Local Application of Strontium in a Calcium Phosphate Cement System Accelerates Healing of Soft Tissue Tendon Grafts in Anterior Cruciate Ligament Reconstruction: Experiment Using a Rabbit Model

Abstract

Background: The healing of soft tissue tendon graft within the bone tunnel in anterior cruciate ligament (ACL) reconstruction is known to be slower than that of bone-patellar tendon-bone graft. There are attempts in accelerating the healing of the graft within the bone tunnel. One of the methods is the use of strontium-enriched calcium phosphate bone cement (Sr-CPC). The early result in animal study was encouraging, though it was not known whether the accelerated healing was solely due to the effect of the strontium within the cement, or due to the calcium phosphate cement (CPC) itself. Hypothesis: There would be differences between a strontium-enriched calcium phosphate cement (Sr-CPC) and a conventional calcium phosphate cement (CPC) in terms of the effect on soft tissue tendon graft healing within the bone tunnels in anterior cruciate ligament (ACL) reconstruction. Study Design: Controlled laboratory study. Methods: Thirty single bundle ACL reconstruction procedures were performed in 15 rabbits with the use of an Achilles tendon allograft. The graft on the left limb was coated with Sr-CPC, while that on the right limb was coated with CPC. Three animals were sacrificed for histological and histomorphometric analysis at 3, 6, 9, 12 and 24 weeks post-operation. Results: In the Sr-CPC group, early Sharpey fiber formation was present at 6 weeks post-operation while early remodeling of a graft-fibrocartilage-bone junction was noted at 12weeks. In the CPC group, early Sharpey fiber formation was only found at 9 to 12 weeks post-operation. At 24 weeks, a direct enthesis was found in both groups. According to histomorphometric score, graft healing in the Sr-CPC group took place 3 weeks faster than that in the CPC group at and before 12 weeks, but there was no difference at 24 weeks. Conclusion: The local application of strontium in a CPC system leads to accelerated graft healing within the bone tunnels. Clinical Relevance: The use of Sr-CPC to enhance graft-bone healing may improve the clinical results of ACL reconstruction using soft tissue tendon graft. Keywords: anterior cruciate ligament (ACL); strontium; calcium phosphate cement