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Ligament Biology and Healing

Overview

Ligament healing is a complex biological process where early controlled motion of stable or surgically stabilized joints improves scar behavior [1]. However, no treatment to date stimulates true ligament regeneration [1]. Early ligament function depends on the cellular population of the repair [2], while early graft function relies on maintaining organized collagen [2]. The anterior cruciate ligament (ACL) has limited healing capability due to a lack of localized hematoma and low reparative cell supply [4]. In contrast, extra-articular ligaments like the medial collateral ligament (MCL) heal spontaneously but with poor mechanical properties [4].

Anterolateral ligament (ALL) injuries also exhibit limited intrinsic healing potential, with only 30.3% healing by 12 months after ACL reconstruction [21]. Treatment of acute tears of the medial ligaments, with or without an associated tear of the anterior cruciate ligament, provides good long-term results and remains recommended [33]. There is a growing body of evidence supporting the use of platelet-rich plasma (PRP) in selected indications for knee disorders [20]. Further work is needed for primary ACL repair, which may prove to be the new frontier in ligament repair [7].

Regarding novel scaffolds, histological analysis shows that additional cell seeding did not enhance osteointegration of a silk fiber–based ACL scaffold [13]. A longer observation period is necessary to determine if a true ligament-bone enthesis will form with this scaffold [13]. In the broader literature, a variety of definitions of failure are used among studies regarding patients who underwent anterior cruciate ligament reconstruction [31].

How It Works

Healing Potential and Biological Constraints: No treatment identified to date stimulates true ligament regeneration [1]. The anterior cruciate ligament (ACL) has limited capability to heal due to a lack of localized hematoma and low reparative cell supply [4]. In contrast, extra-articular ligaments like the medial collateral ligament (MCL) heal spontaneously but with poor mechanical properties [4]. Injury leads to an antifibrotic, catabolic response in the rabbit anterior cruciate ligament [24]. This antifibrotic, catabolic response in the ACL may prevent fibrosis and diminish the risk for loss of joint motion [24].

Cellular and Hemorrhagic Factors: Early ligament function after repair is dependent on the cellular population of the repair [2]. Bleeding at the ligament injury site increases the healing response, evidenced by increased macrophage counts and collagen gene expression [6]. However, biomechanical testing did not demonstrate functional differences despite increased healing response markers associated with hemorrhage [6].

Biologic Augmentation Strategies: The application of a basic fibroblast growth factor (bFGF)-impregnated pellet enhances the healing potential of the partially lacerated ACL [10]. The addition of a collagen-platelet composite (CPC) to a suture repair enhances the structural properties of the ACL [17]. The improvement in ACL healing with a CPC is associated with increased cellularity within the healing ligament [17]. Histologically, additional cell seeding did not enhance osteointegration of a novel silk fiber-based ACL scaffold [13]. A longer observation period is necessary to determine if a true ligament-bone enthesis will be formed with silk fiber-based ACL scaffolds [13].

Clinical and Surgical Implications: Early controlled motion of stable or surgically stabilized joints appears to improve ligament scar behavior [1]. Early graft function after reconstruction is dependent on the maintenance of organized collagen [2]. New techniques utilizing growth factors, cell, and gene therapies may offer the potential to enhance the rate and quality of healing of ligaments of the knee [8]. Recent improvements in ACL reconstruction have focused on strategies to improve graft placements and methodologies to enhance graft healing [9]. New biologic engineering strategies are evolving for clinical application in ACL reconstruction [9]. Further work is needed for primary ACL repair, which may prove to be a new frontier in ligament repair [7]. Clinically applicable solutions to prevent adhesions in tendon healing remain elusive despite progress in understanding the mechanism of tendon healing and adhesions [25].

What the Evidence Shows

Healing Biology and Regeneration: The anterior cruciate ligament (ACL) has limited healing capability due to a lack of localized hematoma and low reparative cell supply [4]. Conversely, extra-articular ligaments such as the medial collateral ligament (MCL) heal spontaneously but with poor mechanical properties [4]. Bleeding at the injury site increases the healing response, evidenced by increased macrophage counts and collagen gene expression [6], though biomechanical testing did not demonstrate functional differences despite these markers [6]. Genetic alterations in key proteoglycans and glycoproteins affect structural development and repair, representing potential drug targets for pathological mechanisms [12].

