The importance of quadriceps and hamstring muscle loading on knee kinematics and in-situ forces in the ACL

This study investigated the effect of hamstring co-contraction with quadriceps on the kinematics of the human knee joint and the in-situ forces in the anterior cruciate ligament (ACL) during a simulated isometric extension motion of the knee. Cadaveric human knee specimens (n = 10) were tested using the robotic universal force moment sensor (UFS) system and measurements of knee kinematics and in-situ forces in the ACL were based on reference positions on the path of passive flexion/extension motion of the knee. With an isolated 200 N quadriceps load, the knee underwent anterior and lateral tibial translation as well as internal tibial rotation with respect to the femur. Both translation and rotation increased when the knee was flexed from full extension to 30 of flexion; with further flexion, these motion decreased. The addition of 80 N antagonistic hamstrings load significantly reduced both anterior and lateral tibial translation as well as internal tibial rotation at knee flexion angles tested except at full extension. At 30 of flexion, the anterior tibial translation, lateral tibial translation, and internal tibial rotation were significantly reduced by 18, 46, and 30%, respectively (p<0.05). The in-situ forces in the ACL under the quadriceps load were found to increase from 27.8+/-9.3 N at full extension to a maximum of 44.9+/-13.8 N at 15 of flexion and then decrease to 10 N beyond 60 of flexion. The in-situ force at 15 was significantly higher than that at other flexion angles (p<0.05). The addition of the hamstring load of 80 N significantly reduced the in-situ forces in the ACL at 15, 30 and 60 of flexion by 30, 43, and 44%, respectively (p<0.05). These data demonstrate that maximum knee motion may not necessarily correspond to the highest in-situ forces in the ACL. The data also suggest that hamstring co-contraction with quadriceps is effective in reducing excessive forces in the ACL particularly between 15 and 60 of knee flexion.     

The effect of weightbearing and external loading on anterior cruciate ligament strain

A force balance between the ligaments, articular contact, muscles and body weight maintains knee joint stability. Thus, it is important to study anterior cruciate ligament (ACL) biomechanics, in vivo, under weightbearing conditions. Our objective was to compare the ACL strain response under weightbearing and non-weightbearing conditions and in combination with three externally applied loadings: (1) anterior-posterior shear forces, (2) internal-external torques, and (3) varus-valgus moments. A strain transducer was implanted on the ACL of 11 subjects. All joint loadings were performed with the knee at 20 degrees of flexion. A significant increase in ACL strain was observed as the knee made the transition from non-weightbearing to weightbearing. During anterior shear loading, the strain values produced during weightbearing were greater than those of the non-weightbearing knee (shear loads <40N). At higher shear loads, the strain values became equal. During axial torsion, an internal torque of 10Nm strained the ACL when the knee was non-weightbearing while an equivalent external torque did not. Weightbearing significantly increased ACL strain values in comparison to non-weightbearing with the application of external torques and low internal torques (<3Nm). The strains became equal for higher internal torques. For V-V loading, the ACL was not strained in the non-weightbearing knee. However, weightbearing increased the ACL strain values over the range of moments tested. These data have important clinical ramifications in the development of rehabilitation protocols following ACL reconstruction since weightbearing has been previously thought to provide a protective mechanism to the healing graft.     

Role of gastrocnemius activation in knee joint biomechanics: gastrocnemius acts as an ACL antagonist

