Analysis of retrieved polymer fiber based replacements for the ACL

The present retrospective analysis of 117 surgically excised anterior cruciate ligament (ACL) prostheses was designed to elucidate the etiology and mechanisms of failure of synthetic ligamentous prostheses. They were harvested from young and active patients (26 +/- 7 yrs) at various orthopaedic centers in France between 1983 and 1993. The average duration of implantation of augmentation and replacement prostheses were 21.5 +/- 12.6 and 33.2 +/- 25.3 months, respectively. The principal causes for their excision were ruptures and synovitis. Each ACL prosthesis was examined macroscopically, histologically, and, after tissue removal, by scanning electron microscopy (SEM) to determine the model, manufacturer, surgical technique used at implantation, the extent of healing, the site of rupture, and the morphology of the damaged fibers. Fourteen types of ACL prostheses were analysed, each fabricated using a different combination of polymers, fibers and textile constructions. Consequently, they generated a variety of healing characteristics and mechanical responses in vivo. SEM observations revealed that abrasion of the textile fibers as a result of yarn-on-yarn and/or yarn-on-bone contact was a common phenomenon to almost all models, and was the primary cause of prosthetic failure. Healing inside the synthetic ACL was poorly organized, incomplete and unpredictable as the extent of collagenous infiltration into the textile structure did not increase with the duration of implantation. In fact, the collagenous infiltration into certain models appeared to be more detrimental than beneficial since it caused deterioration and fraying of the textile structure rather than serving as a reinforcing matrix around the prosthesis. In conclusion, the present study shows that three mechanisms may be involved in the failure of ACL prostheses: (1) inadequate fiber abrasion resistance against osseous surfaces; (2) flexural and rotational fatigue of the fibers, and (3) loss of integrity of the textile structure due to unpredictable tissue infiltration during healing.