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INTRODUCTION
Synthetic devices have been available since the
1970s for the treatment of anterior cruciate
ligament (ACL) injury. Such devices have a
number of potential benefits including the
avoidance of donor site morbidity, provision of
a strong stabilising construct – thereby allowing
aggressive rehabilitation and an early return to
sport – and the absence of the potential for
disease transmission. Despite these potential
benefits, the use of synthetic ligaments for ACL
reconstruction remains controversial. Devices
implanted in the late 1970s and 1980s had poor
outcomes including high failure rates and
significant complications such as synovitis,
osteolysis and osteoarthritis. More recent
devices appear to have better reported outcomes
in the short to mid-term, but have not gained
widespread support.
HISTORICAL OVERVIEW
A full historical account of the use of synthetic
devices in for ACL reconstruction is beyond
the scope of this chapter, but a brief summary is
provided as a background to current thinking.
A more detailed account can be found in the
article by Mascarenhas and MacDonald [6].
One of the major concerns with earlier synthetic
grafts was synovitis. It was attributed to
abrasion and breakage of the synthetic devices
resulting in free debris and particles within the
joint and there was concern that because of the
non-absorbable nature of the synthetic
ligaments, there was an increased risk of
developing osteoarthritis.
There was considerable interest in the potential
of carbon fiber as a scaffold for ligament
regeneration in the 1970s. A number of carbon
fiber devices were developed but were
associated with high failure rates, synovitis and
dissemination of carbon fiber to regional lymph
nodes. Modifications were made to include
polylactic acid and polycapralactone coating in
an ultimately unsuccessful attempt to reduce
problems with carbon wear particles.
Various devices have been developed from
polyester composites. The Leeds-Keio syn
thetic ligament was woven from polyester and
was intended to serve as a scaffold for ingrowth
of ligamentous tissue. Conflicting results with
regard to ingrowth and clinical out come were
reported and concerns were raised about the
presence of foreign body giants cells containing
polyester debris. Like other synthetic ligaments,
the Leeds-Keio ligament fell into disuse.
The Dacron artificial ligament was made of
polyester strips and was designed as an
augmentation. It was nonetheless used by some
surgeons as a prosthetic ligament in “salvage”
IS THERE A PLACE FOR
A SYNTHETIC LIGAMENT?
J.A. FELLER