The effect of anterior cruciate ligament graft elongation at the time of implantation on the biomechanical behavior of the graft and knee.

This investigation determined the effect that anterior cruciate ligament graft elongation at the time of surgical reconstruction has on the long-term biomechanical behavior of the graft and knee joint. We chose the canine model for anterior cruciate ligament reconstruction, using the medial third of the patellar tendon with attached proximal bone block. Elongation of the graft was measured immediately after graft fixation during passive knee flexion using the Hall effect transducer. The dogs were divided into either Group 1 (graft elongation behavior within the 95% confidence limits of the normal anterior cruciate ligament) or Group 2 (graft elongation behavior more than the 95% confidence limits of the normal anterior cruciate ligament). All of the dogs were sacrificed 18 months postoperatively, and we evaluated anteroposterior load displacement (i.e., anteroposterior laxity) of the knee and the structural properties of the graft. The anteroposterior laxity behavior of the reconstructed knees in Group 2 was significantly more than that of Group 1. Group 2 had significantly less linear stiffness of the graft than Group 1. There was no difference in the ultimate failure load and absorbed energy at failure values of the grafts between Groups 1 and 2. The findings from this investigation indicate that the graft elongation behavior at the time of reconstruction is a critical factor that influences the long-term success of anterior cruciate ligament reconstruction.

Effect of anterior cruciate ligament reconstruction with patellar tendon or prosthetic ligament on the morphology of the other ligaments of the knee joint. An experimental study in dogs.

The effect of anterior cruciate ligament replacement on the other ligaments of the knee, including the medial or lateral collateral and posterior cruciate ligaments, was studied histologically in the canine knee. The anterior cruciate ligament was replaced either with the medial third of the patellar tendon or with a prosthetic ligament. Histologic analysis was performed 3 months after prosthetic ligament implantation and 1 year after patellar ligament reconstruction. In all ligaments, numerous pathologic alterations were found. Degenerative changes such as glycosaminoglycan accumulation, metachromasia, collagenolysis, collagen necrosis, and lipomatosis were similar after 3 months and after 1 year. Granulation tissue, a sign that characterizes tissue repair, was seen only in those ligaments taken 3 months after anterior cruciate ligament surgery. Similar degenerative changes also were found in the ligaments of the knees with only a large medial arthrotomy (sham). In the contralateral control knees, the pathologic alterations were rare. Thus, open arthrotomy alone or with anterior cruciate ligament reconstruction seems to result in longstanding degenerative changes in all ligaments of the canine knee joint.

The relationship between anterior-posterior knee laxity and the structural properties of the patellar tendon graft. A study in canines.

We studied the relationship between anterior-posterior knee laxity and the structural properties of autogenous patellar tendon grafts used to replace the anterior cruciate ligaments in dogs 1 year after reconstruction. At 30 degrees (full extension for the dog), 60 degrees, and 90 degrees of flexion a significant inverse correlation was found between anterior-posterior knee laxity and the ultimate failure strength of the graft. Likewise, at 60 degrees and 90 degrees of flexion a significant inverse correlation was found between knee laxity and the linear stiffness of the graft. In all cases, as knee laxity increased, the ultimate failure load and linear stiffness values of the graft were found to decrease. There was also a significant increase in anterior-posterior knee laxity of the reconstructed knees (produced by an increase in anterior translation of the tibia relative to the femur) compared with the contralateral control knee. The group of dogs that underwent a sham operation without reconstruction of the anterior cruciate ligament had no change in anterior-posterior knee laxity or the structural properties of the anterior cruciate ligament. The clinical significance of this investigation is that knee laxity measurements demonstrating an increase in anterior translation of the tibia relative to the femur during graft healing may indicate that the graft has weakened and reduced structural properties.

Desmotomy of the accessory ligament of the superficial digital flexor muscle in equine cadaver limbs.

