A new biological enhancement therapy for anterior cruciate ligament reconstruction: the preclinical proof of anterior cruciate ligament reconstruction with tendon graft reseeded with autologous anterior cruciate ligament-derived cells

Abstract

BackgroundThe current standard of care to treat a ruptured anterior cruciate ligament (ACL) is ACL reconstruction (ACLR), which involves replacing the torn ligament with a tendon graft. The implanted tendon graft undergoes a graft-maturation process known as ligamentization. However, the synthesis of type III collagen, which is typically found in weaker scar tissue, continues at higher concentrations, and the heterogeneous composition of collagen fibers of varying diameters of native ACL is never restored. Culture-expanded ACL-derived cells reseeded to tendon graft have shown the potential for enhanced ligamentization. We performed in vitro and in vivo studies of the outcomes of ACLR with decellularized tendon grafts reseeded with ACL-derived cells combined with acellularized cruciate ligament matrix (ACLM) powder as a biological scaffold. We hypothesized that this tissue-engineered construct would enhance the graft maturation process and mechanical properties of the graft following ACLR.MethodsACL-derived cells were harvested and isolated from remnants of ruptured ACLs within 4 weeks of injury in patients who had undergone ACLR. An ACLM was prepared from human ACL and posterior cruciate ligament tissues. Forty-five Sprague Dawley rats were randomly divided into 3 groups: a standard allograft group, an ACLM powder-only injection group, and an ACL-derived cells and ACLM powder co-injection group (e.g., target group). ACL-derived cells were mixed with ACLM powder and then injected into the decellularized tendon graft before ACLR.ResultsIn vitro experiments found that combining ACLM powder and ACL-derived cells improved survival and integration of reseeded cells in the tendon extracellular matrix, resulting in the successful transplantation of ACL-derived cells. Animal ACLR experiments confirmed histologically improved structural maturation in cellularity, metaplasia, and restoration of collagen crimping in the graft reseeded with ACL-derived cells and ACLM powder. Enhanced gene expression of type I collagen resulted in superior mechanical properties of the tendon graft compared with the control groups.ConclusionImplantation of a tendon graft reseeded with culture-expanded ACL-derived cells, and ACLM powder enhanced the tendon graft's maturation process and mechanical properties. We provide in vitro and in vivo proof-of-concept evidence supporting the efficacy of reseeding a tendon graft with ACL-derived cells combined with ACLM powder as a biological scaffold for ACL reconstruction.