Biologic Augmentation Strategies: New techniques utilizing growth factors, cell therapies, and gene therapies may enhance the rate and quality of ligament healing [8]. Application of a basic fibroblast growth factor (bFGF)-impregnated pellet enhances the healing potential of partially lacerated ACLs in canine models [10]. Addition of a collagen-platelet composite (CPC) to suture repair enhances structural properties in porcine models, associated with increased cellularity [17]. Evidence for platelet-rich plasma augmentation is scattered, requiring more standardization [18]. Preserving small amounts of muscle on tendon grafts is feasible for improving biological success in humans [19]. Recent efforts focus on optimizing the graft-bone interface to promote healing rate and strength [16].

Graft Behavior and Deficits: Early ligament function after repair depends on the cellular population of the repair [2]. Early graft function after reconstruction depends on the maintenance of organized collagen [2]. Despite remodeling, ACL grafts retain a deficit in tensile strength and stiffness compared to the original ligament [14]. This deficit may explain high failure rates in the first year after reconstruction [14]. Autografts and allografts demonstrate equivalent clinical results in posterior cruciate, collateral, and multi-ligament knee reconstruction [35].

Clinical Outcomes and Surgical Decision-Making: Early controlled motion of stable or surgically stabilized joints improves ligament scar behavior [1]. Nonoperative and operative treatments of MCL injuries lead to equally good results [28]. Better functional and clinical outcomes have been achieved with reconstruction rather than repair in multiligament-injured knees [26]. Lateral tenodesis appears to improve the restoration of laxity more effectively than augmented direct anatomical repair in chronic ankle instability [27]. Anterolateral ligament (ALL) injuries have limited intrinsic healing potential, with only 30.3% healing by 12 months after ACL reconstruction [21]. Patients with poor ligament quality have inferior clinical outcomes after arthroscopic all-inside anterior talofibular ligament repair [22]. Poor ligament quality is associated with lower scores and fewer patients exceeding the minimal clinically important difference threshold for sports-related activities [22]. Nonabsorbable suture augmentation protects ligaments from early failure but may negatively impact final strength and composition due to stress shielding [23].

Future Directions and Limitations: Recent improvements in ACL reconstruction focus on strategies to improve graft placement and methodologies to enhance healing [9]. New biologic engineering strategies are evolving for clinical application [9]. Ligament tissue biodegradable devices require dimensioning considerations for composite material solutions in rehabilitation [32]. Potential causes of failure after ACL reconstruction include graft failure, loss of motion, extensor mechanism dysfunction, osteoarthritis, and infection [34]. There is a deficiency in the literature regarding consistent, meaningful postoperative return to sport timelines following lateral ankle ligament repair [11]. More high-quality large randomized clinical trials with longer follow-up comparing ACL suture repair and reconstruction are needed [15].

Practical Considerations

The ACL has limited capability to heal due to a lack of localized hematoma and low reparative cell supply [4]. In contrast, extra-articular ligaments like the MCL heal spontaneously but with poor mechanical properties [4]. Bleeding at the ligament injury site increases the healing response, evidenced by increased macrophage counts and collagen gene expression [6]. However, biomechanical testing did not demonstrate functional differences despite these increased healing response markers associated with hemorrhage [6].

Early controlled motion of stable or surgically stabilized joints appears to improve ligament scar behavior [1]. Early ligament function after repair is dependent on the cellular population of the repair [2]. Early graft function after reconstruction is dependent on the maintenance of organized collagen [2]. Despite remodelling, the graft retains a deficit in tensile strength and stiffness compared to the original ligament [14]. This deficit in tensile strength and stiffness of the graft may explain high failure rates in the first year [14].

Biologic Augmentation: New techniques utilizing growth factors and cell and gene therapies may offer the potential to enhance the rate and quality of healing of ligaments of the knee [8]. The application of a bFGF-impregnated pellet enhances the healing potential of the partially lacerated ACL [10]. There is a growing body of evidence to support the use of PRP in selected indications for knee disorders [20]. Recent efforts at advancing the clinical success of ACL reconstruction have focused on strategies to enhance and optimize the biologic environment of the graft-bone interface [16]. Optimizing the biologic environment of the graft-bone interface aims to promote and potentially improve the healing rate and strength of the reconstruction [16]. Future studies should provide more standardization to investigate the benefits of biological augmentation in ACL surgery [18]. Preserving small amounts of muscle on tendon grafts is feasible for improving the biological success of ACL reconstruction in humans [19].

