To evaluate the effect of posterolateral bundle (PLB) graft fixation angles on graft tension curves and load sharing between the anteromedial bundle (AMB) and the PLB in double-bundle anterior cruciate ligament (ACL) reconstruction.
Twenty-four patients who underwent double-bundle ACL reconstruction were included in this study. AMB and PLB were provisionally fixed to a graft tensioning system during surgery. The graft fixation settings were as follows: (1) AMB at 20° and PLB at 0° (A20P0), (2) AMB at 20° and PLB at 20° (A20P20), and (3) AMB at 20° and PLB at 45° (A20P45). Bundle tension was recorded during knee flexion-extension and in response to anterior or rotatory loads. A pivot-shift test, as well as factors affecting the residual pivot-shift, was also evaluated.
A20P45 created reciprocal tension curves and load sharing, in which the tension in both bundles was equivalent during flexion-extension and during each loading test at 30°. In A20P0, the tension of the AMB was constantly higher than that of the PLB. Seven patients showed grade 1 pivot-shift phenomenon in A20P0, whereas no patient showed a positive pivot-shift at other settings. Larger tension reduction of the PLB between 0° and 30° and smaller load sharing of the PLB were significant factors affecting residual pivot-shift.
In double-bundle ACL reconstruction, fixation of the AMB at 20° and the PLB at 45° created reciprocal tension curves and load sharing between the bundles. Fixation of the AMB at 20° and the PLB at 0° led to insufficient tension in the PLB, resulting in a residual pivot-shift phenomenon in 7 of 24 patients.
Level of Evidence
Level IV, therapeutic case series.
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- The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis.Clin Orthop Relat Res. 1975; : 216-231
- Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries.J Bone Joint Surg Br. 1991; 73: 260-267
- Direct measurement of strain in the posterolateral bundle of the anterior cruciate ligament.J Biomech. 1997; 30: 281-283
- Assessment of the “functional length” of the three bundles of the anterior cruciate ligament.Knee Surg Sports Traumatol Arthrosc. 2008; 16: 167-174
- In vivo elongation of the anterior cruciate ligament and posterior cruciate ligament during knee flexion.Am J Sports Med. 2004; 32: 1415-1420
- Changes in ACL length at different knee flexion angles: An in vivo biomechanical study.Knee Surg Sports Traumatol Arthrosc. 2010; 18: 292-297
- Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads.J Orthop Res. 2004; 22: 85-89
- The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation.Am J Sports Med. 2007; 35: 223-227
- Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction.Am J Sports Med. 2002; 30: 660-666
- The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon. A cadaveric study comparing anterior tibial and rotational loads.J Bone Joint Surg Am. 2002; 84-A: 907-914
- Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: Surgical techniques, clinical outcomes, and complications.Arthroscopy. 2007; 23: 602-609
- Reconstruction of the anterior cruciate ligament. Single- versus double-bundle multistranded hamstring tendons.J Bone Joint Surg Br. 2004; 86: 515-520
- Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients.Am J Sports Med. 2008; 36: 1675-1687
- Double-bundle ACL reconstruction can improve rotational stability.Clin Orthop Relat Res. 2007; 454: 100-107
- A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques.Arthroscopy. 2007; 23: 618-628
- Single- and double-incision double-bundle ACL reconstruction.Clin Orthop Relat Res. 2007; 454: 108-113
- Double-bundle versus single-bundle anterior cruciate ligament reconstruction: A prospective, randomize clinical study.Knee Surg Sports Traumatol Arthrosc. 2007; 15: 500-507
- “Anatomic” anterior cruciate ligament reconstruction: A systematic review of surgical techniques and reporting of surgical data.Arthroscopy. 2010; 26: S2-S12
- The effects of different tensioning strategies on knee laxity and graft tension after double-bundle anterior cruciate ligament reconstruction.Am J Sports Med. 2007; 35: 2083-2090
- Effects of knee flexion angles for graft fixation on force distribution in double-bundle anterior cruciate ligament grafts.Am J Sports Med. 2006; 34: 577-585
