In vivo calibration of a femoral fixation device transducer for measuring anterior cruciate ligament graft tension: a study in an ovine model

Toward developing a transducer for measuring in vivo tension in anterior cruciate ligament grafts in humans, the objectives of this study were to determine the following: (1) whether the calibration of a previously reported femoral fixation device transducer (FDT) (Ventura et al., 1998) is affected by the presence of the graft when implanted in the tibial metaphysis of an ovine model, (2) whether the FDT remains calibrated at 4 weeks postoperatively, and (3) whether the biological incorporation of the graft occurs prior to a change in the FDT calibration. The FDT was implanted in the hind limb of five sheep using an extra-articular procedure. Both the proximal common digital extensor tendon (i.e., graft) and a Teflon-coated wire were looped around the FDT inside a tunnel in the tibial metaphysis. The FDT was calibrated on three occasions using the loop of wire: once intraoperatively before graft insertion, once intraoperatively after graft insertion, and once postoperatively after the animals had been sacrificed at 4 weeks. Following sacrifice, the load transmitted to the FDT by the graft was also determined. The FDT exhibited linear calibration intraoperatively both before and after graft insertion with an average error relative to the calibration before insertion of the graft of -4.6 percent of full-scale load (150 N) and this average relative error was not significantly different from zero (p = 0.183). After 4 weeks of implantation, the average relative percent error was -5.0 percent and was not significantly different from zero (p = 0.434) indicating that the FDT remained calibrated in the in vivo environment. Because only 15 percent of the graft tension was transmitted to the FDT after 4 weeks, biological incorporation of the graft preceded the loss of calibration. In light of these findings, the FDT offers the capability of measuring the intra-articular ACL graft tension in vivo in animal models and possibly humans before the biological bond develops and also of monitoring the formation and maturation of the biological bond between a graft and bone tunnel.     

Static and fatigue strength of a fixation device transducer for measuring anterior cruciate ligament graft tension

To determine which exercises do not overload the graft-fixation complex during intensive rehabilitation from reconstructive surgery of the anterior cruciate ligament (ACL), it would be useful to measure ACL graft loads during rehabilitative activities in vivo in humans. A previous paper by Ventura et al. (1998) reported on the design of an implantable transducer integrated into a femoral fixation device and demonstrated that the transducer could be calibrated to measure graft loads to better than 10 percent full-scale error in cadaveric knees. By measuring both the static and fatigue strengths of the transducer, the purpose of the present study was to determine whether the transducer could be safely implanted in humans without risk of structural failure. Eight devices were loaded to failure statically. Additionally, seven devices were tested using the up-and-down method to estimate the median fatigue strength at a life of 225,000 cycles. The average ultimate strength was 1856 +/- 74 N and the median fatigue strength was 441 N at a life of 225,000 cycles. The maximum graft load during normal daily activities is estimated to be 500 N and the 225,000 cycle life corresponds to that of the average healthy individual during a 12-week period. Considering that patients who have had an ACL reconstruction are less ambulatory than normal immediately following surgery and that biologic incorporation of the graft should be well developed by 12 weeks thus decreasing the load transmitted to the fixation device, the FDT can be safely implanted in humans without undue risk of structural failure.     

Calibration and application of an intra-articular force transducer for the measurement of patellar tendon graft forces: an in situ evaluation.

The objective of this study was to evaluate two calibration methods for the "Arthroscopically Implantable Force Probe" (AIFP) that are potentially suitable for in vivo use: (1) a direct, experimentally based method performed by applying a tensile load directly to the graft after it is harvested but prior to implantation (the "pre-implantation" technique), and (2) an indirect method that utilizes cadaver-based analytical expressions to transform the AIFP output versus anterior shear load relationship, which may be established in vivo, to resultant graft load (the "post-implantation" technique). The AIFP outputs during anterior shear loading of the knee joint using these two calibration methods were compared directly to graft force measurements using a ligament cutting protocol and a 6 DOF load cell. The mean percent error (actual-measured)/(actual)* 100) associated with the pre-implantation calibration ranged between 85 and 175 percent, and was dependent on the knee flexion angle tested. The percent error associated with the post-implantation technique was evaluated in two load ranges: loads less than 40 N, and loads greater than 40 N. For graft force values greater than 40 N, the mean percent errors inherent to the post-implantation calibration method ranged between 20 and 29 percent, depending on the knee flexion angle tested. Below 40 N, these errors were substantially greater. Of the two calibration methods evaluated, the post-implantation approach provided a better estimate of the ACL graft force than the pre-implantation technique. However, the errors for the post-implantation approach were still high and suggested that caution should be employed when using implantable force probes for in vivo measurement of ACL graft forces.     

