of an oriented ECM, as compared to traditional aligned scaffolds. [2]

To address the current challenge of anterior cruciate ligament (ACL) reconstruction, this study is the first to fabricate a braided collagen rope (BCR) which mimics native hamstring for ACL reconstruction. The study aims to evaluate the biological and biomechanical properties of BCR both in vivo and vitro. Rabbit ACL reconstruction model using collagen rope and autograft (hamstring tendon) was conducted. The histological and biomechanical evaluations were conducted at 6-, 12-, 18, 26-week post-operation. In vitro study included cell morphology analysis, cell function evaluation and RNA sequencing of the tenocytes cultured on BCR. A cadaver study was also conducted to verify the feasibility of BCR for ACL reconstruction. BCR displays satisfactory mechanical strength similar to hamstring graft for ACL reconstruction in rabbit. Histological assessment showed BCR restore ACL morphology at 26 weeks similar to native ACL. The superior dynamic ligamentization in BCR over autograft group was evidenced by assessment of cell and collagen morphology and orientation. The in vitro study showed that the natural collagen fibres within BCR enables to signal the morphology adaptation and orientation of human tenocytes in bioreactor. BCR enables to enhance cell proliferation and tenogenic expression of tenocytes as compared to hydrolysed collagen. We performed an RNA-Sequencing (RNA-seq) experiment where RNA was extracted from tenocyte seeded with BCR. Analysis of enriched pathways of the up-regulated genes revealed that the most enriched pathways were the Hypoxia-inducible factor 1-alpha (HIF1A) regulated networks, implicating the possible mechanism BCR induced ACL regeneration. The subsequent cadaver study was conducted to proof the feasibility of BCR for ACL reconstruction. This study demonstrated the proof-of-concept of bio-textile braided collagen rope for ACL reconstruction, and the mechanism by which BCR induces natural collagen fibres that positively regulate morphology and function of tenocytes

To investigate if the countermovement jump height differs between ACL injured and uninjured female adolescents and to explore kinematic differences between limbs. Additionally, the association between isometric knee extension strength and jump height was investigated. Thirty-one ACL injured female adolescents (ACLi, 15.3 ± 1.4yrs, 163.9 ± 6.6cm, 63.0 ± 9.3kg) and thirty-eight uninjured (CON, 13.2±1.7yrs, 161.7 ± 8.1cm, 50.6 ± 11.1kg) participated in this study. All participants performed a countermovement jump task, with 3D kinematics collected using a motion analysis system (Vicon, Nexus, Oxford, UK) at 200Hz, and a maximum isometric knee extension task on an isokinetic dynamometer (Biodex Medical Systems, New York, USA) for three trials. The peak torque was extracted from the isometric trials. Independent samples t-test compared the maximum jump height normalised by the dominant leg length between groups, paired samples t-test compared the maximum hip and knee extension and ankle plantar flexion velocities before take-off between limbs in both groups, and a Pearson's correlation test investigated the association between the isometric knee extension strength and jump height. The ACLi jumped 13% lower compared to the CON (p=0.022). In the ACLi, the maximum hip and knee extension and ankle plantar flexion velocities were greater in the non-injured limb, compared to the injured limb; however, no differences between limbs were found in the CON. The isometric knee extension strength of both limbs was positively correlated with jump height (limb 1: r=0.329; p=0.006, and limb 2: r=0.386; p=0.001; whereas limb 1 corresponds to the ACLi injured limb and CON non-dominant limb, and limb 2 to the ACLi non-injured limb and CON dominant limb). ACL injured female adolescents present lower jump height than controls and greater contribution of their non-injured limb, compared to their injured limb, during a countermovement jump task. Also, current results indicate that jump height is positively related to isometric knee extension strength measure

The Anterior Cruciate Ligament (ACL) plays a vital role in maintaining function and stability in the knee. Over the last several decades, much research has been focused on elucidating the anatomy, structural properties, biomechanics, pathology, and optimal treatments for the ACL. Through careful and objective study, the ACL can be understood to be a dynamic structure, rich in neurovascular supply. Although it is referred to as one ligament, it is comprised of two dis-tinct bundles which function synergistically to facilitate normal knee kinematics. The bony morphology of the knee defines normal knee kinematics, as well as the nature of the soft-tissue structures about the knee. Characterized by individual uniqueness, bony morphology varies from patient to patient. The ACL, which is a reflection of each patient's unique bony morphol-ogy, is inherently subject to both anatomic and morphologic variation as well. Furthermore, the ACL is subject to physiologic aging, which can affect the anatomic and structural properties of the ligament over time. A successful anatomic ACL Reconstruction, which may be considered the functional restoration of the ACL to its native dimensions, collagen orientation, and inser-tion sites according to individual anatomy, considers all these principles. It is vital to respect the nature we observe, rather than to “create” nature to fit a one-size-fits-all surgery. Double bundle ACL Reconstruction may therefore be thought of more as a concept rather than a specific technique, one that respects the individual unique anatomy of each patient to provide a truly indi-vidualized, anatomic, and value-based ACL Reconstruction

