In Vitro and In Vivo Performance of Tissue-Engineered Tendons for Anterior Cruciate Ligament Reconstruction

Kwang Il Lee, Jung Soo Lee, Kyoung Tak Kang, Young Bock Shim, Young Sik Kim, Ju Woong Jang, Seong Hwan Moon, Darryl D. D’Lima

Research output: Contribution to journalArticlepeer-review

21 Citations (Scopus)


Background: Anterior cruciate ligament (ACL) reconstruction is the current standard of care for ACL tears. However, the results are not consistently successful; autografts or allografts have certain disadvantages; and synthetic grafts have had poor clinical results. Purpose: To determine if recellularization of decellularized tendons combined with mechanical stimulation in a bioreactor could replicate the mechanical properties of the native ACL and be successfully used for ACL reconstruction in vivo. Study Design: Controlled laboratory study. Methods: Porcine tibialis tendons were decellularized and then recellularized with human adult bone marrow–derived stem cells. Tendons were cultured in a tissue bioreactor that provided biaxial cyclic loading for up to 7 days. To reproduce mechanical stresses similar to those experienced by the ACL within the knee joint, the tendons were subjected to simultaneous tension and torsion in the bioreactor. Expression of tendon-specific genes and newly synthesized collagen and glycosaminoglycan were used to quantify the efficacy of recellularization and dynamic bioreactor culture. The ultimate tensile load to failure and stiffness of recellularized constructs were measured after dynamic stimulation. Finally, the tissue-engineered tendons were used to reconstruct the ACL in 24 pigs, and ultimate tensile load to failure and stiffness were assessed after 3 months. Results: Dynamic bioreactor culture significantly increased the expression of tendon-specific genes, the quantity of newly synthesized collagen and glycosaminoglycan, and the ultimate tensile load and stiffness of recellularized tendons. After in vivo reconstruction, the ultimate tensile load and stiffness of the tissue-engineered tendons increased significantly up to 3 months after surgery and were within 80% of the ultimate tensile load of the natural ACL. Conclusion: This translational study indicates that recellularization and dynamic mechanical stimuli can significantly enhance matrix synthesis and ultimate tensile load of decellularized porcine tibialis tendons. This approach to tissue engineering can be very useful for ACL reconstruction and may overcome some of the disadvantages of autografts and allografts. Clinical Relevance: Dynamic bioreactor cultivation of tissue-engineered tendons may overcome the limitations of autografts and allografts.

Original languageEnglish
Pages (from-to)1641-1649
Number of pages9
JournalAmerican Journal of Sports Medicine
Issue number7
Publication statusPublished - 2018 Jun 1

Bibliographical note

Funding Information:
§Address correspondence to Seong Hwan Moon, MD, PhD, Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea (email: {Address correspondence to Darryl D. D’Lima, MD, PhD, Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA (email: *The Institute of Biomaterial and Medical Engineering, Cellumed Co, Ltd, Seoul, Republic of Korea. yDepartment of Mechanical Engineering, College of Engineering, Yonsei University, Seoul, Republic of Korea. zDepartment of Orthopaedic Surgery, College of Medicine, Yonsei University, Seoul, Republic of Korea. ||Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, California, USA. S.H.M. and D.D.D. contributed equally to this article. One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by World Premier Materials (grant 10037842) funded by the Ministry of Trade, Industry and Energy, Republic of Korea.

Publisher Copyright:
© 2018, © 2018 The Author(s).

All Science Journal Classification (ASJC) codes

  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation


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