Anterior Cruciate Ligament Reconstruction: Is Biological Augmentation Beneficial?

Abstract

Surgical reconstruction in anterior cruciate ligament (ACL) ruptures has proven to be a highly effective technique that usually provides satisfactory results. However, despite the majority of patients recovering their function after this procedure, ACL reconstruction (ACLR) is still imperfect. To improve these results, various biological augmentation (BA) techniques have been employed mostly in animal models. They include: (1) growth factors (bone morphogenetic protein, epidermal growth factor, granulocyte colony-stimulating factor, basic fibroblast growth factor, transforming growth factor-β, hepatocyte growth factor, vascular endothelial growth factor, and platelet concentrates such as platelet-rich plasma, fibrin clot, and autologous conditioned serum), (2) mesenchymal stem cells, (3) autologous tissue, (4) various pharmaceuticals (matrix metalloproteinase-inhibitor alpha-2-macroglobulin bisphosphonates), (5) biophysical/environmental methods (hyperbaric oxygen, low-intensity pulsed ultrasound, extracorporeal shockwave therapy), (6) biomaterials (fixation methods, biological coatings, biosynthetic bone substitutes, osteoconductive materials), and (7) gene therapy. All of them have shown good results in experimental studies; however, the clinical studies on BA published so far are highly heterogeneous and have a low degree of evidence. The most widely used technique to date is platelet-rich plasma. My position is that orthopedic surgeons must be very cautious when considering using PRP or other BA methods in ACLR.

Complications of the surgical treatment of fractures of the tibial plateau: prevalence, causes, and management

“…The aim of adding LET to ACLR is to reduce the strain on the ACLR graft, reduce the prevalence of the pivot shift, and thereby potentially reduce the rate of ACLR graft failure (119). Finally, there is much debate, which should be clarified in future research, as to whether any type of biological augmentation should be associated with ACLR such as platelet-rich plasma (PRP) (120).…”

Periostin Contributes to Fibrocartilage Layer Growth of the Patella Tendon Tibial Insertion in Mice

“…Periostin is upregulated during muscle regeneration [ 21 ] and fracture healing [ 22 ] and is necessary to regenerate tendons [ 23 ]. The previously mentioned growth factors enhanced tendon-to-bone healing [ 24 ]. Moreover, dynamic tensile stimulation may be an essential factor for tendon regeneration [ 25 ].…”

Intraoperative Administration of Adipose Stromal Vascular Fraction Does Not Improve Functional Outcomes in Young Patients with Anterior Cruciate Ligament Reconstruction

“…To improve clinical outcomes, there has been a growing interest in the development of novel, biologically augmented ACLR techniques [ 1 , 5 ]. To date, among these techniques, the most widely used therapies in the clinical setting are ACLR combined with either stem cells or PRP but yielded unsatisfactory results or a low level of evidence [ 5 , 7 , 8 , 9 , 10 , 11 , 12 ]. For example, Nin et al [ 7 ] reported that the use of platelet-derived growth factor in patients treated with bone-patellar tendon-bone allografts has no discernable clinical or biomechanical effect at 2 years of follow-up.…”

“…To improve the results, recent advances in the area of regenerative medicine have led to the emergence of novel biologically augmented ACLR techniques [ 1 , 5 ]. However, the clinical studies investigating ACLR combined with platelet-derived growth factor, various types of stem cells, or platelet-rich plasma (PRP) either yielded disappointing results [ 5 , 7 , 8 , 9 ] or provided a low degree of evidence [ 10 , 11 , 12 ]. Thus, the effectiveness of the augmentation of ACLR with other biological treatments warrants investigation.…”