The kinematics of the anteromedial (AM) and posterolateral (PL) bundles of the anterior cruciate ligament (ACL) in hyperextension was not well understood. This study investigated elongations of the two bundles in hyperextended knee. Twenty living knees were CT-scanned and fluoroscopy-imaged during a weight-bearing flexion–extension cycle from hyperextension to maximal flexion. The knee positions and the relative elongations of the two bundles were reproduced along the motion path using a combined fluoroscopic imaging and CT modeling technique. Results showed the elongation patterns of the two bundles were distinctively different (p < 0.01). The elongation of the PL bundle was slightly higher than that of the AM bundle at hyperextension and then decreased sharply with flexion. The elongation of the AM bundle was highest between the full extension and 10° flexion, and then decreased gradually with flexion angles. In every 10° from hyperextension to 30° flexion, the increasing rates of the PL bundle elongation were significantly higher than those of the AM bundle (p < 0.01). These data may provide important implications for selection of knee flexion angles for fixation of the AM and PL graft bundles in an anatomic ACL reconstruction that can help prevent over-stretching of the graft and reduce the risk of graft failure.
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Seon, J. K., Gadikota, H. R., Wu, J. L., Sutton, K., Gill, T. J., & Li, G. (2010). Comparison of single- and double-bundle anterior cruciate ligament reconstructions in restoration of knee kinematics and anterior cruciate ligament forces. American Journal of Sports Medicine, 38, 1359–1367.
Kondo, E., Merican, A. M., Yasuda, K., & Amis, A. A. (2010). Biomechanical comparisons of knee stability after anterior cruciate ligament reconstruction between 2 clinically available transtibial procedures: Anatomic double bundle versus single bundle. American Journal of Sports Medicine, 38, 1349–1358.
Musahl, V., Voos, J. E., O’Loughlin, P. F., Choi, D., Stueber, V., Kendoff, D., et al. (2010). Comparing stability of different single- and double-bundle anterior cruciate ligament reconstruction techniques: A cadaveric study using navigation. Arthroscopy, 26, S41–S48.
Hemmerich, A., van der Merwe, W., Batterham, M., & Vaughan, C. L. (2011). Knee rotational laxity in a randomized comparison of single- versus double-bundle anterior cruciate ligament reconstruction. American Journal of Sports Medicine, 39, 48–56.
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.
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 Surgery, Sports Traumatology, Arthroscopy, 15, 720–728.
Ahn, J. H., Choi, S. H., Wang, J. H., Yoo, J. C., Yim, H. S., & Chang, M. J. (2011). Outcomes and second-look arthroscopic evaluation after double-bundle anterior cruciate ligament reconstruction with use of a single tibial tunnel. Journal of Bone and Joint Surgery, 93, 1865–1872. American Volume.
Ohsawa, T., Kimura, M., Hagiwara, K., Yorifuji, H., & Takagishi, K. (2012). Clinical and second-look arthroscopic study comparing 2 tibial landmarks for tunnel insertions during double-bundle ACL reconstruction with a minimum 2-year follow-up. American Journal of Sports Medicine, 40, 2479–2486.
Xu, Y., Ao, Y. F., Wang, J. Q., & Cui, G. Q. (2014). Prospective randomized comparison of anatomic single- and double-bundle anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 22, 308–316.
Markolf, K. L., Park, S., Jackson, S. R., & McAllister, D. R. (2009). Anterior-posterior and rotatory stability of single and double-bundle anterior cruciate ligament reconstructions. Journal of Bone and Joint Surgery, 91, 107–118. American Volume.
Amis, A. A., & Dawkins, G. P. (1991). Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. Journal of Bone and Joint Surgery, 73, 260–267. British Volume.
Sakane, M., Fox, R. J., Woo, S. L., Livesay, G. A., Li, G., & Fu, F. H. (1997). In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. Journal of Orthopaedic Research, 15, 285–293.
Bach, J. M., Hull, M. L., & Patterson, H. A. (1997). Direct measurement of strain in the posterolateral bundle of the anterior cruciate ligament. Journal of Biomechanics, 30, 281–283.
Li, G., Rudy, T. W., Sakane, M., Kanamori, A., Ma, C. B., & Woo, S. L. (1999). The importance of quadriceps and hamstring muscle loading on knee kinematics and in situ forces in the ACL. Journal of Biomechanics, 32, 395–400.
Gabriel, M. T., Wong, E. K., Woo, S. L., Yagi, M., & Debski, R. E. (2004). Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. Journal of Orthopaedic Research, 22, 85–89.
Li, G., Defrate, L. E., Rubash, H. E., & Gill, T. J. (2005). In vivo kinematics of the ACL during weight-bearing knee flexion. Journal of Orthopaedic Research, 23, 340–344.
Jordan, S. S., DeFrate, L. E., Nha, K. W., Papannagari, R., Gill, T. J., & Li, G. (2007). The in vivo kinematics of the anteromedial and posterolateral bundles of the anterior cruciate ligament during weightbearing knee flexion. American Journal of Sports Medicine, 35, 547–554.
Yoo, Y. S., Jeong, W. S., Shetty, N. S., Ingham, S. J., Smolinski, P., & Fu, F. (2010). Changes in ACL length at different knee flexion angles: An in vivo biomechanical study. Knee Surgery, Sports Traumatology, Arthroscopy, 18, 292–297.
Li, G., Zayontz, S., Most, E., DeFrate, L. E., Suggs, J. F., & Rubash, H. E. (2004). In situ forces of the anterior and posterior cruciate ligaments in high knee flexion: An in vitro investigation. Journal of Orthopaedic Research, 22, 293–297.