Analysis of forces of ACL reconstructions at the tunnel entrance: is tunnel enlargement a biomechanical problem?

Bone tunnel enlargement is a common phenomenon following reconstruction of the anterior cruciate ligament (ACL). Biomechanical and biological factors have been reported as potential causes of this problem. However, there is no analysis of forces between the graft and bone, as the graft changes direction at the bone tunnel entrance. The purpose of this study was to study these 'redirecting forces'. Magnetic resonance images of 10 patients with an ACL reconstruction (age: 26+/-6.8 years) were used to determine the angle between graft and drill holes. Vector analysis was used to calculate the direction and magnitude of the perpendicular component of the force between the bone tunnel and the graft at the entrance of the bone tunnel. Force components were projected into the radiographically important sagittal and coronal planes. Tension of ACL reconstructions was recorded during passive knee motion in 10 cadaveric knee experiments (age: 28.9+/-10.6 years) and the tension multiplied with the force component for each plane. Results are reported for the coronal and sagittal planes, respectively: For -10 degrees of extension, the percentages of graft tension were determined to be 17+/-7 (max: 26; min: 7%) and 26+/-9 (max: 39; min: 16%) for the tibia. They were 59+/-6 (max: 66; min: 48%) and 99+/-1 (max: 1.00; min: 99%) for the femur. Force components were 14.68+/-6.54 and 25.73+/-12.96 N for the tibial tunnel. For the femoral tunnel, they were 52.48+/-19.03 and 90.77+/-32.06 N. Percentages of graft tension and force components were significantly higher for the femoral tunnel compared with the tibial tunnel. Moreover, in the sagittal direction, force components for the femoral tunnel were significantly higher compared with the coronal plane (Wilcoxon test, p < 0.01). The differences in force components calculated in this study corresponds with the amount of tunnel enlargement in the radiographic planes in the literature providing evidence that biomechanical forces play a key role in postoperative tunnel expansion.     

Empirical relationship between lengthening an anterior cruciate ligament graft and increases in knee anterior laxity: a human cadaveric study

Lengthening of an anterior cruciate ligament (ACL) graft construct can occur as a result of lengthening at the sites of tibial and/or femoral fixation and manifests as an increase in anterior laxity. Although lengthening at the site of fixation has been measured for a variety of fixation devices, it is difficult to place these results in a clinical context because the mathematical relationship between lengthening of an ACL graft construct and anterior laxity is unknown. The purpose of our study was to determine empirically this relationship. Ten cadaveric knees were reconstructed with a double-looped tendon graft. With the knee in 25 degrees of flexion, the position of the proximal end of the graft inside the femoral tunnel was adjusted by moving the femoral fixation device until the anterior laxity at an applied anterior force of 134 N matched that of the intact knee. In random order, the graft construct was lengthened 1, 2, 3, 4, and 5 mm by moving the femoral fixation device distally along the femoral tunnel and anterior laxity was measured. The increase in the length of the graft construct was related to the increase in anterior laxity by a simple linear regression model. Lengthening the graft construct from 1 to 5 mm caused an equal increase in anterior laxity (slope=1.0 mmmm, r(2)=0.800, p<0.0001). Because an anterior laxity increase of 3 mm or greater in a reconstructed knee is considered unstable clinically and because many fixation devices in widespread use clinically allow 3 mm or greater of lengthening in in vitro tests, our empirical relationship indicates that lengthening at the site of fixation probably is an important cause of knee instability following ACL reconstructive surgery. Our empirical relation also indicates that an important criterion in the design of future fixation devices is that lengthening at the sites of fixation in in vitro tests should be limited to less than 3 mm.     

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.     