More than 250,000 people are suffering from Anterior Cruciate Ligament (ACL) related injuries each year in the US, with a cost of $17–25K/patient. There is an unmet clinical demand for improving grafts/scaffolds to provide biological integration in addition to mechanical support. Currently, no data is available for the utilization of fibrous scaffolds with bimodal distribution for ACL regeneration. The novelty in this study is that it proposes for the first time to investigate the collagen fibril diameter distribution in healthy and injured bovine ACL tissue, and utilization of such structure for scaffold design. Objectives are 1) developing a bovine ACL tear model and measuring the collagen fibril diameter distribution of both healthy and injured ACL tissues, and 2) fabricating scaffolds to mimic the structural properties of healthy and injured ACL tissue. Bovine ACL tissues (1–3 years old) were harvested and characterized for their fibril diameter distribution using Transmission Electron Microscopy (TEM) and biomechanical properties under tension. The electrospun polycaprolactone (PCL) scaffolds were characterized using SEM and mechanical testing. Healthy and injured ACL fibril diameter, and that of PCL scaffolds representing healthy and injured ACL are compared using unpaired student t-test. The proposed fibrous scaffold design represents a significant departure from the conventional unimodal approach, and is expected to have significant contribution to ACL regeneration. These discoveries will serve as the foundation for the development of biomimetic tissue engineering substrates aimed at promoting biological graft fixation

Recent findings have identified the importance of previously undiagnosed or neglected meniscus lesions in association with anterior cruciate ligament (ACL) injuries (e.g. medial meniscus ramp lesions and posterior root tears of the lateral meniscus). There is increasing biomechanical evidence that they bear the potential to alter both anteroposterior and rotational laxity patterns in ACL injured knees. Few data exist with respect to the presence of these specific tear entities in large series of ACL injured patients. The purpose of the study was to analyze the meniscus tear pattern in a series of ACL injured knees with a special focus on ramp lesions of the medial meniscus and posterior root lesions of the lateral meniscus. The hypothesis was that a significant number of ACL injured patients would display these types of lesions. Data from 358 patients undergoing an ACL reconstruction (227 males /131 females, age: 28±10) were extracted from a center-based registry. The type of ACL tear (partial versus complete) as well as the presence of associated meniscus lesions were documented. Meniscus lesions were classified into the following categories: medial ramp lesions, lateral root lesions, medial ramp and lateral root lesion, other medial meniscus injuries, other lateral meniscus injuries, other bimeniscal injuries. Chi-square tests were used to determine whether the percentage of meniscal lesions differed between types of ACL tear, gender and age (below 21, 21–35, above 35). Significance was set at p < 0.05. Isolated ACL tears were present in 107 (30%) of the operated knees (31 partial; 327 complete). Complete ACL lesions were more likely to present an associated meniscus injury (321 out of 327, 71%) than partial tears (13 out of 31, 42%). The incidence of meniscus injuries which are associated with ACL tears is very high (70%). Previously undiagnosed or neglected meniscus injuries like medial ramp or lateral root tears could be identified in 35% of patients. As such, the hypothesis was confirmed that an important amount of ACL injured knees display this specific intraarticular soft tissue damage. A systematic evaluation of these lesions under arthroscopy should thus be performed and specific repair needs to be evaluated