Surgical Technique and Outcomes: Recent improvements in ACL reconstruction have focused on strategies to improve graft placements and methodologies to enhance graft healing [9]. New biologic engineering strategies are evolving for clinical application in ACL reconstruction [9]. Further work is needed for primary ACL repair, though there is renewed interest and focus for this approach [7]. More high-quality large randomized clinical trials with longer follow-up comparing ACL suture repair and reconstruction are needed [15]. Nonabsorbable suture augmentation protects the ligament from early failure [23]. Stress shielding from nonabsorbable suture augmentation may negatively impact the final strength and composition of the reconstructed ligament [23].

Ankle and Spine Applications: There is a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair [11]. Patients with poor ligament quality have inferior clinical outcomes, particularly in terms of sports-related activities, after arthroscopic all-inside anterior talofibular ligament repair [22]. Patients with poor ligament quality have lower scores and fewer patients exceeding the minimal clinically important difference threshold [22]. Minimally invasive techniques and ligament-preserving decompression may help mitigate effects of iatrogenic alterations on adjacent segment degeneration after lumbar fusion surgery [29]. Further research is necessary to fully elucidate mechanisms regarding iatrogenic alterations on adjacent segment degeneration after lumbar fusion surgery [29].

General Health: Exercise is generally recommended for musculoskeletal health during pregnancy but requires counseling on contraindications and specific conditions [30].

