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The effect of graft fixation sequence on force distribution in double-bundle anterior cruciate ligament reconstruction

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

This paper investigated the effect of graft fixation sequence on knee joint biomechanics after a double-bundle ACL reconstruction.

Method

Two independently published biomechanical studies that investigated the biomechanics of double-bundle ACL reconstructions using similar robotic testing systems were compared. In each study, ten human cadaveric knees were tested under three different conditions: intact, ACL deficient, and ACL reconstructed using a double-bundle technique with the anteromedial (AM) graft fixed at 60° of flexion and the posterolateral (PL) graft fixed at full extension. In one study (Study A), the AM graft was fixed first; while in another study (Study B), the PL graft was fixed first. Knee kinematics, in situ forces of the ACL and the ACL grafts were measured under two loading conditions: an anterior tibial load of 134 N and a combined tibial torques (10 N·m valgus and 5 N·m internal tibial torques) in both studies.

Result

When AM graft was fixed first, the in situ force of the AM graft was lower than the native AM bundle at all flexion angles. The in situ force in the PL graft, however, was higher than the native PL bundle at all flexion angles. When the PL graft was fixed first, the in situ force of the AM graft was higher than the native AM bundle, while the in situ forces of the PL graft were lower than the native PL bundle at all flexion angles. Both studies demonstrated that the double-bundle ACL reconstructions can closely restore the normal knee joint kinematics.

Conclusion

Even though the grafts were fixed using similar initial tensions and at same flexion angles, the sequence of fixing the two grafts in a double-bundle ACL reconstruction could alter the in situ forces in the grafts and affect the knee kinematics. These data imply that in clinical application of a double-bundle ACL reconstruction, the sequence of graft fixation should be an important surgical parameter.

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References

  1. Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y (2004) Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons. J Bone Joint Surg Br 86:515–520

    PubMed  CAS  Google Scholar 

  2. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli N (2007) Single- and double-incision double-bundle acl reconstruction. Clin Orthop Relat Res 454:108–113

    Article  PubMed  Google Scholar 

  3. Amis AA, Dawkins GP (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 73:260–267

    PubMed  CAS  Google Scholar 

  4. Asagumo H, Kimura M, Kobayashi Y, Taki M, Takagishi K (2007) Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: surgical techniques, clinical outcomes, and complications. Arthroscopy 23:602–609

    Article  PubMed  Google Scholar 

  5. Basdekis G, Abisafi C, Christel P (2009) Effect of knee flexion angle on length and orientation of posterolateral femoral tunnel drilled through anteromedial portal during anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 25:1108–1114

    Article  PubMed  Google Scholar 

  6. Branch TP, Siebold R, Freedberg HI, Jacobs CA (2010) Double-bundle acl reconstruction demonstrated superior clinical stability to single-bundle acl reconstruction: a matched-pairs analysis of instrumented tests of tibial anterior translation and internal rotation laxity. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-010-1247-5

  7. Buoncristiani AM, Tjoumakaris FP, Starman JS, Ferretti M, Fu FH (2006) Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 22:1000–1006

    Article  PubMed  Google Scholar 

  8. Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH (2005) Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy 21:1275

    Article  PubMed  Google Scholar 

  9. Colombet P, Robinson J, Christel P, Franceschi JP, Djian P, Bellier G, Sbihi A (2006) Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy 22:984–992

    Article  PubMed  Google Scholar 

  10. Crawford C, Nyland J, Landes S, Jackson R, Chang HC, Nawab A, Caborn DN (2007) Anatomic double bundle acl reconstruction: a literature review. Knee Surg Sports Traumatol Arthrosc 15:946–964

    Article  PubMed  Google Scholar 

  11. Cuomo P, Rama KR, Bull AM, Amis AA (2007) The effects of different tensioning strategies on knee laxity and graft tension after double-bundle anterior cruciate ligament reconstruction. Am J Sports Med 35:2083–2090

    Article  PubMed  Google Scholar 

  12. Dienst M, Burks RT, Greis PE (2002) Anatomy and biomechanics of the anterior cruciate ligament. Orthop Clin North Am 33:605–620

    Article  PubMed  Google Scholar 

  13. Fu FH, Shen W, Starman JS, Okeke N, Irrgang JJ (2008) Primary anatomic double-bundle anterior cruciate ligament reconstruction: a preliminary 2-year prospective study. Am J Sports Med 36:1263–1274

    Article  PubMed  Google Scholar 

  14. Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE (2004) Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res 22:85–89