Gastrocnemius is a premier muscle crossing the knee, but its role in knee biomechanics and on the anterior cruciate ligament (ACL) remains less clear when compared to hamstrings and quadriceps. The effect of changes in gastrocnemius force at late stance when it peaks on the knee joint response and ACL force was initially investigated using a lower extremity musculoskeletal model driven by gait kinematics—kinetics. The tibiofemoral joint under isolated isometric contraction of gastrocnemius was subsequently analyzed at different force levels and flexion angles (0°–90°). Changes in gastrocnemius force at late stance markedly influenced hamstrings forces. Gastrocnemius acted as ACL antagonist by substantially increasing its force. Simulations under isolated contraction of gastrocnemius confirmed this role at all flexion angles, in particular, at extreme knee flexion angles (0° and 90°). Constraint on varus/valgus rotations substantially decreased this effect. Although hamstrings and gastrocnemius are both knee joint flexors, they play opposite roles in respectively protecting or loading ACL. Although the quadriceps is also recognized as antagonist of ACL, at larger joint flexion and in contrast to quadriceps, activity in gastrocnemius substantially increased ACL forces (anteromedial bundle). The fact that gastrocnemius is an antagonist of ACL should help in effective prevention and management of ACL injuries.     

Steeper posterior tibial slope markedly increases ACL force in both active gait and passive knee joint under compression

The role of the posterior tibial slope (PTS) in anterior cruciate ligament (ACL) risk of injury has been supported by many imaging studies but refuted by some in vitro works. The current investigation was carried out to compute the effect of ±5^o change in PTS on knee joint biomechanics in general and ACL force/strain in particular. Two validated finite element (FE) models of the knee joint were employed; one active lower extremity musculoskeletal model including a complex FE model of the knee joint driven by in vivo kinematics/kinetics collected in gait of asymptomatic subjects, and the other its isolated unconstrained passive tibiofemoral (TF) joint considered under 1400 N compression at four different knee flexion angles (0°–45°). In the TF model, the compression force was applied at the joint mechanical balance point causing no rotations in sagittal and frontal planes.     

Estimation of ACL forces by reproducing knee kinematics between sets of knees: A novel non-invasive methodology

In situ force in the anterior cruciate ligament (ACL) has been quantified both in vitro in response to relatively simple loads by means of robotic technology, as well as in vivo in response to more complex loads by means of force transducers and computational models. However, a methodology has been suggested to indirectly estimate the in situ forces in the ACL in a non-invasive, non-contact manner by reproducing six-degree of freedom (six-DOF) in vivo kinematics on cadaveric knees using a robotic/UFS testing system. Therefore, the objective of this study was to determine the feasibility of this approach. Kinematics from eight porcine knees (source knees) were collected at 30 degrees , 60 degrees , and 90 degrees of flexion in response to: (1) an anterior load of 100 N and (2) a valgus load of 5 N m. The average of each kinematic data set was reproduced on a separate set of eight knees (target knees). The in situ forces in the ACL were determined for both sets of knees and compared. Significant differences (rho<0.05) were found between the source knees and the target knees for all flexion angles in response to an anterior load. However, in response to valgus loads, there was no significant difference between the source knees and the target knees at 30 degrees and 90 degrees of flexion. It was noted that there was a correlation between anterior knee laxity (the distance along the displacement axis from the origin to the beginning of the linear region of the load-displacement curve) and internal-external rotation. These data suggest that in order to obtain reproducible results one needs to first match knees to knees with comparable anterior knee laxity. Thus, an estimate of the in situ forces in the ACL during in vivo activities might be obtainable using this novel methodology.     

The effects of knee motion and external loading on the length of the anterior cruciate ligament (ACL): a kinematic study

A six-degrees-of-freedom mechanical linkage device was designed and used to study the unconstrained motion of ten intact human cadaver knees. The knees were subjected to externally applied varus and valgus (V-V) moments up to 14 N-m as well as anterior and posterior (A-P) loads up to 100 N. Tests were done at four knee flexion angles; 0, 30, 45, and 90 deg. Significant coupled axial tibial rotation was found, up to 21.0 deg for V-V loading (at 90 deg of flexion) and 14.2 deg for A-P loading (at 45 deg of flexion). Subsequently, the knees were dissected and the locations of the insertion sites to the femur and tibia for the anteromedial (AM), posterolateral (PL), and intermediate (IM) portions of the ACL were identified. The distances between the insertion sites for all external loading conditions were calculated. In the case when the external load was zero, the AM portion of the ACL lengthened with knee flexion, while the PL portion shortened and the intermediate (IM) portion did not change in length. With the application of 14 N-m valgus moment, the PL and IM portions of the ACL lengthened significantly more than the AM portion (p less than 0.001). With the application of 100 N anterior load, the AM portion lengthened slightly less than the PL portion, which lengthened slightly less than the IM portion (p less than 0.005). In general, the amount of lengthening of the three portions of the ACL during valgus and anterior loading was observed to increase with knee flexion angle (p less than 0.001).     

