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Ligamentization of tendon grafts treated with an endogenous preparation rich in growth factors: gros


To investigate whether the application of a particular platelet-rich plasma preparation rich in growth factors (PRGF) during anterior cruciate ligament (ACL) surgery gives a potential advantage for better tendon graft ligamentization.

METHODS This study included 37 volunteers who underwent either

conventional (control group, n = 15) or PRGF-assisted (n = 22) ACL reconstruction with an autogenous hamstring and required second-look arthroscopy to remove hardware or loose bodies, treat meniscal tears or plica syndrome, or resect cyclops lesions at 6 to 24 months after ACL surgery. The gross morphologies of the grafts were evaluated on second-look arthroscopy by use of the full arthroscopic score (0 to 4 points) to evaluate graft thickness and apparent tension (0 to 2 points) plus synovial coverage (0 to 2 points).

At the same time, biopsy specimens were harvested uniformly from the grafted tendons. In these specimens the histologic transformation of the tendon graft to ACL-like tissue was evaluated by use of the Ligament Tissue Maturity Index, and a score to assess the progression of new connective tissue enveloping the graft was created by use of 3 criteria previously used to characterize changes during ligament healing: cellularity, vascularity, and collagen properties.

RESULTS: The overall arthroscopic evaluation of PRGF-treated grafts showed an excellent rating in 57.1% of the knees (score of 4) and a fair rating in 42.9% (score of 2 or 3). In contrast, evaluation of untreated grafts showed an excellent rating in 33.3% of the knees, a fair rating in 46.7%, and a poor rating in 20% (score of 0 or 1). Overall, arthroscopic evaluations were not

statistically different between PRGF and control groups (P = .051). PRGF treatment influenced the histologic characteristics of the tendon graft, resulting in tissue that was more mature than in controls (P = .024). Histologically evident newly formed connective tissue enveloping the graft was present in 77.3% of PRGF-treated grafts and 40% of controls. The appearance of the connective tissue envelope changed with increasing time from surgery. On the basis of the histologic findings, we suggest that the remodeling of PRGF-treated grafts involves the formation of synovial-like tissue enveloping the graft. This tissue is eventually integrated in the remodeled tendon graft, conferring a similar appearance to the normal ACL.


The use of PRGF influenced the histologic characteristics of tendon grafts, resulting in more remodeling compared with untreated grafts. We have shown temporal histologic changes during the 6- to 24-month postoperative period of graft maturation, with newly formed connective tissue enveloping most grafts treated with PRGF.

LEVEL OF EVIDENCE: Level III, case-control study. Authors: Mikel Sánchez, M.D., Eduardo Anitua, M.D., Juan Azofra, M.D., Roberto Prado, Ph.D., Francisco Muruzabal, Ph.D., Isabel Andia, Ph.D.

Copyright 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.


Dr. Kelly Cunningham

Sports can be rough on joints and cartilage, especially shoulders, knees, and hips. Kelly Cunningham, MD, has cared for many young and mature athletes whose joints take a beating day in and day out. He welcomes patients from Austin, Texas, and its surrounding communities to experience the cutting-edge technology and skill offered by his team at Austin Ortho + Biologics.

Dr. Cunningham works with each athlete to develop an individual treatment plan that emphasizes the least invasive treatments possible with a goal of minimal recuperation and downtime. He combines rigorous standards and quality of care with experience and insight, integrating the best new techniques into the care of each patient.

His patients have included skilled athletes in football, basketball, baseball, and hockey, including members of the Dallas Cowboys at their Austin training camp, Austin Ice Bats hockey players, Southwestern University athletes, and many other college and high school athletes. He served for 15 years as a traveling team physician for the men’s alpine downhill US Olympic Ski Team, providing on-the-hill medical race coverage in North America and Europe, including qualifying races for the Winter Olympics.

As a sports medicine specialist, Dr. Cunningham also treats many seasoned weekend warriors such as runners, skiers (downhill, snowboard, and water), and tennis and golf enthusiasts.

After medical school and residency training in Dallas, he completed a sports medicine/knee fellowship with renowned orthopedic specialist Dr. Richard Steadman in Vail, Colorado, and underwent further shoulder training in England and Canada.

While with Dr. Steadman, the originator of the popular microfracture cartilage treatment technique, he developed a strong interest in the care of cartilage injuries and now has more than 20 years of experience with surgical microfracture and related procedures. In recent years, he has closely monitored cutting-edge techniques as they’re developed for use in these acute and chronic problems.

Dr. Kelly Cunningham Physician

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