Li, G., DeFrate, L. E., Sun, H., & Gill, T. J. (2004). In vivo elongation of the anterior cruciate ligament and posterior cruciate ligament during knee flexion. American Journal of Sports Medicine, 32, 1415–1420.
De Carlo, M. S., & Sell, K. E. (1997). Normative data for range of motion and single-leg hop in high school athletes. Journal of Sport Rehabilitation, 6, 246–255.
Shelbourne, K. D., & Gray, T. (2009). Minimum 10-year results after anterior cruciate ligament reconstruction: How the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. American Journal of Sports Medicine, 37, 471–480.
Kozanek, M., Hosseini, A., Liu, F., Van de Velde, S. K., Gill, T. J., Rubash, H. E., et al. (2009). Tibiofemoral kinematics and condylar motion during the stance phase of gait. Journal of Biomechanics, 42, 1877–1884.
Shelbourne, K. D., Freeman, H., & Gray, T. (2012). Osteoarthritis after anterior cruciate ligament reconstruction: the importance of regaining and maintaining full range of motion. Sports Health: A Multidisciplinary Approach, 4, 79–85.
Ferretti, M., Ekdahl, M., Shen, W., & Fu, F. H. (2007). Osseous landmarks of the femoral attachment of the anterior cruciate ligament: An anatomic study. Arthroscopy, 23, 1218–1225.
Purnell, M. L., Larson, A. I., & Clancy, W. (2008). Anterior cruciate ligament insertions on the tibia and femur and their relationships to critical bony landmarks using high-resolution volume-rendering computed tomography. American Journal of Sports Medicine, 36, 2083–2090.
Berg, E. E. (1993). Parsons’ knob (tuberculum intercondylare tertium). A guide to tibial anterior cruciate ligament insertion. Clinical Orthopaedics and Related Research, 292, 229–231.
Tensho, K., Shimodaira, H., Aoki, T., Narita, N., Kato, H., Kakegawa, A., et al. (2014). Bony landmarks of the anterior cruciate ligament tibial footprint: A detailed analysis comparing 3-dimensional computed tomography images to visual and histological evaluations. American Journal of Sports Medicine, 42, 1433–1440.
Edwards, A., Bull, A. M., & Amis, A. A. (2007). The attachments of the anteromedial and posterolateral fibre bundles of the anterior cruciate ligament: Part 1: Tibial attachment. Knee Surgery, Sports Traumatology, Arthroscopy, 15, 1414–1421.
Siebold, R., Ellert, T., Metz, S., & Metz, J. (2008). Tibial insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry, arthroscopic landmarks, and orientation model for bone tunnel placement. Arthroscopy, 24, 154–161.
Zhu, Z., & Li, G. (2012). An automatic 2D-3D image matching method for reproducing spatial knee joint positions using single or dual fluoroscopic images. Computer Methods in Biomechanics and Biomedical Engineering, 15, 1245–1256.
Feng, Y., Tsai, T. Y., Li, J. S., Wang, S., Hu, H., Zhang, C., et al. (2015). Motion of the femoral condyles in flexion and extension during a continuous lunge. Journal of Orthopaedic Research, 33, 591–597.
Most, E., Axe, J., Rubash, H., & Li, G. (2004). Sensitivity of the knee joint kinematics calculation to selection of flexion axes. Journal of Biomechanics, 37, 1743–1748.
Cuomo, P., Rama, K. R., Bull, A. M., & Amis, A. A. (2007). The effects of different tensioning strategies on knee laxity and graft tension after double-bundle anterior cruciate ligament reconstruction. American Journal of Sports Medicine, 35, 2083–2090.
Fu, F. H., Shen, W., Starman, J. S., Okeke, N., & Irrgang, J. J. (2008). Primary anatomic double-bundle anterior cruciate ligament reconstruction: A preliminary 2-year prospective study. American Journal of Sports Medicine, 36, 1263–1274.
Kinugasa, K., Mae, T., Matsumoto, N., Nakagawa, S., Yoneda, M., & Shino, K. (2011). Effect of patient age on morphology of anterior cruciate ligament grafts at second-look arthroscopy. Arthroscopy, 27, 38–45.
Aglietti, P., Giron, F., Buzzi, R., Biddau, F., & Sasso, F. (2004). Anterior cruciate ligament reconstruction: Bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial. Journal of Bone & Joint Surgery: American, 86, 2143–2155.
Ettinger, M., Petri, M., Guenther, D., Liu, C., Krusche, C., Liodakis, E., et al. (2013). Anatomic double-bundle ACL reconstruction restricts knee extension in knees with hyperextension. Knee Surgery, Sports Traumatology, Arthroscopy, 21, 2057–2062.
Mauro, C. S., Irrgang, J. J., Williams, B. A., & Harner, C. D. (2008). Loss of extension following anterior cruciate ligament reconstruction: Analysis of incidence and etiology using IKDC criteria. Arthroscopy, 24, 146–153.
This work was supported by National Key Clinical Specialist Construction Project of China and National Institutes of Health Grant (R01 AR055612).
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Feng, Y., Tsai, TY., Li, JS. et al. In-vivo Elongation Patterns of the Anteromedial and Posterolateral Bundles of the ACL at Low Flexion Angles. J. Med. Biol. Eng. 37, 321–327 (2017). https://doi.org/10.1007/s40846-017-0225-5
- Anterior cruciate ligament (ACL)
- Anteromedial (AM)
- Posterolateral (PL)