Key Evidence

  • [L5] Early controlled motion of stable or surgically stabilized joints appears to improve ligament scar behavior, but no treatment identified to date stimulates true ligament regeneration. (10.5435/00124635-199603000-00002)
  • [L5] These findings suggest there may be key biological differences in development and maintenance of ACL tissue after repair or reconstruction, with early ligament function dependent on cellular population of the repair but early graft function dependent on the maintenance of organized collagen. (10.1177/2325967113512457)
  • [L5] The paper outlines that the ACL has limited capability to heal due to a lack of localized hematoma and low reparative cell supply, whereas extra-articular ligaments like the MCL heal spontaneously but with poor mechanical properties. (10.1186/1758-2555-2-12)
  • [L5] This study suggests there is an increased healing response with bleeding at the ligament injury site, evidenced by increased macrophage counts and collagen gene expression, though biomechanical testing did not demonstrate functional differences. (10.1177/03635465030310050501)
  • [L5] Further work is clearly needed but there is renewed interest and focus for primary ACL repair that may yet prove the new frontier in ligament repair. (10.1186/s40634-018-0136-6)
  • [L5] New techniques utilizing growth factors and cell and gene therapies may offer the potential to enhance the rate and quality of healing of ligaments of the knee. (10.5435/00124635-200011000-00004)
  • [L5] Recent improvements in anterior cruciate ligament reconstruction have focused on strategies to improve graft placements and methodologies to enhance graft healing, with new biologic engineering strategies evolving for clinical application. (10.1177/0363546507311690)
  • [L5] The application of a bFGF-impregnated pellet seems to enhance the healing potential of the partially lacerated ACL. (10.1007/s001670050049)
  • [L4] The review identifies a clear deficiency in the literature pertaining to consistent, meaningful postoperative return to sport timeline following lateral ankle ligament repair. (10.1136/jisakos-2016-000064)
  • [L4] This review summarizes genetic alterations and knockdown approaches to assess the role of key proteoglycans and glycoproteins in the structural development, function, and repair of tendon, ligament, and enthesis, identifying these genes as potential drug targets for disrupting pathological mechanisms leading to tendinopathy, ligamentopathy, and enthesopathy. (10.1155/2013/154812)
  • [L5] Histologically, additional cell seeding did not enhance osteointegration, and a longer observation period is necessary to see if a true ligament-bone enthesis will be formed. (10.1177/0363546518818792)
  • [L5] It notes that despite remodelling, the graft retains a deficit in tensile strength and stiffness compared to the original ligament, which may explain high failure rates in the first year. (10.1136/jisakos-2015-000041)
  • [L1] More high-quality large randomized clinical trials with longer follow-up comparing ACL suture repair and reconstruction are needed. (10.1177/0363546520904690)
  • [L5] Recent efforts at advancing the clinical success of ACL reconstruction have focused on strategies to enhance and optimize the biologic environment of the graft-bone interface to promote and potentially improve the healing rate and strength of the reconstruction. (10.1016/j.csm.2012.08.010)
  • [L5] The addition of a CPC to a suture repair enhanced the structural properties of the ACL, and the improvement was associated with increased cellularity within the healing ligament. (10.1177/0363546509339915)
  • [L1] Future studies should provide more standardisation to investigate the benefits of biological augmentation in ACL surgery. (10.1002/ksa.12127)
  • [L5] Preserving small amounts of muscle on tendon grafts is feasible for improving the biological success of ACL reconstruction in humans. (10.1007/s00167-012-2181-5)
  • [L5] There is a growing body of evidence to support the use of PRP in selected indications for knee disorders. (10.1302/2058-5241.2.160004)
  • [L4] ALL injuries occurred in the majority of ACL-injured knees and had limited intrinsic healing potential, with only 30.3% healing by 12 months after ACLR. (10.1177/03635465211013015)
  • [L3] However, patients with poor ligament quality have inferior clinical outcomes, particularly in terms of sports-related activities, as reflected by both lower scores and fewer patients exceeding the minimal clinically important difference threshold. (10.1016/j.arthro.2025.04.032)
  • [L5] Although nonabsorbable suture augmentation protects the ligament from early failure, stress shielding may negatively impact the final strength and composition of the reconstructed ligament. (10.1016/j.jhsa.2021.09.014)
  • [L5] The results suggest that injury leads to an antifibrotic, catabolic response in the rabbit anterior cruciate ligament, possibly to prevent fibrosis and diminish the risk for loss of joint motion. (10.1177/0363546508316283)
  • [L5] Clinically applicable solutions to prevent adhesions remain elusive despite progress in understanding the mechanism of tendon healing and adhesions. (10.1016/j.jhsa.2017.06.013)
  • [L2] The review suggests that the best treatment does not exist, but better functional and clinical outcomes have been achieved with reconstruction rather than repair. (10.1016/j.injury.2019.01.052)
  • [L3] Objectively, lateral tenodesis appears to improve more effectively restoration of laxity. (10.1007/s00167-018-5244-4)
  • [L1] Nonoperative and operative treatments of medial collateral ligament injuries lead to equally good results. (10.1177/0363546505284889)
  • [L1] Minimally invasive techniques and ligament-preserving decompression may help mitigate these effects, though further research is necessary to fully elucidate these mechanisms. (10.1186/s13018-025-05561-1)
  • [L5] This article reviews existing literature on musculoskeletal health considerations before, during, and after pregnancy to provide practical information to orthopaedic surgeons treating women of all ages and athletic abilities, highlighting that exercise is generally recommended but requires counseling on contraindications and specific conditions. (10.5435/jaaos-d-21-00044)
  • [L4] In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. (10.1016/j.asmr.2023.100801)
  • [L5] This bibliographic review focuses on ligament tissue rehabilitation and the dimensioning considerations of composite material solutions. (10.1016/j.jbiomech.2009.07.019)
  • [L4] This previously described treatment of acute tears of the medial ligaments, with or without an associated tear of the anterior cruciate ligament, provides good long-term results and is still recommended. (10.2106/00004623-199506000-00018)
  • [L4] This review article provides a comprehensive analysis of the potential causes of failure after anterior cruciate ligament reconstruction, including graft failure, loss of motion, extensor mechanism dysfunction, osteoarthritis, and infection. (10.1016/j.csm.2012.08.015)
  • [L4] The review demonstrates equivalent clinical results with the use of autografts or allografts. (10.1007/s00167-019-05426-1)

See Also

  • Osteoarthritis

References

[1] Ligament Healing: Current Knowledge and Clinical Applications. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199603000-00002

[2] Histological Predictors of Maximum Failure Loads Differ Between the Healing ACL and ACL Grafts After 6 and 12 Months In Vivo. Orthopaedic Journal of Sports Medicine. 2013. DOI: 10.1177/2325967113512457

[4] Functional tissue engineering of ligament healing. BMC Sports Science, Medicine and Rehabilitation. 2010. DOI: 10.1186/1758-2555-2-12

[6] Effect of Hemorrhage on Medial Collateral Ligament Healing in a Mouse Model. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310050501

[7] Anterior cruciate ligament repair – past, present and future. Journal of Experimental Orthopaedics. 2018. DOI: 10.1186/s40634-018-0136-6