Strain inhomogeneity in the anterior cruciate ligament under application of external and muscular loads.

To determine whether mathematical relations between strains in different bundles and loads would be needed to predict injury of the anterior cruciate ligament (ACL), this work tested the hypothesis that strains developed in two bundles of the ACL were significantly different under the application of a number of loads important to injury etiology of the ACL. To provide the data for testing this hypothesis, liquid mercury strain gages were installed on both the anteromedial (AMB) and posterolateral (PLB) bundles of the ACL of ten specimens, which were then subjected to passive flexion/extension, hyperextension moment, anterior force, internal and external axial moments, quadriceps, and hamstrings forces. Various combinations of these loads were also applied. Flexion angles ranged from 8 deg of hyperextension through 120 deg of flexion. The data were analyzed using a repeated measures analysis of variance. The analyses indicated that significant strain differences existed between the two bundles only for passive flexion/extension. However, the analyses did not support the hypothesis that AMB and PLB strains are significantly different from each other under the application of external and muscular loads. Because noticeable differences (> 3 percent) between bundle strains did exist in some load cases for limited ranges of flexion and the PLB strain was consistently higher than the AMB strain, it may be sufficient to consider strain in only the PLB when predicting ligament damage based on strain-load relations.     

An implantable transducer for measuring tension in an anterior cruciate ligament graft.

The goal of this study was to develop a new implantable transducer for measuring anterior cruciate ligament (ACL) graft tension postoperatively in patients who have undergone ACL reconstructive surgery. A unique approach was taken of integrating the transducer into a femoral fixation device. To devise a practical in vivo calibration protocol for the fixation device transducer (FDT), several hypotheses were investigated: (1) The use of a cable versus the actual graft as the means for applying load to the FDT during calibration has no significant effect on the accuracy of the FDT tension measurements; (2) the number of flexion angles at which the device is calibrated has no significant effect on the accuracy of the FDT measurements; (3) the friction between the graft and femoral tunnel has no significant effect on measurement accuracy. To provide data for testing these hypotheses, the FDT was first calibrated with both a cable and a graft over the full range of flexion. Then graft tension was measured simultaneously with both the FDT on the femoral side and load cells, which were connected to the graft on the tibial side, as five cadaver knees were loaded externally. Measurements were made with both standard and overdrilled tunnels. The error in the FDT tension measurements was the difference between the graft tension measured by the FDT and the load cells. Results of the statistical analyses showed that neither the means of applying the calibration load, the number of flexion angles used for calibration, nor the tunnel size had a significant effect on the accuracy of the FDT. Thus a cable may be used instead of the graft to transmit loads to the FDT during calibration, thus simplifying the procedure. Accurate calibration requires data from just three flexion angles of 0, 45, and 90 deg and a curve fit to obtain a calibration curve over a continuous range of flexion within the limits of this angle group. Since friction did not adversely affect the measurement accuracy of the FDT, the femoral tunnel can be drilled to match the diameter of the graft and does not need to be overdrilled. Following these procedures, the error in measuring graft tension with the FDT averages less than 10 percent relative to a full-scale load of 257 N.     