Influence of loading rate and cable migration on fiberoptic measurement of tendon force

Several investigators have recently used fiberoptic cables to measure tendon forces in situ. The technique may be subject to significant error due to cable migration and differences in the loading rates used for calibration and those experienced during measurement. This in vitro study examined the impact of these potential sources of error on transducer accuracy. A fiberoptic cable was passed perpendicular to the fibers of four Achilles tendons in the mediolateral direction and each specimen was cyclically loaded to 1000 N. The influence of loading rate on transducer output was investigated by comparing results from tests conducted at 20, 200 and 1000 N/s. The effect of cable migration was examined by comparing the outputs obtained after displacing the cable one tendon width medially and laterally along its path in the tendon and then repeating the 200 N/s testing protocol. It was possible to obtain nonlinear specimen-specific relationships between the fiberoptic output and tendon force. Differences in loading rate resulted in root-mean-square (RMS) errors not larger than 17% maximum load. Hysteresis effects caused RMS errors smaller than 5% maximum load. Cable migration errors were less than 27%. The total RMS error due to the combined effects of loading rate difference and cable movement was less than 32%. Fiberoptic measurement of tendon force is attractive due to its low cost, easy implementation and comparable accuracy relative to other implantable force transducers. Although additional factors such as cable placement, edge artifacts due where the transducer exits the skin and non-uniform loading may also influence fiberoptic output, careful control of loading rate and transducer movement during calibration is imperative if maximum accuracy is to be achieved.     

The effect of femoral tunnel placement on ACL graft orientation and length during in vivo knee flexion

Anatomically placed grafts are believed to more closely restore the function of the ACL. This study measured the effect of femoral tunnel placement on graft orientation and length during weight-bearing flexion. Both knees of twelve patients where the graft was placed near the anteroproximal border of the ACL and ten where the graft was placed near the center of the ACL were imaged using MR. These images were used to create 3D models of the reconstructed and intact contralateral knees, including the attachment sites of the native ACL and graft. Next, patients were imaged using biplanar fluoroscopy while performing a quasi-static lunge. The models were registered to the fluoroscopic images to reproduce in vivo knee motion. From the relative motion of the attachment sites on the models, the length and orientation of the graft and native ACL were measured. Grafts placed anteroproximally on the femur were longer and more vertical than the native ACL in both the sagittal and coronal planes, while anatomically placed grafts more closely mimicked ACL motion. In full extension, the grafts placed anteroproximally were 12.3±5.2° (mean and 95%CI) more vertical than the native ACL in the sagittal plane, whereas the grafts placed anatomically were 2.9±3.7° less vertical. Grafts placed anteroproximally were up to 6±2 mm longer than the native ACL, while the anatomically placed grafts were a maximum of 2±2 mm longer. In conclusion, grafts placed anatomically more closely restored native ACL length and orientation. As a result, anatomic grafts are more likely to restore intact knee kinematics.     

The effects of femoral graft placement on in vivo knee kinematics after anterior cruciate ligament reconstruction

Achieving anatomical graft placement remains a concern in Anterior Cruciate Ligament (ACL) reconstruction. The purpose of this study was to quantify the effect of femoral graft placement on the ability of ACL reconstruction to restore normal knee kinematics under in vivo loading conditions. Two different groups of patients were studied: one in which the femoral tunnel was placed near the anterior and proximal border of the ACL (anteroproximal group, n=12) and another where the femoral tunnel was placed near the center of the ACL (anatomic group, n=10) MR imaging and biplanar fluoroscopy were used to measure in vivo kinematics in these patients during a quasi-static lunge. Patients with anteroproximal graft placement had up to 3.4mm more anterior tibial translation, 1.1mm more medial tibial translation and 3.7° more internal tibial rotation compared to the contralateral side. Patients with anatomic graft placement had motion that more closely replicated that of the intact knee, with anterior tibial translation within 0.8mm, medial tibial translation within 0.5mm, and internal tibial rotation within 1°. Grafts placed anteroproximally on the femur likely provide insufficient restraint to these motions due to a more vertical orientation. Anatomical femoral placement of the graft is more likely to reproduce normal ACL orientation, resulting in a more stable knee. Therefore, achieving anatomical graft placement on the femur is crucial to restoring normal knee function and may decrease the rates of joint degeneration after ACL reconstruction.     

Calibrating joint capsule mechanoreceptors as in vivo soft tissue load cells

A method has been developed whereby the discharge of mechanically sensitive neurons from the cat knee joint capsule can be calibrated and used as load cells. The neurons are located in the upper edge of the capsule which has been previously modeled as a suspension cable and where the loading has been shown to be one dimensional. The calibration procedure relies upon applying known point loads to the cable and measuring its shape. The biomechanical model is then used to compute the cable tension at the neuron location. Results for 20 neurons showed a strong linear relationship between the tension and the frequency of neuronal discharge (r = 0.96, S.D. = 0.05). For 11 of these neurons the in vivo calibration was verified by subsequently excising the posterior capsule and recording from the same neuron while subjecting the cable to measured uniaxial loads. Results showed good agreement between the in vivo and in vitro calibrations. Once calibrated these neurons can be used as load sensors to study in vivo joint loading.     