[8] Healing and Repair of Ligament Injuries in the Knee. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200011000-00004

[9] Strategies to Improve Anterior Cruciate Ligament Healing and Graft Placement. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546507311690

[10] Effect of basic fibroblast growth factor on the healing of defects in the canine anterior cruciate ligament. Knee Surgery, Sports Traumatology, Arthroscopy. 1997. DOI: 10.1007/s001670050049

[11] Return to sport following lateral ankle ligament repair is under-reported: a systematic review. Journal of ISAKOS. 2017. DOI: 10.1136/jisakos-2016-000064

[12] Defects in Tendon, Ligament, and Enthesis in Response to Genetic Alterations in Key Proteoglycans and Glycoproteins: A Review. Arthritis. 2013. DOI: 10.1155/2013/154812

[13] Osteointegration of a Novel Silk Fiber–Based ACL Scaffold by Formation of a Ligament-Bone Interface. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546518818792

[14] Review of Clancy's article on anterior and posterior cruciate ligament reconstruction in rhesus monkeys. Journal of ISAKOS. 2016. DOI: 10.1136/jisakos-2015-000041

[15] Efficacy of Nonaugmented, Static Augmented, and Dynamic Augmented Suture Repair of the Ruptured Anterior Cruciate Ligament: A Systematic Review of the Literature. The American Journal of Sports Medicine. 2020. DOI: 10.1177/0363546520904690

[16] ACL Graft Healing and Biologics. Clinics in Sports Medicine. 2013. DOI: 10.1016/j.csm.2012.08.010

[17] Collagen-Platelet Composite Enhances Biomechanical and Histologic Healing of the Porcine Anterior Cruciate Ligament. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509339915

[18] Platelet‐rich plasma augmentation in anterior cruciate ligament reconstruction: Evidence is still too scattered. A scoping review of randomised controlled trials. Knee Surgery, Sports Traumatology, Arthroscopy. 2024. DOI: 10.1002/ksa.12127

[19] Effect of muscle preserved on tendon graft on intra‐articular healing in anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2181-5

[20] Platelet-rich plasma (PRP) for knee disorders. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160004

[21] The Anterolateral Ligament Has Limited Intrinsic Healing Potential: A Serial, 3-Dimensional–Magnetic Resonance Imaging Study of Anterior Cruciate Ligament–Injured Knees From the SANTI Study Group. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211013015

[22] Ligament Quality Predicts Recurrence and Functional Outcomes After Arthroscopic All‐Inside Anterior Talofibular Ligament Repair. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.04.032

[23] Stress Shielding of Ligaments Using Nonabsorbable Suture Augmentation May Influence the Biology of Ligament Healing. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.09.014

[24] Injury-Induced Changes in mRNA Levels Differ Widely between Anterior Cruciate Ligament and Medial Collateral Ligament. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508316283

[25] Molecular Biology of Flexor Tendon Healing in Relation to Reduction of Tendon Adhesions. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.013

[26] Major concern in the multiligament-injured knee treatment: A systematic review. Injury. 2019. DOI: 10.1016/j.injury.2019.01.052

[27] Lateral ligament reconstruction and augmented direct anatomical repair restore ligament laxity in patients suffering from chronic ankle instability up to 15 years from surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5244-4

[28] Operative and Nonoperative Treatments of Medial Collateral Ligament Rupture with Early Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2006. DOI: 10.1177/0363546505284889

[29] Impact of iatrogenic alterations on adjacent segment degeneration after lumbar fusion surgery: a systematic review. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05561-1

[30] Musculoskeletal Considerations for Exercise and Sport: Before, During, and After Pregnancy. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-21-00044

[31] Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction. Arthroscopy, Sports Medicine, and Rehabilitation. 2023. DOI: 10.1016/j.asmr.2023.100801

[32] Development of ligament tissue biodegradable devices: A review. Journal of Biomechanics. 2009. DOI: 10.1016/j.jbiomech.2009.07.019

[33] The importance of the posterior oblique ligament in repairs of acute tears of the medial ligaments in knees with and without an associated rupture of the anterior cruciate ligament. Results of long-term follow-up.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199506000-00018

[34] Failure of Anterior Cruciate Ligament Reconstruction. Clinics in Sports Medicine. 2013. DOI: 10.1016/j.csm.2012.08.015

[35] The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05426-1

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Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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