In vivo assessment of the interaction of patellar tendon tibial shaft angle and anterior cruciate ligament elongation during flexion

A potential cause of non-contact anterior cruciate ligament (ACL) injury is landing on an extended knee. In line with this hypothesis, studies have shown that the ACL is elongated with decreasing knee flexion angle. Furthermore, at low flexion angles the patellar tendon is oriented to increase the anterior shear component of force acting on the tibia. This indicates that knee extension represents a position in which the ACL is taut, and thus may have an increased propensity for injury, particularly in the presence of excessive force acting via the patellar tendon. However, there is very little in vivo data to describe how patellar tendon orientation and ACL elongation interact during flexion. Therefore, this study measured the patellar tendon tibial shaft angle (indicative of the relative magnitude of the shear component of force acting via the patellar tendon) and ACL length in vivo as subjects performed a quasi-static lunge at varying knee flexion angles. Spearman rho rank correlations within each individual revealed that flexion angles were inversely correlated to both ACL length (rho = −0.94 ± 0.07, mean ± standard deviation, p < 0.05) and patellar tendon tibial shaft angle (rho = −0.99 ± 0.01, p < 0.05). These findings indicate that when the knee is extended, the ACL is both elongated and the patellar tendon tibial shaft angle is increased, resulting in a relative increase in anterior shear force on the tibia acting via the patellar tendon. Therefore, these data support the hypothesis that landing with the knee in extension is a high risk scenario for ACL injury.     

Lateral force–displacement behaviour of the human patella and its variation with knee flexion — a biomechanical study in vitro

This study measured the patellar lateral force–displacement behaviour at a range of knee flexion angles in normal human cadaver specimens. The knee extensor muscles were loaded in proportion to their physiological cross-sectional areas, the tensions being applied in physiological directions along the separate quadriceps muscles. Knee extension was blocked at a range of knee flexion angles from 0 to 90°, and patellar lateral displacement versus force characteristics were measured. This experiment was repeated with three total muscle forces, 20, 175 and 350 N, which were held constant at all flexion angles. It was shown that similar stability variation was obtained with the different total muscle loads, and also the forces required to produce a range of patellar displacements (1, 5, 9 mm) were examined. A 5 mm lateral patellar displacement required a constant displacing force (i.e. the patella had constant lateral stability) up to 60° knee flexion, and then a significant increase at 90°. The results were related to surgicaland anatomical observations.     

Computational biomechanics of knee joint in open kinetic chain extension exercises

Open kinetic chain (OKC) extension exercises are commonly performed to strengthen quadriceps muscles and restore joint function in performance enhancement programs, in exercise therapies and following joint reconstruction. Using a validated 3D nonlinear finite element model, the detailed biomechanics of the entire joint in OKC extension exercises are investigated at 0, 30, 60 and 90 degrees joint angles. Two loading cases are simulated; one with only the weight of the leg and the foot while the second considers also a moderate resistant force of 30 N acting at the ankle perpendicular to the tibia. The presence of the 30 N markedly influences the results both in terms of the magnitude and the trend. The resistant load substantially increases the required quadriceps, patellar tendon, cruciate ligaments and joint contact forces, especially at near 90 degrees angles with the exception of ACL force that is increased at 0 degrees angle. At post-ACL reconstruction period or in the joint with ACL injury, the exercise should preferably be avoided at near full extension positions under large resistant forces.     

Determination of trunk muscle forces for flexion and extension by using a validated finite element model of the lumbar spine and measured in vivo data

Muscle forces stabilize the spine and have a great influence on spinal loads. But little is known about their magnitude. In a former in vitro experiment, a good agreement with intradiscal pressure and fixator loads measured in vivo could be achieved for standing and extension of the lumbar spine. However, for flexion the agreement between in vitro and in vivo measurements was insufficient. In order to improve the determination of trunk muscle forces, a three-dimensional nonlinear finite element model of the lumbar spine with an internal fixation device was created and the same loads were applied as in a previous in vitro experiment. An extensive adaptation process of the model was performed for flexion and extension angles up to 20 degrees and -15 degrees, respectively. With this validated computer model intra-abdominal pressure, preload in the fixators, and a combination of hip- and lumbar flexion angle were varied until a good agreement between analytical and in vivo results was reached for both, intradiscal pressure and bending moments in the fixators. Finally, the fixators were removed and the muscle forces for the intact lumbar spine calculated. A good agreement with the in vivo results could only be achieved at a combination of hip- and lumbar flexion. For the intact spine, forces of 170, 100 and 600 N are predicted in the m. erector spinae for standing, 5 degrees extension and 30 degrees flexion, respectively. The force in the m. rectus abdominus for these body positions is less than 25 N. For more than 10 degrees extension the m. erector spinae is unloaded. The finite element method together with in vivo data allows the estimation of trunk muscle forces for different upper body positions in the sagittal plane. In our patients, flexion of the upper body was most likely a combination of hip- and lumbar spine bending.     