Estimation of in vivo ACL force changes in response to increased weightbearing

Accurate knowledge of in vivo anterior cruciate ligament (ACL) forces is instrumental for understanding normal ACL function and improving surgical ACL reconstruction techniques. The objective of this study was to estimate the change in ACL forces under in vivo loading conditions using a noninvasive technique. A combination of magnetic resonance and dual fluoroscopic imaging system was used to determine ACL in vivo elongation during controlled weightbearing at discrete flexion angles, and a robotic testing system was utilized to determine the ACL force-elongation data in vitro. The in vivo ACL elongation data were mapped to the in vitro ACL force-elongation curve to estimate the change in in vivo ACL forces in response to full body weightbearing using a weighted mean statistical method. The data demonstrated that by assuming that there was no tension in the ACL under zero weightbearing, the changes in in vivo ACL force caused by full body weightbearing were 131.4 ± 16.8 N at 15 deg, 106.7 ± 11.2 N at 30 deg, and 34.6 ± 4.5 N at 45 deg of flexion. However, when the assumed tension in the ACL under zero weightbearing was over 20 N, the change in the estimated ACL force in response to the full body weightbearing approached an asymptotic value. With an assumed ACL tension of 40 N under zero weightbearing, the full body weight caused an ACL force increase in 202.7 ± 27.6 N at 15 deg, 184.9 ± 22.5 N at 30 deg, and 98.6 ± 11.7 N at 45 deg of flexion. The in vivo ACL forces were dependent on the flexion angle with higher force changes at low flexion angles. Under full body weightbearing, the ACL may experience less than 250 N. These data may provide a valuable insight into the biomechanical behavior of the ACL under in vivo loading conditions.     

A model of anterior cruciate ligament reconstructive surgery: A validation construct and computational insights

This study sought to develop a computational framework that emulates the anterior cruciate ligament reconstruction surgery using transtibial portal technique. The proposed model included the tibia–femoral and patella–femoral joints, articular cartilage and menisci. Key surgical parameters were incorporated including bone-patellar-tendon-bone graft excision and pre-tensioning, tunnel morphology, bone plugs, and bone plug fixation. Several simulation steps were parameterized to reflect the clinically reported surgical procedure. Our focus was to explore the intra-operative effects of variations in tunnel directions on the selected metrics of joint mechanics during Lachman and Anterior Drawer tests. A mathematical construct capable of transforming the limited and heterogeneous experimental and surgical data to evidence-based validation was adopted to ensure the viability of the finite element models. We found that the proposed models, subject to a variation in tunnel directions, resulted in simulation outputs that favor the reported experimental data of Lachman and Anterior Drawer tests under uncertainty. Simulation results for a population of three-dimensional tunnel orientations provided insights into the graft–tunnel contact mechanics and the spatial stress distribution in the graft, insights that have been anecdotally observed in prior experimental studies. The intraarticular graft tension was found to be higher than the estimated in tunnel graft force, and larger differences were found for the least inclined tunnels exhibiting higher contact pressures, transverse bending and twisting of the graft and Von-Mises stress at the graft–femoral tunnel interface. Conversely, tunnels with high inclination angles exhibited higher intraarticular graft tension and Von-Mises stress at the graft–tibial bone plug interface.     

Factors influencing the output of an implantable force transducer

The objective of this study was to evaluate the performance of the Arthroscopically Implantable Force Probe (AIFP; MicroStrain, Burlington VT) for measuring force in a patellar tendon graft. Transducer drift, reproducibility of output due to the number of loading cycles and device location, and sensitivity to the tendon cross-sectional area were investigated. The AIFP was initialized, and then implanted into five human patellar tendon grafts three times; twice within the same location and once in a different location. The tendons were cyclically loaded in uniaxial tension for 500 cycles in each insertion site. The AIFP was then removed from the tendon and the baseline output was remeasured. It was determined that transducer drift was negligible. The relationship between the tensile load applied to the graft and AIFP output was quadratic and specimen dependent. The cyclic load response of the tendon-AIFP interface demonstrated a 24.9% decrease over the first 20 loading cycles, and subsequent cycling yielded relatively reproducible output. The output of the transducer varied when it was removed from the tendon and then reimplanted in the same location (range 3.7-109. 4% error), as well as in the second location (range 1.5-202.8% error). No correlation was observed between the cross-sectional area of the tendon and transducer output. This study concludes that implantable force probes should be used with caution and calibrated without removing the transducer from the graft.     