Although autografts represent the gold standard for anterior cruciate ligament (ACL) reconstruction, tissue-engineered ACLs provide a prospect to minimize donor site morbidity and limited graft availability. This given study characterizes the ligamentogenesis in embroidered poly(L-lactide-co-ε-caprolactone) (P(LA-CL)) / polylactic acid (PLA) constructs using a dynamic nude mice xenograft model. (P(LA-CL))/PLA scaffolds remained either untreated (co) or were functionalized by gas fluorination (F), collagen foam cross-linked with hexamethylene diisocyanate (HMDI) (coll), or gas fluorination combined with the foam (F+coll). Cell free constructs or those seeded for 1 week with lapine ACL ligamentocytes were implanted into nude mice for 12 weeks. Following explantation, biomechanical properties, cell vitality and content, histopathology of scaffolds (including organs: liver, kidney, spleen), sulphated glycosaminoglycan (sGAG) contents and biomechanical properties were assessed. Implantation of the scaffolds did not negatively affect mice weight development and organs, indicating biocompatibility. All scaffolds maintained their size and shape for the duration of the implantation. A high cell viability was detected in the scaffolds prior to and following implantation. Coll or F+coll scaffolds seeded with cells yielded superior macroscopic properties when compared to the controls. Mild signs of inflammation (foreign-body giant cells, hyperemia) were limited to scaffolds without collagen. Microscopical score values and sGAG content did not differ significantly. Although remaining stable in vivo, elastic modulus, maximum force, tensile strength and strain at Fmax were significantly lower in the in vivo compared to the samples cultured 1 week in vitro, but did not differ between scaffold subtypes, except for a higher maximum force in F+coll compared with F samples (in vivo). Scaffold functionalization with fluorinated collagen foam provides a promising approach for ACL tissue engineering. (shared first authorship). Acknowledgement: The study was supported by DFG grants SCHU1979/9-1 and SCHU1979/14-1

Successful anterior cruciate ligament (ACL) reconstructions strive a firm ligament-bone integration. Therefore, the aim of this study was to address in more detail the enthesis as the thriphasic bone attachment of the ACL using a tissue engineering approach. To establish a tissue-engineered enthesis-like construct, triphasic scaffolds embroidered from poly(L-lactide-co-caprolactone) and polylactic acid functionalized with collagen foam were colonized with osteogenically differentiated human mesenchymal stromal cells (hMSCs) and lapine (L) ACL fibroblasts. These triphasic scaffolds with a bone-, a fibrocartilage transition- and a ligament phase were seeded directly after spheroid assembly or with 14 days precultured LACL fibroblast spheroids and 14 days osteogenically differentiated hMSCs spheroids (=longer preculture) and cultured for further 14 days. Cell survival was tested. Collagen type I and vimentin were immunolabeled and the content of DNA and sulfated glycosaminoglycan (sGAG) was quantified. The relative gene expression of tenascin C, type I and X collagens, Mohawk and Runx2 was analyzed. Compared to the LACL spheroids the hMSC spheroids adhered better to the scaffold surface with faster cell outgrowth on the fibers. Collagen type I and vimentin were mainly detected in the hMSCs colonizing the bone zone. The DNA content was generally higher in the bone (hMSCs) than in the ligament zones and after short spheroid preculture higher than after longer preculture whereas the sGAG content was greater after longer preculture for both cell types. The longer precultivated hMSCs expressed more type I collagen in comparison to those only shortly precultured before scaffold seeding. Type I collagen and tenascin C were higher expressed in scaffolds directly colonized with LACL compared to those seeded after longer spheroid preculture. The gene expression of ECM components and transcription factors depended on cell type and preculturing condition. Zonal colonization of triphasic scaffolds using the spheroid method is possible offering a novel approach for enthesis tissue engineering

Screw fixation is an established method for anterior cruciate ligament (ACL) reconstruction, although with a high rate of implant-related complications. An allograft system for implant fixation in ACL reconstruction, the Shark Screw ACL (surgebright GmbH) could overcome some of the shortcomings of bioabsorbable screws, such as foreign body reaction, need for implant removal and imaging artefacts. However, it needs to provide sufficient mechanical stability. Therefore, the aim of this study was to investigate the biomechanical stability, especially graft slippage, of the novel allograft system versus a conventional bioabsorbable interference screw (BioComposite Interference Screw; Arthrex Inc.) for tibial implant fixation in ACL reconstruction. Twenty-four paired human proximal tibiae (3 female, 9 male, 72.7 ± 5.6 years) underwent ACL reconstruction. The quadrupled semitendinosus and gracilis tendon graft were fixed in one specimen of each pair using the allograft fixation system Shak Screw ACL and the contralateral one using an interference screw. All specimens were cyclically loaded at 1 Hz with peak load levels monotonically increased from 50 N at a rate of 0.1 N/cycle until catastrophic failure. Relative movements of the graft versus the tibia were captured with a stereographic optical motion tracking system (Aramis SRX; GOM GmbH). The two fixation methods did not demonstrate any statistical difference in ultimate load at graft slippage (p = 0.24) or estimated survival at slippage (p = 0.06). Both, the ultimate load and estimated survival until failure were higher in the interference screw (p = 0.04, and p = 0.018, respectively). Graft displacement at ultimate load reached values of up to 7.2 mm (interference screw) and 11.3 mm (Shark Screw ACL). The allograft screw for implant fixation in ACL reconstruction showed similar behavior in terms of graft slippage compared to the conventional metal interference screw but underperformed in terms of ultimate load. However, the ultimate load may not be considered a direct indicator of clinical failure