    Article  PubMed  Google Scholar 

  15. Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231

    Article  PubMed  Google Scholar 

  16. Giron F, Cuomo P, Edwards A, Bull AM, Amis AA, Aglietti P (2007) Double-bundle “anatomic” anterior cruciate ligament reconstruction: a cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy 23:7–13

    Article  PubMed  Google Scholar 

  17. Hamada M, Shino K, Horibe S, Mitsuoka T, Miyama T, Shiozaki Y, Mae T (2001) Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endobutton femoral fixation: a prospective study. Arthroscopy 17:801–807

    Article  PubMed  CAS  Google Scholar 

  18. Jordan SS, DeFrate LE, Nha KW, Papannagari R, Gill TJ, Li G (2007) The in vivo kinematics of the anteromedial and posterolateral bundles of the anterior cruciate ligament during weightbearing knee flexion. Am J Sports Med 35:547–554

    Article  PubMed  Google Scholar 

  19. Kanaya A, Ochi M, Deie M, Adachi N, Nishimori M, Nakamae A (2009) Intraoperative evaluation of anteroposterior and rotational stabilities in anterior cruciate ligament reconstruction: lower femoral tunnel placed single-bundle versus double-bundle reconstruction. Knee Surg Sports Traumatol Arthrosc 17:907–913

    Article  PubMed  Google Scholar 

  20. Kondo E, Yasuda K (2007) Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability. Arthroscopy 23:1198–1209

    Article  PubMed  Google Scholar 

  21. Li G, DeFrate LE, Sun H, Gill TJ (2004) In vivo elongation of the anterior cruciate ligament and posterior cruciate ligament during knee flexion. Am J Sports Med 32:1415–1420

    Article  PubMed  Google Scholar 

  22. Mae T, Shino K, Matsumoto N, Nakata K, Nakamura N, Iwahashi T (2006) Force sharing between two grafts in the anatomical two-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 14:505–509

    Article  PubMed  Google Scholar 

  23. Mae T, Shino K, Miyama T, Shinjo H, Ochi T, Yoshikawa H, Fujie H (2001) Single- versus two-femoral socket anterior cruciate ligament reconstruction technique: biomechanical analysis using a robotic simulator. Arthroscopy 17:708–716

    Article  PubMed  CAS  Google Scholar 

  24. Markolf KL, Park S, Jackson SR, McAllister DR (2008) Contributions of the posterolateral bundle of the anterior cruciate ligament to anterior-posterior knee laxity and ligament forces. Arthroscopy 24:805–809

    Article  PubMed  Google Scholar 

  25. Miura K, Woo SL, Brinkley R, Fu YC, Noorani S (2006) Effects of knee flexion angles for graft fixation on force distribution in double-bundle anterior cruciate ligament grafts. Am J Sports Med 34:577–585

    Article  PubMed  Google Scholar 

  26. Mochizuki T, Muneta T, Nagase T, Shirasawa S, Akita KI, Sekiya I (2006) Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. Arthroscopy 22:356–361

    Article  PubMed  Google Scholar 

  27. Mott HW (1983) Semitendinosus anatomic reconstruction for cruciate ligament insufficiency. Clin Orthop Relat Res 172:90–92

    PubMed  Google Scholar 

  28. Muneta T, Koga H, Mochizuki T, Ju YJ, Hara K, Nimura A, Yagishita K, Sekiya I (2007) A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy 23:618–628

    Article  PubMed  Google Scholar 

  29. Muneta T, Koga H, Morito T, Yagishita K, Sekiya I (2006) A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction. Arthroscopy 22:252–258

    Article  PubMed  Google Scholar 

  30. Otsubo H, Shino K, Nakamura N, Nakata K, Nakagawa S, Koyanagi M (2007) Arthroscopic evaluation of acl grafts reconstructed with the anatomical two-bundle technique using hamstring tendon autograft. Knee Surg Sports Traumatol Arthrosc 15:720–728

    Article  PubMed  Google Scholar 

  31. Pombo MW, Shen W, Fu FH (2008) Anatomic double-bundle anterior cruciate ligament reconstruction: where are we today? Arthroscopy 24:1168–1177

    Article  PubMed  Google Scholar 

  32. Sakane M, Fox RJ, Woo SL, Livesay GA, Li G, Fu FH (1997) In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res 15:285–293

    Article  PubMed  CAS  Google Scholar 

  33. Sastre S, Popescu D, Nunez M, Pomes J, Tomas X, Peidro L (2010) Double-bundle versus single-bundle acl reconstruction using the horizontal femoral position: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc 18:32–36

