“Ligamentization” in Hamstring Tendon Grafts After Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Literature and a Glimpse Into the Future

The aims of this study were to provide a systematic review of the literature on "ligamentization" in hamstring tendon (HT) grafts after anterior cruciate ligament (ACL) reconstruction and analyze the postoperative remodeling process in human patients and animal models.We performed a search in the Medline, PubMed, Embase and The Cochrane Library databases, followed by a manual search of reference lists to identify relevant articles. Only studies that investigated the ligamentization of hamstring grafts by histologic examination and comprehensively reported on the remodeling process were deemed eligible for review.A total of 4 studies were determined appropriate for systematic review: 2 of the included studies investigated human ACL grafts and 2 were performed in animal models. The studies included the examination of 79 human hamstring graft biopsy specimens and grafts of 27 skeletally mature sheep. To verify the remodeling process, authors reported on various aspects of cellularity, vascularity, and collagen organization. None of the included studies reached a level of evidence higher than 3.A postoperative ligamentization process can be found in HT grafts after ACL reconstruction and shows a typical progression through 3 distinguishable remodeling phases in humans and in animal models, whereas the progression and intensity of remodeling is distinctly increased in animals.Because postoperative remodeling influences biomechanical properties of hamstring grafts, a better understanding of this process and its timing could lead to substantial improvements in postoperative care strategies and indirectly to the optimization of surgical techniques.