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).     

The use of magnetic resonance imaging to predict ACL graft structural properties

Magnetic resonance imaging (MRI) could potentially be used to non-invasively predict the strength of an ACL graft after ACL reconstruction. We hypothesized that the volume and T2 relaxation parameters of the ACL graft measured with MRI will predict the graft structural properties and anteroposterior (AP) laxity of the reconstructed knee. Nine goats underwent ACL reconstruction using a patellar tendon autograft augmented with a collagen or collagen-platelet composite. After 6 weeks of healing, the animals were euthanized, and the reconstructed knees were retrieved and imaged on a 3T scanner. AP laxity was measured prior to dissecting out the femur-graft-tibia constructs which were then tested to tensile failure to determine the structural properties. Regression analysis indicated a statistically significant relationship between the graft volume and the failure load (r(2)=0.502; p=0.049). When graft volume was normalized to the T2 relaxation time, the relationship was even greater (r(2)=0.687; p=0.011). There was a significant correlation between the graft volume and the linear stiffness (r(2)=0.847; p<0.001), which remained significant with T2 normalization (r(2)=0.764; p=0.002). For AP laxity at 30° flexion, there was not a significant correlation with graft volume, but there was a significant correlation with volume normalized by the T2 relaxation time (r(2)=0.512; p=0.046). These results suggest that MRI volumetric measures combined with graft T2 properties may be useful in predicting the structural properties of ACL grafts.     

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.     

Surface EMG force modeling with joint angle based calibration

In this paper, a calibration method to compensate for changes in SEMG amplitude with joint angle is introduced. Calibration factors were derived from constant amplitude surface electromyogram (SEMG) recordings from the biceps brachii (during elbow flexion) and the triceps brachii (during elbow extension) across seven elbow joint angles. SEMG data were then recorded from the elbow flexors (biceps brachii and brachioradialis) and extensors (triceps brachii) during isometric, constant force flexion and extension contractions at the same joint angles. The resulting force at the wrist was measured. The fast orthogonal search method was used to find a mapping between the system inputs – estimated SEMG amplitudes and joint angle – and the system output – measured force, for both calibrated and non-calibrated SEMG data. Models developed with calibrated data yielded a statistically significant improvement in force estimation compared to models developed with non-calibrated data, suggesting that the calibration method can compensate for changes in the SEMG–force relationship with changing joint angle. It was also found that the number of non-linear, joint angle-dependent terms used in the SEMG–force model was reduced with calibration. Additionally, initial inter-session analysis performed for four subjects suggests that calibration values can be used for subsequent recording sessions, and different output force levels.     

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.     

Can markers injected into a single-loop anterior cruciate ligament graft define the axes of the tibial and femoral tunnels? A cadaveric study using roentgen stereophotogrammetric analysis

Lengthening of a soft-tissue anterior cruciate ligament (ACL) graft construct over time, which leads to an increase in anterior laxity following ACL reconstruction, can result from relative motions between the graft and fixation devices and between the fixation devices and bone. To determine these relative motions using Roentgen stereophotogrammetry (RSA), it is first necessary to identify the axes of the tibial and femoral tunnels. The purpose of this in vitro study was to determine the error in using markers injected into the portions of a soft-tissue tendon graft enclosed within the tibial and femoral tunnels to define the axes of these tunnels. Markers were injected into the tibia, femur, and graft in six cadaveric legs the knees of which were reconstructed with single-loop tibialis grafts. The axes of the tunnels were defined by marker pairs that were injected into the bones on lines parallel to the walls of the tibial and femoral tunnels (i.e., standard). By using marker pairs injected into the portions of the graft enclosed within the tibial and femoral tunnels and the marker pairs aligned with the tunnel axes, the directions of vectors were determined by using RSA, while a 150 N anterior force was transmitted at the knee. The average and standard deviations of the angle between the two vectors were 5.5+/-3.3 deg. This angle translates into an average error and standard deviation of the error in lengthening quantities (i.e., relative motions along the tunnel axes) at the sites of fixation of (0.6+/-0.8)%. Identifying the axes of the tunnels by using marker pairs in the graft rather than marker pairs in the walls of the tunnels will shorten the surgical procedure by eliminating the specialized tools and time required to insert marker pairs in the tunnel walls and will simplify the data analysis in in vivo studies.     

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.