Effects of longitudinal compression before and after transection of the accessory ligament of the superficial digital flexor (SDF) muscle were measured in eight equine cadaver forelimbs. When compression was increased from 890 N to 3115 N, the metacarpophalangeal (MCP) and carpal joints hyperextended 20 degrees and 4 degrees, respectively, and strain in the SDF and deep digital flexor tendons was increased 3.5% and 1.4%, respectively. The accessory ligament did not elongate. Immediately after transection of the accessory ligament at 3115 N load, a 2.8 mm gap formed between the transected ends of the accessory ligament, and the muscle belly of the SDF elongated and moved distad. The MCP joint hyperextended 15.8% further and strain of the SDF tendon increased 11.2% further. These results show that the accessory ligament transferred load in the SDF musculotendinous unit away from the muscle belly and that desmotomy altered this function. Decrease in the MCP joint angle indicated that the accessory ligament contributed to the support of the MCP joint under load. Increase in SDF strain after desmotomy was probably influenced by the change in the moment about the MCP joint and increased length of the SDF musculotendinous unit.

Strain in the lateral ligaments of the ankle.

Strain was measured in the normal anterior talofibular ligament (ATF) and the calcaneofibular ligament (CF) using Hall effect strain transducers in five cadaveric ankles. These measurements were made in both ligaments with the ankle in neutral position and with the foot moving from 10 degrees dorsiflexion to 40 degrees plantarflexion in an apparatus that permits physiologic motion. The ankle ligaments were then tested with the foot placed in six different positions that combined supination, pronation, external rotation, and internal rotation. In the neutral position, through a range of motion of 10 degrees dorsiflexion to 40 degrees plantarflexion, the anterior talofibular ligament underwent an increasing strain of 3.3%. No significant strain increase was found with internal rotation. The only significant difference from the strains at the neutral position was in external rotation, which decreased strain 1.9%. In all positions, increased strain occurred with increased plantarflexion. The calcaneofibular ligament was essentially isometric in the neutral position throughout the flexion arc. The calcaneofibular ligament strain was significantly increased by supination and external rotation. However, with increasing plantarflexion in these positions, the strain in the calcaneofibular ligament decreased. Therefore, plantarflexion has a relaxing effect on the calcaneofibular ligament. Thus, the anterior talofibular and calcaneofibular ligaments are synergistic, such that when one ligament is relaxed, the other is strained and vice versa.

An in vivo analysis of the effect of transcutaneous electrical stimulation of the quadriceps and hamstrings on anterior cruciate ligament deformation.

Transcutaneous electrical muscle stimulation (TEMS) has been advocated as a method to rehabilitate the postoperative ACL repaired/reconstructed lower extremity. Isolated quadriceps contraction can potentially disrupt the ACL repair/reconstruction; to minimize this risk simultaneous quadriceps and hamstring stimulation has been used. This study measured the in vivo deformation of the ACL during TEMS of the quadriceps and hamstrings. Six legs in four Rhesus monkeys were immobilized in 0 degrees, 45 degrees, and 90 degrees of flexion in neutral rotation using a Hoffman frame and pins placed through the proximal femur and distal tibia. The hamstrings and quadriceps muscles were stimulated with a dual channel electrical stimulator individually and simultaneously at each point of flexion, and ACL deformation was measured using a Hall effect device placed on the anterior medial fibers of the ACL. The following conclusions were made: 1) Isolated quadriceps contraction produces ACL elongation at 0 degrees and 45 degrees of knee flexion and produces ACL shortening at 90 degrees of knee flexion. 2) Isolated hamstrings contraction produces ACL shortening at 45 degrees and 90 degrees of knee flexion and negligible effects at full knee extension. 3) It is not possible to simultaneously contract the quadriceps and hamstrings using separate stimulator pads for each muscle group. 4) At 45 degrees of knee flexion when the quadriceps muscles are stimulated before the hamstring muscles and simultaneous contraction of both is then sustained, ACL lengthening occurs. 5) When the hamstring muscles are fired before the quadriceps muscles and simultaneous contraction of both is sustained, ACL shortening occurs.

Strain within the anterior cruciate ligament during hamstring and quadriceps activity.