Pure passive hyperextension of the human cadaver knee generates simultaneous bicruciate ligament rupture

Knee hyperextension has been described as a mechanism of isolated anterior cruciate ligament (ACL) tears, but clinical and experimental studies have produced contradictory results for the ligament injuries and the injury sequence caused by the hyperextension loading mechanism. The hypothesis of this study was that bicruciate ligament injuries would occur as a result of knee hyperextension by producing high tibio-femoral (TF) compressive forces that would cause anterior translation of the tibia to rupture the ACL, while joint extension would simultaneously induce rupture of the posterior cruciate ligament (PCL). Six human knees were loaded in hyperextension until gross injury, while bending moments and motions were recorded. Pressure sensitive film documented the magnitude and location of TF compressive forces. The peak bending moment at failure was 108?N?m±46?N?m at a total extension angle of 33.6?deg±11?deg. All joints failed by simultaneous ACL and PCL damages at the time of a sudden drop in the bending moment. High compressive forces were measured in the anterior compartments of the knee and likely produced the anterior tibial subluxation, which contributed to excessive tension in the ACL. The injury to the PCL at the same time may have been due to excessive extension of the joint. These data, and the comparisons with previous experimental studies, may help explain the mechanisms of knee ligament injury during hyperextension. Knowledge of forces and constraints that occur clinically could then help diagnose primary and secondary joint injuries following hyperextension of the human knee.     

Measurement of in vivo anterior cruciate ligament strain during dynamic jump landing

Despite recent attention in the literature, anterior cruciate ligament (ACL) injury mechanisms are controversial and incidence rates remain high. One explanation is limited data on in vivo ACL strain during high-risk, dynamic movements. The objective of this study was to quantify ACL strain during jump landing. Marker-based motion analysis techniques were integrated with fluoroscopic and magnetic resonance (MR) imaging techniques to measure dynamic ACL strain non-invasively. First, eight subjects' knees were imaged using MR. From these images, the cortical bone and ACL attachment sites of the tibia and femur were outlined to create 3D models. Subjects underwent motion analysis while jump landing using reflective markers placed directly on the skin around the knee. Next, biplanar fluoroscopic images were taken with the markers in place so that the relative positions of each marker to the underlying bone could be quantified. Numerical optimization allowed jumping kinematics to be superimposed on the knee model, thus reproducing the dynamic in vivo joint motion. ACL length, knee flexion, and ground reaction force were measured. During jump landing, average ACL strain peaked 55±14 ms (mean and 95% confidence interval) prior to ground impact, when knee flexion angles were lowest. The peak ACL strain, measured relative to its length during MR imaging, was 12±7%. The observed trends were consistent with previously described neuromuscular patterns. Unrestricted by field of view or low sampling rate, this novel approach provides a means to measure kinematic patterns that elevate ACL strains and that provide new insights into ACL injury mechanisms.     