Abstract. Objectives. There is renewed interest in bi-unicondylar arthroplasty (Bi-UKA) for patients with medial and lateral tibiofemoral osteoarthritis, but a spared patellofemoral compartment and functional cruciate ligaments. The bone island between the two tibial components may be at risk of tibial eminence avulsion fracture, compromising function. This finite element analysis compared intraoperative tibial strains for Bi-UKA to isolated medial unicompartmental arthroplasty (UKA-M) to assess the risk of avulsion. Methods. A validated model of a large, high bone-quality tibia was prepared for both UKA-M and Bi-UKA. Load totalling 450N was distributed between the two ACL bundles, implant components and collateral ligaments based on experimental and intraoperative measurements with the knee extended and appropriately sized bearings used. 95th percentile maximum principal elastic strain was predicted in the proximal tibia. The effect of overcuts/positioning for the medial implant were studied; the magnitude of these variations was double the standard deviation associated with conventional technique. Results. For all simulations, strains were an order of magnitude lower than that associated with bone fracture. Highest strain occurred in the spine, under the anteromedial ACL attachment, adjacent to transverse overcut of the medial component. Consequently, Bi-UKA had little effect on strain: <10% increases were predicted when compared to UKA-M with equivalent medial cuts/positioning. However, surgical overcutting/positional variation that resulted in loss of anteromedial bone in the spine increased strain. The biggest increase was for lateral translation of the medial component: 44% and 42% for UKA-M and Bi-UKA, respectively. Conclusions. For a large tibia with high bone quality, Bi-UKA with a well-positioned lateral implant had no tangible effect on the risk of tibial eminence avulsion fracture compared to UKA-M. Malpositioning of the medial component that removes bone from the anterior spine could prove problematic for smaller tibiae. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

After anterior cruciate ligament (ACL) rupture, reconstructive surgery with a hamstring tendon autograft is often performed. Despite overall good results, ACL re-rupture occurs in up to 10% of the patient population, increasing to 30% of the cases for patients aged under 20 years. This can be related to tissue remodelling in the first months to years after surgery, which compromises the graft's mechanical strength. Resident graft fibroblasts secrete matrix metalloproteinases (MMPs), which break down the collagen I extracellular matrix. After necrosis of these fibroblasts, myofibroblasts repopulate the graft, and deposit more collagen III rather than collagen I. Eventually, the cellular and matrix properties converge towards those of the native ACL, but full restoration of the ACL properties is not achieved. It is unknown how inter-patient differences in tissue remodelling capacity contribute to ACL graft rupture risk. This research measured patient-specific tissue remodelling-related properties of human hamstring tendon-derived cells in an in vitro micro-tissue platform, in order to identify potential biological predictors for graft rupture. Human hamstring tendon-derived cells were obtained from remnant autograft tissue after ACL reconstructions. These cells were seeded in collagen I gels on a micro-tissue platform to assess inter-patient cellular differences in tissue remodelling capacity. Remodelling was induced by removing the outermost micro-posts, and micro-tissue compaction over time was assessed using transmitted light microscopy. Protein expression of tendon marker tenomodulin and myofibroblast marker α-smooth muscle actin (αSMA) were measured using Western blot. Expression and activity of remodelling marker MMP2 were determined using gelatin zymography. Cells were obtained from 12 patients (aged 12–51 years). Patient-specific variations in micro-tissue compaction speed or magnitude were observed. Up to 50-fold differences in αSMA expression were found between patients, although these did not correlate with faster or stronger compaction. Surprisingly, tenomodulin was only detected in samples obtained from two patients. Total MMP2 expression varied between patients, but no large differences in active fractions were found. No correlation of patient age with any of the remodelling-related factors was detected. Remodelling-related biological differences between patient tendon-derived cells could be assessed with the presented micro-tissue platform, and did not correlate with age. This demonstrates the need to compare this biological variation in vitro - especially cells with extreme properties - to clinical outcome. Sample size is currently increased, and patient outcome will be determined. Combined with results obtained from the in vitro platform, this could lead to a predictive tool to identify patients at risk for graft rupture

