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The Effect of Skeletal Maturity on Functional Healing of the Anterior Cruciate Ligament
Martha M. Murray, MD1; Elise M. Magarian, BS1; Sophia L. Harrison, BS1; Ashley N. Mastrangelo, MS1; David Zurakowski, PhD1; Braden C. Fleming, PhD2
1 Departments of Orthopaedic Surgery (M.M.M., E.M.M., S.L.H., and A.N.M.) and Anesthesiology (D.Z.), Children's Hospital Boston, Hunnewell 2, 300 Longwood Avenue, Boston, MA 02115. E-mail address for M.M. Murray: martha.murray@childrens.harvard.edu
2 Department of Orthopaedics, Warren Alpert Medical School of Brown University, CORO West, Suite 404, 1 Hoppin Street, Providence, RI 02903
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health (R01 AR054099). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Connective Orthopedics).

A commentary by Mark R. Hutchinson, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at the Departments of Orthopaedic Surgery and Anesthesiology, Children's Hospital Boston, Boston, Massachusetts, and the Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Sep 01;92(11):2039-2049. doi: 10.2106/JBJS.I.01368
A commentary by Mark R. Hutchinson, MD, is available here
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The effects of skeletal maturity on functional ligament healing are unknown. Prior studies have suggested that ligament injuries in skeletally mature animals heal with improved mechanical properties. In this study, we hypothesized that skeletally immature animals have improved functional healing compared with skeletally mature animals.


Twenty-one Yucatan minipigs (eight juvenile, eight adolescent, and five adult animals) underwent bilateral anterior cruciate ligament transection. On one side, the ligament injury was left untreated to determine the intrinsic healing response as a function of age. On the contralateral side, an enhanced suture repair incorporating a collagen-platelet composite was performed. Biomechanical properties of the repairs were measured after fifteen weeks of healing, and histologic analysis was performed.


Anterior cruciate ligaments from skeletally immature animals had significantly improved structural properties over those of adult animals at three months after transection in both the untreated and repair groups. Use of the enhanced suture technique provided the most improvement in the adolescent group, in which an increase of 85% in maximum load was noted with repair. The repair tissue in the adult tissue had the highest degree of hypercellularity at the fifteen-week time point.


Functional ligament healing depends on the level of skeletal maturity of the animal, with immature animals having a more productive healing response than mature animals.

Clinical Relevance: 

As future investigations assess new techniques of ligament healing in animal models, skeletal maturity should be considered in the design and the interpretation of those experiments.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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