Pattern of anterior cruciate ligament force in normal walking

The goal of this study was to calculate and explain the pattern of anterior cruciate ligament (ACL) loading during normal level walking. Knee-ligament forces were obtained by a two-step procedure. First, a three-dimensional (3D) model of the whole body was used together with dynamic optimization theory to calculate body-segmental motions, ground reaction forces, and leg-muscle forces for one cycle of gait. Joint angles, ground reaction forces, and muscle forces obtained from the gait simulation were then input into a musculoskeletal model of the lower limb that incorporated a 3D model of the knee. The relative positions of the femur, tibia, and patella and the forces induced in the knee ligaments were found by solving a static equilibrium problem at each instant during the simulated gait cycle. The model simulation predicted that the ACL bears load throughout stance. Peak force in the ACL (303 N) occurred at the beginning of single-leg stance (i.e., contralateral toe off). The pattern of ACL force was explained by the shear forces acting at the knee. The balance of muscle forces, ground reaction forces, and joint contact forces applied to the leg determined the magnitude and direction of the total shear force acting at the knee. The ACL was loaded whenever the total shear force pointed anteriorly. In early stance, the anterior shear force from the patellar tendon dominated the total shear force applied to the leg, and so maximum force was transmitted to the ACL at this time. ACL force was small in late stance because the anterior shear forces supplied by the patellar tendon, gastrocnemius, and tibiofemoral contact were nearly balanced by the posterior component of the ground reaction.     

A detailed and validated three dimensional dynamic model of the patellofemoral joint

A detailed 3D anatomical model of the patellofemoral joint was developed to study the tracking, force, contact and stability characteristics of the joint. The quadriceps was considered to include six components represented by 15 force vectors. The patellar tendon was modeled using four bundles of viscoelastic tensile elements. Each of the lateral and medial retinaculum was modeled by a three-bundle nonlinear spring. The femur and patella were considered as rigid bodies with their articular cartilage layers represented by an isotropic viscoelastic material. The geometrical and tracking data needed for model simulation, as well as validation of its results, were obtained from an in vivo experiment, involving MR imaging of a normal knee while performing isometric leg press against a constant 140 N force. The model was formulated within the framework of a rigid body spring model and solved using forth-order Runge-Kutta, for knee flexion angles between zero and 50 degrees. Results indicated a good agreement between the model predictions for patellar tracking and the experimental results with RMS deviations of about 2 mm for translations (less than 0.7 mm for patellar mediolateral shift), and 4 degrees for rotations (less than 3 degrees for patellar tilt). The contact pattern predicted by the model was also consistent with the results of the experiment and the literature. The joint contact force increased linearly with progressive knee flexion from 80 N to 210 N. The medial retinaculum experienced a peak force of 18 N at full extension that decreased with knee flexion and disappeared entirely at 20 degrees flexion. Analysis of the patellar time response to the quadriceps contraction suggested that the muscle activation most affected the patellar shift and tilt. These results are consistent with the recent observations in the literature concerning the significance of retinaculum and quadriceps in the patellar stability.     

Forces in anterior cruciate ligament during simulated weight-bearing flexion with anterior and internal rotational tibial load

This study determined in-vitro anterior cruciate ligament (ACL) force patterns and investigated the effect of external tibial loads on the ACL force patterns during simulated weight-bearing knee flexions. Nine human cadaveric knee specimens were mounted on a dynamic knee simulator, and weight-bearing knee flexions with a 100N of ground reaction force were simulated; while a robotic/universal force sensor (UFS) system was used to provide external tibial loads during the movement. Three external tibial loading conditions were simulated, including no external tibial load (termed BW only), a 50N anterior tibial force (ATF), and a 5Nm internal rotation tibial torque (ITT). The tibial and femoral kinematics was measured with an ultrasonic motion capture system. These movement paths were then accurately reproduced on a robotic testing system, and the in-situ force in the ACL was determined via the principle of superposition. The results showed that the ATF significantly increased the in-situ ACL force by up to 60% during 0-55 degrees of flexion, while the ITT did not. The magnitude of ACL forces decreased with increasing flexion angle for all loading conditions. The tibial anterior translation was not affected by the application of ATF, whereas the tibial internal rotation was significantly increased by the application of ITT. These data indicate that, in a weight-bearing knee flexion, ACL provides substantial resistance to the externally applied ATF but not to the ITT.     

