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Reconstruction of Knees with Combined Cruciate Deficiencies

A Biomechanical Study

Investigation performed at the Biomechanics Research Section, Department of Orthopaedic Surgery, University of California at Los Angeles,David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California

Keith L. Markolf, PhD
Geoffery O'Neill, BS
Steven R. Jackson
David R. McAllister, MD
Biomechanics Research Section, University of California at Los Angeles Rehabilitation Center, Room 21-67, 1000 Veteran Avenue, Los Angeles, CA 90095-6902. E-mail address for K.L. Markolf: kmarkolf{at}mednet.ucla.edu

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Musculoskeletal Transplant Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Clinical results of dual cruciate-ligament reconstructions are often poor, with a failure to restore normal anterior-posterior laxity. This could be the result of improper graft tensioning at the time of surgery and stretch-out of one or both grafts from excessive tissue forces. The purpose of this study was to measure anterior-posterior laxities and graft forces in knees before and after reconstructions of both cruciate ligaments performed with a specific graft-tensioning protocol.

Methods: Eleven fresh-frozen cadaveric knee specimens underwent anterior-posterior laxity testing and installation of load cells to record forces in the native cruciate ligaments as the knees were passively extended from 120° to -5° with no applied tibial force, with 100 N of applied anterior and posterior tibial force, and with 5 N-m of applied internal and external tibial torque. Both cruciate ligaments were reconstructed with a bone-patellar tendon-bone allograft. Only isolated cruciate deficiencies were studied. We determined the nominal levels of anterior and posterior cruciate graft tension that restored anterior-posterior laxities to within 2 mm of those of the intact knee and restored anterior cruciate graft forces to within 20 N of those of the native anterior cruciate ligament during passive knee extension. Both grafts were tensioned at 30° of knee flexion, with the posterior cruciate ligament tensioned first. Measurements of anterior-posterior knee laxity and graft forces were repeated with both grafts at their nominal tension levels and with one graft fixed at its nominal tension level and the opposing graft tensioned to 40 N above its nominal level.

Results: The anterior and posterior cruciate graft tensions were found to be interrelated; applying tension to one graft changed the tension of the other (fixed) graft and displaced the tibia relative to the femur. The posterior cruciate graft had to be tensioned first to consistently achieve the nominal combination of mean graft forces at 30° of flexion. At these levels, mean forces in the anterior cruciate graft were restored to those of the intact anterior cruciate ligament under nearly all test conditions. However, the mean posterior cruciate graft forces were significantly higher than the intact posterior cruciate ligament forces at full extension under all test conditions. Anterior-posterior laxity was restored between 0° and 90° of flexion with both grafts at their nominal force levels. Overtensioning of the anterior cruciate graft by 40 N significantly increased its mean force levels during passive knee extension between 110° and -5° of flexion, but it did not significantly change anterior-posterior laxity between 0° and 90° of flexion. In contrast, overtensioning of the posterior cruciate graft by 40 N significantly increased posterior cruciate graft forces during passive knee extension at flexion angles of <5° and >95° and significantly decreased anterior-posterior laxities at all flexion angles except full extension.

Conclusions: It was not possible to find levels of graft tension that restored anterior-posterior laxities at all flexion positions and restored forces in both grafts to those of their native cruciate counterparts during passive motion. Our graft-tensioning protocol represented a compromise between these competing objectives. This protocol aimed to restore anterior-posterior laxities and anterior cruciate graft forces to normal levels. The major shortcoming of this tensioning protocol was the dramatically higher posterior cruciate graft forces produced near full extension under all test conditions.

Clinical Relevance: Applying high tension to the anterior cruciate graft to change anterior-posterior laxity was relatively ineffective and had the unwanted effect of producing abnormally high anterior cruciate graft forces. The key to controlling anterior-posterior laxity was the posterior cruciate graft tension. Clinically, surgeons often apply a high level of tension to the posterior cruciate graft to reduce posterior tibial translation at 90° of flexion. Our results showed that this was an effective strategy for reducing laxity, but relatively high posterior cruciate graft forces were generated when the knee was fully extended. For this reason, the pretensioning protocol used in this study may not be directly applicable to patients at this time. Additional biomechanical and clinical studies of this difficult problem are necessary.

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