Cell sheets are manufactured from a high-density cell layer stabilized by its own freshly produced extracellular matrix (ECM). They could serve as versatile scaffolds for tissue repair. Unfortunately, their production often remains time-consuming requiring weeks of culturing. Ligament cell sheets are so far barely available. Regarding musculoskeletal tissues exposed to high repetitive biomechanical forces, the stability of cell sheets is insufficient. It could help to combine them with a biomechanical competent scaffold e.g. produced by an embroidering technique. Hence, we wanted to (1) develop a very rapid strategy to produce ACL ligamentocyte sheets within 24 h by using a thermoresponsive polymer surface, (2) use the sheets for scaffold seeding and (3) reflect the fibrocartilaginous transition zone of an ACL enthesis by combining sheets of ligamentocytes with chondrocytes or chondrogenic precursor cells as a strategy for directed seeding of two cell types on topologically different scaffold areas. Different cell numbers of lapine ACL ligamentocytes (L-ACLs), lapine articular chondrocytes (L-ACs) and human mesenchymal stromal cells (H-MSCs) were used for sheet formation. Experiments were performed with novel, self-assembled poly(glycidyl ether) (PGE) brushes based on random glycidyl methyl ether and ethyl glycidyl ether copolymers on polystyrene 12-well cell culture plates, which allow rapid sheet formation within 24 h. Uncoated plates served as controls. Temperature-triggered detachment was performed by 10 min incubation with PBS at ambient temperature before treatment with fresh warm PBS for 5 min at 37 degrees Celsius. Harvested cell sheets were transferred on polyglycolic acid (PGA) or embroidered poly-lactic acid / poly-co-caprolactone (PLA/P[LA-CL]) scaffolds, functionalized with collagen foam and fluorine gas treatment (prepared at the IPF in Dresden and the FILK in Freiberg). Cell distribution, growth, vitality and synthesis of ECM components were monitored up to 7 days. Cell numbers required for sheet preparation (3.9 cm2) depended strongly on the cell type (L-ACLs: 0.395 mio/cm2, L-AC: 0.342 mio/cm2, H-MSCs: 0.131 mio/cm2) and was highest for L-ACLs. The majority of cells survived sheet assembly, detachment, transfer onto the scaffolds and culturing. Cells migrated from the sheets into the scaffolds and spread through the scaffolds. L-ACLs and L-ACs produced ECM and maintained their phenotypes (type II collagen and sulfated glycosaminoglycans in L-AC sheets, decorin and tenascin C in L-ACL sheets). The presence and distribution of two cell types in scaffold cocultures (L-ACLs and H-MSCs) was proven by anti-human vimentin labeling. Hence, the PGE brush surface allows rapid formation (24 h) of cell sheets

Ligament fibroblasts must be mechanosensitive and possess sufficient adaptability to a novel mechanomilieu ensuring the permanent load capacity of the tissue. Once mechanoreceptors are activated, the fibroblasts react with a specific signal transmission (mechanotransduction), which ultimately leads to an adaption of their cytoskeletal organization and protein synthesis. However, the cellular response of anterior cruciate ligament (ACL) fibroblasts to cyclic mechanical stretching is still unclear. Hence, this study should allow a deeper understanding of the reaction profile of mechanically stretched ACL cells in two- (2D) and three-dimensional (3D) biomaterial-free and biomaterial cultures with respect to cell survival, size, orientation, migration and distribution. For the 2D approach consisting of monolayers with 6000 lapine (L) ACL cells per cm2 and for the 3D cultures using preformed LACL cell spheroids (2.5–4/cm2) with 25.000 cells per spheroid, silicone chambers were coated with geltrex and statically colonized with the LACL cells for 24 h before cyclically stretched for 48 h (14 percent uniaxial stretch). A second approach using 3D scaffold cultures was performed which were seeded dynamically for 24 h with LACL cells before cyclically stretched in a novel custom-made mechanostimulator. The scaffolds [polylactic acid (PLA) and polycaprolactone (PCL)] were functionalized with 10 percent gas fluorination and a collagen foam. Scaffolds (120 mm2) were precolonized dynamically with an LACL cell suspension (1 mio cells/mL) for 24 h before stretched for 72 h (4 percent uniaxial stretch). Cell vitality and numbers were monitored. The cytoskeleton orientation was shown by cytochemistry (F-actin) and evaluated (ImageJ). Cell proliferation, based on the DNA content was measured. Cell viability in stretched samples (2D, 3D and scaffold) remained above 90 percent. Stretching on the silicone chambers led to increased cell counts, length and significantly higher colonized areas than in unstretched controls. Higher numbers of LACL cells migrated out of the 3D spheroids under stretching conditions. In response to intermittent stretching, cells oriented in a 70 degrees' angle against the stretch direction in silicone chambers, whereas cell arrangement was more compact on the threads of the scaffolds than in unstretched cultures. In summary, stretching induced a rapid (48 h) cell and cytoskeletal alignment in 2D as well as in 3D cultures. The natural ACL is characterized by a strongly uniaxial cell and extracellular matrix organization which might be achieved in tissue engineered constructs by a suitable cyclic stretching protocol in future