- Anatomic double-bundle anterior cruciate ligament reconstruction: Kinematics and knee flexion angle-graft tension relation.Arthroscopy. 2010; 26: 202-213
- Determination of a safe range of knee flexion angles for fixation of the grafts in double-bundle anterior cruciate ligament reconstruction: A human cadaveric study.Am J Sports Med. 2007; 35: 1513-1520
- The effect of graft fixation angles on anteroposterior and rotational knee laxity in double-bundle anterior cruciate ligament reconstruction: Evaluation using computerized navigation.Am J Sports Med. 2012; 40: 615-623
- Kinematic impact of anteromedial and posterolateral bundle graft fixation angles on double-bundle anterior cruciate ligament reconstructions.Am J Sports Med. 2010; 38: 1575-1583
- Osseous landmarks of the femoral attachment of the anterior cruciate ligament: An anatomic study.Arthroscopy. 2007; 23: 1218-1225
- Resident's ridge: Assessing the cortical thickness of the lateral wall and roof of the intercondylar notch.Arthroscopy. 2003; 19: 931-935
- Anatomy of the anterior cruciate ligament with regard to its two bundles.Clin Orthop Relat Res. 2007; 454: 35-47
- Arthroscopic identification of the anterior cruciate ligament posterolateral bundle: The figure-of-four position.Arthroscopy. 2007; 23 (1128.e1-3)
- Radiographic description of femoral tunnel placement expressed as intercondylar clock time in double-bundle anterior cruciate ligament reconstruction.Knee Surg Sports Traumatol Arthrosc. 2010; 19: 418-423
- Tensioning of anterior cruciate ligament hamstring grafts: Comparing equal tension versus equal stress.Arthroscopy. 2008; 24: 1323-1329
- Tension patterns of the anteromedial and posterolateral grafts in a double-bundle anterior cruciate ligament reconstruction.J Orthop Res. 2009; 27: 879-884
- An in vivo biomechanical study on the tension-versus-knee flexion angle curves of 2 grafts in anatomic double-bundle anterior cruciate ligament reconstruction: Effects of initial tension and internal tibial rotation.Arthroscopy. 2008; 24: 276-284
- Force sharing between two grafts in the anatomical two-bundle anterior cruciate ligament reconstruction.Knee Surg Sports Traumatol Arthrosc. 2006; 14: 505-509
- Insufficiency of the anterior cruciate ligament. Review of our 118 cases.Arch Orthop Trauma Surg. 1979; 95: 233-240
- Evaluation of knee ligament injuries with the IKDC form.Knee Surg Sports Traumatol Arthrosc. 1993; 1: 226-234
- Direct measurement of resultant forces in the anterior cruciate ligament. An in vitro study performed with a new experimental technique.J Bone Joint Surg Am. 1990; 72: 557-567
- Effects of different initial bundle tensioning strategies on the outcome of double-bundle ACL reconstruction: A cohort study.Sports Med Arthrosc Rehabil Ther Technol. 2011; 3: 15
- Comparison of 4 femoral tunnel drilling techniques in anterior cruciate ligament reconstruction.Arthroscopy. 2012; 28: 972-979
- Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: An anatomic and biomechanical evaluation of surgical technique.Arthroscopy. 2011; 27: 380-390
- Anatomy of normal human anterior cruciate ligament attachments evaluated by divided small bundles.Am J Sports Med. 2009; 37: 2386-2391
- Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction.Arthroscopy. 2006; 22: 356-361
- Femoral insertion of the ACL. Radiographic quadrant method.Am J Knee Surg. 1997; 10 (discussion 21-12): 14-21
- Tunnel positioning of anteromedial and posterolateral bundles in anatomic anterior cruciate ligament reconstruction: Anatomic and radiographic findings.Am J Sports Med. 2008; 36: 65-72
- Anatomical analysis of the anterior cruciate ligament femoral and tibial footprints.J Orthop Sci. 2008; 13: 122-129
- The accuracy of bone tunnel position using fluoroscopic-based navigation system in anterior cruciate ligament reconstruction.Knee Surg Sports Traumatol Arthros. 2012; 20: 1503-1510
Published online: January 22, 2013
Accepted: October 16, 2012
Received: January 29, 2012
The authors report that they have no conflicts of interest in the authorship and publication of this article.
© 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.