Maturation of anterior cruciate ligament graft—possibilities of surgical enhancement: What do we know so far?

Abstract

The purpose of this study is to review the surgical methods of enhancing anterior cruciate ligament (ACL) graft maturation. Several methods of ACL maturation enhancement were identified through research of the literature available in the PubMed database. ACL remnant preservation was the most extensively investigated technique. ACL reconstruction with a pedunculated hamstring graft provides superior revascularization of the graft along with higher mechanical strength. The usage of a graft enveloped with a periosteum was proposed to enhance the tendon-bone unit formation, and consequently, to prevent the bone tunnel widening. The muscle tissue on the graft is a potential source of stem cells. However, an excessive amount may weaken whole graft strength despite its enhanced remodeling. Similarly, amniotic tissue may augment the ACL reconstruction with stem cells and growth factors. Despite the existence of several surgical techniques that utilize amnion, the outcomes of these augmentation methods are lacking. Lastly, the intra-articular transplantation of the synovium on the surface of an ACL was proposed to augment the graft with synovial tissue and blood vessels. In conclusion, diverse approaches are being developed in order to enhance the maturation of an ACL reconstruction graft. Although these approaches have their foundation in on well-established scientific research, their outcomes are still equivocal. Clinical trials of high quality are needed to evaluate their utility in clinical practice.