Effect of knee musculature on anterior cruciate ligament strain in vivo

Squatting is a commonly prescribed exercise following reconstruction of the anterior cruciate ligament (ACL). The objective of this paper was to measure the in vivo strain patterns of the normal ACL and the load at the knee for the simple squat and for squatting with a “sport cord”. A sport cord is a large elastic rubber tube used for added resistance. Strain patterns were deduced using displacement data from a Hall Effect Strain Transducer (HEST), while joint loads were determined by a mathematical model with inputs from a force plate and electrogoniometers. ACL strain for the free squat in one subject had a maximum of 2% at a knee angle of 10° and was slack for knee angles >17°. In squatting with a sport cord, peak strain was 1% at 10° and was slack at knee angles >14°. Since these peak strains are low, squatting appears to be a safe exercise for conservative rehabilitation of ACL reconstruction patients. In addition, the sport cord is a recommended augmentation to the activity. We believe that the decrease in strain with the sport cord results from added joint stiffness due to greater compressive forces at the tibiofemoral joint. This greater compressive force results from the approximately 10% increase in quadriceps activity. From shear force data predicted by the mathematical model, the maximum anterior drawer force for free squatting (50 N) was considerably less than for sport cord squatting (430 N). Therefore, the value of shear force at the tibiofemoral joint only partially determines the load placed on the ACL.     

In vitro forces in the normal and cruciate-deficient knee during simulated squatting motion

Three orthogonal components of the tibiofemoral and patellofemoral forces were measured simultaneously for knees with intact cruciate ligaments (nine knees), following anterior cruciate ligament resection (six knees), and subsequent posterior cruciate ligament resection (six knees). The knees were loaded using an experimental protocol that modeled static double-leg squat. The mean compressive tibial force increased with flexion angle. The mean anteroposterior tibial shear force acted posteriorly on the tibia below 50 deg flexion and anteriorly above 55 deg. Mediolateral shear forces were low compared to the other force components and tended to be directed medially on both the patella and tibia. The mean value of the ratio of the resultant tibial force divided by the quadriceps force decreased with increasing flexion angle and was between 0.6 and 0.7 above 70 deg flexion. The mean value of the ratio of the resultant tibiofemoral contact force divided by the resultant patellofemoral contact force decreased with increasing flexion and was between 0.8 and 1.0 above 55 deg flexion. Cruciate ligament resection resulted in no significant changes in the patellar contact forces. Following resection of the anterior cruciate ligament, the tibial anteroposterior shear force was directed anteriorly over all flexion angles tested. Subsequent resection of the posterior cruciate ligament resulted in an approximately 10 percent increase in the quadriceps tendon and tibial compressive force.     

Biomechanics of changes in ACL and PCL material properties or prestrains in flexion under muscle force-implications in ligament reconstruction

The effects of changes in cruciate ligament material and prestrain on knee joint biomechanics following ligament reconstruction surgery by a tendon are not adequately known. A 3D nonlinear finite element model of the entire knee joint was used to investigate the joint response at different flexion angles under a quadriceps force while varying ACL and PCL initial strains or material properties. The ACL and PCL forces as well as tibiofemoral contact forces/areas substantially increased with greater ACL or PCL initial strains or stiffness. The patellofemoral contact force slightly increased whereas the tibial extensor moment slightly decreased with tenser or stiffer ACL. Reverse trends were predicted with slacker ACL. Results confirm the hypotheses that changes in the prestrain of one cruciate ligament substantially influence the force in the other cruciate ligament and the entire joint and that the use of the patellar tendon (PT) as a replacement for cruciate ligaments markedly alters the joint biomechanics with trends similar to those predicted when increasing prestrains. Forces in both ACL and PCL ligaments increased as one of them became tenser or stiffer and diminished as it became slacker. These results have important consequences in joint biomechanics following ligament injuries or replacement and tend to recommend the use of grafts with smaller prestrains (i.e. slacker than intact) when using the PT as the replacement material with stiffness greater than that of replaced ligament itself.