The objectives of this study were to measure strain in the ACL during simulated: hamstring activity alone, quadriceps activity alone, and simultaneous quadriceps and hamstring activity. Seven knee specimens removed from cadavers were studied. Heavy sutures applied to load cells were attached to the hamstring and quadriceps tendons. Loads were then applied manually (hamstrings) and/or with an Instron testing machine (quadriceps) to simulate isometric contractions of the various muscle groups. Strain was measured using a Hall effect transducer. Acting alone, the isometric hamstring activity decreased ACL strain relative to the passive normal strain at all positions tested. Thus, hamstring exercises are not detrimental to ACL repairs or reconstruction and can be included early in the rehabilitation program after ACL surgery. Acting alone, at flexion angles of 0 degree to 45 degrees, the quadriceps significantly increased the strain within the ACL relative to the passive normal strain. Strain in the ACL during simultaneous hamstring and quadriceps activity was significantly higher than that during passive normal motion from full extension to 30 degrees of flexion. The hamstrings are not capable of masking the potentially harmful effects of simultaneous quadriceps contraction on freshly repaired or reconstructed ACLs unless the knee flexion angle exceeds 30 degrees.

Analysis of the effect of using two different strain rates on the acoustic emission in bone.

To study the effect of strain rate on the acoustic emission amplitude signature of bone, bovine cortical bone was milled into standard tensile specimens which were tested at two different strain rates while being monitored with acoustic emission equipment. It was demonstrated that the amplitude distribution of the acoustic events in bone is dependent on strain rate. Greater numbers of events occurred with the slower strain rate (0.0001 s-1), but these events were of lower amplitude than those emitted during the more rapid strain rate (0.01 s-1). The plot of the cumulative event amplitude distribution followed the power-law model, and the slope of this output, the b-value, represented a signature of the amplitude distribution. The mechanical test results were consistent with the behavior of a viscoelastic multi-phase composite material.

The functional relationship of the posterior oblique ligament to the medial collateral ligament of the human knee.

Strain in the human knee medial collateral ligament (MCL) was measured in cadavers with a Hall effect strain transducer during normal passive knee flexion, as well as knee flexion accompanied by applied external tibial rotation and valgus torques. In an attempt to determine the contribution of the posterior oblique ligament (POL) to the strain behavior of the MCL, the POL was systematically separated from the MCL and changes in strain in the MCL were observed. These changes in strain were mild and variable, except in the one knee which was later found to be lacking an anterior cruciate ligament. In that particular knee, strain in the MCL increased up to 9.97% under the influence of a valgus torque once the POL fibers had been separated from the MCL. Anatomical dissection and transillumination techniques of the MCL/POL complex demonstrated definite ligament fibers connecting the MCL to the POL. The results demonstrate an intimate anatomical relationship between the POL and MCL. However, the POL and MCL appear to work independently from each other according to our test method.

The biomechanics of anterior cruciate ligament rehabilitation and reconstruction.

The rehabilitation of knee injuries involving the anterior cruciate ligament (ACL) is controversial. This paper describes strain in the normal and reconstructed ACL during a series of passive and active tests of knee flexion with and without varus, valgus, and axial rotation torques on the tibia. Strain in the human knee ACL was significantly different depending on whether the knee flexion angle was changed passively or via simulated quadriceps contraction. The knee joint capsule was found to be important for strain protection of the ACL. Quadriceps activity did not strain the normal or reconstructed ACL when the knee was flexed beyond 60 degrees, but significantly strained the tissue from 0 to 45 degrees of knee flexion. Immobilization may not protect the ACL if isometric quadriceps contractions are allowed to occur. Properly placed reconstructions exhibited strain behavior which closely followed the anteromedial band of the ACL.

Strain measurement in the medial collateral ligament of the human knee: an autopsy study.

A strain transducer was developed which employs a magnetic field sensing device to detect linear displacement. The transducer was attached to the medial collateral ligament (MCL) of human autopsy specimens, minimally influencing their physiologic behavior. A strain 'map' of the MCL as a function of knee flexion (full extension to 120 degrees) both with and without abduction force was obtained. Our investigation revealed consistent differences in the strain patterns between proximal, middle and distal segments of the anterior and posterior borders of the MCL. Anatomic variations in the pattern of collagen fibers within the MCL, interactions between posterior oblique capsular fibers and the MCL, and the skeletal configuration may account for these varied strain patterns.