Remodelling of human hamstring autografts after anterior cruciate ligament reconstruction

Abstract

Purpose: Histological analysis of the remodelling process of human hamstring tendon (HT) grafts after standardized anterior cruciate ligament reconstruction (ACLR) with an accelerated rehabilitation protocol.

Methods: Sixty-seven patients underwent retrieval of mid-substance biopsies after clinically successful hamstring autograft ACLR. Samples were allocated to one of three groups depending on the time point of retrieval: group 1 (6-12 months; n = 15), group 2 (13-24 months; n = 16) and group 3 (>24 months; n = 11). Biopsies from native HT (n = 17) and ACL (n = 8) served as controls. Cellular density, vascular density and myofibroblast density and collagen fibril alignment were analysed by haematoxylin-eosin, Masson-Goldner-Trichrom and immunohistochemical staining protocols.

Results: Compared with native HT (330.4/mm²), total cell number was increased in groups 1-3 (Group 1 = 482.0/mm² (P = 0.036); group 2 = 850.9/mm² (P = 0.005); and group 3 = 595.6/mm² (P = 0.043). There were no significant differences between the groups for vessel density. Myofibroblast density was higher in group 2 (199.6/mm²) compared with native HT (1.9/mm², P = 0.014). Collagen orientation was irregular up to 12 months. Thereafter, collagen orientation became more regular, adapting to, but not fully restoring, the appearance of the intact ACL. For the first 12 months, cells were predominantly ovoid. Ensuing cell morphology changed to spindle shaped in group 2 and predominantly narrow long cells over 24 months.

Conclusion: Human hamstring grafts showed typical stages of graft remodelling, which was not complete up to 2 years after ACLR. The remodelling process in humans was prolonged compared with the results obtained in several animal studies.

Level of evidence: Case-control study, Level III.

Fig. 1

Results of the median cellular density for all biopsy groups. Significant differences between groups 1–3 and native hamstring tendon are illustrated with *

Fig. 2

Results of median vessel density for all biopsy groups

Fig. 3

Results for median myofibroblast density for all biopsy groups. Myofibroblast density was significantly higher in group 2 (13–24 months) compared with native HT control (marked with *)

Fig. 4

Alpha-smooth staining: Group 1 (top left) showed a moderate number of myofibroblasts compared with groups 2 and 3 (right and down). Note an increased number of myofibroblast and vessels in groups 2 and 3

Fig. 5

HE staining: hamstring tendon (top left) with regular collagen orientation, moderate cellular density and little fibroblast activity. Group 1 (top right): irregular collagen alignment, increased cellular density, ovoid cell morphology. Group 2. Further increased cellular and vessel density with an irregular collagen orientation (below left). Group 3 (below right): improved regular collagen arrangement