The morphological effects of synthetic augmentation in posterior cruciate ligament reconstruction: an experimental study in a sheep model.

The treatment of posterior cruciate ligament (PCL) injuries remains controversial. Due to various problems, PCL reconstruction has not consistently produced the knee stability desired. Biological graft tissue undergoes a remarkable healing process comprising different phases. The strength of autogenous graft material decreases soon after operation. During this early healing phase synthetic augmentation could protect the graft tissue from overloading or overstretching, supporting the tissue revitalization and remodeling process. In order to evaluate the morphological effects of the ligament augmentation device (LAD) on a free patellar tendon autograft in PCL reconstruction, a comparative study in sheep was conducted. In 24 mature sheep, the PCL was replaced with either a patellar tendon autograft alone or a patellar tendon autograft augmented by the LAD. The LAD was fixed at both ends. After the operation the animals were not immobilized. Tibial fixation was released 8 weeks postoperation. The autografts of both groups were histologically evaluated after 2, 6, 16, 26, 52, and 104 weeks. In addition to necrotic and degenerative alterations, a remarkable inflammatory reaction could be seen in the LAD-augmented autografts early postoperation. Compared with the nonaugmented autografts, tissue formation and remodeling were delayed in the augmented group. After 1 and 2 years, the morphology of the autograft tissue was similar in both the augmented and nonaugmented group and differed from that of a normal PCL. The LAD was surrounded by a chronic inflammatory reaction, and collagen fiber ingrowth into the LAD was not observed. Using transmission electron microscopy, small diameter collagen fibrils were predominant in the graft tissue of both groups. Thus, a better remodeling of the autograft tissue in the presence of the LAD could not be demonstrated in this particular study. The value of synthetic augmentation of biological grafts in PCL reconstruction seems to be questionable at present.