    Article  PubMed  Google Scholar 

  34. Seon JK, Gadikota HR, Wu JL, Sutton KM, Gill TJ, Li G (2010) Comparison of single- and double-bundle anterior cruciate ligament reconstructions in restoration of knee kinematics and anterior cruciate ligament forces. Am J Sports Med 38:1359–1367

    Article  PubMed  Google Scholar 

  35. Streich NA, Friedrich K, Gotterbarm T, Schmitt H (2008) Reconstruction of the acl with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc 16:232–238

    Article  PubMed  Google Scholar 

  36. Takahashi M, Doi M, Abe M, Suzuki D, Nagano A (2006) Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med 34:787–792

    Article  PubMed  Google Scholar 

  37. Vercillo F, Woo SL, Noorani SY, Dede O (2007) Determination of a safe range of knee flexion angles for fixation of the grafts in double-bundle anterior cruciate ligament reconstruction: a human cadaveric study. Am J Sports Med 35:1513–1520

    Article  PubMed  Google Scholar 

  38. Wu C, Noorani S, Vercillo F, Woo SL (2009) Tension patterns of the anteromedial and posterolateral grafts in a double-bundle anterior cruciate ligament reconstruction. J Orthop Res 27:879–884

    Article  PubMed  Google Scholar 

  39. Wu JL, Seon JK, Gadikota HR, Hosseini A, Sutton KM, Gill TJ, Li G (2010) In situ forces in the anteromedial and posterolateral bundles of the anterior cruciate ligament under simulated functional loading conditions. Am J Sports Med 38:558–563

    Article  PubMed  Google Scholar 

  40. Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M (2007) Double-bundle acl reconstruction can improve rotational stability. Clin Orthop Relat Res 454:100–107

    Article  PubMed  Google Scholar 

  41. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL (2002) Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 30:660–666

    PubMed  Google Scholar 

  42. Yamamoto Y, Hsu WH, Woo SL, Van Scyoc AH, Takakura Y, Debski RE (2004) Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med 32:1825–1832

    Article  PubMed  Google Scholar 

  43. Yasuda K, Ichiyama H, Kondo E, Miyatake S, Inoue M, Tanabe Y (2008) An in vivo biomechanical study on the tension-versus-knee flexion angle curves of 2 grafts in anatomic double-bundle anterior cruciate ligament reconstruction: effects of initial tension and internal tibial rotation. Arthroscopy 24:276–284

    Article  PubMed  Google Scholar 

  44. Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama H, Minami A (2004) Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 20:1015–1025

    Article  PubMed  Google Scholar 

  45. Yasuda K, Kondo E, Ichiyama H, Tanabe Y, Tohyama H (2006) Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy 22:240–251

    Article  PubMed  Google Scholar 

  46. Yasuda K, Tsujino J, Tanabe Y, Kaneda K (1997) Effects of initial graft tension on clinical outcome after anterior cruciate ligament reconstruction. Autogenous doubled hamstring tendons connected in series with polyester tapes. Am J Sports Med 25:99–106

    Article  PubMed  CAS  Google Scholar 

  47. Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH (2006) Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc 14:982–992

    Article  PubMed  Google Scholar 

  48. Zaricznyj B (1987) Reconstruction of the anterior cruciate ligament of the knee using a doubled tendon graft. Clin Orthop Relat Res 220:162–175

    PubMed  Google Scholar 

  49. Zelle BA, Brucker PU, Feng MT, Fu FH (2006) Anatomical double-bundle anterior cruciate ligament reconstruction. Sports Med 36:99–108

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors gratefully acknowledge the support of the National Institutes of Health (R01AR055612).

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Authors and Affiliations

  1. Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street—GRJ 1215, Boston, MA, 02114, USA

    Chih-Hui Chen, Hemanth R. Gadikota, Thomas J. Gill & Guoan Li

  2. Department of Orthopaedic Surgery, Taichung Veterans General Hospital, Taichung City, Taiwan

    Chih-Hui Chen

  3. Institute of Biomedical Engineering, National Yang-Ming University, Taipei City, Taiwan

    Chih-Hui Chen

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  1. Chih-Hui Chen
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  4. Guoan Li
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Correspondence to Guoan Li.

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Chen, CH., Gadikota, H.R., Gill, T.J. et al. The effect of graft fixation sequence on force distribution in double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19, 712–718 (2011). https://doi.org/10.1007/s00167-010-1319-6

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  • DOI: https://doi.org/10.1007/s00167-010-1319-6

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