To investigate temporal changes in synovial lymphatic system (SLS) drainage function after Anterior cruciate ligament (ACL) injury, a non-invasive ACL rupture model was used to induce the PTOA phenotype without altering the SLS structure. We have created a non-invasive ACL rupture model in the right knee (single overload impact) of 12- week-old C57bl/6 male mice to mimic the ACL rupture-induced PTOA development. 70 kDa-TxRedDextran were injected into the right knee of the mice at 0, 1, 2, and 4 wks post modeling (n=5/group), and the fluorescence signal distribution and intensity were measured by the IVIS system at 1 and 6 hrs post-injection. After 24 hrs, the drainage lymph nodes and whole knee joint were harvested and subjected to ex vivo IVIS imaging and immunofluorescence detection respectively. Manual ACL rupture was induced by 12N overloaded force and validated by a front drawer test. Intraarticular clearance of TxRed-Dextran detected by the IVIS was significantly reduced at 1, and 2 wks at a level of 43% and 55% respectively but was not significantly different from baseline levels at 4 wks (89%). TxRed-Dextran signal in draining lymph nodes was significantly reduced at 1 week at the level of but not for 2 and 4 wks compared to baseline levels (week 1–29%, week 2–50%, week 4–94%). TxRed-Dextran particle was significantly enriched in the synovium at 1, 2 wks but was not significantly different from baseline levels at 4 wks rupture-post ACL rupture (Particle numbers: Sham Ctrl-34 ±14, week 1, 113 ± 17; week 2, 89 ± 13; week 4, 46 ± 18; mean ± SD). We observed the drainage function of SLS significantly decreased at 1 and 2 wks after the ACL rupture, and was slowly restored at 4 wks post-injury in a non-invasive ACL rupture model. Early impairment of SLS drainage function may lead to accumulation of inflammatory factors and promote PTOA progression

To investigate differences in the drop vertical jump height in female adolescents with an ACL injury and healthy controls and the contribution of each limb in this task. Forty female adolescents with an ACL injury (ACLi, 15.2 ± 1.4 yrs, 164.6 ± 6.0 cm, 63.1 ± 10.0 kg) and thirty-nine uninjured (CON, 13.2 ± 1.7 yrs, 161.7 ± 8.0 cm, 50.6 ± 11.0 kg) were included in this study. A 10-camera infrared motion analysis system (Vicon, Nexus, Oxford, UK) tracked pelvis, thigh, shank, and foot kinematics at 200Hz, while the participants performed 3 trials of double-legged drop vertical jumps (DVJ) on two force plates (Bertec Corp., Columbus, USA) sampled at 2000Hz.The maximum jump height normalised by dominant leg length was compared between groups using independent samples t-test. The maximum vertical ground reaction force (GRFz) and sagittal ankle, knee and hip velocities before take-off were compared between limbs in both groups, using paired samples t-test. The normalised jump height was 11% lower in the ACLi than in the CON (MD=0.04 cm, p=0.020). In the ACLi, the maximum GRFz (MD=46.17N) and the maximum velocities of ankle plantar flexion (MD=79.83°/s), knee extension (MD=85.80°/s), and hip extension (MD=36.08°/s) were greater in the non-injured limb, compared to the injured limb. No differences between limbs were found in the CON. ACL injured female adolescents jump lower than the healthy controls and have greater contribution of their non-injured limb, compared to their injured limb, in the DVJ task. Clinicians should investigate differences in the contribution between limbs during double-legged drop vertical jump when assessing patients with an ACL injury, as this could help identify asymmetries, and potentially improve treatment, criteria used to clear athletes to sport, and re-injury prevention